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Mitral stenosis, a condition marked by the narrowing of the mitral valve, necessitates an integrated approach for effective management. This approach includes preventative measures, medical therapy, and surgical interventions to reduce symptoms and prevent complications.PreventionPrevention of mitral stenosis primarily focuses on reducing the incidence of bacterial infections, particularly streptococcal infections, which can lead to rheumatic fever and subsequent valvular damage. Timely...
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Mitral regurgitation (MR) is characterized by retrograde blood circulation from the left ventricle into the left atrium due to inadequate mitral valve closure. The severity of the condition, symptoms, and underlying cause determine treatment strategies.Monitoring and Pharmacological TreatmentPatients with mild to moderate MR typically do not need immediate intervention but regular monitoring to assess progression and guide treatment. Patients with mild MR should have an echocardiogram every 3-5...
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Reduced Leaflet Motion after Transcatheter Aortic-Valve Replacement.

Ole De Backer1, George D Dangas1, Hasan Jilaihawi1

  • 1From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland.

The New England Journal of Medicine
|November 17, 2019
PubMed
Summary

Rivaroxaban-based therapy after transcatheter aortic-valve replacement (TAVR) reduced leaflet abnormalities but increased risks of death, clots, and bleeding compared to antiplatelet therapy.

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Area of Science:

  • Cardiology
  • Medical Imaging
  • Pharmacology

Background:

  • Subclinical leaflet thickening and reduced motion in bioprosthetic aortic valves are detectable by 4D CT.
  • The efficacy of anticoagulation in mitigating these post-transcatheter aortic-valve replacement (TAVR) phenomena is unknown.

Purpose of the Study:

  • To investigate whether a rivaroxaban-based antithrombotic strategy reduces subclinical leaflet abnormalities after TAVR compared to antiplatelet therapy.
  • To assess the safety of rivaroxaban-based therapy in this patient population.

Main Methods:

  • A substudy of a randomized trial assigned TAVR patients without anticoagulation indications to either rivaroxaban plus aspirin or clopidogrel plus aspirin.
  • Four-dimensional CT evaluated prosthetic valve leaflet motion and thickening at approximately 90 days post-randomization.
  • Primary endpoint was the percentage of patients with significant leaflet motion reduction (grade 3 or higher).

Main Results:

  • Rivaroxaban significantly reduced leaflet motion abnormalities (2.1% vs. 10.9%, P=0.01) and thickening (12.4% vs. 32.4%) compared to antiplatelet therapy.
  • The main trial revealed higher risks of death or thromboembolic events (HR 1.35) and major bleeding (HR 1.50) with rivaroxaban.

Conclusions:

  • A rivaroxaban-based strategy effectively prevented subclinical leaflet abnormalities after TAVR in patients not requiring long-term anticoagulation.
  • However, this benefit was outweighed by increased risks of adverse cardiovascular events and bleeding in the main trial.