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Kedhi E, Hermanides RS, Dambrink JHE, Singh SK, Ten Berg JM, van Ginkel D, Hudec M, Amoroso G, Amat-Santos IJ, Andreas M, Campante Teles R, Bonnet G, Van Belle E, Conradi L, van Garsse L, Wojakowski W, Voudris V, Sacha J, Cervinka P, Lipsic E, Somi S, Nombela-Franco L, Postma S, Piayda K, De Luca G, Kolkman E, Malinowski KP, Modine T. TransCatheter aortic valve implantation and fractional flow reserve-guided percutaneous coronary intervention versus conventional surgical aortic valve replacement and coronary bypass grafting for treatment of patients with aortic valve stenosis and complex or multivessel coronary disease (TCW): an international, multicentre, prospective, open-label, non-inferiority, randomised controlled trial. Lancet 2025; 404:2593-2602. [PMID: 39644913 DOI: 10.1016/s0140-6736(24)02100-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 08/21/2024] [Accepted: 09/19/2024] [Indexed: 12/09/2024]
Abstract
BACKGROUND Patients with severe aortic stenosis present frequently (∼50%) with concomitant obstructive coronary artery disease. Current guidelines recommend combined surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) as the preferred treatment. Transcatheter aortic valve implantation (TAVI) and fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) represent a valid treatment alternative. We aimed to test the non-inferiority of FFR-guided PCI plus TAVI versus SAVR plus CABG in patients with severe aortic stenosis and complex coronary artery disease. METHODS This international, multicentre, prospective, open-label, non-inferiority, randomised controlled trial was conducted at 18 tertiary medical centres across Europe. Patients (aged ≥70 years) with severe aortic stenosis and complex coronary artery disease, deemed feasible for percutaneous or surgical treatment according to the on-site Heart Team, were randomly assigned (1:1) to FFR-guided PCI plus TAVI or SAVR plus CABG according to a computer-generated sequence with random permuted blocks sizes stratified by site. The primary endpoint was a composite of all-cause mortality, myocardial infarction, disabling stroke, clinically driven target-vessel revascularisation, valve reintervention, and life-threatening or disabling bleeding at 1 year post-treatment. The trial was powered for non-inferiority (with a margin of 15%) and if met, for superiority. The primary and safety analyses were done per an intention-to-treat principle. This trial is registered with ClinicalTrials.gov (NCT03424941) and is closed. FINDINGS Between May 31, 2018, and June 30, 2023, 172 patients were enrolled, of whom 91 were assigned to the FFR-guided PCI plus TAVI group and 81 to the SAVR plus CABG group. The mean age of patients was 76·5 years (SD 3·9). 118 (69%) of 172 patients were male and 54 (31%) patients were female. FFR-guided PCI plus TAVI resulted in favourable outcomes for the primary endpoint (four [4%] of 91 patients) versus SAVR plus CABG (17 [23%] of 77 patients; risk difference -18·5 [90% CI -27·8 to -9·7]), which was below the 15% prespecified non-inferiority margin (pnon-inferiority<0·001). FFR-guided PCI plus TAVI was superior to SAVR plus CABG (hazard ratio 0·17 [95% CI 0·06-0·51]; psuperiority<0·001), which was driven mainly by all-cause mortality (none [0%] of 91 patients vs seven (10%) of 77 patients; p=0·0025) and life-threatening bleeding (two [2%] vs nine [12%]; p=0·010). INTERPRETATION The TCW trial is the first trial to compare percutaneous treatment versus surgical treatment in patients with severe aortic stenosis and complex coronary artery disease, showing favourable primary endpoint and mortality outcomes with percutaneous treatment. FUNDING Isala Heart Centre and Medtronic.
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Affiliation(s)
- Elvin Kedhi
- Royal Victoria Hospital, McGill University Health Center, Montreal, QC, Canada; Department of Cardiology and Structural Heart Disease, Medical University of Silesia, Katowice, Poland.
| | | | | | - Sandeep K Singh
- Department of Thoracic Surgery, Isala Heart Center, Zwolle, Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - DirkJan van Ginkel
- Department of Cardiology, St Antonius Hospital, Nieuwegein, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Martin Hudec
- Stredoslovenský Ústav Srdcových a Cievnych Chorôb, Banská, Bystrica, Slovakia
| | - Giovanni Amoroso
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Ignacio J Amat-Santos
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Madrid, Spain; Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Rui Campante Teles
- Hospital de Santa Cruz, Carnaxide, Portugal; Comprehensive Health Research Center, Nova Medical School, Lisbon, Portugal
| | - Guillaume Bonnet
- Hôpital haut Lévêque, Unite Médico Chirurgicale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Eric Van Belle
- Department of Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases and Institut Coeur Poumon, Centre Hospitalier Universitaire Lille, Lille, France; INSERM U1011, Lille, France; Université de Lille, Lille, France
| | - Lenard Conradi
- Klinik und Poliklinik für Herz- und Gefäßchirurgie, Universitäres Herz- und Gefäßzentrum Hamburg, Hamburg, Germany
| | - Leen van Garsse
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Wojtek Wojakowski
- Department of Cardiology and Structural Heart Disease, Medical University of Silesia, Katowice, Poland
| | - Vassilis Voudris
- Interventional Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Jerzy Sacha
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland; Faculty of Physical Education and Physiotherapy, Opole University of Technology, Opole, Poland
| | - Pavel Cervinka
- 1st Department Medicine-Cardioangiology, Charles University Prague, Medical Faculty and University Hospital Hradec Kralove, Prague, Czech Republic; University of Jan Evangelista Purkyne, Usti nad Labem, Czech Republic
| | - Erik Lipsic
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Samer Somi
- Department of Cardiology, Haga Hospital, The Hague, Netherlands
| | | | | | - Kerstin Piayda
- Department of Cardiology and Vascular Medicine, Medical Faculty, Justus-Liebig-University Giessen, Giessen, Germany
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera Universitaria Policlinico Gaetano Martino, University of Messina, Messina, Italy; Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, Milan, Italy
| | | | - Krzysztof P Malinowski
- Center for Digital Medicine and Robotics, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland; Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Thomas Modine
- Hôpital haut Lévêque, Unite Médico Chirurgicale, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
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Mohammadi NSH, Tavakoli K, Taebi M, Zafari A, Riahi M, Molaei MM, Farooqi MA, Khanipour R, Karvane HB, Shahrzad S, Vaseghi M, Lakkirrddy GR, Mattumpuram J, Tzeis S, Jenab Y, Hosseini K. Comparative Prognostic Value of Risk Factors for Predicting Pacemaker Implantation After Transcatheter Aortic Valve Replacement: A Systematic Review and Network Meta-Analysis. Am J Cardiol 2025:S0002-9149(25)00296-6. [PMID: 40348046 DOI: 10.1016/j.amjcard.2025.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2025] [Revised: 04/29/2025] [Accepted: 05/03/2025] [Indexed: 05/14/2025]
Abstract
This study compares the prognostic value of risk factors for Permanent pacemaker implantation (PPI) following transcatheter aortic valve replacement (TAVR). PubMed, Embase, Scopus, and Cochrane Library databases were searched until November 2024 for studies reporting PPI incidence within 30 days post-TAVR. A random-effect model was used to pool risk ratios (RR) and standardized mean differences (SDM) for binary and continuous risk factors. Network meta-analysis estimated pooled risk differences (ΔRR) for binary predictors with male sex as the reference. Significant predictors were ranked based on their surface under the cumulative ranking curve (SUCRA) values. A total of 108 studies comprising 77,538 patients (14,560 requiring PPI) were included. Male sex (RR: 1.13), baseline atrial fibrillation (AF) (RR: 1.12), 2nd degree Mobitz I (RR: 5.16) and Mobitz II (RR: 2.30) atrioventricular blocks (AVB), 3rd degree AVB (RR: 13.46), left anterior (LAHB) (RR: 1.79) and posterior hemiblocks (LPHB) (RR: 2.57), bifascicular block (RR: 2.34), right bundle branch block (RBBB) (RR: 3.20) and intraprocedural AVB (RR: 4.15) were identified as predictors for PPI post-TAVR. The risk of PPI was higher with self-expandable valves (RR: 1.79), subclavian access (RR: 1.75), and 29 mm prostheses (RR: 1.33) compared to balloon-expandable valves, transfemoral access, and 23 mm prostheses. Network meta-analysis ranked 3rd degree AVB (SUCRA <0.01), Mobitz I AVB (SUCRA: 0.14), Mobitz II AVB (SUCRA: 0.33), intraprocedural AVB (SUCRA: 0.42), bifascicular block (SUCRA: 0.48), RBBB (SUCRA: 0.49) and LPHB (SUCRA: 0.54) as major predictors of PPI in descending order of significance. In conclusion, clinicians should closely monitor conduction abnormalities as key predictors of PPI following TAVR. Additionally, other risk factors such as subclavian access, self-expanding implantation, AF, large prosthesis diameter, and male sex should not be overlooked.
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Affiliation(s)
- Negin Sadat Hosseini Mohammadi
- Tehran Heart Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kiarash Tavakoli
- Tehran Heart Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Morvarid Taebi
- Tehran Heart Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Zafari
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mobina Riahi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - Ramtin Khanipour
- Department of Internal Medicine, HCA Florida Bayonet Point Hospital - University of South Florida
| | - Houshang Bavandpour Karvane
- Tehran Heart Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Soraya Shahrzad
- Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Marmar Vaseghi
- Division of Cardiology, Department of Medicine, UCLA Cardiac Arrhythmia Center, University of California, Los Angeles, CA, USA
| | | | - Jishanth Mattumpuram
- Division of Cardiology, University of Louisville School of Medicine, Louisville, KY, USA
| | - Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, Hygeia Group, Athens, Greece
| | - Yaser Jenab
- Tehran Heart Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Cardiovascular Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
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Jabri A, Ayyad M, Albandak M, Al-Abdouh A, Madanat L, Khalefa BB, Alhuneafat L, Ayyad A, Lemor A, Mhanna M, Al Jebaje Z, Fadel R, Gonzalez PE, O'Neill B, Bagur R, Hanson ID, Abbas AE, Frisoli T, Lee J, Wang DD, Aggarwal V, Alaswad K, O'Neill WW, Aronow HD, AlQarqaz M, Villablanca P. Outcomes following TAVR in patients with cardiogenic shock: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2025; 74:8-13. [PMID: 39209579 DOI: 10.1016/j.carrev.2024.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 07/25/2024] [Accepted: 08/12/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND While transcatheter aortic valve replacement (TAVR) has broadened treatment options for critically ill patients, outcomes among those with concomitant cardiogenic shock (CS) are not well-explored. METHODS We conducted a comprehensive search of major databases for studies comparing outcomes following TAVR in patients with and without CS since inception up to October 31, 2023. Our meta-analysis included five non-randomized observational. Dichotomous outcomes were assessed using the Mantel-Haenszel method (risk ratio, 95 % CI), and continuous outcomes were evaluated using mean difference and 95 % CI with the inverse variance method. Statistical heterogeneity was determined using the inconsistency test (I2). RESULTS Among 26,283 patients across five studies, 30-day mortality was higher in the CS group (7267 patients; 27.6 %) compared to those without CS (OR 3.41, 95 % CI [2.01, 5.76], p < 0.01), as well as 30-day major vascular complications (OR 1.72, 95 % CI [1.54, 1.92], p < 0.01). At 1-year follow-up, there was no statistically significant difference in mortality rates between the compared groups (OR 2.68, 95 % CI [0.53, 13.46], p = 0.12). No significant between-group differences were observed in the likelihood of 30-day aortic valve reintervention (OR 3.20, 95 % CI [0.63, 16.22], p = 0.09) or post-TAVR aortic insufficiency (OR 0.91, 95 % CI [0.33, 2.51], p = 0.73). Furthermore, 30-day stroke, pacemaker implantation, and in-hospital major bleeding were comparable between both cohorts. CONCLUSION Among patients undergoing TAVR, short-term mortality is higher but one-year outcomes are similar when comparing those with, to those without, CS. Future studies should examine whether TAVR outcomes are improved when the procedure is delayed to optimize CS and when delay is not possible, whether particular management strategies lead to more favorable periprocedural outcomes.
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Affiliation(s)
- Ahmad Jabri
- Department of Cardiovascular Medicine, William Beaumont University Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Mohammed Ayyad
- Department of Internal Medicine, Rutgers New Jersey Medical school, Newark, NJ, USA
| | - Maram Albandak
- Division of Hospital Medicine, University of Kentucky, Lexington, KY, USA
| | - Ahmad Al-Abdouh
- Division of Hospital Medicine, University of Kentucky, Lexington, KY, USA
| | - Luai Madanat
- Department of Cardiovascular Medicine, William Beaumont University Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | | | - Laith Alhuneafat
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Asem Ayyad
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA
| | - Alejandro Lemor
- Division of Cardiovascular Disease, Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mohammed Mhanna
- Division of Cardiovascular Medicine, University of Iowa, IA, USA
| | - Zaid Al Jebaje
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA
| | - Raef Fadel
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA
| | - Pedro Engel Gonzalez
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA
| | - Brian O'Neill
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA
| | - Rodrigo Bagur
- Division of Cardiology, Department of Medicine, London Health Sciences Centre, Western University, Canada Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ivan D Hanson
- Department of Cardiovascular Medicine, William Beaumont University Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Amr E Abbas
- Department of Cardiovascular Medicine, William Beaumont University Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Tiberio Frisoli
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA
| | - James Lee
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA
| | - Dee Dee Wang
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA
| | - Vikas Aggarwal
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA
| | - Khaldoon Alaswad
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA
| | - William W O'Neill
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA
| | - Herbert D Aronow
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA
| | - Mohammad AlQarqaz
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA
| | - Pedro Villablanca
- Division of Cardiovascular Medicine, Henry Ford Hospital, Michigan State University, College of Human Medicine, Detroit, MI, USA.
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Amani-Beni R, Darouei B, Rabiee Rad M, Ghasempour Dabaghi G, Eshraghi R, Bahrami A, Amini-Salehi E, Hashemi SM, Mazaheri-Tehrani S, Movahed MR. Perioperative Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement with Concomitant Mitral Regurgitation: A Meta-Analysis. Cardiol Rev 2025:00045415-990000000-00476. [PMID: 40262017 DOI: 10.1097/crd.0000000000000919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/24/2025]
Abstract
Transcatheter aortic valve replacement (TAVR) is widely performed in high-risk patients with severe aortic stenosis. However, the effects of baseline concomitant mitral regurgitation (MR) on perioperative outcomes remain unclear. This study evaluated the impact of concomitant MR severity on short-term TAVR outcomes. A systematic search of 6 electronic databases was conducted. Studies that stratified patients based on MR severity (MR ≥2 vs. <2 or MR ≥3 vs. <3) and reported perioperative outcomes, including short-term mortality, in-hospital mortality, acute kidney injury (AKI), pacemaker implantation, bleeding, vascular complications, and MR improvement (up to 1 week and 1 month) were eligible. Data from 26 studies (32,453 patients) demonstrated that patients with baseline moderate-to-severe MR (MR ≥2) had a 49% (95% confidence interval (CI), 1.32-1.70) increased risk of short-term mortality, a 41% (95% CI, 1.22-1.63) higher risk of in-hospital mortality, and a 38% (95% CI, 1.17-1.62) higher risk of AKI than those with none-to-mild MR (MR<2). Patients with an MR ≥3 had an even greater 72% (95% CI, 1.37-2.16) increase in short-term mortality. No significant differences were observed in pacemaker implantation, bleeding, or vascular complications between groups. Additionally, after TAVR, MR improved in 36% of patients by at least 1 grade within 1 week, increasing to 44% by 1 month. In TAVR patients, MR ≥2 was associated with significantly higher early mortality and AKI risk, underscoring the need for a comprehensive perioperative risk assessment. Future studies should examine the differential impact of functional and degenerative MR.
