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Oettinger V, Hilgendorf I, Wolf D, Stachon P, Heidenreich A, Zehender M, Westermann D, Kaier K, von Zur Mühlen C. Transcatheter aortic valve replacement in Germany with need for a surgical bailout. J Cardiol 2024; 84:99-104. [PMID: 38307247 DOI: 10.1016/j.jjcc.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 01/20/2024] [Accepted: 01/25/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND In transcatheter aortic valve replacement (TAVR), complications may force the need for a surgical bailout, but knowledge is rare about outcomes in Germany. METHODS Using national health records, we investigated all TAVR in German hospitals between 2007 and 2020, focusing on 2018-2020. We extracted data on those interventions with need for a surgical bailout. RESULTS A total of 159,643 TAVR were analyzed, with an overall rate of surgical bailout of 2.30 %, an overall in-hospital mortality of 3.85 %, and in-hospital mortality in case of bailout of 16.51 %. The number of all annual TAVR procedures increased substantially (202 to 22,972), with the rate of surgical bailout declining from 27.23 to 0.61 % and overall mortality from 11.39 to 2.29 %. However, in-hospital mortality after bailout was still high (28.37 % in 2020). The standardized rates of overall mortality and surgical bailout between 2018 and 2020 were significantly lower for balloon-expandable and self-expanding transfemoral TAVR than for transapical TAVR after risk adjustment [transapical/transfemoral balloon-expandable/transfemoral self-expanding TAVR: in-hospital mortality: 5.66 % (95 % CI 4.81 %; 6.52 %)/2.30 % (2.03 %; 2.57 %)/2.32 % (2.07 %; 2.57 %); surgical bailout: 2.33 % (1.68 %; 2.97 %)/0.79 % (0.60 %; 0.98 %)/0.42 % (0.31 %; 0.53 %)]. Coronary artery disease [risk-adjusted OR = 1.50 (1.21; 1.85), p < 0.001] and atrial fibrillation [OR = 1.29 (1.07; 1.57), p = 0.009] were found to be the main risk factors for bailout. CONCLUSIONS Rates of TAVR with need for a surgical bailout and overall in-hospital mortality have declined noticeably over the years in Germany. However, the outcomes are still unfavorable after surgical bailout, as in-hospital mortality is continuously high. We present risk factors for surgical bailout to improve preparation of subsequent measures. It must be a major goal to further reduce the rate of surgical bailouts in the future.
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Affiliation(s)
- Vera Oettinger
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Ingo Hilgendorf
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dennis Wolf
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Adrian Heidenreich
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Mühlen
- Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Maznyczka A, Pilgrim T. Antithrombotic Treatment After Transcatheter Valve Interventions: Current Status and Future Directions. Clin Ther 2024; 46:122-133. [PMID: 37926630 DOI: 10.1016/j.clinthera.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/15/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE The optimal antithrombotic strategy after transcatheter valve interventions is a subject of ongoing debate. Although there is evidence from randomized trials in patients undergoing transcatheter aortic valve replacement (TAVR), current evidence on optimal antithrombotic management after transcatheter mitral or tricuspid valve interventions is sparse. This article appraises the current evidence on this topic. METHODS This narrative review presents key research findings and guideline recommendations, as well as highlights areas for future research. FINDINGS After TAVR, randomized trial evidence suggests that single antiplatelet therapy is reasonable for patients without pre-existing indications for oral anticoagulation (OAC). If there is a concurrent indication for OAC, the addition of antiplatelet therapy increases bleeding risk. Whether direct oral anticoagulants achieve better outcomes than vitamin K antagonists is uncertain in this setting. Although OAC has been shown to reduce subclinical leaflet thrombosis (which may progress to structural valve degeneration), bleeding events are unacceptably high. There is a lack of randomized trial data comparing antithrombotic strategies after transcatheter mitral or tricuspid valve replacement or after mitral or tricuspid transcatheter edge-to-edge repair. Single antiplatelet therapy after mitral or tricuspid transcatheter edge-to-edge repair may be appropriate, whereas at least 3 months of OAC is suggested after transcatheter mitral valve replacement or transcatheter tricuspid valve replacement. IMPLICATIONS Randomized studies are warranted to address the knowledge gaps in antithrombotic therapy after transcatheter valve interventions and to optimize outcomes.
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Affiliation(s)
- Annette Maznyczka
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, Bern, Switzerland.
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3
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Sharma N, Heslin RF, Aleem SU, Medamana J, Gasimli-Gamache L, Yoo J, Bhasin V, Avvento PJ, Wiley J, Billfinger TV, Tannous HJ, Parikh PB, Kort S, Labropoulos N, Dangas GD, Reilly JP, Pyo RT. Prevalence of Neurovascular Microemboli After Transcatheter Aortic Valve Replacement. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101180. [PMID: 39131988 PMCID: PMC11308225 DOI: 10.1016/j.jscai.2023.101180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/16/2023] [Accepted: 09/12/2023] [Indexed: 08/13/2024]
Abstract
Background Neurolotic sequelae after transcatheter aortic valve replacement (TAVR) can cause significant morbidity and mortality. Transcranial Doppler (TCD) imaging can show real-time high intensity transient signals (HITS), which reflect active microembolization. Although it is well known that intraprocedural microembolism occurs, it is not known if this embolic phenomenon continues in the postprocedural period. We investigated whether microemboli occur post-TAVR and whether we could determine any clinical, procedural, or echocardiographic predictors. Methods We evaluated HITS in 51 consecutive patients undergoing unprotected TAVR with low-, intermediate-, or high-risk Society of Thoracic Surgeons score. Patients were excluded if they did not have temporal windows for insonation of the middle cerebral artery or if they were not willing to participate. Primary outcomes of HITS 24 hours post-TAVR were observed using a Philips iU22 TCD. TCD was performed at 3 time points (pre-, peri-, and post-TAVR) for each patient, before, during, and 24 hours postprocedure. Results While no HITS were detected in any of the patients preoperatively, all patients had HITS during the procedure. Interestingly, 56.8% had HITS 24 hours post-TAVR. One patient with HITS post-TAVR had a stroke 48 hours after TAVR. Conclusion We observed a high prevalence of microemboli 24 hours post-TAVR. None of the predictors for intraprocedural microembolism seemed to play an important role for post-TAVR microemboli.
