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Custódio P, Madeira S, Teles R, Almeida M. Coronary artery disease and its management in TAVI. Hellenic J Cardiol 2024; 78:36-41. [PMID: 37689181 DOI: 10.1016/j.hjc.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 07/31/2023] [Accepted: 09/05/2023] [Indexed: 09/11/2023] Open
Abstract
OBJECTIVE Aortic stenosis and coronary artery disease (CAD) are frequently associated. The preprocedural evaluation and indications for treatment in patients undergoing transcatheter aortic valve intervention (TAVI) remain controversial. This study sought to 1) determine the prevalence and angiographic characteristics of CAD in TAVI candidates, along with revascularization patterns, and 2) to evaluate the impact of the presence and complexity of CAD, as well as angiography-guided percutaneous coronary intervention, on prognosis after TAVI. METHODS Single-center retrospective study from a prospectively collected institutional registry that included all patients that underwent TAVI between 2009 and 2018 and pre TAVI coronary angiography (CA) in our institution in the context of pre-procedure work-up. A multivariate analysis was performed to determine the effect of CAD and PCI on 2-year mortality. RESULTS A total of 379 patients were included: 55 patients (14.5%) presented with normal coronary arteries, 120 (31.6%) with non-obstructive CAD, and 204 (53.8%) with obstructive CAD (the mean SxS was 8.2). Ultimately, 110 patients (29%) underwent PCI. Two-year survival after TAVI was decreased in patients with complex coronary lesions (SS > 22), while it was not affected by the overall presence of non-obstructive CAD, obstructive CAD, residual SxS, or pre-TAVI PCI of angiographically significant lesions (OR 0.631, 95%CI 0.192-1.406). CONCLUSION In our population, the overall presence and management of obstructive CAD did not appear to impact mortality at 2 years after TAVI. Survival was decreased in patients with baseline complex coronary anatomies.
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Affiliation(s)
- Pedro Custódio
- Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal.
| | | | - Rui Teles
- Hospital de Santa Cruz, Carnaxide, Portugal
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Sammartino S, Laterra G, Pilgrim T, Amat Santos IJ, De Backer O, Kim WK, Ribeiro HB, Saia F, Bunc M, Tchetche D, Garot P, Ribichini FL, Mylotte D, Burzotta F, Watanabe Y, Bedogni F, Tesorio T, Rheude T, Sardella G, Tocci M, Franzone A, Valvo R, Savontaus M, Wienemann H, Porto I, Gandolfo C, Iadanza A, Bortone AS, Mach M, Latib A, Biasco L, Taramasso M, De Marco F, Frittitta V, Dipietro E, Reddavid C, Strazzieri O, Motta S, Comis A, Melfa C, Calì M, Sgroi C, Abdel-Wahab M, Stefanini G, Tamburino C, Barbanti M, Costa G. Characterization and Management of Stable Coronary Artery Disease in Patients Undergoing Transcatheter Aortic Valve Implantation. J Clin Med 2024; 13:3497. [PMID: 38930026 PMCID: PMC11204567 DOI: 10.3390/jcm13123497] [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: 04/05/2024] [Revised: 05/24/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
Background/Objectives: To date, data regarding the characteristics and management of obstructive, stable coronary artery disease (CAD) encountered in patients undergoing transcatheter aortic valve implantation (TAVI) are sparse. The aim of the study was to analyze granular details, treatment, and outcomes of patients undergoing TAVI with obstructive, stable CAD from real-world practice. Methods: REVASC-TAVI (Management of myocardial REVASCularization in patients undergoing Transcatheter Aortic Valve Implantation with coronary artery disease) is an investigator-initiated, multicenter registry, which collected data from patients undergoing TAVI with obstructive stable CAD found during the pre-TAVI work-up. Results: A total of 2025 patients from 30 centers worldwide with complete follow-up were included in the registry. Most patients had single-vessel CAD (56.1%). An involvement of proximal coronary tracts was detected in 62.5% of cases, with 12.0% of patients having CAD in left main (LM). Most patients received percutaneous coronary intervention (PCI) (n = 1617, 79.9%), especially those with proximal CAD (90.4%). At 2 years, the rates of all-cause death [Kaplan-Meier (KM) estimates 20.1% vs. 18.8%, plog-rank = 0.86] and of the composite of all-cause death, stroke, myocardial infarction, and rehospitalization for heart failure (KM estimates 29.7% vs. 27.5%, plog-rank = 0.82) did not differ between patients undergoing PCI and those who were not. Conclusions: Patients undergoing TAVI with obstructive CAD more commonly had a single-vessel disease and an involvement of proximal coronary tracts. They were commonly treated with PCI, with similar outcomes compared to those treated conservatively.
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Affiliation(s)
- Sofia Sammartino
- Department of Cardiology, University of Catania, 95124 Catania, Italy; (S.S.); (V.F.); (E.D.); (C.R.); (O.S.); (S.M.); (A.C.); (C.M.); (M.C.); (G.C.)
| | | | - Thomas Pilgrim
- Bern University Hospital, Inselspital, 3010 Bern, Switzerland;
| | - Ignacio J. Amat Santos
- Division of Cardiology, Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain;
| | - Ole De Backer
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, 1165 Copenhagen, Denmark;
| | - Won-Keun Kim
- Kerckhoff Heart Center, 61231 Bad Nauheim, Germany;
| | | | - Francesco Saia
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Matjaz Bunc
- Department of Cardiology, University Medical Centre Ljubljana, 1525 Ljubljana, Slovenia;
| | | | - Philippe Garot
- Institut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, 91300 Massy, France;
| | - Flavio Luciano Ribichini
- Division of Cardiology, Azienda Ospedaliera Universitaria Integrata di Verona, 37126 Verona, Italy;
| | | | - Francesco Burzotta
- Department of Cardiology, IRCSS Policlinico Universitario “Agostino Gemelli”, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine, Tokyo 173-8605, Japan;
| | - Francesco Bedogni
- Division of Cardiology, IRCSS Policlinico San Donato, 20097 San Donato Milanese, Italy; (F.B.); (R.V.)
| | - Tullio Tesorio
- Clinica Montevergine, GVM Care & Research, 48033 Mercogliano, Italy;
| | | | - Gennaro Sardella
- Division of Cardiology, Policlinico Umberto I, 00185 Roma, Italy; (G.S.); (M.T.)
| | - Marco Tocci
- Division of Cardiology, Policlinico Umberto I, 00185 Roma, Italy; (G.S.); (M.T.)
| | - Anna Franzone
- Division of Cardiology, AOU Federico II, Università di Napoli, 80125 Napoli, Italy;
| | - Roberto Valvo
- Division of Cardiology, IRCSS Policlinico San Donato, 20097 San Donato Milanese, Italy; (F.B.); (R.V.)
| | - Mikko Savontaus
- Heart Center, Turku University Hospital, 20014 Turku, Finland;
| | - Hendrik Wienemann
- Faculty of Medicine, University Hospital Cologne, Clinic III for Internal Medicine, University of Cologne, 50923 Cologne, Germany;
| | - Italo Porto
- CardioThoracic and Vascular Department, San Martino Policlinico Hospital, 16132 Genova, Italy;
| | - Caterina Gandolfo
- Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione (ISMETT), 90127 Palermo, Italy;
| | - Alessandro Iadanza
- Azienda Ospedaliera Universitaria Senese, UOSA Cardiologia Interventistica, Policlinico Le Scotte, 53100 Siena, Italy;
| | - Alessandro Santo Bortone
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, 70124 Bari, Italy;
| | - Markus Mach
- Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Azeem Latib
- Montefiore Medical Center, New York, NY 10461, USA;
| | - Luigi Biasco
- Azienda Sanitaria Locale di Ciriè, Chivasso e Ivrea, ASLTO4, 10034 Chivasso, Italy;
| | - Maurizio Taramasso
- Heart and Valve Center, University Hospital of Zurich, University of Zurich, 8006 Zurich, Switzerland;
| | | | - Valentina Frittitta
- Department of Cardiology, University of Catania, 95124 Catania, Italy; (S.S.); (V.F.); (E.D.); (C.R.); (O.S.); (S.M.); (A.C.); (C.M.); (M.C.); (G.C.)
