Author + information
- Sonny Palmer, MBBS∗ (, )
- Douglas F. Muir, MD,
- Mark A. de Belder, MA, MD and
- Paul Williams, MD
- ↵∗Department of Cardiology, James Cook University Hospital, Middlesbrough TS4 3BW, United Kingdom
We read with great interest the paper by Bijuklic et al. (1) that reported an increased risk of cerebral embolization with direct transcatheter aortic valve replacement (TAVR) without preceding balloon aortic valvuloplasty (BAV) using a balloon-expandable TAVR system.
Although this is a thought-provoking study, we feel that there are several issues. This is a small, retrospective series, and the 2 groups are not well-matched. The direct TAVR group consists entirely of S3 valves, whereas the BAV group were mostly Sapien XT valves. These 2 valves have different characteristics: for instance, the S3 valve has a smaller sheath and delivery system, which increases the proportion of patients who can be treated by the transfemoral approach and means that the cohort of patients treated may be different. To support this theory, there were higher rates of atrial fibrillation, diabetes mellitus, and hypertension in the direct group, which are important risk factors for stroke. The 13 S3 patients in the BAV group had small valve areas or valve calcium, which will introduce selection bias. The authors do not report differences in valvular calcification.
We also feel that Figure 1 requires further clarification. These data represent the most important results of the paper, but it is only represented in chart form, and the data are not included in the Results section. It is also not clear whether the error bars represent standard deviation or standard error of the mean. Furthermore, the error bars are missing from chart A.
Finally, the authors have only shown an association between direct TAVR and an increased volume of cerebral ischemic lesions. Because the overall number of lesions is not increased, and given the aforementioned issues, we feel that a title stating that there is an increased risk of cerebral embolization without prior balloon valvuloplasty in TAVR is potentially misleading.
Please note: Dr. Muir has been a proctor for Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2016 American College of Cardiology Foundation