ImportanceIn patients with severe aortic valve stenosis at intermediate surgical risk, transcatheter aortic valve replacement (TAVR) with a self-expanding supra-annular valve was noninferior to surgery for all-cause mortality or disabling stroke at 2 years. Comparisons of longer-term clinical and hemodynamic outcomes in these patients are limited.ObjectiveTo report prespecified secondary 5-year outcomes from the Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement (SURTAVI) randomized clinical trial.Design, Setting, and ParticipantsSURTAVI is a prospective randomized, unblinded clinical trial. Randomization was stratified by investigational site and need for revascularization determined by the local heart teams. Patients with severe aortic valve stenosis deemed to be at intermediate risk of 30-day surgical mortality were enrolled at 87 centers from June 19, 2012, to June 30, 2016, in Europe and North America. Analysis took place between August and October 2021.InterventionPatients were randomized to TAVR with a self-expanding, supra-annular transcatheter or a surgical bioprosthesis.Main Outcomes and MeasuresThe prespecified secondary end points of death or disabling stroke and other adverse events and hemodynamic findings at 5 years. An independent clinical event committee adjudicated all serious adverse events and an independent echocardiographic core laboratory evaluated all echocardiograms at 5 years.ResultsA total of 1660 individuals underwent an attempted TAVR (n = 864) or surgical (n = 796) procedure. The mean (SD) age was 79.8 (6.2) years, 724 (43.6%) were female, and the mean (SD) Society of Thoracic Surgery Predicted Risk of Mortality score was 4.5% (1.6%). At 5 years, the rates of death or disabling stroke were similar (TAVR, 31.3% vs surgery, 30.8%; hazard ratio, 1.02 [95% CI, 0.85-1.22]; P = .85). Transprosthetic gradients remained lower (mean [SD], 8.6 [5.5] mm Hg vs 11.2 [6.0] mm Hg; P < .001) and aortic valve areas were higher (mean [SD], 2.2 [0.7] cm2 vs 1.8 [0.6] cm2; P < .001) with TAVR vs surgery. More patients had moderate/severe paravalvular leak with TAVR than surgery (11 [3.0%] vs 2 [0.7%]; risk difference, 2.37% [95% CI, 0.17%- 4.85%]; P = .05). New pacemaker implantation rates were higher for TAVR than surgery at 5 years (289 [39.1%] vs 94 [15.1%]; hazard ratio, 3.30 [95% CI, 2.61-4.17]; log-rank P < .001), as were valve reintervention rates (27 [3.5%] vs 11 [1.9%]; hazard ratio, 2.21 [95% CI, 1.10-4.45]; log-rank P = .02), although between 2 and 5 years only 6 patients who underwent TAVR and 7 who underwent surgery required a reintervention.Conclusions and RelevanceAmong intermediate-risk patients with symptomatic severe aortic stenosis, major clinical outcomes at 5 years were similar for TAVR and surgery. TAVR was associated with superior hemodynamic valve performance but also with more paravalvular leak and valve reinterventions.

FIGURE 1. Poststroke depression (PSD) is common among survivors of stroke. A recent meta-analysis of population-based studies (green squares) and a longitudinal study that utilized a large stroke registry (blue squares) both reported that more than 30% of patients developed PSD within the first few months after a stroke. 1,2 The longitudinal study also found that half of these cases remitted by 1 year. 1 A similar pattern was reported in a study of first-ever ischemic stroke (pink squares). 3 Of note, a study using data from a stroke registry that included patients with transient ischemic attacks (TIAs) reported similar rates of depression following stroke (gold squares)and TIA (gold triangles). 4 Rates of developing major depression (MDD) after traumatic brain injury (TBI) are also similar when patients with moderate-severe TBI (orange squares) are compared with patients with mild TBI (orange triangles). 5 Overall, these results suggest that severity of brain injury is not a primary pathophysiological mechanism for development of depression.