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Affiliation(s)
- Reza Amani-Beni
- From the Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Bahar Darouei
- From the Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehrdad Rabiee Rad
- From the Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ghazal Ghasempour Dabaghi
- From the Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reza Eshraghi
- Social Determinants of Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ashkan Bahrami
- Student Research Committee, Kashan University of Medical Sciences, Kashan, Iran
| | | | - Seyyed Mohammad Hashemi
- Cardiovascular Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Sadegh Mazaheri-Tehrani
- Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Reza Movahed
- Department of Medicine, University of Arizona College of Medicine, Phoenix; and
- Department of Medicine, University of Arizona Sarver Heart Center, Tucson, AZ
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Lee L, Chan BMW, Spencer M, Leung J, Liew D, Kim H. A Narrative Review of the Evidence for Transcatheter Aortic Valve Implants. J Cardiovasc Dev Dis 2025; 12:113. [PMID: 40278172 PMCID: PMC12027517 DOI: 10.3390/jcdd12040113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2025] [Revised: 03/18/2025] [Accepted: 03/22/2025] [Indexed: 04/26/2025] Open
Abstract
Currently, multiple transcatheter aortic valves exist in clinical use, with varying efficacy and safety rates. This review aims to evaluate the evidence base for current transcatheter valves used in the management of aortic stenosis in Australia to improve informed decision making for both clinicians and patients. The evidence base included published peer-reviewed human studies of aortic valves with approval for use in Australia through the Therapeutic Goods Administration (TGA). Embase was utilised on the 17 September 2024, and one hundred ninety-seven publications met the inclusion criteria, including six from citation searching. The Sapien series led with the largest number of patients reported in the literature (n = 91,614) and publications (n = 147), followed by the CoreValve/Evolut series with 65,459 patients and 125 publications. Evidence for both of these transcatheter aortic valve series were also published in high impact journals, with the greatest H-index journal being The New England Journal of Medicine. In conclusion, the evidence base for the safety and efficacy of the Sapien and CoreValve/Evolut series currently leads in both quantity and quality. This review also summarises the Australian medical device regulatory and funding process in the context of transcatheter aortic valves.
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Affiliation(s)
- Leonard Lee
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD 4215, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2050, Australia
| | - Brendan Min-Wei Chan
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2050, Australia
| | - Melinda Spencer
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD 4215, Australia
| | - Jovi Leung
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
| | - Danny Liew
- Faculty of Health, Medicine and Behavioural Sciences, University of Queensland, Brisbane, QLD 4072, Australia
| | - Hansoo Kim
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD 4215, Australia
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Emami Meybodi M, Bamarinejad A, Bamarinejad F, Abhari AP, Fakhrolmobasheri M, Khosravi Larijani F, Nasiri S, Shafie D. Prognostic Implication of Preprocedural Pulmonary Hypertension in Patients with Severe Aortic Valve Stenosis Undergoing Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-analysis. Cardiol Rev 2025; 33:120-128. [PMID: 38285645 DOI: 10.1097/crd.0000000000000583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
Pulmonary hypertension (PH) is a common comorbidity in patients with aortic stenosis (AS) who are candidates for transcatheter aortic valve implantation (TAVI). Herein, we sought to elucidate the prognostic value of preprocedural PH on the early and late mortality after TAVI. The Cochrane Library, Scopus, PubMed, Web of Science, Embase, and ProQuest were screened using a predefined search query. We considered odds ratios (ORs) as the measure of effect. Meta-regression analysis was applied to investigate the potential impact of baseline characteristics on the outcomes. Egger's and Begg's tests were used to assess the publication bias. Thirty-three studies comprising 34 datasets representing 68,435 patients were included in the analysis. Regardless of the definition and severity of PH, pooled data analysis indicated that preprocedural PH was associated with higher cardiac and overall 30-day [OR, 1.45 (1.15-1.82) and OR, 1.75 (1.42-2.17), respectively], and 1-year mortality [OR, 1.63 (1.35-1.96) and OR, 1.59 (1.38-1.82), respectively]. Meta-regression analysis demonstrated that older age, higher New York Heart Association function class, history of hypertension, diabetes, and lower left ventricular ejection fraction were predictors of higher mortality rate following TAVI. Moreover, we found that preprocedural PH is significantly associated with higher in-hospital mortality and 30-day acute kidney injury. Our results demonstrated that preprocedural PH is associated with higher early and late cardiac and overall mortality following TAVI; however, this finding is limited regarding the considerable inconsistency in the definition of PH and PH severity among studies.
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Affiliation(s)
- Mahmood Emami Meybodi
- From the Department of Cardiology, Afshar Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Atefe Bamarinejad
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fateme Bamarinejad
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir Parsa Abhari
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Fakhrolmobasheri
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Shidrokh Nasiri
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Davood Shafie
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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7
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Hohri Y, Zen K, Kawajiri H, Yashige M, Fujimoto T, Nakamura S, Tani R, Matoba S. A comparative study on iliofemoral artery calcification distribution in alternative TAVR approaches. Indian J Thorac Cardiovasc Surg 2025; 41:272-280. [PMID: 39975870 PMCID: PMC11832847 DOI: 10.1007/s12055-024-01841-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 09/09/2024] [Accepted: 09/10/2024] [Indexed: 02/21/2025] Open
Abstract
Background Alternative access approaches are required for transcatheter aortic valve replacement (TAVR) cases wherein the transfemoral approach is restrictive with severe calcification. We aimed to examine the safety of the external iliac artery (EIA) as an alternative access site by evaluating the calcification distributions from the common iliac artery (CIA) to the common femoral arteries (CFA). Methods We retrospectively enrolled 402 patients who underwent TAVR. Using computed tomography, calcification was visually assessed based on the maximal circumferential involvement, length, and morphology, and its volumes were quantitatively measured using a minimum threshold of 600 Hounsfield units in 804 arteries. Results The calcification volumes were 0.301 (interquartile range, 0.114-0.624) cc in the CIA, 0.0 (0.0-0.041) cc in the EIA, and 0.047 (0.002-0.158) cc in the CFA (p < 0.01). Maximum calcification of >50% of the arterial circumference was observed in only 7.3% of the EIA, compared to 35.2% and 10.8% of the CIA and CFA, respectively. Almost 55% of the EIA had no calcification, compared with only <5% and 22.7% of the CIA and CFA, respectively. In a subgroup analysis of patients on dialysis, the calcification volume was smallest in the EIA at 0.011 (0.0-0.127) cc (p < 0.01). In all, 33.3% of EIAs had no calcification, while 2.0% of CIAs and 19.6% of CFAs were calcification-free. Conclusions Calcification rarely presents qualitatively and quantitatively in the EIA, suggesting that it could be an option for TAVR when the transfemoral access is unsuitable. Graphical Abstract We qualitatively and quantitatively evaluated the distribution of calcification in the iliofemoral arteries of patients who underwent TAVR. The calcification was more rarely present in the EIA than in the CIA or CFA. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-024-01841-3.
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Affiliation(s)
- Yu Hohri
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Irving Medical Center, 707 Fort Washington Avenue, New York, NY 10032 USA
| | - Kan Zen
- Department of Cardiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hidetake Kawajiri
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masaki Yashige
- Department of Cardiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomotaka Fujimoto
- Department of Cardiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shunsuke Nakamura
- Department of Cardiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ryotaro Tani
- Department of Cardiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
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8
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Patel R, Kokori E, Olatunji G, Abraham IC, Akinboade A, Agyemang EA, Babalola A, Aderinto N. Balancing the risks: continuous vs. interrupted anticoagulation during TAVI - what does the evidence say? Thromb J 2025; 23:7. [PMID: 39849548 PMCID: PMC11756126 DOI: 10.1186/s12959-025-00686-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2024] [Accepted: 01/07/2025] [Indexed: 01/25/2025] Open
Abstract
Anticoagulation therapy is a critical component of post-transcatheter aortic valve implantation (TAVI) management, aimed at reducing the risk of thromboembolic events and mortality. This review examines the efficacy of continuous versus interrupted anticoagulation strategies in TAVI patients, focusing on mortality, stroke rates, and composite events. A literature review was conducted, analyzing recent studies that evaluate the impact of different anticoagulation regimens on clinical outcomes in TAVI patients. Key outcomes assessed include all-cause mortality, thromboembolic events, and major cardiovascular complications within 30 days and up to one year post-procedure. The review identifies a trend favoring continuous anticoagulation, particularly with direct-acting oral anticoagulants (DOACs), which was associated with lower mortality rates and reduced stroke incidence in high-risk patients. However, findings were inconsistent across studies, with some reporting no significant differences in outcomes between continuous and interrupted strategies. Additionally, the review highlights the need to balance the benefits of thromboembolic prevention with the increased risk of bleeding and vascular complications associated with continuous therapy. The findings show the importance of individualized anticoagulation strategies tailored to patient risk profiles. Clinicians should weigh the potential benefits of continuous anticoagulation against the risks, particularly in high-risk populations. Ongoing research is essential to refine anticoagulation protocols in TAVI patients, enhancing both safety and efficacy in clinical practice.
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Affiliation(s)
- Ravi Patel
- Methodist Health System Dallas, Dallas, TX, USA
| | - Emmanuel Kokori
- Department of Medicine and Surgery, University of Ilorin, Ilorin, Nigeria
| | - Gbolahan Olatunji
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Adeola Akinboade
- Department of Medicine and Surgery, University of Ilorin, Ilorin, Nigeria
| | | | - Adetola Babalola
- Kornberg School of Dentistry, Temple University, Philadelphia, USA
| | - Nicholas Aderinto
- Department of Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria.
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9
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Campanella C, Voss S, Schreyer J, Puluca N, Amabile A, Wirth F, Krane M, Ruge H. Analysis of Calcium Patterns in the Thoracic Aorta and Clinical Outcomes of TAVR Patients Presenting with Porcelain Aorta. J Clin Med 2025; 14:503. [PMID: 39860509 PMCID: PMC11766034 DOI: 10.3390/jcm14020503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2024] [Revised: 01/10/2025] [Accepted: 01/12/2025] [Indexed: 01/27/2025] Open
Abstract
Background/Objectives: In the presence of porcelain aorta (PA), transcatheter aortic valve replacement (TAVR) has become a class I therapeutic indication for the treatment of severe aortic valve stenosis. To date, few studies have analyzed the clinical outcomes of TAVR in PA patients. We aim to analyze the calcification patterns of the thoracic aorta in PA patients and to evaluate their clinical implications for TAVR procedures. Methods: This study included 161 patients who had PA confirmed through pre-operative CT and underwent TAVR between 11/2014 and 12/2022. The primary outcome was to perform a multi-slice CT (MSCT) analysis assessing the calcification in the proximal, middle, and distal thoracic aortic segments. Each segment was divided into quadrants for scoring calcifications on a scale from 1 (<25%) to 4 (>75%). The cohort was categorized into circular or noncircular calcification group. The secondary clinical outcomes were defined according to VARC-3 criteria. Results: The study cohort included 161 patients (median age, 77.2 years; IQR, 70.1-82.6 years). The median EuroSCORE II and STS predicted risk of mortality were 3.10% [1.80-5.58] and 2.70% [1.70-4.30], respectively. In 75% of patients (n = 121/161), TAVR was performed via transfemoral access. Circular calcifications were found in 8.1% of patients, while noncircular calcifications were present in 91.9%. Significant calcifications were primarily in the right quadrant of the proximal segment (33.54%), superior quadrant of the middle segment (39.75%), and left quadrant of the distal segment (73.29%). The 30-day mortality rate was 3.11% and periprocedural ischemic stroke rate 3.38%. Conclusions: Most TAVR patients with PA exhibited noncircular calcification. The most extensive calcifications were primarily in areas relevant to surgical manipulation. Patients with PA displayed low short-term mortality and relatively few stroke events. In view of these findings, TAVR constitutes a valid treatment option for patients with PA and aortic stenosis.
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Affiliation(s)
- Caterina Campanella
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (C.C.); (S.V.); (J.S.); (N.P.); (A.A.); (F.W.)
| | - Stephanie Voss
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (C.C.); (S.V.); (J.S.); (N.P.); (A.A.); (F.W.)
| | - Julia Schreyer
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (C.C.); (S.V.); (J.S.); (N.P.); (A.A.); (F.W.)
| | - Nazan Puluca
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (C.C.); (S.V.); (J.S.); (N.P.); (A.A.); (F.W.)
| | - Andrea Amabile
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (C.C.); (S.V.); (J.S.); (N.P.); (A.A.); (F.W.)
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15219, USA
| | - Felix Wirth
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (C.C.); (S.V.); (J.S.); (N.P.); (A.A.); (F.W.)
| | - Markus Krane
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (C.C.); (S.V.); (J.S.); (N.P.); (A.A.); (F.W.)
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
- Division of Cardiac Sugery, Department of Surgery, Yale School of Medicine, New Haven, CT 06510, USA
| | - Hendrik Ruge
- Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine & Health, Technical University of Munich, Lazarettstrasse 36, 80636 Munich, Germany; (C.C.); (S.V.); (J.S.); (N.P.); (A.A.); (F.W.)
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10
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Poniedziałek B, Perek B, Proch A, Komosa A, Niedzielski P, Buczkowski P, Jemielity M, Rzymski P. Mineral composition and ratios in aortic valves, serum, and epicardial fat among patients with aortic stenosis undergoing aortic valve replacement. Sci Rep 2025; 15:1233. [PMID: 39775052 PMCID: PMC11707200 DOI: 10.1038/s41598-025-85141-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2024] [Accepted: 01/01/2025] [Indexed: 01/11/2025] Open
Abstract
Aortic stenosis (AS) is a leading cause of surgical intervention in adults with acquired heart disease, driven by an aging population and advancements in diagnostic and treatment approaches. This study aimed to investigate levels of macroelements (Ca, K, Na, Mg, and P) in aortic valve tissues, serum, and epicardial fat in patients undergoing aortic valve replacement due to degenerative disease. Elemental composition was determined using inductively coupled plasma mass spectrometry. Analyses revealed a distinct accumulation of Ca and P in aortic valve tissues, not correlated to and exceeding that in epicardial adipose tissue, suggesting localized mineralization. Significant relationships between serum and aortic valve element concentrations were found, with serum K and Mg levels inversely correlated with Ca and P deposition and Ca/P ratio in the valve, highlighting their potential role as calcification inhibitors. Moreover, serum and valvular Na/K ratios were positively correlated. Furthermore, patient age was associated with increased Ca, Mg, Na, P levels, and Ca/P ratio in valve tissues, reinforcing age as a risk factor for valvular calcification. Creatinine and lipoprotein (a) levels correlated positively with valvular K content and Ca/P ratio, respectively, while high-density lipoprotein cholesterol concentration was positively associated with Ca, Mg, and P content in epicardial fat. Patients with increased transvalvular systolic pressure gradient revealed higher valvular Na content. Future longitudinal research should address mineralization across earlier disease stages, exploring additional trace elements and molecular contributors to advance understanding of calcification mechanisms, ultimately aiding in developing biomarkers or therapeutic strategies for postponing or preventing AS onset.
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Affiliation(s)
- Barbara Poniedziałek
- Department of Environmental Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Bartłomiej Perek
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Aleksandra Proch
- Department of Analytical Chemistry, Adam Mickiewicz University, Poznań, Poland
| | - Anna Komosa
- Department of Hypertensiology, Angiology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Piotr Buczkowski
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marek Jemielity
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Piotr Rzymski
- Department of Environmental Medicine, Poznan University of Medical Sciences, Poznan, Poland.
