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Stähli BE, Linke A, Westermann D, Van Mieghem NM, Leistner DM, Massberg S, Alber H, Mügge A, Musumeci G, Kesterke R, Schneider S, Kastrati A, Ford I, Ruschitzka F, Kasel MA. A Randomized Comparison of the Treatment Sequence of Percutaneous Coronary Intervention and Transcatheter Aortic Valve Implantation: Rationale and Design of the TAVI PCI Trial. Am Heart J 2024:S0002-8703(24)00184-4. [PMID: 39121916 DOI: 10.1016/j.ahj.2024.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 07/29/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND About half of patients with severe aortic stenosis present with concomitant coronary artery disease. The optimal timing of percutaneous coronary intervention (PCI) and transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis and concomitant coronary artery disease remains unknown. STUDY DESIGN The TAVI PCI trial is a prospective, international, multicenter, randomized, two-arm, open-label study planning to enroll a total of 986 patients. It is designed to investigate whether the strategy "angiography-guided complete revascularization after (within 1-45 days) TAVI" is non-inferior to the strategy "angiography-guided complete revascularization before (within 1-45 days) TAVI" using the Edwards SAPIEN 3 or 3 Ultra Transcatheter Heart Valve™ in patients with severe aortic stenosis and concomitant coronary artery disease. Patients are randomized in a 1:1 ratio to one of the two treatment strategies. The primary end point is a composite of all-cause death, non-fatal myocardial infarction, ischemia-driven revascularization, rehospitalization (valve- or procedure-related including heart failure), or life-threatening/disabling or major bleeding at 1 year. CONCLUSIONS The TAVI PCI trial tests the hypothesis that the strategy "PCI after TAVI" is non-inferior to the strategy "PCI before TAVI" in patients with severe aortic stenosis and concomitant coronary artery disease.
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Affiliation(s)
- Barbara E Stähli
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland.
| | - Axel Linke
- Technische Universität Dresden, Department of Internal Medicine and Cardiology, Herzzentrum Dresden, University Clinic, Dresden, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Nicolas M Van Mieghem
- Department of Cardiology, Cardiovascular Institute, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - David M Leistner
- Department of Medicine, Cardiology, Goethe University Hospital, and DZHK Partner Site Rhein-Main, Frankfurt
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I, LMU University Hospital, LMU Munich, DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hannes Alber
- Department of Internal Medicine and Cardiology, Landeskrankenhaus, Klagenfurt, Carynthia, Austria
| | - Andreas Mügge
- University Hospital St Josef-Hospital, Cardiology and Rhythmology, Ruhr University Bochum, Bochum, Germany
| | | | - Rahel Kesterke
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | | | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität, Munich, DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Germany
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Markus A Kasel
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
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Langenbach IL, Langenbach MC, Mayrhofer T, Foldyna B, Maintz D, Klein K, Wienemann H, Krug KB, Hellmich M, Adam M, Naehle CP. Reduction of contrast medium for transcatheter aortic valve replacement planning using a spectral detector CT: a prospective clinical trial. Eur Radiol 2024; 34:4089-4099. [PMID: 37979008 PMCID: PMC11166752 DOI: 10.1007/s00330-023-10403-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/25/2023] [Accepted: 09/17/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION This study investigated the use of dual-energy spectral detector computed tomography (CT) and virtual monoenergetic imaging (VMI) reconstructions in pre-interventional transcatheter aortic valve replacement (TAVR) planning. We aimed to determine the minimum required contrast medium (CM) amount to maintain diagnostic CT imaging quality for TAVR planning. METHODS In this prospective clinical trial, TAVR candidates received a standardized dual-layer spectral detector CT protocol. The CM amount (Iohexol 350 mg iodine/mL, standardized flow rate 3 mL/s) was reduced systematically after 15 patients by 10 mL, starting at 60 mL (institutional standard). We evaluated standard, and 40- and 60-keV VMI reconstructions. For image quality, we measured signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and diameters in multiple vessel sections (i.e., aortic annulus: diameter, perimeter, area; aorta/arteries: minimal diameter). Mixed regression models (MRM), including interaction terms and clinical characteristics, were used for comparison. RESULTS Sixty consecutive patients (mean age, 79.4 ± 7.5 years; 28 females, 46.7%) were included. In pre-TAVR CT, the CM reduction to 40 mL is possible without affecting the image quality (MRM: SNR: -1.1, p = 0.726; CNR: 0.0, p = 0.999). VMI 40-keV reconstructions showed better results than standard reconstructions with significantly higher SNR (+ 6.04, p < 0.001). Reduction to 30 mL CM resulted in a significant loss of quality (MRM: SNR: -12.9, p < 0.001; CNR: -13.9, p < 0.001), regardless of the reconstruction. Across the reconstructions, we observed no differences in the metric evaluation (p > 0.914). CONCLUSION Among TAVR candidates undergoing pre-interventional CT at a dual-layer spectral detector system, applying 40 mL CM is sufficient to maintain diagnostic image quality. VMI 40-keV reconstructions improve the vessel attenuation and are recommended for evaluation. CLINICAL RELEVANCE STATEMENT Contrast medium reduction to 40 mL in pre-interventional transcatheter aortic valve replacement CT using dual-energy CT maintains image quality, while 40-keV virtual monoenergetic imaging reconstructions enhance vessel attenuation. These results offer valuable recommendations for interventional transcatheter aortic valve replacement evaluation and potentially improve nephroprotection in patients with compromised renal function. KEY POINTS • Patients undergoing transcatheter aortic valve replacement (TAVR), requiring pre-interventional CT, are often multimorbid with impaired renal function. • Using a spectral detector dual-layer CT, contrast medium reduction to 40 mL is feasible, maintaining diagnostic image quality. • The additional application of virtual monoenergetic image reconstructions with 40 keV improves vessel attenuation significantly in clinical practice.
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Affiliation(s)
- Isabel L Langenbach
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA.
- Institute for Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany.
| | - Marcel C Langenbach
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
- Institute for Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
- School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Borek Foldyna
- Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - David Maintz
- Institute for Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany
| | - Konstantin Klein
- Institute for Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany
| | - Hendrik Wienemann
- Clinic III for Internal Medicine, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Kathrin B Krug
- Institute for Diagnostic and Interventional Radiology, University Hospital Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, Medical Faculty, University of Cologne, Cologne, Germany
| | - Matti Adam
- Clinic III for Internal Medicine, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
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Zivkovic M, Tomovic S, Busic I, Zivic K, Vukcevic V, Wojakowski W, Binder RK, Banovic M. Acute Coronary Syndrome Following Transcatheter Aortic Valve Replacement. Curr Probl Cardiol 2024; 49:102016. [PMID: 37544628 DOI: 10.1016/j.cpcardiol.2023.102016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
Extending the indication of transcatheter aortic valve replacement (TAVR) to younger and lower-risk patients naturally results in longer life expectancy and survival rates after the intervention. The longer life expectancy of these patients leads to an increased possibility of future acute coronary events, necessitating the development of effective and appropriate treatment strategies. Acute coronary syndromes (ACS) in patients with previous TAVR procedures present with modified clinical characteristics when compared to the non-TAVR population. In populations with prior TAVR procedures, plaque rupture remains the main cause of ACS. However, unlike the non-TAVR population, there is an increased frequency of nonatherotrombotic mechanisms, like emboli and mechanical obstruction of coronary ostia by valve components. The main observation related to the treatment of ACS TAVR patients is the significantly lower percentage of patients undergoing invasive management. Furthermore, ACS in TAVR patients is associated with poor prognosis, higher long-term mortality rates, and higher incidence of MACE. It is surprising that considering this significant and increasingly recognized issue, there are only a few studies that have investigated ACS after TAVR. The scope of the present review is to address available data about ACS following TAVR, focusing on incidence, timing, mechanism, and causes. We also examined current knowledge regarding optimal invasive treatment and analyzed short and long-term clinical outcomes.
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Affiliation(s)
- Milorad Zivkovic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia
| | - Sara Tomovic
- Belgrade Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Ivan Busic
- Belgrade Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Katarina Zivic
- Belgrade Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Vladan Vukcevic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia; Belgrade Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Wojtek Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Ronald K Binder
- Department of Internal Medicine II, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Marko Banovic
- Cardiology Clinic, University Clinical Center of Serbia, Belgrade, Serbia; Belgrade Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia.
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Möllmann H, Linke A, Nombela-Franco L, Sluka M, Francisco Oteo Dominguez J, Montorfano M, Kim WK, Arnold M, Vasa-Nicotera M, Fichtlscherer S, Conradi L, Camuglia A, Bedogni F, Kohli K, Manoharan G. Valve Hemodynamics by Valve Size and 1-Year Survival Following Implantation of the Portico Valve in the Multicenter CONFIDENCE Registry. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2024; 8:100226. [PMID: 38283573 PMCID: PMC10818152 DOI: 10.1016/j.shj.2023.100226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 08/09/2023] [Accepted: 08/31/2023] [Indexed: 01/30/2024]
Abstract
Background The CONtrolled delivery For ImproveD outcomEs with cliNiCal Evidence registry was initiated to characterize the clinical safety and device performance from experienced transcatheter aortic valve implantation (TAVI) centers in Europe and Australia that use the Portico valve to treat patients with severe aortic stenosis. We herein report for the first time the valve performance at 30-day across all implanted valve sizes and the 1-year survival from this registry. Methods This was a prospective, multicenter, single-arm observational clinical investigation of patients clinically indicated for implantation of a Portico valve in experienced TAVI centers. Patients were treated with a commercially available valve (size 23, 25, 27, or 29 mm) using either the first-generation delivery system (DS) (n = 501) or the second-generation (FlexNav) DS (n = 500). Adverse events were adjudicated by an independent clinical events committee according to Valve Academic Research Consortium-2 criteria. Echocardiographic outcomes were assessed at 30 days by an independent core laboratory, and a survival check was performed at 1 year. Results We enrolled 1001 patients (82.0 years, 62.5% female, 63.7% New York Heart Association functional class III/IV at baseline) from 27 clinical sites in 8 countries across Europe and one site in Australia. Implantation of a single valve was successful in 97.5% of subjects. Valve hemodynamics at 30 days were substantially improved relative to baseline, with large aortic valve areas and low mean gradients across all implanted valve sizes (aortic valve areas were 1.7 ± 0.4, 1.7 ± 0.5, 1.8 ± 0.5, and 2.0 ± 0.5 cm2, and mean gradients were 7.0 ± 2.7, 7.5 ± 4.7, 7.3 ± 3.3, and 6.4 ± 3.3 mmHg for 23, 25, 27, and 29 mm valve sizes, respectively). Across all implanted valve sizes, most patients (77.1%) had no patient-prosthesis mismatch. Death from any cause within 1 year occurred in 13.7% of the patients in the first-generation DS group as compared with 11.0% in the second-generation DS group (p = 0.2). Conclusions The Portico valve demonstrated excellent hemodynamic performance across all valve sizes in a large cohort of subjects implanted in experienced TAVI centers. One-year survival rates were favorable when using both the first-generation and second-generation (FlexNav) DSs in this high-risk cohort. ClinicalTrialsgov Identifier NCT03752866.
