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Dai N, Tang X, Ling R, Zhou F, Chen S, Zhang L, Duan S, Pan W, Zhang J, Zhou D, Ge J. Prognostic implications of pre-transcatheter aortic valve replacement computed tomography-derived coronary plaque characteristics and stenosis severity. Eur Radiol 2024; 34:5923-5933. [PMID: 38308681 DOI: 10.1007/s00330-024-10633-7] [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: 09/10/2023] [Revised: 11/27/2023] [Accepted: 12/08/2023] [Indexed: 02/05/2024]
Abstract
OBJECTIVES The study aimed to investigate the prognostic value of pre-transcatheter aortic valve replacement (TAVR) computed tomography angiography (CTA) in assessing physiological stenosis severity (CTA-derived fractional flow reserve (CT-FFR)) and high-risk plaque characteristics (HRPC). MATERIALS AND METHODS Among TAVR patients who underwent pre-procedure CTA, the presence and number of HRPCs (minimum lumen area of < 4 mm2, plaque burden ≥ 70%, low-attenuating plaques, positive remodeling, napkin-ring sign, or spotty calcification) as well as CT-FFR were assessed. The risk of vessel-oriented composite outcome (VOCO, a composite of vessel-related ischemia-driven revascularization, vessel-related myocardial infarction, or cardiac death) was compared according to the number of HRPC and CT-FFR categories. RESULTS Four hundred and twenty-seven patients (68.4% were male) with 1072 vessels were included. Their mean age was 70.6 ± 10.6 years. Vessels with low CT-FFR (≤ 0.80) (41.7% vs. 15.8%, adjusted hazard ratio (HRadj) 1.96; 95% confidence interval (CI): 1.28-2.96; p = 0.001) or lesions with ≥ 3 HRPC (38.7% vs. 16.0%, HRadj 1.81; 95%CI 1.20-2.71; p = 0.005) demonstrated higher VOCO risk. In the CT-FFR (> 0.80) group, lesions with ≥ 3 HRPC showed a significantly higher risk of VOCO than those with < 3 HRPC (34.7% vs. 13.0%; HRadj 2.04; 95%CI 1.18-3.52; p = 0.011). However, this relative increase in risk was not observed in vessels with positive CT-FFR (≤ 0.80). CONCLUSIONS In TAVR candidates, both CT-FFR and the presence of ≥ 3 HRPC were associated with an increased risk of adverse clinical events. However, the value of HRPC differed with the CT-FFR category, with more incremental predictability among vessels with negative CT-FFR but not among vessels with positive CT-FFR. CLINICAL RELEVANCE STATEMENT In transcatheter aortic valve replacement (TAVR) candidates, pre-TAVR CTA provided the opportunity to assess coronary physiological stenosis severity and high-risk plaque characteristics, both of which are associated with worse clinical outcomes. KEY POINTS • The current study investigated the prognostic value of coronary physiology significance and plaque characteristics in transcatheter aortic valve replacement patients. • The combination of coronary plaque vulnerability and physiological significance showed improved accuracy in predicting clinical outcomes in transcatheter aortic valve replacement patients. • Pre-transcatheter aortic valve replacement CT can be a one-stop-shop tool for coronary assessments in clinical practice.
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Affiliation(s)
- Neng Dai
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Xianglin Tang
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Runjianya Ling
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Fan Zhou
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Shasha Chen
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Lei Zhang
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | | | - Wenzhi Pan
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Jiayin Zhang
- Department of Radiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, #85 Wujin Rd, Shanghai, 200080, China.
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China.
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China.
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China.
- National Clinical Research Center for Interventional Medicine, 180 Fenglin Road, Xuhui District, Shanghai, 200032, China.
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Langenbach MC, Langenbach IL, Foldyna B, Mauri V, Klein K, Macherey-Meyer S, Heyne S, Meertens M, Lee S, Baldus S, Maintz D, Halbach M, Adam M, Wienemann H. Advanced CT measures of coronary artery disease with intermediate stenosis in patients with severe aortic valve stenosis. Eur Radiol 2024; 34:4897-4908. [PMID: 38189982 PMCID: PMC11255039 DOI: 10.1007/s00330-023-10549-8] [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: 08/22/2023] [Revised: 10/20/2023] [Accepted: 12/04/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Coronary artery disease (CAD) and severe aortic valve stenosis (AS) frequently coexist. While pre-transcatheter aortic valve replacement (TAVR) computed tomography angiography (CTA) allows to rule out obstructive CAD, interpreting hemodynamic significance of intermediate stenoses is challenging. This study investigates the incremental value of CT-derived fractional flow reserve (CT-FFR), quantitative coronary plaque characteristics (e.g., stenosis degree, plaque volume, and composition), and peri-coronary adipose tissue (PCAT) density to detect hemodynamically significant lesions among those with AS and CAD. MATERIALS AND METHODS We included patients with severe AS and intermediate coronary lesions (20-80% diameter stenosis) who underwent pre-TAVR CTA and invasive coronary angiogram (ICA) with resting full-cycle ratio (RFR) assessment between 08/16 and 04/22. CTA image analysis included assessment of CT-FFR, quantitative coronary plaque analysis, and PCAT density. Coronary lesions with RFR ≤ 0.89 indicated hemodynamic significance as reference standard. RESULTS Overall, 87 patients (age 77.9 ± 7.4 years, 38% female) with 95 intermediate coronary artery lesions were included. CT-FFR showed good discriminatory capacity (area under receiver operator curve (AUC) = 0.89, 95% confidence interval (CI) 0.81-0.96, p < 0.001) to identify hemodynamically significant lesions, superior to anatomical assessment, plaque morphology, and PCAT density. Plaque composition and PCAT density did not differ between lesions with and without hemodynamic significance. Univariable and multivariable analyses revealed CT-FFR as the only predictor for functionally significant lesions (odds ratio 1.28 (95% CI 1.17-1.43), p < 0.001). Overall, CT-FFR ≤ 0.80 showed diagnostic accuracy, sensitivity, and specificity of 88.4% (95%CI 80.2-94.1), 78.5% (95%CI 63.2-89.7), and 96.2% (95%CI 87.0-99.5), respectively. CONCLUSION CT-FFR was superior to CT anatomical, plaque morphology, and PCAT assessment to detect functionally significant stenoses in patients with severe AS. CLINICAL RELEVANCE STATEMENT CT-derived fractional flow reserve in patients with severe aortic valve stenosis may be a useful tool for non-invasive hemodynamic assessment of intermediate coronary lesions, while CT anatomical, plaque morphology, and peri-coronary adipose tissue assessment have no incremental or additional benefit. These findings might help to reduce pre-transcatheter aortic valve replacement invasive coronary angiogram. KEY POINTS • Interpreting the hemodynamic significance of intermediate coronary stenoses is challenging in pre-transcatheter aortic valve replacement CT. • CT-derived fractional flow reserve (CT-FFR) has a good discriminatory capacity in the identification of hemodynamically significant coronary lesions. • CT-derived anatomical, plaque morphology, and peri-coronary adipose tissue assessment did not improve the diagnostic capability of CT-FFR in the hemodynamic assessment of intermediate coronary stenoses.
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Affiliation(s)
- Marcel C Langenbach
- Faculty of Medicine and University Hospital Cologne, Institute for Diagnostic and Interventional Radiology, University of Cologne, Kerpener Strasse 62, Cologne, 50937, Germany.
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA.
| | - Isabel L Langenbach
- Faculty of Medicine and University Hospital Cologne, Institute for Diagnostic and Interventional Radiology, University of Cologne, Kerpener Strasse 62, Cologne, 50937, Germany
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Borek Foldyna
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - Victor Mauri
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Konstantin Klein
- Faculty of Medicine and University Hospital Cologne, Institute for Diagnostic and Interventional Radiology, University of Cologne, Kerpener Strasse 62, Cologne, 50937, Germany
| | - Sascha Macherey-Meyer
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Sebastian Heyne
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Max Meertens
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Samuel Lee
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Stephan Baldus
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - David Maintz
- Faculty of Medicine and University Hospital Cologne, Institute for Diagnostic and Interventional Radiology, University of Cologne, Kerpener Strasse 62, Cologne, 50937, Germany
| | - Marcel Halbach
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Matti Adam
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Hendrik Wienemann
- Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
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Will M, Schwarz K, Weiss T, Leibundgut G, Schmidt E, Vock P, Mousavi R, Borovac JA, Kwok CS, Hoppe UC, Mascherbauer J, Lamm G. The impact of concomitant chronic total occlusion on clinical outcomes in patients undergoing transcatheter aortic valve replacement: a large single-center analysis. Front Cardiovasc Med 2024; 11:1338253. [PMID: 38464840 PMCID: PMC10921092 DOI: 10.3389/fcvm.2024.1338253] [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: 11/14/2023] [Accepted: 02/12/2024] [Indexed: 03/12/2024] Open
Abstract
Background Coronary artery disease (CAD) is a common finding in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). However, the impact on prognosis of chronic total occlusions (CTOs), a drastic expression of CAD, remains unclear. Methods and results We retrospectively reviewed 1,487 consecutive TAVR cases performed at a single tertiary care medical center. Pre-TAVR angiograms were analyzed for the presence of a CTO. At the time of TAVR, 11.2% (n = 167) patients had a CTO. There was no significant association between the presence of a CTO and in-hospital or 30-day mortality. There was also no difference in long-term survival. LV ejection fraction and mean aortic gradients were lower in the CTO group. Conclusions Our analysis suggests that concomitant CTO lesions in patients undergoing TAVR differ in their risk profile and clinical findings to patients without CTO. CTO lesion per se were not associated with increased mortality, nevertheless CTOs which supply non-viable myocardium in TAVR population were associated with increased risk of death. Additional research is needed to evaluate the prognostic significance of CTO lesions in TAVR patients.
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Affiliation(s)
- Maximilian Will
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine 3, University Hospital St. Pölten, St. Pölten, Austria
- Karl Landsteiner Institute for Cardiometabolics, Karl Landsteiner Society, St Poelten, Austria
| | - Konstantin Schwarz
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine 3, University Hospital St. Pölten, St. Pölten, Austria
| | - Thomas Weiss
- Karl Landsteiner Institute for Cardiometabolics, Karl Landsteiner Society, St Poelten, Austria
- Medical School, Sigmund-Freud University, Vienna, Austria
| | - Gregor Leibundgut
- Klinik für Kardiologie, Universitätsspital Basel, Basel, Switzerland
| | - Elisabeth Schmidt
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine 3, University Hospital St. Pölten, St. Pölten, Austria
| | - Paul Vock
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine 3, University Hospital St. Pölten, St. Pölten, Austria
| | - Roya Mousavi
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine 3, University Hospital St. Pölten, St. Pölten, Austria
| | - Josip A Borovac
- Cardiovascular Diseases Department, University Hospital of Split, Split, Croatia
| | - Chun Shing Kwok
- Department of Post-Qualifying Healthcare Practice, School of Nursing and Midwifery, Birmingham City University, Birmingham, United Kingdom
- Department of Cardiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Uta C Hoppe
- University Department of Internal Medicine II, Cardiology and Internal Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Julia Mascherbauer
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine 3, University Hospital St. Pölten, St. Pölten, Austria
| | - Gudrun Lamm
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Division of Internal Medicine 3, University Hospital St. Pölten, St. Pölten, Austria
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Costa G, Giannini C, Mazzola M, Angelillis M, Primerano C, Spontoni P, Stazzoni L, Faggioni L, Neri E, De Carlo M, Petronio AS. Evolving Paradigms in Transcatheter Aortic Valve Replacement: Results from a High-Volume, Single Center Experience. Am J Cardiol 2024; 212:118-126. [PMID: 38036051 DOI: 10.1016/j.amjcard.2023.11.048] [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: 08/07/2023] [Revised: 10/19/2023] [Accepted: 11/14/2023] [Indexed: 12/02/2023]
Abstract
Given the expanding indications toward younger patients at lower surgical risk, transcatheter aortic valve replacement (TAVR) simplification and streamlining are gaining increasing importance. Patients who underwent TAVR from the year 2015 to 2020 were prospectively enrolled. The patients were divided in time tertiles according to the date of intervention. Data on preprocedural planning, including coronary computed tomography angiography (CCTA), procedures, and outcomes, were compared between the time tertiles. A total of 771 consecutive patients from a single institution were enrolled. We observed a trend toward the use of a fully percutaneous versus surgical approach for the index access, left radial artery versus contralateral femoral artery for the secondary access, and left ventricular pacing on the stiff guidewire versus right ventricular pacing. Immediate device success significantly increased, whereas the length of hospital stay decreased. Overall, approximately 60% of the total study population underwent CCTA instead of coronary angiography, with no adverse events. One-year survival rates significantly improved over time. A simplified TAVR approach was associated with better survival, whereas low baseline functional capacity, preexisting coronary artery disease, renal impairment, periprocedural blood transfusions, and paravalvular leak were related to worse outcomes. In conclusion, our study showed a constant tendency to procedure streamlining and improve procedural success and 1-year outcomes. A strategy based on CCTA allows sparing safely almost half of the preoperative invasive coronary angiography.