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11
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Abe T, Nagai T, Yuasa A, Tokuda Y, Ishizaka S, Takenaka S, Mizuguchi Y, Nakao M, Sato T, Temma T, Kamiya K, Anzai T. Usefulness of frailty assessment using the revised Japanese version of the Cardiovascular Health Study on the prediction of clinical outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. Cardiovasc Interv Ther 2025; 40:144-151. [PMID: 39223348 DOI: 10.1007/s12928-024-01043-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
Frailty assessment is essential for deciding the treatment strategy for patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). Recently, the revised Japanese version of the Cardiovascular Health Study (J-CHS) criteria has been proposed for the frailty assessment; however, it is unclear whether the criteria are useful for the risk stratification in these patients. We investigated the impact of frailty assessment using the revised J-CHS criteria on clinical outcomes in patients with AS undergoing TAVR. We examined 205 consecutive severe AS patients who underwent TAVR at two tertiary hospitals from May 2018 to December 2022. Frailty was defined by the revised J-CHS criteria (score ≥ 3) before TAVR. The primary outcome was major adverse cardiac or cerebrovascular events (MACCE). Among the studied patients, the mean age was 84 years and 65% were female. Frailty was present in 51% of patients. During a median follow-up period of 1000 (interquartile range 677-1210) days, MACCE occurred in 22 patients. Frailty was significantly independently associated with higher risks of the MACCE adjusted for confounders related to nutritional status, severity of AS, comorbidities [hazard ratio (HR) 5.09, 95% confidence interval (CI) 1.70-15.23; HR 3.94, 95% CI 1.34-11.55; HR 3.12, 95% CI 1.14-8.53; HR 3.31, 95% CI 1.21-9.02, respectively]. Frailty determined by the revised J-CHS criteria was associated with clinical outcomes, suggesting these criteria would be useful for risk stratification in Japanese patients with AS undergoing TAVR.
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Affiliation(s)
- Takahiro Abe
- Department of Rehabilitation, Hokkaido University Hospital, Sapporo, Japan
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Atsunori Yuasa
- Department of Rehabilitation, Hakodate Municipal Hospital, Hakodate, Japan
| | - Yusuke Tokuda
- Department of Cardiovascular Medicine, Hakodate Municipal Hospital, Hakodate, Japan
| | - Suguru Ishizaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Sakae Takenaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Yoshifumi Mizuguchi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Motoki Nakao
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Takuma Sato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Taro Temma
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Kiwamu Kamiya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
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12
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Patel KP, Rathod KS, Lansky AJ, Prendergast B, Kharbanda RK, Mathur A, Perry R, Baumbach A. Cerebrovascular Events in Patients Undergoing Transcatheter Aortic Valve Replacement: A Review. Stroke 2024; 55:2754-2764. [PMID: 39371005 DOI: 10.1161/strokeaha.124.047149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2024]
Abstract
Cerebrovascular events (CVEs) are a dreaded complication of transcatheter aortic valve replacement (TAVR). They are associated with significant mortality, morbidity, and reduced quality of life and impose a significant burden to health care systems. Although the rates of clinical stroke have reduced since the advent of TAVR, it remains an important complication, particularly as TAVR is increasingly utilized. CVE may occur at the time of the TAVR, as a direct consequence of the procedure, or may occur later, related to thrombosis of the prosthetic valve, atrial fibrillation, and other comorbidities. Imaging of the brain has revealed a high prevalence of subclinical cerebral infarcts (68%-98%) associated with the TAVR procedure. Although their clinical significance has not been fully established, clinically evident CVE ranges between 3% and 5% in patients considered at high operative risk to between 1% and 3% in low operative risk patients. Periprocedural CVEs are largely the result of embolization of the thrombus and tissue derived from the valve, vasculature, or myocardium. Cerebral embolic protection devices have been studied in multiple trials, with some evidence supporting a reduction in new cerebral lesion volume, number, and potentially disabling strokes. However, thus far, there is no robust evidence that they reduce the overall stroke rate. The number and severity of comorbidities, in particular, new-onset atrial fibrillation, are associated with CVEs. Valve thrombosis diagnosed using computed tomography as areas of hypoattenuated leaflet thickening has been identified in 10% to 15% of patients. This is a dynamic process associated with an increase in CVEs, but that resolves with anticoagulation or sometimes without it. Routine use of anticoagulation compared with a single antiplatelet agent is associated with an increased risk of bleeding, without any additional alleviation in risk of thromboembolism. Future studies to improve risk stratification could facilitate the tailoring of preventive therapies to patients at high risk of CVE, who stand to gain the most benefit.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular Science, University College London, UK (K.P.P.)
- Barts Heart Centre, St Bartholomew's Hospital, London, UK (K.P.P., K.S.R., A.M., A.B.)
| | - Krishnaraj S Rathod
- Barts Heart Centre, St Bartholomew's Hospital, London, UK (K.P.P., K.S.R., A.M., A.B.)
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, UK (K.S.R., A.M., A.B.)
| | | | - Bernard Prendergast
- Cleveland Clinic London, UK (B.P., A.B.)
- St Thomas' Hospital, London, UK (B.P.)
| | - Rajesh K Kharbanda
- Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, UK (R.K.K.)
| | - Anthony Mathur
- Barts Heart Centre, St Bartholomew's Hospital, London, UK (K.P.P., K.S.R., A.M., A.B.)
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, UK (K.S.R., A.M., A.B.)
- National Institute of Health and Care Research (NINR) Barts Biomedical Research Centre, Queen Mary University of London, UK (A.M., A.B.)
| | - Richard Perry
- University College London, Queen Square Institute of Neurology and the National Hospital for Neurology & Neurosurgery, UK (R.P.)
| | - Andreas Baumbach
- Barts Heart Centre, St Bartholomew's Hospital, London, UK (K.P.P., K.S.R., A.M., A.B.)
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, UK (K.S.R., A.M., A.B.)
- Cleveland Clinic London, UK (B.P., A.B.)
- National Institute of Health and Care Research (NINR) Barts Biomedical Research Centre, Queen Mary University of London, UK (A.M., A.B.)
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13
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Nerla R, Mikus E, Sanseviero A, Squeri A, Calvi S, Savini C, Sangiorgi D, Castriota F. Zero-Contrast Transcatheter Aortic Valve Implantation vs. Standard Practice: Periprocedural and Long-Term Clinical Outcomes. J Clin Med 2024; 13:5405. [PMID: 39336891 PMCID: PMC11432651 DOI: 10.3390/jcm13185405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 09/01/2024] [Accepted: 09/06/2024] [Indexed: 09/30/2024] Open
Abstract
Background: We aimed to compare the procedural efficacy and long-term clinical results of a totally contrast-free Transcatheter Aortic Valve Implantation (TAVI) procedure (i.e., contrast dye was not used for either the pre-procedural assessment or during the procedure) to those of standard practice in patients with severe renal dysfunction. Methods: All consecutive patients with a glomerular filtration rate (GFR) ≤ 35 mL/min and severe aortic stenosis who were treated with transfemoral TAVI at our Institution were included in the registry. The zero-contrast patients underwent carbon dioxide angiography and a non-contrast CT scan for assessment of vascular access suitability, and aortic annulus sizing was performed by a TEE, and the procedural guidance was fluoroscopic and echocardiographic. Procedural outcomes were evaluated, and clinical long-term follow-up was performed for all included patients. Results: A total of 44 patients (median age, 85 (IQR, 80.75-87.00)) were included in the zero-contrast group (TEE guidance and general anesthesia in 37 (84%) patients), while 63 patients were included in the standard practice arm (82 ± 78 mL of contrast dye used). Procedural success was obtained in 100% of cases. There were no differences in procedural outcomes, including final mean aortic gradients (5.5 (IQR, 5.0-10.0) mmHg in the zero-contrast group vs. 6.0 (IQR, 5.0-10.0) mmHg in the standard practice group) and rate of at least a moderate paravalvular leak (0% vs. 1.6% in the zero-contrast and standard practice groups, respectively; p = 0.31). No differences in AKI during the hospital stay were observed. Over a median follow-up of 3.3 years, there was a significantly lower rate of AKI (1.2% vs. 25.9%, p < 0.001) and rehospitalizations (1.6% vs. 35.5%, p < 0.00) in standard practice group. Conclusions: We showed for the first time the feasibility and efficacy of a totally contrast-free strategy compared to standard practice in TAVI patients with severe renal dysfunction. Besides achieving comparable procedural results, the zero-contrast strategy showed a better long-term clinical outcome in reducing hospital readmissions for kidney function deterioration.
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Affiliation(s)
- Roberto Nerla
- Interventional Cardiology Unit, GVM (Gruppo Villa Maria) Care & Research, Maria Cecilia Hospital, 48033 Cotignola, Italy
| | - Elisa Mikus
- Cardiac Surgery Unit, GVM Care & Research, Maria Cecilia Hospital, 48033 Cotignola, Italy
| | - Angela Sanseviero
- Interventional Cardiology Unit, GVM (Gruppo Villa Maria) Care & Research, Maria Cecilia Hospital, 48033 Cotignola, Italy
| | - Angelo Squeri
- Interventional Cardiology Unit, GVM (Gruppo Villa Maria) Care & Research, Maria Cecilia Hospital, 48033 Cotignola, Italy
| | - Simone Calvi
- Cardiac Surgery Unit, GVM Care & Research, Maria Cecilia Hospital, 48033 Cotignola, Italy
| | - Carlo Savini
- Cardiac Surgery Unit, GVM Care & Research, Maria Cecilia Hospital, 48033 Cotignola, Italy
- Department of Experimental Diagnostic and Surgical Medicine (DIMEC), University of Bologna, 40133 Bologna, Italy
| | - Diego Sangiorgi
- Cardiac Surgery Unit, GVM Care & Research, Maria Cecilia Hospital, 48033 Cotignola, Italy
| | - Fausto Castriota
- Interventional Cardiology Unit, GVM (Gruppo Villa Maria) Care & Research, Maria Cecilia Hospital, 48033 Cotignola, Italy
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14
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Barth S, Ahmed M, Hautmann MB, Reents W, Zacher M, Kerber S, Lüsebrink U, Schmandra TC. Prognostic benefits of early vascular surgical intervention in patients with major peripheral vascular complications following transcatheter aortic valve implantation. Hellenic J Cardiol 2024; 77:1-12. [PMID: 37611868 DOI: 10.1016/j.hjc.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/08/2023] [Accepted: 08/11/2023] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVES This study aimed to analyze the incidence, surgical management of major vascular complications, and outcomes in patients undergoing transfemoral (TF) transcatheter aortic valve replacement (TAVR) at our center after strict selection of the access route, carefully considering all known major predictors. METHODS Data of 494 consecutive patients with pre-interventional multi-slice computed tomography (CT) of the aorta who had undergone TF TAVR from 2009 to 2019 were analyzed. RESULTS In total, 23/494 (4.7%) patients had major vascular and access-related complications of peripheral vessels and/or infrarenal aorta. These included hematomas that met the Valve Academic Research Consortium 3-criteria of major vascular complications (7/494, 1.4%), arterial dissections (3/494, 0.6%), pseudoaneurysm (6/494, 1.2%), thrombus of the external iliac artery leading to acute limb ischemia (1/494, 0.2%), fistula (1/494, 0.2%), and perforation (5/494, 1.0%). In total, 17/23 (73.9%) major vascular complications required immediate endovascular and/or open surgery. In 16/17 (94%) cases, only 1 surgical procedure was performed. The long-term survival of patients with and without major vascular complications of the peripheral vessels was determined after 2 years. CONCLUSIONS Early vascular surgery intervention reversed the mortality disadvantage in patients with major complications of the peripheral vessels after TAVR. This underscores the importance of immediate vascular surgery stand-by as an indispensable requirement.
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Affiliation(s)
- Sebastian Barth
- Cardiovascular Center Bad Neustadt/Saale, Department of Cardiology, Bad Neustadt/Saale, Germany.
| | - Mohammed Ahmed
- Cardiovascular Center Bad Neustadt/Saale, Department of Cardiology, Bad Neustadt/Saale, Germany
| | - Martina B Hautmann
- Cardiovascular Center Bad Neustadt/Saale, Department of Cardiology, Bad Neustadt/Saale, Germany
| | - Wilko Reents
- Cardiovascular Center Bad Neustadt/Saale, Department Cardiac Surgery, Bad Neustadt/Saale, Germany
| | - Michael Zacher
- Department of Medical Documentation, Bad Neustadt/Saale, Germany
| | - Sebastian Kerber
- Cardiovascular Center Bad Neustadt/Saale, Department of Cardiology, Bad Neustadt/Saale, Germany
| | | | - Thomas C Schmandra
- Cardiovascular Center Bad Neustadt/Saale, Department of Vascular Surgery, Bad Neustadt/Saale, Germany
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Arévalos V, Spione F, Vela P, Iacovelli F, Sanchis L, Freixa X, Brugaletta S, Tesorio T, Altisent OAJ, Sabaté M, Regueiro A. [Coronary obstruction following transcatheter aortic valve replacement. Risk evaluation and preventive strategies]. REC: INTERVENTIONAL CARDIOLOGY 2024; 6:117-126. [PMID: 40416347 PMCID: PMC12097366 DOI: 10.24875/recic.m23000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 11/06/2023] [Indexed: 05/27/2025] Open
Abstract
Coronary obstruction (CO) is a rare but potentially fatal complication of transcatheter aortic valve implantation (TAVI). The present article aims to summarize the evidence on CO risk factors and provide an overview of preventive strategies. We performed a comprehensive literature review focused on these items. The analysis included studies addressing patient-specific characteristics, procedural aspects, and the effectiveness of various prevention techniques in mitigating CO risk. Specific risk factors for CO, which can be assessed by evaluating patient characteristics using computed tomography, are described. Procedural factors associated with an increased risk of CO are discussed. Preventive techniques, including the chimney stent and bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA), are also described, highlighting the advantages and disadvantages of each method. The present review also provides an overview of emerging dedicated devices designed to address this complication. In conclusion, identifying patients at risk for CO is crucial for optimizing TAVI outcomes. Comprehensive imaging assessment and appropriate preventive strategies, such as the BASILICA technique, can mitigate the risk of CO and improve patient outcomes. Further research is needed to validate emerging dedicated devices.