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Affiliation(s)
- Helge Möllmann
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | - Axel Linke
- Department of Internal Medicine/Cardiology, University Hospital of the Technical University of Dresden, Heart Center Dresden, Dresden, Germany
| | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Martin Sluka
- Department of Medicine-Cardiology, University Hospital Olomouc, Olomouc, Czech Republic
| | | | - Matteo Montorfano
- Interventional Cardiology Unit IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Won-Keun Kim
- Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | - Martin Arnold
- Department of Cardiology, Friedrich-Alexander-Universität Erlangen Nuremberg, Erlangen, Germany
| | - Mariuca Vasa-Nicotera
- Department of Cardiology, University Hospital of the Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Stephan Fichtlscherer
- Department of Cardiology, University Hospital of the Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center, Hamburg, Germany
| | - Anthony Camuglia
- University of Queensland, Brisbane, Australia
- The Wesley Hospital, Brisbane, Australia
| | | | - Keshav Kohli
- Abbott Laboratories, Santa Clara, California, USA
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Park DY, Simonato M, Ahmad Y, Banks AZ, Lowenstern A, Nanna MG. Insight Into the Optimal Timing of Percutaneous Coronary Intervention and Transcatheter Aortic Valve Replacement. Curr Probl Cardiol 2024; 49:102050. [PMID: 37643698 PMCID: PMC10924682 DOI: 10.1016/j.cpcardiol.2023.102050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023]
Abstract
Patients being considered for transcatheter aortic valve replacement (TAVR) are frequently diagnosed with coronary artery disease. In patients requiring revascularization, there is a paucity of data informing when to perform percutaneous coronary artery intervention (PCI). We evaluated the impact of PCI timing on clinical outcomes and readmissions after TAVR. From the National Readmissions Database 2016 to 2019, we stratified the duration between PCI and TAVR into 3 groups: same-day PCI and TAVR, TAVR ≤30 days after PCI, and TAVR >30 days after PCI. We then compared primary and secondary outcomes among them. A total of 5207 patients were included, 1413 (27.1%) of whom underwent PCI and TAVR on the same day, while 2161 (41.5%) underwent TAVR ≤30 days after PCI, and 1632 (31.3%) underwent TAVR >30 days after PCI. There was no significant difference for in-hospital mortality among the groups (adjusted odds ratio [aOR] 0.49, 95% confidence interval [CI] 0.16-1.48, p = 0.203 for same-day versus ≤30 days; aOR 2.07, 95% CI 0.68-6.30, p = 0.199 for same-day versus >30 days). Patients who underwent TAVR ≤30 days after PCI had higher odds of acute kidney injury (aOR 1.49, 95% CI 1.05-2.10, p = 0.024), nonhome discharge (aOR 1.53, 95% CI 1.20-1.96, p = 0.001), and 90-day readmission (aOR 1.35, 95% CI 1.04-1.76, p = 0.026) compared with those who underwent same-day PCI and TAVR. Concomitant PCI and TAVR was associated with lower rates of 90-day readmissions and acute kidney injury compared with TAVR shortly after PCI (<30 days) and should be considered in select patients.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, IL
| | | | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Adam Z Banks
- Division of Cardiology, Presbyterian Hospital, Albuquerque, NM
| | - Angela Lowenstern
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT.
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Silva G, Silva M, Guerreiro C, Sampaio F, Pires-Morais G, Santos L, Melica B, Rodrigues A, Braga P, Fontes-Carvalho R. Coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement: Feasibility in clinical practice. Rev Port Cardiol 2023; 42:749-756. [PMID: 36958581 DOI: 10.1016/j.repc.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 10/08/2022] [Accepted: 10/15/2022] [Indexed: 03/25/2023] Open
Abstract
INTRODUCTION AND OBJECTIVE Coronary artery disease is highly prevalent among patients with severe aortic stenosis who undergo transcatheter aortic valve replacement (TAVR). As indications for TAVR are now expanding to younger and lower-risk patients, the need for coronary angiography (CA) and percutaneous coronary intervention (PCI) during their lifetime is expected to increase. The objective of our study was to assess the need for CA and the feasibility of re-engaging the coronary ostia after TAVR. METHODS We performed a retrospective analysis of 853 consecutive patients undergoing TAVR between August 2007 and December 2020. Patients who needed CA after TAVR were selected. The primary endpoint was the rate of successful coronary ostia cannulation after TAVR. RESULTS Of a total of 31 CAs in 28 patients (3.5% of 810 patients analyzed: 57% male, age 77.8±7.0 years) performed after TAVR, 28 (90%) met the primary endpoint and in three cannulation was semi-selective. All failed selective coronary ostia cannulations occurred in patients with a self-expanding valve. Sixteen (52%) also had indication for PCI, which was successfully performed in all. The main indication for CA was non-ST-elevation acute coronary syndrome (35%, n=11). Two cases of primary PCI occurred without delay. There were no complications reported during or after the procedure. CONCLUSION Although CA was rarely needed in patients after TAVR, selective diagnostic CA was possible in the overwhelming majority of patients. PCI was performed successfully in all cases, without complications.
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Affiliation(s)
- Gualter Silva
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal.
| | - Mariana Silva
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Cláudio Guerreiro
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Francisco Sampaio
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Gustavo Pires-Morais
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Lino Santos
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Bruno Melica
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Alberto Rodrigues
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Pedro Braga
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Ricardo Fontes-Carvalho
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal; Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
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Belur AD, Solankhi N, Sharma R. Management of coronary artery disease in patients with aortic stenosis in the era of transcatheter aortic valve replacement. Front Cardiovasc Med 2023; 10:1139360. [PMID: 37408653 PMCID: PMC10318168 DOI: 10.3389/fcvm.2023.1139360] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/30/2023] [Indexed: 07/07/2023] Open
Abstract
Aortic stenosis (AS) is a common valve disorder among the elderly, and these patients frequently have concomitant coronary artery disease (CAD). Risk factors for calcific AS are similar to those for CAD. Historically, the treatment of these conditions involved simultaneous surgical replacement of the aortic valve (AV) with coronary artery bypass grafting. Since the advancement of transcatheter AV therapies, there have been tremendous advancements in the safety, efficacy, and feasibility of this procedure with expanding indications. This has led to a paradigm shift in our approach to the patient with AS and concomitant CAD. Data regarding the management of CAD in patients with AS are largely limited to single-center studies or retrospective analyses. This article aims to review available literature around the management of CAD in patients with AS and assist in the current understanding in approaches toward management.
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Affiliation(s)
- Agastya D. Belur
- Cardiovascular Disease Fellowship Program, University of Louisville School of Medicine, Louisville, KY, United States
| | - Naresh Solankhi
- Jewish Hospital Cardiology, University of Louisville Jewish Hospital, Louisville, KY, United States
| | - Ravi Sharma
- Jewish Hospital Cardiology, University of Louisville Jewish Hospital, Louisville, KY, United States
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Weferling M, Lan Cheong Wah S, Fischer-Rasokat U, Hain A, Renker M, Charitos EI, Liebetrau C, Treiber J, Choi YH, Hamm CW, Kim WK. Incidence and predictors of hemodynamic compromise due to high-grade AV block after TAVI. Front Cardiovasc Med 2023; 10:1161871. [PMID: 37346284 PMCID: PMC10280067 DOI: 10.3389/fcvm.2023.1161871] [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: 02/08/2023] [Accepted: 05/24/2023] [Indexed: 06/23/2023] Open
Abstract
Background High-grade AV block (HAVB) is the most frequent adverse event after transcatheter aortic valve implantation (TAVI). In rare cases, HAVB is associated with hemodynamic compromise (HC) followed by syncope or application of cardiopulmonary resuscitation (CPR), but data on this severe complication are scarce. The aim of the present study was to investigate the incidence and predictors of HC due to HAVB in patients undergoing TAVI. Methods In this retrospective analysis of 4,602 TAVI cases between 2010 and 2022, 466 developed HAVB. Baseline characteristics and procedural and postprocedural findings were compared for patients with HC versus those without. Univariate and multivariable regression analyses were used to investigate independent predictors of HC. Results Forty-nine of 466 patients (10.5%) had HC due to HAVB after TAVI. Patients with HC had a longer hospital stay [10 (8-13) vs. 13 (9-18) days; p < 0.001], more frequent peripheral artery disease (PAD) (28.6% vs. 15.1%; p = 0.016), and lower hemoglobin levels [11.8 (±) vs. 12.5 (±) g/dl; p = 0.006]. In the HC group, HAVB onset post-TAVI was delayed compared with the non-HC group [2 (1-4) vs. 1 (0-3) days; p < 0.001]. Before HAVB onset, patients in the HC group more frequently developed post-TAVI delirium [18 (4.6%) vs. 11 (25.0%); p < 0.001]. In univariate regression analysis, PAD, hemoglobin, procedural time, contrast agent volume, and post-TAVI delirium were significant predictors of HC. After adjustment, only post-TAVI delirium and contrast agent volume remained independent predictors [OR 3.22 (95% CI: 1.05-9.89); p = 0.042 and OR: 1.01 (95% CI: 1.0-1.01); p = 0.04, respectively]. Conclusion HC due to HAVB after TAVI occurred in over 10% of cases. Development of post-TAVI delirium and contrast agent volume are independent predictors of this severe complication.
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Affiliation(s)
- Maren Weferling
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
| | | | | | - Andreas Hain
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Matthias Renker
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | | | - Christoph Liebetrau
- Cardioangiological Center Bethanien (CCB), Department of Cardiology, Agaplesion Bethanien Hospital, Frankfurt, Germany
| | - Julia Treiber
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Yeong-Hoon Choi
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Christian W. Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
- Department of Cardiology, University Hospital of Giessen, Giessen, Germany
| | - Won-Keun Kim
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
- Department of Cardiac Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
- Department of Cardiology, University Hospital of Giessen, Giessen, Germany
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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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10
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Feasibility of selective coronary angiography and percutaneous coronary intervention following self-expanding transcatheter aortic valve replacement: a systematic review and meta-analysis. Coron Artery Dis 2022; 33:678-681. [DOI: 10.1097/mca.0000000000001182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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11
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Personalised Treatment in Aortic Stenosis: A Patient-Tailored Transcatheter Aortic Valve Implantation Approach. J Cardiovasc Dev Dis 2022; 9:jcdd9110407. [PMID: 36421942 PMCID: PMC9694505 DOI: 10.3390/jcdd9110407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/13/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVI) has become a game changer in the management of severe aortic stenosis shifting the concept from inoperable or high-risk patients to intermediate or low surgical-risk individuals. Among devices available nowadays, there is no clear evidence that one device is better than the other or that one device is suitable for all patients. The selection of the optimal TAVI valve for every patient represents a challenging process for clinicians, given a large number of currently available devices. Consequently, understanding the advantages and disadvantages of each valve and personalising the valve selection based on patient-specific clinical and anatomical characteristics is paramount. This review article aims to both analyse the available devices in the presence of specific clinical and anatomic features and offer guidance to select the most suitable valve for a given patient.