| | - Elena Dipietro
- Department of Cardiology, University of Catania, 95124 Catania, Italy; (S.S.); (V.F.); (E.D.); (C.R.); (O.S.); (S.M.); (A.C.); (C.M.); (M.C.); (G.C.)
| | - Claudia Reddavid
- Department of Cardiology, University of Catania, 95124 Catania, Italy; (S.S.); (V.F.); (E.D.); (C.R.); (O.S.); (S.M.); (A.C.); (C.M.); (M.C.); (G.C.)
| | - Orazio Strazzieri
- Department of Cardiology, University of Catania, 95124 Catania, Italy; (S.S.); (V.F.); (E.D.); (C.R.); (O.S.); (S.M.); (A.C.); (C.M.); (M.C.); (G.C.)
| | - Silvia Motta
- Department of Cardiology, University of Catania, 95124 Catania, Italy; (S.S.); (V.F.); (E.D.); (C.R.); (O.S.); (S.M.); (A.C.); (C.M.); (M.C.); (G.C.)
| | - Alessandro Comis
- Department of Cardiology, University of Catania, 95124 Catania, Italy; (S.S.); (V.F.); (E.D.); (C.R.); (O.S.); (S.M.); (A.C.); (C.M.); (M.C.); (G.C.)
| | - Chiara Melfa
- Department of Cardiology, University of Catania, 95124 Catania, Italy; (S.S.); (V.F.); (E.D.); (C.R.); (O.S.); (S.M.); (A.C.); (C.M.); (M.C.); (G.C.)
| | - Mariachiara Calì
- Department of Cardiology, University of Catania, 95124 Catania, Italy; (S.S.); (V.F.); (E.D.); (C.R.); (O.S.); (S.M.); (A.C.); (C.M.); (M.C.); (G.C.)
| | - Carmelo Sgroi
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico-San Marco”, 95123 Catania, Italy; (C.S.); (C.T.)
| | | | | | - Corrado Tamburino
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico-San Marco”, 95123 Catania, Italy; (C.S.); (C.T.)
| | - Marco Barbanti
- Department of Cardiology, Università degli Studi di Enna “Kore”, Piazza dell’Università, 94100 Enna, Italy
| | - Giuliano Costa
- Department of Cardiology, University of Catania, 95124 Catania, Italy; (S.S.); (V.F.); (E.D.); (C.R.); (O.S.); (S.M.); (A.C.); (C.M.); (M.C.); (G.C.)
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Persits I, Layoun H, Kondoleon NP, Spilias N, Badwan O, Sipko J, Yun JJ, Kalra A, Dykun I, Tereshchenko LG, Krishnaswamy A, Reed GW, Kapadia SR, Puri R. Impact of untreated chronic obstructive coronary artery disease on outcomes after transcatheter aortic valve replacement. Eur Heart J 2024; 45:1890-1900. [PMID: 38270189 DOI: 10.1093/eurheartj/ehae019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 11/24/2023] [Accepted: 01/09/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND AND AIMS In transcatheter aortic valve replacement (TAVR) recipients, the optimal management of concomitant chronic obstructive coronary artery disease (CAD) remains unknown. Some advocate for pre-TAVR percutaneous coronary intervention, while others manage it expectantly. The aim of this study was to assess the impact of varying degrees and extent of untreated chronic obstructive CAD on TAVR and longer-term outcomes. METHODS The authors conducted a retrospective cohort study of TAVR recipients from January 2015 to November 2021, separating patients into stable non-obstructive or varying degrees of obstructive CAD. The major outcomes of interest were procedural all-cause mortality and complications, major adverse cardiovascular events, and post-TAVR unplanned coronary revascularization. RESULTS Of the 1911 patients meeting inclusion, 75%, 6%, 10%, and 9% had non-obstructive, intermediate-risk, high-risk, and extreme-risk CAD, respectively. Procedural complication rates overall were low (death 0.4%, shock 0.1%, extracorporeal membrane oxygenation 0.1%), with no difference across groups. At a median follow-up of 21 months, rates of acute coronary syndrome and unplanned coronary revascularization were 0.7% and 0.5%, respectively, in the non-obstructive population, rising in incidence with increasing severity of CAD (P < .001 for acute coronary syndrome/unplanned coronary revascularization). Multivariable analysis did not yield a significantly greater risk of all-cause mortality or major adverse cardiovascular events across groups. One-year acute coronary syndrome and unplanned coronary revascularization rates in time-to-event analyses were significantly greater in the non-obstructive (98%) vs. obstructive (94%) subsets (Plog-rank< .001). CONCLUSIONS Transcatheter aortic valve replacement can be performed safely in patients with untreated chronic obstructive CAD, without portending higher procedural complication rates and with relatively low rates of unplanned coronary revascularization and acute coronary syndrome at 1 year.
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Affiliation(s)
- Ian Persits
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Habib Layoun
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | | | - Nikolaos Spilias
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph Sipko
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - James J Yun
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | | | - Iryna Dykun
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Larisa G Tereshchenko
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Grant W Reed
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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4
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Eltchaninoff H, Durand E. Transfemoral aortic valve implantation and concomitant CAD: the jury is out. Eur Heart J 2024:ehae141. [PMID: 38819811 DOI: 10.1093/eurheartj/ehae141] [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: 06/01/2024] Open
Affiliation(s)
- Helene Eltchaninoff
- Univ Rouen Normandie, Inserm U1096, CHU Rouen, Department of Cardiology, F-76000 Rouen, France
| | - Eric Durand
- Univ Rouen Normandie, Inserm U1096, CHU Rouen, Department of Cardiology, F-76000 Rouen, France
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5
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Mehier B, Mahmoudi K, Veugeois A, Masri A, Amabile N, Giudice CD, Paul JF. Diagnostic performance of deep learning to exclude coronary stenosis on CT angiography in TAVI patients. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:981-990. [PMID: 38461472 DOI: 10.1007/s10554-024-03063-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 02/03/2024] [Indexed: 03/12/2024]
Abstract
We evaluated the diagnostic performance of a deep-learning model (DLM) (CorEx®, Spimed-AI, Paris, France) designed to automatically detect > 50% coronary stenosis on coronary computed tomography angiography (CCTA) images. We studied inter-observer variability as an additional aim. CCTA images obtained before transcatheter aortic valve implantation (TAVI) were assessed by two radiologists and the DLM, and the results were compared to those of invasive coronary angiography (ICA) used as the reference standard. 165 consecutive patients underwent both CCTA and ICA as part of their TAVI work-up. We excluded the 42 (25.5%) patients with a history of stenting or bypass grafting and the 23 (13.9%) patients with low-quality images. We retrospectively subjected the CCTA images from the remaining 100 patients to evaluation by the DLM and compared the DLM and ICA results. All 25 patients with > 50% stenosis by ICA also had > 50% stenosis by DLM evaluation of CCTA: thus, the DLM had 100% sensitivity and 100% negative predictive value. False-positive DLM results were common, yielding a positive predictive value of only 39% (95% CI, 27-51%). Two radiologists with 3 and 25 years' experience, respectively, performed similarly to the DLM in evaluating the CCTA images; thus, accuracy did not differ significantly between each reader and the DLM (p = 0.625 and p = 0.375, respectively). The DLM had 100% negative predictive value for > 50% stenosis and performed similarly to experienced radiologists. This tool may hold promise for identifying the up to one-third of patients who do not require ICA before TAVI.