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Affiliation(s)
- Giulia Costa
- Cardiac Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
| | - Cristina Giannini
- Cardiac Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Matteo Mazzola
- Cardiac Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Marco Angelillis
- Cardiac Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Chiara Primerano
- Cardiac Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Paolo Spontoni
- Cardiac Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Laura Stazzoni
- Cardiac Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Lorenzo Faggioni
- Department of Translational Research, Academic Radiology, University of Pisa, Pisa, Italy
| | - Emanuele Neri
- Department of Translational Research, Academic Radiology, University of Pisa, Pisa, Italy
| | - Marco De Carlo
- Cardiac Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Anna Sonia Petronio
- Cardiac Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Bansal K, Soni A, Shah M, Kosinski AS, Gilani F, Khera S, Vemulapalli S, Elmariah S, Kolte D. Association Between Polyvascular Disease and Transcatheter Aortic Valve Replacement Outcomes: Insights From the STS/ACC TVT Registry. Circ Cardiovasc Interv 2023; 16:e013578. [PMID: 37870587 DOI: 10.1161/circinterventions.123.013578] [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: 09/01/2023] [Accepted: 10/13/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Atherosclerotic cardiovascular disease is highly prevalent in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Polyvascular disease (PVD), defined as involvement of ≥2 vascular beds (VBs), that is, coronary, cerebrovascular, or peripheral, portends a poor prognosis in patients with atherosclerotic cardiovascular disease; however, data on the association of PVD with outcomes of patients undergoing TAVR are limited. METHODS The Society of Thoracic Surgeons and the American College of Cardiology Transcatheter Valve Therapy Registry was analyzed to identify patients who underwent TAVR from November 2011 to March 2022. The exposure of interest was PVD. The primary outcome was all-cause mortality. Secondary outcomes included major vascular complications, major/life-threatening bleeding, myocardial infarction, transient ischemic attack/stroke, and valve- and non-valve-related readmissions. Outcomes were assessed at 30 days and 1 year. RESULTS Of 443 790 patients who underwent TAVR, PVD was present in 150 823 (34.0%; 111 425 [25.1%] with 2VB-PVD and 39 398 [8.9%] with 3VB-PVD). On multivariable analysis, PVD was associated with increased all-cause mortality at 1 year (hazard ratio, 1.17 [95% CI, 1.14-1.20]). There was an incremental increase in 1-year mortality with an increasing number of VBs involved (no PVD [reference]; 2VB-PVD: hazard ratio, 1.12 [95% CI, 1.09-1.15]: and 3VB-PVD: hazard ratio, 1.31 [95% CI, 1.26-1.36]). Patients with versus without PVD had higher rates of major vascular complications, major/life-threatening bleeding, transient ischemic attack/stroke, and non-valve-related readmissions at 30 days and 1 year. CONCLUSIONS PVD is associated with worse outcomes after TAVR, and the risk is highest in patients with 3VB-PVD.
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Affiliation(s)
- Kannu Bansal
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA (K.B., A.S.)
| | - Aakriti Soni
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA (K.B., A.S.)
| | - Miloni Shah
- Duke Clinical Research Institute, Durham, NC (M.S., A.S.K.)
| | | | - Fahad Gilani
- Division of Cardiovascular Medicine, Catholic Medical Center, Manchester, NH (F.G.)
| | - Sahil Khera
- Division of Interventional Cardiology, Mount Sinai Hospital, New York, NY (S.K.)
| | - Sreekanth Vemulapalli
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (S.V.)
- Division of Cardiology, Duke University Medical Center, Durham, NC (S.V.)
| | - Sammy Elmariah
- Division of Cardiology, University of California, San Francisco (S.E.)
| | - Dhaval Kolte
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston (D.K.)
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Mosleh W, Mather JF, Delago AJ, Eastman L, Crain N, Swann EL, Masih R, DeVries JT, McKay RG, Young MN. The Benefit of Percutaneous Coronary Intervention Before Transcatheter Aortic Valve Replacement: A Multicenter Retrospective Outcome-Based Study. Am J Cardiol 2023; 206:175-184. [PMID: 37708748 DOI: 10.1016/j.amjcard.2023.08.064] [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: 06/25/2023] [Revised: 08/03/2023] [Accepted: 08/11/2023] [Indexed: 09/16/2023]
Abstract
There is inadequate evidence regarding the role of percutaneous coronary intervention (PCI) in patients who underwent transcatheter aortic valve replacement (TAVR). The current American Heart Association/American College of Cardiology guidelines are limited to class 2A recommendations for pre-TAVR revascularization in the setting of hemodynamically significant left main (LM), proximal left anterior descending (pLAD), or extensive bifurcation disease regardless of angina status. We performed a multicenter, retrospective, observational study assessing the benefit of PCI in patients with coronary artery disease who underwent transfemoral TAVR for severe symptomatic aortic stenosis. Patients were divided into 2 cohorts: (1) patients who did not undergo pre-TAVR PCI within the preceding 12 months (no-PCI group) and (2) patients who received pre-TAVR PCI within the preceding 12 months (PCI group). The primary outcome was defined as the composite end point of in-hospital and 30-day adverse events, including all-cause mortality, cardiac arrest, and myocardial infarction. Subgroup analyses were performed on patients with LM and/or pLAD disease and other high-risk features, including angina and heart failure. Comparisons were made between 1,809 consecutive patients (1,364 in the no-PCI group and 445 in the PCI group). There were no differences between the 2 cohorts regarding the primary composite outcome (2.0% vs 2.8%, p = 0.918) or individual secondary outcomes. Although LM/pLAD disease, New York Heart Association classes III to IV, and Society of Thoracic Surgeons risk score ≥8 were all independent predictors of the primary outcome, none of the subgroups demonstrated a benefit favoring PCI. In conclusion, there is no observed benefit from PCI within 12 months pre-TAVR in patients with severe aortic stenosis and concomitant coronary artery disease, including patients with LM/pLAD disease.
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Affiliation(s)
- Wassim Mosleh
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Augustin J Delago
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Lauren Eastman
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Nathan Crain
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Emily L Swann
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Rohit Masih
- Cardiology, Hartford Healthcare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - James T DeVries
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Raymond G McKay
- Cardiology, Hartford Healthcare Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael N Young
- Department of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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Tarantini G, Tang G, Nai Fovino L, Blackman D, Van Mieghem NM, Kim WK, Karam N, Carrilho-Ferreira P, Fournier S, Pręgowski J, Fraccaro C, Vincent F, Campante Teles R, Mylotte D, Wong I, Bieliauskas G, Czerny M, Bonaros N, Parolari A, Dudek D, Tchetche D, Eltchaninoff H, de Backer O, Stefanini G, Sondergaard L. Management of coronary artery disease in patients undergoing transcatheter aortic valve implantation. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions in collaboration with the ESC Working Group on Cardiovascular Surgery. EUROINTERVENTION 2023; 19:37-52. [PMID: 36811935 PMCID: PMC10174192 DOI: 10.4244/eij-d-22-00958] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/19/2023] [Indexed: 02/24/2023]
Abstract
Significant coronary artery disease (CAD) is a frequent finding in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), and the management of these two conditions becomes of particular importance with the extension of the procedure to younger and lower-risk patients. Yet, the preprocedural diagnostic evaluation and the indications for treatment of significant CAD in TAVI candidates remain a matter of debate. In this clinical consensus statement, a group of experts from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery aims to review the available evidence on the topic and proposes a rationale for the diagnostic evaluation and indications for percutaneous revascularisation of CAD in patients with severe aortic stenosis undergoing transcatheter treatment. Moreover, it also focuses on commissural alignment of transcatheter heart valves and coronary re-access after TAVI and redo-TAVI.
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Affiliation(s)
- Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Gilbert Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, NY, USA
| | - Luca Nai Fovino
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Daniel Blackman
- Leeds Teaching Hospitals NHS Trust, University of Leeds, Leeds, UK
| | | | | | - Nicole Karam
- Department of Cardiology, Hôpital Européen Georges-Pompidou, Paris, France
| | - Pedro Carrilho-Ferreira
- Serviço de Cardiologia, Hospital de Santa Maria, CHULN, and Centro de Cardiologia da Universidade de Lisboa, Faculdade de Medicina de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | | | | | - Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Flavien Vincent
- Division of Cardiology, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | | | - Darren Mylotte
- Department of Cardiology, University Hospital Galway, Galway, Ireland
| | - Ivan Wong
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Gintautas Bieliauskas
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Martin Czerny
- University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Alessandro Parolari
- Department of Biomedical Sciences for Health, University of Milano, Milan, Italy and University Cardiac Surgery, Policlinico San Donato IRCCS, Milan, Italy
| | - Darius Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Ravenna, Italy
| | | | | | - Ole de Backer
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy
| | - Lars Sondergaard
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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8
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Will M, Schwarz K, Weiss T, Leibundgut G, Lamm G, Vock P, Mascherbauer J, Kwok CS. The impact of chronic total occlusions in patients undergoing transcatheter aortic valve replacement: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2023; 101:806-812. [PMID: 36802136 DOI: 10.1002/ccd.30601] [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: 12/27/2022] [Revised: 01/30/2023] [Accepted: 02/05/2023] [Indexed: 02/21/2023]
Abstract
Coronary artery disease (CAD) is frequently encountered in patients evaluated for transcatheter aortic valve replacement (TAVR) due to severe aortic stenosis. The prognostic relevance of chronic total occlusions (CTOs) in this setting is poorly understood. We conducted a search of MEDLINE and EMBASE to identify studies evaluating patients who underwent TAVR and evaluated outcomes depending on the presence of coronary CTOs. Pooled analysis was performed to estimate the rate and risk ratio for mortality. Four studies involving 25,432 patients fulfilled the inclusion criteria. The follow up ranged from in-hospital outcomes to 8-years follow-up. Coronary artery disease was present in 67.8% to 75.5% of patients in 3 studies which reported this variable. The prevalence of CTOs varied between 2% and 12.6% in this cohort. The presence of CTOs was associated with increase in length of stay (8.1 ± 8.2 vs. 5.9 ± 6.5, p < 0.01), cardiogenic shock (5.1% vs. 1.7%, p < 0.01), acute myocardial infarction (5.8% vs. 2.8%, p = 0.02) and acute kidney injury (18.6% vs. 13.9%, p = 0.048). The pooled 1-year death rate revealed 41 deaths in 165 patients in the CTO group and 396 deaths in 1663 patients with no CTO ((24.8%) vs. (23.8%)). The meta-analysis of death with CTO versus no CTO showed a nonsignificant trend toward increased mortality with CTOs (risk ratio 1.11 95% CI 0.90-1.40, I2 = 0%). Our analysis suggests that concomitant CTO lesions in patients undergoing TAVR are common, and its presence was associated with increased in-hospital complications. However, CTO presence by itself was not associated with increased long-term mortality, only a nonsignificant trend toward an increased risk of death in patients with CTO was found. Further studies are warranted to assess the prognostic relevance of CTO lesion in TAVR patients.
