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Bornemann KM, Jahren SE, Obrist D. The relation between aortic morphology and transcatheter aortic heart valve thrombosis: Particle tracing and platelet activation in larger aortic roots with and without neo-sinus. Comput Biol Med 2024; 179:108828. [PMID: 38996554 DOI: 10.1016/j.compbiomed.2024.108828] [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: 03/27/2024] [Revised: 06/05/2024] [Accepted: 06/29/2024] [Indexed: 07/14/2024]
Abstract
Transcatheter aortic heart valve thrombosis (THVT) affects long-term valve durability, transvalvular pressure gradient and leaflet mobility. In this study, we conduct high-fidelity fluid-structure interaction simulations to perform Lagrangian particle tracing in a generic model with larger aortic diameters (THVT model) with and without neo-sinus which is compared to a model of unaffected TAVI patients (control model). Platelet activation indices are computed for each particle to assess the risk of thrombus formation induced by high shear stresses followed by flow stagnation. Particle tracing indicates that fewer particles contribute to sinus washout of the THVT model with and without neo-sinus compared to the control model (-34.9%/-34.1%). Stagnating particles in the native sinus of the THVT model show higher platelet activation indices than for the control model (+39.6% without neo-sinus, +45.3% with neo-sinus). Highest activation indices are present for particles stagnating in the neo-sinus of the larger aorta representing THVT patients (+80.2% compared to control). This fluid-structure interaction (FSI) study suggests that larger aortas lead to less efficient sinus washout in combination with higher risk of platelet activation among stagnating particles, especially within the neo-sinus. This could explain (a) a higher occurrence of thrombus formation in transcatheter valves compared to surgical valves without neo-sinus and (b) the neo-sinus as the prevalent region for thrombi in TAV. Pre-procedural identification of larger aortic roots could contribute to better risk assessment of patients and improved selection of a patient-specific anti-coagulation therapy.
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Affiliation(s)
- Karoline-Marie Bornemann
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, Bern, 3010, Switzerland.
| | - Silje Ekroll Jahren
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, Bern, 3010, Switzerland
| | - Dominik Obrist
- ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, Bern, 3010, Switzerland
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2
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Giuliani C, Zanuttini A, Salaun E, Côté N, Clavel MA, Pibarot P. Subclinical valve leaflet thrombosis following bioprosthetic aortic valve replacement. Curr Opin Cardiol 2024; 39:457-464. [PMID: 38899782 DOI: 10.1097/hco.0000000000001161] [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: 06/21/2024]
Abstract
PURPOSE OF REVIEW Subclinical leaflet thrombosis (SLT) is often an incidental finding characterized by a thin layer of thrombus involving one, two or three leaflets, with typical appearance on multi-detector computed tomography (MDCT) of hypo-attenuating defect at the aortic side of the leaflet, also called hypo-attenuating leaflet thickening (HALT). SLT may occur following both transcatheter aortic replacement (TAVR) or biological surgical aortic valve replacement (SAVR). The aim of this review is to present an overview of the current state of knowledge on the incidence, diagnosis, clinical impact, and management of SLT following TAVR or SAVR. RECENT FINDINGS SLT occurs in 10-20% of patients following TAVR and is somewhat more frequent than following SAVR (5-15%). SLT may regress spontaneously without treatment in about 50% of the cases but may also progress to clinically significant valve thrombosis in some cases. Oral anticoagulation with vitamin K antagonist is reasonable if SLT is detected by echocardiography and/or MDCT during follow-up and is generally efficient to reverse SLT. SLT is associated with mild increase in the risk of stroke but has no impact on survival. SLT has been linked with accelerated structural valve deterioration and may thus impact valve durability and long-term outcomes. SUMMARY SLT is often an incidental finding on echocardiography or MDCT that occurs in 10-20% of patients following TAVR or 5-15% following biological SAVR and is associated with a mild increase in the risk of thrombo-embolic event with no significant impact on mortality but may be associated with reduced valve durability.
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Affiliation(s)
- Carlos Giuliani
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada
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3
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Adrichem R, Rodes Cabau J, Mehran R, Park DW, Ten Berg JM, de Backer O, Hengstenberg C, Budde RPJ, Dangas GD, Makkar R, Van Mieghem NM. Treatment of Transcatheter Aortic Valve Thrombosis: JACC Review Topic of the Week. J Am Coll Cardiol 2024; 84:848-861. [PMID: 39168571 DOI: 10.1016/j.jacc.2024.05.064] [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: 03/21/2024] [Revised: 05/01/2024] [Accepted: 05/13/2024] [Indexed: 08/23/2024]
Abstract
Transcatheter aortic valve (TAV) thrombosis may manifest as subclinical leaflet thrombosis (SLT) and clinical valve thrombosis. SLT is relatively common (10%-20%) after transcatheter aortic valve replacement, but clinical implications are uncertain. Clinical valve thrombosis is rare (1.2%) and associated with bioprosthetic valve failure, neurologic or thromboembolic events, heart failure, and death. Treatment for TAV thrombosis has been understudied. In principle, anticoagulation may prevent TAV thrombosis. Non-vitamin K oral anticoagulants, as compared to antiplatelet therapy, are associated with reduced incidence of SLT, although at the cost of higher bleeding and all-cause mortality risk. We present an overview of existing literature for management of TAV thrombosis and propose a rational treatment algorithm. Vitamin K antagonists or non-vitamin K oral anticoagulants are the cornerstone of antithrombotic treatment. In therapy-resistant or clinically unstable patients, ultraslow, low-dose infusion of thrombolytics seems effective and safe and may be preferred over redo-transcatheter aortic valve replacement or explant surgery.
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Affiliation(s)
- Rik Adrichem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Josep Rodes Cabau
- Department of Cardiology, Quebec Heart and Lung Institute, Quebec, Quebec, Canada
| | - Roxana Mehran
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jurrien M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands; Department of Cardiology, University Medical Center Maastricht, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Ole de Backer
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - George D Dangas
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raj Makkar
- Deparment of Cardiology, Cedars Sinai Heart Institute, Los Angeles, California, USA
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands.
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4
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Guedeney P, Rodés-Cabau J, Ten Berg JM, Windecker S, Angiolillo DJ, Montalescot G, Collet JP. Antithrombotic therapy for transcatheter structural heart intervention. EUROINTERVENTION 2024; 20:972-986. [PMID: 39155752 PMCID: PMC11317833 DOI: 10.4244/eij-d-23-01084] [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: 12/21/2023] [Accepted: 05/22/2024] [Indexed: 08/20/2024]
Abstract
Percutaneous transcatheter structural heart interventions have considerably expanded within the last two decades, improving clinical outcomes and quality of life versus guideline-directed medical therapy for patients frequently ineligible for surgical treatment. Transcatheter structural heart interventions comprise valve implantation or repair and also occlusions of the patent foramen ovale, atrial septal defects and left atrial appendage. These procedures expose structural devices to arterial or venous blood flow with various rheological conditions leading to potential thrombotic complications and embolisation. Furthermore, these procedures may concern comorbid patients at high risk of both ischaemic and bleeding complications. This state-of-the-art review provides a description of the device-related thrombotic risk associated with these transcatheter structural heart interventions and of the current evidence-based guidelines regarding antithrombotic treatments. Gaps in evidence for each of the studied transcatheter interventions and the main ongoing trials are also summarised.
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Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Paris, France
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Gilles Montalescot
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Paris, France
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5
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Gall E, Benamer H, Fourchy D, Romano M, Garot P, Akodad M. [How to deal with elevated gradient following TAVR?]. Ann Cardiol Angeiol (Paris) 2024; 73:101789. [PMID: 39126748 DOI: 10.1016/j.ancard.2024.101789] [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: 07/04/2024] [Accepted: 07/10/2024] [Indexed: 08/12/2024]
Abstract
Over the past two decades, transcatheter aortic valve implantation (TAVI) has become a safe and effective therapeutic option for symptomatic and severe aortic stenosis, regardless of the surgical risk spectrum. With the expansion of TAVI indications to low-risk and younger patients, it is crucial to ensure satisfactory and durable hemodynamic outcomes to guarantee transcatheter heart valve (THV) longevity. However, secondary THV dysfunction may occur, often manifested by an increased transvalvular gradient. According to VARC-3 criteria, these dysfunctions can be attributed to four main mechanisms: 1) structural valve deterioration; 2) non-structural valve dysfunction; 3) thrombosis; 4) and endocarditis. Each mechanism leads to specific abnormalities, requiring a systematic diagnostic approach and appropriate treatment. This article illustrates, through two clinical cases, the diagnosis and management of secondary transvalvular gradient elevation after TAVI.
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Affiliation(s)
- Emmanuel Gall
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300, Massy, France; Université Paris-Cité, Department of Cardiology, University Hospital of Lariboisiere, (Assistance Publique des Hôpitaux de Paris, AP-HP), 75010, Paris, France; Inserm MASCOT - UMRS 942, University Hospital of Lariboisiere, 75010, Paris, France; MIRACL.ai laboratory, Multimodality Imaging for Research and Artificial Intelligence Core Laboratory, University Hospital of Lariboisiere (AP-HP), 75010, Paris, France
| | - Hakim Benamer
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300, Massy, France
| | - Dominique Fourchy
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300, Massy, France
| | - Mauro Romano
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300, Massy, France
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300, Massy, France
| | - Mariama Akodad
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Ramsay Santé, 91300, Massy, France.
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6
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Boccalini S, Mayard C, Lacombe H, Villien M, Si-Mohamed S, Delahaye F, Boussel L, Budde RPJ, Pozzi M, Douek P. Ultra-High-Resolution and K-Edge Imaging of Prosthetic Heart Valves With Spectral Photon-Counting CT: A Phantom Study. Invest Radiol 2024; 59:589-598. [PMID: 38421666 DOI: 10.1097/rli.0000000000001068] [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: 03/02/2024]
Abstract
BACKGROUND AND PURPOSE The contribution of cardiac computed tomography (CT) for the detection and characterization of prosthetic heart valve (PHV) complications is still limited due mainly to artifacts. Computed tomography systems equipped with photon-counting detectors (PCDs) have the potential to overcome these limitations. Therefore, the aim of the study was to compare image quality of PHV with PCD-CT and dual-energy dual-layer CT (DEDL-CT). MATERIALS AND METHODS Two metallic and 3 biological PHVs were placed in a tube containing diluted iodinated contrast inside a thoracic phantom and scanned repeatedly at different angles on a DEDL-CT and PCD-CT. Two small lesions (~2 mm thickness; containing muscle and fat, respectively) were attached to the structure of 4 valves, placed inside the thoracic phantom, with and without an extension ring, and scanned again. Acquisition parameters were matched for the 2 CT systems and used for all scans. Metallic valves were scanned again with parameters adapted for tungsten K-edge imaging. For all valves, different metallic parts were measured on conventional images to assess their thickness and blooming artifacts. In addition, 6 parallelepipeds per metallic valve were drawn, and all voxels with density <3 times the standard deviation of the contrast media were recorded as an estimate of streak artifacts. For subjective analysis, 3 expert readers assessed conventional images of the valves, with and without lesions, and tungsten K-edge images. Conspicuity and sharpness of the different parts of the valve, the lesions, metallic, and blooming artifacts were scored on a 4-point scale. Measurements and scores were compared with the paired t test or Wilcoxon test. RESULTS The objective analysis showed that, with PCD-CT, valvular metallic structures were thinner and presented less blooming artifacts. Metallic artifacts were also reduced with PCD-CT (11 [interquartile (IQ) = 6] vs 40 [IQ = 13] % of voxels). Subjective analysis allowed noticing that some structures were visible or clearly visible only with PCD-CT. In addition, PCD-CT yielded better scores for the conspicuity and for the sharpness of all structures (all P s < 0.006), except for the conspicuity of the leaflets of the mechanical valves, which were well visible with either technique (4 [IQ = 3] for both). Both blooming and streak artifacts were reduced with PCD-CT ( P ≤ 0.01). Overall, the use of PCD-CT resulted in better conspicuity and sharpness of the lesions compared with DEDL-CT (both P s < 0.02). In addition, only with PCD-CT some differences between the 2 lesions were detectable. Adding the extension ring resulted in reduced conspicuity and sharpness with DEDL-CT ( P = 0.04 and P = 0.02, respectively) and only in reduced sharpness with PCD-CT ( P = 0.04). Tungsten K-edge imaging allowed for the visualization of the only dense structure containing it, the leaflets, and it resulted in images judged having less blooming and metallic artifacts as compared with conventional PCD-CT images ( P < 0.01). CONCLUSIONS With PCD-CT, objective and subjective image quality of metallic and biological PHVs is improved compared with DEDL-CT. Notwithstanding the improvements in image quality, millimetric lesions attached to the structure of the valves remain a challenge for PCD-CT. Tungsten K-edge imaging allows for even further reduction of artifacts.
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Affiliation(s)
- Sara Boccalini
- From the University of Lyon, INSA-Lyon, University Claude Bernard Lyon 1, Villeurbanne, France (S.B., F.D.); Department of Cardiovascular and Thoracic Radiology, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France (S.B., C.M., S.S.-M., L.B., P.D.); University Lyon, INSA-Lyon, University Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, Villeurbanne, France (H.L., S.S.-M., L.B., P.D.); Philips Healthcare, Suresnes, France (M.V.); Department of Cardiology, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France (F.D.); Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands (R.B.); and Department of Cardiac Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France (M.P.)
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7
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Steiner-Gager GM, Rogozarski J, Kronberger C, Dizdarevic AM, Quehenberger P, Schernthaner R, Loewe C, Reider L, Strassl A, Kovacevic Miljevic K, Jilma B, Ay C, Königsbrügge O, Postula M, Hengstenberg C, Siller-Matula JM. Prediction model for leaflet thrombosis in patients undergoing transcatheter aortic valve implantation: the EFFORT study. Clin Res Cardiol 2024:10.1007/s00392-024-02486-3. [PMID: 39012508 DOI: 10.1007/s00392-024-02486-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/24/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Leaflet thrombosis (LT) is a multifaceted and underexplored condition that can manifest following transcatheter aortic valve implantation (TAVI). The objective of this study was to formulate a prediction model based on laboratory assessments and clinical parameters, providing additional guidance and insight into this relatively unexplored aspect of post-TAVI complications. METHODS The present study was an observational prospective hypothesis-generating study, including 101 patients who underwent TAVI and a screening for LT (the primary endpoint) by multidetector computed tomography (MDCT). All images were acquired on a third-generation dual-source CT system. Levels of von Willebrand factor (vWF) activity, hemoglobin (Hb), and lactate dehydrogenase (LDH) were measured among other parameters. A predictive score utilizing binary logistic regression, Kaplan-Meier time-to-event analysis, and receiver operating characteristics (ROC) analysis was established. RESULTS LT (11 subclinical and 2 clinical) was detected in 13 of 101 patients (13%) after a median time to screening by MDCT of 105 days (IQR, 98-129 days). Elevated levels of vWF activity (> 188%) pre-TAVI, decreased Hb values (< 11.9 g/dL), as well as increased levels of LDH (> 312 U/L) post-TAVI and absence of oral anticoagulation (OAC) were found in patients with subsequent LT formation as compared to patients without LT. The established EFFORT score ranged from - 1 to 3 points, with an increased probability for LT development in patients with ≥ 2 points (85.7% of LT cases) vs < 2 points (14.3% of LT cases; p < 0.001). Achieving an EFFORT score of ≥ 2 points was found to be significantly associated with a 10.8 times higher likelihood of developing an LT (p = 0.001). The EFFORT score has an excellent c-statistic (area under the curve (AUC) = 0.89; 95% CI 0.74-1.00; p = 0.001) and a high negative predictive value (98%). CONCLUSION An EFFORT score might be a helpful tool to predict LT development and could be used in risk assessment, if validated in confirmatory studies. Therefore, the score has the potential to guide the stratification of individuals for the planning of subsequent MDCT screenings.