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Affiliation(s)
- Víctor Arévalos
- Departamento de Cardiología, Institut Clinic Cardiovascular, Hospital Clinic, Barcelona, EspañaDepartamento de CardiologíaInstitut Clinic CardiovascularHospital ClinicBarcelonaEspaña
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, EspañaInstitut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de BarcelonaBarcelonaEspaña
| | - Francesco Spione
- Interventional Cardiology Service, “Montevergine” Clinic, Mercogliano, ItaliaInterventional Cardiology Service“Montevergine” ClinicMercoglianoItalia
- Department of Advanced Biomedical Sciences – University of Naples “Federico II”, Nápoles, ItaliaDepartment of Advanced Biomedical Sciences – University of Naples “Federico II”Department of Advanced Biomedical Sciences – University of Naples “Federico II”NápolesItalia
| | - Paula Vela
- Departamento de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, EspañaDepartamento de CardiologíaHospital Universitario Puerta de HierroMajadahondaEspaña
| | - Fortunato Iacovelli
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, Bari, ItaliaDivision of University CardiologyCardiothoracic DepartmentPoliclinico University HospitalBariItalia
- Division of Cardiology, “SS. Annunziata” Hospital, Taranto, ItaliaDivision of Cardiology“SS Annunziata” HospitalTarantoItalia
| | - Laura Sanchis
- Departamento de Cardiología, Institut Clinic Cardiovascular, Hospital Clinic, Barcelona, EspañaDepartamento de CardiologíaInstitut Clinic CardiovascularHospital ClinicBarcelonaEspaña
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, EspañaInstitut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de BarcelonaBarcelonaEspaña
| | - Xavier Freixa
- Departamento de Cardiología, Institut Clinic Cardiovascular, Hospital Clinic, Barcelona, EspañaDepartamento de CardiologíaInstitut Clinic CardiovascularHospital ClinicBarcelonaEspaña
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, EspañaInstitut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de BarcelonaBarcelonaEspaña
| | - Salvatore Brugaletta
- Departamento de Cardiología, Institut Clinic Cardiovascular, Hospital Clinic, Barcelona, EspañaDepartamento de CardiologíaInstitut Clinic CardiovascularHospital ClinicBarcelonaEspaña
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, EspañaInstitut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de BarcelonaBarcelonaEspaña
| | - Tullio Tesorio
- Interventional Cardiology Service, “Montevergine” Clinic, Mercogliano, ItaliaInterventional Cardiology Service“Montevergine” ClinicMercoglianoItalia
| | - Omar Abdul-Jawad Altisent
- Departamento de Cardiología, Institut Clinic Cardiovascular, Hospital Clinic, Barcelona, EspañaDepartamento de CardiologíaInstitut Clinic CardiovascularHospital ClinicBarcelonaEspaña
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, EspañaInstitut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de BarcelonaBarcelonaEspaña
| | - Manel Sabaté
- Departamento de Cardiología, Institut Clinic Cardiovascular, Hospital Clinic, Barcelona, EspañaDepartamento de CardiologíaInstitut Clinic CardiovascularHospital ClinicBarcelonaEspaña
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, EspañaInstitut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)Universitat de BarcelonaBarcelonaEspaña
| | - Ander Regueiro
- Departamento de Cardiología, Institut Clinic Cardiovascular, Hospital Clinic, Barcelona, EspañaDepartamento de CardiologíaInstitut Clinic CardiovascularHospital ClinicBarcelonaEspaña
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16
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Hiruma T, Saji M, Izumi Y, Higuchi R, Takamisawa I, Shimizu J, Nanasato M, Shimokawa T, Isobe M. Frailty assessment using photographs in patients undergoing transcatheter aortic valve replacement. J Cardiol 2024; 83:155-162. [PMID: 37517607 DOI: 10.1016/j.jjcc.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/29/2023] [Accepted: 07/18/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND When frailty is considered in patient selection, better outcomes are achieved in transcatheter aortic valve replacement (TAVR) procedures. This study investigated whether patient photographs could be utilized to qualitatively assess patient frailty and independently predict poor outcomes following TAVR. METHODS This study included 1345 patients with severe aortic stenosis who underwent TAVR at the Sakakibara Heart Institute, Japan, between 2013 and 2022. Patient photographs were taken prior to the initial outpatient clinic examination or at discharge in case the patient's first visit was unplanned admission. Frailty was assessed from patient photographs using a four-point photographic frailty scale; 1 (non-frail), 2 (vulnerable), 3 (mild frail), and 4 (frail). Photographic frailty scale of 3 and 4 were defined as high. The primary endpoint was all-cause mortality following TAVR. RESULTS Seven hundred ninety-six patients who had their facial photographs taken within six months before the TAVR procedure were analyzed. Patients with a higher photographic frailty scale belonged to New York Heart Association classes III/IV, and had higher Society of Thoracic Surgeons scores, higher incidence of wheelchair usage, lower hemoglobin, and smaller aortic valve areas. According to the frailty assessment, patients with a higher photographic frailty scale exhibited slower performance in the 5-m walk test, reduced hand grip strength, more severe dementia, had a higher clinical frailty scale, and lower serum albumin level. Multivariable Cox regression analysis revealed that the high photographic frailty scale was independently associated with all-cause mortality (adjusted hazard ratio 1.62, 95 % confidence interval 1.12-2.33, p = 0.010). Kaplan-Meier analysis indicated that patients with high photographic frailty scale had higher all-cause mortality rates compared to those with low scale (log-rank p = 0.011). CONCLUSIONS Patient registration photographs can be used to obtain qualitative assessments of frailty in severe aortic stenosis cases, and such assessments can independently predict poor outcomes following TAVR.
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Affiliation(s)
- Takashi Hiruma
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan; Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan; Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan.
| | - Yuki Izumi
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Ryosuke Higuchi
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Itaru Takamisawa
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Jun Shimizu
- Department of Anesthesia, Sakakibara Heart Institute, Tokyo, Japan
| | - Mamoru Nanasato
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Tomoki Shimokawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
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Datta R, Bharadwaj P, Keshavamurthy G, Guleria VS, Kj R, Abbot AK. Transcatheter aortic valve implantation using coplanar and cuspal overlap techniques in Indian patients. Indian Heart J 2024; 76:36-43. [PMID: 38218314 PMCID: PMC10943560 DOI: 10.1016/j.ihj.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 01/05/2024] [Accepted: 01/07/2024] [Indexed: 01/15/2024] Open
Abstract
INTRODUCTION Transcatheter Aortic Valve Implantation (TAVI) techniques gradually evolved since 2002 and have undergone various refinements. Achieving optimal implantation depth has become crucial for good long term outcome. High implantation decreases the likelihood of conduction disturbances. Conventionally TAVI valve is positioned in a tricusp coplanar (CON) fluoroscopic projection however it does not ensure a optimal implantation. In an attempt to attain higher implantation(3 mm) and decrease rate of permanent pacemaker, cuspal overlap technique (COT) view has been developed. There is scarcity of Indian literature comparing TAVI deployment using coplanar and cuspal overlap techniques. METHODS We included 111 patients who underwent TAVR with a self-expanding Core Valve Evolut R (Medtronic, Minneapolis, Minnesota), between January 2017 to September 2022 at our centre.Transcatheter Heart Valves (THV) were implanted using the traditional coplanar in 55 patients, while in 56 patients valves were implanted using the COT. RESULTS Baseline characteristics including electrocardiographic findings were comparable in both groups. In all patients Evolut R or Evolut PRO valves were used. Procedure was done in conscious sedation in 90.9 % of patients in CON and 96.4 % in COT group. Predilatation and postdilatation was used in 38.8 % vs 33.9 % and 27 % vs 32 % in CON and COT groups respectively. 90 day PPI rate was less in COT group (7.3 % CON vs 3.5 % COP). Majority of patients who received permanent pacemaker implantation (PPI) had baseline ECG abnormality (RBBB in 50 %, LBBB in 16 %, Grade 1 AV block 16 %). Mean time of post procedure PPI was 5.6 days in COT group and 7.3 days in CON group. New onset LBBB was also less in COT group (21 % CON vs 12.5 % COT).There were 3.6 % intraprocedural deaths in CON group and 1.8 % in COT group. Depth of deployed valve was 4.8 ± 2.34 mm in COT and 6.6 ± 2.11 mm in CON group. Valve deployment time was more in COT group(10.40 CON vs 14.34 min COT). Average valve recapture rate was 2.58 in COP and 2.11 in CON. Stroke rate was more in COT group(3.6 % CON vs 7.14 % COT). Pericardial effusions were also more in COT group. All cause mortality at 3 months was 10.9 % in CON group and 5.3 % in COT. CONCLUSION In this study we achieved lower rates of PPI and new onset LBBB using COT technique in Indian patients using self-expandable prostheses. However valve deployment time, stroke rate and pericardial effusion were seen more in COT group. All cause mortality was low in cuspal overlap technique.
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Affiliation(s)
- Rajat Datta
- Department of Cardiology, AHRR, Delhi, India.
| | | | | | | | - Ratheesh Kj
- Department of Cardiology, AHRR, Delhi, India.
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18
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Carande EJ, Salim TS, Chase A, Sekar B, Aldalati O, Hailan A, Khurana A, Smith D, Obaid DR. Computed tomography defined femoral artery plaque composition predicts vascular complications during transcatheter aortic valve implantation. Br J Radiol 2023; 96:20230296. [PMID: 37747290 PMCID: PMC10646661 DOI: 10.1259/bjr.20230296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/16/2023] [Accepted: 07/25/2023] [Indexed: 09/26/2023] Open
Abstract
OBJECTIVE Vascular and bleeding complications after transcatheter aortic valve implantation (TAVI) are common and lead to increased morbidity and mortality. Analysis of plaque at the arterial access site may improve prediction of complications. METHODS We investigated the association between demographic and procedural risk factors for Valve Academic Research Consortium (VARC-3) vascular complications in patients undergoing transfemoral TAVI with use of a vascular closure device (ProGlide® or MANTA®) in this retrospective cohort study. The ability of pre-procedure femoral CT angiography to predict complications was investigated including a novel method of quantifying plaque composition of the common femoral artery using plaque maps created with patient specific X-ray attenuation cut-offs. RESULTS 23 vascular complications occurred in the 299 patients in the study group (7.7%). There were no demographic risk factors associated with vascular complications and no statistical difference between use of closure device (ProGlide® vs MANTA®) and vascular complications. Vascular complications after TAVI were associated with sheath size (OR 1.36, 95% CI 1.08-1.76, P 0.01) and strongly associated with CT-derived necrotic core volume in the common femoral artery of the procedural side (OR 17.49, 95% CI 1.21-226.60, P 0.03). CONCLUSION Plaque map analysis of the common femoral artery by CT angiography reveals patients with greater necrotic core are at increased risk of VARC-3 vascular complications. ADVANCES IN KNOWLEDGE The novel measurement of necrotic core volume in the common femoral artery on the procedural side by CT analysis was associated with post-TAVI vascular complications, which can be used to highlight increased risk.
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Affiliation(s)
- Elliott J. Carande
- Cwm Taff Morgannwg University Health Board, Princess of Wales Hospital, Coity Road, Bridgend, United Kingdom
| | - Tarik S Salim
- Swansea Bay University Health Board, Morriston Hospital, Swansea, United Kingdom
| | - Alexander Chase
- Swansea Bay University Health Board, Morriston Hospital, Swansea, United Kingdom
| | - Baskar Sekar
- Swansea Bay University Health Board, Morriston Hospital, Swansea, United Kingdom
| | - Omar Aldalati
- Swansea Bay University Health Board, Morriston Hospital, Swansea, United Kingdom
| | - Ahmed Hailan
- Swansea Bay University Health Board, Morriston Hospital, Swansea, United Kingdom
| | - Ayush Khurana
- Swansea Bay University Health Board, Morriston Hospital, Swansea, United Kingdom
| | - Dave Smith
- Swansea Bay University Health Board, Morriston Hospital, Swansea, United Kingdom
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Alwan L, Ruge H, Krane M, Prinzing A, Noebauer C, Lange R, Erlebach M. Incidence of Prosthesis-Patient Mismatch in Valve-in-Valve with a Supra-Annular Valve. Thorac Cardiovasc Surg 2023; 71:632-640. [PMID: 35255516 DOI: 10.1055/s-0042-1742755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) for a degenerated surgical bioprosthesis (valve-in-valve [ViV]) has become an established procedure. Elevated gradients and patient-prosthesis mismatch (PPM) have previously been reported in mixed TAVR cohorts. We analyzed our single-center experience using the third-generation self-expanding Medtronic Evolut R prosthesis, with an emphasis on the incidence and outcomes of PPM. METHODS This is a retrospective analysis of prospectively collected data from our TAVR database. Intraprocedural and intrahospital outcomes are reported. RESULTS Eighty-six patients underwent ViV-TAVR with the Evolut R prosthesis. Mean age was 75.5 ± 9.5 years, 64% were males. The mean log EuroScore was 21.6 ± 15.7%. The mean time between initial surgical valve implantation and ViV-TAVR was 8.8 ± 3.2 years. The mean true internal diameter of the implanted surgical valves was 20.9 ± 2.2 mm. Post-AVR, 60% had no PPM, 34% had moderate PPM, and 6% had severe PPM. After ViV-TAVR, 33% had no PPM, 29% had moderate, and 39% had severe PPM. After implantation, the mean transvalvular gradient was reduced significantly from 36.4 ± 15.2 to 15.5 ± 9.1 mm Hg (p < 0.001). No patient had more than mild aortic regurgitation after ViV-TAVR. No conversion to surgery was necessary. Estimated Kaplan-Meier survival at 1 year for all patients was 87.4%. One-year survival showed no significant difference according to post-ViV PPM groups (p = 0.356). CONCLUSION ViV-TAVR using a supra-annular valve resulted in low procedural and in-hospital complication rates. However, moderate or severe PPM was common, with no influence on short-term survival. PPM may not be a suitable factor to predict survival after ViV-TAVR.
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Affiliation(s)
- Louhai Alwan
- Department of Cardiovascular Surgery, German Heart Centre Munich, Munchen, Germany
| | - Hendrik Ruge
- Department of Cardiovascular Surgery, German Heart Centre Munich, Munchen, Germany
| | - Markus Krane
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, United States
| | - Anatol Prinzing
- Department of Cardiovascular Surgery, German Heart Centre Munich, Munchen, Germany
| | - Christian Noebauer
- Department of Cardiovascular Surgery, German Heart Centre Munich, Munchen, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Centre Munich, Munchen, Germany
| | - Magdalena Erlebach
- Department of Cardiovascular Surgery, German Heart Centre Munich, Munchen, Germany
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20
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Cafaro A, Spione F, Burattini O, De Feo D, Xhelo A, Palmitessa C, D’Alessandro M, Amendola VP, Rimmaudo F, Guaricci AI, Bortone AS, Pestrichella V, Contegiacomo G, Tesorio T, Colonna G, Iacovelli F. Fluoroscopy Time as a New Predictor of Short-Term Outcomes after Transcatheter Aortic Valve Replacement. J Cardiovasc Dev Dis 2023; 10:459. [PMID: 37998517 PMCID: PMC10671838 DOI: 10.3390/jcdd10110459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is an almost totally cine-fluoroscopic guided procedure. The amount of radiation used during the procedure is strictly related to the fluoroscopy time (FT), that has already been demonstrated to be associated with outcomes and complexity of coronary procedures. The aim of our study is to demonstrate the relationship between FT and the short-term outcomes after TAVR defined by to the Valve Academic Research Consortium (VARC)-2 and -3 consensus documents. METHODS After splitting 1797 consecutive patients into tertiles of FT, the composite endpoint early safety (ES) was adjudicated according to VARC-2 and VARC-3 definitions, whereas the composite endpoints device success (DS) and technical success (TS) according to VARC-3 criteria. RESULTS The absence of all these outcomes (VARC-2 ES amd VARC-3 TS, DS, and ES) was significantly associated with longer FT: this association was independent from both intraprocedural complications and other intraprocedural factors linked to longer FT, and still persisted after propensity score matching analysis. Notwithstanding, after receiver operating characteristic analysis, FT had adequate diagnostic accuracy in identifying the absence of only VARC-3 TS and VARC-2 ES. CONCLUSION Longer FT is related with periprocedural and short-term outcomes after the procedure, especially in those that are more challenging. A FT duration of more than 30 min has an adequate accuracy in identifying VARC-3 technical failure (TS and DS) and absence of VARC-2 ES, selecting patients who are likely to take advantage from more careful in-hospital follow-up.
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Affiliation(s)
| | - Francesco Spione
- Interventional Cardiology Service, “Montevergine” Clinic, GVM Care & Research, 83013 Mercogliano, Italy; (F.S.); (T.T.)