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Affiliation(s)
- Navneet Sharma
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Ryan F. Heslin
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Saadat U. Aleem
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
| | - John Medamana
- Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Leyla Gasimli-Gamache
- Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Jeanwoo Yoo
- Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Varun Bhasin
- Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Peter J. Avvento
- Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Jose Wiley
- Divison of Cardiology, Tulane University, New Orleans, Louisiana
| | - Thomas V. Billfinger
- Division of Cardiothoracic Surgery, Stony Brook University Medical Center, Stony Brook, New York
| | - Henry J. Tannous
- Division of Cardiothoracic Surgery, Stony Brook University Medical Center, Stony Brook, New York
| | - Puja B. Parikh
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Smadar Kort
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Nicos Labropoulos
- Divison of Cardiology, Tulane University, New Orleans, Louisiana
- Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, New York
| | - George D. Dangas
- Division of Cardiology, The Mount Sinai Hospital, New York, New York
| | - John P. Reilly
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Robert T. Pyo
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
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Dodgson CS, Beitnes JO, Kløve SF, Herstad J, Opdahl A, Undseth R, Eek CH, Broch K, Gullestad L, Aaberge L, Lunde K, Bendz B, Lie ØH. An investigator-sponsored pragmatic randomized controlled trial of AntiCoagulation vs AcetylSalicylic Acid after Transcatheter Aortic Valve Implantation: Rationale and design of ACASA-TAVI. Am Heart J 2023; 265:225-232. [PMID: 37634655 DOI: 10.1016/j.ahj.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND The optimal antithrombotic therapy after transcatheter aortic valve implantation (TAVI) is unknown. Bioprosthetic valve dysfunction (BVD) is associated with adverse outcomes and may be prevented by anticoagulation therapy. A dedicated randomized trial comparing monotherapy NOAC to single antiplatelet therapy has not been performed previously. We hypothesize that therapy with any anti-factor Xa NOAC will reduce BVD compared to antiplatelet therapy, without compromising safety. METHODS ACASA-TAVI is a multicenter, prospective, randomized, open-label, blinded endpoint, all-comers trial comparing a monotherapy anti-factor Xa NOAC strategy (intervention arm) with a single antiplatelet therapy strategy (control arm) after successful TAVI. Three-hundred and sixty patients without indication for oral anticoagulation will be randomized in a 1:1 ratio to either apixaban 5 mg twice per day, edoxaban 60 mg daily, or rivaroxaban 20 mg daily for 12 months followed by acetylsalicylic acid 75 mg daily indefinitely, or to acetylsalicylic acid 75 mg daily indefinitely. The 2 co-primary outcomes are (1) incidence of Hypo-Attenuated Leaflet Thickening (HALT) on 4-dimensional cardiac CT at 12 months, and (2) a Safety Composite of VARC-3 bleeding events, thromboembolic events (myocardial infarction and stroke), and death from any cause, at 12 months. RESULTS The first 100 patients had a mean age of 74 ± 3.6 years, 33% were female, the average body-mass index was 27.9 ± 4.4 kg/m2, and 15% were smokers. A balloon-expanded valve was used in 82% and a self-expandable valve in 18%. CONCLUSIONS The trial is planned, initiated, funded, and conducted without industry involvement. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT05035277.
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Affiliation(s)
- Christopher S Dodgson
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jan Otto Beitnes
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Sophie F Kløve
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Jon Herstad
- Department of Cardiology, Haukeland University Hospital, Bergen, Norway
| | - Anders Opdahl
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
| | | | - Christian H Eek
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Kaspar Broch
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; K. G. Jebsen Cardiac Research Centre, University of Oslo, Oslo, Norway
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; K. G. Jebsen Cardiac Research Centre, University of Oslo, Oslo, Norway
| | - Lars Aaberge
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Ketil Lunde
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Øyvind H Lie
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway.
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Zaman A, Prendergast B, Hildick-Smith D, Blackman D, Anderson R, Spence MS, Mylotte D, Smith D, Wilding B, Chapman C, Atkins K, Pollock KG, Qureshi AC, Banning A. An Update on Anti-thrombotic Therapy Following Transcatheter Aortic Valve Implantation: Expert Cardiologist Opinion from a UK and Ireland Delphi Group. Interv Cardiol 2023; 18:e13. [PMID: 37398870 PMCID: PMC10311398 DOI: 10.15420/icr.2022.11] [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: 04/11/2022] [Accepted: 10/11/2022] [Indexed: 07/04/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is an effective and established treatment for symptomatic aortic stenosis. However, there is a lack of consensus concerning the need for peri- and post-procedural anti-thrombotic medication. Contemporary guidelines recommend that anti-thrombotic therapy is balanced against a patient's bleeding risk following TAVI, but do not fully consider the evolving evidence base. The purpose of the Delphi panel recommendations presented here is to provide a consensus elicited from a panel of experts who regularly prescribe anti-thrombotic therapy post-TAVI. The goal was to address evidence gaps across four key topics: anti-thrombotic therapy (anti-platelet and/or anti-coagulant) in TAVI patients in sinus rhythm; anti-thrombotic therapy in TAVI patients with AF; direct oral anti-coagulants versus vitamin K antagonists; and the need for UK/Ireland specific guidance. This consensus statement aims to inform clinical decision-making by providing a concise, evidence-based summary of best practice for prescribing anti-thrombotic therapies following TAVI and highlights areas where further research is needed.