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Affiliation(s)
- Benjamin Mehier
- Department of Radiology, Cardiac Imaging, Institut Mutualiste Montsouris, 75014, Paris, France.
| | - Khalil Mahmoudi
- Interventional Cardiology Department, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Aurélie Veugeois
- Interventional Cardiology Department, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Alaa Masri
- Interventional Cardiology Department, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Nicolas Amabile
- Interventional Cardiology Department, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Costantino Del Giudice
- Radiology and Interventional Radiology Department, Cardiac Imaging, Institut Mutualiste Montsouris, 75014, Paris, France
| | - Jean-François Paul
- Department of Radiology, Cardiac Imaging, Institut Mutualiste Montsouris, Spimed-AI, 75014, Paris, France
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Damluji AA, Nanna MG, Rymer J, Kochar A, Lowenstern A, Baron SJ, Narins CR, Alkhouli M. Chronological vs Biological Age in Interventional Cardiology: A Comprehensive Approach to Care for Older Adults: JACC Family Series. JACC Cardiovasc Interv 2024; 17:961-978. [PMID: 38597844 PMCID: PMC11097960 DOI: 10.1016/j.jcin.2024.01.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 04/11/2024]
Abstract
Aging is the gradual decline in physical and physiological functioning leading to increased susceptibility to stressors and chronic illnesses, including cardiovascular disease. With an aging global population, in which 1 in 6 individuals will be older than 60 years by 2030, interventional cardiologists are increasingly involved in providing complex care for older individuals. Although procedural aspects remain their main clinical focus, interventionalists frequently encounter age-associated risks that influence eligibility for invasive care, decision making during the intervention, procedural adverse events, and long-term management decisions. The unprecedented growth in transcatheter interventions, especially for structural heart diseases at extremes of age, have pushed age-related risks and implications for cardiovascular care to the forefront. In this JACC state-of-the-art review, the authors provide a comprehensive overview of the aging process as it relates to cardiovascular interventions, with special emphasis on the difference between chronological and biological aging. The authors also address key considerations to improve health outcomes for older patients during and after their invasive cardiovascular care. The role of "gerotherapeutics" in interventional cardiology, technological innovation in measuring biological aging, and the integration of patient-centered outcomes in the older adult population are also discussed.
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Affiliation(s)
- Abdulla A Damluji
- Inova Center of Outcomes Research, Fairfax, Virginia, USA; Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael G Nanna
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jennifer Rymer
- Duke University School of Medicine, Durham, North Carolina USA
| | - Ajar Kochar
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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7
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Del Portillo JH, Farjat-Pasos J, Galhardo A, Avvedimento M, Mas-Peiro S, Mengi S, Nuche J, Mohammadi S, Rodés-Cabau J. Aortic Stenosis With Coronary Artery Disease: SAVR or TAVR-When and How? Can J Cardiol 2024; 40:218-234. [PMID: 37758014 DOI: 10.1016/j.cjca.2023.09.023] [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: 07/17/2023] [Revised: 09/10/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023] Open
Abstract
The growing number of candidates for transcatheter aortic valve replacement (TAVR) has increased the interest in the concomitant presence of coronary artery disease (CAD) and severe aortic stenosis (AS), prompting the need to define the appropriate revascularization strategy for each case. The reported prevalence of concurrent AS and CAD has varied over the years on the basis of the CAD definition and the population evaluated. Revascularization for treating CAD in patients with severe AS involves additional interventions that could impact outcomes. The addition of coronary artery bypass grafting (CABG) to surgical aortic valve replacement (SAVR) has demonstrated favourable effects on long-term prognosis, while the impact of adding percutaneous coronary intervention (PCI) to TAVR may depend on the CAD complexity and the feasibility of achieving complete or reasonably incomplete revascularization. Furthermore, the comparison between SAVR+CABG and TAVR+PCI in low-intermediate surgical risk and low-intermediate complex CAD patients did not reveal differences in all-cause mortality or stroke between the groups. However, there is some evidence showing a lower incidence of major cardiovascular events with the SAVR+CABG strategy for patients with complex CAD. Thus, SAVR+CABG seems to be the best option for patients with low-intermediate surgical risk and complex CAD, and TAVR+PCI for high surgical risk patients seeking complete and/or reasonable incomplete revascularization. After deciding between TAVR+PCI or SAVR+CABG, factors such as timing for PCI, low ejection fraction, coronary reaccess, and valve durability must be considered. Finally, alternative methods for assessing CAD severity are currently under evaluation to ascertain their real value for guiding revascularization in patients with severe AS with CAD.
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Affiliation(s)
| | - Julio Farjat-Pasos
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Attilio Galhardo
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Marisa Avvedimento
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Silvia Mas-Peiro
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Siddhartha Mengi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Jorge Nuche
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Siamak Mohammadi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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8
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Aarts HM, van Hemert ND, Meijs TA, van Nieuwkerk AC, Berg JMT, Wykrzykowska JJ, van Royen N, Schotborgh CE, Tonino PAL, IJsselmuiden A, Vossenberg TN, van Houwelingen GK, Slagboom T, Voskuil M, Delewi R. Percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis. Neth Heart J 2023; 31:489-499. [PMID: 37910336 PMCID: PMC10667197 DOI: 10.1007/s12471-023-01824-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2023] [Indexed: 11/03/2023] Open
Abstract
OBJECTIVE The importance of revascularisation of significant coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) is unclear. Despite the lack of randomised controlled trials comparing different revascularisation strategies, guidelines currently recommend percutaneous coronary intervention (PCI) in patients with significant proximal CAD undergoing TAVI. METHODS In this systematic review and meta-analysis, a systematic search was conducted to identify studies comparing TAVI with and without PCI in patients with significant CAD on pre-TAVI coronary angiography. Endpoints were all-cause mortality, cardiac death, stroke, myocardial infarction and major bleeding. RESULTS In total, 14 studies were included, involving 3838 patients, of whom 1806 (47%) underwent PCI before TAVI. All-cause mortality did not differ significantly between TAVI with and without preceding PCI at 30 days, 1 year and > 1 year. There were no significant differences in risk of cardiac death, stroke or myocardial infarction between the groups. However, TAVI performed with PCI resulted in a higher risk of major bleeding within 30 days after TAVI (odds ratio: 0.66; 95% confidence interval: 0.46-0.94). CONCLUSION This systematic review and meta-analysis showed no significant differences in clinical outcomes between patients with concomitant significant CAD who were treated with TAVI with and without preceding PCI at both short- and long-term follow-up. However, there was a higher risk of major bleeding at 30 days in patients undergoing TAVI with preceding PCI. In the context of serious risk of bias in the included studies, results of randomised controlled trials are warranted.
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Affiliation(s)
- Hugo M Aarts
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Nicole D van Hemert
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Timion A Meijs
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Astrid C van Nieuwkerk
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Joanna J Wykrzykowska
- Department of Cardiology, Groningen University Medical Centre, University of Groningen, Groningen, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Pim A L Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Tessel N Vossenberg
- Department of Cardiology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Gert K van Houwelingen
- Department of Cardiology, Thorax Centre Twente, Medical Spectrum Twente, Enschede, The Netherlands
| | - Ton Slagboom
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands.
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9
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Sharma H, Afzal S, Leick J, Werner N, Doshi SN, Nadir MA. Antithrombotic therapy following transcatheter aortic valve intervention. Pharmacol Ther 2023; 250:108509. [PMID: 37572882 DOI: 10.1016/j.pharmthera.2023.108509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/27/2023] [Accepted: 08/08/2023] [Indexed: 08/14/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is increasingly being performed to treat symptomatic patients with aortic stenosis and annual procedure volume has overtaken surgical aortic valve replacement in the United States. However, current international guidelines were written prior to the publication of several important recent studies. Furthermore, European and American guidelines differ in their recommendations of antithrombotic therapy following TAVR. Consequently, there is a need to examine the literature to provide clinicians guidance on the optimum antithrombotic strategy, particularly as different patient populations exist. In this review, we examine the data for antiplatelet and anticoagulation therapy post-TAVR.
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Affiliation(s)
- Harish Sharma
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Shazia Afzal
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Jürgen Leick
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Nikos Werner
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Sagar N Doshi
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - M Adnan Nadir
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK.