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Osvaldo Burattini
- Division of Cardiology, “SS. Annunziata” Hospital, 74121 Taranto, Italy; (O.B.); (F.I.)
| | - Daniele De Feo
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, 70124 Bari, Italy; (D.D.F.); (A.X.); (C.P.); (M.D.); (V.P.A.); (A.I.G.)
| | - Alessandro Xhelo
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, 70124 Bari, Italy; (D.D.F.); (A.X.); (C.P.); (M.D.); (V.P.A.); (A.I.G.)
| | - Chiara Palmitessa
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, 70124 Bari, Italy; (D.D.F.); (A.X.); (C.P.); (M.D.); (V.P.A.); (A.I.G.)
| | - Maurizio D’Alessandro
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, 70124 Bari, Italy; (D.D.F.); (A.X.); (C.P.); (M.D.); (V.P.A.); (A.I.G.)
| | - Vincenzo Pio Amendola
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, 70124 Bari, Italy; (D.D.F.); (A.X.); (C.P.); (M.D.); (V.P.A.); (A.I.G.)
| | - Flavio Rimmaudo
- Division of Cardiology, “Vittorio Emanuele” Hospital, 93012 Gela, Italy;
| | - Andrea Igoren Guaricci
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, 70124 Bari, Italy; (D.D.F.); (A.X.); (C.P.); (M.D.); (V.P.A.); (A.I.G.)
| | - Alessandro Santo Bortone
- Division of University Heart Surgery, Cardiothoracic Department, Policlinico University Hospital, 70124 Bari, Italy;
| | | | - Gaetano Contegiacomo
- Interventional Cardiology Service, “Anthea” Clinic, GVM Care & Research, 70124 Bari, Italy;
| | - Tullio Tesorio
- Interventional Cardiology Service, “Montevergine” Clinic, GVM Care & Research, 83013 Mercogliano, Italy; (F.S.); (T.T.)
| | - Giuseppe Colonna
- Division of Cardiology, “V. Fazzi” Hospital, 73100 Lecce, Italy;
| | - Fortunato Iacovelli
- Division of Cardiology, “SS. Annunziata” Hospital, 74121 Taranto, Italy; (O.B.); (F.I.)
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, 70124 Bari, Italy; (D.D.F.); (A.X.); (C.P.); (M.D.); (V.P.A.); (A.I.G.)
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Pampori A, Shekhar S, Kapadia SR. Implications of Renal Disease in Patients Undergoing Structural Interventions. Interv Cardiol Clin 2023; 12:539-554. [PMID: 37673498 DOI: 10.1016/j.iccl.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Percutaneous structural interventions have a major impact on the morbidity, mortality, and quality of life of patients by providing a lower-risk alternative to cardiac surgery. However, renal disease has a significant impact on outcomes of these interventions. This review explores the incidence, outcomes, pathophysiology, and preventative measures of acute kidney injury and chronic kidney disease on transcatheter aortic valve replacement, transcatheter mitral valve repair, and percutaneous balloon mitral valvuloplasty. Given the expanding indications for percutaneous structural interventions, further research is needed to identify ideal patients with chronic kidney disease or end-stage renal disease who would benefit from intervention.
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Affiliation(s)
- Adam Pampori
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, J2-3, Cleveland, OH 44195, USA
| | - Shashank Shekhar
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, J2-3, Cleveland, OH 44195, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, J2-3, Cleveland, OH 44195, USA.
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22
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Faridi KF, Strom JB, Kundi H, Butala NM, Curtis JP, Gao Q, Song Y, Zheng L, Tamez H, Shen C, Secemsky EA, Yeh RW. Association Between Claims-Defined Frailty and Outcomes Following 30 Versus 12 Months of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention: Findings From the EXTEND-DAPT Study. J Am Heart Assoc 2023; 12:e029588. [PMID: 37449567 PMCID: PMC10382113 DOI: 10.1161/jaha.123.029588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/31/2023] [Indexed: 07/18/2023]
Abstract
Background Frailty is rarely assessed in clinical trials of patients who receive dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. This study investigated whether frailty defined using claims data is associated with outcomes following percutaneous coronary intervention, and if there is a differential association in patients receiving standard versus extended duration DAPT. Methods and Results Patients ≥65 years of age in the DAPT (Dual Antiplatelet Therapy) Study, a randomized trial comparing 30 versus 12 months of DAPT following percutaneous coronary intervention, had data linked to Medicare claims (n=1326), and a previously validated claims-based index was used to define frailty. Net adverse clinical events, a composite of all-cause mortality, myocardial infarction, stroke, and major bleeding, were compared between frail and nonfrail patients. Patients defined as frail using claims data (12.0% of the cohort) had higher incidence of net adverse clinical events (23.1%) compared with nonfrail patients (10.7%; P<0.001) at 18-month follow-up and increased risk after multivariable adjustment (adjusted hazard ratio [HR], 2.24 [95% CI, 1.38-3.63]). There were no differences in effects of extended duration DAPT on net adverse clinical events for frail (HR, 1.42 [95% CI, 0.73-2.75]) and nonfrail patients (HR, 1.18 [95% CI, 0.83-1.68]; interaction P=0.61), although analyses were underpowered. Bleeding was highest among frail patients who received extended duration DAPT. Conclusions Among older patients in the DAPT Study, claims-defined frailty was associated with higher net adverse clinical events. Effects of extended duration DAPT were not different for frail patients, although comparisons were underpowered. Further investigation of how frailty influences ischemic and bleeding risks with DAPT are warranted. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00977938.
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Affiliation(s)
- Kamil F. Faridi
- Section of Cardiovascular Medicine, Department of MedicineYale School of MedicineNew HavenCTUSA
| | - Jordan B. Strom
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMAUSA
| | - Harun Kundi
- Department of CardiologyAnkara City HospitalAnkaraTurkey
| | - Neel M. Butala
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMAUSA
- Cardiology Division, Department of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMAUSA
| | - Jeptha P. Curtis
- Section of Cardiovascular Medicine, Department of MedicineYale School of MedicineNew HavenCTUSA
| | - Qi Gao
- Baim Institute for Clinical ResearchBostonMAUSA
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMAUSA
| | - Luke Zheng
- Baim Institute for Clinical ResearchBostonMAUSA
| | - Hector Tamez
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMAUSA
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMAUSA
- BiogenCambridgeMAUSA
| | - Eric A. Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMAUSA
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMAUSA
- Baim Institute for Clinical ResearchBostonMAUSA
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Conzelmann L, Grotherr P, Dapeng L, Würth A, Widder J, Jacobshagen C, Mehlhorn U. Valve-Related Complications in TAVI Leading to Emergent Cardiac Surgery. Thorac Cardiovasc Surg 2023; 71:107-117. [PMID: 36446625 DOI: 10.1055/s-0042-1758073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is now a standard procedure for the treatment of symptomatic aortic valve stenosis in many patients. In Germany, according to the annual reports from the German Institute for Quality Assurance and Transparency in Healthcare (Institut für Qualitätssicherung und Transparenz im Gesundheitswesen), the rate of serious intraprocedural complications, such as valve malpositioning or embolization, coronary obstruction, aortic dissection, annular rupture, pericardial tamponade, or severe aortic regurgitation requiring emergency cardiac surgery has decreased markedly in recent years from more than 5.5% in 2012 to 2.0% in 2019. However, with increased use, the total number of adverse events remains about 500 per year, about 100 of which require conversion to sternotomy. These, sometimes, fatal events can occur at any time and are still challenging. Therefore, the interdisciplinary TAVI heart team should be prepared and aware of possible rescue strategies.
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Affiliation(s)
- Lars Conzelmann
- Department of Cardiac Surgery, HELIOS Clinic for Cardiac Surgery Karlsruhe, Karlsruhe, Germany
| | - Philipp Grotherr
- Department of Cardiology, Medical Clinic IV, Municipal Hospital Karlsruhe, Karlsruhe, Germany
| | - Lu Dapeng
- Department of Cardiology, Intensive Care Medicine and Angiology, Vincentius-Diakonissen Hospital Karlsruhe, Karlsruhe, Germany
| | - Alexander Würth
- Department of Cardiology, Medical Clinic IV, Municipal Hospital Karlsruhe, Karlsruhe, Germany
| | - Julian Widder
- Department of Cardiology, Medical Clinic IV, Municipal Hospital Karlsruhe, Karlsruhe, Germany
| | - Claudius Jacobshagen
- Department of Cardiology, Intensive Care Medicine and Angiology, Vincentius-Diakonissen Hospital Karlsruhe, Karlsruhe, Germany
| | - Uwe Mehlhorn
- Department of Cardiac Surgery, HELIOS Clinic for Cardiac Surgery Karlsruhe, Karlsruhe, Germany
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24
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Iatrogenic Strokes and Covert Brain Infarcts After Percutaneous Cardiac Procedures: An Update. Can J Cardiol 2023; 39:200-209. [PMID: 36435326 DOI: 10.1016/j.cjca.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
Millions of cardiac procedures are performed worldwide each year, making the potential complication of periprocedural iatrogenic stroke an important concern. These strokes can occur intraoperatively or within 30 days of a procedure and can be categorised as either overt or covert, occurring without obvious acute neurologic symptoms. Understanding the prevalence, risk factors, and strategies for preventing overt and covert strokes associated with cardiac procedures is imperative for reducing periprocedural morbidity and mortality. In this narrative review, we focus on the impacts of perioperative ischemic strokes for several of the most common interventional cardiac procedures, their relevance from a neurologic standpoint, and future directions for the care and research on perioperative strokes. Depending on the percutaneous procedure, the rates of periprocedural overt strokes can range from as little as 0.01% to as high as 2.9%. Meanwhile, covert brain infarctions (CBIs) occur much more frequently, with rates for different procedures ranging from 10%-84%. Risk factors include previous stroke, atherosclerotic disease, carotid stenosis, female sex, and African race, as well as other patient- and procedure-level factors. While the impact of covert brain infarctions is still a developing field, overt strokes for cardiac procedures lead to longer stays in hospital and increased costs. Potential preventative measures include screening and vascular risk factor control, premedicating, and procedural considerations such as the use of cerebral embolic protection devices. In addition, emerging treatments from the neurologic field, including neuroprotective drugs and remote ischemic conditioning, present promising avenues for preventing these strokes and merit investigation in cardiac procedures.
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25
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Solla-Suárez P, Avanzas P, Fernández-Fernández M, Pascual I, Moreno-Planillo C, Almendárez M, López-Álvarez E, Álvarez R, Coto-Montes A, Morís C, Gutiérrez-Rodríguez J. Functional continuum: independent predictor of one-year mortality and key decision-making element in older adults with severe aortic stenosis amenable to aortic valve replacement. Aging Clin Exp Res 2023; 35:323-331. [PMID: 36417136 DOI: 10.1007/s40520-022-02300-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/02/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The impact of functional capacity over the entire functional continuum in older adults undergoing aortic valve replacement (AVR) has not been studied to date. This study aims to analyze 1.- the distribution of a cohort of older adults presenting severe aortic stenosis (AS) amenable to AVR in the different categories of the Functional Continuum Scale (FCS); 2.- its association with decision-making regarding valve disease; and 3.- its impact upon the one-year mortality rate of surgical (SAVR), transcatheter (TAVR) aortic valve replacement, or the decision to provide conservative management (OMT). METHODS This prospective study included patients from the FRESAS (FRailty-Evaluation-in-Severe-Aortic-Stenosis) registry evaluated by the reference Heart-Team of a region in northern Spain. All the patients underwent comprehensive geriatric assessment. RESULTS The study comprised 257 patients aged 84.0 ± 3.9 years. MANAGEMENT SAVR: 25.3%, TAVR: 58.0% and OMT: 16.7%. Increased patient functional capacity was associated with an increased tendency to perform more invasive valve disease treatment. The overall one-year survival rate was 81.3%. One-year all-cause mortality: FCS-1 to FCS-2 "robust" 11.5%, FCS-3 to FCS-4 "prefrail" 14.7%, FCS-5 "frail" 19.2% and FCS-6 to FCS-8 "dependent" 45.0%; p < 0.001. Adjusted mortality analysis: FCS with HR = 1.206 [95%CI, 0.999-1.451 (p = 0.051)]; EuroSCORE-II with HR = 1.071 [95%CI, 1.006-1.161 (p = 0.033)]; and OMT with HR = 2.840 [95%CI, 1.409-5.772 (p = 0.004)] were retained in the final multivariable logistic regression model. CONCLUSIONS In older AS patients amenable to AVR, the FCS is a useful predictive tool that may aid clinical decision-making.
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Affiliation(s)
- Pablo Solla-Suárez
- Geriatrics Department, Geriatrics Clinical Management Area, Hospital Monte Naranco, HMN, Oviedo, Spain. .,Health Research Institute of Asturias, ISPA, Oviedo, Spain.
| | - Pablo Avanzas
- Cardiology Department, Cardiac Area, Hospital Universitario Central de Asturias, HUCA, Oviedo, Spain.,Health Research Institute of Asturias, ISPA, Oviedo, Spain.,University of Oviedo, UOV, Oviedo, Spain
| | - Marta Fernández-Fernández
- Geriatrics Department, Geriatrics Clinical Management Area, Hospital Monte Naranco, HMN, Oviedo, Spain
| | - Isaac Pascual
- Cardiology Department, Cardiac Area, Hospital Universitario Central de Asturias, HUCA, Oviedo, Spain.,Health Research Institute of Asturias, ISPA, Oviedo, Spain.,University of Oviedo, UOV, Oviedo, Spain
| | - Carmen Moreno-Planillo
- Geriatrics Department, Geriatrics Clinical Management Area, Hospital Monte Naranco, HMN, Oviedo, Spain
| | - Marcel Almendárez
- Cardiology Department, Cardiac Area, Hospital Universitario Central de Asturias, HUCA, Oviedo, Spain.,Health Research Institute of Asturias, ISPA, Oviedo, Spain
| | - Eva López-Álvarez
- Geriatrics Department, Geriatrics Clinical Management Area, Hospital Monte Naranco, HMN, Oviedo, Spain
| | - Rut Álvarez
- Cardiology Department, Cardiac Area, Hospital Universitario Central de Asturias, HUCA, Oviedo, Spain.,Health Research Institute of Asturias, ISPA, Oviedo, Spain
| | - Ana Coto-Montes
- Health Research Institute of Asturias, ISPA, Oviedo, Spain.,University of Oviedo, UOV, Oviedo, Spain.,Institute of Neurosciences of the Principality of Asturias, INEUROPA, Oviedo, Spain
| | - César Morís
- Cardiology Department, Cardiac Area, Hospital Universitario Central de Asturias, HUCA, Oviedo, Spain.,Health Research Institute of Asturias, ISPA, Oviedo, Spain.,University of Oviedo, UOV, Oviedo, Spain
| | - José Gutiérrez-Rodríguez
- Geriatrics Department, Geriatrics Clinical Management Area, Hospital Monte Naranco, HMN, Oviedo, Spain.,Health Research Institute of Asturias, ISPA, Oviedo, Spain
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26
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Généreux P. Pulmonary Hypertension and Aortic Stenosis. J Am Coll Cardiol 2022; 80:1614-1616. [DOI: 10.1016/j.jacc.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 01/07/2023]
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27
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Boxhammer E, Gharibeh SX, Wernly B, Kelm M, Franz M, Kretzschmar D, Hoppe UC, Lauten A, Lichtenauer M. Conundrum of Classifying Subtypes of Pulmonary Hypertension-Introducing a Novel Approach to Classify "Borderline" Patients in a Population with Severe Aortic Stenosis Undergoing TAVI. J Cardiovasc Dev Dis 2022; 9:294. [PMID: 36135439 PMCID: PMC9505198 DOI: 10.3390/jcdd9090294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/23/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Transcatheter aortic valve implantation (TAVI) is an established therapeutic option in patients with severe aortic valve stenosis (AS) and a high surgical risk profile. Pulmonary hypertension (PH)—often co-existing with severe AS—is associated with a limited factor for prognosis and survival. The purpose of this study was to evaluate the prevalence of PH in patients undergoing TAVI, classify these patients based on right heart catheter (RHC) measurements in different PH subtypes, and analyze prognostic values on survival after TAVI. Methods: 284 patients with severe AS underwent an RHC examination for hemodynamic assessment prior to TAVI and were categorized into subtypes of PH according to the 2015 European Society of Cardiology (ESC) guidelines. TAVI patients were followed-up with for one year with regard to 30-days and 1-year mortality as primary endpoints. Results: 74 of 284 participants showed a diastolic pressure gradient (DPG) < 7 mmHg and a pulmonary vascular resistance (PVR) > 3 Wood units (WU) and could not be formally allocated to either isolated post-capillary PH (ipc-PH) or combined pre- and post-capillary PH (cpc-PH). Therefore, a new subgroup called “borderline post-capillary PH” (borderlinepc-PH) was introduced. Compared with TAVI patients with pre-capillary PH (prec-PH), ipc-PH patients suffering from borderlinepc-PH (HR 7.114; 95% CI 2.015−25.119; p = 0.002) or cpc-PH (HR 56.459; 95% CI 7.738−411.924; p < 0.001) showed a significantly increased 1-year mortality. Conclusions: Postcapillary PH was expanded to include the so-called “borderlinepc-PH” variant in addition to the ipc-PH and cpc-PH subtypes. The one-year survival after TAVI was significantly different between the subgroups, with the worst prognosis for borderlinepc-PH and cpc-PH.