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Affiliation(s)
- Azfar Zaman
- Department of Cardiology, Freeman HospitalNewcastle upon Tyne, UK
- Newcastle UniversityNewcastle upon Tyne, UK
| | - Bernard Prendergast
- Department of Cardiology, St Thomas’ HospitalLondon, UK
- Cleveland ClinicLondon, UK
| | - David Hildick-Smith
- Sussex Cardiac Centre, Regional Specialist Unit, Brighton and Sussex University HospitalsBrighton, UK
| | - Daniel Blackman
- Department of Cardiology, Leeds Teaching Hospitals NHS TrustLeeds, UK
| | - Richard Anderson
- Department of Cardiology, University Hospital of WalesCardiff, UK
- Cardiff Metropolitan UniversityCardiff, UK
| | - Mark S Spence
- Department of Cardiology Mater Private HospitalDublin, Ireland
| | - Darren Mylotte
- Department of Cardiology, University Hospitals GalwayGalway, Ireland
- National University of GalwayGalway, Ireland
| | - David Smith
- Department of Cardiology, Morriston HospitalSwansea, UK
- University of SwanseaSwansea, UK
| | - Ben Wilding
- Health Economics and Outcomes ResearchCardiff, UK
| | - Chris Chapman
- Bristol Myers Squibb PharmaceuticalsUxbridge, Middlesex, UK
| | - Kirsty Atkins
- Bristol Myers Squibb PharmaceuticalsUxbridge, Middlesex, UK
| | | | | | - Adrian Banning
- Department of Cardiology, John Radcliffe HospitalOxford, UK
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Junquera L, Kalavrouziotis D, Dumont E, Rodés-Cabau J, Mohammadi S. Paradigm shifts in alternative access for transcatheter aortic valve replacement: An update. J Thorac Cardiovasc Surg 2023; 165:1359-1370.e2. [PMID: 34052017 DOI: 10.1016/j.jtcvs.2021.04.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Lucía Junquera
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Dimitri Kalavrouziotis
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Eric Dumont
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Siamak Mohammadi
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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Oettinger V, Hilgendorf I, Wolf D, Stachon P, Heidenreich A, Zehender M, Westermann D, Kaier K, von zur Mühlen C. Treatment of pure aortic regurgitation using surgical or transcatheter aortic valve replacement between 2018 and 2020 in Germany. Front Cardiovasc Med 2023; 10:1091983. [PMID: 37200971 PMCID: PMC10187752 DOI: 10.3389/fcvm.2023.1091983] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/17/2023] [Indexed: 05/20/2023] Open
Abstract
Background In pure aortic regurgitation, transcatheter aortic valve replacement (TAVR) is not yet used on a regular base. Due to constant development of TAVR, it is necessary to analyze current data. Methods By use of health records, we analyzed all isolated TAVR or surgical aortic valve replacements (SAVR) for pure aortic regurgitation between 2018 and 2020 in Germany. Results 4,861 procedures-4,025 SAVR and 836 TAVR-for aortic regurgitation were identified. Patients treated with TAVR were older, showed a higher logistic EuroSCORE, and had more pre-existing diseases. While results indicate a slightly higher unadjusted in-hospital mortality for transapical TAVR (6.00%) vs. SAVR (5.71%), transfemoral TAVR showed better outcomes, with self-expanding compared to balloon-expandable transfemoral TAVR having significantly lower in-hospital mortality (2.41% vs. 5.17%; p = 0.039). After risk adjustment, balloon-expandable as well as self-expanding transfemoral TAVR were associated with a significantly lower mortality vs. SAVR (balloon-expandable: risk adjusted OR = 0.50 [95% CI 0.27; 0.94], p = 0.031; self-expanding: OR = 0.20 [0.10; 0.41], p < 0.001). Furthermore, the observed in-hospital outcomes of stroke, major bleeding, delirium, and mechanical ventilation >48 h were significantly in favor of TAVR. In addition, TAVR showed a significantly shorter length of hospital stay compared to SAVR (transapical: risk adjusted Coefficient = -4.75d [-7.05d; -2.46d], p < 0.001; balloon-expandable: Coefficient = -6.88d [-9.06d; -4.69d], p < 0.001; self-expanding: Coefficient = -7.22 [-8.95; -5.49], p < 0.001). Conclusions TAVR is a viable alternative to SAVR in the treatment of pure aortic regurgitation for selected patients, showing overall low in-hospital mortality and complication rates, especially with regard to self-expanding transfemoral TAVR.
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Affiliation(s)
- Vera Oettinger
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Correspondence: Vera Oettinger
| | - Ingo Hilgendorf
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dennis Wolf
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Adrian Heidenreich
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center—University of Freiburg, Freiburg, Germany
| | - Constantin von zur Mühlen
- Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center for Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology, University Heart Center, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Hindi MN, Akodad M, Nestelberger T, Sathananthan J. Antithrombotic Therapy After Transcatheter Aortic Valve Replacement: An Overview. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100085. [PMID: 37288058 PMCID: PMC10242582 DOI: 10.1016/j.shj.2022.100085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/29/2022] [Accepted: 08/04/2022] [Indexed: 06/09/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is an established procedure for the treatment of patients with severe aortic stenosis. The optimal antithrombotic regimen following TAVR, currently unknown and inconsistently applied, is impacted by thromboembolic risk, frailty, bleeding risk, and comorbidities. There is a quickly growing body of literature examining the complex issues underlying antithrombotic regimens post-TAVR. This review provides an overview of thromboembolic and bleeding events following TAVR, summarizes the evidence regarding optimal antiplatelet and anticoagulant use post-TAVR, and highlights current challenges and future directions. By understanding appropriate indications and outcomes associated with different antithrombotic regimens post-TAVR, morbidity and mortality can be minimized in a generally frail and elderly patient population.