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Affiliation(s)
- Maximilian Will
- Department of Internal Medicine 3, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, Krems, Austria.,Karl Landsteiner Institute for Cardiometabolics, Karl Landsteiner Society, St Poelten, Austria
| | - Konstantin Schwarz
- Department of Internal Medicine 3, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Thomas Weiss
- Karl Landsteiner Institute for Cardiometabolics, Karl Landsteiner Society, St Poelten, Austria.,Medical School, Sigmund-Freud University, Vienna, Austria
| | - Gregor Leibundgut
- Klinik für Kardiologie, Universitätsspital Basel, Basel, Switzerland
| | - Gudrun Lamm
- Department of Internal Medicine 3, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Paul Vock
- Department of Internal Medicine 3, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine 3, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Chun Shing Kwok
- Department of Post-Qualifying Healthcare Practice, School of Nursing and Midwifery, Birmingham City University, Birmingham, UK.,Department of Cardiology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
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9
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Ibrahim H, Williams MR. When Fixing Hinders, Why We Should Sometimes Fight the Urge to Fix. Circ Cardiovasc Interv 2022; 15:e012654. [PMID: 36538581 DOI: 10.1161/circinterventions.122.012654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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10
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Clinical Outcomes of Revascularization with Percutaneous Coronary Intervention Prior to Transcatheter Aortic Valve Replacement: A Comprehensive Meta-Analysis. Curr Probl Cardiol 2022; 47:101339. [PMID: 35908687 DOI: 10.1016/j.cpcardiol.2022.101339] [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: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Prior studies on revascularization prior to transcatheter aortic valve replacement (TAVR), in patients with significant coronary artery disease (CAD), have reported mixed results. AIM We sought to perform a meta-analysis combining current evidence by investigating outcomes of revascularization in patients who undergo TAVR with coexisting CAD. METHODS We searched literature for studies reporting on outcomes following TAVR performed with versus without pre-TAVR PCI, for coexisting CAD. Random-effect model was used to pool estimates of odds ratios (ORs). RESULTS Twenty-four reports with 12,182 TAVR patients were included: 22 observational and 2 clinical trials. 4,110 (33.7%) were in the pre-TAVR PCI group, 51.4% were females, and mean age was 81.9 years. The 30-day mortality was 5.2% versus 5.0% in patients with versus without pre-TAVR PCI, respectively [OR= 1.19 (95% CI: 0.91-1.55, p= 0.20)]. Pooled 1-year mortality was 18.1% versus 19.1% in patients with versus without pre-TAVR PCI (OR= 1.12, 95% CI: 0.95-1.31, p= 0.61). There was no significant difference between the groups for myocardial infarction, stroke, acute kidney injury, pacemaker implantation, or rehospitalization. Pre-TAVR PCI was associated with increased risk of life-threatening bleeding at 30 days. CONCLUSION Pre-TAVR revascularization with PCI was not associated with improved 30-day or 1-year mortality; however, it was associated with increased risk of life-threatening bleeding at 30-day post-TAVR. Our results do not support routine revascularization with PCI prior to TAVR with coexisting CAD. Future trials addressing anatomical complexity and symptom burden may help better risk stratify patients who may benefit with pre-TAVR revascularization.
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11
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Ricottini E, Carpenito M, Nusca A, Melfi R, Rinaldi R, Grigioni F, Ussia GP. Combined procedure of transcatheter aortic valve replacement and coronary intravascular lithotripsy. J Cardiovasc Med (Hagerstown) 2022; 23:487-492. [PMID: 35763774 DOI: 10.2459/jcm.0000000000001321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Elisabetta Ricottini
- Unit of Cardiovascular Sciences, Department of Medicine, Campus Bio-Medico University of Rome, Italy
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12
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Acute Kidney Injury Following Transcatheter Aortic Valve Implantation: Association with Contrast Media Dosage and Contrast Media Based Risk Predication Models. J Clin Med 2022; 11:jcm11051181. [PMID: 35268271 PMCID: PMC8911230 DOI: 10.3390/jcm11051181] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/18/2022] [Accepted: 02/18/2022] [Indexed: 12/10/2022] Open
Abstract
The effect of contrast media (CM), delivered prior to- and during transcatheter aortic valve implantation (TAVI), on kidney function, following the procedure, is debatable. Consequently, the performance of CM-based, acute kidney injury (AKI) risk prediction models is also questionable. We retrospectively studied 210 patients that underwent TAVI. We recorded the dose of CM used prior and during TAVI, calculated the results of different AKI risk assessment models containing a CM module, and tested their association with AKI after the procedure. AKI was diagnosed in 38 patients (18.1%). The baseline estimated glomerular filtration rate (eGFR) was lower in the AKI+ group compared to AKI− group (51 ± 19.3 versus 64.5 ± 19 mL/min/1.73 mr2, respectively). While the dose of CM delivered prior to TAVI, during TAVI or the cumulative amount of both did not differ between the groups, the results of all tested risk models were higher in AKI+ patients. However, by multivariable analysis, only eGFR had a consistent independent association with AKI. We suggest that the dose of CM delivered prior or during TAVI is not associated with AKI and that the predictive power of CM based AKI risk models is, in all probability, limited to eGFR alone.
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13
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OUP accepted manuscript. Eur Heart J 2022; 43:2729-2750. [DOI: 10.1093/eurheartj/ehac105] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/22/2022] [Accepted: 02/01/2022] [Indexed: 11/12/2022] Open
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Lim Y, Tan KA, Kuntjoro I, Hon JKF, Yip J, Tay E. Coronary Artery Disease in Patients Undergoing Transvalvular Aortic Valve Implantation. Interv Cardiol 2022; 17:e13. [PMID: 36304067 PMCID: PMC9585643 DOI: 10.15420/icr.2021.25] [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: 08/28/2021] [Accepted: 05/02/2022] [Indexed: 01/09/2023] Open
Abstract
Coronary artery disease (CAD) is common in patients with severe aortic stenosis. With the advent of transcatheter aortic valve implantation (TAVI) as a therapeutic option, management of CAD in such patients has undergone a revolution. Younger patients are now candidates for treatment, and have a greater life-time probability of requiring post-TAVI coronary access. Considerations include pre-procedural assessment and revascularisation, procedural planning to avoid coronary obstruction as well as optimisation of post-procedural coronary access. The authors review the challenges of managing CAD in TAVI patients, shed light on the evidence base, and provide guidance on how to optimise management.
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Affiliation(s)
- Yinghao Lim
- Department of Cardiology, National University Heart CentreSingapore
| | - Kent Anthony Tan
- Department of Cardiology, National University Heart CentreSingapore
| | | | - Jimmy KF Hon
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart CentreSingapore
| | - James Yip
- Department of Cardiology, National University Heart CentreSingapore
| | - Edgar Tay
- Department of Cardiology, National University Heart CentreSingapore
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15
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Stephan T, Thoma E, Rattka M, Felbel D, Buckert D, Rottbauer W, Gonska B, Markovic S. Impact of extent of coronary artery disease and percutaneous revascularization assessed by the SYNTAX score on outcomes following transcatheter aortic valve replacement. BMC Cardiovasc Disord 2021; 21:568. [PMID: 34847875 PMCID: PMC8638523 DOI: 10.1186/s12872-021-02374-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/05/2021] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES The aim of the study was to analyze the impact of concomitant coronary artery disease (CAD) assessed by the SYNTAX score (SS) and periprocedural percutaneous coronary intervention (PCI) on outcomes after transcatheter aortic valve replacement (TAVR). BACKGROUND Due to controversial data regarding the effect of CAD on outcomes after TAVR, proper revascularization strategies remain a matter of debate. METHODS 553 patients with severe aortic stenosis undergoing TAVR were included in this study. SS was calculated for each patient at baseline and after PCI. Primary outcome was one-year all-cause mortality. RESULTS 60.2% of patients (N = 333) exhibited CAD with a mean SS of 10.8 ± 8.8. Of those, 120 patients (36.0%) received periprocedural PCI. In the treatment group, mean SS was decreased from 14.9 ± 9.1 to 6.3 ± 6.7. Patients with concomitant CAD suffered more frequently from myocardial infarction (MI) post TAVR compared to those without CAD (2.1% vs. 0.0%; P < 0.01). In the CAD cohort, MI rates were comparable between patients with and without PCI (2.2% vs. 2.5%; P = 0.71). Regarding SS, patients with a residual SS < 8 showed significant lower rates of one-year mortality (9.0% vs. 18.2%; P = 0.016) and MACCE (16.5% vs. 32.2%; P = 0.001). Besides left bundle brunch, predictors for an increased one-year mortality were a residual SS ≥ 8 in the CAD group (OR = 3.17; P = 0.011) and a EuroSCORE ≥ 4% in the entire study population (OR = 2.18; P = 0.017). CONCLUSION Our results suggest that a residual SS-guided revascularization strategy may improve prognosis after TAVR in patients with concomitant CAD. PCI aiming for a residual SS < 8 was associated with improved one-year clinical outcomes.
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Affiliation(s)
- Tilman Stephan
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, University Hospital Ulm, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Eva Thoma
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, University Hospital Ulm, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Manuel Rattka
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, University Hospital Ulm, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Dominik Felbel
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, University Hospital Ulm, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Dominik Buckert
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, University Hospital Ulm, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Wolfgang Rottbauer
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, University Hospital Ulm, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Birgid Gonska
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, University Hospital Ulm, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Sinisa Markovic
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, University Hospital Ulm, University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
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16
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Patterson T, Clayton T, Dodd M, Khawaja Z, Morice MC, Wilson K, Kim WK, Meneveau N, Hambrecht R, Byrne J, Carrié D, Fraser D, Roberts DH, Doshi SN, Zaman A, Banning AP, Eltchaninoff H, Le Breton H, Smith D, Cox I, Frank D, Gershlick A, de Belder M, Thomas M, Hildick-Smith D, Prendergast B, Redwood S. ACTIVATION (PercutAneous Coronary inTervention prIor to transcatheter aortic VAlve implantaTION): A Randomized Clinical Trial. JACC Cardiovasc Interv 2021; 14:1965-1974. [PMID: 34556269 DOI: 10.1016/j.jcin.2021.06.041] [Citation(s) in RCA: 101] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 06/22/2021] [Accepted: 06/29/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study sought to determine if percutaneous coronary intervention (PCI) prior to transcatheter aortic valve replacement (TAVR) in patients with significant coronary artery disease would produce noninferior clinical results when compared with no PCI (control arm). BACKGROUND PCI in patients undergoing TAVR is not without risk, and there are no randomized data to inform clinical practice. METHODS Patients with severe symptomatic aortic stenosis and significant coronary artery disease with Canadian Cardiovascular Society class ≤2 angina were randomly assigned to receive PCI or no PCI prior to TAVR. The primary endpoint was a composite of all-cause death or rehospitalization at 1 year. Noninferiority testing (prespecified margin of 7.5%) was performed in the intention-to-treat population. RESULTS At 17 centers, 235 patients underwent randomization. At 1 year, the primary composite endpoint occurred in 48 (41.5%) of the PCI arm and 47 (44.0%) of the no-PCI arm. The requirement for noninferiority was not met (difference: -2.5%; 1-sided upper 95% confidence limit: 8.5%; 1-sided noninferiority test P = 0.067). On analysis of the as-treated population, the difference was -3.7% (1-sided upper 95% confidence limit: 7.5%; P = 0.050). Mortality was 16 (13.4%) in the PCI arm and 14 (12.1%) in the no-PCI arm. At 1 year, there was no evidence of a difference in the rates of stroke, myocardial infarction, or acute kidney injury, with higher rates of any bleed in the PCI arm (P = 0.021). CONCLUSIONS Observed rates of death and rehospitalization at 1 year were similar between PCI and no PCI prior to TAVR; however, the noninferiority margin was not met, and PCI resulted in a higher incidence of bleeding. (Assessing the Effects of Stenting in Significant Coronary Artery Disease Prior to Transcatheter Aortic Valve Implantation; ISRCTN75836930).