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Affiliation(s)
- Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Sarah X. Gharibeh
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Bernhard Wernly
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, 5110 Oberndorf, Austria
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Düsseldorf, 40225 Düsseldorf, Germany
| | - Marcus Franz
- Universitätsherzzentrum Thüringen, Clinic of Internal Medicine I, Departement of Cardiology, Friedrich Schiller University, 07737 Jena, Germany
| | - Daniel Kretzschmar
- Universitätsherzzentrum Thüringen, Clinic of Internal Medicine I, Departement of Cardiology, Friedrich Schiller University, 07737 Jena, Germany
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Alexander Lauten
- Department of General and Interventional Cardiology and Rhythmology, Helios Clinic, 99084 Erfurt, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Berlin, 10115 Berlin, Germany
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
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28
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Ranka S, Lahan S, Chhatriwalla AK, Allen KB, Chiang M, O'Neill B, Verma S, Wang DD, Lee J, Frisoli T, Eng M, Bagur R, O'Neill W, Villablanca P. Network Meta-Analysis Comparing the Short- and Long-Term Outcomes of Alternative Access for Transcatheter Aortic Valve Replacement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 40:1-10. [PMID: 34972667 PMCID: PMC9066708 DOI: 10.1016/j.carrev.2021.11.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/15/2021] [Accepted: 11/29/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Several studies have pair-wise compared access sites for transcatheter aortic valve replacement (TAVR) but pooled estimate of overall comparative efficacy and safety outcomes are not well known. We sought to compare short- and long-term outcomes following various alternative access routes for TAVR. METHODS Thirty-four studies with a pooled sample size of 32,756 patients were selected by searching PubMed and Cochrane library databases from inception through 11th June 2021 for patients undergoing TAVR via 1 of 6 different access sites: Transfemoral (TF), Transaortic (TAO), Transapical (TA), Transcarotid (TC), Transaxillary/Subclavian (TSA), and Transcaval (TCV). Data were extracted to conduct a frequentist network meta-analysis with a random-effects model using TF access as a reference group. RESULTS Compared with TF, both TAO [RR 1.91, 95% CI (1.46-2.50)] and TA access [RR 2.12, 95% CI (1.84-2.46)] were associated with an increased risk of 30-day mortality. No significant difference was observed for stroke, myocardial infarction, major bleeding, conversion to open surgery, and major adverse cardiovascular or cerebrovascular events at 30 days between different accesses. Major vascular complications were lower in TA [RR 0.43, (95% CI, 0.28-0.67)] and TC [RR 0.51, 95% CI (0.35-0.73)] access compared to TF. The 1-year mortality was higher in TAO [RR of 1.35, (95% CI, 1.01-1.81)] and TA [RR 1.44, (95% CI, 1.14-1.81)] groups. CONCLUSION Non-thoracic alternative access site utilization for TAVR implantation (TC, TSA and TCV) is associated with outcomes similar to conventional TF access. Thoracic TAVR access (TAO and TA) translates into increased short and long-term mortality.
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Affiliation(s)
- Sagar Ranka
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Shubham Lahan
- Division of Cardiovascular Prevention & Wellness, Department of Cardiology, Houston Methodist, Houston, TX, United States
| | - Adnan K Chhatriwalla
- Department of Cardiothoracic Surgery, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, United States
| | - Keith B Allen
- Department of Cardiothoracic Surgery, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, United States
| | - Michael Chiang
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States
| | - Brian O'Neill
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States
| | - Sadhika Verma
- Department of Family Medicine, Henry Ford Allegiance Health, Jackson, MI, United States
| | - Dee Dee Wang
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States
| | - James Lee
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States
| | - Tiberio Frisoli
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States
| | - Marvin Eng
- Department of Cardiology, Banner University Medical Center, Phoenix, AZ, United States
| | - Rodrigo Bagur
- Division of Cardiology, Department of Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - William O'Neill
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States
| | - Pedro Villablanca
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States.
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29
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Tomey MI, Camaj A, Kini AS, Sharma SK. Aortic Valvuloplasty and Large‐Bore Percutaneous Arterial Access. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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30
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Strom JB, Secemsky EA. Seeing the entire elephant: The challenges of frailty assessment for peripheral artery disease. Vasc Med 2022; 27:258-260. [PMID: 35485401 DOI: 10.1177/1358863x221088860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jordan B Strom
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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31
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New Evidence About Aortic Valve Stenosis and Cardiovascular Hemodynamics. High Blood Press Cardiovasc Prev 2022; 29:231-237. [PMID: 35438477 PMCID: PMC9050777 DOI: 10.1007/s40292-022-00520-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 11/27/2022] Open
Abstract
Aortic stenosis (AS) is the most common degenerative valvular disease in western word. In patients with severe AS, small changes in aortic valve area can lead to large changes in hemodynamics. The correct understanding of cardiac hemodynamics and its interaction with vascular function is of paramount importance for correct identification of severe AS and to plan effective strategies for its treatment. In the current review with highlight the importance of pressure recovery phenomenon and valvular arterial impedance as novel tools in the evaluation of patients with aortic stenosis.
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32
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Sá MP, Sun T, Fatehi Hassanabad A, Awad AK, Van den Eynde J, Malin JH, Sicouri S, Torregrossa G, Ruhparwar A, Weymann A, Ramlawi B. Complete transcatheter versus complete surgical treatment in patients with aortic valve stenosis and concomitant coronary artery disease: Study‐level meta‐analysis with reconstructed time‐to‐event data. J Card Surg 2022; 37:2072-2083. [DOI: 10.1111/jocs.16511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/26/2022] [Accepted: 03/05/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
- Department of Cardiothoracic Surgery Research Lankenau Institute for Medical Research Wynnewood Pennsylvania USA
| | - Tian Sun
- Department of Cardiothoracic Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
| | - Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Libin Cardiovascular Institute Cumming School of Medicine, University of Calgary Calgary Alberta Canada
| | - Ahmed K. Awad
- Faculty of Medicine, Ain Shams University Cairo Egypt
| | - Jef Van den Eynde
- Department of Cardiovascular Sciences KU Leuven Leuven Belgium
- Helen B. Taussig Heart Center The Johns Hopkins Hospital and School of Medicine Baltimore Maryland USA
| | - John H. Malin
- Philadelphia College of Osteopathic Medicine Bala Cynwyd Pennsylvania USA
| | - Serge Sicouri
- Department of Cardiothoracic Surgery Research Lankenau Institute for Medical Research Wynnewood Pennsylvania USA
| | - Gianluca Torregrossa
- Department of Cardiothoracic Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
- Department of Cardiothoracic Surgery Research Lankenau Institute for Medical Research Wynnewood Pennsylvania USA
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen University Hospital of Essen, University Duisburg‐Essen Essen Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen University Hospital of Essen, University Duisburg‐Essen Essen Germany
| | - Basel Ramlawi
- Department of Cardiothoracic Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
- Department of Cardiothoracic Surgery Research Lankenau Institute for Medical Research Wynnewood Pennsylvania USA
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33
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Aleksandric S, Banovic M, Beleslin B. Challenges in Diagnosis and Functional Assessment of Coronary Artery Disease in Patients With Severe Aortic Stenosis. Front Cardiovasc Med 2022; 9:849032. [PMID: 35360024 PMCID: PMC8961810 DOI: 10.3389/fcvm.2022.849032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/16/2022] [Indexed: 01/10/2023] Open
Abstract
More than half of patients with severe aortic stenosis (AS) over 70 years old have coronary artery disease (CAD). Exertional angina is often present in AS-patients, even in the absence of significant CAD, as a result of oxygen supply/demand mismatch and exercise-induced myocardial ischemia. Moreover, persistent myocardial ischemia leads to extensive myocardial fibrosis and subsequent coronary microvascular dysfunction (CMD) which is defined as reduced coronary vasodilatory capacity below ischemic threshold. Therefore, angina, as well as noninvasive stress tests, have a low specificity and positive predictive value (PPV) for the assessment of epicardial coronary stenosis severity in AS-patients. Moreover, in symptomatic patients with severe AS exercise testing is even contraindicated. Given the limitations of noninvasive stress tests, coronary angiography remains the standard examination for determining the presence and severity of CAD in AS-patients, although angiography alone has poor accuracy in the evaluation of its functional severity. To overcome this limitation, the well-established invasive indices for the assessment of coronary stenosis severity, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), are now in focus, especially in the contemporary era with the rapid increment of transcatheter aortic valve replacement (TAVR) for the treatment of AS-patients. TAVR induces an immediate decrease in hyperemic microcirculatory resistance and a concomitant increase in hyperemic flow velocity, whereas resting coronary hemodynamics remain unaltered. These findings suggest that FFR may underestimate coronary stenosis severity in AS-patients, whereas iFR as the non-hyperemic index is independent of the AS severity. However, because resting coronary hemodynamics do not improve immediately after TAVR, the coronary vasodilatory capacity in AS-patients treated by TAVR remain impaired, and thus the iFR may overestimate coronary stenosis severity in these patients. The optimal method for evaluating myocardial ischemia in patients with AS and co-existing CAD has not yet been fully established, and this important issue is under further investigation. This review is focused on challenges, limitations, and future perspectives in the functional assessment of coronary stenosis severity in these patients, bearing in mind the complexity of coronary physiology in the presence of this valvular heart disease.
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Affiliation(s)
- Srdjan Aleksandric
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marko Banovic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Soluble ST2 as a Potential Biomarker for Risk Assessment of Pulmonary Hypertension in Patients Undergoing TAVR? Life (Basel) 2022; 12:life12030389. [PMID: 35330140 PMCID: PMC8954652 DOI: 10.3390/life12030389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/03/2022] [Accepted: 03/04/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Severe aortic valve stenosis (AS) is associated with pulmonary hypertension (PH) and has been shown to limit patient survival. Soluble suppression of tumorigenicity-2 (sST2) is a cardiovascular biomarker that has proven to be an important prognostic marker for survival in patients undergoing transcatheter aortic valve replacement (TAVR). The aim of this study was to assess the importance of the sST2 biomarker for risk stratification in patients with severe AS in presence or absence of PH. Methods: In 260 patients with severe AS undergoing TAVR procedure, sST2 serum level concentrations were analyzed. Right heart catheter measurements were performed in 152 patients, with no PH detection in 43 patients and with PH detection in 109 patients. Correlation analyses according to Spearman, AUROC analyses and Kaplan–Meier curves were calculated. Results: Patients with severe AS and PH showed significantly higher serum sST2 concentrations (p = 0.006). The sST2 cut-off value for non-PH patients regarding 1-year survival yielded 5521.15 pg/mL, whereas the cut-off value of PH patients was at a considerably higher level of 10,268.78 pg/mL. A cut-off value of 6990.12 pg/mL was related with a significant probability of PH presence. Survival curves showed that patients with severe AS and PH not only had higher 1-year mortality, but also that increased levels of sST2 plasma concentration were associated with earlier death. Conclusion: sST2 definitely has the potential to provide information about the presence of PH in patients with severe AS, in a noninvasive way.
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Lux A, Müllenberg L, Veenstra LF, Dohmen W, Kats S, Maesen B, van’t Hof AW. Iliofemoral tortuosity increases the risk of access site-related complications after aortic valve implantation and plug-based access site closure. CJC Open 2022; 4:609-616. [PMID: 35865026 PMCID: PMC9294987 DOI: 10.1016/j.cjco.2022.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 03/15/2022] [Indexed: 11/23/2022] Open
Abstract
Background Access-site-related complications are often related to high-risk anatomy and technical pitfalls and impair the outcomes of transfemoral aortic valve implantations (TAVIs). Calcification and tortuosity are widely recognized risk factors, and their impact on procedural planning is left to the implanting experts’ discretion. To facilitate decision-making, we introduced a quantitative measure for iliofemoral tortuosity and assessed its predictive value for access-site-related vascular and bleeding complications. Methods We performed a single-centre prospective cohort study of consecutive, percutaneous transfemoral TAVI performed between April 2019 and March 2020. Medical history and all-cause mortality were extracted from the electronic patient files. Arterial anatomy and calcifications were evaluated using 3mensio Structural Heart software. The primary outcome was access-site-related vascular or bleeding complications. Results In this elderly, intermediate-risk population, we registered the primary outcome in 43 patients (39%), and major access-site complications in 10 patients (9.2%). Complete hemostasis was achieved in 77 patients (70.6%), by the application of the MANTA plug alone. In the group with access-site-related adverse events, compared with the group without, the tortuosity index was higher median (26% interquartile range [IQR 18%-33%] vs median 19% [IQR 13%-29%], respectively; P = 0.012), as was maximal angulation median (50° [IQR 40°-59°] vs median 43° [IQR 36°-51°], respectively; P = 0.026) were higher. Both variables had a significant effect on our primary outcome, with odds ratios (OR) of 3.1 (tortuosity, P = 0.005) and 2.6 (angulation, P = 0.020). The degree of angulation was a predictor of major complications too (odds ratio 7 [1.4-34.8]; P = 0.017). Conclusions Steeper angles and greater arterial elongation increase the risk of vascular and bleeding complications after femoral TAVI with the utilization of a plug-based closure device.
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Affiliation(s)
- Arpad Lux
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht University, Maastricht, The Netherlands
- Corresponding author: Dr Arpad Lux, Cardiology Secretariat, PO Box 5800 | 6202 AZ Maastricht, The Netherlands. Tel.: +31(0)43-3875087.
| | - Lisa Müllenberg
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Leo F. Veenstra
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Wim Dohmen
- Business Information Management, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Suzanne Kats
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Bart Maesen
- Cardiovascular Research Institute Maastricht University, Maastricht, The Netherlands
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Arnoud W.J. van’t Hof
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centrum, Heerlen, The Netherlands
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Hahn J, Virk HUH, Al-Azzam F, Greason K, Yue B, El Hachem K, Lee M, Sharma S, Palazzo A, Mehran R, Alam M, Jneid H, Krittanawong C. Outcomes of Transcatheter Aortic Valve Implantation in Patients With Chronic and End-Stage Kidney Disease. Am J Cardiol 2022; 164:100-102. [PMID: 34823840 DOI: 10.1016/j.amjcard.2021.10.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/11/2021] [Accepted: 10/15/2021] [Indexed: 11/27/2022]
Abstract
Patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) are at higher risk of aortic stenosis. Data regarding transcatheter aortic valve implantation (TAVI) in these patients are limited. Herein, we aim to investigate TAVI outcomes in patients with ESKD and CKD. We analyzed clinical data of patients with ESKD and CKD who underwent TAVI from 2008 to 2018 in a large urban healthcare system. Patients' demographics were compared, and significant morbidity and mortality outcomes were noted. Multivariable analyses were used to adjust for potential baseline variables. A total of 643 patients with CKD underwent TAVI with an overall in-hospital mortality of 5.1%, whereas 84 patients with ESKD underwent TAVI with an overall mortality rate of 11.9%. The most frequently observed comorbidities in patients with CKD were heart failure, atrial fibrillation (AF), mitral stenosis (MS), pulmonary hypertension, and chronic lung disease. After multivariable analysis, MS (adjusted odds ratio (OR) 3.92; 95% confidence interval (CI) 1.09 to 11.1, p <0.05) and AF (adjusted OR 2.42; 95% CI 1.3 to 4.4 p <0.05) were independently associated with mortality in patients with CKD. The most common comorbidities observed in patients with ESKD undergoing TAVI were heart failure, chronic lung disease, AF, MS, and pulmonary hypertension. An association between MS and increased mortality was observed (adjusted OR 2.01; 95 CI 0.93 to 2.02, p = 0.09) in patients with ESKD, but was not statistically significant. In conclusion, in patients with CKD undergoing TAVI, AF and MS were independently associated with increased mortality.