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Affiliation(s)
- Mathew N. Hindi
- Centre for Cardiovascular and Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada
| | - Mariama Akodad
- Centre for Cardiovascular and Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada
| | - Thomas Nestelberger
- Centre for Cardiovascular and Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Janarthanan Sathananthan
- Centre for Cardiovascular and Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada
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Bernardi FLDM, Ribeiro HB, Nombela-Franco L, Cerrato E, Maluenda G, Nazif T, Lemos PA, Sztejfman M, Lamelas P, Echeverri D, Lopes MACQ, Brito FSD, Abizaid AA, Mangione JA, Eltchaninoff H, Søndergaard L, Rodes-Cabau J. Evolução e Estado Atual das Práticas de Implante Transcateter de Válvula Aórtica na América Latina – Estudo WRITTEN LATAM. Arq Bras Cardiol 2022; 118:1085-1096. [PMID: 35703645 PMCID: PMC9345155 DOI: 10.36660/abc.20210327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 09/01/2021] [Indexed: 12/25/2022] Open
Abstract
Fundamento: Implante transcateter de valva aórtica (TAVI) é um procedimento adotado em todo o mundo e suas práticas evoluem rapidamente. Variações regionais e temporais são esperadas. Objetivo: Comparar a prática de TAVI na América Latina com aquela no resto do mundo e avaliar suas mudanças na América Latina de 2015 a 2020. Método: A pesquisa foi realizada em centros de TAVI em todo o mundo entre março e setembro de 2015, e novamente nos centros latino-americanos entre julho de 2019 e janeiro de 2020. As seguintes questões foram abordadas: i) informação geral sobre os centros; ii) avaliação pré-TAVI; iii) técnicas do procedimento; iv) conduta pós-TAVI; v) seguimento. As respostas da pesquisa dos centros latino-americanos em 2015 (LATAM15) foram comparadas àquelas dos centros no resto do mundo (WORLD15) e ainda àquelas da pesquisa dos centros latino-americanos de 2020 (LATAM20). Adotou-se o nível de significância de 5% na análise estatística. Resultados: 250 centros participaram da pesquisa em 2015 (LATAM15=29; WORLD15=221) e 46 na avaliação LATAM20. No total, foram 73.707 procedimentos, sendo que os centros WORLD15 realizaram, em média, 6 e 3 vezes mais procedimentos do que os centros LATAM15 e LATAM20, respectivamente. Os centros latino-americanos realizaram menor número de TAVI minimalista do que os do restante do mundo, mas aumentaram significativamente os procedimentos menos invasivos após 5 anos. Quanto à assistência pós-procedimento, observaram-se menor tempo de telemetria e de manutenção do marca-passo temporário, além de menor uso de terapia dupla antiplaquetária nos centros LATAM20. Conclusão: A despeito do volume de procedimentos ainda significativamente menor, muitos aspectos da prática de TAVI nos centros latino-americanos evoluíram recentemente, acompanhando a tendência dos centros dos países desenvolvidos.
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10
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Sotade OT, Jorm LR, Kushwaha VV, Yu J, Sedrakyan A, Falster MO, Pearson SA. Post-Discharge Antithrombotic Therapy Following Transcatheter Aortic Valve Implantation in Australian Patients. Heart Lung Circ 2022; 31:1144-1152. [PMID: 35637093 DOI: 10.1016/j.hlc.2022.04.048] [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: 01/13/2022] [Revised: 03/29/2022] [Accepted: 04/26/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Guidelines recommend antithrombotic therapy for patients following transcatheter aortic valve implantation (TAVI) to reduce the risk of ischaemic events and bioprosthetic valve thrombosis. OBJECTIVE To describe antithrombotic dispensing within 30 days of discharge for Australian patients receiving TAVI. METHODS We performed a state-wide retrospective cohort study using linked hospital and medicines dispensing data from January 2013 to December 2018 for all patients receiving TAVI in New South Wales, Australia. We identified patients dispensed oral anticoagulants (vitamin K antagonists [warfarin], direct oral anticoagulants [DOACs]) or clopidogrel within 30 days of discharge. We examined demographic and clinical predictors of antithrombotic dispensing. RESULTS Our cohort comprised 1,217 patients who underwent TAVI; median age was 84 years and 707 (58.1%) were male. Of these, 808 patients (66.4%) had an antithrombotic dispensed within 30 days of hospital discharge. One-third (33.7%) of these patients were dispensed an anticoagulant (16.1% warfarin; 17.6% DOACs) and two-thirds (66.3%) were dispensed clopidogrel. Patients undergoing TAVI were more likely to be dispensed an antithrombotic medicine within 30-days of hospital discharge if they had been dispensed antithrombotic medicines (RR 1.07; 95% CI 1.03-1.11) or angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers (RR 1.04; 95% CI 1.00-1.07) in the 6 months prior to admission. Patients with a history of haemorrhage were less likely to be dispensed an antithrombotic medicine within 30 days of hospital discharge (RR 0.93; 95% CI 0.89-0.98). CONCLUSIONS We observed gaps in best evidence pharmacotherapy for patients post-TAVI, with almost one third of patients not receiving antithrombotic medicines post-discharge. Further research is needed to quantify the impact of emerging clinical guidelines recommending single antiplatelet therapy, on adherence to best-practice care.
