1
|
Caetano L, Gibicoski TB, Rodriguez F, Scabello I, da Silva Neto EP, Iplinski B. Impact of carotid artery stenosis on outcomes of transcatheter aortic valve replacement: A systematic review and meta-analysis. Int J Cardiol 2024; 399:131670. [PMID: 38141726 DOI: 10.1016/j.ijcard.2023.131670] [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: 06/26/2023] [Revised: 12/03/2023] [Accepted: 12/18/2023] [Indexed: 12/25/2023]
Abstract
INTRODUCTION Carotid Artery Stenosis (CAS) is common in elderly patients undergoing Transcatheter Aortic Valve Replacement (TAVR). However, the impact of CAS on the outcomes of TAVR is unclear. PURPOSE This systematic review and meta-analysis aimed to compare the clinical and periprocedural outcomes in patients with and without CAS undergoing TAVR. METHODS PubMed, Embase, and Cochrane databases were searched until February 2023. We included studies that performed a direct comparison of outcomes of TAVR in CAS versus non-CAS patients. Data was extracted from published reports and the ROBINS-I tool was utilized for quality assessment. The R studio software (version 4.2.2) was adopted for statistical analysis. RESULTS Five observational studies and 111.915 patients were included. The mean age was 80.7 ± 8.2 years and 46.3% were female. The risk of stroke or transient ischemic attack was elevated in the group of patients with CAS (OR 1.44; 95% CI 1.07-1.95; p = 0.016). In contrast, myocardial infarction (OR 1.24; 95% CI 1.05-1.47; p = 0.074) and all-cause mortality (OR 0.99; 95% CI 0.73-1.35; p = 0.95) were not significantly different between CAS and non-CAS groups. Acute kidney injury and new pacemaker implantation did not differ between patients with and without CAS. CONCLUSIONS Our findings suggest that CAS is significantly associated with cerebrovascular events in patients undergoing TAVR, without significantly impacting all-cause mortality. Further prospective studies are needed for a more granular assessment of additional determinants of this association, such as unilateral vs. bilateral involvement and whether there is a threshold of CAS severity for increased risk.
Collapse
Affiliation(s)
- Lucas Caetano
- Department of Medicine, Federal University of Paraiba, Joao Pessoa, Brazil.
| | | | | | | | | | | |
Collapse
|
2
|
Vella A, Roux O, Antiochos P, Monney P, Maurizi N, Skalidis I, Fournier S, Eeckhout E, Roguelov C, Oestreicher S, Kirsch M, Muller O, Lu H. Meta-Analysis of the Prognostic Significance of Carotid Artery Stenosis in Patients Who Underwent Transcatheter Aortic Valve Implantation. Am J Cardiol 2023; 200:225-231. [PMID: 37355356 DOI: 10.1016/j.amjcard.2023.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/10/2023] [Accepted: 04/18/2023] [Indexed: 06/26/2023]
Abstract
Stroke is a known complication of both transcatheter aortic valve implantation (TAVI) and carotid artery stenosis (CAS). Whether CAS is a predictor of worse prognosis after TAVI is unclear. We performed a meta-analysis to assess the impact of CAS on the incidence of neurovascular complications and mortality after TAVI. We searched PubMed/MEDLINE and EMBASE databases from inception to January 2023. CAS was defined by ≥50% stenosis of at least 1 carotid artery. Studies comparing CAS versus non-CAS TAVI populations were included. Patients' baseline characteristics and 30-day clinical outcomes were extracted. End points included the 30-day incidence of neurovascular complications (stroke or transient ischemic attack) and 30-day all-cause mortality. We identified six studies, totaling 6,763 patients in the CAS group and 23,861 patients in the non-CAS group. Patients with CAS had a higher prevalence of hypertension, diabetes mellitus, dyslipidemia, previous myocardial infarction, coronary artery bypass graft, peripheral artery disease, previous neurovascular disease, and chronic kidney disease. There was no significant difference in the rates of 30-day neurovascular complications between CAS and non-CAS groups (relative risk 1.23, 95% confidence interval 0.63 to 2.40, p = 0.54). CAS was associated with a higher risk of 30-day all-cause mortality (relative risk 1.28, 95% confidence interval 1.12 to 1.47, p <0.001), not found in a sensitivity analysis. In conclusion, patients with CAS presented with a significantly higher co-morbidity burden. CAS was not associated with an increased risk of 30-day neurovascular complications. 30-day mortality was higher in the CAS group but that may be a surrogate of the heavy co-morbidity burden of patients with CAS.