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Affiliation(s)
- Gloria M Steiner-Gager
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jovan Rogozarski
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christina Kronberger
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Al Medina Dizdarevic
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Ruediger Schernthaner
- Department of Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Central Radiology Institute, Diagnostic and Interventional Radiology, Klinik Landstraße, Vienna, Austria
| | - Christian Loewe
- Department of Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Lukas Reider
- Department of Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Andreas Strassl
- Department of Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Oliver Königsbrügge
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Marek Postula
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
| | - Christian Hengstenberg
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Jolanta M Siller-Matula
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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8
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Samadzadeh Tabrizi N, Fishberger G, Musuku SR, Shapeton AD. Hypoattenuated Leaflet Thickening: A Comprehensive Review of Contemporary Data. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00434-8. [PMID: 39043491 DOI: 10.1053/j.jvca.2024.06.043] [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: 03/21/2024] [Accepted: 06/27/2024] [Indexed: 07/25/2024]
Abstract
Nearly one-third of patients who undergo surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) develop hypoattenuated leaflet thickening (HALT) within a year. HALT typically represents subclinical leaflet thrombosis in asymptomatic patients, and as a result it often is detected incidentally. However, HALT also may worsen in severity, resulting in leaflet immobility and/or valve deterioration. The clinical significance of HALT is a topic of ongoing debate, and currently there is no consensus on the screening and management of HALT in patients following TAVR or SAVR. This review provides a comprehensive evaluation of the available evidence on risk factors, preventative measures, treatment, and prognosis for this growing patient cohort.
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Affiliation(s)
| | | | | | - Alexander D Shapeton
- Veterans Affairs Boston Healthcare System; Department of Anesthesia, Critical Care and Pain Medicine, and Tufts University School of Medicine, Boston MA
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9
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Chitturi KR, Aladin AI, Braun R, Al-Qaraghuli AK, Banerjee A, Reddy P, Merdler I, Chaturvedi A, Abusnina W, Haberman D, Lupu L, Rodriguez-Weisson FJ, Case BC, Wermers JP, Ben-Dor I, Satler LF, Waksman R, Rogers T. Bioprosthetic Aortic Valve Thrombosis: Definitions, Clinical Impact, and Management: A State-of-the-Art Review. Circ Cardiovasc Interv 2024; 17:e014143. [PMID: 38853766 DOI: 10.1161/circinterventions.123.014143] [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] [Indexed: 06/11/2024]
Abstract
Bioprosthetic aortic valve thrombosis is frequently detected after transcatheter and surgical aortic valve replacement due to advances in cardiac computed tomography angiography technology and standardized surveillance protocols in low-surgical-risk transcatheter aortic valve replacement trials. However, evidence is limited concerning whether subclinical leaflet thrombosis leads to clinical adverse events or premature structural valve deterioration. Furthermore, there may be net harm in the form of bleeding from aggressive antithrombotic treatment in patients with subclinical leaflet thrombosis. This review will discuss the incidence, mechanisms, diagnosis, and optimal management of bioprosthetic aortic valve thrombosis after transcatheter aortic valve replacement and bioprosthetic surgical aortic valve replacement.
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Affiliation(s)
- Kalyan R Chitturi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Amer I Aladin
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Ryan Braun
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD (R.B., T.R.)
| | - Abdullah K Al-Qaraghuli
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Avantika Banerjee
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Pavan Reddy
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Ilan Merdler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Abhishek Chaturvedi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Waiel Abusnina
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Dan Haberman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Lior Lupu
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Fernando J Rodriguez-Weisson
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Jason P Wermers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD (R.B., T.R.)
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10
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Otsuka Y, Ishii M, Tabata N, Oda S, Kidoh M, Shirahama Y, Egashira K, Kuyama N, Rokutanda T, Noda K, Horio E, Sakamoto T, Kudo T, Shimomura H, Ikemoto T, Tsunoda R, Nakamura T, Matsui K, Kaikita K, Tsujita K. Subclinical leaflet thrombus in patients with severe aortic stenosis and atrial fibrillation -ENRICH-AF TAVI study. Sci Rep 2024; 14:14902. [PMID: 38942790 PMCID: PMC11213935 DOI: 10.1038/s41598-024-65600-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/21/2024] [Indexed: 06/30/2024] Open
Abstract
Subclinical leaflet thrombosis (SLT) can be one of the causes of transcatheter heart valve (THV) failure after transcatheter aortic valve implantation (TAVI). We sought to clarify the formation process of SLT and thrombogenicity during the perioperative period of TAVI. This multicenter, prospective, single-arm interventional study enrolled 26 patients treated with edoxaban for atrial fibrillation and who underwent TAVI for severe aortic stenosis between September 2018 and September 2022. We investigated changes in maximal leaflet thickness detected by contrast-enhanced computed tomography between 1 week and 3 months after TAVI in 18 patients and measured the thrombogenicity by Total Thrombus-formation Analysis System (T-TAS) and flow stagnation volume by computational fluid dynamics (CFD) (n = 11). SLT was observed in 16.7% (3/18) at 1 week, but decreased to 5.9% (1/17) at 3 months after TAVI. Patients with SLT at 1 week had a significantly decreased maximal leaflet thickness compared to those without SLT. Thrombogenicity assessed by T-TAS decreased markedly at 1 week and tended to increase at 3 months. The stagnation volume assessed by CFD was positively associated with a higher maximum leaflet thickness. This study showed the course of leaflet thrombus formation and visualization of stagnation in neo-sinus of THV in the acute phase after TAVI.
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Affiliation(s)
- Yasuhiro Otsuka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo Chuo-ku, Kumamoto, 860-8556, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo Chuo-ku, Kumamoto, 860-8556, Japan.
- Department of Medical Information Science, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo Chuo-ku, Kumamoto, 860-8556, Japan.
| | - Noriaki Tabata
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo Chuo-ku, Kumamoto, 860-8556, Japan
| | - Seitaro Oda
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masafumi Kidoh
- Department of Diagnostic Radiology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuichiro Shirahama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo Chuo-ku, Kumamoto, 860-8556, Japan
| | - Koichi Egashira
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo Chuo-ku, Kumamoto, 860-8556, Japan
| | - Naoto Kuyama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo Chuo-ku, Kumamoto, 860-8556, Japan
| | | | | | - Eiji Horio
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Takashi Kudo
- Fukuoka Tokushukai Medical Center, Fukuoka, Japan
| | | | | | | | - Taishi Nakamura
- Department of Medical Information Science, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo Chuo-ku, Kumamoto, 860-8556, Japan
| | - Kunihiko Matsui
- Department of General Medicine and Primary Care, Kumamoto University Hospital, Kumamoto, Japan
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo Chuo-ku, Kumamoto, 860-8556, Japan
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11
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Izumi C, Amano M, Fukushima S, Yaku H, Eishi K, Sakaguchi T, Minami M, Yamamoto H, Onda K, Omae K. Efficacy and Safety of Edoxaban in Anticoagulant Therapy Early After Surgical Bioprosthetic Valve Replacement: Rationale and Design of the ENBALV Trial. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07585-x. [PMID: 38913220 DOI: 10.1007/s10557-024-07585-x] [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] [Accepted: 05/21/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND AND PURPOSE Anticoagulant therapy with vitamin K antagonists is recommended within 3 to 6 months after bioprosthetic valve replacement to prevent thromboembolic events. However, data regarding whether direct oral anticoagulants can be an alternative to warfarin in such patients are limited. The purpose of this study is to compare the efficacy and safety of edoxaban versus warfarin within 3 months after bioprosthetic valve replacement. METHODS The ENBALV trial is an investigator-initiated, phase 3, randomized, open-label, multicenter study. It involves patients aged 18 to 85 years undergoing bioprosthetic valve replacement at the aortic and/or mitral position. They are randomized 1:1 to receive either edoxaban or warfarin. Administration of edoxaban or warfarin is to be continued for 12 weeks after surgery. The primary outcome is the occurrence rate of stroke or systemic embolism at 12 weeks after surgery. The net clinical outcome is a composite of stroke, systemic embolism, or major bleeding, which is included in the secondary outcomes. CONCLUSION The ENBALV trial demonstrates the efficacy and safety of edoxaban compared with warfarin in patients early after bioprosthetic valve replacement, including patients with sinus rhythm, which will bring a significant benefit to patients in clinical practice. TRIAL REGISTRATION Japan Registry of Clinical Trials (jRCT) 2051210209. 30 Mar 2022 https://jrct.niph.go.jp/latest-detail/jRCT2051210209 .
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Affiliation(s)
- Chisato Izumi
- Department of Heart Failure and Transplant, National Cerebral and Cardiovascular Center, 6-1 Kishibe Shimmachi, Suita-City, Osaka, 564-8565, Japan.
| | - Masashi Amano
- Department of Heart Failure and Transplant, National Cerebral and Cardiovascular Center, 6-1 Kishibe Shimmachi, Suita-City, Osaka, 564-8565, Japan
| | - Satsuki Fukushima
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kiyoyuki Eishi
- Department of Cardiovascular Surgery, Hakujyuji Hospital, Fukuoka, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, Hyogo Medical University, Nishinomiya, Japan
| | - Manabu Minami
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Haruko Yamamoto
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Onda
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Katsuhiro Omae
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
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12
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Pallante F, Costa F, Garcia Ruiz V, Vizzari G, Iannello P, Teresi L, Carciotto G, Lo Giudice S, Iuvara G, Laterra G, Regueiro A, Giustino G, Alonso Briales JH, Hernandez JM, Barbanti M, Micari A, Patanè F. Antithrombotic Therapy in Patients Undergoing Transcatheter Aortic Valve Implantation. J Clin Med 2024; 13:3636. [PMID: 38999202 PMCID: PMC11242616 DOI: 10.3390/jcm13133636] [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: 05/18/2024] [Accepted: 06/18/2024] [Indexed: 07/14/2024] Open
Abstract
Transcatheter aortic valve implantation (TAVI) now represents the mainstay of treatment for severe aortic stenosis. Owing to its exceptional procedural efficacy and safety, TAVI has been extended to include patients at lower surgical risk, thus now encompassing a diverse patient population receiving this treatment. Yet, long-term outcomes also depend on optimal medical therapy for secondary vascular prevention, with antithrombotic therapy serving as the cornerstone. Leveraging data from multiple randomized controlled trials, the current guidelines generally recommend single antithrombotic therapy, with either single antiplatelet therapy (SAPT) or oral anticoagulation (OAC) alone in those patients without or with atrial fibrillation, respectively. Yet, individualization of this pattern, as well as specific case uses, may be needed based on individual patient characteristics and concurrent procedures. This review aims to discuss the evidence supporting antithrombotic treatments in patients treated with TAVI, indications for a standardized treatment, as well as specific considerations for an individualized approach to treatment.
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Affiliation(s)
- Francesco Pallante
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | - Francesco Costa
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, 98122 Messina, Italy
- Departamento de Medicina UMA, Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, 29010 Malaga, Spain
| | - Victoria Garcia Ruiz
- Departamento de Medicina UMA, Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, 29010 Malaga, Spain
| | - Giampiero Vizzari
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | | | - Lucio Teresi
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | - Gabriele Carciotto
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | - Stefania Lo Giudice
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | - Giustina Iuvara
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | - Giulia Laterra
- Faculty of Medicine and Surgery, Università degli Studi di Enna "Kore", 94100 Enna, Italy
| | - Ander Regueiro
- Hospital Clinic, Cardiovascular Institute, Institut D'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Gennaro Giustino
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Juan Horacio Alonso Briales
- Departamento de Medicina UMA, Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, 29010 Malaga, Spain
| | - Jose Maria Hernandez
- Departamento de Medicina UMA, Área del Corazón, Hospital Universitario Virgen de la Victoria, CIBERCV, IBIMA Plataforma BIONAND, 29010 Malaga, Spain
| | - Marco Barbanti
- Faculty of Medicine and Surgery, Università degli Studi di Enna "Kore", 94100 Enna, Italy
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, 98122 Messina, Italy
| | - Francesco Patanè
- Department of Biomedical and Dental Sciences and of Morphological and Functional Images, University of Messina, 98122 Messina, Italy
- Cardiology Division, Papardo Hospital, 98158 Messina, Italy
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13
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Takla A, Sourial K, Sharma G. Recurrent hypo-attenuated leaflet thickening after TAVR: Clinical implications. Catheter Cardiovasc Interv 2024; 103:1156-1158. [PMID: 38529691 DOI: 10.1002/ccd.31017] [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: 12/07/2023] [Revised: 02/27/2024] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
Subclinical bioprosthetic valve thrombosis (BPVT) is a relatively common finding in asymptomatic patients during follow-up imaging. However, its clinical significance is unclear. Data from registries associate BPVT with elevated valve gradients, thromboembolic complications, recurrence, and valve degeneration. Given the dynamic nature of the disease process, management is challenging. The duration of anticoagulation is unpredictable, and the need for frequent monitoring of BPVT, even in subclinical scenarios, is unclear. Our report is shedding the light on the clinical implications BPVT.
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Affiliation(s)
- Andrew Takla
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Kirolus Sourial
- Department of Cardiovascular Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Gaurav Sharma
- Department of Cardiovascular Medicine, Rochester General Hospital, Rochester, New York, USA
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14
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Shashank S, Balireddi LD, Inban P, Al‐ezzi SMS, Reddy NJ, Alalousi Y, Prajjwal P, John J, Shajeri MAA, Almadhoun MKIKH, Sulaimanov M, Amiri B, Marsool MDM, Amir Hussin O. Subclinical leaflet thrombosis and anticoagulation strategy following trans-catheter aortic valve replacement: A systematic review. Health Sci Rep 2024; 7:e2200. [PMID: 38933424 PMCID: PMC11199189 DOI: 10.1002/hsr2.2200] [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: 10/12/2023] [Revised: 05/30/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024] Open
Abstract
Objective Subclinical leaflet thrombosis (SLT) develops in 15% of patients undergoing trans-catheter aortic valve replacement (TAVR). TAVR is a procedure in which a faulty aortic valve is replaced with a mechanical one. An aortic valve replacement can be done with open-heart surgery; this is called surgical aortic valve replacement (SAVR). A significant problem is defining the best course of treatment for asymptomatic individuals with SLT post-TAVR, including the use of oral anticoagulation (OAC) in it. Study design Systematic review. Method The most pertinent published research (original papers and reviews) in the scientific literature were searched for and critically assessed using the online, internationally indexed databases PubMed, Medline, and Cochrane Reviews. Keywords like "Transcatheter valve replacement" and "Subclinical leaflet thrombosis" were used to search the papers. Selected studies were critically assessed for inclusion based on predefined criteria. Results The review examined the prevalence and characteristics of SLT after TAVR. To note, the incidence of SLT is seen to be higher in TAVR compared SAVR. Dual antiplatelet therapy, which is utilized in antithrombotic regimens post-TAVR, can possibly hasten SLT progression which could result in the impaired mobility of leaflets and the worsening of pressure gradients. Conclusion The use of dual antiplatelet drugs in routine antithrombotic therapy tends to accelerate initial subclinical leaflet thrombosis after TAVI, which results in a developing restriction of leaflet mobility and an increase in pressure differences.