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10
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Demola P, Colaiori I, Bosi D, Musto D’Amore S, Vitolo M, Benatti G, Vignali L, Tadonio I, Gabbieri D, Losi L, Magnavacchi P, Sgura FA, Boriani G, Guiducci V. Quantitative flow ratio-based outcomes in patients undergoing transcatheter aortic valve implantation quaestio study. Front Cardiovasc Med 2023; 10:1188644. [PMID: 37711555 PMCID: PMC10499393 DOI: 10.3389/fcvm.2023.1188644] [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: 03/17/2023] [Accepted: 08/14/2023] [Indexed: 09/16/2023] Open
Abstract
Background Coronary artery disease (CAD) is common in patients with aortic valve stenosis (AS) ranging from 60% to 80%. The clinical and prognostic role of coronary artery lesions in patients undergoing Transcatheter Aortic Valve Implantation (TAVI) remains unclear. The aim of the present observational study was to estimate long-term clinical outcomes by Quantitative Flow Ratio (QFR) characterization of CAD in a well-represented cohort of patients affected by severe AS treated by TAVI. Methods A total of 439 invasive coronary angiographies of patients deemed eligible for TAVI by local Heart Teams with symptomatic severe AS were retrospectively screened for QFR analysis. The primary endpoint of the study was all-cause mortality. The secondary endpoint was a composite of cardiovascular mortality, stroke/transient ischemic attack (TIA), acute myocardial infarction (AMI), and any hospitalization after TAVI. Results After exclusion of patients with no follow-up data, coronary angiography not feasible for QFR analysis and previous surgical myocardial revascularization (CABG) 48/239 (20.1%) patients had a QFR value lower or equal to 0.80 (QFR + value), while the remaining 191/239 (79.9%) did not present any vessel with a QFR positive value. In the adjusted Cox regression analysis, patients with positive QFR were independently associated with an increased risk of all-casual mortality (Model 1, HR 3.47, 95% CI, 2.35-5.12; Model 2, HR 5.01, 95% CI, 3.17-7.90). In the adjusted covariate analysis, QFR+ involving LAD (37/48, 77,1%) was associated with the higher risk of the composite outcome compared to patients without any positive value of QFR or non-LAD QFR positive value (11/48, 22.9%). Conclusions Pre-TAVI QFR analysis can be used for a safe, simple, wireless functional assessment of CAD. QFR permits to identify patients at high risk of cardiovascular mortality or MACE, and it could be considered by local Heart Teams.
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Affiliation(s)
- Pierluigi Demola
- Cardiology Unit, Azienda USL—IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Iginio Colaiori
- Cardiology Unit, Azienda USL—IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Davide Bosi
- Cardiology Unit, Azienda USL—IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Giorgio Benatti
- Cardiology Department, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Luigi Vignali
- Cardiology Department, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Iacopo Tadonio
- Cardiology Department, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | | | - Luciano Losi
- U.O. Cardiologia, Ospedale “Guglielmo da Saliceto”, Piacenza, Italy
| | | | - Fabio Alfredo Sgura
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Vincenzo Guiducci
- Cardiology Unit, Azienda USL—IRCCS di Reggio Emilia, Reggio Emilia, Italy
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11
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Kondoleon NP, Layoun H, Spilias N, Sipko J, Kanaan C, Harb S, Reed G, Puri R, Yun J, Krishnaswamy A, Kapadia SR. Effectiveness of Pre-TAVR CTA as a Screening Tool for Significant CAD Before TAVR. JACC Cardiovasc Interv 2023; 16:1990-2000. [PMID: 37648347 DOI: 10.1016/j.jcin.2023.05.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/10/2023] [Accepted: 05/16/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Computed tomography angiography (CTA) and invasive coronary angiography (ICA) are routinely performed before transcatheter aortic valve replacement (TAVR) to assess aortic root anatomy and screen for coronary artery disease (CAD), respectively. OBJECTIVES This study explored the efficacy of CTA as a screening tool for significant proximal CAD before TAVR. METHODS With proper ethical oversight, patients undergoing TAVR at Cleveland Clinic with a preprocedural CTA and invasive coronary angiography (ICA), and no prior percutaneous intervention, were identified from 2015 to 2021. Blinded to ICA results, the authors reviewed the left main, proximal left anterior descending coronary artery, proximal left circumflex coronary artery, and proximal right coronary artery by CTA coronary reconstruction to assess for nonsignificant stenosis (0% to 49%), moderate stenosis (50% to 69%), and severe stenosis (≥70%). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Cohen Kappa statistic were analyzed. RESULTS 2,217 patients (53.4% male, age 79.2 ± 8.5 years) met inclusion criteria. CTA evaluation revealed a sensitivity of 90%, specificity of 92%, PPV of 74%, and NPV of 97% for detecting ≥50% stenosis. Using a ≥70% stenosis cutoff, evaluation revealed a sensitivity of 91%, specificity of 97%, PPV of 83%, and NPV of 99%. Assessment of bypass graft patency revealed a sensitivity of 86%, specificity of 97%, PPV of 84%, and NPV of 98%. Cohen Kappa analysis indicated substantial to near perfect agreement between pre-TAVR CTA and ICA. CONCLUSIONS Pre-TAVR CTA has a high NPV for high-grade proximal stenosis of each coronary artery. As a result, CTA can be used as a screening tool to rule out significant proximal CAD in patients undergoing TAVR.
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Affiliation(s)
- Nicholas P Kondoleon
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA. https://twitter.com/npkondo
| | - Habib Layoun
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nikolaos Spilias
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Joseph Sipko
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Christopher Kanaan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Serge Harb
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Grant Reed
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - James Yun
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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12
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Gherasie FA, Achim A. TAVR Interventions and Coronary Access: How to Prevent Coronary Occlusion. Life (Basel) 2023; 13:1605. [PMID: 37511980 PMCID: PMC10381891 DOI: 10.3390/life13071605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/06/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
Due to technological advancements during the past 20 years, transcatheter aortic valve replacements (TAVRs) have significantly improved the treatment of symptomatic and severe aortic stenosis, significantly improving patient outcomes. The continuous evolution of transcatheter valve models, refined imaging planning for enhanced accuracy, and the growing expertise of technicians have collectively contributed to increased safety and procedural success over time. These notable advancements have expanded the scope of TAVR to include patients with lower risk profiles as it has consistently demonstrated more favorable outcomes than surgical aortic valve replacement (SAVR). As the field progresses, coronary angiography is anticipated to become increasingly prevalent among patients who have previously undergone TAVR, particularly in younger cohorts. It is worth noting that aortic stenosis is often associated with coronary artery disease. While the task of re-accessing coronary artery access following TAVR is challenging, it is generally feasible. In the context of valve-in-valve procedures, several crucial factors must be carefully considered to optimize coronary re-access. To obtain successful coronary re-access, it is essential to align the prosthesis with the native coronary ostia. As part of preventive measures, strategies have been developed to safeguard against coronary obstruction during TAVR. One such approach involves placing wires and non-deployed coronary balloons or scaffolds inside an at-risk coronary artery, a procedure known as chimney stenting. Additionally, the bioprosthetic or native aortic scallops intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure offers an effective and safer alternative to prevent coronary artery obstructions. The key objective of our study was to evaluate the techniques and procedures employed to achieve commissural alignment in TAVR, as well as to assess the efficacy and measure the impact on coronary re-access in valve-in-valve procedures.
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Affiliation(s)
| | - Alexandru Achim
- Department of Cardiology, Medizinische Universitätsklinik, Kantonsspital Baselland, Rheinstrasse 26, 4410 Liestal, Switzerland
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13
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Huang B, Yan H, Li Y, Zhou Q, Abudoureyimu A, Cao G, Jiang H. Transcatheter Aortic Valve Replacement in Elderly Patients: Opportunities and Challenges. J Cardiovasc Dev Dis 2023; 10:279. [PMID: 37504535 PMCID: PMC10380827 DOI: 10.3390/jcdd10070279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023] Open
Abstract
Over the past two decades, the rapid evolution of transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe aortic stenosis (AS) in the elderly. The prevalence of comorbidities in elderly AS patients presents a considerable challenge to the effectiveness and prognosis of patients after TAVR. In this article, we aim to summarize some of the clinical aspects of the current use of TAVR in elderly patients and attempt to highlight the challenges and issues that need further consideration.