Collapse
Affiliation(s)
- Agnese Vella
- Service of Cardiology, Geneva University Hospital and University of Geneva, Geneva, Switzerland
| | - Olivier Roux
- HerzHirslanden Group, Herzzentrum im Park AG, Zurich, Switzerland
| | - Panagiotis Antiochos
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pierre Monney
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Niccolo Maurizi
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ioannis Skalidis
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Stephane Fournier
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eric Eeckhout
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christan Roguelov
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Simon Oestreicher
- Service of Internal Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Matthias Kirsch
- Service of Cardiovascular Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Olivier Muller
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Henri Lu
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| |
Collapse
|
3
|
Nates R, Arazi M, Grosman-Rimon L, Israel R, Gohari J, Sternik L, Kachel E. The routine use of preoperative non-contrast chest computerized tomography and carotid arteries Doppler prior to cardiac surgery. J Cardiothorac Surg 2022; 17:178. [PMID: 35871007 PMCID: PMC9308923 DOI: 10.1186/s13019-022-01927-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/09/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction There is no consensus as to which patients should undergo Non-Contrast Chest Computerized Tomography (NCCCT) and carotid arteries Doppler (CD) prior to cardiac surgery. The objective of this study was to examine whether preoperative imaging modalities provide clinical benefits and a change in surgical strategy. Methods We routinely performed NCCCT and CD in all non-urgent cardiac surgery patients. Major NCCCT/CD findings related to cardiovascular findings (aortic calcification/atherosclerosis, carotid artery plaque/stenosis), or other incidental findings (lung kidney, thyroid, adrenal, gastrointestinal sites etc.) were documented. The results were divided into 3 categories: (A) findings requiring both changes in surgical strategy and post-operative evaluation/treatment; (B) findings requiring changes in surgical strategy, but not requiring a specific post-operative evaluation/treatment; (C) findings not requiring changes in surgical strategy but requiring post-operative evaluation/treatment. Results In this cohort, 93 (18.6%) out of 500 patients had significant cardiac and extra-cardiac findings on NCCCT and/or CD. Among the 93 patients with significant findings, 33.33% (31 patients, 6.2% of all patients) were in group A, 7.5% (7 patients, 1.4% of all patients) were in group B, and 59.14% (55 patients, 11% of all patients) were in group C. Change in surgical strategies included, for example, switching from planned on-pump Coronary Artery Bypass Graft surgery (CABG) to off-pump CABG and performing additional procedures to the originally planned heart surgery. Conclusion Routine preoperative NCCCT and CD evaluation in all non-urgent cardiac surgical patients is an effective measure for uncovering cardiac and extra-cardiac findings prior to surgery.
Collapse
|
4
|
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.
Collapse
|
5
|
Prevalence and Prognostic Impact of Carotid Artery Disease in Patients Undergoing TAVI. Ann Vasc Surg 2022; 84:61-68. [PMID: 35341937 DOI: 10.1016/j.avsg.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the prevalence of atherosclerotic carotid artery disease (ACAD) in patients undergoing transcatheter aortic valve implantation (TAVI) and postoperative cerebrovascular and evaluate its prognostic impact on post-operative cerebrovascular incidents (CVA). METHODS Retrospective review of all consecutive patients with severe symptomatic aortic valve stenosis (AVS) who underwent TAVI at a single tertiary university hospital (January 2008-December 2018). Patients with AVS scheduled for TAVI and concomitant carotid stenosis were evaluated for prophylactic carotid revascularization (carotid endarterectomy, CEA or carotid artery stenting, CAS). RESULTS 771 consecutive patients (mean age 80 years, 52% males), were treated by TAVI procedures. Carotid stenosis >70% was detected in 69 patients (9%); it was unilateral in 47 (68%) and bilateral in 22 (32%). Prophylactic carotid revascularization was performed before TAVI in 45 patients (31%): in 63.1% of patients (30/47) with unilateral carotid stenosis >70%, and in 68.1% (15/22) with bilateral carotid stenosis >70%. Postoperative CVA following TAVI procedures were recorded in 25 patients (3.2%): 22 cases of stroke (2.8%) and 3 cases of transient ischemic attack (0.4%). At multiple logistic regression, only bilateral carotid stenosis >70% (OR 1.16, CI 95% 1.03-1.31; p=.0009) was found as independent predictors of periprocedural CVA. CONCLUSIONS In patients with severe symptomatic AVS undergoing TAVI, carotid stenosis was frequently observed. Unilateral carotid stenosis >70% did not show a significant association with early CVA following TAVI. However, in the cohort of patients with bilateral carotid stenosis >70%, a significant association with postoperative CVA was observed.