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Affiliation(s)
| | - Louisa R Jorm
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Jennifer Yu
- Prince of Wales Hospital, Sydney, NSW, Australia
| | | | - Michael O Falster
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
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11
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Camaj A, Razuk V, Dangas GD. Antithrombotic Strategies in Valvular and Structural Heart Disease Interventions. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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12
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Brown AD, Li B, Gabriel S, Cusimano RJ, Chung J, Horlick E, Osten MD, Ouzounian M, Roche-Nagle G. Association Between Sarcopenia and Adverse Events Following Transcatheter Aortic Valve Implantation. CJC Open 2021; 4:173-179. [PMID: 35198934 PMCID: PMC8843889 DOI: 10.1016/j.cjco.2021.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/13/2021] [Indexed: 12/17/2022] Open
Abstract
Background Sarcopenia, the age-related loss of skeletal muscle mass/function, has been identified as a marker of frailty. We examined the association between sarcopenia and adverse events following transcatheter aortic valve implantation (TAVI). Methods A retrospective cohort study was conducted at Toronto General Hospital. All patients who underwent TAVI in the time period 2007-2017 with preoperative computed tomography were included. Skeletal muscle index (SMI) was calculated radiographically using psoas muscle area at the L3 vertebral level, divided by height. Various measures of sarcopenia, including mean SMI, SMI below the sex-specific median, and SMI in the lowest sex-specific quartile were calculated. The primary outcome was postoperative adverse events, defined as a composite of in-hospital mortality and morbidity including cardiovascular, pulmonary, neurologic, access-related, and gastrointestinal complications. Univariate and multivariate logistic regression were performed to determine the association between sarcopenia and adverse events. Results A total of 468 patients (mean age: 80.7 years) were included. Baseline comorbidity burden was high, particularly congestive heart failure (93.4%). Postoperative adverse events occurred in 62 patients (13.2%). Univariate logistic regression demonstrated that postoperative adverse events were correlated with mean SMI (odds ratio [OR] 0.81, 95% confidence interal [CI] 0.66-0.97), events were less than the SMI (OR 2.16, 95% CI 1.24-3.84), and SMI in the sex-specific lowest quartile (OR 2.34, 95% CI 1.33-4.07). On multivariate analysis, SMI in the sex-specific lowest quartile was an independent predictor of adverse events (OR 2.53, 95% CI 1.41-4.50). Conclusions Sarcopenia defined by radiologic psoas muscle measurements was independently associated with in-hospital mortality and morbidity following TAVI.
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Affiliation(s)
- Andrew D. Brown
- Division of Interventional Radiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Ben Li
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Samantha Gabriel
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robert J. Cusimano
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Eric Horlick
- Division of Cardiology, Peter Munk Cardiac Centre, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mark D. Osten
- Division of Cardiology, Peter Munk Cardiac Centre, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Corresponding author: Dr Graham Roche-Nagle, Division of Vascular Surgery, University Health Network, 6E-218, Toronto General Hospital, 200 Elizabeth St, Toronto, Ontario M5G 2C4, Canada. Tel.: +1-416-340-5332; fax: +1-416-340-5029.
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13
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Minha S, Yarkoni Y, Segev A, Finkelstein A, Danenberg H, Fefer P, Orvin K, Steinvil A, Maor E, Beinart R, Rosso R, Golovchiner G, Kornowski R, Guetta V, Barbash IM. Comparison of permanent pacemaker implantation rate after first and second generation of transcatheter aortic valve implantation-A retrospective cohort study. Catheter Cardiovasc Interv 2021; 98:E990-E999. [PMID: 34347381 DOI: 10.1002/ccd.29891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 07/01/2021] [Accepted: 07/17/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES This study aimed to compare permanent pacemaker implantation (PPMI) rates among patients undergoing Trans-catheter Aortic Valve Implantation (TAVI) with first generation (G1) versus second generation (G2) valves and the impact of PPMI on long-term mortality. BACKGROUND PPMI is a known adverse event after TAVI. Recently, two novel iterations of valve designs of both the balloon expandable valves (BEV) and self-expanding valves (SEV) were introduced as a second generation valves. METHODS All patients included in the Israeli multicenter TAVI registry were grouped according to valve type (BEV vs. SEV) and generation (G1 vs. G2). A comparison was made for clinical and outcome indices of patients undergoing TAVI with G1 and G2 in each of the valve systems. RESULTS A total of 1377 patients were included. The incidence of PPMI did not differ between G1-BEV versus G2-BEV (15.3% vs. 17.4%; p = 0.598) nor between G1-SEV versus G2-SEV (23.4% vs. 20.3%; p = 0.302). Depth of implantation and complete right bundle branch block were independently associated with PPMI post-TAVI in both valve systems. PPMI was not associated with an increased risk for 2-year mortality. CONCLUSIONS The incidence of PPMI remains a relevant adverse event post-TAVI even when the newer generation valves are used. Since the predictors for PPMI are well established, a standardized approach for the management of conduction disorders is much needed.