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Affiliation(s)
| | | | | | | | | | - Yarub Alalousi
- St Joseph University Medical Center, PatersonBrooklynNew YorkUSA
| | | | - Jobby John
- Dr. Somervell Memorial CSI Medical College and Hospital, NeyyāttinkaraThiruvananthapuramIndia
| | | | | | | | - Bita Amiri
- Cardiovascular Research CenterTabriz University of Medical SciencesTabrizIran
| | | | - Omniat Amir Hussin
- Internal MedicineAl Manhal University Academy of ScienceKhartoum NorthSudan
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15
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Karadzha A, Schaff HV, Padang R, Dearani JA, Arghami A, Stulak JM, Greason KL, Saran N, Lee AT, Lahr BD, Crestanello JA. Restricted cusp motion in newly implanted tricuspid bioprostheses: Incidence, predictors, and impact on survival. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00452-5. [PMID: 38825178 DOI: 10.1016/j.jtcvs.2024.05.021] [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: 02/04/2024] [Revised: 05/08/2024] [Accepted: 05/18/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVE To investigate the occurrence of restricted cusp motion (RCM) at the time of bioprosthetic tricuspid valve replacement (TVR) and analyze associated risk factors and outcomes. METHODS This study involved adult patients who underwent TVR with a bioprosthesis at our institution between 2012 and 2022. Bioprosthetic cusp motion was analyzed de novo through a detailed review of intraoperative transesophageal echocardiograms (TEE). Two models of porcine valves were implanted: the Medtronic Hancock II bioprosthesis and the St Jude Medical Epic bioprosthesis. RESULTS Among the 476 patients who met the inclusion criteria, RCM was identified on immediate post-bypass TEE in 150 (31.5%); there was complete immobility of the cusp in 63 patients (13.2%) and limited movement of a cusp in 87 patients (18.3%). In a multivariable logistic regression analysis, the Hancock II model (odds ratio [OR], 6.15; P < .001), a larger orifice area (per IQR increase: OR, 1.58; P = .017), a smaller body surface area (per IQR increase: OR, .68; P = .040), and a lower ejection fraction (per IQR increase: OR, .60; P = .033) were independently associated with having RCM. Cox regression adjusting for 15 covariates revealed that RCM at the time of TVR was independently associated with an increased risk of mortality (hazard ratio, 1.35; P = .049). CONCLUSIONS This study revealed a high incidence of RCM in bioprosthetic valves in the tricuspid position detected shortly postimplantation, which was associated with increased late mortality. To reduce the probability of RCM, it is important to select the appropriate prosthesis model and size, particularly in small patients.
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Affiliation(s)
| | | | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Alex T Lee
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minn
| | - Brian D Lahr
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minn
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16
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Kopjar T, Gasparovic H, Paar MH, Lovric D, Cerina P, Tokic T, Milicic D. Comparison of apixaban versus aspirin for the prevention of latent bioprosthetic aortic valve thrombosis: study protocol for a prospective randomized trial. Trials 2024; 25:324. [PMID: 38755709 PMCID: PMC11097528 DOI: 10.1186/s13063-024-08175-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/13/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND The optimal antithrombotic strategy early after aortic valve replacement surgery with a biological valve remains controversial due to lack of high-quality evidence. Either oral anticoagulants or acetylsalicylic acid should be considered for the first 3 months. Hypo-attenuated leaflet thickening on cardiac computed tomography has been associated with latent bioprosthetic valve thrombosis and may be prevented with anticoagulation. We hypothesize that anticoagulation with apixaban is superior to single antiplatelet therapy with acetylsalicylic acid in reducing hypo-attenuated leaflet thickening of bioprosthetic aortic valve prostheses. METHODS In this prospective, open-label, randomized trial, patients undergoing isolated aortic valve replacement surgery with rapid deployment bioprosthetic valves will be randomized. The treatment group will receive 5 mg of apixaban twice a day for the first 3 months and 100 mg of acetylsalicylic acid thereafter. The control group will be administered 100 mg of acetylsalicylic acid once a day, indefinitely. After the 3-month treatment period, a contrast-enhanced electrocardiogram-gated cardiac computed tomography will be performed to identify hypo-attenuated leaflet thickening of the bioprosthetic valve. The primary objective of the study is to assess the impact of apixaban on the prevention of hypo-attenuated leaflet thickening at 3 months. The secondary and exploratory endpoints will be clinical outcomes and safety profiles of the two strategies. DISCUSSION Antithrombotic therapy after aortic valve replacement is used to prevent valve thrombosis and systemic thromboembolism. Latent bioprosthetic valve thrombosis is a precursor of clinically significant prosthetic valve dysfunction or thromboembolic events. The hallmark feature of latent bioprosthetic valve thrombosis is hypo-attenuated leaflet thickening on cardiac computed tomography. Subclinical leaflet thrombosis occurs frequently in bioprosthetic aortic valves, more commonly in transcatheter than in surgical valves. There is no evidence on the effect of direct oral anticoagulants on the incidence of hypo-attenuated leaflet thickening after surgical aortic valve replacement with rapid deployment bioprostheses. TRIAL REGISTRATION ClinicalTrials.gov NCT06184113. Registered on December 28, 2023.
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Affiliation(s)
- Tomislav Kopjar
- Department of Cardiac Surgery, University Hospital Center Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia.
- University of Zagreb School of Medicine, Zagreb, Croatia.
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Center Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Maja Hrabak Paar
- Department of Radiology, University Hospital Center Zagreb, Zagreb, Croatia
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Daniel Lovric
- Department of Cardiovascular Diseases, University Hospital Center Zagreb, Zagreb, Croatia
| | - Petra Cerina
- Department of Cardiac Surgery, University Hospital Center Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia
| | - Tomislav Tokic
- Department of Cardiac Surgery, University Hospital Center Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia
| | - Davor Milicic
- Department of Cardiovascular Diseases, University Hospital Center Zagreb, Zagreb, Croatia
- University of Zagreb School of Medicine, Zagreb, Croatia
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17
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Natarajan T, Singh-Gryzbon S, Chen H, Sadri V, Ruile P, Neumann FJ, Yoganathan AP, Dasi LP. Sensitivity of Post-TAVR Hemodynamics to the Distal Aortic Arch Anatomy: A High-Fidelity CFD Study. Cardiovasc Eng Technol 2024:10.1007/s13239-024-00728-z. [PMID: 38653932 DOI: 10.1007/s13239-024-00728-z] [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: 09/13/2023] [Accepted: 03/22/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Patient-specific simulations of transcatheter aortic valve (TAV) using computational fluid dynamics (CFD) often rely on assumptions regarding proximal and distal anatomy due to the limited availability of high-resolution imaging away from the TAV site and the primary research focus being near the TAV. However, the influence of these anatomical assumptions on computational efficiency and resulting flow characteristics remains uncertain. This study aimed to investigate the impact of different distal aortic arch anatomies-some of them commonly used in literature-on flow and hemodynamics in the vicinity of the TAV using large eddy simulations (LES). METHODS Three aortic root anatomical configurations with four representative distal aortic arch types were considered in this study. The arch types included a 90-degree bend, an idealized distal aortic arch anatomy, a clipped version of the idealized distal aortic arch, and an anatomy extruded along the normal of segmented anatomical boundary. Hemodynamic parameters both instantaneous and time-averaged such as Wall Shear Stress (WSS), and Oscillatory Shear Index (OSI) were derived and compared from high-fidelity CFD data. RESULTS While there were minor differences in flow and hemodynamics across the configurations examined, they were generally not significant within our region of interest i.e., the aortic root. The choice of extension type had a modest impact on TAV hemodynamics, especially in the vicinity of the TAV with variations observed in local flow patterns and parameters near the TAV. However, these differences were not substantial enough to cause significant deviations in the overall flow and hemodynamic characteristics. CONCLUSIONS The results suggest that under the given configuration and boundary conditions, the type of outflow extension had a modest impact on hemodynamics proximal to the TAV. The findings contribute to a better understanding of flow dynamics in TAV configurations, providing insights for future studies in TAV-related experiments as well as numerical simulations. Additionally, they help mitigate the uncertainties associated with patient-specific geometries, offering increased flexibility in computational modeling.
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Affiliation(s)
- Thangam Natarajan
- Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Shelly Singh-Gryzbon
- Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
- Department of Chemical Engineering, University of the West Indies, St.Augustine, Trinidad and Tobago
| | - Huang Chen
- Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Vahid Sadri
- Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
- Abbott Laboratories, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Philipp Ruile
- Department of Cardiology and Angiology, Medical Center - University of Freiburg, and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology, Medical Center - University of Freiburg, and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ajit P Yoganathan
- Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle, Atlanta, GA, 30313-2412, USA
| | - Lakshmi P Dasi
- Department of Biomedical Engineering, Georgia Institute of Technology, 387 Technology Circle, Atlanta, GA, 30313-2412, USA.
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Thyregod HGH, Jørgensen TH, Ihlemann N, Steinbrüchel DA, Nissen H, Kjeldsen BJ, Petursson P, De Backer O, Olsen PS, Søndergaard L. Transcatheter or surgical aortic valve implantation: 10-year outcomes of the NOTION trial. Eur Heart J 2024; 45:1116-1124. [PMID: 38321820 PMCID: PMC10984572 DOI: 10.1093/eurheartj/ehae043] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/26/2023] [Accepted: 01/16/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND AND AIMS Transcatheter aortic valve implantation (TAVI) has become a viable treatment option for patients with severe aortic valve stenosis across a broad range of surgical risk. The Nordic Aortic Valve Intervention (NOTION) trial was the first to randomize patients at lower surgical risk to TAVI or surgical aortic valve replacement (SAVR). The aim of the present study was to report clinical and bioprosthesis outcomes after 10 years. METHODS The NOTION trial randomized 280 patients to TAVI with the self-expanding CoreValve (Medtronic Inc.) bioprosthesis (n = 145) or SAVR with a bioprosthesis (n = 135). The primary composite outcome was the risk of all-cause mortality, stroke, or myocardial infarction. Bioprosthetic valve dysfunction (BVD) was classified as structural valve deterioration (SVD), non-structural valve dysfunction (NSVD), clinical valve thrombosis, or endocarditis according to Valve Academic Research Consortium-3 criteria. Severe SVD was defined as (i) a transprosthetic gradient of 30 mmHg or more and an increase in transprosthetic gradient of 20 mmHg or more or (ii) severe new intraprosthetic regurgitation. Bioprosthetic valve failure (BVF) was defined as the composite rate of death from a valve-related cause or an unexplained death following the diagnosis of BVD, aortic valve re-intervention, or severe SVD. RESULTS Baseline characteristics were similar between TAVI and SAVR: age 79.2 ± 4.9 years and 79.0 ± 4.7 years (P = .7), male 52.6% and 53.8% (P = .8), and Society of Thoracic Surgeons score < 4% of 83.4% and 80.0% (P = .5), respectively. After 10 years, the risk of the composite outcome all-cause mortality, stroke, or myocardial infarction was 65.5% after TAVI and 65.5% after SAVR [hazard ratio (HR) 1.0; 95% confidence interval (CI) 0.7-1.3; P = .9], with no difference for each individual outcome. Severe SVD had occurred in 1.5% and 10.0% (HR 0.2; 95% CI 0.04-0.7; P = .02) after TAVI and SAVR, respectively. The cumulative incidence for severe NSVD was 20.5% and 43.0% (P < .001) and for endocarditis 7.2% and 7.4% (P = 1.0) after TAVI and SAVR, respectively. No patients had clinical valve thrombosis. Bioprosthetic valve failure occurred in 9.7% of TAVI and 13.8% of SAVR patients (HR 0.7; 95% CI 0.4-1.5; P = .4). CONCLUSIONS In patients with severe AS and lower surgical risk randomized to TAVI or SAVR, the risk of major clinical outcomes was not different 10 years after treatment. The risk of severe bioprosthesis SVD was lower after TAVR compared with SAVR, while the risk of BVF was similar.
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Affiliation(s)
- Hans Gustav Hørsted Thyregod
- Department of Cardiothoracic Surgery, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Troels Højsgaard Jørgensen
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Nikolaj Ihlemann
- Department of Cardiology, Bispebjerg University Hospital, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Daniel Andreas Steinbrüchel
- Department of Cardiothoracic Surgery, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Henrik Nissen
- Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Bo Juel Kjeldsen
- Department of Cardiothoracic and Vascular Surgery, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - Petur Petursson
- Department of Cardiology, Sahlgrenska University Hospital, Blå Stråket 5, 413 45 Gothenburg, Sweden
| | - Ole De Backer
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Peter Skov Olsen
- Department of Cardiothoracic Surgery, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Lars Søndergaard
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
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19
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Kim M, Ahn JM, Kang DY, Kim MJ, Kim KW, Koo HJ, Yang DH, Jung SC, Kim B, Wong YTA, Lam CCS, Yin WH, Wei J, Lee YT, Kao HL, Lin MS, Yu Ko T, Kim WJ, Kang SH, Lee SA, Ko E, Kim DH, Kang JW, Lee JH, Lee J, Park J, Kim H, Choi Y, Park SJ, Park DW. Low- or standard-dose edoxaban versus antiplatelet therapy for leaflet thrombus and cerebral thromboembolism after TAVR: A prespecified analysis of randomized ADAPT-TAVR trial. Am Heart J 2024; 269:167-178. [PMID: 38123045 DOI: 10.1016/j.ahj.2023.12.006] [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: 09/21/2023] [Revised: 12/04/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The risks of leaflet thrombosis and the associated cerebral thromboembolism are unknown according to different anticoagulation dosing after transcatheter aortic valve replacement (TAVR). The aim was to evaluate the incidence of leaflet thrombosis and cerebral thromboembolism between low-dose (30 mg) or standard-dose (60 mg) edoxaban and dual antiplatelet therapy (DAPT) after TAVR. METHODS In this prespecified subgroup analysis of the ADAPT-TAVR trial, the primary endpoint was the incidence of leaflet thrombosis on 4-dimensional computed tomography at 6-months. Key secondary endpoints were new cerebral lesions on brain magnetic resonance imaging and neurological and neurocognitive dysfunction. RESULTS Of 229 patients enrolled in this study, 118 patients were DAPT group and 111 were edoxaban group (43 [39.1%] 60 mg vs 68 [61.3%] 30 mg). There was a significantly lower incidence of leaflet thrombosis in the standard-dose edoxaban group than in the DAPT group (2.4% vs 18.3%; odds ratio [OR] 0.11; 95% confidence interval [CI], 0.01-0.55; P = .03). However, no significant difference was observed between low-dose edoxaban and DAPT (15.0% vs 18.3%; OR 0.79; 95% CI, 0.32-1.81; P = .58). Irrespective of different antithrombotic regiments, the percentages of patients with new cerebral lesions on brain MRI and worsening neurological or neurocognitive function were not significantly different. CONCLUSIONS In patients without an indication for anticoagulation after TAVR, the incidence of leaflet thrombosis was significantly lower with standard-dose edoxaban but not with low-dose edoxaban, as compared with DAPT. However, this differential effect of edoxaban on leaflet thrombosis was not associated with a reduction of new cerebral thromboembolism and neurological dysfunction.