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Affiliation(s)
- Tiffany Patterson
- Cardiovascular Department, St Thomas' Hospital, Kings College London, London, United Kingdom
| | - Tim Clayton
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Matthew Dodd
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Zeeshan Khawaja
- Cardiology Department, Lewisham and Greenwich NHS Foundation Trust, United Kingdom
| | - Marie Claude Morice
- Institut Cardiovasculaire Paris Sud, Massy, France; Cardiovascular European Research Center, Massy, France
| | - Karen Wilson
- Cardiovascular Department, St Thomas' Hospital, Kings College London, London, United Kingdom
| | - Won-Keun Kim
- Cardiology Department, Kerckhoff-Klinik Bad Nauheim Abteilung Kardiologie, Bad Nauheim, Germany
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Rainer Hambrecht
- Cardiology Department, Klinikum Links der Weser GmbH, Bremen, Germany
| | - Jonathan Byrne
- Cardiothoracic Department, King's College Hospital, London, United Kingdom
| | - Didier Carrié
- Cardiology Department, Hôpital Rangueil, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Doug Fraser
- Cardiology Department, Manchester Royal Infirmary, Manchester, United Kingdom
| | - David H Roberts
- Lancashire Cardiac Centre, Blackpool Victoria Hospital NHS Trust, Blackpool, United Kingdom
| | - Sagar N Doshi
- Cardiology Department, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Azfar Zaman
- Cardiology Department, Newcastle upon Tyne Hospitals NHS Foundation Trust of the Freeman Hospital, Newcastle, United Kingdom
| | - Adrian P Banning
- Department of Cardiology, John Radcliffe Hospital, Oxford, United Kingdom
| | - Hélène Eltchaninoff
- Cardiology Department, Hôpital Charles-Nicolle, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | - Hervé Le Breton
- Service de Cardiologie, Hôpital Pontchaillou, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - David Smith
- Cardiology Department, Morriston Hospital, Swansea, United Kingdom
| | - Ian Cox
- Cardiology Department, Derriford Hospital, Plymouth, United Kingdom
| | - Derk Frank
- Cardiology Department, Oberarzt Facharzt für Innere Medizin und Kardiologie, Kiel, Germany
| | - Anthony Gershlick
- Department of Cardiovascular Sciences, Glenfield Hospital, University of Leicester, Leicester, United Kingdom
| | - Mark de Belder
- Cardiology Department, Barts Heart Centre, London, United Kingdom
| | | | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Bernard Prendergast
- Cardiovascular Department, St Thomas' Hospital, Kings College London, London, United Kingdom
| | - Simon Redwood
- Cardiovascular Department, St Thomas' Hospital, Kings College London, London, United Kingdom.
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Sabbah M, Engstrøm T, De Backer O, Søndergaard L, Lønborg J. Coronary Assessment and Revascularization Before Transcutaneous Aortic Valve Implantation: An Update on Current Knowledge. Front Cardiovasc Med 2021; 8:654892. [PMID: 34095249 PMCID: PMC8175649 DOI: 10.3389/fcvm.2021.654892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/18/2021] [Indexed: 12/22/2022] Open
Abstract
Transcutaneous aortic valve implantation (TAVI) has led to a paradigm shift in the treatment of severe aortic stenosis (AS) in the elderly and is expanding to still younger and lower-risk patients with severe AS as an alternative to surgical aortic valve replacement (SAVR). While the role of coronary artery bypass grafting with SAVR is well-documented, the analog of percutaneous coronary intervention with TAVI is less so. The aim of this review is to provide an overview of the important challenges in treating severe AS and co-existing coronary artery disease in patients planned for TAVI.
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Affiliation(s)
- Muhammad Sabbah
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole De Backer
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Søndergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jacob Lønborg
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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18
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The Role of Mechanical Circulatory Support in Patients With Severe Left Ventricular Impairment Treated With Transcatheter Aortic Valve Implantation and Percutaneous Coronary Intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 28S:169-175. [PMID: 33875387 DOI: 10.1016/j.carrev.2021.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 02/28/2021] [Accepted: 03/27/2021] [Indexed: 01/18/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) has become an established treatment for patients with severe aortic stenosis (AS) in an ever-growing patient population. It is not uncommon for patients who are undergoing TAVI to have technically difficult anatomy, simultaneous severe left ventricular (LV) impairment and/or extensive coronary artery disease. In this case series we present examples where the use of mechanical circulatory support (MCS) facilitated a safe aortic and coronary intervention in extremely complex patients who would have otherwise carried prohibitive procedural risk.
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Pathophysiology, Diagnosis, and Treatment of Patients with Concomitant Severe Aortic Stenosis and Coronary Artery Disease: A Closer Look to the Unresolved Perplexity. J Clin Med 2021; 10:jcm10081617. [PMID: 33920349 PMCID: PMC8070187 DOI: 10.3390/jcm10081617] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/01/2021] [Accepted: 04/08/2021] [Indexed: 01/09/2023] Open
Abstract
Degenerative aortic stenosis (AS) and coronary artery disease (CAD) are the most prevalent cardiovascular diseases in developed countries, and they coexist in up to 50% of patients. The pathophysiological rationale behind concomitant AS and CAD is discussed in detail in this review, together with prognostic implications. Detecting CAD in patients with AS may be challenging, as AS may mask the existence and symptoms of CAD. The safety and reliability of invasive and non-invasive physiological assessment for epicardial coronary disease are also a matter of debate. Finally, the selection and timing of optimal treatment of CAD in patients with severe AS are still unclear. Given the aging of the population, the increase in the prevalence of AS, and the ongoing paradigm shift in its treatment, controversies in the diagnosis and treatment of CAD in the setting of AS are deemed to grow in importance. In this paper, we present contemporary issues in the diagnosis and management of CAD in patients with severe AS who are transcatheter aortic valve implantation (TAVI) candidates and provide perspective on the treatment approach.
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20
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Impact of Coronary Artery Disease and Percutaneous Coronary Intervention on Transcatheter Aortic Valve Implantation. J Interv Cardiol 2021; 2021:6672400. [PMID: 33824628 PMCID: PMC8016584 DOI: 10.1155/2021/6672400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/07/2021] [Accepted: 03/16/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction The prevalence of coronary artery disease (CAD) detected in preoperative work-up for transcatheter aortic valve implantation (TAVI) is high. Instead, the management of a concomitant CAD remains unclear. We evaluate the impact of CAD and percutaneous coronary intervention (PCI) on TAVI procedures. Materials and Methods A retrospective study was conducted on 1336 consecutive patients who underwent TAVI in Toulouse University Hospital, Rangueil, France. The studied population was divided into 2 groups: CAD-TAVI group and No CAD-TAVI group. Then, the CAD-TAVI group was segregated into 2 subgroups: PCI-TAVI group and No PCI-TAVI group. In-hospital adverse clinical outcomes were assessed in each group. Results Pre-TAVI work-up revealed significant CAD in 36% of 1030 patients eligible for inclusion in the study. The overall prevalence of in-hospital death, stroke, major or life-threatening bleeding, minor bleeding, major vascular complications, minor vascular complications, pacemaker implantation, and acute kidney injury was 2.7%, 2.4%, 2.8%, 3.6%, 3.9%, 7.5%, 12.5%, and 2.7%, respectively. Among the studied population, 55% were admitted to the cardiac care unit. No significant statistical difference was observed between groups. Discussion. CAD-TAVI population was not more likely to develop in-hospital adverse clinical outcomes post-TAVI procedure compared to others. Also, no significant difference regarding in-hospital death was observed. In parallel, performing PCI prior to TAVI did not increase the risk of in-hospital death and complications. The difference in terms of the distribution of antithrombotic regimen may explain the higher prevalence of bleeding events in the PCI-TAVI group. Conclusion This study provides direct clinical relevance useful in daily practice. No negative impact has been attributed to the presence of a concomitant CAD and/or preoperative PCI on the TAVI hospitalization period.
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21
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Outcomes of concomitant percutaneous coronary interventions and transcatheter aortic valve replacement. Arch Med Sci Atheroscler Dis 2021; 5:e284-e289. [PMID: 33644487 PMCID: PMC7885813 DOI: 10.5114/amsad.2020.103092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/02/2020] [Indexed: 12/02/2022] Open
Abstract
Introduction Coronary artery disease is a common diagnosis among patients undergoing transcatheter aortic valve replacement (TAVR). The treatment and timing of percutaneous coronary intervention (PCI) remain controversial. We sought to compare in-hospital periprocedural outcomes of combined TAVR and PCI during the same index hospitalization versus the isolated TAVR procedure. Material and methods The study population was extracted from the 2016 Nationwide Readmissions Data (NRD) using International Classification of Diseases, tenth edition, clinical modifications/procedure coding system codes for TAVR, coronary PCI, and post-procedural complications. Study endpoints included in-hospital all-cause mortality, length of index hospital stay, cardiogenic shock, need for mechanical circulatory support (MCS) devices, mechanical complications of prosthetic valve, paravalvular leak (PVL), acute kidney injury (AKI), bleeding and total hospital charges. Propensity matching was used to adjust for baseline characteristics. Results There were 23,604 TAVRs in the 2016 NRD, of which 852 were combined with PCI during the same index hospitalization. Mean age was 80.5 years and 45.9% were female. In comparison to isolated TAVR, TAVR-PCI was associated with higher in-hospital all-cause mortality (4.5% vs. 1.7%, p < 0.01), longer length of stay (10.5 vs. 5.4 days, p < 0.01), and higher incidence of cardiogenic shock (9.4% vs. 2.1%, p < 0.01), use of MCS devices (6.8% vs. 0.7%, p < 0.01), mechanical complications of prosthetic valve (6.8% vs. 0.7%, p < 0.01), PVL (0.9% vs. 0.4%, p = 0.01), AKI (25.5% vs. 11.5%, p < 0.01), bleeding (25.2% vs. 18.1%, p < 0.01), and total hospital charges ($354,725 vs. $220474, p < 0.01). Conclusions In comparison to isolated TAVR, combined TAVR-PCI was associated with a higher incidence of in-hospital morbidity and mortality. The association and mechanism of increased mortality warrant further study.