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12
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Okuno T, Demirel C, Tomii D, Heg D, Häner J, Siontis GCM, Lanz J, Räber L, Strotecky S, Fürholz M, Praz F, Windecker S, Pilgrim T. Long-term risk of unplanned percutaneous coronary intervention after transcatheter aortic valve replacement. EUROINTERVENTION 2022; 18:797-803. [PMID: 36039573 PMCID: PMC9725053 DOI: 10.4244/eij-d-22-00342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/28/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Coronary access after transcatheter aortic valve replacement (TAVR) can be challenging and complicate percutaneous coronary intervention (PCI). AIMS We aimed to investigate the incidence, characteristics, and predictors of unplanned PCI after TAVR. METHODS In a single-centre registry, TAVR candidates were systematically screened for concomitant coronary artery disease (CAD) through the use of coronary angiography prior to TAVR. Rates of unplanned PCI were prospectively collected and independently adjudicated. RESULTS Among 3,015 patients undergoing TAVR between August 2007 and December 2020, 67 patients (2.2%) underwent unplanned PCI after TAVR. The indication for unplanned PCI was acute coronary syndrome in more than half of the cases. Patients with unplanned PCI were younger (80.2±6.5 years vs 81.9±6.4 years; p=0.028) and more likely to be male (75% vs 50%; p<0.001) than those without unplanned PCI. In a multivariable analysis, the number of diseased vessels, male sex, and younger age were independently associated with an increased risk of unplanned PCI. The cumulative incidence rates of unplanned PCI at 1, 5, and 10 years were 0.1%, 0.4%, and 0.6% in patients with no CAD at the time of TAVR, 0.7%, 2.5%, and 3.4% in patients with single-vessel disease, and 1.5%, 5.4%, and 7.4% in patients with multivessel disease, respectively. CONCLUSIONS The lifetime risk of unplanned PCI after TAVR is low in patients with no CAD at the time of TAVR but accumulates over time in patients with known CAD, particularly multivessel disease. CLINICALTRIALS gov: NCT01368250.
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Affiliation(s)
- Taishi Okuno
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Caglayan Demirel
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Daijiro Tomii
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Dik Heg
- CTU, University of Bern, Bern, Switzerland
| | - Jonas Häner
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - George C M Siontis
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Stefan Strotecky
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Monika Fürholz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
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13
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Lim Y, Anthony Tan K, Kuntjoro I, KF Hon J, 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] [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 Centre, Singapore
| | - Kent Anthony Tan
- Department of Cardiology, National University Heart Centre, Singapore
| | - Ivandito Kuntjoro
- Department of Cardiology, National University Heart Centre, Singapore
| | - Jimmy KF Hon
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre, Singapore
| | - James Yip
- Department of Cardiology, National University Heart Centre, Singapore
| | - Edgar Tay
- Department of Cardiology, National University Heart Centre, Singapore
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14
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Haseeb ul Rasool M, Saleem M, Nadeem M, Maqbool M, Aziz AA, Fox JM, Suleiman A. The Role of Transcatheter Aortic Valve Replacement in Asymptomatic Aortic Stenosis: A Feasibility Analysis. Cureus 2022; 14:e29522. [PMID: 36312695 PMCID: PMC9589522 DOI: 10.7759/cureus.29522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 11/26/2022] Open
Abstract
Surgical aortic valve replacement (SAVR) is the current treatment of choice for good surgical candidates with moderate to severe symptomatic aortic stenosis (AS). As transcatheter aortic valvular replacement (TAVR) has shown an improved one and two-year all-cause mortality, it has been chosen for moderately symptomatic severe AS patients. The purpose of this review was to perform a clinical comparison of TAVR vs. SAVR and to analyze the Health Index Factor (HIF) that makes TAVR a treatment of choice in asymptomatic AS patients. An extensive literature search of PubMed, Cochrane, and Embase databases was performed using the keywords “Aortic stenosis”, “SAVR”, “TAVR”, and “Asymptomatic”. A total of 45 prospective randomized clinical trials in the English language that were published from the year 2000 onwards were included in the final analysis. It has been found that 59.3% of asymptomatic AS patients are likely to die in the next five years without proactive treatment. Multiple studies have proven that early intervention with aortic valve replacement is superior to conservative treatment in severe asymptomatic AS; however, the choice between SAVR and TAVR is not well established. The NOTION Trial, SURTAVI Trail, and PARTNER 3 study have shown the non-inferiority of TAVR over SAVR, during one-year follow-up for low surgical risk patients. Evolut Low-Risk study and Early TAVR are the only two prospective studies performed to date that have enrolled patients with asymptomatic severe AS. The Evolut Trial demonstrated no difference in all-cause mortality at 30 days (1.3% vs. 4.8%. p=0.23), and 12 days (1.3% vs. 6.5%, p=0.11). Additionally, TAVR also decreases the risk of post-procedural atrial fibrillation, acute kidney injury (AKI), and rehospitalization, and leads to significant improvement in the mean trans-aortic pressure gradient. TAVR also showed marked improvement in the 30-day Quality of Life (QOL) index, where SAVR did not report any significant change in the QOL index. However, the official recommendations of Early TAVR are still awaited. TAVR has consistently shown a statistically non-significant difference in case mortality, risk of stroke, and rehospitalization with moderate to high surgical risk patients whereby recent initial trials have shown significant improvement in the QOL index and hemodynamic index for patients with asymptomatic disease. More extensive studies are required to prove the risk stratifications, long-term outcomes, and clinical characteristics that would make TAVR a preferred intervention in asymptomatic patients.
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15
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Lunardi M, Venturi G, Del Sole PA, Ruzzarin A, Mainardi A, Pighi M, Pesarini G, Scarsini R, Tavella D, Gottin L, Ribichini FL. Optimal timing for percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation. Int J Cardiol 2022; 365:114-122. [PMID: 35870638 DOI: 10.1016/j.ijcard.2022.07.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The best timing to perform percutaneous coronary interventions (PCI) in patients undergoing TAVI is unknown. Most PCI are performed before TAVI, because of concerns about potential ischemic complications during valve implantation. In this study we aimed to compare short-and long-term outcomes of patients undergoing PCI before or after TAVI. METHODS Patients undergoing TAVI and PCI from 2010 to 2021 were analyzed. PCI was defined as high-risk when involving unprotected left main, proximal left anterior descending, proximal dominant right coronary artery or 3-vessel disease. The primary endpoint was the cumulative incidence of any TAVI procedural complication and in-hospital adverse events (VARC-3 criteria). RESULTS Out of 1162 patients, 144 underwent PCI, 68% after TAVI, 78.4% of which were at high-risk. The primary endpoint occurred in 28.4% of patients in PCI pre-TAVI group vs 21.4% in PCI post-TAVI group (p = 0.403) and in 34.4% vs 17.3% of patients respectively among high-risk patients (p = 0.075). A higher rate of stroke was observed in the PCI pre-TAVI group regardless of the PCI complexity (6.5% vs 0.0%, p = 0.031; 9.3% vs 0.0% p = 0.025 in the high-risk group). At 24 months, MACCE-free survival was lower in patients who underwent PCI before TAVI (84.4% vs 97.9%, adjusted HR 10.16, 95% CI 1.19-86.57, p = 0.019; and 84.4% vs 97.3%, adjusted HR 7.34 95% CI 0.78-62.28 p = 0.082 in the high-risk group). CONCLUSIONS PCI performed after TAVI does not expose patients to higher risks of peri-procedural hazards and provides a trend towards favourable clinical outcome at mid-to-long term.
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Affiliation(s)
- Mattia Lunardi
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | - Gabriele Venturi
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | | | | | - Andrea Mainardi
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | - Michele Pighi
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | - Gabriele Pesarini
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | - Roberto Scarsini
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | - Domenico Tavella
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | - Leonardo Gottin
- Division of Cardio-Thoracic Anesthesiology and Intensive Care, Department of Surgery, University of Verona, Verona, Italy
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16
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Kumar A, Reed GW, Puri R, Krishnaswamy A, Kapadia S. TAVR in the Low Risk Era: One Size Doesn't Fit All. Prog Cardiovasc Dis 2022; 72:93-95. [PMID: 35654171 DOI: 10.1016/j.pcad.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Anirudh Kumar
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Grant W Reed
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rishi Puri
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Samir Kapadia
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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17
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Keller LS, Panagides V, Mesnier J, Nuche J, Rodés-Cabau J. Percutaneous Coronary Intervention Pre-TAVR: Current State of the Evidence. Curr Cardiol Rep 2022; 24:1011-1020. [PMID: 35622221 DOI: 10.1007/s11886-022-01717-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW This review intends to give an up-to-date overview of the current state of evidence in the treatment of coronary artery disease (CAD) in patients undergoing transcatheter aortic valve replacement (TAVR), focusing on percutaneous coronary interventions (PCI) pre-TAVR. RECENT FINDINGS The recently published ACTIVATION trial is the 1st randomized trial comparing coronary revascularization (PCI) versus medical treatment in patients with significant CAD undergoing TAVR. With the caveat of several major limitations of the trial, the results of this study raised the question about the appropriateness of the common practice to routinely revascularize coronary stenosis before TAVR. Aortic valve stenosis is the most common valvular heart disease among the elderly and it often co-occurs with CAD. TAVR is increasingly considered an alternative to surgical aortic valve replacement not only in the elderly population but also in younger and lower-risk patients. The impact of co-existing CAD on clinical outcomes as well as the optimal timing of PCI in TAVR candidates is still unclear and the subject of ongoing randomized trials. Meanwhile, it is common practice in many centers to routinely perform invasive coronary angiography and PCI for significant coronary disease as part of the TAVR workup. While computed tomography angiography has emerged as a possible alternative to the invasive coronary angiography in patients with low pre-test probability for CAD, the value of functional invasive assessment of coronary lesions in the pre-TAVR setting has still to be clarified. Also, there is an increasing interest in the clinical relevance and optimal management of the potentially challenging coronary access post-TAVR, requiring further research.