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Affiliation(s)
- Mijin Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Do-Yoon Kang
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min-Ju Kim
- Division of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyung Won Kim
- Asan Image Metrics, Clinical Trial Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Republic of Korea
| | - Hyun Jung Koo
- Department of Radiology Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Yang
- Department of Radiology Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung Chai Jung
- Department of Radiology Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byungjun Kim
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yiu Tung Anthony Wong
- Division of Cardiology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Cheung Chi Simon Lam
- Division of Cardiology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Jeng Wei
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yung-Tsai Lee
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Mao-Shin Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung Yu Ko
- Division of Cardiology, Department of Internal Medicine, Hsin-Chu Branch, National Taiwan University Hospital, Hsin-Chu, Taiwan
| | - Won-Jang Kim
- Department of Cardiology, CHA Bundang Medical Center, Seongnam, Republic of Korea
| | - Se Hun Kang
- Department of Cardiology, CHA Bundang Medical Center, Seongnam, Republic of Korea
| | - Seung-Ah Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Euihong Ko
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Dae-Hee Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joon-Won Kang
- Department of Radiology Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae-Hong Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinho Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsun Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hoyun Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeonwoo Choi
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Abbasciano RG, Magouliotis DE, Koulouroudias M, Spiliopoulos K, Xanthopoulos A, Kourliouros A, Casula R, Athanasiou T, Viviano A. Valve Type and Operative Risks in Surgical Explantation of Transcatheter Aortic Valves: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:1262. [PMID: 38592075 PMCID: PMC10932147 DOI: 10.3390/jcm13051262] [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: 01/28/2024] [Revised: 02/15/2024] [Accepted: 02/17/2024] [Indexed: 04/10/2024] Open
Abstract
Indication to perform surgical explantation of TAVR is becoming increasingly more frequent, due to the higher number of transcatheter procedures performed in patients with longer life expectancy. We proposed to perform a systematic review and meta-analysis with metaregression to identify potential factors that can determine an increase in the high mortality and morbidity that characterize these surgical procedures. MEDLINE and Embase were searched for relevant studies. Twelve studies were eligible according to our inclusion criteria. TAVR explantation was confirmed as a procedure with high 30-day mortality (0.17; 95% CI, 0.14-0.21) and morbidity (stroke incidence 5%; 95% CI, 0.04-0.07; kidney injury incidence 16%; 95% CI, 0.11-0.24). The type of transcatheter valve implanted during the index procedure did not influence the outcomes after surgical explantation. The role of these high-risk operations is growing, and it will likely expand in the coming years. Specific tools for risk stratification are required.
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Affiliation(s)
- Riccardo G. Abbasciano
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London W12 0HS, UK; (R.G.A.); (R.C.)
- Department of Surgery & Cancer, Imperial College, London SW7 2BX, UK;
| | - Dimitrios E. Magouliotis
- Unit of Quality Improvement, Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41 110 Larissa, Greece;
| | - Marinos Koulouroudias
- Department of Cardiac Surgery, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK;
| | - Kyriakos Spiliopoulos
- Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41 110 Larissa, Greece;
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 413 34 Larissa, Greece;
| | - Antonios Kourliouros
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Roberto Casula
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London W12 0HS, UK; (R.G.A.); (R.C.)
| | - Thanos Athanasiou
- Department of Surgery & Cancer, Imperial College, London SW7 2BX, UK;
| | - Alessandro Viviano
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, London W12 0HS, UK; (R.G.A.); (R.C.)
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21
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Alaour B, Ferrari E, Heg D, Tueller D, Pilgrim T, Muller O, Noble S, Jeger R, Reuthebuch O, Toggweiler S, Templin C, Wenaweser P, Nietlispach F, Taramasso M, Huber C, Roffi M, Windecker S, Stortecky S. Non-Vitamin K Antagonist Versus Vitamin K Antagonist Oral Anticoagulant Agents After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2024; 17:405-418. [PMID: 38355269 DOI: 10.1016/j.jcin.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Studies comparing long-term outcomes between non-vitamin K antagonist (VKA) oral anticoagulant agents (direct oral anticoagulant agents [DOACs]) and VKA anticoagulant agents after transcatheter aortic valve replacement (TAVR) are scarce, with conflicting results. OBJECTIVES The aim of this study was to examine the periprocedural, short-term, and long-term safety and effectiveness of DOACs vs VKAs in patients undergoing TAVR via femoral access with concomitant indications for oral anticoagulation. METHODS Consecutive patients undergoing transfemoral TAVR in the prospective national SwissTAVI Registry between February 2011 and June 2021 were analyzed. Net clinical benefit (a composite of all-cause mortality, myocardial infarction, stroke, and life-threatening or major bleeding) and the primary safety endpoint (a composite of life-threatening and major bleeding) were compared between the VKA and DOAC groups at 30 days, 1 year, and 5 years after TAVR. RESULTS After 1:1 propensity score matching, 1,454 patients were available for analysis in each group. There was no significant difference in the rate of the net clinical benefit and the safety endpoints between the groups as assessed at 30 days and 1 and 5 years post-TAVR between VKAs and DOACs. VKAs were associated with significantly higher rates of 1- year (HR: 1.28; 95% CI: 1.01-1.62) and 5-year (HR: 1.25; 95% CI: 1.11-1.40) all-cause mortality. Long-term risk for disabling stroke was significantly lower in the VKA group after excluding periprocedural events (HR: 0.64; 95% CI: 0.46-0.90). CONCLUSIONS At 5 years after TAVR, VKAs are associated with a higher risk for all-cause mortality, a lower risk for disabling stroke, and a similar rate of life-threatening or major bleeding compared with DOACs. (SwissTAVI Registry; NCT01368250).
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Affiliation(s)
- Bashir Alaour
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Enrico Ferrari
- Department of Cardiovascular Surgery, Cardiocentro Ticino Institute-EOC, Lugano, Switzerland
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - David Tueller
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital-CHUV, Lausanne, Switzerland
| | - Stephane Noble
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Raban Jeger
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland; University of Basel, Basel, Switzerland
| | - Oliver Reuthebuch
- University of Basel, Basel, Switzerland; Department of Cardiovascular Surgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | | | - Christian Templin
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Peter Wenaweser
- Heart Clinic Hirslanden, Hirslanden Clinic Zurich, Zurich, Switzerland
| | | | | | - Christoph Huber
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Marco Roffi
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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22
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Ishizu K, Shirai S, Miyawaki N, Nakano K, Fukushima T, Ko E, Tsuru Y, Tashiro H, Tabata H, Nakamura M, Morofuji T, Morinaga T, Hayashi M, Isotani A, Ohno N, Kakumoto S, Ando K. Impact of Transjugular Intracardiac Echocardiography-Guided Self-Expandable Transcatheter Aortic Valve Implantation on Reduction of Conduction Disturbances. Circ Cardiovasc Interv 2024; 17:e013094. [PMID: 38152879 DOI: 10.1161/circinterventions.123.013094] [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: 03/26/2023] [Accepted: 10/20/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND A high permanent pacemaker implantation (PPI) risk remains a concern of self-expandable transcatheter aortic valve implantation, despite the continued improvements in implantation methodology. We aimed to assess the impact of real-time direct visualization of the membranous septum using transjugular intracardiac echocardiography (ICE) during transcatheter aortic valve implantation on reducing the rates of conduction disturbances including the need for PPI. METHODS Consecutive patients treated with Evolut R and Evolut PRO/PRO+ from February 2017 to September 2022 were included in this study. We compared outcomes between the conventional implantation method using the 3-cusps view (3 cusps without ICE group), the recent method using cusp-overlap view (cusp overlap without ICE group), and our novel method using ICE (cusp overlap with ICE group). RESULTS Of the 446 patients eligible for analysis, 211 (47.3%) were categorized as the 3 cusps without ICE group, 129 (28.9%) were in the cusp overlap without ICE group, and 106 (23.8%) comprised the cusp overlap with ICE group. Compared with the 3 cusps without ICE group, the cusp overlap without ICE group had a smaller implantation depth (2.2 [interquartile range, 1.0-3.5] mm versus 4.3 [interquartile range, 3.3-5.4] mm; P<0.001) and lower 30-day PPI rates (7.0% versus 14.2%; P=0.035). Compared with the cusp overlap without ICE group, the cusp overlap with ICE group had lower 30-day PPI rates (0.9%; P=0.014), albeit with comparable implantation depths (1.9 [interquartile range, 0.9-2.9] mm; P=0.150). Multivariable analysis showed that our novel method using ICE with the cusp-overlap view was independently associated with a 30-day PPI rate reduction. There were no group differences in 30-day all-cause mortality (1.4% versus 1.6% versus 0%; P=0.608). CONCLUSIONS Our novel implantation method using transjugular ICE, which enable real-time direct visualization of the membranous septum, achieved a predictably high position of prostheses, resulting in a substantial reduction of conduction disturbances requiring PPI after transcatheter aortic valve implantation.
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Affiliation(s)
- Kenichi Ishizu
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Shinichi Shirai
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Norihisa Miyawaki
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kenji Nakano
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Tadatomo Fukushima
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Euihong Ko
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Yasuo Tsuru
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Hiroaki Tashiro
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Hiroyuki Tabata
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Miho Nakamura
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Toru Morofuji
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Takashi Morinaga
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Masaomi Hayashi
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Akihiro Isotani
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Nobuhisa Ohno
- Department of Cardiovascular Surgery (N.O.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Shinichi Kakumoto
- Department of Anesthesiology (S.K.), Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kenji Ando
- Department of Cardiology (K.I., S.S., N.M., K.N., T.F., E.K., Y.T., H. Tashiro, H. Tabata, M.N., T. Morofuji, T. Morinaga, M.H., A.I., K.A.), Kokura Memorial Hospital, Kitakyushu, Japan
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Kim JH, Sadri V, Chen H, Bhat S, Kohli K, Makkar R, Babaliaros VC, Sharma RP, Yoganathan AP. Effect of Ascending Aortic Curvature on Flow in the Sinus and Neo-sinus Following TAVR: A Patient-Specific Study. Ann Biomed Eng 2024; 52:425-439. [PMID: 37922056 DOI: 10.1007/s10439-023-03392-x] [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: 04/04/2023] [Accepted: 10/23/2023] [Indexed: 11/05/2023]
Abstract
Patient-specific aortic geometry and its influence on the flow in the vicinity of Transcatheter Aortic Valve (TAV) has been highlighted in numerous studies using both in silico and in vitro experiments. However, there has not yet been a detailed Particle Image Velocimetry (PIV) experiment conducted to quantify the relationship between the geometry, flow downstream of TAV, and the flow in the sinus and the neo-sinus. We tested six different patient-specific aorta models with a 26-mm SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA, USA) in a left heart simulator with coronary flow. Velocities in all three cusps and circulation downstream of TAV were computed to evaluate the influence of the ascending aorta curvature on the flow field. The in vitro analysis showed that the patient-specific aortic curvature had positive correlation to the circulation in the ascending aorta (p = 0.036) and circulation had negative correlation to the particle washout time in the cusps (p = 0.011). These results showed that distinct vortical flow patterns in the ascending aorta as the main jet impinges on the aortic wall causes a recirculation region that facilitates the flow back into the sinus and the neo-sinus, thus reducing the risk of flow stagnation and washout time.
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Affiliation(s)
- Jae Hyun Kim
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Vahid Sadri
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Huang Chen
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Sanchita Bhat
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Keshav Kohli
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Raj Makkar
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, USA
| | | | - Rahul P Sharma
- Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA.
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Maznyczka A, Pilgrim T. Antithrombotic Treatment After Transcatheter Valve Interventions: Current Status and Future Directions. Clin Ther 2024; 46:122-133. [PMID: 37926630 DOI: 10.1016/j.clinthera.2023.09.028] [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: 06/26/2023] [Revised: 09/15/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE The optimal antithrombotic strategy after transcatheter valve interventions is a subject of ongoing debate. Although there is evidence from randomized trials in patients undergoing transcatheter aortic valve replacement (TAVR), current evidence on optimal antithrombotic management after transcatheter mitral or tricuspid valve interventions is sparse. This article appraises the current evidence on this topic. METHODS This narrative review presents key research findings and guideline recommendations, as well as highlights areas for future research. FINDINGS After TAVR, randomized trial evidence suggests that single antiplatelet therapy is reasonable for patients without pre-existing indications for oral anticoagulation (OAC). If there is a concurrent indication for OAC, the addition of antiplatelet therapy increases bleeding risk. Whether direct oral anticoagulants achieve better outcomes than vitamin K antagonists is uncertain in this setting. Although OAC has been shown to reduce subclinical leaflet thrombosis (which may progress to structural valve degeneration), bleeding events are unacceptably high. There is a lack of randomized trial data comparing antithrombotic strategies after transcatheter mitral or tricuspid valve replacement or after mitral or tricuspid transcatheter edge-to-edge repair. Single antiplatelet therapy after mitral or tricuspid transcatheter edge-to-edge repair may be appropriate, whereas at least 3 months of OAC is suggested after transcatheter mitral valve replacement or transcatheter tricuspid valve replacement. IMPLICATIONS Randomized studies are warranted to address the knowledge gaps in antithrombotic therapy after transcatheter valve interventions and to optimize outcomes.
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Affiliation(s)
- Annette Maznyczka
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, Bern, Switzerland.
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25
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Magyari B, Kittka B, Goják I, Schönfeld K, Szapáry LB, Simon M, Kiss R, Bertalan A, Várady E, Gyimesi A, Szokodi I, Horváth IG. Single-Center Experience with the Balloon-Expandable Myval Transcatheter Aortic Valve System in Patients with Bicuspid Anatomy: Procedural and 30-Day Follow-Up. J Clin Med 2024; 13:513. [PMID: 38256647 PMCID: PMC10816957 DOI: 10.3390/jcm13020513] [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: 12/10/2023] [Revised: 01/04/2024] [Accepted: 01/13/2024] [Indexed: 01/24/2024] Open
Abstract
Aims: To report our single-center data regarding the initial 52 consecutive patients with a bicuspid aortic valve who underwent a Transcatheter Aortic Valve Implantation (TAVI) procedure using the new balloon-expandable MYVAL system. The focus is on reporting procedural details and outcomes over the 30-day postoperative period. Methods: From December 2019 to July 2023, 52 consecutive patients underwent a TAVI procedure with bicuspid anatomy. All patients had moderate to-high surgical risk or were unsuitable for surgical aortic valve replacement based on the Heart Team's decision. Outcomes were analyzed according to the VARC-2 criteria. The results of bicuspid patients were compared to patients with tricuspid anatomy in the overall study group, and further analysis involved a comparison between 52 pairs after propensity score matching. The device performance was evaluated using transthoracic echocardiography. Data collection was allowed by the Local Ethical Committee. Results: The mean age was 71 ± 7.1 years, and 65.4% were male. The mean Euroscore II and STS score were 3.3 ± 3.2 and 5.2 ± 3.3, respectively. Baseline characteristics and echocardiographic parameters were well balanced even in the unmatched comparison. Procedures were significantly longer in the bicuspid group and resulted in a significantly higher ARI index. All relevant anatomic dimensions based on the CT scans were significantly higher in bicuspid anatomy, including a higher implantation angulation, a higher rate of horizontal aorta and a higher proportion of patients with aortopathy. In the unmatched bicuspid vs. tricuspid comparison, postprocedural outcomes were as follows: in-hospital mortality 0% vs. 1.4% (p = 0.394), device success 100% vs. 99.1% (p = 0.487), TIA 1.9% vs. 0% (p = 0.041), stroke 1.9% vs. 0.9% (p = 0.537), major vascular complication 3.8% vs. 2.3% (p = 0.530), permanent pacemaker implantation 34% vs. 30.4% (p = 0.429), and cardiac tamponade 0% vs. 0.5% (p = 0.624). In the propensity-matched bicuspid vs. tricuspid comparison, postprocedural outcomes were as follows: in-hospital mortality 0% vs. 0%, device success 100% vs. 100%, TIA 1.9% vs. 0% (p = 0.315), stroke 1.9% vs. 0.9% (p = 0.315), major vascular complication 3.8% vs. 0% (p = 0.475), permanent pacemaker implantation 34% vs. 24% (p = 0.274), and cardiac tamponade 0% vs. 0%. There was no annular rupture nor need for second valve or severe aortic regurgitation in both the unmatched and matched comparison. The peak and mean aortic gradients did not differ at discharge and at 30-day follow-up between the two groups regardless of whether the comparison was unmatched or matched. There were no paravalvular leakages (moderate or above) in the bicuspid patients. Intermediate and extra sizes of the Myval THV system used a significantly higher proportion in bicuspid anatomy with a significantly higher oversize percentage in tricuspid anatomy. Conclusions: The TAVI procedure using the Myval THV system in patients with significant aortic stenosis and bicuspid aortic valve anatomy is safe and effective. Hemodynamic parameters do not differ between tricuspid and bicuspid patients. However, the permanent pacemaker implantation rate is higher than expected; its relevance on long-term survival is controversial.