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Affiliation(s)
- Sa'ar Minha
- Cardiology Department, Shamir Medical Center, Be'er Yaakov, Israel.,Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Yuval Yarkoni
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
| | - Amit Segev
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Ariel Finkelstein
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Haim Danenberg
- Heart Institute, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Paul Fefer
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Katia Orvin
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
| | - Arie Steinvil
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Elad Maor
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Roy Beinart
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Raphael Rosso
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Gregory Golovchiner
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
| | - Ran Kornowski
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
| | - Victor Guetta
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Israel M Barbash
- Sackler School of Medicine, Tel-Aviv University, Ramat-Aviv, Israel.,Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel
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Mach M, Poschner T, Hasan W, Kerbel T, Szalkiewicz P, Hasimbegovic E, Andreas M, Gross C, Strouhal A, Delle-Karth G, Grabenwöger M, Adlbrecht C, Schober A. Transcatheter versus Isolated Surgical Aortic Valve Replacement in Young High-Risk Patients: A Propensity Score-Matched Analysis. J Clin Med 2021; 10:jcm10153447. [PMID: 34362230 PMCID: PMC8346998 DOI: 10.3390/jcm10153447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/22/2021] [Accepted: 07/31/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Younger patients with severe symptomatic aortic stenosis are a particularly challenging collective with regard to the choice of intervention. High-risk patients younger than 75 years of age are often eligible for both the transcatheter aortic valve replacement (TAVR) and the isolated surgical aortic valve replacement (iSAVR). Data on the outcomes of both interventions in this set of patients are scarce. Methods: One hundred and forty-four propensity score-matched patients aged 75 years or less who underwent TAVR or iSAVR at the Hietzing Heart Center in Vienna, Austria, were included in the study. The mean age was 68.9 years (TAVR 68.7 vs. SAVR 67.6 years; p = 0.190) and the average EuroSCORE II was 5.4% (TAVR 4.3 [3.2%] vs. iSAVR 6.4 (4.3%); p = 0.194). Results: Postprocedural adverse event data showed higher rates of newly acquired atrial fibrillation (6.9% vs. 19.4%; p = 0.049), prolonged ventilation (2.8% vs. 25.0%; p < 0.001) and multi-organ failure (0% vs. 6.9%) in the surgical cohort. The in-hospital and 30-day mortality was significantly higher for iSAVR (1.4% vs. 13.9%; p = 0.012; 12.5% vs. 2.8%; p = 0.009, respectively). The long-term survival (median follow-up 5.0 years (2.2–14.1 years)) of patients treated with the surgical approach was superior to that of patients undergoing TAVR (p < 0.001). Conclusion: Although the survival analysis revealed a higher in-hospital and 30-day survival rate for high-risk patients aged ≤75 years who underwent TAVR, iSAVR was associated with a significantly higher long-term survival rate.
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Affiliation(s)
- Markus Mach
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (T.P.); (T.K.); (P.S.); (E.H.); (M.A.); (C.G.)
- Department of Cardio-Vascular Surgery, Hospital Floridsdorf and Karl Landsteiner Institute for Cardio-Vascular Research, 1210 Vienna, Austria;
- Correspondence: ; Tel.: +43-1-40400-52620
| | - Thomas Poschner
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (T.P.); (T.K.); (P.S.); (E.H.); (M.A.); (C.G.)
| | - Waseem Hasan
- Faculty of Medicine, Imperial College London, London SW7 2AZ, UK;
| | - Tillmann Kerbel
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (T.P.); (T.K.); (P.S.); (E.H.); (M.A.); (C.G.)
| | - Philipp Szalkiewicz
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (T.P.); (T.K.); (P.S.); (E.H.); (M.A.); (C.G.)
| | - Ena Hasimbegovic
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (T.P.); (T.K.); (P.S.); (E.H.); (M.A.); (C.G.)
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (T.P.); (T.K.); (P.S.); (E.H.); (M.A.); (C.G.)
| | - Christoph Gross
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (T.P.); (T.K.); (P.S.); (E.H.); (M.A.); (C.G.)
- Center of Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria
| | - Andreas Strouhal
- Department of Cardiology, Hospital Floridsdorf and the Karl Landsteiner Institute for Cardiovascular and Critical Care Research Vienna, 1210 Vienna, Austria; (A.S.); (G.D.-K.); (C.A.); (A.S.)
| | - Georg Delle-Karth
- Department of Cardiology, Hospital Floridsdorf and the Karl Landsteiner Institute for Cardiovascular and Critical Care Research Vienna, 1210 Vienna, Austria; (A.S.); (G.D.-K.); (C.A.); (A.S.)
| | - Martin Grabenwöger
- Department of Cardio-Vascular Surgery, Hospital Floridsdorf and Karl Landsteiner Institute for Cardio-Vascular Research, 1210 Vienna, Austria;
- Faculty of Medicine, Sigmund Freud University, 1020 Vienna, Austria
| | - Christopher Adlbrecht
- Department of Cardiology, Hospital Floridsdorf and the Karl Landsteiner Institute for Cardiovascular and Critical Care Research Vienna, 1210 Vienna, Austria; (A.S.); (G.D.-K.); (C.A.); (A.S.)
- Imed19, Private Research Center, 1190 Vienna, Austria
| | - Andreas Schober
- Department of Cardiology, Hospital Floridsdorf and the Karl Landsteiner Institute for Cardiovascular and Critical Care Research Vienna, 1210 Vienna, Austria; (A.S.); (G.D.-K.); (C.A.); (A.S.)