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Affiliation(s)
- Bing Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Hui Yan
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Yunyao Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Qiping Zhou
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Ayipali Abudoureyimu
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Guiqiu Cao
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
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14
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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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15
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Prandi FR, Niv Granot Y, Margonato D, Belli M, Illuminato F, Vinayak M, Barillà F, Romeo F, Tang GHL, Sharma S, Kini A, Lerakis S. Coronary Obstruction during Valve-in-Valve Transcatheter Aortic Valve Replacement: Pre-Procedural Risk Evaluation, Intra-Procedural Monitoring, and Follow-Up. J Cardiovasc Dev Dis 2023; 10:jcdd10050187. [PMID: 37233154 DOI: 10.3390/jcdd10050187] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/27/2023] Open
Abstract
Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is emerging as an effective treatment for patients with symptomatically failing bioprosthetic valves and a high prohibitive surgical risk; a longer life expectancy has led to a higher demand for these valve reinterventions due to the increased possibilities of outliving the bioprosthetic valve's durability. Coronary obstruction is the most feared complication of valve-in-valve (ViV) TAVR; it is a rare but life-threatening complication and occurs most frequently at the left coronary artery ostium. Accurate pre-procedural planning, mainly based on cardiac computed tomography, is crucial to determining the feasibility of a ViV TAVR and to assessing the anticipated risk of a coronary obstruction and the eventual need for coronary protection measures. Intraprocedurally, the aortic root and a selective coronary angiography are useful for evaluating the anatomic relationship between the aortic valve and coronary ostia; transesophageal echocardiographic real-time monitoring of the coronary flow with a color Doppler and pulsed-wave Doppler is a valuable tool that allows for a determination of real-time coronary patency and the detection of asymptomatic coronary obstructions. Because of the risk of developing a delayed coronary obstruction, the close postprocedural monitoring of patients at a high risk of developing coronary obstructions is advisable. CT simulations of ViV TAVR, 3D printing models, and fusion imaging represent the future directions that may help provide a personalized lifetime strategy and tailored approach for each patient, potentially minimizing complications and improving outcomes.
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Affiliation(s)
- Francesca Romana Prandi
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Division of Cardiology, Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Yoav Niv Granot
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Davide Margonato
- Cardiovascular Imaging Unit, San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Martina Belli
- Division of Cardiology, Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
- Cardiovascular Imaging Unit, San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Federica Illuminato
- Division of Cardiology, Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Manish Vinayak
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Francesco Barillà
- Division of Cardiology, Department of Systems Medicine, Tor Vergata University, 00133 Rome, Italy
| | - Francesco Romeo
- Faculty of Medicine, Unicamillus-Saint Camillus International University of Health and Medical Sciences, 00131 Rome, Italy
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Samin Sharma
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Annapoorna Kini
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Stamatios Lerakis
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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16
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Chen K, Davidson LJ, Sweis RN, Flaherty JD. Heart Attack After TAVR: Are We Taking It Seriously Enough? Am J Cardiol 2023; 196:102-103. [PMID: 37059609 DOI: 10.1016/j.amjcard.2023.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 04/16/2023]
Affiliation(s)
- Kelley Chen
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Laura J Davidson
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ranya N Sweis
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - James D Flaherty
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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17
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Abstract
Aortic stenosis (AS) is the most common valvular heart disorder in the elderly population. As a result of the shared pathophysiological processes, AS frequently coexists with coronary artery disease (CAD). These patients have traditionally been managed through surgical aortic valve replacement (SAVR) and coronary artery bypass grafting. However, increasing body of evidence supports transcatheter aortic valve implantation (TAVI) as an alternative treatment for severe AS across the spectrum of operative risk. This has created the potential for treating AS and concurrent CAD completely percutaneously. In this review we consider the evidence guiding the optimal management of patients with severe AS and CAD. While invasive coronary angiography plays a central role in detecting CAD in patients with AS undergoing surgery or TAVI, the benefits of complementary functional assessment of coronary stenosis in the context of AS have not been fully established. Although the indications for revascularisation of significant proximal CAD in SAVR patients have not recently changed, routine revascularisation of all significant CAD before TAVI in patients with minimal angina is not supported by the latest evidence. Several ongoing trials will provide new insights into physiology-guided revascularisation in TAVI recipients. The role of the heart team remains essential in this complex patient group, and if revascularisation is being considered careful evaluation of clinical, anatomical and procedural factors is essential for individualised decision-making.
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Affiliation(s)
- Vitaliy Androshchuk
- Rayne Institute, BHF Centre of Research Excellence, King's College London, St Thomas' Hospital, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Tiffany Patterson
- Rayne Institute, BHF Centre of Research Excellence, King's College London, St Thomas' Hospital, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Simon R Redwood
- Rayne Institute, BHF Centre of Research Excellence, King's College London, St Thomas' Hospital, Guy's and St Thomas' Hospitals NHS Trust, London, UK
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18
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Loizzi F, Burattini O, Cafaro A, Spione F, Salemme L, Cioppa A, Fimiani L, Rimmaudo F, Pignatelli A, Palmitessa C, Mancini G, Pucciarelli A, Bortone AS, Contegiacomo G, Tesorio T, Iacovelli F. Early acute kidney injury after transcatheter aortic valve implantation: predictive value of currently available risk scores. Hellenic J Cardiol 2022; 70:19-27. [PMID: 36581137 DOI: 10.1016/j.hjc.2022.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) is a frequent complication associated with adverse outcomes and mortality. Various scores have been developed to predict this complication in the coronary setting. However, none have ever been tested in a large TAVI population. This study aimed to evaluate the power of four different scores in predicting AKI after TAVI. METHODS Overall, 1535 consecutive TAVI patients from the observational multicentric "Magna Graecia" TAVI registry were included in the analysis. Of the study population, 235 (15.31%) developed AKI early. The Mehran, William Beaumont Hospital, CR4EATME3AD3, and ACEF scores were calculated retrospectively. RESULTS The patients who developed TAVI-related AKI had significantly higher absolute values of all risk scores than those who did not. The receiver-operating characteristic analysis also showed a significant correlation between these four scores and AKI, but without a significant difference among all of them (p value = 0.176). Nevertheless, based on their area under the curve values (≤0.604 for all), none had adequate diagnostic accuracy in predicting TAVI-related AKI. Importantly, multivariate analysis identified myocardial revascularization close to the TAVI procedure and implantation of self-expanding prostheses, as well as atrial fibrillation, low-osmolar contrast media administration, corrected contrast medium volume, and any transfusion (p value < 0.05 for all) as independent risk factors for AKI. CONCLUSIONS Although high values of current AKI risk scores are significantly associated with the development of this complication, these are not sufficiently accurate. Further studies are needed so that a TAVI-dedicated AKI risk score may be created.
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Affiliation(s)
- Francesco Loizzi
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, Bari, Italy; Division of Cardiology, "Cardiocentro Ticino" Institute, Lugano, Switzerland.
| | | | | | - Francesco Spione
- Cardiovascular Clinic Institute, Clìnic University Hospital, August Pi I Sunyer Biomedical Research Institute, Barcelona, Spain; Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy.
| | - Luigi Salemme
- Interventional Cardiology Service, "Montevergine" Clinic, GVM Care & Research, Mercogliano, Italy.
| | - Angelo Cioppa
- Interventional Cardiology Service, "Montevergine" Clinic, GVM Care & Research, Mercogliano, Italy.
| | - Luigi Fimiani
- Division of Cardiology, "Papardo" Hospital, Messina, Italy.
| | - Flavio Rimmaudo
- Division of Cardiology, "Vittorio Emanuele" Hospital, Gela, Italy.
| | | | - Chiara Palmitessa
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, Bari, Italy.
| | - Giandomenico Mancini
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, Bari, Italy.
| | - Armando Pucciarelli
- Interventional Cardiology Service, "Montevergine" Clinic, GVM Care & Research, Mercogliano, Italy.
| | - Alessandro S Bortone
- Division of University Heart Surgery, Cardiothoracic Department, Policlinico University Hospital, Bari, Italy.
| | - Gaetano Contegiacomo
- Interventional Cardiology Service, "Anthea" Clinic, GVM Care & Research, Bari, Italy.
| | - Tullio Tesorio
- Interventional Cardiology Service, "Montevergine" Clinic, GVM Care & Research, Mercogliano, Italy.
| | - Fortunato Iacovelli
- Division of University Cardiology, Cardiothoracic Department, Policlinico University Hospital, Bari, Italy; Division of Cardiology, "SS. Annunziata" Hospital, Taranto, Italy.