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Affiliation(s)
- Balázs Magyari
- Heart Institute, Medical School, University of Pécs, 13 Ifjuság Str., H-7624 Pécs, Hungary; (B.K.); (I.G.); (K.S.); (L.B.S.); (M.S.); (R.K.); (A.B.); (I.S.); (I.G.H.)
- Szentágothai Research Centre, University of Pécs, H-7624 Pécs, Hungary
| | - Bálint Kittka
- Heart Institute, Medical School, University of Pécs, 13 Ifjuság Str., H-7624 Pécs, Hungary; (B.K.); (I.G.); (K.S.); (L.B.S.); (M.S.); (R.K.); (A.B.); (I.S.); (I.G.H.)
- Szentágothai Research Centre, University of Pécs, H-7624 Pécs, Hungary
| | - Ilona Goják
- Heart Institute, Medical School, University of Pécs, 13 Ifjuság Str., H-7624 Pécs, Hungary; (B.K.); (I.G.); (K.S.); (L.B.S.); (M.S.); (R.K.); (A.B.); (I.S.); (I.G.H.)
| | - Kristóf Schönfeld
- Heart Institute, Medical School, University of Pécs, 13 Ifjuság Str., H-7624 Pécs, Hungary; (B.K.); (I.G.); (K.S.); (L.B.S.); (M.S.); (R.K.); (A.B.); (I.S.); (I.G.H.)
- Szentágothai Research Centre, University of Pécs, H-7624 Pécs, Hungary
| | - László Botond Szapáry
- Heart Institute, Medical School, University of Pécs, 13 Ifjuság Str., H-7624 Pécs, Hungary; (B.K.); (I.G.); (K.S.); (L.B.S.); (M.S.); (R.K.); (A.B.); (I.S.); (I.G.H.)
- Szentágothai Research Centre, University of Pécs, H-7624 Pécs, Hungary
| | - Mihály Simon
- Heart Institute, Medical School, University of Pécs, 13 Ifjuság Str., H-7624 Pécs, Hungary; (B.K.); (I.G.); (K.S.); (L.B.S.); (M.S.); (R.K.); (A.B.); (I.S.); (I.G.H.)
- Szentágothai Research Centre, University of Pécs, H-7624 Pécs, Hungary
| | - Rudolf Kiss
- Heart Institute, Medical School, University of Pécs, 13 Ifjuság Str., H-7624 Pécs, Hungary; (B.K.); (I.G.); (K.S.); (L.B.S.); (M.S.); (R.K.); (A.B.); (I.S.); (I.G.H.)
| | - Andrea Bertalan
- Heart Institute, Medical School, University of Pécs, 13 Ifjuság Str., H-7624 Pécs, Hungary; (B.K.); (I.G.); (K.S.); (L.B.S.); (M.S.); (R.K.); (A.B.); (I.S.); (I.G.H.)
| | - Edit Várady
- Department of Medical Imaging, Medical School, University of Pécs, H-7624 Pécs, Hungary;
| | - András Gyimesi
- EconNet Research Group, Faculty of Business and Economics, University of Pécs, H-7624 Pécs, Hungary;
| | - István Szokodi
- Heart Institute, Medical School, University of Pécs, 13 Ifjuság Str., H-7624 Pécs, Hungary; (B.K.); (I.G.); (K.S.); (L.B.S.); (M.S.); (R.K.); (A.B.); (I.S.); (I.G.H.)
- Szentágothai Research Centre, University of Pécs, H-7624 Pécs, Hungary
| | - Iván Gábor Horváth
- Heart Institute, Medical School, University of Pécs, 13 Ifjuság Str., H-7624 Pécs, Hungary; (B.K.); (I.G.); (K.S.); (L.B.S.); (M.S.); (R.K.); (A.B.); (I.S.); (I.G.H.)
- Szentágothai Research Centre, University of Pécs, H-7624 Pécs, Hungary
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26
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Passaniti G, Prandi FR, Sharma S, Kini A, Lerakis S. Echo HALT: do we really need a cardiac CT? THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:81-82. [PMID: 37983001 DOI: 10.1007/s10554-023-03009-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 11/07/2023] [Indexed: 11/21/2023]
Abstract
Leaflet thrombosis is usually an incidental finding and Cardiac CT is the gold standard for its diagnosis, but the classic features of hypoattenuation leaflet thickening (HALT) and hypoattenuation affecting motion (HAM) can also be seen on echocardiography and more specifically on trans-esophageal echocardiography. We describe a case of transcatheter aortic valve thrombosis where both the diagnosis and treatment were based exclusively on the echocardiographic evaluation, without the need of cardiac CT, with good outcome for the patient.
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Affiliation(s)
- Giulia Passaniti
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- CAST, Cardiology Division, A.U.O. Policlinico "G. Rodolico-San Marco", Catania, 95123, Italy
| | - Francesca Romana Prandi
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
- Tor Vergata University, Rome, 00133, Italy
| | - Samin Sharma
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Annapoorna Kini
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Stamatios Lerakis
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
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27
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Jung S, Ammon F, Smolka S, Moshage M, Marwan M, Achenbach S. Commissural misalignment independently predicts leaflet thrombosis after transcatheter aortic valve implantation. Clin Res Cardiol 2024; 113:29-37. [PMID: 37022472 PMCID: PMC10808532 DOI: 10.1007/s00392-023-02192-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 03/24/2023] [Indexed: 04/07/2023]
Abstract
AIMS Transcatheter aortic valve implantation (TAVI) has become a minimally invasive alternative to surgical aortic valve replacement. Hypo-attenuated leaflet thickening (HALT)-a marker of subclinical leaflet thrombosis commonly detected by cardiac computed tomography (CT) after TAVI-may influence valve durability and function. The purpose of this study was to compare commissural alignment of the native and prosthetic aortic valves in cardiac CT in subjects with and without HALT and thereby identify commissural misalignment as potential predictor for leaflet thrombosis after TAVI. METHODS AND RESULTS In 170 subjects, 85 with and 85 without HALT in post-TAVI CT, commissural orientation of the prosthesis was determined comparing native and prosthetic aortic valve orientation in cardiac CT by measuring the commissural angle relative to the right coronary ostium in the aortic valve plane. For the prosthetic valve, any deviation ≤ 15° compared to the native valve was classified as "aligned"; 16-30° as "mild", 31-45° as "moderate" and ≥ 45° as "severe" misalignment. Among subjects with HALT, median angular deviation was higher (36°, IQR 31°) than in the control group (29°, IQR 29°, p = 0.042). "Severe" misalignment was more frequent in subjects who developed HALT (n = 31, 37%) compared to the control group (n = 17, 20%, p = 0.013). In logistic regression analysis, more severe deviation (p = 0.015, OR = 1.02 per 1° deviation) and "severe" misalignment (p = 0.018, OR = 2.2) represented independent predictors for the occurrence of HALT after TAVI. CONCLUSION Subclinical leaflet thrombosis after TAVI is associated with commissural misalignment. Potential clinical advantages of obtaining commissural alignment remain to be systematically assessed.
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Affiliation(s)
- Susanne Jung
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany.
| | - Fabian Ammon
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Silvia Smolka
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Maximilian Moshage
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Mohamed Marwan
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Stephan Achenbach
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
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28
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Kawashima H, Numasawa Y, Hayakawa N, Asano T, Tanaka S, Torii S, Ueshima D, Hishikari K, Hioki H, Watanabe Y, Mizutani K, Matsuo Y, Hayashida K, Jujo K, Nakazawa G. Review of Bleeding and Thrombotic Risks Associated With Antithrombotic Therapy After Transcatheter Structural Heart Interventions. JACC. ASIA 2024; 4:1-9. [PMID: 38222261 PMCID: PMC10782401 DOI: 10.1016/j.jacasi.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 01/16/2024]
Abstract
Transcatheter structural heart interventions have drastically evolved over the past 2 decades. However, most catheterization procedures require the deployment of devices in the body; therefore, the adhesion of thrombi to those devices is a major problem, resulting in the requirement of a period of postprocedural antithrombotic regimen. However, in recent years, bleeding associated with these antithrombotic therapies has also become a major concern, attracting the attention of investigators. This is complicated by the fact that patients at high thrombotic risk are also at high bleeding risk, making the issue of administrating antithrombotic therapy challenging. The objective of this review was to identify the important issues and summarize the current status of postoperative antithrombotic therapy and assessment of the bleeding risk following transcatheter structural heart interventions such as transcatheter aortic valve replacement, transcatheter edge-to-edge repair, and transcatheter left atrial appendage occlusion.
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Affiliation(s)
- Hideyuki Kawashima
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Naoki Hayakawa
- Department of Cardiovascular Medicine, Asahi General Hospital, Asahi, Japan
| | - Taku Asano
- Department of Cardiovascular Medicine, St. Luke’s International Hospital, St. Luke's International University, Tokyo, Japan
| | - Shigemitsu Tanaka
- Department of Cardiology, Tokai University School of Medicine, Isehara, Japan
| | - Sho Torii
- Department of Cardiology, Tokai University School of Medicine, Isehara, Japan
| | - Daisuke Ueshima
- Department of Cardiology, Kameda Medical Center, Kamogawa, Japan
| | - Keiichi Hishikari
- Department of Cardiology, Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Hirofumi Hioki
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Kazuki Mizutani
- Department of Cardiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Yae Matsuo
- Department of Cardiovascular Medicine, Cardiovascular Hospital of Central Japan (Kitakanto Cardiovascular Hospital), Shibukawa, Gunma, Japan
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Jujo
- Department of Cardiology, Saitama Medical University/Saitama Medical Center, Saitama, Japan
| | - Gaku Nakazawa
- Department of Cardiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - SUNRISE Lab Investigators
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
- Department of Cardiovascular Medicine, Asahi General Hospital, Asahi, Japan
- Department of Cardiovascular Medicine, St. Luke’s International Hospital, St. Luke's International University, Tokyo, Japan
- Department of Cardiology, Tokai University School of Medicine, Isehara, Japan
- Department of Cardiology, Kameda Medical Center, Kamogawa, Japan
- Department of Cardiology, Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
- Department of Cardiology, Kindai University Faculty of Medicine, Osaka, Japan
- Department of Cardiovascular Medicine, Cardiovascular Hospital of Central Japan (Kitakanto Cardiovascular Hospital), Shibukawa, Gunma, Japan
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
- Department of Cardiology, Saitama Medical University/Saitama Medical Center, Saitama, Japan
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29
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Thong EHE, Kong WKF, Poh KK, Wong R, Chai P, Sia CH. Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review. J Cardiovasc Dev Dis 2023; 11:13. [PMID: 38248883 PMCID: PMC10816708 DOI: 10.3390/jcdd11010013] [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: 11/08/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.
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Affiliation(s)
| | - William K. F. Kong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Raymond Wong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ping Chai
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
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30
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Choi Y, Ahn JM, Kang DY, Kim HJ, Kim H, Lee J, Kim M, Park J, Kim KW, Koo HJ, Yang DH, Jung SC, Kim B, Anthony Wong YT, Simon Lam CC, Yin WH, Wei J, Lee YT, Kao HL, Lin MS, Ko TY, Kim WJ, Kang SH, Lee SA, Kim DH, Lee JH, Park SJ, Park DW. Frequency, Predictors, and Clinical Impact of Valvular and Perivalvular Thrombus After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2023; 16:2967-2981. [PMID: 38151311 DOI: 10.1016/j.jcin.2023.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Subclinical aortic valve complex (valvular and perivalvular) thrombus is not rare after transcatheter aortic valve replacement (TAVR). The risk factors and clinical implications of these findings remain uncertain. OBJECTIVES This study sought to evaluate the frequency, predictors, and clinical outcome of aortic valve complex thrombus after TAVR. METHODS In the ADAPT-TAVR (Anticoagulation Versus Dual Antiplatelet Therapy for Prevention of Leaflet Thrombosis and Cerebral Embolization After Transcatheter Aortic Valve Replacement) trial comparing edoxaban vs dual antiplatelet therapy in TAVR patients without an indication for chronic anticoagulation, the frequency of valvular (subclinical leaflet thrombus) and perivalvular (supravalvular, subvalvular, and sinus of Valsalva) thrombus was evaluated by 4-dimensional computed tomography at 6 months. The association of these phenomena with new cerebral thromboembolism on brain magnetic resonance imaging, neurologic and neurocognitive dysfunction, and clinical outcomes was assessed. RESULTS Among 211 patients with 6-month computed tomography evaluations, 91 patients (43.1%) had thrombus at any aortic valve complex, 30 (14.2%) patients had leaflet thrombus, and 78 (37.0%) patients had perivalvular thrombus. A small maximum diameter of the stent at the valve level and low body surface area were independent predictors of aortic valve complex and perivalvular thrombus, and decreased renal function was an independent predictor of leaflet thrombus. No significant differences were observed in new cerebral lesions, neurologic or neurocognitive functions, or clinical outcomes among patients with or without valvular or perivalvular thrombus. CONCLUSIONS Subclinical aortic valve complex (valvular and perivalvular) thrombus was common in patients who had undergone successful TAVR. However, these imaging phenomena were not associated with new cerebral thromboembolism, neurologic or neurocognitive dysfunction, or adverse clinical outcomes. (Anticoagulation Versus Dual Antiplatelet Therapy for Prevention of Leaflet Thrombosis and Cerebral Embolization After Transcatheter Aortic Valve Replacement [ADAPT-TAVR]; NCT03284827).