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Marin F, Scarsini R, Kotronias RA, Printzios DT, Burrage MK, Bray JJH, Ciofani JL, Venturi G, Pighi M, De Maria GL, Banning AP. Aortic Valve Disease and Associated Complex CAD: The Interventional Approach. J Clin Med 2021; 10:946. [PMID: 33804391 PMCID: PMC7957505 DOI: 10.3390/jcm10050946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/19/2021] [Accepted: 02/20/2021] [Indexed: 01/09/2023] Open
Abstract
Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis (AS). The management of CAD is a central aspect of the work-up of patients undergoing transcatheter aortic valve implantation (TAVI), but few data are available on this field and the best percutaneous coronary intervention (PCI) practice is yet to be determined. A major challenge is the ability to elucidate the severity of bystander coronary stenosis independently of the severity of aortic valve stenosis and subsequent impact on blood flow. The prognostic role of CAD in patients undergoing TAVI is being still debated and the benefits and the best timing of PCI in this context are currently under evaluation. Additionally, PCI in the setting of advanced AS poses some technical challenges, due to the complex anatomy, risk of hemodynamic instability, and the increased risk of bleeding complications. This review aims to provide a comprehensive synthesis of the available literature on myocardial revascularization in patients with severe AS undergoing TAVI. This work can assist the Heart Team in individualizing decisions about myocardial revascularization, taking into account available diagnostic tools as well as the risks and benefits.
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Affiliation(s)
- Federico Marin
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford OX3 9DU, UK; (F.M.); (R.A.K.); (D.T.P.); (M.K.B.); (G.L.D.M.)
| | - Roberto Scarsini
- Department of Cardiology, University of Verona, 37129 Verona, Italy; (R.S.); (G.V.); (M.P.)
| | - Rafail A. Kotronias
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford OX3 9DU, UK; (F.M.); (R.A.K.); (D.T.P.); (M.K.B.); (G.L.D.M.)
| | - Dimitrios Terentes Printzios
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford OX3 9DU, UK; (F.M.); (R.A.K.); (D.T.P.); (M.K.B.); (G.L.D.M.)
| | - Matthew K. Burrage
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford OX3 9DU, UK; (F.M.); (R.A.K.); (D.T.P.); (M.K.B.); (G.L.D.M.)
| | - Jonathan J. H. Bray
- Institute of Life Sciences 2, Swansea Bay University Health Board and Swansea University Medical School, SA2 8QA Swansea, UK;
| | - Jonathan L. Ciofani
- Department of Cardiology, Royal North Shore Hospital, 2065 Sydney, Australia;
| | - Gabriele Venturi
- Department of Cardiology, University of Verona, 37129 Verona, Italy; (R.S.); (G.V.); (M.P.)
| | - Michele Pighi
- Department of Cardiology, University of Verona, 37129 Verona, Italy; (R.S.); (G.V.); (M.P.)
| | - Giovanni L. De Maria
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford OX3 9DU, UK; (F.M.); (R.A.K.); (D.T.P.); (M.K.B.); (G.L.D.M.)
| | - Adrian P. Banning
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford OX3 9DU, UK; (F.M.); (R.A.K.); (D.T.P.); (M.K.B.); (G.L.D.M.)
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Assessment and management of coronary artery disease in patients undergoing transcatheter aortic valve replacement. Curr Opin Cardiol 2020; 35:540-547. [PMID: 32649355 DOI: 10.1097/hco.0000000000000768] [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] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW Coronary artery disease (CAD) is commonly observed in patients undergoing transcatheter aortic valve replacement (TAVR). Significant variability exists across institutions for strategies used for CAD diagnosis and its management. The heart team often relies upon traditional practice patterns and the decision for revascularization by percutaneous coronary intervention (PCI) is influenced by patient, angiographic, operator, and system-related factors. RECENT FINDINGS Contemporary coronary tomography angiography (CTA) shows significant promise for detection of clinically important CAD and preliminary data support CTA use for TAVR patients. The prognostic implications of CAD in a TAVR population remain unclear with studies showing conflicting data for the benefits of PCI. Recent trials show that medical management is an effective initial treatment strategy for stable CAD, a finding likely also applicable for asymptomatic and stable TAVR patients. In addition, PCI performed pre-TAVR, concomitant with TAVR or after TAVR has been shown to produce similar outcomes. Dual antiplatelet therapy (DAPT) is mandated after PCI but associated with increased risk of bleeding in TAVR population with accumulating evidence for single antiplatelet therapy (SAPT) post-TAVR unless DAPT or anticoagulation is indicated for another reason. SUMMARY Although coronary angiography remains the predominant modality for CAD assessment, CTA is increasingly being used in TAVR patients. There is limited evidence to guide CAD management in TAVR patients with significant variability in practice patterns. Medical therapy is recommended for asymptomatic and stable CAD patients with applicability for TAVR population. Despite prior concerns, recent studies suggest successful coronary access post-TAVR and similar outcomes for PCI offered pre-TAVR, concomitant with TAVR and post-TAVR settings. Safety of DAPT should be an important consideration for PCI in TAVR patients. Ongoing studies will determine the preferred testing for CAD diagnosis, benefit of revascularization, timing of PCI, and optimum antithrombotic therapy for TAVR populations.
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Degenerative Severe Aortic Stenosis and Concomitant Coronary Artery Disease: What Is Changing in the Era of the “Transcatheter Revolution”? Curr Atheroscler Rep 2020; 22:17. [PMID: 32451750 DOI: 10.1007/s11883-020-0835-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Katta N, Abbott JD, Kalra A, Alenezi F, Goldsweig A, Aronow H, Velagapudi P. Management of Coronary Artery Disease in the Setting of Transcatheter Aortic Valve Replacement. Heart Int 2020; 14:24-28. [PMID: 36277671 PMCID: PMC9524713 DOI: 10.17925/hi.2020.14.1.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 03/06/2020] [Indexed: 07/21/2023] Open
Abstract
Aortic stenosis and coronary artery disease (CAD) frequently co-exist, as they share a common pathophysiology and risk factors. Due to lack of randomised controlled trials (RCTs) and exclusion of significant CAD in transcatheter aortic valve replacement (TAVR) trials, the optimal method of revascularisation of CAD in patients undergoing TAVR remains unknown. Observational studies and meta-analyses have shown varied results in outcomes for patients with CAD undergoing TAVR, and no significant difference in post-TAVR outcomes in patients who underwent revascularisation either prior to or during TAVR versus those who did not. However, some observational studies have shown that patients with lower residual SYNTAX score (rSS) post-revascularisation have better outcomes post-TAVR compared to those with higher rSS. RCTs are needed to clearly understand whether revascularisation is beneficial in these patients. Until then, management of CAD in patients undergoing TAVR must be individualised based on discussion with the heart team.
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Affiliation(s)
- Natraj Katta
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Ankur Kalra
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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Strong C, Ferreira A, Teles RC, Mendes G, Abecasis J, Cardoso G, Guerreiro S, Freitas P, Santos AC, Saraiva C, Brito J, Raposo L, Gonçalves PDA, Gabriel HM, Almeida MDS, Mendes M. Diagnostic accuracy of computed tomography angiography for the exclusion of coronary artery disease in candidates for transcatheter aortic valve implantation. Sci Rep 2019; 9:19942. [PMID: 31882777 PMCID: PMC6934755 DOI: 10.1038/s41598-019-56519-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/10/2019] [Indexed: 01/02/2023] Open
Abstract
Coronary CT angiography (CTA) is currently considered a reliable method to exclude obstructive coronary artery disease (CAD) before valvular heart surgery in patients with low pretest probability. However, its role in excluding obstructive CAD before transcatheter aortic valve implantation (TAVI) is less well established. Single-center retrospective study where patients with severe symptomatic aortic stenosis underwent both CTA and invasive coronary angiography (ICA) as part of TAVI planning. CTA exams were conducted on a 64-slice dual source scanner, with a median interval of 45 days to ICA (IQR 25–75 [13–82]). In both tests, obstructive CAD was defined as a ≥50% stenosis in an epicardial vessel ≥2 mm diameter. Per-patient, per-vessel and per-proximal segment analyses were conducted, excluding and including non-evaluable segments. The study included 200 patients (120 women, mean age 83 ± 6 years). The prevalence of obstructive CAD on ICA was 35.5% (n = 71). On a per-patient analysis (assuming non-evaluable segments as stenotic), CTA showed sensitivity of 100% (95% CI, 95–100%), specificity of 42% (95% CI, 33–51%), and positive and negative predictive values of 48% (95% CI, 44–51%) and 100% (95% CI, 92–100%), respectively. CTA was able to exclude obstructive CAD in 54 patients (27%), in whom ICA could have been safely withheld. Despite the high rate of inconclusive tests, pre-procedural CTA is able to safely exclude obstructive CAD in a significant proportion of patients undergoing TAVI, possibly avoiding the need for ICA in roughly one quarter of the cases.
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Affiliation(s)
- Christopher Strong
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal.
| | - António Ferreira
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - Rui Campante Teles
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - Gustavo Mendes
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - João Abecasis
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - Gonçalo Cardoso
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - Sara Guerreiro
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - Pedro Freitas
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | | | - Carla Saraiva
- Hospital de Santa Cruz, Radiology department, Lisboa, 2790-134, Portugal
| | - João Brito
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | - Luís Raposo
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
| | | | | | | | - Miguel Mendes
- Hospital de Santa Cruz, Cardiology department, Lisboa, 2790-134, Portugal
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Mylotte D, Wijns W. Anatomical or Functional Assessment of Coronary Artery Disease in Aortic Stenosis: Haven't We Been Down This Road Before? J Am Heart Assoc 2019; 8:e014367. [PMID: 31718440 PMCID: PMC6915286 DOI: 10.1161/jaha.119.014367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Darren Mylotte
- The Lambe Institute for Translational Medicine and Curam Saolta University Healthcare Group Galway Ireland
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam Saolta University Healthcare Group Galway Ireland
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[What antithrombotic treatment should we prescribe after transvalvular aortic valve implantation?]. Ann Cardiol Angeiol (Paris) 2019; 68:462-467. [PMID: 31653334 DOI: 10.1016/j.ancard.2019.09.020] [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: 09/19/2019] [Accepted: 09/20/2019] [Indexed: 11/20/2022]
Abstract
The performance and indications of transvalvular aortic valve implantation or TAVI has considerably expanded and is now the first therapeutic line option in the management of severe aortic stenosis. The targeted population shares both high risk of ischemic complications, particularly stroke or subclinical leaflet thrombosis of the bioprothesis, as well as hemorrhagic complications, strongly correlated to death. Based on previous experience with intracoronary stents, a dual antiplatelet therapy has been recommended by experts' consensus. This paradigm is now challenged by the observed increased risk of hemorrhagic complications without a reduction of ischemic events. Moreover, the role of non-vitamin K oral anticoagulant in patients undergoing TAVI remains to be determined. Several large ongoing randomized controlled trials will likely change our practice within the next coming year.