Endovascular therapy (EVT), with IV tPA if eligible, is the standard of care for large vessel occlusion (LVO) in acute ischemic stroke. Many patients transferred from outside hospitals to comprehensive stroke centers (CSCs) for potential EVT are found to be ineligible. We aimed to determine predictors of EVT candidacy for suspected LVO strokes in patients transferred from telestroke network hospitals within 24 hours of last known normal time. Methods: All adult patients transferred after telestroke consultation to our CSC emergency department with acute ischemic stroke and suspected LVO from November 2017 to June 2018 were retrospectively reviewed. This time frame was chosen due to practice changes following the establishment of an extended EVT time window. Data analyzed included demographics, risk factors, BP, NIHSS, presence of cerebellar signs and cortical signs (i.e., aphasia, gaze palsy, visual field defect, neglect). With EVT candidacy as the dependent variable, stepwise logistic regression was done with the significance level both for a factor to enter and stay in the model set at 0.15. Results: A total of 133 patients (mean age 67.5 ± 16 years, 47.4% women, 85.7% White, 14.3% non-White) were identified. EVT was performed in 36 of 133 patients (27%). The mean NIHSS for EVT patients was 13.1 ± 6.7 compared to 8.5 ± 8.0 for non-EVT patients (p=0.0030). Each unit increase in NIHSS was associated with being more likely to receive EVT (p=0.10). Cortical signs were present in 32 of 36 EVT patients (88.9%) compared to 57 of 97 non-EVT patients (58.8%) (p=0.0010). The presence of cortical signs was associated with receiving EVT (OR 4.60, 95% CI 1.30-16.26; p=0.02). A history of CHF was associated with being less likely to receive EVT (OR 0.31, 95% CI 0.10-1.02, p=0.05). There was a trend toward non-White race being associated with receiving EVT (OR 2.91, 95% CI 0.88-9.62; p=0.08). Conclusion: The presence of cortical signs, more so than the collinear variable of higher NIHSS, was a significant predictor of candidacy for EVT. Non-White race and CHF are variables that will need to be validated in future studies. These findings, combined with further studies, could help telestroke physicians establish improved selection criteria for transfer of stroke patients to CSCs for EVT.

Introduction: Detecting atrial fibrillation (AF) after an ischemic stroke may be challenging. We aimed to determine whether using the left atrial volume index (LAVi) can help screen patients at risk of having AF after an ischemic stroke or transient ischemic attack (TIA). Methods: All adult patients who were admitted to our comprehensive stroke center with ischemic strokes or TIA from January 2017 to January 2018 were retrospectively analyzed. Demographics, risk factors, stroke etiology and transthoracic echocardiography (TTE) data were collected. AF detection was based on either in-hospital cardiac telemetry and/or a 14-day or 30-day ambulatory ECG monitoring. Reference values for LAVi were derived from 2015 Guidelines from the American Society of Echocardiography. TTE and ECG parameters were analyzed using Fisher’s exact test for categorical variables and non-parametric tests for continuous variables. Results: We identified 334 patients with ischemic strokes and TIA without documented AF (66 ± 11 years, 49% females, 70% White, 23% African American, 6% Other). The mean total days of cardiac monitoring was 9.8 ± 7.2 days and it was lower in patients with AF vs without AF (3.8 ± 5.0 days vs. 10.6 ± 7.1 days, p < 0.0001). Newly diagnosed AF was detected in 37 of 334 patients (11%). Of the 241 patients with normal left atrium (LA), 15 (6%) were diagnosed with AF; 10 of 49 (20%) with mildly dilated LA; 5 of 23 (22%) with moderately dilated LA; 7 of 21 (33%) with severely dilated LA. The proportions of AF detection differed significantly between the LA categories ( p < 0.0001). The mean LAVi was higher in patients with AF vs without AF (40.0 ± 13.8 mL/m 2 vs. 28 ± 10.5 mL/m 2 , p < 0.001), and in those with cardioembolic strokes (34.7 ± 13.3 mL/m 2 , p < 0.0001). The mean LAVi for non-cardioembolic strokes including cryptogenic, small vessel and large vessel were 29.3 ± 10.2 mL/m 2 , 28.6 ± 8.5 mL/m 2 , 26.2 ± 12.8 mL/m 2 , respectively. Conclusion: Our data demonstrates a significant association between higher LAVi on routine TTE and detecting AF using non-invasive ECG monitoring in patients with ischemic strokes or TIA. Use of LAVi measured during the stroke hospitalization may help identify patients who would benefit from additional non-invasive cardiac monitoring post-discharge.

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