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Affiliation(s)
- Yeonwoo Choi
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do-Yoon Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwa Jung Kim
- Division of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hoyun Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jinho Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mijin Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jinsun Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Won Kim
- Asan Image Metrics, Clinical Trial Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - Hyun Jung Koo
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Hyun Yang
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Chai Jung
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byungjun Kim
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yiu Tung Anthony Wong
- Division of Cardiology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Cheung Chi Simon Lam
- Division of Cardiology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Jeng Wei
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yung-Tsai Lee
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Mao-Shin Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung-Yu Ko
- Division of Cardiology, Department of Internal Medicine, Hsin-Chu Branch, National Taiwan University Hospital, Hsin-Chu, Taiwan
| | - Won-Jang Kim
- Department of Cardiology, CHA Medical Center, Korea
| | - Se Hun Kang
- Department of Cardiology, CHA Medical Center, Korea
| | - Seung-Ah Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Hee Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Hong Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Okuno T, Alaour B, Heg D, Tueller D, Pilgrim T, Muller O, Noble S, Jeger R, Reuthebuch O, Toggweiler S, Ferrari E, Templin C, Wenaweser P, Nietlispach F, Taramasso M, Huber C, Roffi M, Windecker S, Stortecky S. Long-Term Risk of Stroke After Transcatheter Aortic Valve Replacement: Insights From the SwissTAVI Registry. JACC Cardiovasc Interv 2023; 16:2986-2996. [PMID: 38151313 DOI: 10.1016/j.jcin.2023.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/26/2023] [Accepted: 10/10/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Stroke after transcatheter aortic valve replacement (TAVR) is associated with considerable morbidity and mortality. Predictors of stroke and the long-term risk after TAVR remain incompletely understood. OBJECTIVES The authors sought to investigate the short- and long-term incidence and predictors of stroke after TAVR in the SwissTAVI Registry. METHODS Between February 2011 and June 2021, consecutive patients undergoing TAVR were included. Standardized stroke ratios (SSRs) were calculated to compare trends in stroke of TAVR patients with an age- and sex-matched general population in Switzerland derived from the 2019 Global Burden of Disease study. RESULTS A total of 11,957 patients (81.8 ± 6.5 years of age, 48.0% female) were included. One-third of the patients (32.3%) had a history of atrial fibrillation, and 11.8% had a history of cerebrovascular accident. The cumulative 30-day incidence rate of stroke was 3.0%, with 69% of stroke events occurring within the first 48 hours after TAVR. The incidence of stroke was 4.3% at 1 year, and 7.8% at 5 years. Compared with an age- and sex-adjusted general population, the risk of stroke was significantly higher in the TAVR population during the first 2 years after TAVR: first year: SSR 7.26 (95% CI: 6.3-8.36) and 6.82 (95% CI: 5.97-7.79) for males and females, respectively; second year: SSR 1.98 (95% CI: 1.47-2.67) and 1.48 (95% CI: 1.09-2.02) for males and females, respectively; but returned to a comparable level to that observed in the matched population thereafter. CONCLUSIONS Compared with an age- and sex-matched population, TAVR patients experienced a higher risk of stroke for up to 2 years after the procedure, and a comparable risk thereafter. (SwissTAVI Registry; NCT01368250).
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Affiliation(s)
- Taishi Okuno
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Bashir Alaour
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - David Tueller
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital - CHUV, Lausanne, Switzerland
| | - Stephane Noble
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Raban Jeger
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland; University of Basel, Basel, Switzerland
| | - Oliver Reuthebuch
- University of Basel, Basel, Switzerland; Department of Cardiovascular Surgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | | | - Enrico Ferrari
- Department of Cardiovascular Surgery, Cardiocentro Ticino Institute, Lugano, Switzerland
| | - Christian Templin
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Peter Wenaweser
- Heart Clinic Hirslanden, Hirslanden Clinic Zurich, Zurich, Switzerland
| | - Fabian Nietlispach
- Cardiovascular Center Zurich, Hirslanden Klinik Im Park, Zurich, Switzerland
| | | | - Christoph Huber
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Marco Roffi
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland.
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Jiménez Díaz VA, Juan-Salvadores P. Valve Thrombosis After TAVR: Beyond HALT and RELM. JACC Cardiovasc Interv 2023; 16:2982-2985. [PMID: 38151312 DOI: 10.1016/j.jcin.2023.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Víctor Alfonso Jiménez Díaz
- Cardiology Department, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Pontevedra, Spain; Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain.
| | - Pablo Juan-Salvadores
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain
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Roule V, Guedeney P, Silvain J, Beygui F, Zeitouni M, Sorrentino S, Kerneis M, Barthelemy O, Beaupré F, Portal JJ, Vicaut E, Montalescot G, Collet JP. Bioprosthetic leaflet thrombosis and reduced leaflet motion after transcatheter aortic valve replacement: A systematic review and meta-analysis. Arch Cardiovasc Dis 2023; 116:563-571. [PMID: 37968182 DOI: 10.1016/j.acvd.2023.10.003] [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: 05/17/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Leaflet thrombosis and reduced leaflet motion have become a concern with the expanding use of transcatheter aortic valve replacement in lower-risk patients. AIMS To assess the proportions, predictors and clinical impact of leaflet thrombosis and reduced leaflet motion after transcatheter aortic valve replacement. METHODS We performed a meta-analysis of studies assessing the proportions of and/or clinical outcomes according to the presence of leaflet thrombosis after transcatheter aortic valve replacement identified with computed tomography and/or echocardiography. RESULTS Fifty-three studies, representing 25,258 patients undergoing transcatheter aortic valve replacement, were considered. The proportion of leaflet thrombosis was 5.2% overall, and was higher in computed tomography versus echocardiography (16.4% vs. 1.1%, respectively); reduced leaflet motion was identified in 11% of patients with four-dimensional computed tomography. Intra-annular bioprostheses were associated with a higher proportion of leaflet thrombosis, whereas chronic oral anticoagulation was protective for leaflet thrombosis in both computed tomography and echocardiographic studies (9.7% vs. 17.5%; relative risk [RR]: 0.51, 95% confidence interval [95% CI]: 0.37-0.71 and 0.9% vs. 2.7%; RR: 0.22, 95% CI: 0.06-0.79, respectively) and for reduced leaflet motion (2.5% vs. 12.4%; RR: 0.32, 95% CI: 0.13-0.76). Leaflet thrombosis was not associated with an increased risk of death, but with a higher risk of stroke in computed tomography studies (2.8% vs. 2.4%; RR: 1.63, 95% CI: 1.05-2.55), a difference more pronounced when considering reduced leaflet motion (3.5% vs. 1.7%; RR: 2.39, 95% CI: 0.63-8.34). CONCLUSIONS The proportion of leaflet thrombosis is highly variable according to the screening approach, the type of valve and the use of oral anticoagulation. The occurrence of cerebral events is increased when leaflet thrombosis and/or reduced leaflet motion are diagnosed, but leaflet thrombosis has no impact on survival.
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Affiliation(s)
- Vincent Roule
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France; Service de Cardiologie, CHU de Caen Normandie, Normandie Université, 14000 Caen, France
| | - Paul Guedeney
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
| | - Johanne Silvain
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
| | - Farzin Beygui
- Service de Cardiologie, CHU de Caen Normandie, Normandie Université, 14000 Caen, France
| | - Michel Zeitouni
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
| | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Science, Magna Graecia University, 88100 Catanzaro, Italy
| | - Mathieu Kerneis
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
| | - Olivier Barthelemy
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
| | - Frédéric Beaupré
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
| | - Jean-Jacques Portal
- ACTION Study Group, Unité de Recherche Clinique, Lariboisière Hospital, AP-HP, 75010 Paris, France
| | - Eric Vicaut
- ACTION Study Group, Unité de Recherche Clinique, Lariboisière Hospital, AP-HP, 75010 Paris, France
| | - Gilles Montalescot
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France.
| | - Jean-Philippe Collet
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
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Moey MYY, Udani K, Nifong LW, Carabello BA, Morris DL, Shah NN. Optimal antiplatelet and antithrombotic regimen post-transcatheter aortic valve replacement. Eur J Clin Invest 2023; 53:e14071. [PMID: 37539630 DOI: 10.1111/eci.14071] [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: 05/26/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND There are limited data regarding optimal antiplatelet/antithrombotic therapy following transcatheter aortic valve replacement (TAVR). METHODS In this single-centre retrospective study including TAVR patients from 2012 to 2020, ischemic and bleeding outcomes were compared between antiplatelet (dual antiplatelet [DAPT] vs. single antiplatelet [SAPT]) and oral anticoagulation (OAC) groups using incidence rate, Kaplan-Meier and Cox proportional hazards analysis. RESULTS Total 492 patients (mean age 79.7 ± 7.7 years, 53.7% males, 83.5% Caucasian) were included. There was higher incidence of 1-year death or ischemia with DAPT vs. SAPT (23.6 vs. 14.8 per 100 patient-years [PY], incidence rate ratio [IRR] 1.60, 95% confidence interval [CI] 0.97-2.68, p = .05), especially in those without coronary artery disease (23.9 vs. 10.7 per 100 PY, IRR 2.24, 95% CI 1.10-4.47, p = .017). There was significantly higher major bleeding in those on OAC vs. no OAC (15 vs. 8 per 100 PY, IRR 1.87, 95% CI 1.10-3.11, p = .016), especially late (>1-year) bleeding (10.2 vs. 3.6 per 100 PY, IRR 2.81, 95% CI 1.33-5.92, p = .004). In multivariate analysis, DAPT was an independent predictor of death or ischemia (adjusted hazard ratio [aHR] 1.41, 95% CI 1.01-1.96, p = .041). OAC was an independent predictor of major bleeding (aHR 2.32, 95% CI 1.31-4.13, p = .004). CONCLUSIONS There is signal to harm with routine use of DAPT post-TAVR. There is higher incidence of late bleeding post-TAVR with OAC, suggesting potential role for alternate antithrombotic strategies.
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Affiliation(s)
- Melissa Y Y Moey
- Department of Cardiovascular Disease, East Carolina University (ECU), Greenville, North Carolina, USA
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kunjan Udani
- Department of Cardiovascular Disease, East Carolina University (ECU), Greenville, North Carolina, USA
| | - L Wiley Nifong
- Department of Cardiac Surgery, East Carolina University, Greenville, North Carolina, USA
| | | | - D Lynn Morris
- Department of Cardiovascular Disease, East Carolina University (ECU), Greenville, North Carolina, USA
| | - Neeraj N Shah
- Department of Cardiovascular Disease, East Carolina University (ECU), Greenville, North Carolina, USA
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Hell MM, Emrich T, Lurz P, von Bardeleben RS, Schmermund A. Cardiac CT Beyond Coronaries: Focus on Structural Heart Disease. Curr Heart Fail Rep 2023; 20:484-492. [PMID: 38019324 PMCID: PMC10746749 DOI: 10.1007/s11897-023-00635-9] [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] [Accepted: 11/06/2023] [Indexed: 11/30/2023]
Abstract
PURPOSE OF REVIEW Cardiac computed tomography (CT) is an established non-invasive imaging tool for the assessment of coronary artery disease. Furthermore, it plays a key role in the preinterventional work-up of patients presenting with structural heart disease. RECENT FINDINGS CT is the gold standard for preprocedural annular assessment, device sizing, risk determination of annular injury, coronary occlusion or left ventricular outflow tract obstruction, calcification visualization and quantification of the target structure, and prediction of a co-planar fluoroscopic angulation for transcatheter interventions in patients with structural heart disease. It is further a key imaging modality in postprocedural assessment for prosthesis thrombosis, degeneration, or endocarditis. CT plays an integral part in the imaging work-up of novel transcatheter therapies for structural heart disease and postprocedural assessment for prosthesis thrombosis or endocarditis. This review provides a comprehensive overview of the key role of CT in the context of structural heart interventions.
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Affiliation(s)
- Michaela M Hell
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany.
| | - Tilman Emrich
- Department of Diagnostic and Interventional Radiology, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Philipp Lurz
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany
| | | | - Axel Schmermund
- Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
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Soschynski M, Hein M, Capilli F, Hagar MT, Ruile P, Breitbart P, Westermann D, Taron J, Schuppert C, Schlett CL, Bamberg F, Krauss T. Investigation of factors determining haemodynamic relevance of leaflet thrombosis after transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging 2023; 24:1672-1681. [PMID: 37409579 DOI: 10.1093/ehjci/jead156] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/20/2023] [Accepted: 06/25/2023] [Indexed: 07/07/2023] Open
Abstract
AIMS To determine the conditions under which early hypoattenuated leaflet thickening (HALT) after transcatheter aortic valve implantation (TAVI) becomes haemodynamically relevant. METHODS AND RESULTS The study included 100 patients (age: 81.5 ± 5.5 years; female 63%), thereof 50 patients with HALT. After anonymization and randomization, blinded readers measured maximum thrombus thickness per prosthesis (MT_pr) and movement restriction (MR_pr) on electrocardiogram (ECG)-gated whole heart cycle computed tomography angiography. These measurements were compared with echocardiographic mean pressure gradient (mPG), its increase from baseline (ΔmPG), and Doppler velocity index (DVI). Haemodynamic valve deterioration (HVD) was defined as mPG > 20 mmHg. Age, body mass index, valve type, valve size, left ventricular ejection fraction, and atrial fibrillation were considered as influencing factors. Multiple regression analysis revealed that only valve size (P = 0.001) and MT_pr (P = 0.02) had a significant influence on mPG. In an interaction model, valve size moderated the effect of MT_pr on mPG significantly (P = 0.004). Sub-group analysis stratified by valve sizes showed a strong correlation between MT_pr and echocardiographic parameters for 23 mm valves (mPG: r = 0.57, ΔmPG: r = 0.68, DVI: r = 0.55, each with P < 0.001), but neither for 26 nor 29 mm valves (r < 0.2, P > 0.2 for all correlations). Six of seven prostheses with HVD had a 23 mm valve diameter, while one had 29 mm (P = 0.02). CONCLUSION Early HALT rarely causes significant mPG increase. Our study shows that valve size is a key factor influencing the haemodynamic impact of HALT. In small valve sizes, mPG is more likely to increase. Our study is the first to offer in vivo evidence supporting previous in vitro findings on this topic.
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Affiliation(s)
- Martin Soschynski
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Manuel Hein
- Department of Cardiology and Angiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Fabio Capilli
- Department of Radiology, Neuroradiology and Nuclear Medicine, Medical Center Vest, Ruhr University Bochum, Dorstener Straße 151, 45657 Recklinghausen, Germany
| | - Muhammad Taha Hagar
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Philipp Ruile
- Department of Cardiology and Angiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Philipp Breitbart
- Department of Cardiology and Angiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Jana Taron
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
- Cardiac MR PET CT Program, Massachusetts General-Hospital-Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Schuppert
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Christopher L Schlett
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Fabian Bamberg
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
| | - Tobias Krauss
- Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106 Freiburg, Germany
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Hu X, Xu H, Wang C, Wang Y, Wang Y, Zhou D, Zhu Q, Xu K, Yang J, Zhang H, Jiang N, Zhang J, Fang Z, Fu G, Guo Y, Li Y, Wang M, Feng D, Niu G, Zhang E, Chen Y, Ye Y, Wu Y. Early 6 months usage of single anTiplAtelet OR anTicoAgulant followed by single antiplatelet after transcatheter aortic valve replacement: protocol for a multicentre, open-label, randomised controlled clinical trial. BMJ Open 2023; 13:e076781. [PMID: 37989381 PMCID: PMC10668142 DOI: 10.1136/bmjopen-2023-076781] [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: 06/16/2023] [Accepted: 10/24/2023] [Indexed: 11/23/2023] Open
Abstract
INTRODUCTION The strategy for initiating antithrombotic therapy to prevent bioprosthetic valve thrombosis (BPVT) after transcatheter aortic valve replacement (TAVR) remains uncertain. There is still lacking evidence on the efficacy and safety of early 6 months usage of single-antiplatelet therapy (SAPT) or oral anticoagulant (OAC) after TAVR in patients without anticoagulant indications. METHODS AND ANALYSIS This is a multicentre, randomised controlled, open-label trial, and 650 patients undergoing TAVR from 13 top TAVR centres in China will be recruited. Each eligible participant will be randomly assigned to two groups (1:1 ratio) as (1) SAPT (aspirin 75-100 mg for 6 months) group or (2) OAC group (warfarin, therapeutic international normalised ratio at 1.8-2.5 for 6 months), both followed by sequential aspirin 75-100 mg for 6 months. Participants in both groups will be invited for three follow-up visits of 1, 6 and 12 months after discharge. We will use both the net clinical benefit endpoint (composite of all-cause mortality, myocardial infarction, stroke/transient ischaemic attacks, peripheral artery thrombosis, intracardiac thrombosis and major bleeding and disabling or life-threatening bleeding) and the BPVT endpoint evaluated by four-dimensional CT as our primary endpoints. P value of <0.05 of two-sided test will be considered statistically significant. ETHICS AND DISSEMINATION The present study was approved by the Institutional Review Boards at Fuwai Hospital, National Center for Cardiovascular Diseases of China (Approval No. 2023-1947). All patients will be informed of the details of the study and will sign an informed consent prior to inclusion in the study. Results of this study will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT05375474.