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15
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Muntané-Carol G, Nombela-Franco L, Serra V, Urena M, Amat-Santos I, Vilalta V, Chamandi C, Lhermusier T, Veiga-Fernandez G, Kleiman N, Canadas-Godoy V, Francisco-Pascual J, Himbert D, Castrodeza J, Fernandez-Nofrerias E, Baudinaud P, Mondoly P, Campelo-Parada F, De la Torre Hernandez JM, Pelletier-Beaumont E, Philippon F, Rodés-Cabau J. Late arrhythmias in patients with new-onset persistent left bundle branch block after transcatheter aortic valve replacement using a balloon-expandable valve. Heart Rhythm 2021; 18:1733-1740. [PMID: 34082083 DOI: 10.1016/j.hrthm.2021.05.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/10/2021] [Accepted: 05/26/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The arrhythmic burden after discharge in patients with new-onset left bundle branch block (LBBB) undergoing transcatheter aortic valve replacement (TAVR) with the balloon-expandable SAPIEN 3 (S3) valve remains largely unknown. OBJECTIVE The purpose of this study was to determine the incidence of late arrhythmias in patients with new-onset LBBB undergoing TAVR with the balloon-expandable S3 valve. METHODS This was a multicenter, prospective study that included 104 consecutive TAVR patients with new-onset persistent LBBB following TAVR with the S3 valve. An implantable cardiac monitor (Reveal XT, Reveal LINQ) was implanted before discharge. The primary endpoint was the incidence of high-degree atrioventricular block or complete heart block (HAVB/CHB). RESULTS A total of 40 patients (38.5%) had at least 1 significant arrhythmic event, leading to a treatment change in 17 (42.5%). Significant bradyarrhythmias occurred in 20 of 104 patients (19.2%) (34 HAVB/CHB episodes, 252 severe bradycardia episodes), with 10 of 20 patients (50%) exhibiting at least 1 episode of HAVB/CHB. Most HAVB/CHB episodes (60%) occurred within 4 weeks after discharge. Nine patients (8.7%) underwent permanent pacemaker implantation at 12 months based on the Reveal findings (6 HAVB/CHB, 3 severe bradycardia). CONCLUSION S3 valve recipients with new-onset LBBB have a high arrhythmic burden, with more than one-third of patients exhibiting at least 1 significant arrhythmic episode within 12 months (HAVB/CHB in 10% of patients). About one-half of bradyarrhythmic events occurred within 4 weeks after discharge. These results should inform future strategies on the use of continuous electrocardiographic monitoring in TAVR S3 patients with new conduction disturbances following the procedure.
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Affiliation(s)
- Guillem Muntané-Carol
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Luis Nombela-Franco
- Instituto Cardiovascular, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Vicenç Serra
- Department of Cardiology, Hospital Universitari Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Marina Urena
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Höpital Bichat-Claude Bernard, Paris, France
| | - Ignacio Amat-Santos
- Department of Cardiology, Hospital Universitario de Valladolid, Valladolid, Spain
| | - Victoria Vilalta
- Department of Cardiology, Hospital Germans Trias i Pujol, Badalona, Spain
| | | | - Thibault Lhermusier
- Department of Cardiology, Hôpital Universitaire de Toulouse, Toulouse, France
| | | | - Neal Kleiman
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | | | | | - Dominique Himbert
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Höpital Bichat-Claude Bernard, Paris, France
| | - Javier Castrodeza
- Department of Cardiology, Hospital Universitario de Valladolid, Valladolid, Spain
| | | | - Pierre Baudinaud
- Department of Cardiology, Hôpital Européen George Pompidou, Paris, France
| | - Pierre Mondoly
- Department of Cardiology, Hôpital Universitaire de Toulouse, Toulouse, France
| | | | | | - Emilie Pelletier-Beaumont
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - François Philippon
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada; Hospital Clínic de Barcelona, Barcelona, Spain.
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16
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Abstract
PURPOSE OF REVIEW Transcatheter aortic valve replacement (TAVR) has expanded as a treatment option for severe aortic stenosis throughout the surgical risk spectrum. Decreasing procedural risk and inclusion of lower risk population has shifted the focus to optimization of postprocedural management and balancing the thrombotic and bleeding complications. In this review, we outline various patient and procedure related factors affecting choice of antithrombotic therapy post TAVR and provide an update of recent development in this area. RECENT FINDINGS Multiple studies have confirmed the high incidence of both ischemic and bleeding complications in the early to midterm post-TAVR. In addition, new data has emerged for the role of high resolution computed tomography to detect decreased leaflet mobility and leaflet micro thrombi associated with implications for bioprosthetic valve dysfunction and cerebrovascular events post TAVR. Randomized clinical trials have reported increased bleeding with dual antiplatelet therapy (DAPT) and oral anticoagulation (OAC) plus antiplatelet therapy. These findings suggest that aspirin monotherapy or OAC monotherapy likely provides the appropriate balance for antithrombotic protection and risk of bleeding. SUMMARY Majority of patients undergoing TAVR have multiple comorbidities and are at increased risk of ischemic and bleeding complications. In the absence of robust clinical evidence, there is significant variability among guideline recommendations and antithrombotic therapy post TAVR across institutions. The available evidence confirms a high rate of bleeding with more potent and prolonged antithrombotic regimens without a documented benefit for clinical endpoints. The authors favor a conservative anti thrombotic approach and suggest monotherapy with aspirin or systemic anticoagulation based upon an individual's risk of thromboembolic complications. DAPT is reserved for patients with recent stenting and OAC plus aspirin is prescribed for patients with established CAD in the post TAVR setting.
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17
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Diemberger I, Massaro G, Rossillo A, Chieffo E, Dugo D, Guarracini F, Pellegrino PL, Perna F, Landolina M, De Ponti R, Berisso MZ, Ricci RP, Boriani G. Temporary transvenous cardiac pacing: a survey on current practice. J Cardiovasc Med (Hagerstown) 2021; 21:420-427. [PMID: 32332379 DOI: 10.2459/jcm.0000000000000959] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Temporary transvenous cardiac pacing (TTCP) is a standard procedure in current practice, despite limited coverage in consensus guidelines. However, many authors reported several complications associated with TTCP, especially development of infections of cardiac implantable electronic devices (CIED). The aim of this survey was to provide a country-wide picture of current practice regarding TTCP. METHODS Data were collected using an online survey that was administered to members of the Italian Association of Arrhythmology and Cardiac Pacing. RESULTS We collected data from 102 physicians, working in 81 Italian hospitals from 17/21 regions. Our data evidenced that different strategies are adopted in case of acute bradycardia with a tendency to limit TTCP mainly to advanced atrioventricular block. However, some centers reported a greater use in elective procedures. TTCP is usually performed by electrophysiologists or interventional cardiologists and, differently from previous reports, mainly by a femoral approach and with nonfloating catheters. We found high inhomogeneity regarding prevention of infections and thromboembolic complications and in post-TTCP management, associated with different TTCP volumes and a strategy for management of acute bradyarrhythmias. CONCLUSION This survey evidenced a high inhomogeneity in the approaches adopted by Italian cardiologists for TTCP. Further studies are needed to explore if these divergences are associated with different long-term outcomes, especially incidence of CIED-related infections.