Collapse
|
6
|
Alkhouli M, Moussa I, Deshmukh A, Ammash NM, Klaas JP, Holmes DR. The Heart Brain Team and Patient-Centered Management of Ischemic Stroke. JACC. ADVANCES 2022; 1:100014. [PMID: 38939078 PMCID: PMC11198076 DOI: 10.1016/j.jacadv.2022.100014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/28/2022] [Accepted: 02/28/2022] [Indexed: 06/29/2024]
Abstract
The multifaceted connections between the heart and the brain have been extensively studied at the anatomy, pathophysiology, and clinical levels. Studies have suggested a vital role for both cardiologists and neurologists in the management of various cardiovascular and neurological disorders. However, a true heart-brain team-based approach remained confined to large, specialized centers. In this paper, we review the various intersection areas of cardiology and neurology with regard to ischemic stroke. We focus our discussion on the challenges and opportunity for a heart-team approach to stroke in the context of atrial fibrillation, carotid disease, and patent foramen ovale, and in the setting of strokes complicating transcatheter endovascular interventions.
Collapse
Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Issam Moussa
- Carle Illinois College of Medicine, University of Illinois, Carle Heart and Vascular Institute, Champaign, Illinois, USA
| | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nasser M. Ammash
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - James P. Klaas
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - David R. Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
7
|
Perpetua EM, Guibone KA, Keegan PA, Palmer R, Speight MK, Jagnic K, Michaels J, Nguyen RA, Pickett ES, Ramsey D, Schnell SJ, Wong SC, Reisman M. Best Practice Recommendations for Optimizing Care in Structural Heart Programs: Planning Efficient and Resource Leveraging Systems (PEARLS). STRUCTURAL HEART 2021; 5:168-179. [PMID: 35378800 PMCID: PMC8968322 DOI: 10.1080/24748706.2021.1877858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/11/2021] [Accepted: 09/26/2021] [Indexed: 11/24/2022]
Abstract
The COVID19 pandemic brought unprecedented disruption to healthcare. Staggering morbidity, mortality, and economic losses prompted the review and refinement of care for structural heart disease (SHD). To mitigate negative impacts in the face of crisis or capacity constraints, this paper offers best practice recommendations for Planning Efficient and Resource Leveraging Systems (PEARLS) in structural heart programs. A systematic assessment is recommended for hospital capacity, Heart Team roles and functions, and patient and procedural risks associated with increased resource utilization. Strategies, tactics, and pathways are provided for the delivery of patient-centered, efficient and resource-leveraging care from referral to follow-up. Through the optimal use of capacity and resources, paired with dynamic triage, forecasting, and surveillance, Heart Teams may aspire to plan and implement an optimized system of care for SHD. Abbreviations: AS: aortic stenosis; ASD: atrioseptal defect; COVID19: Coronavirus disease 19; LAAO: left atrial appendage occlusion; MI: myocardial infarction; MR: mitral regurgitation; PFO: patent foramen ovale; PVL: paravalvular leak; SHD: structural heart disease; SAVR: surgical aortic valve replacement; SDM: shared decision-making; TAVR: transcatheter aortic valve replacement; TMVr: transcatheter mitral valve repair; TMVR: transcatheter mitral valve replacement; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography.
Collapse
|
8
|
Commentary: Knowledge is key: We may have been looking in the wrong place. J Thorac Cardiovasc Surg 2020; 163:977-978. [PMID: 32680642 DOI: 10.1016/j.jtcvs.2020.06.010] [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: 05/29/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 11/22/2022]
|
9
|
Rossi PJ, Wood JC, Jim J. Concomitant transcarotid artery revascularization and transcatheter aortic valve replacement. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:205-208. [PMID: 32322777 PMCID: PMC7162957 DOI: 10.1016/j.jvscit.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 02/08/2020] [Indexed: 11/24/2022]
Abstract
Concomitant carotid artery disease and aortic valve disease is common. Whereas carotid stenosis does not appear to have an effect on outcomes of patients undergoing aortic valve replacement, the management of a patient with symptomatic carotid disease and severe aortic stenosis is challenging. The advent of minimally invasive endovascular techniques has provided less invasive and effective treatment options for these respective conditions. In this report, we describe two cases of patients successfully treated with concomitant transcatheter aortic valve replacement and transcarotid artery revascularization.