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Affiliation(s)
- Lukas S Keller
- Québec Heart and Lung Institute, Laval University, 2725 Chemin Ste-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Vassili Panagides
- Québec Heart and Lung Institute, Laval University, 2725 Chemin Ste-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Jules Mesnier
- Québec Heart and Lung Institute, Laval University, 2725 Chemin Ste-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Jorge Nuche
- Québec Heart and Lung Institute, Laval University, 2725 Chemin Ste-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Josep Rodés-Cabau
- Québec Heart and Lung Institute, Laval University, 2725 Chemin Ste-Foy, Québec City, Québec, G1V 4G5, Canada.
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18
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Tarantini G, Nai Fovino L, Scotti A, Massussi M, Cardaioli F, Rodinò G, Benedetti A, Boiago M, Matsuda Y, Continisio S, Montonati C, Cacciavillani L, Pavei A, Masiero G, Napodano M, Fraccaro C, Fabris T, Iliceto S. Coronary Access After Transcatheter Aortic Valve Replacement With Commissural Alignment: The ALIGN-ACCESS Study. Circ Cardiovasc Interv 2022; 15:e011045. [PMID: 35167332 DOI: 10.1161/circinterventions.121.011045] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Coronary access (CA) after transcatheter aortic valve replacement (TAVR) with supra-annular transcatheter heart valves (THV) can be challenging. Specific Evolut R/Pro and Acurate Neo THVs orientations are associated with reduced neo-commissure overlap with coronary ostia, while SAPIEN 3 THV cannot be oriented. With the ALIGN-ACCESS study (TAVR With Commissural Alignment Followed by Coronary Access), we investigated the impact of commissural alignment on the feasibility of CA after TAVR. METHODS We performed coronary angiography after TAVR with intra-annular SAPIEN 3, supra-annular Evolut R/Pro, and Acurate Neo THVs in 206 patients. Evolut THVs were implanted aiming for commissure alignment. Alignment of Acurate Neo was retrospectively assessed in 36, intentionally attempted in 26 cases. The primary end point was the rate of unfeasible and nonselective CA after TAVR. RESULTS Thirty-eight percent of patients received SAPIEN 3, 31.1% Evolut Pro/R, 30.1% Acurate Neo THV. Final valve orientation was favorable to commissural alignment in 85.9% of Evolut and 69.4% of Acurate Neo cases (with intentional alignment successful in 88.5%). Selective CA was higher for SAPIEN 3 than for aligned and misaligned supra-annular THVs (95% versus 71% versus 46%, P<0.001). Cannulation of at least one coronary was unfeasible with 11% misaligned supra-annular, 3% aligned supra-annular, and 0% SAPIEN 3 THVs. Independent predictors of unfeasible/nonselective CA were implantation of a misaligned supra-annular THV (odds ratio, 4.59 [95% CI, 1.81-11.61]; P<0.01), sinus of Valsalva height (odds ratio, 0.83 [95% CI, 0.7-0.98]; P=0.03), and THV-sinus of Valsalva relation (odds ratio, 1.06 [95% CI, 1.02-1.1]; P<0.01). CONCLUSIONS Commissural alignment improves the rate of selective CA after TAVR with supra-annular THVs. Nevertheless, aligned supra-annular THVs carry higher risk of unfeasible/nonselective CA than SAPIEN 3. Patients with a misaligned supra-annular THV, low sinus of Valsalva, and higher THV-sinus of Valsalva relation are at highest risk of impaired CA after TAVR.
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Affiliation(s)
| | | | - Andrea Scotti
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Mauro Massussi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Francesco Cardaioli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Giulio Rodinò
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Alice Benedetti
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Mauro Boiago
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Yuji Matsuda
- Department of Cardiovascular Medicine, Graduate School of General Medical and Dental Science, Tokyo Medical and Dental University, Tokyo, Japan (Y.M.)
| | - Saverio Continisio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Carolina Montonati
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Luisa Cacciavillani
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Andrea Pavei
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Giulia Masiero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Massimo Napodano
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Tommaso Fabris
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
| | - Sabino Iliceto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Italy (G.T., L.N.F., A.S., M.M., F.C., G.R., A.B., M.B., S.C., C.M., L.C., A.P., G.M., M.N., C.F., T.F., S.I.)
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19
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Valvo R, Costa G, Tamburino C, Barbanti M. Coronary artery cannulation after transcatheter aortic valve implantation. EUROINTERVENTION 2021; 17:835-847. [PMID: 34796879 PMCID: PMC9724942 DOI: 10.4244/eij-d-21-00158] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) has revolutionised the treatment of severe, symptomatic aortic stenosis and it is now a proven and effective alternative to surgery for patients regardless of preoperative risk stratification. Nevertheless, the consequent expansion towards younger patients with longer life expectancy focuses attention on long-term considerations. In particular, although the prevalence of coronary artery disease has been shown to decrease with the lowering of estimated risk stratification, the chance of requirement of future coronary interventions after TAVI increases dramatically as a function of patients' life expectancy. To date, however, only a few studies have investigated the feasibility and reproducibility of coronary artery cannulation after TAVI. Different conditions related mainly to aortic root anatomy and specific transcatheter aortic valve (TAV) designs and deployment have been associated with impaired coronary access after TAVI. In the present review, we will examine the conditions that may make coronary access after TAVI more challenging or even impossible.
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Affiliation(s)
- Roberto Valvo
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico-San Marco”, Catania, Italy
| | - Giuliano Costa
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico-San Marco”, Catania, Italy
| | - Corrado Tamburino
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico-San Marco”, Catania, Italy
| | - Marco Barbanti
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico - San Marco”, Via Santa Sofia 78, 95123 Catania, Italy
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20
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Simon IV, De Poli F, Couppié P, Uhry S, Heyer H, Morel O, Ohlmann P, Hess S, Leddet P. [Challenges of coronary catheterization after TAVR]. Ann Cardiol Angeiol (Paris) 2021; 70:299-307. [PMID: 34635331 DOI: 10.1016/j.ancard.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 08/28/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Coronary catheterization after transcatheter aortic valve implantation (TAVR) may be challenging. The main objective of the study is to assess the feasibility of coronary catheterization and angioplasty according to each type of valve. PATIENTS AND METHOD We retrospectively studied coronary angiography or percutaneous angioplasty procedures after TAVR in two different centers. The catheterization success of coronary artery was evaluated according to the quality of engagement in ostium and opacification of the artery. Other indicators were collected including catheters used, fluoroscopy and angiography times, DAP and the volume of the contrast agent. RESULTS Among 1512 TAVR procedures, 33 patients were included. The Sapien 3® valve was implanted in 22 patients and the Evolut® in 11 patients (7 Evolut-R® and 4 Evolut Pro®). Coronary angiography with selective or partially selective catheterization has been successfully performed in all patients with a Sapien 3® valve. In the Evolut® group we identified 3 cases of non-selective catheterization for the right coronary and 1 case for the left coronary. Standard Judkins catheters seem to be the most suitable for both types of valve with very good efficiency. CONCLUSION The results of our study is promising for the future of TAVR with a coronary catheterization success rate close to 100% with some difficulties for the Evolut® supra-annular valves. Special attention should be paid to the technique of implantation and orientation of cups in the aortic sinus.
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Affiliation(s)
- I V Simon
- Service de Cardiologie, Centre Hospitalier Haguenau, 67 Avenue du Professeur René Leriche, 67500, Haguenau.
| | - F De Poli
- Service de Cardiologie, Centre Hospitalier Haguenau, 67 Avenue du Professeur René Leriche, 67500, Haguenau
| | - P Couppié
- Service de Cardiologie, Centre Hospitalier Haguenau, 67 Avenue du Professeur René Leriche, 67500, Haguenau
| | - S Uhry
- Service de Cardiologie, Centre Hospitalier Haguenau, 67 Avenue du Professeur René Leriche, 67500, Haguenau
| | - H Heyer
- Service de Cardiologie, Centre Hospitalier Haguenau, 67 Avenue du Professeur René Leriche, 67500, Haguenau
| | - O Morel
- Service de Cardiologie, CHU Strasbourg, 1 Place de l'Hôpital, 67000 Strasbourg
| | - P Ohlmann
- Service de Cardiologie, CHU Strasbourg, 1 Place de l'Hôpital, 67000 Strasbourg
| | - S Hess
- Service de Cardiologie, CHU Strasbourg, 1 Place de l'Hôpital, 67000 Strasbourg
| | - P Leddet
- Service de Cardiologie, Centre Hospitalier Haguenau, 67 Avenue du Professeur René Leriche, 67500, Haguenau
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21
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Patel KP, Michail M, Treibel TA, Rathod K, Jones DA, Ozkor M, Kennon S, Forrest JK, Mathur A, Mullen MJ, Lansky A, Baumbach A. Coronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis. JACC Cardiovasc Interv 2021; 14:2083-2096. [PMID: 34620388 DOI: 10.1016/j.jcin.2021.07.058] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/25/2021] [Accepted: 07/27/2021] [Indexed: 01/09/2023]
Abstract
Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist, with up to two thirds of patients with AS having significant CAD. Given the challenges when both disease states are present, these patients require a tailored approach diagnostically and therapeutically. In this review the authors address the impact of AS and aortic valve replacement (AVR) on coronary hemodynamic status and discuss the assessment of CAD and the role of revascularization in patients with concomitant AS and CAD. Remodeling in AS increases the susceptibility of myocardial ischemia, which can be compounded by concomitant CAD. AVR can improve coronary hemodynamic status and reduce ischemia. Assessment of the significance of coexisting CAD can be done using noninvasive and invasive metrics. Revascularization in patients undergoing AVR can benefit certain patients in whom CAD is either prognostically or symptomatically important. Identifying this cohort of patients is challenging and as yet incomplete. Patients with dual pathology present a diagnostic and therapeutic challenge; both AS and CAD affect coronary hemodynamic status, they provoke similar symptoms, and their respective treatments can have an impact on both diseases. Decisions regarding coronary revascularization should be based on understanding this complex relationship, using appropriate coronary assessment and consensus within a multidisciplinary team.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Michael Michail
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Krishnaraj Rathod
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Daniel A Jones
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Mick Ozkor
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Simon Kennon
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - John K Forrest
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anthony Mathur
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Michael J Mullen
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Alexandra Lansky
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andreas Baumbach
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Yale University School of Medicine, New Haven, Connecticut, USA.