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Affiliation(s)
- Xiangming Hu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haiyan Xu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Can Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Wang
- Medical Research & Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Wang
- Department of Cardiology, Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, Fujian, China
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qifeng Zhu
- Department of Cardiology, The Second Affiliated Hospital Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Kai Xu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Jian Yang
- Department of Cardiovascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Haibo Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nan Jiang
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin Medical University, Tianjin, China
| | - Junjie Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhenfei Fang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yi Li
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Moyang Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dejing Feng
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guannan Niu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Erli Zhang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Chen
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunqing Ye
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongjian Wu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Chang J, Yu L, Lei J, Liu X, Li C, Zheng Y, Chen H. A multifunctional bio-patch crosslinked with glutaraldehyde for enhanced mechanical performance, anti-coagulation properties, and anti-calcification properties. J Mater Chem B 2023; 11:10455-10463. [PMID: 37888984 DOI: 10.1039/d3tb01724a] [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: 10/28/2023]
Abstract
Bio-patches for the treatment of valvular disease have been evaluated in clinical trials. It has been shown that failure of these devices, occurring within a few years of implantation, may be due to cytotoxicity, immune response, calcification and thrombosis. Some of these effects may be due to the glutaraldehyde crosslinking process used in the preparation of the materials. A number of studies have focused on strategies to control calcification, while others have concentrated on the prevention of micro-thrombus formation. In the present work, we have introduced amino-terminated poly(ethylene glycol) (NH2-PEG-NH2) as an intermolecular bridge, which not only eliminates free aldehyde groups to prevent calcification, but also introduces sites for the attachment of anticoagulant molecules. Furthermore, PEG, itself a hydrophilic polymer with good biocompatibility, may effectively prevent protein adsorption in the early stages of blood contact leading to thrombus formation. After further covalent attachment of heparin, modified bovine pericardium (BP) showed strong anti-calcification (calcium content: 39.3 ± 3.1 μg mg-1) and anti-coagulation properties (partial thromboplastin time: >300 s). The biocompatibility and mechanical properties, important for clinical use, were also improved by modification. The strategy used in this work includes new ideas and technologies for the improvement of valve products used in the clinic.
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Affiliation(s)
- Jiahao Chang
- State and Local Joint Engineering Laboratory for Novel Functional Polymeric Materials, College of Chemistry, Chemical Engineering and Materials Science, Soochow University, 199 Ren-Ai Road, Suzhou 215123, P. R. China.
| | - Liyin Yu
- Jiangsu Biosurf Biotech Company Ltd., Building 26, Dongjing Industrial Square, No. 1, Jintian Road, Suzhou Industrial Park, Suzhou 215123, P. R. China.
| | - Jiao Lei
- State and Local Joint Engineering Laboratory for Novel Functional Polymeric Materials, College of Chemistry, Chemical Engineering and Materials Science, Soochow University, 199 Ren-Ai Road, Suzhou 215123, P. R. China.
| | - Xiaoli Liu
- State and Local Joint Engineering Laboratory for Novel Functional Polymeric Materials, College of Chemistry, Chemical Engineering and Materials Science, Soochow University, 199 Ren-Ai Road, Suzhou 215123, P. R. China.
| | - Chunxiao Li
- The SIP Biointerface Engineering Research Institute, Suzhou 215123, P. R. China
| | - Yali Zheng
- The SIP Biointerface Engineering Research Institute, Suzhou 215123, P. R. China
| | - Hong Chen
- State and Local Joint Engineering Laboratory for Novel Functional Polymeric Materials, College of Chemistry, Chemical Engineering and Materials Science, Soochow University, 199 Ren-Ai Road, Suzhou 215123, P. R. China.
- The SIP Biointerface Engineering Research Institute, Suzhou 215123, P. R. China
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Dodgson CS, Beitnes JO, Kløve SF, Herstad J, Opdahl A, Undseth R, Eek CH, Broch K, Gullestad L, Aaberge L, Lunde K, Bendz B, Lie ØH. An investigator-sponsored pragmatic randomized controlled trial of AntiCoagulation vs AcetylSalicylic Acid after Transcatheter Aortic Valve Implantation: Rationale and design of ACASA-TAVI. Am Heart J 2023; 265:225-232. [PMID: 37634655 DOI: 10.1016/j.ahj.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND The optimal antithrombotic therapy after transcatheter aortic valve implantation (TAVI) is unknown. Bioprosthetic valve dysfunction (BVD) is associated with adverse outcomes and may be prevented by anticoagulation therapy. A dedicated randomized trial comparing monotherapy NOAC to single antiplatelet therapy has not been performed previously. We hypothesize that therapy with any anti-factor Xa NOAC will reduce BVD compared to antiplatelet therapy, without compromising safety. METHODS ACASA-TAVI is a multicenter, prospective, randomized, open-label, blinded endpoint, all-comers trial comparing a monotherapy anti-factor Xa NOAC strategy (intervention arm) with a single antiplatelet therapy strategy (control arm) after successful TAVI. Three-hundred and sixty patients without indication for oral anticoagulation will be randomized in a 1:1 ratio to either apixaban 5 mg twice per day, edoxaban 60 mg daily, or rivaroxaban 20 mg daily for 12 months followed by acetylsalicylic acid 75 mg daily indefinitely, or to acetylsalicylic acid 75 mg daily indefinitely. The 2 co-primary outcomes are (1) incidence of Hypo-Attenuated Leaflet Thickening (HALT) on 4-dimensional cardiac CT at 12 months, and (2) a Safety Composite of VARC-3 bleeding events, thromboembolic events (myocardial infarction and stroke), and death from any cause, at 12 months. RESULTS The first 100 patients had a mean age of 74 ± 3.6 years, 33% were female, the average body-mass index was 27.9 ± 4.4 kg/m2, and 15% were smokers. A balloon-expanded valve was used in 82% and a self-expandable valve in 18%. CONCLUSIONS The trial is planned, initiated, funded, and conducted without industry involvement. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT05035277.
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Affiliation(s)
- Christopher S Dodgson
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jan Otto Beitnes
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Sophie F Kløve
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Jon Herstad
- Department of Cardiology, Haukeland University Hospital, Bergen, Norway
| | - Anders Opdahl
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
| | | | - Christian H Eek
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Kaspar Broch
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; K. G. Jebsen Cardiac Research Centre, University of Oslo, Oslo, Norway
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; K. G. Jebsen Cardiac Research Centre, University of Oslo, Oslo, Norway
| | - Lars Aaberge
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Ketil Lunde
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Øyvind H Lie
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway.
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Koren O, Patel V, Chakravarty T, Jilaihawi H, Gupta A, Sadri S, Makkar RR. Leaflet thrombosis in transcatheter aortic valve intervention: mechanisms, prevention, and treatment options. Front Cardiovasc Med 2023; 10:1249604. [PMID: 37868777 PMCID: PMC10590104 DOI: 10.3389/fcvm.2023.1249604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Transcatheter aortic valve intervention (TAVR) has emerged as a promising alternative to surgical aortic valve replacement for patients with severe aortic stenosis. However, leaflet thrombosis has raised concerns about the long-term durability and outcomes of TAVR. This study aims to provide an overview of the mechanisms, prevention strategies, and treatment options for leaflet thrombosis in TAVR. Clinical evidence Leaflet thrombosis refers to the formation of blood clots on bioprosthetic valve leaflets, leading to impaired leaflet mobility, early valve degeneration and dysfunction, and potential clinical implications. While the mechanisms underlying thrombus formation on valve leaflets are not fully understood, several factors, such as altered blood flow patterns within valve neosinuses, prothrombotic surfaces, and patient-related causes, have been implicated. Two distinct entities have been identified, namely, hypoattenuated leaflet thickening and restricted leaflet motion. Their occurrence appears dynamic over time and is related to the valve type. Imaging, including transesophageal echocardiography and multidetector computed tomography, plays a crucial role in the diagnosis and follow-up of leaflet thrombosis. Prevention and treatment options Preventing leaflet thrombosis requires a comprehensive and tailored approach involving identifying high-risk patients, close monitoring, and antithrombotic therapy. Antithrombotic therapy with dual antiplatelet agents or anticoagulation is commonly employed in TAVR patients, although the optimal regimen is yet to be defined. Novel antithrombotic agents, such as direct oral anticoagulants, are being investigated for their efficacy and safety in preventing leaflet thrombosis. When leaflet thrombosis is detected, treatment options include intensified antithrombotic therapy, valve-in-valve intervention, or balloon valvuloplasty. The long-term outcomes and impact of leaflet thrombosis on valve durability and patient prognosis are areas of ongoing research. Summary Leaflet thrombosis in TAVR is a considerable complication affecting valve function and patient outcomes. Understanding the mechanisms underlying thrombus formation and implementing appropriate prevention strategies are essential for mitigating this risk. Treatment options aim to restore leaflet mobility and optimize valve performance. Further research is needed to establish standardized protocols for antithrombotic therapy, identify high-risk patient populations, and determine the long-term consequences of leaflet thrombosis on TAVR outcomes.
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Affiliation(s)
- Ofir Koren
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
- Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Vivek Patel
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Tarun Chakravarty
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Hasan Jilaihawi
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Aakriti Gupta
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Shirin Sadri
- Department of Medicine, Stanford University, Stanford, CA, United States
| | - Raj R Makkar
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
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Dobesh PP, Goldsweig AM. Antithrombotic therapy with Transcatheter aortic valve replacement. Pharmacotherapy 2023; 43:1064-1083. [PMID: 37464970 DOI: 10.1002/phar.2847] [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: 02/03/2023] [Revised: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 07/20/2023]
Abstract
Aortic valve replacement is a necessary management strategy for patients with severe aortic stenosis. The use of transaortic valve replacement (TAVR) has increased significantly over the last decade and now exceeds traditional surgical aortic valve replacement. Since the valve systems used in TAVR consist of bioprosthetic valve tissue encased in a metal stent frame, antithrombotic therapy recommendations cannot be extrapolated from prior data with differently constructed surgical bioprosthetic or mechanical valves. Data on the use of antithrombotic therapy with TAVR are a rapidly developing area of medicine. Choice of agents depends on several patient factors. Patients undergoing TAVR also have a relatively high incidence of subclinical valve thrombosis. The clinical impact of this phenomenon and the implications for antithrombotic therapy continue to evolve. It is critical for clinicians who treat patients undergoing TAVR to have a firm understanding of practice guidelines, the evolving evidence, and its implications for the use of antithrombotic therapy in these patients.
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Affiliation(s)
- Paul P Dobesh
- Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andrew M Goldsweig
- Cardiac Catheterization Laboratory, Cardiovascular Clinical Research, Baystate Medical Center, Springfield, Massachusetts, USA
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Sharma H, Afzal S, Leick J, Werner N, Doshi SN, Nadir MA. Antithrombotic therapy following transcatheter aortic valve intervention. Pharmacol Ther 2023; 250:108509. [PMID: 37572882 DOI: 10.1016/j.pharmthera.2023.108509] [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: 06/03/2023] [Revised: 07/27/2023] [Accepted: 08/08/2023] [Indexed: 08/14/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is increasingly being performed to treat symptomatic patients with aortic stenosis and annual procedure volume has overtaken surgical aortic valve replacement in the United States. However, current international guidelines were written prior to the publication of several important recent studies. Furthermore, European and American guidelines differ in their recommendations of antithrombotic therapy following TAVR. Consequently, there is a need to examine the literature to provide clinicians guidance on the optimum antithrombotic strategy, particularly as different patient populations exist. In this review, we examine the data for antiplatelet and anticoagulation therapy post-TAVR.
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Affiliation(s)
- Harish Sharma
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Shazia Afzal
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Jürgen Leick
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Nikos Werner
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Sagar N Doshi
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - M Adnan Nadir
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK.
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Moscarelli M, Prestera R, Pernice V, Milo S, Violante F, Cuffari F, Di Pasquale C, Ferlisi A, Speziale G, Angelini GD, Fattouch K. Subclinical Leaflet Thrombosis Following Surgical and Transcatheter Aortic Valve Replacement: A Meta-Analysis. Am J Cardiol 2023; 204:171-177. [PMID: 37544140 DOI: 10.1016/j.amjcard.2023.07.089] [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: 05/18/2023] [Accepted: 07/13/2023] [Indexed: 08/08/2023]
Abstract
Subclinical leaflets valve thrombosis (SLT) is a recently identified phenomenon with multidetector computer tomography after tissue aortic valve replacement. Whether SLT is more frequent after transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) is currently not known. Thus, the aim of this pairwise meta-analysis was to investigate the incidence of SLT after both TAVR and SAVR, the association with anticoagulation therapy, and the risk for neurological events. We searched PubMed, Google Scholar, and Ovid MEDLINE/Embase (January 02, 2023, last update) (PROSPERO registration: CRD42022383295). Statistical analysis was performed according to a prespecified statistical analysis plan. Time-to-event outcomes were summarized as incidence rate ratios (IRR). Pooled estimates were calculated using inverse variance method and random effect model. Overall, 2 registries, 2 randomized trials, and 1 observational study (1,593 patients) were included in this meta-analysis. There was a statistically significant difference in the incidence rate at follow-up of SLT between patients who underwent TAVR and SAVR (IRR 2.07, 95% confidence interval [CI]: [1.06; 4.03], I2 79%, 95% CI: [44; 92], p = 0.03). Oral anticoagulation therapy was associated with a reduced incidence of SLT (IRR 7.51, 95% CI: [3.24; 17.37], I2 62%, 95% CI: [0; 87], p <0.001). However, the incidence of later neurological events did not differ between patients with or without SLT (IRR 1.05, 95% CI: [0.32; 3.47], p = 0.93). In conclusion, SLT was more frequently detected after TAVR than SAVR. However, it was not associated with an increased risk for neurological events. Oral anticoagulation therapy seemed to reduce the incidence of SLT.