Collapse
Affiliation(s)
- Peter J Rossi
- Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, Wisc
| | - Jacob C Wood
- Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, Wisc
| | - Jeffrey Jim
- Section of Vascular Surgery, Washington University in St. Louis, St. Louis, Mo
| |
Collapse
|
10
|
Dzierwa K, Piatek J, Paluszek P, Przewlocki T, Tekieli L, Konstanty-Kalandyk J, Tomaszewski T, Drwila R, Trystula M, Musialek P, Pieniazek P. One-day, sequential carotid artery stenting followed by cardiac surgery in patients with severe carotid and cardiac disease. Vasc Med 2019; 24:431-438. [PMID: 31543030 DOI: 10.1177/1358863x19872547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Optimal management of patients with internal carotid artery (ICA) stenosis concurrent with severe cardiac disease remains undefined. The aim of this study is to evaluate the safety and feasibility of the one-day, sequential approach by carotid artery stenting (CAS) immediately followed by cardiac surgery. The study included 70 consecutive patients with symptomatic > 50% or ⩾ 80% asymptomatic ICA stenosis coexisting with severe coronary/valve disease, who underwent one-day, sequential CAS + cardiac surgery. The majority of patients (85.7%) had CSS class III or IV angina and 10% had non-ST elevation myocardial infarction. The EuroSCORE II risk was 2.4% (IQR 1.69-3.19%). All CAS procedures were performed according to the 'tailored' algorithm with a substantial use of proximal neuroprotection devices of 44.3%. Closed-cell (75.7%) and mesh-covered (18.6%) stents were implanted in most cases. The majority of patients underwent isolated coronary artery bypass grafting (88.6%) or isolated valve replacement (7.1%). No major adverse cardiac and cerebrovascular events (MACCE) occurred at the CAS stage. There were three (4.3%) perioperative MACCE: one myocardial infarction and two deaths. All MACCE were related to cardiac surgery and were due to the high surgical risk profile of the patients. Up to 30 days, no further MACCE were observed. No perioperative or 30-day neurological complications occurred. In this patient series, one-day, sequential CAS and cardiac surgery was relatively safe and did not result in neurological complications. Thus, a strategy of preoperative CAS could be considered for patients with severe or symptomatic ICA stenosis who require urgent cardiac surgery.
Collapse
Affiliation(s)
- Karolina Dzierwa
- Department of Invasive Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Jacek Piatek
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Piotr Paluszek
- Department of Vascular and Endovascular Surgery, John Paul II Hospital, Krakow, Poland
| | - Tadeusz Przewlocki
- Department of Invasive Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Lukasz Tekieli
- Department of Invasive Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Janusz Konstanty-Kalandyk
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | | | - Rafal Drwila
- Department of Intensive Therapy, John Paul II Hospital, Krakow, Poland
| | - Mariusz Trystula
- Department of Vascular and Endovascular Surgery, John Paul II Hospital, Krakow, Poland
| | - Piotr Musialek
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Piotr Pieniazek
- Department of Invasive Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| |
Collapse
|
11
|
Thourani VH, O'Brien SM, Kelly JJ, Cohen DJ, Peterson ED, Mack MJ, Shahian DM, Grover FL, Carroll JD, Brennan JM, Forcillo J, Arnold SV, Vemulapalli S, Fitzgerald S, Holmes DR, Bavaria JE, Edwards FH. Development and Application of a Risk Prediction Model for In-Hospital Stroke After Transcatheter Aortic Valve Replacement: A Report From The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Ann Thorac Surg 2018; 107:1097-1103. [PMID: 30529671 DOI: 10.1016/j.athoracsur.2018.11.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 09/30/2018] [Accepted: 11/01/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Stroke is a serious complication after transcatheter aortic valve replacement (TAVR), yet predictive models are not available. A new risk model for in-hospital stroke after TAVR was developed and used to estimate site-specific performance. METHODS We included 97,600 TAVR procedures from 521 sites in The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry from July 2014 to June 2017. Association between baseline covariates and in-hospital stroke was estimated by logistic regression. Discrimination was evaluated by C-statistic. Calibration was tested internally via cross-validation. Hierarchical modeling was used to estimate risk-adjusted site-specific performance. RESULTS Median age was 82 years, 44,926 (46.0%) were women, and 1,839 (1.9%) had in-hospital stroke. Covariates associated with stroke (odds ratio) included transapical access (1.44), access excluding transapical and transfemoral (1.77), prior stroke (1.57), prior transient ischemic attack (1.50), preprocedural shock, inotropes or mechanical assist device (1.48), smoking (1.28), porcelain aorta (1.23), peripheral arterial disease (1.21), age per 5 years (1.11), glomerular filtration rate per 5 mL/min (0.97), body surface area per m2 (0.55 male; 0.43 female), and prior aortic valve (0.78) and nonaortic valvular (0.42) procedures. The C-statistic was 0.622. Calibration curves demonstrated agreement between observed and expected stroke rates. Hierarchical modeling showed 10 (1.9%) centers with significantly higher odds ratios for in-hospital stroke than their peers. CONCLUSIONS A risk model for in-hospital stroke after TAVR was developed from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry and used to estimate site-specific stroke performance. This model can serve as a valuable resource for quality improvement, clinical decision making, and patient counseling.