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22
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Tugaoen Z, Nguyen P, Arora S, Vavalle J. The selection of transcatheter heart valves in transcatheter aortic valve replacement. Trends Cardiovasc Med 2021; 32:513-522. [PMID: 34634481 DOI: 10.1016/j.tcm.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 10/20/2022]
Abstract
Transcatheter heart valve technology has rapidly progressed since initial approval in the United States. There are currently two widely available transcatheter heart valve delivery systems approved in the US; however limited data exist on optimal device selection for various patient populations. This review explores the characteristics of currently approved transcatheter heart valve systems and scenarios where one valve system may be favored over others. We provide a simplified decision tree for selecting the optimal transcatheter valve system for specific patient-centered characteristics.
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Affiliation(s)
- Zachary Tugaoen
- Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Peter Nguyen
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, United States
| | - Sameer Arora
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, United States
| | - John Vavalle
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, United States.
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23
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Alkhalil M, Jabri A, Puri R, Kalra A. Revascularization in the Transcatheter Aortic Valve Replacement Population. Interv Cardiol Clin 2021; 10:553-563. [PMID: 34593117 DOI: 10.1016/j.iccl.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) is a standard treatment option for patients with severe aortic stenosis. Management of concomitant coronary artery disease (CAD) in these patients remains controversial with no randomized clinical trials to guide decision making in this cohort. The role of CAD in TAVR has been difficult to evaluate given the current heterogeneity in defining CAD, and the used methods to assess CAD. Subsequently, the role of coronary revascularization remains individualized and assessed on a case-by-case basis by the heart team. In this article, the authors discuss the rationale and prognostic role of CAD in patients undergoing TAVR.
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Affiliation(s)
- Mohammad Alkhalil
- Department of Cardiothoracic Services, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK; Vascular Biology, Newcastle University, Newcastle-upon-Tyne NE7 7DN, UK
| | - Ahmad Jabri
- Case Western Reserve University/MetroHealth Medical Center, Cleveland, OH 44109, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Ankur Kalra
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA; Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 224 West Exchange Street, Suite 225, Akron, OH 44302, USA.
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24
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Beska B, Manoharan D, Mohammed A, Das R, Edwards R, Zaman A, Alkhalil M. Role of coronary angiogram before transcatheter aortic valve implantation. World J Cardiol 2021; 13:361-371. [PMID: 34589171 PMCID: PMC8436680 DOI: 10.4330/wjc.v13.i8.361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/26/2021] [Accepted: 07/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation (TAVI). Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes, challenging the clinical value of routine coronary angiogram (CA).
AIM To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.
METHODS This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI. A selective approach for performing CA tailored to patient clinical need was developed. Clinical outcomes were compared based on whether patients underwent CA. The primary endpoint was a composite of all-cause mortality, myocardial infraction, repeat CA, and re-admission with heart failure.
RESULTS Of 348 patients (average age 81 ± 7 and 57% male) were included with a median follow up of 19 (9-31) mo. One hundred and fifty-four (44%) patients, underwent CA before TAVI procedure. Patients who underwent CA were more likely to have previous myocardial infarction (MI) and previous percutaneous revascularisation. The primary endpoint was comparable between the two group (22.6% vs 22.2%; hazard ratio 1.05, 95%CI: 0.67-1.64, P = 0.82). Patients who had CA were less likely to be readmitted with heart failure (P = 0.022), but more likely to have repeat CA (P = 0.002) and MI (P = 0.007). In those who underwent CA, the presence of flow limiting lesions did not affect the incidence of primary endpoint, or its components, except for increased rate of repeat CA.
CONCLUSION Selective CA is a feasible and safe approach. The clinical value of routine CA should be challenged in future randomised trials
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Affiliation(s)
- Benjamin Beska
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
| | - Divya Manoharan
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
| | - Ashfaq Mohammed
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
| | - Rajiv Das
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
| | - Richard Edwards
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
| | - Azfar Zaman
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
| | - Mohammad Alkhalil
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
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25
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Role of coronary angiogram before transcatheter aortic valve implantation. World J Cardiol 2021. [DOI: 10.4330/wjc.v13.i8.362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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26
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Stefanini GG, Cerrato E, Pivato CA, Joner M, Testa L, Rheude T, Pilgrim T, Pavani M, Brouwer J, Lopez Otero D, Munoz Garcia E, Barbanti M, Biasco L, Varbella F, Reimers B, Jimenez Diaz VA, Leoncini M, Salido Tahoces ML, Ielasi A, de la Torre Hernandez JM, Mylotte D, Garot P, Chieffo A, Nombela-Franco L. Unplanned Percutaneous Coronary Revascularization After TAVR: A Multicenter International Registry. JACC Cardiovasc Interv 2021; 14:198-207. [PMID: 33478637 DOI: 10.1016/j.jcin.2020.10.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/24/2020] [Accepted: 10/20/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES This study sought to evaluate the incidence and causes of percutaneous coronary intervention (PCI) at different time periods following transcatheter aortic valve replacement (TAVR). BACKGROUND Coronary artery disease (CAD) and aortic stenosis frequently coexist, but the optimal management of CAD following TAVR remains incompletely elucidated. METHODS Patients undergoing unplanned PCI after TAVR were retrospectively included in an international multicenter registry. RESULTS Between July 2008 and March 2019, a total of 133 patients (0.9%; from a total cohort of 15,325) underwent unplanned PCI after TAVR (36.1% after balloon-expandable bioprosthesis, 63.9% after self-expandable bioprosthesis). The median time to PCI was 191 days (interquartile range: 59 to 480 days). The daily incidence of PCI was highest during the first week after TAVR and then declined over time. Overall, the majority of patients underwent PCI due to an acute coronary syndrome, and specifically 32.3% had non-ST-segment elevation myocardial infarction, 15.4% had unstable angina, 9.8% had ST-segment elevation myocardial infarction, and 2.2% had cardiac arrest. However, chronic coronary syndromes are the main indication beyond 2 years. PCI success was reported in almost all cases (96.6%), with no significant differences between patients treated with balloon-expandable and self-expandable bioprostheses (100% vs. 94.9%; p = 0.150). CONCLUSIONS Unplanned PCI after TAVR is rare, with an incidence declining over time after TAVR. The main indication to PCI is acute coronary syndrome in the first 2 years after TAVR, and thereafter chronic coronary syndromes become prevalent. Unplanned PCIs are frequently successfully performed after TAVR, with no apparent differences between balloon-expandable and self-expandable bioprostheses. (Revascularization After Transcatheter Aortic Valve Implantation [REVIVAL]; NCT03283501).
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Affiliation(s)
- Giulio G Stefanini
- Humanitas Clinical and Research Center IRCCS, Rozzano - Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele - Milan, Italy.
| | - Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano, and Rivoli Infermi Hospital, Rivoli, Turin, Italy
| | - Carlo Andrea Pivato
- Humanitas Clinical and Research Center IRCCS, Rozzano - Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele - Milan, Italy
| | | | - Luca Testa
- IRCSS Policlinico San Donato, Milan, Italy
| | | | | | | | - Jorn Brouwer
- St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | - Marco Barbanti
- AOU Policlinico "G. Rodolico - San Marco", Catania, Italy
| | - Luigi Biasco
- Department of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Ferdinando Varbella
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano, and Rivoli Infermi Hospital, Rivoli, Turin, Italy
| | - Bernhard Reimers
- Humanitas Clinical and Research Center IRCCS, Rozzano - Milan, Italy
| | | | - Massimo Leoncini
- SSD Cardiologia Interventistica Ospedale di Sanremo, Sanremo, Italy
| | | | - Alfonso Ielasi
- Sant'Ambrogio Clinical Institute, Milan, Italy; Seriate Hospital, Bergamo, Italy
| | | | | | - Philippe Garot
- Hopital Privé Jacques Cartier, Institut Cardiovasculaire Paris-Sud, Ramsay-Santé, Massy, France
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Hermiller JB, Gunnarsson CL, Ryan MP, Moore KA, Clancy SJ, Irish W. The need for future coronary access following surgical or transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2021; 98:950-956. [PMID: 34227736 DOI: 10.1002/ccd.29841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/24/2021] [Accepted: 06/11/2021] [Indexed: 11/10/2022]
Abstract
The aim of the study was to estimate the percentage of Medicare patients needing coronary access for percutaneous coronary intervention (PCI) or coronary angiography following aortic valve replacement (AVR). Indications for TAVR have expanded to include younger and low-risk patients, raising the question of coronary access for future procedures. Medicare patients <80 years old with an AVR between 2011 and 2018 were included. Time-to-event analyses were conducted using Cox hazard models to estimate risk of coronary access up to 7 years after AVR. Model adjustments included age, sex, race, region, comorbidity, concomitant CABG, and smoking. A total of 13,469 Medicare patients (mean age 70.6) met inclusion criteria. Models estimated that 2.5% of patients at 1-year post-index and 17% at over 7 years would need coronary access. For patients who had SAVR (with or without CABG), estimates for coronary access were similar and over 15% after 6.5 years. For TAVR patients, with a previous PCI, 28% at 4.5 years required coronary access, which was higher than TAVR patients without a previous PCI. SAVR patients with and without CAD at baseline were similar; however, TAVR patients with CAD had a 22% rate of coronary access versus 7% for those without at 3 years. Approximately half of patients who needed coronary access returned to the same hospital as their initial AVR. Coronary access is required in a substantial portion of AVR patients especially those with PCI or a history of CAD undergoing TAVR. The need for coronary access may increase as transcatheter AVR becomes accessible to younger patients with a longer life expectancy.
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Affiliation(s)
- James B Hermiller
- Deptartment of Cardiology, Ascension St. Vincent's Heart Center of Indiana, Indianapolis, Indiana, USA
| | | | | | | | | | - William Irish
- Department of Surgery, East Carolina University, Greenville, North Carolina, USA
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Saha S, Peterss S, Mueller C, Deseive S, Sadoni S, Hausleiter J, Massberg S, Hagl C, Joskowiak D. Cardiac surgery following transcatheter aortic valve replacement. Eur J Cardiothorac Surg 2021; 60:1149-1155. [PMID: 34021322 DOI: 10.1093/ejcts/ezab217] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/12/2021] [Accepted: 03/09/2021] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES The objective of this study was to retrospectively analyse surgical outcomes of patients undergoing secondary cardiac surgery after initial transcatheter aortic valve replacement (TAVR). METHODS Between December 2012 and February 2020, a total of 41 consecutive patients underwent cardiac surgery after a TAVR procedure at our institution. Patients who underwent emergency operations due to periprocedural complications such as ventricular rupture and TAVR dislocation were excluded from this study (n = 12). Thus, 29 patients were included in the analysis. Data are presented as medians (25th-75th quartiles) or as absolute numbers (percentages). RESULTS The median age was 76 years (68-80); 58.6% were men. The median time to a secondary conventional procedure was 23 months (8-40), with 8 patients requiring surgical intervention within the first year post TAVR. The indications for secondary conventional procedures were prosthesis endocarditis (n = 15), prosthesis degeneration or dysfunction (n = 7) and progression of valvular, aortic or coronary artery disease (n = 7). Surgical redo aortic valve replacement was performed in 24 patients (82.8%). No complications involving the aortic root or the aortomitral continuity were observed. The operative mortality was 10.3%. Extracorporeal life support was required in 3 patients (10.3%) for a median duration of 3 days (3-3 days). No adverse cerebrovascular events were observed postoperatively. Postoperatively, 4 patients (13.8%) required a pacemaker and 7 patients (24.1%) required renal replacement therapy. Overall survival at 1 year was 83.0%. CONCLUSIONS Conventional cardiac surgical procedures following TAVR are feasible with reasonable results and a low complication rate.