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Bhatia M, Kumar P, Maity P, Arora N. Computed Tomographic Assessment before Transcatheter Aortic and Mitral Valve Replacement. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2022. [DOI: 10.4103/jiae.jiae_38_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Useini D, Schlömicher M, Beluli B, Christ H, Ewais E, Haldenwang P, Patsalis P, Moustafine V, Bechtel M, Strauch J. Transapical-transcatheter aortic valve implantation using the Edwards SAPIEN 3 valve. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:609-617. [PMID: 35037446 DOI: 10.23736/s0021-9509.21.11523-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Scarcely any data has been published on the mid-term effect of transapical-transcatheter aortic valve implantation (TA-TAVI) using the Edwards SAPIEN 3 valve (S3; Edwards Lifesciences Corp., Irvine, CA, USA). We present mid-term clinical and echocardiographic outcomes after TA-TAVI utilizing S3. METHODS Between 02/2014-06/2017, 122 elderly patients with severe aortic stenosis underwent TA-TAVI utilizing S3 at our institution. We conducted clinical and echocardiographic follow-up. The mean follow-up was 15 months. All end-point-related outcomes were adjudicated according to Valve Academic Research Consortium-2 definitions. RESULTS The STS-score of the entire cohort was 6.26±4.6. More than one-third of the patients exhibited severe peripheral artery disease. The 30-d all-cause mortality, all-stroke rate, and myocardial infarction of the entire cohort were 4.1%, 1.6%, and 0.8% respectively. Median survival time of the entire cohort was 35 months. The cumulative mid-term myocardial infarction and stroke rate was 2.6% and 3.5%, respectively. The postoperative moderate/severe paravalvular leakage occurred in 1.6% of cases. At discharge, one-year and two-year postprocedure peak/mean gradients were 16.6±8.3/ 9±5.1 mmHg, 18±6.9/ 10±4.5 mmHg, and 22.2±5.4/ 12.8±4.6 mmHg, respectively. The rate of new pacemaker cases was 14.1%. Acute kidney injury network 2/3 appears, as an independent predictor of mortality. CONCLUSIONS We observed very promising early and mid-term clinical outcomes with a high degree of device success and good hemodynamic performance after TA-TAVI using the S3 in the intermediate risk patient profile.
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Affiliation(s)
- Dritan Useini
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany -
| | - Markus Schlömicher
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Blerta Beluli
- Department of Internal Medicine, St. Anna Hospital, Herne, Germany
| | - Hildegard Christ
- Institute of Medical Statistics and Computational Biology (IMSB), University Hospital of Cologne, Cologne, Germany
| | - Elias Ewais
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Peter Haldenwang
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Polykarpos Patsalis
- Department of Cardiology and Angiology, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Vadim Moustafine
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Matthias Bechtel
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
| | - Justus Strauch
- Department of Cardiothoracic Surgery, Ruhr-University Hospital Bergmannsheil, Bochum, Germany
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Onorato EM, Vercellino M, Costante AM, Cioppa A, Sada L, Santoro A, Popusoi G, Tesorio T. Percutaneous Closure of Paravalvular Regurgitation After Third-Generation Transcatheter Aortic Valve Replacement. Int Heart J 2021; 62:1403-1410. [PMID: 34789644 DOI: 10.1536/ihj.21-262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Significant paravalvular leak regurgitation (PVLR) after transcatheter aortic valve replacement (TAVR) is a well-known complication associated with disabling symptoms related to heart failure and hemolysis or both, with poor prognostic implications. Although challenging and technically demanding, percutaneous closure is an effective treatment option for high-risk patients with symptomatic PVLR. Here, we present two cases of transcatheter PVLR closure after replacement of third-generation (one self-expandable and one balloon-expandable) transcatheter aortic valves, each with peculiar challenges, and the strategies adopted to increase the success rate of percutaneous closure.
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Affiliation(s)
| | | | - Anna Maria Costante
- Department of Cardiology, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo
| | - Angelo Cioppa
- Department of Cardiology, Invasice Cardiology and Intensive Care Unit, Clinica Montevergine di Mercogliano (Av)
| | - Lidia Sada
- Department of Cardiology, Invasice Cardiology and Intensive Care Unit, Clinica Montevergine di Mercogliano (Av)
| | - Alessandro Santoro
- Department of Cardiology, Invasice Cardiology and Intensive Care Unit, Clinica Montevergine di Mercogliano (Av)
| | - Gregory Popusoi
- Department of Cardiology, Invasice Cardiology and Intensive Care Unit, Clinica Montevergine di Mercogliano (Av)
| | - Tullio Tesorio
- Department of Cardiology, Invasice Cardiology and Intensive Care Unit, Clinica Montevergine di Mercogliano (Av)
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Strom JB, Xu J, Orkaby AR, Shen C, Song Y, Charest BR, Kim DH, Cohen DJ, Kramer DB, Spertus JA, Gerszten RE, Yeh RW. The Role of Frailty in Identifying Benefit from Transcatheter Versus Surgical Aortic Valve Replacement. Circ Cardiovasc Qual Outcomes 2021; 14:e008566. [PMID: 34779656 DOI: 10.1161/circoutcomes.121.008566] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Frailty is associated with a higher risk for adverse outcomes after aortic valve replacement (AVR) for severe aortic valve stenosis, but whether or not frail patients derive differential benefit from transcatheter (TAVR) vs. surgical (SAVR) AVR is uncertain. Methods: We linked adults ≥ 65 years old in the US CoreValve High Risk (HiR) or Surgical or Transcatheter Aortic-Valve Replacement in Intermediate Risk Patients (SURTAVI) trial to Medicare claims, 2/2/2011-9/30/2015. Two frailty measures, a deficit-based (DFI) and phenotype-based (PFI) frailty index, were generated. The treatment effect of TAVR vs. SAVR was evaluated within frailty index (FI) tertiles for the primary endpoint of death and non-death secondary outcomes, using multivariable Cox regression. Results: Of 1,442 (linkage rate = 60.0%) individuals included, 741 (51.4%) individuals received TAVR and 701 (48.6%) received SAVR (mean age 81.8 ± 6.1 years, 44.0% female). Though 1-year death rates in the highest FI tertiles (DFI 36.7%, PFI 33.8%) were 2-3-fold higher than the lowest tertiles (DFI 13.4%, HR 3.02, 95% CI 2.26-4.02, p < 0.001; PFI 17.9%; HR 2.05, 95% CI 1.58-2.67, p < 0.001), there were no significant differences in the relative or absolute treatment effect of SAVR vs. TAVR across FI tertiles for all death, non-death, and functional outcomes (all interaction p-values > 0.05). Results remained consistent across individual trials, frailty definitions, and when considering the non-linked trial data. Conclusions: Two different frailty indices based on Fried and Rockwood definitions identified individuals at higher risk of death and functional impairment but no differential benefit from TAVR vs. SAVR.
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Affiliation(s)
- Jordan B Strom
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Jiaman Xu
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Ariela R Orkaby
- Harvard Medical School, Boston, MA; Veterans Affairs Healthcare System, Boston, MA
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Brian R Charest
- Harvard Medical School, Boston, MA; Veterans Affairs Healthcare System, Boston, MA
| | - Dae H Kim
- Harvard Medical School, Boston, MA; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Daniel B Kramer
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - John A Spertus
- Section of Cardiovascular Disease, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Robert E Gerszten
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Robert W Yeh
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, MA; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
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Asami M, Bernhard B, Demirel C, Okuno T, Stortecky S, Heg D, Tomii D, Reineke D, Praz F, Lanz J, Windecker S, Gräni C, Pilgrim T. Clinical outcomes following transcatheter aortic valve implantation in patients with porcelain aorta. J Cardiovasc Comput Tomogr 2021; 16:215-221. [PMID: 34756819 DOI: 10.1016/j.jcct.2021.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/02/2021] [Accepted: 10/25/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Current guidelines favor transcatheter aortic valve implantation (TAVI) over surgical aortic valve replacement in patients with porcelain aorta (PAo). The clinical relevance of PAo in patients undergoing TAVI is however incompletely understood. The purpose of this study is to evaluate clinical outcome of patients with PAo undergoing TAVI. METHODS Consecutive patients undergoing TAVI were enrolled in a prospective single-center registry. Presence of PAo was evaluated by ECG-gated multi-slice computed tomography prior to the intervention. The primary endpoint was disabling stroke. RESULTS Among 2199 patients (mean age, 82.0 ± 6.3 years; 1135 females [51.6%]) undergoing TAVI between August 2007 and December 2019, 114 patients (5.2%) met VARC-2 criteria for PAo. Compared to individuals without PAo, patients with PAo were younger (79.4 ± 7.4 years vs. 82.1 ± 6.2 years; p < 0.001), had a lower left ventricular ejection fraction (51.8 ± 14.9% vs. 55.3 ± 14.2%; p = 0.009) and higher STS-PROM Scores (6.5 ± 4.3% vs. 4.9 ± 3.4%; p < 0.001). At 1 year, disabling stroke occurred more often in patients with PAo (7.2%) than in those without (3.0%) (HRadj, 2.49; 95% CI, 1.12-5.55). The risk difference emerged within 30 days after TAVI (HRadj, 3.70; 95% CI, 1.52-9.03), and was driven by a high PAo-associated risk of disabling stroke in patients with alternative access (HRadj, 5.79; 95% CI, 1.38-24.3), not in those with transfemoral (HRadj, 1.47; 95% CI 0.45-4.85). CONCLUSIONS TAVI patients with PAo had a more than three-fold increased risk of periprocedural disabling stroke compared to patients with no PAo. The difference was driven by a higher risk of stroke in patients treated by alternative access.
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Affiliation(s)
- Masahiko Asami
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Benedikt Bernhard
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Caglayan Demirel
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Taishi Okuno
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Dik Heg
- Clinical Trials Unit, University of Bern, Bern, Switzerland
| | - Daijiro Tomii
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - David Reineke
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland.
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Perrin N, Bonnet G, Leroux L, Ibrahim R, Modine T, Ben Ali W. Transcatheter Aortic Valve Implantation: All Transfemoral? Update on Peripheral Vascular Access and Closure. Front Cardiovasc Med 2021; 8:747583. [PMID: 34660747 PMCID: PMC8511676 DOI: 10.3389/fcvm.2021.747583] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/30/2021] [Indexed: 12/19/2022] Open
Abstract
Transfemoral access remains the most widely used peripheral vascular approach for transcatheter aortic valve implantation (TAVI). Despite technical improvement and reduction in delivery sheath diameters of all TAVI platforms, 10-20% of patients remain not eligible to transfemoral TAVI due to peripheral artery disease. In this review, we aim at presenting an update of recent data concerning transfemoral access and percutaneous closure devices. Moreover, we will review peripheral non-transfemoral alternative as well as caval-aortic accesses and discuss the important features to assess with pre-procedural imaging modalities before TAVI.
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Affiliation(s)
- Nils Perrin
- Structural Heart Intervention Program, Montreal Heart Institute, Montreal, QC, Canada.,Cardiology Division, Geneva University Hospitals, Geneva, Switzerland
| | - Guillaume Bonnet
- Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle, Hôpital Cardiologique de Haut Lévèque, CHU Bordeaux, Bordeaux, France
| | - Lionel Leroux
- Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle, Hôpital Cardiologique de Haut Lévèque, CHU Bordeaux, Bordeaux, France
| | - Réda Ibrahim
- Structural Heart Intervention Program, Montreal Heart Institute, Montreal, QC, Canada
| | - Thomas Modine
- Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle, Hôpital Cardiologique de Haut Lévèque, CHU Bordeaux, Bordeaux, France
| | - Walid Ben Ali
- Structural Heart Intervention Program, Montreal Heart Institute, Montreal, QC, Canada.,Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle, Hôpital Cardiologique de Haut Lévèque, CHU Bordeaux, Bordeaux, France
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43
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Strom JB, Xu J, Orkaby AR, Shen C, Charest BR, Kim DH, Cohen DJ, Kramer DB, Spertus JA, Gerszten RE, Yeh RW. Identification of Frailty Using a Claims-Based Frailty Index in the CoreValve Studies: Findings from the EXTEND-FRAILTY Study. J Am Heart Assoc 2021; 10:e022150. [PMID: 34585597 PMCID: PMC8649149 DOI: 10.1161/jaha.121.022150] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background In aortic valve disease, the relationship between claims‐based frailty indices (CFIs) and validated measures of frailty constructed from in‐person assessments is unclear but may be relevant for retrospective ascertainment of frailty status when otherwise unmeasured. Methods and Results We linked adults aged ≥65 years in the US CoreValve Studies (linkage rate, 67%; mean age, 82.7±6.2 years, 43.1% women), to Medicare inpatient claims, 2011 to 2015. The Johns Hopkins CFI, validated on the basis of the Fried index, was generated for each study participant, and the association between CFI tertile and trial outcomes was evaluated as part of the EXTEND‐FRAILTY substudy. Among 2357 participants (64.9% frail), higher CFI tertile was associated with greater impairments in nutrition, disability, cognition, and self‐rated health. The primary outcome of all‐cause mortality at 1 year occurred in 19.3%, 23.1%, and 31.3% of those in tertiles 1 to 3, respectively (tertile 2 versus 1: hazard ratio, 1.22; 95% CI, 0.98–1.51; P=0.07; tertile 3 versus 1: hazard ratio, 1.73; 95% CI, 1.41–2.12; P<0.001). Secondary outcomes (bleeding, major adverse cardiovascular and cerebrovascular events, and hospitalization) were more frequent with increasing CFI tertile and persisted despite adjustment for age, sex, New York Heart Association class, and Society of Thoracic Surgeons risk score. Conclusions In linked Medicare and CoreValve study data, a CFI based on the Fried index consistently identified individuals with worse impairments in frailty, disability, cognitive dysfunction, and nutrition and a higher risk of death, hospitalization, bleeding, and major adverse cardiovascular and cerebrovascular events, independent of age and risk category. While not a surrogate for validated metrics of frailty using in‐person assessments, use of this CFI to ascertain frailty status among patients with aortic valve disease may be valid and prognostically relevant information when otherwise not measured.