Collapse
Affiliation(s)
- Vinod H Thourani
- Department of Cardiac Surgery, Medstar Heart and Vascular Institute and Georgetown University, Washington, DC.
| | - Sean M O'Brien
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - John J Kelly
- Division of Cardiac Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Cohen
- Division of Cardiology, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Michael J Mack
- Heart Hospital Baylor Plano, Baylor Healthcare System, Plano, Texas
| | - David M Shahian
- Department of Surgery and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Frederick L Grover
- Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - John D Carroll
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - J Matthew Brennan
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Jessica Forcillo
- Department of Cardiac Surgery, University of Montreal Hospital Centre, Montreal, Quebec, Canada
| | - Suzanne V Arnold
- Division of Cardiology, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri
| | | | | | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph E Bavaria
- Division of Cardiac Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fred H Edwards
- Division of Cardiothoracic Surgery, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| |
Collapse
|
12
|
Kochar A, Li Z, Harrison JK, Hughes GC, Thourani VH, Mack MJ, Matsouaka RA, Cohen DJ, Peterson ED, Jones WS, Vemulapalli S. Stroke and Cardiovascular Outcomes in Patients With Carotid Disease Undergoing Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2018; 11:e006322. [DOI: 10.1161/circinterventions.117.006322] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/13/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Ajar Kochar
- From the Duke Clinical Research Institute, Duke University School of Medicine (A.K., Z.L., J.K.H., G.C.H., R.A.M., E.D.P., W.S.J., S.V.)
| | - Zhuokai Li
- From the Duke Clinical Research Institute, Duke University School of Medicine (A.K., Z.L., J.K.H., G.C.H., R.A.M., E.D.P., W.S.J., S.V.)
| | - J. Kevin Harrison
- From the Duke Clinical Research Institute, Duke University School of Medicine (A.K., Z.L., J.K.H., G.C.H., R.A.M., E.D.P., W.S.J., S.V.)
| | - G. Chad Hughes
- From the Duke Clinical Research Institute, Duke University School of Medicine (A.K., Z.L., J.K.H., G.C.H., R.A.M., E.D.P., W.S.J., S.V.)
| | - Vinod H. Thourani
- Duke University, Durham, NC; MedStar Washington Hospital Center/Georgetown University, DC (V.H.T.)
| | - Michael J. Mack
- The Heart Hospital Baylor Plano Research Center, TX (M.J.M.)
| | - Roland A. Matsouaka
- From the Duke Clinical Research Institute, Duke University School of Medicine (A.K., Z.L., J.K.H., G.C.H., R.A.M., E.D.P., W.S.J., S.V.)
- Department of Biostatistics and Bioinformatics (R.A.M.)
| | | | - Eric D. Peterson
- From the Duke Clinical Research Institute, Duke University School of Medicine (A.K., Z.L., J.K.H., G.C.H., R.A.M., E.D.P., W.S.J., S.V.)
| | - W. Schuyler Jones
- From the Duke Clinical Research Institute, Duke University School of Medicine (A.K., Z.L., J.K.H., G.C.H., R.A.M., E.D.P., W.S.J., S.V.)
| | - Sreekanth Vemulapalli
- From the Duke Clinical Research Institute, Duke University School of Medicine (A.K., Z.L., J.K.H., G.C.H., R.A.M., E.D.P., W.S.J., S.V.)