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29
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[TAVI and coronary revascularization]. Ann Cardiol Angeiol (Paris) 2019; 68:423-428. [PMID: 31648796 DOI: 10.1016/j.ancard.2019.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 09/20/2019] [Indexed: 11/23/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) has become the major approach to manage the severe aortic stenosis in inoperable patients that frequently present a coronary artery disease. To date, the available data related to the impact of these coronary lesions on survival is conflicting. When indicated, coronary revascularization could be beneficial for proximal lesions when performed before or during TAVI. The per-procedure coronary artery occlusion is rare, but with a bad prognosis. The coronary occlusion is more frequent with short distance of the coronary implantation and the small aortic sinuses, mostly occurring in the left main coronary. The scan analysis to identify high-risk cases is therefore important before the procedure in order to anticipate and prevent complications by specific techniques. Recently, late occlusion cases have been described and linked to thrombus or fibrosis mechanisms. The rate of success of percutaneous coronary intervention (PCI) after TAVI approach is weak, because of the difficulties of selective catheterization due to the stent of prosthesis. The different techniques of PCI have been outlined according to the type of the prosthesis.
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30
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Aljure OD, Fabbro M. Percutaneous Coronary Artery Revascularization and Transcatheter Aortic Valve Replacement: Is There a Who, Why, and When? J Cardiothorac Vasc Anesth 2019; 33:1696-1697. [DOI: 10.1053/j.jvca.2019.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Indexed: 11/11/2022]
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Impact of coronary artery disease on outcomes of severe aortic stenosis treatment with transcatheter aortic valve implantation. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2019; 15:167-175. [PMID: 31497049 PMCID: PMC6727222 DOI: 10.5114/aic.2019.84394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/10/2018] [Indexed: 01/12/2023] Open
Abstract
Introduction The presence of coronary artery disease (CAD) in patients who underwent transcatheter aortic valve implantation (TAVI) may increase in-hospital and long-term mortality. Aim To evaluate the impact of CAD in patients who underwent TAVI. Material and methods The study group consisted of the first 142 patients treated with TAVI between 26 November 2008 and 31 December 2015. The patients were divided into two groups: group I comprised 103 (72.5%) patients with CAD, and group II comprised 39 (27.5%) patients without CAD. Results Group I was characterized by a significantly higher risk according to EuroSCORE - 11.2 ±2.5 vs. 9 ±2.3 in group II (p < 0.001) and Logistic EuroSCORE - 25.4 ±13.4 vs. 16.3 ±8.7 (p < 0.001). 30-day mortality was 8 (7.8%) vs. 2 (5.1%) (p = NS) and 1-year mortality was 22 (21.4%) vs. 6 (15.4%) (p = NS) in group I and II respectively. The composite endpoint evaluating the efficacy of TAVI was achieved in 82 (79.6%) vs. 31 (79.5%) (p = NS) in group I and II respectively. The composite endpoint, which involved 30-day observation, occurred in 39 (37.86%) vs. 12 (30.77%) (p = NS) and the composite endpoint, which involved 1-year evaluation of the clinical efficacy of TAVI, occurred in 48 (57.8%) vs. 13 (48.1%) (p = NS) in patients with and without CAD respectively. Conclusions The short- and mid-term outcomes of TAVI patients with CAD, despite higher risk profile, did not differ from the outcomes of treatment in patients without CAD.
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Affiliation(s)
- Tiffany Patterson
- Cardiovascular Department, King's College London, St Thomas' Hospital, London, United Kingdom
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33
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Mahabadi AA, Kahlert P, Kahlert HA, Dykun I, Balcer B, Forsting M, Heusch G, Rassaf T. Comparison of Lipoprotein(a)-Levels in Patients ≥70 Years of Age With Versus Without Aortic Valve Stenosis. Am J Cardiol 2018; 122:645-649. [PMID: 29954600 DOI: 10.1016/j.amjcard.2018.04.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 04/23/2018] [Accepted: 04/23/2018] [Indexed: 01/08/2023]
Abstract
Although lipoprotein(a) (Lp[a]) is linked with aortic valve calcification and clinical aortic valve stenosis (AVS) in middle-aged cohorts, patients aged ≥70 years represent a majority of patients with AVS, in which mechanisms leading to AVS may differ. We sought to determine whether Lp(a) distinguishes patients ≥70 years with and without AVS. We matched 484 patients ≥70 years with AVS, scheduled for transcatheter aortic valve implantation with 484 patients without AVS by age group and gender. Lp(a) levels were compared in patients with and without AVS and stratified by presence and absence of clinical coronary artery disease (CAD) manifestation. A total of 968 patients (mean age 80 ± 5 years, 48% women) were included. When comparing patients with and without AVS, no difference in Lp(a) was observed (AVS: 17 [8; 56] mg/dl, no AVS: 18.5 [8.5; 57] mg/dl, p = 0.56). In contrast, patients with clinical CAD manifestation had higher Lp(a) levels than those without clinical CAD manifestation (coronary artery disease: 19 [9; 60] mg/dl, no coronary artery disease 15 [7; 44] mg/dl, p = 0.0006). In regression analysis, no significant association of Lp(a) with AVS was observed in unadjusted (OR [95% CI]: 0.98 [0.91 to 1.06], p = 0.59) and risk factor-adjusted models (0.98 [0.90 to 1.06], p = 0.57). However, Lp(a) was independently associated with clinical CAD manifestation (unadjusted: 1.14 [1.04 to 1.24], p = 0.003, risk factor adjusted: 1.17 [1.07 to 1.27], p = 0.0006). In conclusion, in a large cohort of patients ≥70 years, Lp(a) was associated with clinical CAD manifesation, but not with AVS. Our results suggest that in patients over 70 years, the development of AVS is not influenced by Lp(a).
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Bao L, Gao Q, Chen S, Chen Y, Elhmidi Y, Shehada SE, Wang S, Ma C. Feasibility and safety of combined percutaneous coronary intervention among high-risk patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2018; 54:1052-1059. [PMID: 29982414 DOI: 10.1093/ejcts/ezy240] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/31/2018] [Indexed: 02/05/2023] Open
Affiliation(s)
- Liming Bao
- Department of Cardiac Surgery, Aerospace Center Hospital, Beijing, China
| | - Qing Gao
- Department of Cardiac Surgery, Peking University People’s Hospital, Beijing, China
| | - Shenglong Chen
- Department of Cardiac Surgery, Peking University People’s Hospital, Beijing, China
| | - Yu Chen
- Department of Cardiac Surgery, Peking University People’s Hospital, Beijing, China
| | - Yacine Elhmidi
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technische Universität München, Munich, Germany
| | - Sharaf-Eldin Shehada
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Sheng Wang
- Department of Cardiovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Chenming Ma
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technische Universität München, Munich, Germany
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Ali N, Patel PA, Lindsay SJ. Recent developments and controversies in transcatheter aortic valve implantation. Eur J Heart Fail 2018; 20:642-650. [PMID: 29368369 DOI: 10.1002/ejhf.1141] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 12/03/2017] [Accepted: 12/26/2017] [Indexed: 12/19/2022] Open
Abstract
Interventional cardiology has been revolutionised by transcatheter aortic valve implantation (TAVI), which has become established as the benchmark treatment for severe aortic stenosis in patients at high risk for surgical aortic valve replacement (AVR). Increased procedural familiarity and progression in device technology has enabled improvements to be made in complication rates, which have led to a commensurate expansion in the use of TAVI; it is now a viable alternative to AVR in patients at intermediate surgical risk, and has been used in cohorts such as those with bicuspid aortic valves or pure, severe aortic regurgitation. Given the rapid expansion in the use of TAVI, including cohorts of younger patients with fewer co-morbidities, attention must be paid to further reducing remaining complications, such as cardiac tamponade or stroke. To this end, novel techniques and devices have been devised and trialled, with varying levels of success. Furthermore, significant work has gone into refining the technique with exploration of alternative imaging modalities, as well as alternative access routes to provide greater options for patients with challenging vascular anatomy. Whilst significant progress has been made with TAVI, areas of uncertainty remain such as the management of concomitant coronary artery disease and the optimum post-procedure antiplatelet regimen. As such, research in this field continues apace, and is likely to continue as use of TAVI becomes more widespread. This review provides a summary of the existing evidence, as well as an overview of recent developments and contentious issues in the field of TAVI.
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Affiliation(s)
- Noman Ali
- Department of Cardiology, Leeds General Infirmary, Leeds, UK
| | - Peysh A Patel
- Department of Cardiology, Leeds General Infirmary, Leeds, UK
| | - Steven J Lindsay
- Department of Cardiology, Bradford Royal Infirmary, Bradford, UK
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Cao D, Chiarito M, Pagnotta P, Reimers B, Stefanini GG. Coronary Revascularisation in Transcatheter Aortic Valve Implantation Candidates: Why, Who, When? Interv Cardiol 2018; 13:69-76. [PMID: 29928311 DOI: 10.15420/icr.2018:2:2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Coronary artery disease (CAD) and aortic stenosis (AS) frequently coexist. The presence of CAD has been consistently associated with an impaired prognosis in patients undergoing surgical aortic valve replacement during short- and long-term follow-up. Accordingly, current guidelines recommend coronary revascularisation of all significant stenoses in patients undergoing surgical aortic valve replacement. Conversely, the management of concomitant CAD in patients with severe AS undergoing transcatheter aortic valve implantation (TAVI) is still a matter of debate. The aim of this review article is to provide an overview on the role of coronary revascularisation in TAVI patients.
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Affiliation(s)
- Davide Cao
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan Italy.,Cardio Center, Humanitas Research Hospital, Rozzano-Milan Italy
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan Italy.,Cardio Center, Humanitas Research Hospital, Rozzano-Milan Italy
| | - Paolo Pagnotta
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan Italy.,Cardio Center, Humanitas Research Hospital, Rozzano-Milan Italy
| | - Bernhard Reimers
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan Italy.,Cardio Center, Humanitas Research Hospital, Rozzano-Milan Italy
| | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan Italy.,Cardio Center, Humanitas Research Hospital, Rozzano-Milan Italy
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Millan-Iturbe O, Sawaya FJ, Lønborg J, Chow DH, Bieliauskas G, Engstrøm T, Søndergaard L, De Backer O. Coronary artery disease, revascularization, and clinical outcomes in transcatheter aortic valve replacement: Real-world results from the East Denmark Heart Registry. Catheter Cardiovasc Interv 2017; 92:818-826. [DOI: 10.1002/ccd.27440] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 10/25/2017] [Accepted: 11/11/2017] [Indexed: 11/08/2022]
Affiliation(s)
| | - Fadi J. Sawaya
- The Heart Center, Rigshospitalet University Hospital; Copenhagen Denmark
| | - Jacob Lønborg
- The Heart Center, Rigshospitalet University Hospital; Copenhagen Denmark
| | - Danny H.F. Chow
- The Heart Center, Rigshospitalet University Hospital; Copenhagen Denmark
| | | | - Thomas Engstrøm
- The Heart Center, Rigshospitalet University Hospital; Copenhagen Denmark
| | - Lars Søndergaard
- The Heart Center, Rigshospitalet University Hospital; Copenhagen Denmark
| | - Ole De Backer
- The Heart Center, Rigshospitalet University Hospital; Copenhagen Denmark
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Nijenhuis VJ, Bennaghmouch N, Kuijk JPV, Capodanno D, ten Berg JM. Antithrombotic treatment in patients undergoing transcatheter aortic valve implantation (TAVI). Thromb Haemost 2017; 113:674-85. [DOI: 10.1160/th14-10-0821] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 11/27/2014] [Indexed: 12/31/2022]
Abstract
SummaryTranscatheter aortic valve implantation (TAVI) is an established treatment option for symptomatic patients with severe aortic valvular disease who are not suitable for conventional surgical aortic valve replacement. Despite improving experience and techniques, ischaemic and bleeding complications after TAVI remain prevalent and impair survival in this generally old and comorbid-rich population. Due to changing aetiology of complications over time, antiplatelet and anticoagulant therapy after TAVI should be carefully balanced. Empirically, a dual antiplatelet strategy is generally used after TAVI for patients without an indication for oral anticoagulation (OAC; e. g. atrial fibrillation, mechanical mitral valve prosthesis), including aspirin and a thienopyridine. For patients on OAC, a combination of OAC and aspirin or thienopyridine is generally used. This review shows that current registries are unfit to directly compare antithrombotic regimens. Small exploring studies suggest that additional clopidogrel after TAVI only affects bleeding and not ischemic complications. However, these studies are lack in quality in terms of Cochrane criteria. Currently, three randomised controlled trials are recruiting to gather more knowledge about the effects of clopidogrel after TAVI.