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Clinical Outcomes of Revascularization with Percutaneous Coronary Intervention Prior to Transcatheter Aortic Valve Replacement: A Comprehensive Meta-Analysis. Curr Probl Cardiol 2022; 47:101339. [PMID: 35908687 DOI: 10.1016/j.cpcardiol.2022.101339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Prior studies on revascularization prior to transcatheter aortic valve replacement (TAVR), in patients with significant coronary artery disease (CAD), have reported mixed results. AIM We sought to perform a meta-analysis combining current evidence by investigating outcomes of revascularization in patients who undergo TAVR with coexisting CAD. METHODS We searched literature for studies reporting on outcomes following TAVR performed with versus without pre-TAVR PCI, for coexisting CAD. Random-effect model was used to pool estimates of odds ratios (ORs). RESULTS Twenty-four reports with 12,182 TAVR patients were included: 22 observational and 2 clinical trials. 4,110 (33.7%) were in the pre-TAVR PCI group, 51.4% were females, and mean age was 81.9 years. The 30-day mortality was 5.2% versus 5.0% in patients with versus without pre-TAVR PCI, respectively [OR= 1.19 (95% CI: 0.91-1.55, p= 0.20)]. Pooled 1-year mortality was 18.1% versus 19.1% in patients with versus without pre-TAVR PCI (OR= 1.12, 95% CI: 0.95-1.31, p= 0.61). There was no significant difference between the groups for myocardial infarction, stroke, acute kidney injury, pacemaker implantation, or rehospitalization. Pre-TAVR PCI was associated with increased risk of life-threatening bleeding at 30 days. CONCLUSION Pre-TAVR revascularization with PCI was not associated with improved 30-day or 1-year mortality; however, it was associated with increased risk of life-threatening bleeding at 30-day post-TAVR. Our results do not support routine revascularization with PCI prior to TAVR with coexisting CAD. Future trials addressing anatomical complexity and symptom burden may help better risk stratify patients who may benefit with pre-TAVR revascularization.
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Update on Minimalist TAVR Care Pathways: Approaches to Care in 2022. Curr Cardiol Rep 2022; 24:1179-1187. [PMID: 35767177 PMCID: PMC9244066 DOI: 10.1007/s11886-022-01737-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2022] [Indexed: 11/20/2022]
Abstract
Purpose of Review This review summarizes current data supporting a minimalist TAVR approach and identifies the need for additional study to optimize TAVR care. The authors discuss future directions of the TAVR landscape and how this necessitates evolution of minimalist care pathways. Recent Findings Transcatheter aortic valve replacement (TAVR) has become a mainstay in the treatment of aortic stenosis since the initial procedure in 2002. Recently, attention has shifted to TAVR optimization and the minimalist approach with a focus on minimizing procedural sedation, protocolization of perioperative management, and prioritization on early discharge. This approach has been shown to be safe and reduce procedure time, length of stay, and overall cost for hospital systems. Summary The minimalist care pathway avoids general anesthesia, shortens procedure time and length of stay, and reduces cost without changing mortality or readmission rates at 30 days. A variety of protocols have been proposed without a clear consensus on specific components or patient eligibility. There is a continued need for data regarding patient risk stratification, valve selection, and discharge strategy as TAVR becomes increasingly common.
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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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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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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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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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Clinical Impact of Pre-Procedural Percutaneous Coronary Intervention in Low- and Intermediate-Risk Transcatheter Aortic Valve Replacement Recipients. J Pers Med 2021; 11:jpm11070633. [PMID: 34357100 PMCID: PMC8304453 DOI: 10.3390/jpm11070633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 12/02/2022] Open
Abstract
The clinical relevance of as well as the optimal treatment strategy for coronary artery disease (CAD) in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS) are unclear. Current data are conflicting, and mainly derived from high-risk patients. We aimed to investigate the feasibility and safety of complete revascularization prior to TAVR for severe AS in low- and intermediate-risk patients. We enrolled 449 patients at low (STS score < 4%) and intermediate risk (STS score 4–8%) undergoing TAVR for severe AS and investigated the influence of recent (<3 months) and prior (>3 months) complete revascularization on clinical outcome. Primary study endpoint was all-cause mortality. Overall, 58% of patients had no or non-significant CAD; 18% had a history of complete revascularization prior to TAVR and 24% had complete revascularization shortly before TAVR. Two-year all-cause mortality was not different between patients with recent revascularization prior to TAVR and patients with no or non-significant CAD (13.7% vs. 14.2%, p = 0.905). Cox regression did not reveal an effect on all-cause mortality for recent revascularization. The present analysis reassures that percutaneous complete revascularization prior to TAVR procedures is neutral in terms of all-cause mortality in patients at low and intermediate surgical risk.
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Rahman F, Resar JR. TAVI Beyond 3 Years: Durability and Predictors for Survival. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:417-425. [PMID: 34182824 DOI: 10.1177/15569845211017558] [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: 11/16/2022]
Abstract
The use of transcatheter aortic valve implantation (TAVI) has greatly increased over the past 2 decades and now has overtaken surgical aortic valve replacement. We have limited data regarding the long-term durability of TAVI and the predictors of survival. Calcification, inflammation, fibrous tissue deposition, and mechanical stress are important in the structural deterioration of surgical bioprosthetic valves and likely contribute to TAVI durability. However, TAVI has several differences to surgical valve replacement such as valve preparation, valve to native anatomy interaction, and valve sizing which all likely contribute to durability and long-term survival. Most procedures have been performed on older patients and therefore long-term follow-up studies have noted mortality of approximately 50% at 5 years and 75% by 7 years. Current data are limited by the high mortality of patients who have received TAVI often as a result of age, frailty, and other competing comorbidities. TAVI as compared with surgical valve replacement is associated with several differences including higher conduction abnormalities (i.e., need for pacemakers) and paravalvular leak, both of which may affect long-term morbidity and mortality. In this review, we discuss the current status of our knowledge and identify areas that require further investigation.
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Affiliation(s)
- Faisal Rahman
- 1501 Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jon R Resar
- 1501 Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Variation of computed tomographic angiography-based fractional flow reserve after transcatheter aortic valve implantation. Eur Radiol 2021; 31:6220-6229. [PMID: 34156556 DOI: 10.1007/s00330-021-08099-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/19/2021] [Accepted: 05/26/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVES We sought to identify the impact of transcatheter aortic valve implantation (TAVI) on changes of fractional flow reserve computed tomography (FFRCT) values and the associated clinical impact. METHODS A retrospective analysis was done with CT obtained pre-TAVI, prior to hospital discharge and at 1-year follow-up, which provided imaging sources for the calculation of FFRCT values based on an online platform. RESULTS A total of 190 patients were enrolled. Patients with pre-procedural FFRCT value > 0.80 (i.e., negative) and ≤ 0.80 (i.e., positive) demonstrated a significantly opposite change in the value after TAVI (0.8798 vs. 0.8718, p < 0.001 and 0.7634 vs. 0.8222, p < 0.001, respectively). The history of coronary artery disease (CAD) was identified as an independent predictor for FFRCT changing from negative to positive after TAVI (odds ratio [OR] 2.927, 95% confidence interval [CI] 1.130-7.587, p = 0.027), with lesions more severely stenosed (OR 1.039, 95% CI 1.003-1.076, p = 0.034) and in left anterior descending coronary artery (LAD) (OR 3.939, 95% CI 1.060-14.637, p = 0.041) being prone to change. CONCLUSIONS TAVI directly brings improvement in FFRCT values in patients with compromised coronary flow. Patients with a history of CAD, especially with lesions more severely stenosed and in LAD, were under risk of FFRCT changing from negative to positive after TAVI. KEY POINTS •The effect of TAVI on coronary hemodynamics might be influenced by different ischemic severity and coronary territories reflected by FFRCT values. •As different FFRCT variations did not impact outcomes of TAVI patients, AS, but not coronary issues, may be the primary problem to affect, which needs further validation.