| |
Collapse
|
13
|
Thirumala PD, Muluk S, Udesh R, Mehta A, Schindler J, Mulukutla S, Jeevanantham V, Wechsler L, Gleason T. Carotid artery disease and periprocedural stroke risk after transcatheter aortic valve implantation. Ann Card Anaesth 2017; 20:145-151. [PMID: 28393772 PMCID: PMC5408517 DOI: 10.4103/aca.aca_13_17] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective/Background: To examine the role of carotid stenosis (CS) and other independent risk factors of perioperative stroke, following transcatheter aortic valve implantation (TAVI). Materials and Methods: Using data from the National Inpatient Sample database for analysis, patients who underwent TAVI were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Various preoperative and perioperative risk factors and their association with perioperative strokes were studied. Results: Data on 7566 patients who underwent a TAVI procedure from 2012 to 2013 were extracted. The average age of the patient population was 81.2 ± 0.32 years. The overall perioperative stroke rate in our patient cohort was 2.79%. Majority (94.6%) of the strokes were ischemic. Multivariate analysis showed the following independent risk factors for perioperative strokes after TAVI: female gender odds ratio (OR) = 2.25 (95% confidence interval [CI], 1.42–3.57), higher van Walraven score OR = 6.6 (95% CI = 3.71–11.73), bilateral CS OR = 4.46 (95% CI = 2.03–9.82), and TAVI with a cardiac procedure done under cardiopulmonary bypass OR = 2.84 (95% CI = 1.57–5.14). Conclusion: Bilateral carotid disease is a significant risk factor for perioperative strokes following TAVI. Preoperative screening with carotid Doppler to identify high-risk patients appears to be warranted. In addition, patients of female gender were found to have an increased risk for carotid disease.
Collapse
Affiliation(s)
- Parthasarathy D Thirumala
- Department of Neurological Surgery and Neurology; Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Reshmi Udesh
- Department of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amol Mehta
- Department of Neurological Surgery and Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - John Schindler
- Department of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Suresh Mulukutla
- Department of Cardiology, University of Pittsburgh; Department of Cardiology, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Vinodh Jeevanantham
- Department of Cardiothoracic Surgery, Saints Heart and Vascular Institute, St. Anthony Hospital, Oklahoma City, USA
| | - Lawrence Wechsler
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas Gleason
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
14
|
Carotid Doppler Assessment in Patients With Severe Aortic Stenosis. Ann Thorac Surg 2017; 104:1100. [DOI: 10.1016/j.athoracsur.2016.11.043] [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: 11/07/2016] [Accepted: 11/14/2016] [Indexed: 11/18/2022]
|
15
|
Carotid Doppler Before Aortic Valve Replacement and Perioperative Management. Ann Thorac Surg 2017; 104:1096-1097. [PMID: 28838492 DOI: 10.1016/j.athoracsur.2016.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 11/10/2016] [Indexed: 11/24/2022]
|
16
|
Condado JF, Thourani VH. Reply. Ann Thorac Surg 2017; 104:1097. [PMID: 28838493 DOI: 10.1016/j.athoracsur.2017.01.017] [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: 01/09/2017] [Accepted: 01/15/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Jose F Condado
- Emory Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Vinod H Thourani
- Emory Structural Heart and Valve Center, Division of Cardiothoracic Surgery, Emory University School of Medicine, 550 Peachtree St NE, Atlanta, GA 30308.
| |
Collapse
|
17
|
Abstract
Patients with inoperable, high-risk, and intermediate-risk aortic stenosis can now be treated with transcatheter aortic valve replacement. Centers for Medicare and Medicaid Services and the Food and Drug Administration selectively choose centers based on experience and require a collaborative, multidisciplinary team approach in the treatment and decision making for these patients. The work-up has been streamlined. Gated multislice computed tomography angiogram has emerged as the gold standard for assessment of valve anatomy and sizing of the transcatheter heart valve. Assessment of risk has evolved to include a more comprehensive functional and frailty evaluation. Long term-results are needed before the expansion of transcatheter aortic valve replacement into the low-risk category.
Collapse
Affiliation(s)
- John H Braxton
- Structural Heart Services, Marshfield Clinic, Saint Joseph Hospital, 1000 North Oak Avenue, Section 2C2, Marshfield, WI 54449, USA.
| | - Kelly S Rasmussen
- Structural Heart Services, Department of Cardiology, Marshfield Clinic, Saint Joseph Hospital, 1000 North Oak Avenue, Section 2C2, Marshfield, WI 54449, USA
| | - Milind S Shah
- Structural Heart Services, Section of Cardiology, Marshfield Clinic, Saint Joseph Hospital, 1000 North Oak Avenue, Section 2C2, Marshfield, WI 54449, USA
| |
Collapse
|