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Huczek Z, Zbroński K, Grodecki K, Scisło P, Rymuza B, Kochman J, Dąbrowski M, Witkowski A, Wojakowski W, Parma R, Ochała A, Grygier M, Olasińska-Wiśniewska A, Araszkiewicz A, Jagielak D, Ciećwierz D, Puchta D, Paczwa K, Filipiak KJ, Wilimski R, Zembala M, Opolski G. Concomitant coronary artery disease and its management in patients referred to transcatheter aortic valve implantation: Insights from the POL-TAVI Registry. Catheter Cardiovasc Interv 2017; 91:115-123. [PMID: 28843025 DOI: 10.1002/ccd.27251] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 06/25/2017] [Accepted: 07/22/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) and degenerative aortic stenosis often coexist. However, the impact of CAD and its management on the prognosis after transcatheter aortic valve implantation (TAVI) remains uncertain. We sought to evaluate the impact of obstructive CAD, SYNTAX score (Ss), and percutaneous coronary intervention (PCI) prior to TAVI on short-term outcome. METHODS Overall, 896 patients who underwent TAVI after heart team decision was included. Pre-procedural angiograms were analysed to calculate baseline Ss (bSs) and residual Ss (rSs). Baseline, procedural and follow-up data up to 30 days was acquired from the national POL-TAVI registry. RESULTS Patients with obstructive CAD at baseline (n = 462, 52%) had higher mortality as compared with the remaining (8.7 vs. 5.1%, log-rank P = 0.039). Also, after correction for confounding factors obstructive CAD was identified as independent predictor of mortality (hazard ratio [HR] 1.74, 95% confidence intervals [CIs] 1.03-2.94, P = 0.037). In obstructive CAD, neither bSs (AUC 0.47, CI 0.38-0.56, P = 0.47) nor rSs (AUC 0.47, CI 0.30-0.64, P = 0.72 for those undergoing PCI and AUC 0.48, CI 0.37-0.59, P = 0.75 for the remaining) was predictive of mortality. When revascularization status was considered, patients with PCI prior to TAVI had similar outcome as those without obstructive CAD at baseline (7.7 vs. 5.1%, log-rank P = 0.23) with no negative impact on mortality (HR 1.13, CI 0.62-2.09, P = 0.69). CONCLUSIONS In conclusion, obstructive CAD at baseline evaluation for TAVI has independent negative impact on short-term prognosis. However, neither baseline nor residual Ss values have prognostic ability in patients undergoing TAVI. Revascularization prior to TAVI seems to improve survival to levels comparable with patients without obstructive CAD at baseline.
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Affiliation(s)
- Zenon Huczek
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Karol Zbroński
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Kajetan Grodecki
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Scisło
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Bartosz Rymuza
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Janusz Kochman
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Wojciech Wojakowski
- Third Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Radosław Parma
- Third Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Andrzej Ochała
- Third Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Marek Grygier
- First Department of Cardiology, Medical University of Poznan, Poznan, Poland
| | | | | | - Dariusz Jagielak
- Department of Cardiac and Vascular Surgery, Medical University of Gdańsk, Gdańsk, Poland
| | - Dariusz Ciećwierz
- Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Dominika Puchta
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Paczwa
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Marian Zembala
- Department of Cardiac Surgery, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Grzegorz Opolski
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
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Barbanti M, Todaro D, Costa G, Pilato G, Picci A, Gulino S, Capranzano P, La Spina K, Di Simone E, D’Arrigo P, Deste W, Indelicato A, Cannata S, Giannazzo D, Immè S, Tamburino C, Patanè M, Buccheri S, Capodanno D, Sgroi C, Tamburino C. Optimized Screening of Coronary Artery Disease With Invasive Coronary Angiography and Ad Hoc Percutaneous Coronary Intervention During Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.117.005234. [DOI: 10.1161/circinterventions.117.005234] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 06/20/2017] [Indexed: 12/18/2022]
Abstract
Background—
We sought to describe an optimized approach to coronary artery disease (CAD) screening and management in patients undergoing transcatheter aortic valve replacement (TAVR).
Methods and Results—
When invasive coronary angiography showed CAD, the treatment strategy and completeness of revascularization was determined based on coronary anatomy. TAVR was performed in the same setting if percutaneous coronary intervention (PCI) was uncomplicated; otherwise TAVR was postponed. A total of 604 patients undergoing CAD screening at the time of TAVR procedure were prospectively included in this study. Severe CAD was found in 136 patients (22.5%). Among patients with severe CAD, 53 patients (8.8%) underwent uncomplicated PCI. After PCI, TAVR was postponed in 2 patients (0.3%). In 83 patients (13.8%), coronary angiography showed severe CAD that was left untreated. After TAVR, all-cause and cardiovascular 30-day mortality rates were 2.4% and 1.4%, respectively. Disabling stroke, myocardial infarction, and life-threatening bleeding occurred in 0.5%, 0.8%, and 4.0% of patients, respectively. Acute kidney injury II or III rate was 3.3%. At 2 years, all-cause mortality rate was 14.1%. Disabling stroke and myocardial infarction occurred in 2.5% and 1.8% of patients, respectively. Patients undergoing TAVR and PCI in the same session had similar rate of the composite of death, disabling stroke, and myocardial infarction when compared with patients without CAD, and patients with severe CAD left untreated (TAVR+PCI: 10.4%; severe CAD left untreated: 15.4%; no-CAD: 14.8%;
P
=0.765).
Conclusions—
In patients undergoing TAVR, screening of CAD with invasive coronary angiography and ad hoc PCI during TAVR is feasible and was not associated with increased periprocedural risks. PCI followed by TAVR in the same session had similar outcomes than TAVR in which PCI was not performed.
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Affiliation(s)
- Marco Barbanti
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Denise Todaro
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Giuliano Costa
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Gerlando Pilato
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Andrea Picci
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Simona Gulino
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Piera Capranzano
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Ketty La Spina
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Emanuela Di Simone
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Paolo D’Arrigo
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Wanda Deste
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Antonino Indelicato
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Stefano Cannata
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Daniela Giannazzo
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Sebastiano Immè
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Claudia Tamburino
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Martina Patanè
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Sergio Buccheri
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Davide Capodanno
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Carmelo Sgroi
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
| | - Corrado Tamburino
- From the Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy (M.B., D.T., G.C., G.P., A.P., S.G., P.C., K.L.S., E.D.S., P.D., W.D., A.I., S.C., D.G., S.I., C.T., M.P., S.B., D.C., C.S., C.T.); and ETNA Foundation, Catania, Italy (C.T.)
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Impact of coronary artery disease in patients undergoing transfemoral transcatheter aortic valve implantation. Int J Cardiol 2017; 245:215-221. [PMID: 28789844 DOI: 10.1016/j.ijcard.2017.07.082] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/30/2017] [Accepted: 07/21/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND The impact of coronary artery disease (CAD) and revascularization on outcome in patients undergoing transcatheter aortic valve implantation (TAVI) has not been fully elucidated so far. OBJECTIVES To assess whether the degree of CAD influences the prognosis of patients undergoing TAVI. METHODS Before TAVI, all patients underwent revascularization of the proximal vessels or the left main stem if indicated (stenosis ≥70% or 50%, respectively). In 666 patients, we calculated the baseline (bSS) and residual SYNTAX Score (rSS) prior to TAVI. In patients with revascularization, we determined the SYNTAX Revascularization Index (SRI=(1-(rSS/bSS))∗100). We also assessed the SYNTAX Score II (SS-II), combining anatomical and clinical variables. The primary endpoint was 3-year all-cause mortality. RESULTS Higher baseline and residual SYNTAX Score were associated with increased 3-year mortality (no CAD 26.2%, low bSS 34.8%, high bSS 46.8%; p=0.001, respectively, no CAD 25.9%, low rSS 31.4%, high rSS 41.5%; p=0.01). The extent of revascularization represented by the SRI was not associated with outcome. The SYNTAX Score II was also associated with increased 3-year mortality. However, baseline and residual SYNTAX Score as well as SYNTAX Score II did not independently predict mortality. CONCLUSION The anatomic severity of CAD as assessed by the baseline and residual SYNTAX Score is associated with survival after TAVI. Coronary artery disease seems to reflect general comorbidity burden and is associated with a higher risk profile of the patient.
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Finn MT, Nazif TM, Fried J, Labbé BM, Mohammadi S, Leon MB, Kodali SK, Rodés-Cabau J, Paradis JM. Coronary Revascularization in Patients Undergoing Transcatheter Aortic Valve Replacement. Can J Cardiol 2017; 33:1099-1109. [PMID: 28669699 DOI: 10.1016/j.cjca.2017.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/22/2017] [Accepted: 03/22/2017] [Indexed: 10/19/2022] Open
Abstract
Concomitant coronary artery disease (CAD) is highly prevalent among patients with severe aortic stenosis (AS). Historically, surgical aortic valve replacement with coronary artery bypass grafting was the only treatment option for patients with severe AS and significant CAD. The rapid expansion of transcatheter aortic valve replacement has led to significant paradigm shifts in the treatment of severe AS and has raised new questions regarding the optimal management of CAD in these patients. We review the evidence regarding management of concomitant CAD in severe AS patients, specifically focusing on issues surrounding transcatheter aortic valve replacement. In the absence of robust evidence supporting specific treatment strategies, decisions regarding coronary revascularization in severe AS should be individualized and made within the context of a multidisciplinary heart team.
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Affiliation(s)
- Matthew T Finn
- Columbia University Medical Center, New-York Presbyterian Hospital, New-York, New York, USA
| | - Tamim M Nazif
- Columbia University Medical Center, New-York Presbyterian Hospital, New-York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Justin Fried
- Columbia University Medical Center, New-York Presbyterian Hospital, New-York, New York, USA
| | - Benoit M Labbé
- Quebec Heart and Lung Institute, Laval University, Ville de Québec, Quebec, Canada
| | - Siamak Mohammadi
- Quebec Heart and Lung Institute, Laval University, Ville de Québec, Quebec, Canada
| | - Martin B Leon
- Columbia University Medical Center, New-York Presbyterian Hospital, New-York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Susheel K Kodali
- Columbia University Medical Center, New-York Presbyterian Hospital, New-York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Ville de Québec, Quebec, Canada
| | - Jean-Michel Paradis
- Quebec Heart and Lung Institute, Laval University, Ville de Québec, Quebec, Canada.
