CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

November 14th, 2011

Stenosis vs. Stroke: Is Treatment Worth the Risk?

Several Cardiology Fellows who are attending AHA.11 this week are blogging together on CardioExchange.  The Fellows include Revathi Balakrishnan, Eiman Jahangir, John Ryan (moderator), and Amit Shah. Read the previous post here. Check back often to learn about the biggest buzz in Orlando.

On Sunday morning, I feel like the conference has really begun. I am sitting in the Chaplin Theater, a very large auditorium that is about half full of people. They’re waiting to hear various presentations and discussions during the “Groundbreaking Studies in the Cardiovascular Medicine: Circulation Editor’s Choice,”  a 3-hour session full of presentations and discussions on topics from dabigatran to transcatheter aortic heart valve implantation (TAVI) to racial and ethical differences in the treatment of AMI.

The TAVI discussion really drew my interest. As a future interventional cardiologist, I believe that treating structural heart disease and using procedures such as TAVI are going to be a large portion of my practice over the next decade. Presenters discussed recent results from the PARTNER B trial that evaluated the use of TAVI in old and fragile patients who were unable to obtain surgery and who had many comorbidities. TAVI showed superior 2-year all-cause mortality compared with conventional surgery (approximately 18% vs. 35%) as well as similarly improved rate of repeat hospitalizations. Despite these benefits, patients in the TAVI arm did have increased stroke risk compared to surgery. These results are both exciting and concerning. While aortic stenosis causes severe comorbidity and mortality, the risk of stroke may be too high for some individuals (over 13% in the TAVI arm).

As a physician, nothing scares me more than causing harm to a patient, especially in the form of stroke. I know this harm well because my grandfather had a devastating stroke in the early 1990s after a CABG. Since his stroke, my grandfather has had aphasia and hemiparalysis. He went from a professor of pharmacology to being dependent on others for his care.  Stroke is a known and low risk of many procedures, but its impact is severe both to patients and to their families.

Do you think that a 13% risk for stroke is too high for the treatment of aortic stenosis?

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3 Responses to “Stenosis vs. Stroke: Is Treatment Worth the Risk?”

  1. John Ryan, MD says:
    November 14, 2011 at 2:53 pm

    Interesting comments Eiman. As part of your interventional fellowship, you will presumably be involved in TAVI cases. As a trainee, how do you feel you will handle this risk of stroke, which, as you pointed out, is not an uncommon complication from this procedure?

  2. Gian Carlo Giove, MD says:
    November 14, 2011 at 5:38 pm

    I believe subsequent studies will show a marked decrease on the numbers of Stroke.

    Competing interests pertaining specifically to this post, comment, or both:
    non

  3. Eiman Jahangir, MD says:
    November 14, 2011 at 10:36 pm

    I agree with Dr. Giove. I am interested to see how things go with subsequent studies, but I too believe the stroke risk will improve over time and in larger studies. I guess time will tell.