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Affiliation(s)
- Shekhar Saha
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Christoph Mueller
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Simon Deseive
- Department of Cardiology, LMU University Hospital, Munich, Germany
| | - Sebastian Sadoni
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Jörg Hausleiter
- Department of Cardiology, LMU University Hospital, Munich, Germany
| | - Steffen Massberg
- Department of Cardiology, LMU University Hospital, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Dominik Joskowiak
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
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Rigatelli G, Zuin M, Roncon L, Nanjiundappa A, Daggubati R. Real world coronary artery ostia full accessibility after last generation transcatheter aortic valve implantation. Asian Cardiovasc Thorac Ann 2021; 30:276-284. [PMID: 34000821 DOI: 10.1177/02184923211018041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM We evaluate, performing a pooled meta-analysis, the current coronary artery accessibility rate in transcatheter aortic valve implantation (TAVI) patients during the follow-up. Full coronary artery accessibility after TAVI has not been adequately addressed by the current literature. METHODS According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, data on coronary artery access were obtained from the ratio between in the full coronary engagement (n) and the number of coronary angiography and/or percutaneous coronary intervention (N). Data were synthesized using random-effects meta-analyses. RESULTS Out of 7048 TAVI patients, 276 (3.9%) (mean age 76.8 years, 111 (40.2%) females) were analysed. Full coronary artery accessibility for coronary angiographies and percutaneous coronary interventions were obtained in 83.0% (95% confidence interval (CI): 0.66-0.92, p = 0.001, I2: 88.2%) and 96.0% (95% CI: 0.90-0.98, p < 0.0001, I2: 0) of cases (p for difference < .0.001). Left coronary artery (n = 219) was easily fully engaged compared to the right one (90.9% (95% CI: 0.80-0.96, p < 0.0001, I2: 58.4% and 82.0% (95% CI: 0.60-0.93, p = 0.006, I2: 83.2%), respectively, (p for difference < 0.001). Using age as moderator variable, meta-regression revealed a positive and negative correlation with coronary artery accessibility in patients treated with Sapien-Edwards (p = 0.008) and CoreValve (p = 0.010) platforms, respectively. Conversely, a negative correlation (p = 0.01) was found between coronary artery accessibility and mean time after Sapien-Edwards platform implantation (p = 0.01). CONCLUSIONS Full coronary artery accessibility during coronary angiographies and/or percutaneous coronary interventions results suboptimal for both coronary artery ostia and worse for right compared to left coronary artery after TAVI.
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Affiliation(s)
| | - Marco Zuin
- Department of Translational Medicine, Section of Internal and CardioRespiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Loris Roncon
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Aravinda Nanjiundappa
- Center of Vascular Excellence, West Virginia University Medical School, Charlstone, USA
| | - Ramesh Daggubati
- West Virginia University School of Medicine, Heart and Vascular Institute, Morgantown, USA
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Weferling M, Hamm CW, Kim WK. Percutaneous Coronary Intervention in Transcatheter Aortic Valve Implantation Patients: Overview and Practical Management. Front Cardiovasc Med 2021; 8:653768. [PMID: 34017866 PMCID: PMC8129193 DOI: 10.3389/fcvm.2021.653768] [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: 01/15/2021] [Accepted: 03/18/2021] [Indexed: 01/07/2023] Open
Abstract
Coronary artery disease (CAD) is present in 40-75% of patients undergoing transcatheter aortic valve implantation (TAVI) for severe symptomatic aortic stenosis. Currently, the indication for TAVI is expanding toward younger patients at lower surgical risk. Given the progressive nature of CAD, the necessity for coronary angiography (CA), including percutaneous coronary intervention (PCI), will subsequently increase as in the future TAVI patients will be younger and have a longer life expectancy. Data on the impact of PCI in patients with severe CAD scheduled for TAVI are controversial, and although European and US guidelines recommend PCI before TAVI, the optimal timing for PCI remains unclear due to a lack of evidence. Depending on the valve type, position, and axial alignment of the implanted device, CA and/or PCI after TAVI can be challenging. Hence, every interventionalist should be familiar with the different types of transcatheter heart valves and their characteristics and technical issues that can arise during invasive coronary procedures. This review provides an overview of current data regarding the prevalence and clinical implications of CAD and PCI in TAVI patients and includes useful guidance for practical management in the clinical routine.
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Affiliation(s)
- Maren Weferling
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research (DZHK), Frankfurt, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research (DZHK), Frankfurt, Germany.,Department of Cardiology, University Hospital of Giessen, Giessen, Germany
| | - Won-Keun Kim
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research (DZHK), Frankfurt, Germany.,Department of Cardiology, University Hospital of Giessen, Giessen, Germany.,Department of Cardio-Thoracic Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
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Saad M, Seoudy H, Frank D. Challenging Anatomies for TAVR-Bicuspid and Beyond. Front Cardiovasc Med 2021; 8:654554. [PMID: 33928138 PMCID: PMC8076502 DOI: 10.3389/fcvm.2021.654554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/15/2021] [Indexed: 12/23/2022] Open
Abstract
Transcatheter aortic valve replacement has emerged as the standard treatment for the majority of patients with symptomatic aortic stenosis. As transcatheter aortic valve replacement expands to patients across all risk groups, optimal patient selection strategies and device implantation techniques become increasingly important. A significant number of patients referred for transcatheter aortic valve replacement present with challenging anatomies and clinical indications that had been historically considered a contraindication for transcatheter aortic valve replacement. This article aims to highlight and discuss some of the potential obstacles that are encountered in clinical practice with a particular emphasis on bicuspid aortic valve disease.
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Affiliation(s)
- Mohammed Saad
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Hatim Seoudy
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Derk Frank
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Kiel, Germany
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von Stumm M, Sequeira-Gross T, Petersen J, Naito S, Müller L, Sinning C, Girdauskas E. Narrative review of the contemporary surgical treatment of unicuspid aortic valve disease. Cardiovasc Diagn Ther 2021; 11:503-517. [PMID: 33968629 DOI: 10.21037/cdt-20-814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Unicuspid aortic valve disease (UAVD) is a frequent and long-lasting challenge for adult congenital heart disease centers. UAVD patients become usually symptomatic in their twenties or thirties and require a surgical treatment plan which should respect their complete lifespan combined with an adequate quality of life. Unfortunately, all current surgical strategies of congenital aortic valve disease bear some important limitations: (I) Aortic valve replacement using bioprosthetic valves is associated with early structural degeneration and leads frequently to re-operations. (II) Mechanical valves are commonly associated with lifelong risk of severe bleeding due to oral anticoagulation. (III) Using a pulmonary autograft (i.e., Ross procedure) for aortic valve replacement is associated with excellent long-term results in non-elderly patients. However, failure of pulmonary autograft or pulmonary homograft may require re-operations. (IV) Aortic valve repair or Ozaki procedure is only performed in a few heart centers worldwide and is associated with a limited reproducibility and early patch degeneration, suture dehiscence or increased risk of endocarditis. In contrast to degenerative tricuspid aortic valve disease, UAVD remains relatively understudied and reports on UAVD treatment are rare and usually limited to retrospective single-center observations. For this review, we searched PubMed for papers in the English language by using the search words unicuspid aortic valve, congenital aortic valve, Ross procedure, Ozaki procedure, aortic valve repair, mechanical/bioprosthetic aortic replacement, homograft. We read the abstracts of relevant titles to confirm their relevance, and the full papers were then extracted. References from extracted papers were checked for additional relevant reports. This review summarizes current surgical treatment strategies for UAVD including aortic valve replacement using bioprosthetic or mechanical valves, homografts, pulmonary autografts (i.e., Ross procedure) and aortic valve repair techniques for UAV. Furthermore, Ozaki procedure will be discussed.
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Affiliation(s)
- Maria von Stumm
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tatjana Sequeira-Gross
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Petersen
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Shiho Naito
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lisa Müller
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Sinning
- Department of Cardiology, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Lim Y, Gochuico CFS, D'Ascenzo F, Ho KW, Lin MS, Gil IJN, Ielasi A, Tespili M, Mejía AC, DePaoli A, Yap J, Kao HL, Lee MKY, Tay E. Assessing the Impact of Transcatheter Aortic Valve Implantation on Cardiac Catheterisation: A Multicentric Study. Heart Lung Circ 2021; 30:1397-1405. [PMID: 33812787 DOI: 10.1016/j.hlc.2021.02.014] [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: 09/03/2020] [Revised: 12/07/2020] [Accepted: 02/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The success rate of coronary angiography (CA) after transcatheter aortic valve implantation (TAVI) is variable. Our aim was to investigate CA difficulty, outcomes, and predictors of difficult CA after TAVI. METHOD This was an international multicentric retrospective cohort study that included patients with TAVI and subsequent CA between January 2010 and December 2019. Difficulty with CA was graded as 1 (normal), 2 (partial engagement, complete vessel opacification), 3 (partial engagement, incomplete vessel opacification), and 4 (unsuccessful angiography). Patients were grouped as (a) "easy" (grade 1 for left and right) or (b) "difficult" (grade >1 for either). We compared baseline characteristics and outcomes, and performed multivariate logistic regression for predictors of difficult CA. RESULTS Of 96 patients included (mean age 77.4±8.7 years, 48 [50%] male), 88 (92%) had successful CA. Right CA was successful in 80 (83%) patients and left CA in 91 (95%) (p<0.0001). The "difficult" group (n=41 [43%]) had higher Society of Thoracic Surgery (STS) scores (7.6±4.9 vs 5.4±4.0; p=0.022), smaller annulus perimeters (72.4±5.4 mm vs 76.2±9.4 mm; p=0.049), greater use of self-expanding valves (83% vs 18%; p<0.0001), increased valve size (26.8±2.1 mm vs 25.6±3.0 mm; p=0.032), and increased oversizing for area (44.3%±17.4% vs 23.6%±22.0%; p=0.0002) and perimeter (17.5%±8.2% vs 7.1%±10.8%; p<0.0001). There was no difference in outcomes except for increased major bleeding (7.3% vs 0.0%; p=0.042). The strongest predictor for "difficult" CA was self-expanding valves when compared to balloon-expandable valves (adjusted odds ratio [aOR], 15.23; 95% confidence interval [CI], 2.27-102.40). Society of Thoracic Surgery score was borderline predictive (aOR, 1.26; 95% CI, 1.04-1.52). CONCLUSIONS Our results show that after TAVI, CA success rate is high, right CA is more difficult than left, self-expanding valves predispose to difficult CA, and STS score weakly predicts difficult CA. This study is hypothesis-generating and more research is required to confirm these findings.