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Affiliation(s)
- Jordan B Strom
- Department of Medicine Cardiovascular Division Beth Israel Deaconess Medical Center Boston MA.,Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Boston MA.,Harvard Medical School Boston MA
| | - Jiaman Xu
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Boston MA.,Harvard Medical School Boston MA
| | - Ariela R Orkaby
- Harvard Medical School Boston MA.,Department of Medicine Veterans Affairs Healthcare System Boston MA
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Boston MA.,Harvard Medical School Boston MA
| | - Brian R Charest
- Harvard Medical School Boston MA.,Department of Medicine Veterans Affairs Healthcare System Boston MA
| | - Dae H Kim
- Harvard Medical School Boston MA.,Division of Gerontology Beth Israel Deaconess Medical Center Boston MA
| | | | - Daniel B Kramer
- Department of Medicine Cardiovascular Division Beth Israel Deaconess Medical Center Boston MA.,Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Boston MA.,Harvard Medical School Boston MA
| | - John A Spertus
- Section of Cardiovascular Disease University of Missouri-Kansas City School of Medicine Kansas City MO
| | - Robert E Gerszten
- Department of Medicine Cardiovascular Division Beth Israel Deaconess Medical Center Boston MA.,Harvard Medical School Boston MA
| | - Robert W Yeh
- Department of Medicine Cardiovascular Division Beth Israel Deaconess Medical Center Boston MA.,Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology Beth Israel Deaconess Medical Center Boston MA.,Harvard Medical School Boston MA
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Mantovani F, Barbieri A, Albini A, Bonini N, Fanti D, Fezzi S, Setti M, Rossi A, Ribichini F, Benfari G. The Common Combination of Aortic Stenosis with Mitral Regurgitation: Diagnostic Insight and Therapeutic Implications in the Modern Era of Advanced Echocardiography and Percutaneous Intervention. J Clin Med 2021; 10:jcm10194364. [PMID: 34640380 PMCID: PMC8509644 DOI: 10.3390/jcm10194364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 09/10/2021] [Accepted: 09/20/2021] [Indexed: 11/16/2022] Open
Abstract
The combination of aortic stenosis (AS) and mitral regurgitation (MR) is common in patients with degenerative valvular disease. It is characterized by having complex pathophysiology, leading to potential diagnostic pitfalls. Evidence is scarce in the literature to direct the diagnostic framework and treatment of patients with this particular combination of multiple valvular diseases. In this complex scenario, the appropriate use of advanced echocardiography and multimodality imaging methods plays a central role. Transcatheter mitral valve replacement or repair and transcatheter aortic valve replacement widen the surgical options for valve diseases. Therefore, there is an increasing need to reconsider the function, timing, and mode intervention for patients with a combination of AS with MR towards more personalized treatment.
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Affiliation(s)
- Francesca Mantovani
- Division of Cardiology, Azienda USL–IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy;
| | - Andrea Barbieri
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, University of Modena and Reggio Emilia, 41121 Modena, Italy; (A.B.); (A.A.); (N.B.)
| | - Alessandro Albini
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, University of Modena and Reggio Emilia, 41121 Modena, Italy; (A.B.); (A.A.); (N.B.)
| | - Niccolò Bonini
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, University of Modena and Reggio Emilia, 41121 Modena, Italy; (A.B.); (A.A.); (N.B.)
| | - Diego Fanti
- Section of Cardiology, University of Verona, 37129 Verona, Italy; (D.F.); (S.F.); (M.S.); (A.R.); (F.R.)
| | - Simone Fezzi
- Section of Cardiology, University of Verona, 37129 Verona, Italy; (D.F.); (S.F.); (M.S.); (A.R.); (F.R.)
| | - Martina Setti
- Section of Cardiology, University of Verona, 37129 Verona, Italy; (D.F.); (S.F.); (M.S.); (A.R.); (F.R.)
| | - Andrea Rossi
- Section of Cardiology, University of Verona, 37129 Verona, Italy; (D.F.); (S.F.); (M.S.); (A.R.); (F.R.)
| | - Flavio Ribichini
- Section of Cardiology, University of Verona, 37129 Verona, Italy; (D.F.); (S.F.); (M.S.); (A.R.); (F.R.)
| | - Giovanni Benfari
- Section of Cardiology, University of Verona, 37129 Verona, Italy; (D.F.); (S.F.); (M.S.); (A.R.); (F.R.)
- Correspondence: ; Tel.: +39-045-8122320
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Clinical outcomes following transapical TAVR with ACURATE neo in the CHANGE neo TA study. IJC HEART & VASCULATURE 2021; 36:100862. [PMID: 34504944 PMCID: PMC8411222 DOI: 10.1016/j.ijcha.2021.100862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/20/2021] [Accepted: 08/21/2021] [Indexed: 11/29/2022]
Abstract
Background A transapical (TA) approach to transcatheter aortic valve replacement (TAVR) may be used when a transfemoral (TF) approach is not feasible. The CHANGE neo TA study evaluated patients treated in routine clinical practice via TA-TAVR with the ACURATE neo bioprosthetic aortic valve. Methods and results This single-arm post-market study had a planned enrolment of 200 subjects; enrolment was terminated early due to declining TA-TAVR procedures at participating centers. Final enrolment was 107 patients (mean age: 79.3 years; 54.2% female; mean STS score at baseline: 6.2%). The mortality rate in the intent-to-treat population was 11.2% at 30 days (primary endpoint) and 25.6% at 12 months. The VARC-2 composite endpoint for 30-day safety occurred in 24.3% of patients. Six patients (5.6%) received a permanent pacemaker within 30 days. Site-reported echocardiographic data showed early improvements in mean aortic valve gradient (baseline: 38.8 [SD 13.1] mmHg, discharge: 6.7 [SD 3.7] mmHg) and effective orifice area (baseline: 0.7 [SD 0.2] cm2, discharge: 1.9 [SD 0.6] cm2), and the discharge rate of paravalvular regurgitation was low (74.7% none/trace, 24.2% mild, 1.1% severe). Conclusions TA-TAVR with the ACURATE neo valve system yields acceptable clinical outcomes, providing an alternative for patients with aortic stenosis who are not candidates for TF-TAVR.
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Tirado-Conte G, McInerney A, Jimenez-Quevedo P, Carnero M, Marroquin Donday LA, De Agustin A, Witberg G, Pozo E, Islas F, Marcos-Alberca P, Cobiella J, Koronowski R, Macaya C, Rodes-Cabau J, Nombela-Franco L. Managing the patient undergoing transcatheter aortic valve replacement with ongoing mitral regurgitation. Expert Rev Cardiovasc Ther 2021; 19:711-723. [PMID: 34275408 DOI: 10.1080/14779072.2021.1955347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Significant mitral regurgitation (MR) frequently coexists in patients with severe symptomatic aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). These patients have worse clinical outcomes than those with non-significant MR, especially if MR persists after treatment of the aortic stenosis. The optimal treatment approach for this challenging high-risk population is not well defined. AREAS COVERED This review aims to present the current literature on concomitant significant MR in the TAVR population, and to provide a comprehensive algorithmic approach for clinical decision-making in this challenging cohort of patients. EXPERT OPINION Concomitant mitral and aortic valve disease is a complex clinical entity. An exhaustive and comprehensive assessment of patient's clinical characteristics and mitral valve anatomy and function is required in order to assess the surgical risk, predict the MR response after AVR and evaluate the feasibility of percutaneous MV treatment if necessary. Further developments in transcatheter techniques will expand the indications for double valve treatment in operable and inoperable patients with concomitant significant MR and aortic stenosis.
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Affiliation(s)
- Gabriela Tirado-Conte
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Angela McInerney
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Pilar Jimenez-Quevedo
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Manuel Carnero
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Luis A Marroquin Donday
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Alberto De Agustin
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Guy Witberg
- Department of Cardiology, Rabin Medical Centre, Petach-Tikvav, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eduardo Pozo
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Fabian Islas
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Pedro Marcos-Alberca
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Javier Cobiella
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Ran Koronowski
- Department of Cardiology, Rabin Medical Centre, Petach-Tikvav, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Carlos Macaya
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Luis Nombela-Franco
- Department of Cardiology, Unit of Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
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Guo R, Xie M, Yim WY, Wu W, Jiang W, Wang Y, Hu X. Dose approach matter? A meta-analysis of outcomes following transfemoral versus transapical transcatheter aortic valve replacement. BMC Cardiovasc Disord 2021; 21:358. [PMID: 34320946 PMCID: PMC8320184 DOI: 10.1186/s12872-021-02158-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 07/09/2021] [Indexed: 01/01/2023] Open
Abstract
Background Transcatheter aortic valve replacement (TAVR) has gained increasing acceptance for patients with aortic disease. Both transfemoral (TF-TAVR) and transapical (TA-TAVR) approach were widely adopted while their performances are limited to a few studies with controversial results. This meta-analysis aimed to compare the mortality and morbidity of complications between TF- versus TA-TAVR based on the latest data. Methods Electronic databases were searched until April 2021. RCTs and observational studies comparing the outcomes between TF-TAVR versus TA-TAVR patients were included. Heterogeneity assumption was assessed by an I2 test. The pooled odds ratios(OR) or mean differences with corresponding 95% confidence intervals (CI) were used to evaluate the difference for each end point using a fixed-effect model or random-effect model based on I2 test. Results The meta-analysis included 1 RCT and 20 observational studies, enrolling 19,520 patients (TF-TAVR, n = 11,986 and TA-TAVR, n = 7,534). Compared with TA-TAVR, TF-TAVR patients showed significantly lower rate of postoperative in-hospital death (OR = 0.67, 95% CI 0.59–0.77, P < 0.001) and 1-year death (OR = 0.53, 95% CI 0.41–0.69, P < 0.001). Incidence of major bleeding and acute kidney injury were lower and length of hospital stay was shorter, whereas those of permanent pacemaker and major vascular complication were higher in TF-TAVR patients. There were no significant differences between TF-TAVR versus TA-TAVR for stroke and mid-term mortality. Conclusions There were fewer early deaths in patients with transfemoral approach, whereas the number of mid-term deaths and stroke was not significantly different between two approaches. TF-TAVR was associated with lower risk of bleeding, acute kidney injury as well as shorter in-hospital stay, but higher incidence of vascular complication and permanent pacemaker implantation. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02158-4.
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Affiliation(s)
- Ruikang Guo
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277# Jiefang Avenue, Wuhan, 430022, China
| | - Minghui Xie
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277# Jiefang Avenue, Wuhan, 430022, China
| | - Wai Yen Yim
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277# Jiefang Avenue, Wuhan, 430022, China
| | - Wenconghui Wu
- Department of Gastroenterology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Weiwei Jiang
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yin Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277# Jiefang Avenue, Wuhan, 430022, China.
| | - Xingjian Hu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277# Jiefang Avenue, Wuhan, 430022, China.
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Ullah W, Zahid S, Zaidi SR, Sarvepalli D, Haq S, Roomi S, Mukhtar M, Khan MA, Gowda SN, Ruggiero N, Vishnevsky A, Fischman DL. Predictors of Permanent Pacemaker Implantation in Patients Undergoing Transcatheter Aortic Valve Replacement - A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 10:e020906. [PMID: 34259045 PMCID: PMC8483489 DOI: 10.1161/jaha.121.020906] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background As transcatheter aortic valve replacement (TAVR) technology expands to healthy and lower‐risk populations, the burden and predictors of procedure‐related complications including the need for permanent pacemaker (PPM) implantation needs to be identified. Methods and Results Digital databases were systematically searched to identify studies reporting the incidence of PPM implantation after TAVR. A random‐ and fixed‐effects model was used to calculate unadjusted odds ratios (OR) for all predictors. A total of 78 studies, recruiting 31 261 patients were included in the final analysis. Overall, 6212 patients required a PPM, with a mean of 18.9% PPM per study and net rate ranging from 0.16% to 51%. The pooled estimates on a random‐effects model indicated significantly higher odds of post‐TAVR PPM implantation for men (OR, 1.16; 95% CI, 1.04–1.28); for patients with baseline mobitz type‐1 second‐degree atrioventricular block (OR, 3.13; 95% CI, 1.64–5.93), left anterior hemiblock (OR, 1.43; 95% CI, 1.09–1.86), bifascicular block (OR, 2.59; 95% CI, 1.52–4.42), right bundle‐branch block (OR, 2.48; 95% CI, 2.17–2.83), and for periprocedural atriorventricular block (OR, 4.17; 95% CI, 2.69–6.46). The mechanically expandable valves had 1.44 (95% CI, 1.18–1.76), while self‐expandable valves had 1.93 (95% CI, 1.42–2.63) fold higher odds of PPM requirement compared with self‐expandable and balloon‐expandable valves, respectively. Conclusions Male sex, baseline atrioventricular conduction delays, intraprocedural atrioventricular block, and use of mechanically expandable and self‐expanding prosthesis served as positive predictors of PPM implantation in patients undergoing TAVR.
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Affiliation(s)
- Waqas Ullah
- Thomas Jefferson University Hospitals Philadelphia PA
| | | | | | | | | | | | - Maryam Mukhtar
- University Hospitals of Leicester NHS Trust Leicester UK
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Hungerford SL, Adji AI, Hayward CS, Muller DWM. Ageing, Hypertension and Aortic Valve Stenosis: A Conscious Uncoupling. Heart Lung Circ 2021; 30:1627-1636. [PMID: 34274230 DOI: 10.1016/j.hlc.2021.05.108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/17/2021] [Accepted: 05/18/2021] [Indexed: 10/20/2022]
Abstract
Aortic valve stenosis (AS) is no longer considered to be a disease of fixed left ventricular (LV) afterload (due to an obstructive valve), but rather, functions as a series circuit with important contributions from both the valve and ageing vasculature. Patients with AS are frequently elderly, with hypertension and a markedly remodelled aorta. The arterial component is sizable, and yet, the contribution of ventricular afterload has been difficult to determine. Arterial stiffening increases the speed of propagation of the blood pressure wave along the central arteries (estimated as the pulse wave velocity), which results in an earlier return of reflected waves. The effect is to augment blood pressure in the proximal aorta during systole, increasing the central pulse pressure and, in turn, placing even greater afterload on the heart. Elevated global LV afterload is known to have adverse consequences on LV remodelling, function and survival in patients with AS. Consequently, there is renewed focus on methods to estimate the relative contributions of local versus global changes in arterial mechanics and valvular haemodynamics in patients with AS. We present a review on existing and upcoming methods to quantify valvulo-arterial impedance and thereby global LV load in patients with AS.
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Affiliation(s)
- Sara L Hungerford
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; The University of New South Wales, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia.
| | - Audrey I Adji
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; The University of New South Wales, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia; Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Christopher S Hayward
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; The University of New South Wales, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - David W M Muller
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; The University of New South Wales, Sydney, NSW, Australia; Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
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Occurrence and Persistency of Conduction Disturbances during Transcatheter Aortic Valve Implantation. ACTA ACUST UNITED AC 2021; 57:medicina57070695. [PMID: 34356976 PMCID: PMC8303948 DOI: 10.3390/medicina57070695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/02/2021] [Accepted: 07/06/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Conduction disturbances such as left bundle branch block (LBBB) and complete atrio-ventricular block (cAVB) are relatively frequent complications following trans-catheter aortic valve implantation (TAVI). We investigated the dynamics of these conduction blocks to further understand luxating factors and predictors for their persistency. Materials and Methods: We prospectively included 157 consecutive patients who underwent a TAVI procedure. Electrocardiograms (ECGs) were obtained at specific time points during the TAVI procedure and at follow-up until at least six months post-procedure. Results: Of the 106 patients with a narrow QRS complex (nQRS) before TAVI, ~70% developed LBBB; 28 (26.4%) being classified as super-transient (ST-LBBB), 20 (18.9%) as transient (T-LBBB) and 24 (22.6%) as persistent (P-LBBB). Risk of LBBB was higher for self-expandable (SE) than for balloon-expandable (BE) prostheses and increased with larger implant depth. During the TAVI procedure conduction disturbances showed a dynamic behavior, as illustrated by alternating kinds of blocks in 18 cases. Most LBBBs developed during balloon aortic valvuloplasty (BAV) and at positioning and deployment of the TAVI prosthesis. The incidence of LBBB was not significantly different between patients who did and did not undergo BAV prior to TAVI implantation (65.3% and 74.2%, respectively (p = 0.494)). Progression to cAVB was most frequent for patients with preexisting conduction abnormalities (5/34) patients) and in patients showing ST-LBBB (6/28). Conclusions: During the TAVI procedure, conduction disturbances showed a dynamic behavior with alternating types of block in 18 cases. After a dynamic period of often alternating types of block, most BBBs are reversible while one third persist. Patients with ST-LBBB are most prone to progressing into cAVB. The observation that the incidence of developing LBBB after TAVI is similar with and without BAV suggests that a subgroup of patients has a substrate to develop LBBB regardless of the procedure.
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