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Shroff GR, Bangalore S, Bhave NM, Chang TI, Garcia S, Mathew RO, Rangaswami J, Ternacle J, Thourani VH, Pibarot P. Evaluation and Management of Aortic Stenosis in Chronic Kidney Disease: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e1088-e1114. [PMID: 33980041 DOI: 10.1161/cir.0000000000000979] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aortic stenosis with concomitant chronic kidney disease (CKD) represents a clinical challenge. Aortic stenosis is more prevalent and progresses more rapidly and unpredictably in CKD, and the presence of CKD is associated with worse short-term and long-term outcomes after aortic valve replacement. Because patients with advanced CKD and end-stage kidney disease have been excluded from randomized trials, clinicians need to make complex management decisions in this population that are based on retrospective and observational evidence. This statement summarizes the epidemiological and pathophysiological characteristics of aortic stenosis in the context of CKD, evaluates the nuances and prognostic information provided by noninvasive cardiovascular imaging with echocardiography and advanced imaging techniques, and outlines the special risks in this population. Furthermore, this statement provides a critical review of the existing literature pertaining to clinical outcomes of surgical versus transcatheter aortic valve replacement in this high-risk population to help guide clinical decision making in the choice of aortic valve replacement and specific prosthesis. Finally, this statement provides an approach to the perioperative management of these patients, with special attention to a multidisciplinary heart-kidney collaborative team-based approach.
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Dagan M, Dawson LP, Stehli J, Koh JQS, Quine E, Stub D, Htun NM, Walton A, Duffy SJ. Periprocedural myocardial injury and coronary artery disease in patients undergoing transcatheter aortic valve replacement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 35:8-15. [PMID: 33863658 DOI: 10.1016/j.carrev.2021.04.006] [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: 01/07/2021] [Revised: 03/22/2021] [Accepted: 04/06/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND/PURPOSE PPMI and CAD are common in patients undergoing TAVR. Despite several studies evaluating their interaction as well as the influence these factors play on outcomes, there remains no consensus. We sought to evaluate the impact of peri-procedural myocardial injury (PPMI) and incidental coronary artery disease (iCAD) on outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS/MATERIALS We analyzed prospective data from 400 patients undergoing TAVI for severe aortic stenosis between 2008 and 2018 to determine rates of PPMI (troponin 15× the upper limit of normal) and iCAD (≥50% stenosis) and their impact on long-term mortality. RESULTS Mean age was 83 ± 6 years; 45% were female. PPMI was observed in 65% (254/400). On multivariable logistic regression analysis, higher left ventricular ejection fraction (LVEF) (OR 1.04, 95%CI 1.01-1.06, p = 0.002), and first generation valves (OR 3.00, 95%CI 1.75-5.15, p < 0.001) were independently associated with PPMI, while oral anticoagulation was inversely associated (OR 0.48, 95%CI 0.28-0.82, p = 0.007). PPMI was not associated with 30-day, 1-year or long-term mortality. After excluding previous bypass grafting, iCAD was observed in 40% (129/324). In patients with iCAD, PCI was associated with reduced long-term mortality compared to medical management in adjusted analysis (OR 0.37, 95%CI 0.16-0.88, p = 0.03). CONCLUSIONS PPMI and iCAD in patients undergoing TAVR are common. PPMI is associated with older generation valves and higher LVEF rather than traditional cardiovascular risk factors. In our study, PPMI was not associated with long-term mortality. However, in patients with iCAD, PCI was associated with reduced long-term mortality compared to medical management.
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Affiliation(s)
- Misha Dagan
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | - Luke P Dawson
- Department of Cardiology, Royal Melbourne Hospital, Victoria, Australia
| | - Julia Stehli
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | | | - Edward Quine
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Hospital, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Nay M Htun
- Department of Cardiology, Alfred Hospital, Victoria, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Hospital, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Hospital, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
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Impact of Coronary Artery Disease and Percutaneous Coronary Intervention on Transcatheter Aortic Valve Implantation. J Interv Cardiol 2021; 2021:6672400. [PMID: 33824628 PMCID: PMC8016584 DOI: 10.1155/2021/6672400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/07/2021] [Accepted: 03/16/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction The prevalence of coronary artery disease (CAD) detected in preoperative work-up for transcatheter aortic valve implantation (TAVI) is high. Instead, the management of a concomitant CAD remains unclear. We evaluate the impact of CAD and percutaneous coronary intervention (PCI) on TAVI procedures. Materials and Methods A retrospective study was conducted on 1336 consecutive patients who underwent TAVI in Toulouse University Hospital, Rangueil, France. The studied population was divided into 2 groups: CAD-TAVI group and No CAD-TAVI group. Then, the CAD-TAVI group was segregated into 2 subgroups: PCI-TAVI group and No PCI-TAVI group. In-hospital adverse clinical outcomes were assessed in each group. Results Pre-TAVI work-up revealed significant CAD in 36% of 1030 patients eligible for inclusion in the study. The overall prevalence of in-hospital death, stroke, major or life-threatening bleeding, minor bleeding, major vascular complications, minor vascular complications, pacemaker implantation, and acute kidney injury was 2.7%, 2.4%, 2.8%, 3.6%, 3.9%, 7.5%, 12.5%, and 2.7%, respectively. Among the studied population, 55% were admitted to the cardiac care unit. No significant statistical difference was observed between groups. Discussion. CAD-TAVI population was not more likely to develop in-hospital adverse clinical outcomes post-TAVI procedure compared to others. Also, no significant difference regarding in-hospital death was observed. In parallel, performing PCI prior to TAVI did not increase the risk of in-hospital death and complications. The difference in terms of the distribution of antithrombotic regimen may explain the higher prevalence of bleeding events in the PCI-TAVI group. Conclusion This study provides direct clinical relevance useful in daily practice. No negative impact has been attributed to the presence of a concomitant CAD and/or preoperative PCI on the TAVI hospitalization period.
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Grines CL, Tummala PE. Coronary Revascularization Before Transcatheter Aortic Valve Replacement: It Is Safe, But Is It Necessary? JACC Cardiovasc Interv 2020; 13:2614-2616. [PMID: 33069646 DOI: 10.1016/j.jcin.2020.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Cindy L Grines
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia.
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32
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Gupta H, Kaur N, Sharma Y, Barwad P. ROTAVI: simultaneous left main rotablation and transcutaneous aortic valve implantation in calcified coronaries and severe aortic stenosis - a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-5. [PMID: 33204950 PMCID: PMC7649449 DOI: 10.1093/ehjcr/ytaa196] [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: 03/24/2020] [Revised: 04/16/2020] [Accepted: 06/09/2020] [Indexed: 11/30/2022]
Abstract
Background There is a high incidence of calcified coronary artery disease in patients with severe valvular aortic stenosis (AS). With transcutaneous aortic valve replacement (TAVR) as one of the promising options for severe AS in high and intermediate surgical risk patients; we will encounter more and more patients who will require both complex percutaneous coronary intervention (PCI) with rotablation (RA) and TAVR. The timing of PCI in patients undergoing TAVR; however remains indecisive. Due to the complexity of procedures and the risks involved, very few cases of concomitant TAVR and coronary RA have been reported so far. Case summary Seventy-five years old high surgical risk female had severe AS with calcified left main (LM) distal and ostial left anterior descending (LAD) artery lesion. Successful PCI with RA to LM-LAD lesion was done followed by uneventful transfemoral TAVR in the same setting. Discussion This is probably one of the very few cases reported where PCI to LM with RA and TAVR was done successfully in the same setting. Since the calcified lesion was focal and left ventricular ejection fraction of the patient was normal, we went ahead with PCI without prior balloon dilatation of aortic valve (BAV) which was a deviation from the prior reported cases, where BAV was performed prior to complex PCI to improve the cardiac output. We herein discuss our case and thoughts about concomitant complex PCI and TAVR.