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Affiliation(s)
- Yinghao Lim
- Department of Cardiology, National University Heart Centre, Singapore.
| | | | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Science, University of Turin, Città della Salute e Della Scienza, Turin, Italy
| | | | - Mao-Shin Lin
- Cardiovascular Centre, National Taiwan University Hospital Cardiology Division, Department of Internal Medicine, National Taiwan University Hospital Medical School, National Taiwan University, Taipei City, Taiwan
| | - Iván J Núñez Gil
- Cardiovascular Institute, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Alfonso Ielasi
- Clinical and Interventional Cardiology Unit, Sant'Ambrogio Cardio-Thoracic Center, Milan, Italy
| | - Maurizio Tespili
- Clinical and Interventional Cardiology Unit, Sant'Ambrogio Cardio-Thoracic Center, Milan, Italy
| | - Alex Castro Mejía
- Cardiovascular Institute, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Alessandro DePaoli
- Division of Cardiology, Department of Medical Science, University of Turin, Città della Salute e Della Scienza, Turin, Italy
| | | | - Hsien-Li Kao
- Cardiovascular Centre, National Taiwan University Hospital Cardiology Division, Department of Internal Medicine, National Taiwan University Hospital Medical School, National Taiwan University, Taipei City, Taiwan
| | | | - Edgar Tay
- Department of Cardiology, National University Heart Centre, Singapore
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de Azevedo Filho AF, Accorsi TA, Ribeiro HB. Coronary Artery Disease in Patients with Aortic Stenosis and Transcatheter Aortic Valve Implantation: Implications for Management. Eur Cardiol 2021; 16:e49. [PMID: 34950245 PMCID: PMC8674631 DOI: 10.15420/ecr.2021.27] [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: 06/11/2021] [Accepted: 08/16/2021] [Indexed: 01/09/2023] Open
Abstract
Aortic valve stenosis (AS) is the most common valvular heart disease among elderly patients. Since the pathophysiology of degenerative AS shares common pathways with atherosclerotic disease, the severity of AS in the elderly population is often concurrent to the presence of coronary artery disease (CAD). Although surgical aortic valve replacement has been the standard treatment for severe AS, the high operative morbidity and mortality in complex and fragile patients was the trigger to develop less invasive techniques. Transcatheter aortic valve implantation (TAVI) has been posed as the standard of care for elderly patients with severe AS with various risk profiles, which has meant that the concomitant management of CAD has become a crucial issue in such patients. Given the lack of randomised controlled trials evaluating the management of CAD in TAVI patients, most of the recommendations are based on retrospective cohort studies so that the Heart Team approach - together with an assessment of multiple parameters including symptoms and clinical characteristics, invasive and non-invasive ischaemic burden and anatomy - are crucial for the proper management of these patients. This article provides a review of current knowledge about assessment and therapeutic approaches for CAD and severe AS in patients undergoing TAVI.
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Affiliation(s)
| | - Tarso Ad Accorsi
- Department of Valvular Heart Disease, Heart Institute (InCor), University of São Paulo São Paulo, Brazil
- Samaritano Paulista Hospital São Paulo, Brazil
| | - Henrique B Ribeiro
- Samaritano Paulista Hospital São Paulo, Brazil
- Interventional Cardiology Department, Heart Institute (InCor), University of São Paulo São Paulo, Brazil
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A systematic review and meta-analysis of delayed coronary artery access for coronary angiography with or without percutaneous coronary intervention (PCI) in patients who underwent transcatheter aortic valve replacement (TAVR). Cardiovasc Interv Ther 2021; 37:167-181. [PMID: 33453034 DOI: 10.1007/s12928-020-00753-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
Coronary artery disease (CAD) and severe aortic valve stenosis frequently coexist. Given the progressive nature of CAD, silent or non-significant CAD may become symptomatic or functionally relevant years after TAVR. However, there is a paucity of data documenting the feasibility of either coronary angiography and/or PCI after TAVR. We systematically searched Medline, Pubmed, Embase, Cochrane database, Google Scholar, Science Direct, Web of Science, and conference abstracts from conception to March 2020 using OvidSP in TAVR patients undergoing coronary angiography with or without PCI at least 6 months after TAVR. Patients and procedural characteristics were summarized. The primary outcome of interest was successful coronary angiography for either the left main coronary artery (LMCA) or right coronary artery (RCA) with or without PCI. Pooled estimates were calculated using a random-effects meta-analysis. The study protocol was registered in PROSPERO. Eleven reports for a total of 696 coronary angiograms and 287 PCI were included in the analysis. Patients were slightly predominantly male, older and had a mean left ventricular ejection fraction of more than 50% with an intermediate STS. The summary estimate rates of successful LMCA and RCA angiography with a Medtronic self-expandable valve (SEV) were 84% (95% CI 73-90%, I2 = 79, p = 0.015) and 69% (95% CI 37-89%, I2 = 86, p = 0.23), respectively, while with the Edwards Lifesciences balloon expandable valve (BEV), the summary estimate rates for successful LMCA and RCA angiography were 94% (95% CI 72-99%, I2 = 66, p = 0.003) and 95% (95% CI 48-99%, I2 = 83, p = 0.05), respectively. The summary estimate rate of successful PCI post TAVR with either a Medtronic SEV or Edwards Lifesciences BEV was 93% (95% CI 86-96%, I2 = 33, p = 0.0001). The overall achievement of a successful coronary angiography with or without PCI in post-TAVR patients is high, with a lower success rate for RCA angiography in patients with the Medtronic SEV Mortality and bleeding did not differ in our analysis.
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Abdel-Wahab M. Revisiting the Coronary Arteries After TAVR: A Potentially Challenging Endeavor. JACC Cardiovasc Interv 2020; 13:2556-2559. [PMID: 33069652 DOI: 10.1016/j.jcin.2020.07.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Mohamed Abdel-Wahab
- Department of Structural Heart Disease/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.
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Arshi A, Yakubov SJ, Stiver KL, Sanchez CE. Overcoming the transcatheter aortic valve replacement Achilles heel: coronary re-access. Ann Cardiothorac Surg 2020; 9:468-477. [PMID: 33312904 PMCID: PMC7724072 DOI: 10.21037/acs-2020-av-38] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 07/09/2020] [Indexed: 01/30/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) for the treatment of symptomatic severe aortic stenosis (AS). Coronary artery disease (CAD) is common in patients with severe AS. As the indications for TAVR extend to lower risk patients with longer life expectancy and as CAD is a progressive condition, coronary angiography will become increasingly common in patients who have had a previous TAVR. Coronary artery re-access after TAVR may be challenging but is possible in most cases. Commissural alignment of the prosthesis with the native coronary ostia plays an important role in successful coronary re-access. Coronary artery obstruction is a potentially devastating complication of TAVR, particularly in valve-in-valve procedures. In the present keynote lecture, we review techniques used to mitigate the risk of coronary obstruction, as well as catheter selection and strategies for selective coronary artery engagement for specific transcatheter aortic valve (TAV) bioprostheses.
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Affiliation(s)
- Arash Arshi
- OhioHealth Riverside Methodist Hospital, Columbus, Ohio, USA
| | | | - Kevin L Stiver
- OhioHealth Riverside Methodist Hospital, Columbus, Ohio, USA
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Coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement with medtronic self-expanding prosthesis: Insights from correlations with computer tomography. Int J Cardiol 2020; 317:18-24. [DOI: 10.1016/j.ijcard.2020.05.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/11/2020] [Accepted: 05/20/2020] [Indexed: 11/20/2022]
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Gonçalves M, de Araújo Gonçalves P, Campante Teles R, de Sousa Almeida M, Félix de Oliveira A, Brito J, Raposo L, Mesquita Gabriel H, Nolasco T, Neves JP, Mendes M, Garcia-Garcia HM. Low Rate of Invasive Coronary Angiography Following Transcatheter Aortic Valve Implantation: Real-World Prospective Cohort Findings. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 28:42-49. [PMID: 32921596 DOI: 10.1016/j.carrev.2020.07.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 11/18/2022]
Abstract
AIM To evaluate the real need for coronary access after transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS Prospective observational single-center registry, including 563 consecutive patients who underwent TAVI between April 2008 and November 2018, with both self- and balloon-expandable valves in a tertiary European center. Mean age was 82.4 ± 6.9 years, 53.3% were female, 16% had previous history of coronary artery bypass grafting, 33% of previous percutaneous coronary intervention (PCI), and 16.6% of myocardial infarction (MI). Twenty-four percent of the patients were revascularized within one year before TAVI in preparation for the procedure. Median Society of Thoracic Surgeons score was 4.82 (IQ 2.84). In a median follow-up of 24 months (IQ 21.5), 18 patients (3.2%) were identified as potentially in need for invasive coronary angiography: 9 (1.6%) in the setting of stable coronary artery disease and 9 (1.6%) for an acute coronary syndrome. A total of 11 PCIs were performed in 9 patients, with a complete success rate of 63.6%. Procedures that were unsuccessful or partially unsuccessful were due to the inability to cross the stent or the drug-eluting balloon through the valve struts or misplacement within the coronary artery due to lack of catheter support. CONCLUSION In this population, a strategy of previous guideline-directed revascularization before TAVI was associated with a low rate of MI and repeated need of coronary access, with a scattered distribution over time. Assuring future access to coronary arteries in patients at increased risk may depend on the revascularization strategy rather than device selection.
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Affiliation(s)
- Mariana Gonçalves
- Division of Interventional Cardiology of Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Pedro de Araújo Gonçalves
- Division of Interventional Cardiology of Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal; NOVA Medical School, Lisbon, Portugal
| | - Rui Campante Teles
- Division of Interventional Cardiology of Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal; NOVA Medical School, Lisbon, Portugal.
| | - Manuel de Sousa Almeida
- Division of Interventional Cardiology of Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal; NOVA Medical School, Lisbon, Portugal
| | - Afonso Félix de Oliveira
- Division of Interventional Cardiology of Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - João Brito
- Division of Interventional Cardiology of Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Luís Raposo
- Division of Interventional Cardiology of Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Henrique Mesquita Gabriel
- Division of Interventional Cardiology of Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Tiago Nolasco
- Division of Cardiac Surgery of Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - José Pedro Neves
- Division of Cardiac Surgery of Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Miguel Mendes
- Division of Interventional Cardiology of Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Hector M Garcia-Garcia
- Division of Interventional Cardiology of MedStar Cardiovascular Research Network at MedStar Washington Hospital Center, USA.