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Affiliation(s)
- Marco Moscarelli
- Department of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy.
| | - Rosa Prestera
- Department of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Vincenzo Pernice
- Department of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Sabrina Milo
- Department of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Francesco Violante
- Department of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Federico Cuffari
- Department of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Claudia Di Pasquale
- Department of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Angelo Ferlisi
- Department of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Giuseppe Speziale
- Department of Cardiovascular Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Gianni D Angelini
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, United Kingdom
| | - Khalil Fattouch
- Department of Cardiovascular Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy; DICHIRONS, Discipline Chirurgiche, Oncologiche e Stomatologiche, University of Palermo, Palermo, Italy
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Sadri V, Kohli K, Ncho B, Inci EK, Perdoncin E, Lisko JC, Lederman R, Greenbaum AB, Babaliaros V, Yoganathan AP. Effect of leaflet laceration on transcatheter aortic valve replacement fluid mechanics and comparison with surgical aortic valve replacement. J Thorac Cardiovasc Surg 2023; 166:e130-e141. [PMID: 37086238 PMCID: PMC10493236 DOI: 10.1016/j.jtcvs.2023.03.006] [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: 07/21/2022] [Revised: 02/12/2023] [Accepted: 03/03/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Leaflet thrombosis after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) may be caused by blood flow stagnation in the native and neosinus regions. To date, aortic leaflet laceration has been used to mitigate coronary obstruction following TAVR; however, its influence on the fluid mechanics of the native and neosinus regions is poorly understood. This in vitro study compared the flow velocities and flow patterns in the setting of SAVR vs TAVR with and without aortic leaflet lacerations. METHODS Two valves, (23-mm Perimount and 26-mm SAPIEN 3; Edwards Lifesciences) were studied in a validated mock flow loop under physiologic conditions. Neosinus and native sinus fluid mechanics were quantified using particle image velocimetry in the left and noncoronary cusp, with an increasing number of aortic leaflets lacerated or removed. RESULTS Across all conditions, SAVR had the highest average sinus and neosinus velocities, and this value was used as a reference to compare against the TAVR conditions. With an increasing number of leaflets lacerated or removed with TAVR, the average sinus and neosinus velocities increased from 25% to 70% of SAVR flow (100%). Diastolic velocities were substantially augmented by leaflet laceration. Also, the shorter frame of the SAVR led to higher flow velocities compared with the longer frame of the TAVR, even after complete leaflet removal. CONCLUSIONS Leaflet laceration augmented TAVR native and neosinus flow fields, approaching that of SAVR. These findings may have potential clinical implications for the use of single or multiple leaflet lacerations to reduce leaflet thrombosis and thus potentially improve TAVR durability.
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Affiliation(s)
- Vahid Sadri
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Institute of Technology and Emory University, Atlanta, Ga
| | - Keshav Kohli
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Institute of Technology and Emory University, Atlanta, Ga
| | - Beatrice Ncho
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Institute of Technology and Emory University, Atlanta, Ga
| | - Errol K Inci
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Ga
| | - Emily Perdoncin
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Ga
| | - John C Lisko
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Ga
| | - Robert Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Adam B Greenbaum
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Ga
| | - Vasilis Babaliaros
- Structural Heart and Valve Center, Emory University Hospital, Atlanta, Ga
| | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering at Georgia Institute of Technology and Emory University, Atlanta, Ga.
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Bańka P, Wybraniec M, Bochenek T, Gruchlik B, Burchacka A, Swinarew A, Mizia-Stec K. Influence of Aortic Valve Stenosis and Wall Shear Stress on Platelets Function. J Clin Med 2023; 12:6301. [PMID: 37834945 PMCID: PMC10573628 DOI: 10.3390/jcm12196301] [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: 08/28/2023] [Revised: 09/19/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
Aortic valve stenosis (AS) is a common heart valve disease in the elderly population, and its pathogenesis remains an interesting area of research. The degeneration of the aortic valve leaflets gradually progresses to valve sclerosis. The advanced phase is marked by the presence of extracellular fibrosis and calcification. Turbulent, accelerated blood flow generated by the stenotic valve causes excessive damage to the aortic wall. Elevated shear stress due to AS leads to the degradation of high-molecular weight multimers of von Willebrand factor, which may involve bleeding in the mucosal tissues. Conversely, elevated shear stress has been associated with the release of thrombin and the activation of platelets, even in individuals with acquired von Willebrand syndrome. Moreover, turbulent blood flow in the aorta may activate the endothelium and promote platelet adhesion and activation on the aortic valve surface. Platelets release a wide range of mediators, including lysophosphatidic acid, which have pro-osteogenic effects in AS. All of these interactions result in blood coagulation, fibrinolysis, and the hemostatic process. This review summarizes the current knowledge on high shear stress-induced hemostatic disorders, the influence of AS on platelets and antiplatelet therapy.
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Affiliation(s)
- Paweł Bańka
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 40-635 Katowice, Poland
| | - Maciej Wybraniec
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 40-635 Katowice, Poland
| | - Tomasz Bochenek
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 40-635 Katowice, Poland
| | - Bartosz Gruchlik
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 40-635 Katowice, Poland
| | - Aleksandra Burchacka
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 40-635 Katowice, Poland
| | - Andrzej Swinarew
- Faculty of Science and Technology, University of Silesia in Katowice, 40-007 Katowice, Poland
- Department of Swimming and Water Rescue, Institute of Sport Science, The Jerzy Kukuczka Academy of Physical Education, 40-065 Katowice, Poland
| | - Katarzyna Mizia-Stec
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 40-635 Katowice, Poland
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Lee JH, Ahn JM, Kang DY, Kim KW, Koo HJ, Yang DH, Jung SC, Kim B, Wong YTA, Lam CCS, Yin WH, Wei J, Lee YT, Kao HL, Lin MS, Ko TY, Kim WJ, Kang SH, Yun SC, Ko E, Park H, Lee SA, Kim DH, Park SJ, Park DW. Effect of Edoxaban Versus Antiplatelet Therapy on Leaflet Thrombosis and Cerebral Thromboembolism After TAVI According to Major Clinical and Anatomic Factors in Prespecified Subgroup Analysis from the ADAPT-TAVR Trial. Am J Cardiol 2023; 203:352-361. [PMID: 37517131 DOI: 10.1016/j.amjcard.2023.06.018] [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: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 08/01/2023]
Abstract
It is unknown whether edoxaban versus dual antiplatelet therapy (DAPT) has differential treatment effects on leaflet thrombosis, cerebral thromboembolism, and neurologic or neurocognitive dysfunction according to clinical and anatomic factors after transcatheter aortic valve implantation. To investigate the relative effects of edoxaban and DAPT on leaflet and cerebral thromboembolism in patients with major risk factors. The primary end point of this study was the incidence of leaflet thrombosis on computed tomography at 6 months. The secondary end points were new cerebral lesions on brain magnetic resonance imaging and neurologic and neurocognitive dysfunction between baseline and 6-month follow-up. Cox regression models assessed the consistency of the treatment effects in the prespecified subgroups. The favorable effect of edoxaban versus DAPT on the leaflet thrombosis was consistent across multiple clinical or anatomic subgroups, without significant interaction between the drug effect and each subgroup (p for interaction for age = 0.597, gender = 0.557, body mass index = 0.866, Society of Thoracic Surgeons score = 0.307, valve type = 0.702, edoxaban reduction criteria = 0.604, and valve morphology = 0.688). However, the incidence of new cerebral lesions on brain magnetic resonance imaging and worsening of neurologic and neurocognitive function were not significantly different between the groups among the various key subgroups. The relative effects of edoxaban and DAPT on the risk of leaflet thrombosis, cerebral thromboembolism, and neurologic dysfunction were consistent across a diverse spectrum of clinical or anatomical factors. Further studies are required to define tailored antithrombotic therapy for high-risk groups with specific clinical or anatomic characteristics.
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Affiliation(s)
| | | | | | - Kyung Won Kim
- Asan Image Metrics, Clinical Trial Center, Asan Institute for Life Sciences
| | - Hyun Jung Koo
- Department of Radiology Research Institute of Radiology, and
| | - Dong Hyun Yang
- Department of Radiology Research Institute of Radiology, and
| | - Seung Chai Jung
- Department of Radiology Research Institute of Radiology, and
| | - Byungjun Kim
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yiu Tung Anthony Wong
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Cheung Chi Simon Lam
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Jeng Wei
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yung-Tsai Lee
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Mao-Shin Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung-Yu Ko
- Division of Cardiology, Department of Internal Medicine, Hsin-Chu Branch, National Taiwan University Hospital, Hsin-Chu, Taiwan
| | - Won-Jang Kim
- Department of Cardiology, CHA Ilsan Medical Center, Goyang, Korea
| | - Se Hun Kang
- Department of Cardiology, CHA Bundang Medical Center, Seongnam, Korea
| | - Sung-Cheol Yun
- Division of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Euihong Ko
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu-city, Fukuoka, Japan
| | - Hanbit Park
- Department of Cardiology, GangNeung Asan Hospital, GangNeung, Korea
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Fazzari F, Baggiano A, Fusini L, Ghulam Ali S, Gripari P, Junod D, Mancini ME, Maragna R, Mushtaq S, Pontone G, Pepi M, Muratori M. Early Biological Valve Failure: Structural Valve Degeneration, Thrombosis, or Endocarditis? J Clin Med 2023; 12:5740. [PMID: 37685807 PMCID: PMC10488994 DOI: 10.3390/jcm12175740] [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: 07/28/2023] [Revised: 08/24/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
Biological valve failure (BVF) is an inevitable condition that compromises the durability of biological heart valves (BHVs). It stems from various causes, including rejection, thrombosis, and endocarditis, leading to a critical state of valve dysfunction. Echocardiography, cardiac computed tomography, cardiac magnetic resonance, and nuclear imaging play pivotal roles in the diagnostic multimodality workup of BVF. By providing a comprehensive overview of the pathophysiology of BVF and the diagnostic approaches in different clinical scenarios, this review aims to aid clinicians in their decision-making process. The significance of early detection and appropriate management of BVF cannot be overstated, as these directly impact patients' prognosis and their overall quality of life. Ensuring timely intervention and tailored treatments will not only improve outcomes but also alleviate the burden of this condition on patients' life. By prioritizing comprehensive assessments and adopting the latest advancements in diagnostic technology, medical professionals can significantly enhance their ability to manage BVF effectively.
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Affiliation(s)
- Fabio Fazzari
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Via Carlo Parea 4, 20138 Milan, Italy; (A.B.); (L.F.); (S.G.A.); (P.G.); (D.J.); (M.E.M.); (R.M.); (S.M.); (G.P.); (M.P.); (M.M.)
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Ferstl P, Achenbach S, Marwan M, Bittner DO. Comparison of oral anticoagulation by vitamin-K antagonists and non-vitamin-K antagonists for treatment of leaflet thickening after transcatheter aortic valve implantation (TAVI). Int J Cardiol 2023; 386:104-108. [PMID: 37244382 DOI: 10.1016/j.ijcard.2023.05.034] [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: 02/05/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Hypoattenuated leaflet thickening (HALT), as identified by CT imaging, is not infrequent after transcatheter aortic valve implantation (TAVI). The best choice of oral anticoagulation is unknown. We compared the effectiveness of Direct Oral AntiCoagulants (DOAC) and Vitamin-K Antagonists (VKA) to resolve HALT in patients with serial CT aquisitions. METHODS A total of 46 consecutive TAVI patients in whom anticoagulation had been initiated because of HALT and who underwent follow-up CT were identified. Indication and type of anticoagulation was according to physician discretion. Patients on DOAC were compared to VKA therapy regarding resolution of HALT. RESULTS Mean age of the 46 patients was 80 ± 6 years (59% men), and the mean duration of anticoagulation was 156 days. Overall, 41 patients (89%) showed resolution of HALT with anticoagulation therapy, whereas HALT persisted in 5 patients (11%). Resolution of HALT was seen in 26 out of 30 (87%) patients receiving VKA and in 15 out of 16 (94%) patients receiving DOAC, respectively. Groups did not differ regarding age, cardiovascular risk factors, TAVI prosthesis type and size or duration of anticoagulation (all p > 0.05). CONCLUSION Anticoagulation therapy resolves leaflet thickening after TAVI in most patients. Non-Vitamin-K antagonists seem to be an effective alternative to Vitamin-K antagonists. This finding needs to be confirmed in larger prospective trials.
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Affiliation(s)
- P Ferstl
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany.
| | - S Achenbach
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
| | - M Marwan
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
| | - D O Bittner
- Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Department of Cardiology, Erlangen, Germany
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Agricola E, Ancona F, Bartel T, Brochet E, Dweck M, Faletra F, Lancellotti P, Mahmoud-Elsayed H, Marsan NA, Maurovich-Hovart P, Monaghan M, Pontone G, Sade LE, Swaans M, Von Bardeleben RS, Wunderlich N, Zamorano JL, Popescu BA, Cosyns B, Donal E. Multimodality imaging for patient selection, procedural guidance, and follow-up of transcatheter interventions for structural heart disease: a consensus document of the EACVI Task Force on Interventional Cardiovascular Imaging: part 1: access routes, transcatheter aortic valve implantation, and transcatheter mitral valve interventions. Eur Heart J Cardiovasc Imaging 2023; 24:e209-e268. [PMID: 37283275 DOI: 10.1093/ehjci/jead096] [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: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 06/08/2023] Open
Abstract
Transcatheter therapies for the treatment of structural heart diseases (SHD) have expanded dramatically over the last years, thanks to the developments and improvements of devices and imaging techniques, along with the increasing expertise of operators. Imaging, in particular echocardiography, is pivotal during patient selection, procedural monitoring, and follow-up. The imaging assessment of patients undergoing transcatheter interventions places demands on imagers that differ from those of the routine evaluation of patients with SHD, and there is a need for specific expertise for those working in the cath lab. In the context of the current rapid developments and growing use of SHD therapies, this document intends to update the previous consensus document and address new advancements in interventional imaging for access routes and treatment of patients with aortic stenosis and regurgitation, and mitral stenosis and regurgitation.
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Affiliation(s)
- Eustachio Agricola
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy
- Vita-Salute San Raffaele University, via Olgettina 58, Milan 20132, Italy
| | - Francesco Ancona
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, via Olgettina 60, Milan 20132, Italy
| | - Thomas Bartel
- Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, 26th Street, Dubai, United Arab Emirates
| | - Eric Brochet
- Cardiology Department, Hopital Bichat, 46 rue Huchard, Paris 75018, France
| | - Marc Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4SB, UK
| | - Francesco Faletra
- Senior SHD Consultant Istituto Cardiocentro Via Tesserete 48, CH-6900 Lugano, Switzerland
- Senior Imaging Consultant ISMETT UPCM Hospital, Discesa dei Giudici, 4, 90133 Palermo, Italy
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liège Hospital, Domaine Universitaire du Sart Tilman, Liège B4000, Belgium
- Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | | | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Leyla Elif Sade
- University of Pittsburgh-Heart & Vascular Institute UPMC, 200 Lothrop St Ste E354.2, Pıttsburgh, PA 15213, USA
- Cardiology Department, Baskent University, Ankara, Turkey
| | - Martin Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Nina Wunderlich
- Asklepios Klinik Langen Röntgenstrasse 20, Langen 63225, Germany
| | | | - Bogdan A Popescu
- Department of Cardiology, University of Medicine and Pharmacy 'Carol Davila' -Euroecolab, Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Bucharest, Romania
| | - Bernard Cosyns
- Cardiology Department, Centrum voor Hart en Vaatziekten (CHVZ), Universitair ziekenhuis Brussel, Brussels, Belgium
| | - Erwan Donal
- Cardiologie, CHU de RENNES, LTSI UMR1099, INSERM, Universite´ de Rennes-1, Rennes, France
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McInerney A, Bagur R. Hypoattenuated Leaflet Thickening After Transcatheter Aortic Valve Implantation: The Research Around HALT Does Not Halt. Am J Cardiol 2023; 201:378-381. [PMID: 37468396 DOI: 10.1016/j.amjcard.2023.06.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/14/2023] [Indexed: 07/21/2023]
Affiliation(s)
- Angela McInerney
- Galway University Hospital, National University of Ireland Galway, Galway, Ireland
| | - Rodrigo Bagur
- London Health Sciences Centre, Western University, London, Ontario, Canada.
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