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Affiliation(s)
- Himanshu Gupta
- Department of Cardiology, PGIMER, Chandigarh 160012, India
| | - Navjyot Kaur
- Department of Cardiology, PGIMER, Chandigarh 160012, India
| | | | - Parag Barwad
- Department of Cardiology, PGIMER, Chandigarh 160012, India
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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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Faroux L, Campelo-Parada F, Munoz-Garcia E, Nombela-Franco L, Fischer Q, Donaint P, Serra V, Veiga G, Gutiérrez E, Vilalta V, Alperi A, Regueiro A, Asmarats L, Ribeiro HB, Matta A, Munoz-Garcia A, Armijo G, Urena M, Metz D, Rodenas-Alesina E, de la Torre Hernandez JM, Fernandez-Nofrerias E, Pascual I, Perez-Fuentes P, Arzamendi D, Campanha-Borges DC, Del Val D, Couture T, Rodés-Cabau J. Procedural Characteristics and Late Outcomes of Percutaneous Coronary Intervention in the Workup Pre-TAVR. JACC Cardiovasc Interv 2020; 13:2601-2613. [PMID: 33069647 DOI: 10.1016/j.jcin.2020.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/23/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study sought to determine, in patients undergoing percutaneous coronary intervention (PCI) during the work-up pre-transcatheter aortic valve replacement (TAVR): 1) the clinical and peri-procedural PCI characteristics; 2) the long-term outcomes; and 3) the clinical events in those patients with complex coronary features. BACKGROUND A PCI is performed in about 25% of TAVR candidates, but procedural features and late outcomes of pre-TAVR PCI remain largely unknown. METHODS Multicenter study including 1197 consecutive patients who had PCI in the work-up pre-TAVR. A total of 1,705 lesions (1.5 ± 0.7 lesions per patient) were included. Death, stroke, myocardial infarction, and major adverse cardiovascular and cerebrovascular events (MACCE) were recorded, as well as target lesion failure (TLF) and target vessel failure (TVF). RESULTS One-half of patients exhibited a multivessel disease and the mean SYNTAX (SYNergy between PCI with TAXUS and Cardiac Surgery) score was 12.1 ± 9.1. The lesions were of B2/C type, calcified, bifurcation, and ostial in 49.9%, 45.8%, 21.4%, and 19.3% of cases, respectively. After a median follow-up of 2 (interquartile range: 1 to 3) years, a total of 444 (37.1%) patients presented an MACCE. Forty patients exhibited TVF (3.3%), with TLF identified in 32 (2.7%) patients. By multivariable analysis, previous peripheral artery disease (p < 0.001), chronic obstructive pulmonary disease (p = 0.002), atrial fibrillation (p = 0.003), diabetes mellitus (p = 0.012), and incomplete revascularization (p = 0.014) determined an increased risk of MACCE. In patients with unprotected left main or SYNTAX score >32 (n = 128), TLF, TVF, and MACCE rates were 3.9%, 6.3%, and 35.9%, respectively (p = 0.378; p = 0.065, and p = 0.847, respectively, vs. the rest of the population). CONCLUSIONS Patients undergoing PCI in the work-up pre-TAVR frequently exhibited complex coronary lesions and multivessel disease. PCI was successful in most cases, and TLF and TVF rates at 2-year follow-up were low, also among patients with high-risk coronary features. However, overall MACCE occurred in about one-third of patients, with incomplete revascularization determining an increased risk. These results should inform future studies to better determine the optimal revascularization strategy pre-TAVR.
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Affiliation(s)
- Laurent Faroux
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Erika Munoz-Garcia
- Cardiology Department, Hospital Universitario Virgen de la Victoria, Malaga, Spain
| | - Luis Nombela-Franco
- Cardiology Department, Instituto Cardiovascular, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Quentin Fischer
- Cardiology Department, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pierre Donaint
- Cardiology Department, Reims University Hospital, Reims, France
| | - Vicenç Serra
- Cardiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Gabriela Veiga
- Cardiology Department, Hospital Marques de Valdecilla, Santander, Spain
| | | | - Victoria Vilalta
- Cardiology Department, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Alberto Alperi
- Cardiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Ander Regueiro
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Lluis Asmarats
- Cardiology Department, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Henrique B Ribeiro
- Cardiology Department, Heart Institute, University of São Paulo, São Paulo, Brazil
| | - Anthony Matta
- Cardiology Department, Hôpital Universitaire de Toulouse, Toulouse, France
| | - Antonio Munoz-Garcia
- Cardiology Department, Hospital Universitario Virgen de la Victoria, Malaga, Spain
| | - German Armijo
- Cardiology Department, Instituto Cardiovascular, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Marina Urena
- Cardiology Department, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Damien Metz
- Cardiology Department, Reims University Hospital, Reims, France
| | | | | | | | - Isaac Pascual
- Cardiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Pedro Perez-Fuentes
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Dabit Arzamendi
- Cardiology Department, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | | | - David Del Val
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Thomas Couture
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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Assessment and management of coronary artery disease in patients undergoing transcatheter aortic valve replacement. Curr Opin Cardiol 2020; 35:540-547. [PMID: 32649355 DOI: 10.1097/hco.0000000000000768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW Coronary artery disease (CAD) is commonly observed in patients undergoing transcatheter aortic valve replacement (TAVR). Significant variability exists across institutions for strategies used for CAD diagnosis and its management. The heart team often relies upon traditional practice patterns and the decision for revascularization by percutaneous coronary intervention (PCI) is influenced by patient, angiographic, operator, and system-related factors. RECENT FINDINGS Contemporary coronary tomography angiography (CTA) shows significant promise for detection of clinically important CAD and preliminary data support CTA use for TAVR patients. The prognostic implications of CAD in a TAVR population remain unclear with studies showing conflicting data for the benefits of PCI. Recent trials show that medical management is an effective initial treatment strategy for stable CAD, a finding likely also applicable for asymptomatic and stable TAVR patients. In addition, PCI performed pre-TAVR, concomitant with TAVR or after TAVR has been shown to produce similar outcomes. Dual antiplatelet therapy (DAPT) is mandated after PCI but associated with increased risk of bleeding in TAVR population with accumulating evidence for single antiplatelet therapy (SAPT) post-TAVR unless DAPT or anticoagulation is indicated for another reason. SUMMARY Although coronary angiography remains the predominant modality for CAD assessment, CTA is increasingly being used in TAVR patients. There is limited evidence to guide CAD management in TAVR patients with significant variability in practice patterns. Medical therapy is recommended for asymptomatic and stable CAD patients with applicability for TAVR population. Despite prior concerns, recent studies suggest successful coronary access post-TAVR and similar outcomes for PCI offered pre-TAVR, concomitant with TAVR and post-TAVR settings. Safety of DAPT should be an important consideration for PCI in TAVR patients. Ongoing studies will determine the preferred testing for CAD diagnosis, benefit of revascularization, timing of PCI, and optimum antithrombotic therapy for TAVR populations.
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Katta N, Abbott JD, Kalra A, Alenezi F, Goldsweig A, Aronow H, Velagapudi P. Management of Coronary Artery Disease in the Setting of Transcatheter Aortic Valve Replacement. Heart Int 2020; 14:24-28. [PMID: 36277671 PMCID: PMC9524713 DOI: 10.17925/hi.2020.14.1.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 03/06/2020] [Indexed: 07/21/2023] Open
Abstract
Aortic stenosis and coronary artery disease (CAD) frequently co-exist, as they share a common pathophysiology and risk factors. Due to lack of randomised controlled trials (RCTs) and exclusion of significant CAD in transcatheter aortic valve replacement (TAVR) trials, the optimal method of revascularisation of CAD in patients undergoing TAVR remains unknown. Observational studies and meta-analyses have shown varied results in outcomes for patients with CAD undergoing TAVR, and no significant difference in post-TAVR outcomes in patients who underwent revascularisation either prior to or during TAVR versus those who did not. However, some observational studies have shown that patients with lower residual SYNTAX score (rSS) post-revascularisation have better outcomes post-TAVR compared to those with higher rSS. RCTs are needed to clearly understand whether revascularisation is beneficial in these patients. Until then, management of CAD in patients undergoing TAVR must be individualised based on discussion with the heart team.
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Affiliation(s)
- Natraj Katta
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Ankur Kalra
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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Zelis JM, Tonino PAL, Johnson NP. Why Can Fractional Flow Reserve Decrease After Transcatheter Aortic Valve Implantation? J Am Heart Assoc 2020; 9:e04905. [PMID: 32102613 PMCID: PMC7335563 DOI: 10.1161/jaha.120.015806] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jo M Zelis
- Department of Cardiology Catharina Hospital Eindhoven Netherlands
| | - Pim A L Tonino
- Department of Cardiology Catharina Hospital Eindhoven Netherlands
| | - Nils P Johnson
- Division of Cardiology Department of Medicine Weatherhead PET Center McGovern Medical School at UTHealth and Memorial Hermann Hospital Houston TX
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