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A comparison of surgical, total percutaneous, and hybrid approaches to treatment of combined coronary artery and valvular heart disease. Curr Opin Cardiol 2020; 35:559-565. [DOI: 10.1097/hco.0000000000000764] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Konsensuspapier der Deutschen Gesellschaft für Kardiologie (DGK) und der Deutschen Gesellschaft für Thorax‑, Herz- und Gefäßchirurgie (DGTHG) zur kathetergestützten Aortenklappenimplantation (TAVI) 2020. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00398-020-00373-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Kuck KH, Bleiziffer S, Eggebrecht H, Ensminger S, Frerker C, Möllmann H, Nef H, Thiele H, Treede H, Wimmer-Greinecker G, Walther T. Konsensuspapier der Deutschen Gesellschaft für Kardiologie (DGK) und der Deutschen Gesellschaft für Thorax‑, Herz- und Gefäßchirurgie (DGTHG) zur kathetergestützten Aortenklappenimplantation (TAVI) 2020. KARDIOLOGE 2020. [DOI: 10.1007/s12181-020-00398-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Coronary Artery Disease and Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 74:362-372. [PMID: 31319919 DOI: 10.1016/j.jacc.2019.06.012] [Citation(s) in RCA: 168] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/10/2019] [Indexed: 01/09/2023]
Abstract
About one-half of transcatheter aortic valve replacement (TAVR) candidates have coronary artery disease (CAD), and controversial results have been reported regarding the effect of the presence and severity of CAD on clinical outcomes post-TAVR. In addition to coronary angiography, promising data has been recently reported on both the use of computed tomography angiography and the functional invasive assessment of coronary lesions in the work-up pre-TAVR. While waiting for the results of ongoing randomized trials, percutaneous revascularization of significant coronary lesions has been the routine strategy in TAVR candidates with CAD. Also, scarce data exists on the incidence, characteristics, and management of coronary events post-TAVR, and increasing interest exist on potential coronary access challenges in patients requiring coronary angiography/intervention post-TAVR. This review provides an updated overview of the current landscape of CAD in TAVR recipients, focusing on its prevalence, clinical impact, pre- and post-procedural evaluation and management, unresolved issues and future perspectives.
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Asgar AW, Ouzounian M, Adams C, Afilalo J, Fremes S, Lauck S, Leipsic J, Piazza N, Rodes-Cabau J, Welsh R, Wijeysundera HC, Webb JG. 2019 Canadian Cardiovascular Society Position Statement for Transcatheter Aortic Valve Implantation. Can J Cardiol 2020; 35:1437-1448. [PMID: 31679616 DOI: 10.1016/j.cjca.2019.08.011] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/29/2019] [Accepted: 08/02/2019] [Indexed: 01/12/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) or replacement has rapidly changed the treatment of patients with severe symptomatic aortic stenosis. It is now the standard of care for patients believed to be inoperable or at high surgical risk, and a reasonable alternative to surgical aortic valve replacement for those at intermediate surgical risk. Recent clinical trial data have shown the benefits of this technology in patients at low surgical risk as well. This update of the 2012 Canadian Cardiovascular Society TAVI position statement incorporates clinical evidence to provide a practical framework for patient selection that does not rely on surgical risk scores but rather on individual patient evaluation of risk and benefit from either TAVI or surgical aortic valve replacement. In addition, this statement features new wait time categories and treatment time goals for patients accepted for TAVI. Institutional requirements and recommendations for operator training and maintenance of competency have also been revised to reflect current standards. Procedural considerations such as decision-making for concomitant coronary intervention, antiplatelet therapy after intervention, and follow-up guidelines are also discussed. Finally, we suggest that all patients with aortic stenosis might benefit from evaluation by the heart team to determine the optimal individualized treatment decision.
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Affiliation(s)
- Anita W Asgar
- Institut de Cardiologie de Montreal, Universite de Montreal, Montreal, Quebec, Canada.
| | - Maral Ouzounian
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Corey Adams
- Health Sciences Centre, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Jonathan Afilalo
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Stephen Fremes
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sandra Lauck
- St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathan Leipsic
- St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Josep Rodes-Cabau
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Universite de Laval, Quebec, Quebec, Canada
| | - Robert Welsh
- Mazankowski Alberta Heart Institute and University of Alberta, Edmonton, Alberta, Canada
| | | | - John G Webb
- St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Ochiai T, Yoon SH, Flint N, Sharma R, Chakravarty T, Kaewkes D, Patel V, Nakamura M, Cheng W, Makkar R. Timing and Outcomes of Percutaneous Coronary Intervention in Patients Who Underwent Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 125:1361-1368. [PMID: 32106928 DOI: 10.1016/j.amjcard.2020.01.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/27/2020] [Accepted: 01/31/2020] [Indexed: 12/12/2022]
Abstract
Limited data exist regarding the timing of percutaneous coronary intervention (PCI) in patients with coronary artery disease who underwent transcatheter aortic valve implantation (TAVI). We aimed to investigate clinical outcomes of patients who underwent TAVI and planned PCI according to the timing of PCI in relation to the TAVI. Consecutive patients with severe aortic stenosis who underwent TAVI with planned PCI between January 2013 and November 2017 were included. Patients were divided according to the timing of PCI. The primary end point was major adverse cardiac and cerebrovascular events, defined as a composite of all-cause death, myocardial infarction, unplanned revascularization, and stroke. Among 1,756 patients who underwent TAVI, 258 patients underwent planned PCI either before TAVI (n = 143, 55.4%), concomitantly with TAVI (n = 77, 29.8%), or after TAVI (n = 38, 14.7%). All patients in the post-TAVI PCI group were treated using balloon-expandable valves, and neither hemodynamic instability during TAVI nor PCI-related complications were observed. In a multivariable analysis, the timing of PCI was not associated with 2-year major adverse cardiac and cerebrovascular events rate (concomitant vs pre-TAVI, hazard ratio [HR]: 0.92; 95% confidence interval [CI]: 0.52 to 1.66; p = 0.79; post- vs pre-TAVI, HR: 0.45; 95% CI: 0.18 to 1.16; p = 0.10). In conclusion, there were no significant differences in terms of mid-term outcomes among pre-TAVI, concomitant, and post-TAVI PCI groups when the timing of PCI was carefully selected by heart team.
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Affiliation(s)
- Tomoki Ochiai
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Sung-Han Yoon
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nir Flint
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Tel Aviv Sourasky Medical Center affiliated to the Sackler faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rahul Sharma
- Stanford Health Care, and Stanford University, Stanford, California
| | - Tarun Chakravarty
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Danon Kaewkes
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Vivek Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mamoo Nakamura
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Wen Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Raj Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Ozaki Y, Garcia-Garcia HM, Rogers T, Torguson R, Craig PE, Hideo-Kajita A, Gordon P, Ehsan A, Parikh P, Bilfinger T, Butzel D, Buchanan S, Levitt R, Hahn C, Buchbinder M, Hanna N, Garrett R, Wilson SR, Goncalves JA, Ali S, Asch FM, Weissman G, Shults C, Ben-Dor I, Satler LF, Waksman R. Coronary Artery Disease Assessed by Computed Tomography-Based Leaman Score in Patients With Low-Risk Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 125:1216-1221. [PMID: 32087995 DOI: 10.1016/j.amjcard.2020.01.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/13/2020] [Accepted: 01/17/2020] [Indexed: 01/05/2023]
Abstract
We aimed to evaluate the burden of coronary artery disease (CAD) using the computed tomography (CT) Leaman score in low-risk transcatheter aortic valve implantation (TAVI) patients. The extent of CAD in low-risk patients with aortic stenosis who are candidates for TAVI has not been accurately quantified. The CT Leaman score was developed to quantify coronary CT angiography (CCTA) atherosclerotic burden and has been validated to evaluate the extent of CAD. CT Leaman score >5 has been associated with an increase in major adverse cardiac events over long-term follow-up. The study population included patients enrolled in the Low Risk TAVI trial who underwent CCTA before the procedure. For the CT Leaman score, we used 3 sets of weighting factors: (1) location of coronary plaques, (2) type of plaque, and (3) degree of stenosis. A total of 200 patients were enrolled in the Low Risk TAVI trial. Excluded were 31 patients who had no analyzable CCTA imaging. For the remaining 169 patients, the mean CT Leaman score was 6.27 ± 0.27, of whom 102 (60.4%) had CT Leaman score >5. Nearly all analyzed patients (97%) had coronary plaques. Furthermore, 33 patients (19.5%) had potentially obstructive coronary plaques (>50% stenosis by CCTA) in proximal segments. Most low-risk TAVI patients have significant CAD burden by CCTA. It should be a priority for future TAVI devices to guarantee unimpeded access to the coronary arteries for selective angiography and interventions.
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Luthra S, Ohri SK. Transcatheter aortic valve implantation for low-risk aortic stenosis: are we ready? Eur J Cardiothorac Surg 2020; 57:413-417. [PMID: 31972001 DOI: 10.1093/ejcts/ezz372] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Suvitesh Luthra
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Sunil K Ohri
- Division of Cardiac Surgery, Wessex Cardiothoracic Centre, Southampton University Hospitals NHS Trust, Southampton, UK
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Ochiai T, Chakravarty T, Yoon SH, Kaewkes D, Flint N, Patel V, Mahani S, Tiwana R, Sekhon N, Nakamura M, Cheng W, Makkar R. Coronary Access After TAVR. JACC Cardiovasc Interv 2020; 13:693-705. [DOI: 10.1016/j.jcin.2020.01.216] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/13/2020] [Accepted: 01/13/2020] [Indexed: 11/26/2022]
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Abdelghani M, Landt M, Traboulsi H, Becker B, Richardt G. Coronary Access After TAVR With a Self-Expanding Bioprosthesis. JACC Cardiovasc Interv 2020; 13:709-722. [DOI: 10.1016/j.jcin.2020.01.229] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/07/2020] [Accepted: 01/28/2020] [Indexed: 10/24/2022]
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50
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Nai Fovino L, Scotti A, Massussi M, Fabris T, Cardaioli F, Rodinò G, Matsuda Y, Frigo F, Fraccaro C, Tarantini G. Incidence and feasibility of coronary access after transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2020; 96:E535-E541. [DOI: 10.1002/ccd.28720] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 12/31/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Luca Nai Fovino
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Andrea Scotti
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Mauro Massussi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Tommaso Fabris
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Francesco Cardaioli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Giulio Rodinò
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Yuji Matsuda
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Francesca Frigo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
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