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Witberg G, Regev E, Chen S, Assali A, Barbash IM, Planer D, Vaknin-Assa H, Guetta V, Vukasinovic V, Orvin K, Danenberg HD, Segev A, Kornowski R. The Prognostic Effects of Coronary Disease Severity and Completeness of Revascularization on Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2017; 10:1428-1435. [DOI: 10.1016/j.jcin.2017.04.035] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/17/2017] [Accepted: 04/19/2017] [Indexed: 11/27/2022]
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Auffret V, Regueiro A, Del Trigo M, Abdul-Jawad Altisent O, Campelo-Parada F, Chiche O, Puri R, Rodés-Cabau J. Predictors of Early Cerebrovascular Events in Patients With Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2017; 68:673-84. [PMID: 27515325 DOI: 10.1016/j.jacc.2016.05.065] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 05/14/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Identifying transcatheter aortic valve replacement (TAVR) patients at high risk for cerebrovascular events (CVE) is of major clinical relevance. However, predictors have varied across studies. OBJECTIVES The purpose of this study was to analyze the predictors of 30-day CVE post-TAVR. METHODS A systematic review of studies that reported the incidence of CVE post-TAVR while providing raw data for predictors of interest was performed. Data on study, patient, and procedural characteristics were extracted. Crude risk ratios (RRs) and 95% confidence intervals for each predictor were calculated. RESULTS Sixty-four studies involving 72,318 patients (2,385 patients with a CVE within 30 days post-TAVR) were analyzed. Incidence of CVE ranged from 1% to 11% (median 4%) without significant differences between single and multicenter studies, or according to CVE adjudication availability. The summary RRs indicated lower risk for men (RR: 0.82; p = 0.02) and higher risk for patients with chronic kidney disease (RR: 1.29; p = 0.03) and with new-onset atrial fibrillation post-TAVR (RR: 1.85; p = 0.005), and for procedures performed within the first half of center experience (RR: 1.55; p = 0.003). The use of balloon post-dilation tended to be associated with a higher risk of CVE (RR: 1.43; p = 0.07). Valve type (balloon-expandable vs. self-expandable, p = 0.26) and approach (transfemoral vs. nontransfemoral, p = 0.81) did not predict CVE. CONCLUSIONS Female sex, chronic kidney disease, enrollment date, and new-onset atrial fibrillation were predictors of CVE post-TAVR. This study provides effect estimates to identify high-risk TAVR patients for early CVE, providing possible guidance for tailored preventive strategies.
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Affiliation(s)
- Vincent Auffret
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada; Rennes 1 University, Signal and Image Processing Laboratory, Rennes, France
| | - Ander Regueiro
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - María Del Trigo
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | | | - Olivier Chiche
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Rishi Puri
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada.
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Pineda AM, Gowani SA, Mihos CG, Chandra R, Santana O, Lamelas J, Beohar N. Coronary Artery Disease Complexity on the Outcomes of a Staged Approach of Pci Followed by Minimally Invasive Valve Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017. [DOI: 10.1177/155698451701200204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Andrés M. Pineda
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, FL USA
| | - Saqib A. Gowani
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, FL USA
| | - Christos G. Mihos
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, FL USA
| | - Ramesh Chandra
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, FL USA
| | - Orlando Santana
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, FL USA
| | - Joseph Lamelas
- Department of Cardiac Surgery, Mount Sinai Medical Center, Miami Beach, FL USA
| | - Nirat Beohar
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach, FL USA
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Coronary Artery Disease Complexity on the Outcomes of a Staged Approach of PCI Followed by Minimally Invasive Valve Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017; 12:95-101. [PMID: 28129316 DOI: 10.1097/imi.0000000000000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE A staged approach of percutaneous coronary intervention (PCI) followed by minimally invasive valve surgery (MIVS) is an alternative to the combined coronary artery bypass graft and valve surgery for patients with concomitant coronary artery (CAD) and valvular heart disease. We sought to evaluate the impact of the complexity of CAD, as assessed by the Syntax score, on the outcomes of the staged approach. METHODS We retrospectively evaluated 138 patients who underwent PCI and MIVS at our institution between January 2009 and June 2013. The baseline Syntax score was calculated, and the patients were divided into two groups: low risk (Syntax scores, 0-22) or intermediate-high risk (>22). RESULTS There were 125 patients with low (mean ± standard deviation, 8 ± 5) and 13 with intermediate-high (mean ± standard deviation, 26 ± 4) Syntax scores. Baseline, PCI, and operative characteristics were similar between the groups, except for an observed higher incidence of peripheral arterial disease, multivessel coronary disease, mitral valve replacement, and a higher predicted The Society of Thoracic Surgeons mortality risk score in the intermediate-high Syntax group. The short-term postoperative complications, 30-day mortality, and 3-year survival (84% vs 77%) were similar between the groups. Patients in the intermediate-high-risk group had a higher incidence of repeat target vessel revascularization during follow-up (0.8% vs 16.7%). CONCLUSIONS A staged approach of PCI followed by MIVS is a safe and feasible alternative for patients with valvular heart disease and concomitant CAD. However, it may confer an increased incidence of repeat target vessel revascularization in patients with intermediate- to high-complexity CAD.
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Boukantar M, Gallet R, Mouillet G, Belarbi A, Rubimbura V, Ternacle J, Dubois-Rande JL, Teiger E. Coronary Procedures After TAVI With the Self-Expanding Aortic Bioprosthesis Medtronic CoreValve™, Not an Easy Matter. J Interv Cardiol 2017; 30:56-62. [PMID: 28078734 DOI: 10.1111/joic.12363] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To evaluate the feasibility of coronary procedures after transcatheter aortic valve implantation (TAVI) with the CoreValve™ device. BACKGROUND Due to its design, CoreValve™ prosthesis may interfere with coronary procedures. Data on this issue are sparse. METHODS Between 2007 and 2015, 550 patients underwent CoreValve™ TAVI in our hospital. Among them, 16 underwent coronary angiogram after TAVI and were included in our retrospective study. For each patient, we compared the characteristics of coronary angiograms performed before and after TAVI. RESULTS Coronary angiogram was deemed successful in 9 patients. The mean number of different catheters used in attempts to cannulate the coronary arteries was 3.6 ± 1.4 and the rate of selective intubation was low. Fluoroscopy time (13.2 ± 5.8 vs. 7.2 ± 4.6 min, P = 0.003), dose area product (5,347 ± 4,919 vs. 3,433 ± 3,420 cGy/m2 , P = 0.004), and contrast volume (157.7 ± 69.6 vs. 108.3 ± 42.6 mL, P = 0.006) were more important in coronary angiograms performed after CoreValve™ implantation. Percutaneous coronary intervention was successfully performed in 6 out of 7 patients who required it. CONCLUSION Coronary procedures after CoreValve™ TAVI are feasible, but challenging. This problem is currently rare but will be more common as the indications of TAVI are expanded to younger patients with longer life expectancies. Recommendations for post-TAVI coronary procedures are needed, particularly for centers unfamiliar with the management of post-TAVI patients.
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Affiliation(s)
- Madjid Boukantar
- Department of Cardiovascular, Henri Mondor University Hospital, Creteil, France
| | - Romain Gallet
- Department of Cardiovascular, Henri Mondor University Hospital, Creteil, France
| | - Gauthier Mouillet
- Department of Cardiovascular, Henri Mondor University Hospital, Creteil, France
| | - Abdelkaoui Belarbi
- Department of Cardiovascular, Henri Mondor University Hospital, Creteil, France
| | - Vladimir Rubimbura
- Department of Cardiovascular, Henri Mondor University Hospital, Creteil, France
| | - Julien Ternacle
- Department of Cardiovascular, Henri Mondor University Hospital, Creteil, France
| | | | - Emmanuel Teiger
- Department of Cardiovascular, Henri Mondor University Hospital, Creteil, France
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Kleczynski P, Dziewierz A, Bagienski M, Rzeszutko L, Sorysz D, Trebacz J, Sobczynski R, Tomala M, Gackowski A, Dudek D. Impact of Coronary Artery Disease Burden on 12-Month Mortality of Patients After Transcatheter Aortic Valve Implantation. J Interv Cardiol 2016; 29:375-81. [PMID: 27358194 DOI: 10.1111/joic.12308] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES The aim of the study was to compare 12-month mortality rate of patients with and without complete coronary revascularization before transcatheter aortic valve implantation (TAVI). BACKGROUND There are limited data on the impact of coronary artery disease burden in patients with severe aortic stenosis undergoing TAVI. METHODS One hundred and one consecutive patients undergoing TAVI were enrolled. Of them 16 (15.8%) had an incomplete coronary revascularization. The primary endpoint was 12-month all-cause mortality. RESULTS Twelve-month all-cause mortality was higher in patients with incomplete coronary revascularization than in patients with complete coronary revascularization or without significant lesions (75.0% vs 7.1%; P < 0.001). Importantly, incomplete coronary revascularization was an independent predictor of higher mortality rate after 12 months (hazard ratio (HR) for incomplete coronary revascularization 10.86, 95% CI 3.72-31.73; P < 0.001; HR for a history of stroke/TIA 3.93, 95% confidence interval (CI) 1.39-11.07; P < 0.001; HR for blood transfusion 2.84 95% CI (1.06-7.63); P = 0.039). In 9 of 16 (56.3%) patients, incomplete revascularization was related to the presence of chronic total occlusions (CTO). Patients with CTO had an increased mortality rate after 12 months (55.6% vs 14.1%; P = 0.008) as compared to patients without the CTO. CONCLUSIONS Incomplete coronary revascularization and a history of stroke or TIA may be independent predictors of all-cause mortality in patients undergoing TAVI. However, further studies are recommended to confirm the results, especially in terms of the impact of CTO presence on long-term mortality after TAVI.
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Khawaja MZ, Asrress KN, Haran H, Arri S, Nadra I, Bolter K, Wilson K, Clack L, Hancock J, Young CP, Bapat V, Thomas M, Redwood S. The effect of coronary artery disease defined by quantitative coronary angiography and SYNTAX score upon outcome after transcatheter aortic valve implantation (TAVI) using the Edwards bioprosthesis. EUROINTERVENTION 2016; 11:450-5. [PMID: 24832041 DOI: 10.4244/eijy14m05_09] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIMS We sought to evaluate the effects of significant coronary artery disease (CAD) upon outcome after transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS We performed a retrospective study of 271 consecutive patients undergoing TAVI using either the Edwards SAPIEN or Edwards SAPIEN XT valve. Pre-procedural coronary angiograms were analysed by quantitative coronary angiography (defining significant CAD as a stenosis of ≥70% or ≥50% if in the left main stem or a vein graft). Ninety-three out of 271 patients had significant CAD. There was no difference in mortality at 30 days or 12 months between the two groups (6.7% vs. 7.5% and 21.5% vs. 23.7%; log-rank p=0.805). A secondary analysis using the SYNTAX algorithm of coronary anatomy complexity was performed on 189 patients. Those in the high SYNTAX score (>33) group had higher mortality at 30 days and 12 months (14.3% and 57.1%) than the low (5.2% and 23.3%) and intermediate-risk groups (11.1% and 22.2%; log-rank p=0.007). ROC analysis identified a SYNTAX score of >9 at the time of TAVI as the optimal cut-off, with an independent association with mortality (HR 1.95 [95% CI: 1.21-3.13]; p=0.006). Patients with a SYNTAX score >9 had greater 30-day, 12-month and overall mortalities than those with a SYNTAX score <9 (3.7% vs. 11.3% and 20.7% vs. 34.3%; log-rank p=0.005). CONCLUSIONS Significant CAD, as defined using "real-world" QCA margins, did not have a significant effect upon mortality after TAVI for severe aortic stenosis. However, higher-risk SYNTAX groups, including those with a score >9, had increased mortality.
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Affiliation(s)
- Muhammed Zeeshan Khawaja
- British Heart Foundation Centre of Research Excellence, Cardiovascular Division, The Rayne Institute, King's College London, London, United Kingdom
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Management of Coronary Artery Disease and Conduction Abnormalities in Transcatheter Aortic Valve Implantation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:9. [DOI: 10.1007/s11936-015-0432-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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