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Affiliation(s)
- Igor Diemberger
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, Policlinico S.Orsola-Malpighi University of Bologna, Bologna
| | - Giulia Massaro
- Institute of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine, Policlinico S.Orsola-Malpighi University of Bologna, Bologna
| | | | - Enrico Chieffo
- Institute of Cardiology, Maggiore Hospital, Crema, Italy
| | - Daniela Dugo
- Department of Cardiology and Angiology, Cardioangiologisches Centrum Bethanien, Agaplesion Markus Krankenhaus, Frankfurt/Main, Germany
| | | | | | - Francesco Perna
- Department of Cardiovascular Sciences, Catholic University of Sacred Heart, Rome
| | | | - Roberto De Ponti
- Department of Heart and Vessels, Circolo e Fondazione Macchi Hospital, Varese
| | | | | | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena University of Modena and Reggio Emilia, Modena, Italy
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Saito Y, Nazif T, Baumbach A, Tchétché D, Latib A, Kaple R, Forrest J, Prendergast B, Lansky A. Adjunctive Antithrombotic Therapy for Patients With Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement. JAMA Cardiol 2021; 5:92-101. [PMID: 31721980 DOI: 10.1001/jamacardio.2019.4367] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Transcatheter aortic valve replacement (TAVR) is an established alternative to surgery for patients with severe symptomatic aortic stenosis. Adjunctive antithrombotic therapy used to mitigate thrombotic risks in patients undergoing TAVR must be balanced against bleeding complications, since both are associated with increased mortality. Observation Stroke risk associated with TAVR is lower than that associated with surgical aortic valve replacement in recent trials including patients at intermediate or low risk, but it is constant beginning at the time of implant and accrues over time based on patient risk factors. Patients with aortic stenosis undergoing TAVR also have a sizable risk of life-threatening or major bleeding. Although dual antiplatelet therapy for 3 to 6 months after TAVR is the guideline-recommended regimen, this practice is not well supported by current evidence. In patients with no indication for oral anticoagulation, current registry-based evidence suggests that single antiplatelet therapy may be safer than dual antiplatelet therapy. Similarly, oral anticoagulation monotherapy appears superior to anticoagulation plus antiplatelet therapy in those where oral anticoagulant use is indicated. To date, no risk prediction models have been established to guide antithrombotic therapy. Conclusions and Relevance Despite the growing volume of TAVR procedures to treat patients with severe aortic stenosis, evidence for adjunctive antithrombotic therapy remains rather scarce. Ongoing clinical trials will provide better understanding to guide antithrombotic therapy.
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Affiliation(s)
- Yuichi Saito
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Tamim Nazif
- Columbia University Medical Center, New York, New York
| | - Andreas Baumbach
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.,Barts Heart Centre, London and Queen Mary University of London, London, United Kingdom
| | | | - Azeem Latib
- Montefiore Medical Center, New York, New York
| | - Ryan Kaple
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - John Forrest
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Alexandra Lansky
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.,Barts Heart Centre, London and Queen Mary University of London, London, United Kingdom
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19
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Antithrombotic therapy with or without clopidogrel after transcatheter aortic valve replacement. A meta-analysis of randomized controlled trials. Clin Res Cardiol 2020; 111:14-22. [PMID: 33367949 PMCID: PMC8766395 DOI: 10.1007/s00392-020-01791-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/08/2020] [Indexed: 10/29/2022]
Abstract
AIMS To investigate the clinical outcomes associated with an antithrombotic therapy with or without clopidogrel after transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS This is a study-level meta-analysis including all randomized trials investigating antithrombotic regimens after TAVR. The protocol was registered with PROSPERO (CRD42020191036). We searched electronic scientific databases for eligible studies. The primary outcome was all-cause death. Main secondary outcome was major bleeding. Other outcomes were life-threatening (or disabling) bleeding, myocardial infarction (MI) and stroke. Six eligible trials randomly allocated 3056 TAVR patients to aspirin or oral anticoagulation (OAC) with clopidogrel (n = 1525) versus aspirin and/or OAC without clopidogrel (n = 1531). In the overall estimates, an antithrombotic therapy with clopidogrel versus without displayed a comparable risk of all-cause death [Risk Ratio-RR = 0.83, 95% Confidence intervals-CI (0.57-1.20); P = 0.25] and major bleeding [RR = 1.33, 95% CI (0.61-2.92); P = 0.39]. However, the combination of aspirin or OAC with clopidogrel doubled the risk of major bleeding as compared to aspirin or OAC without clopidogrel [RR = 2.08, 95% CI (1.27-3.42); P = 0.015, P for interaction = 0.021]. Treatment strategies did not differ with respect to the risk of life-threatening bleeding, MI and stroke. CONCLUSIONS In patients receiving TAVR, a therapeutic strategy of aspirin or OAC with clopidogrel significantly increases the risk of major bleeding without impact on mortality and ischemic outcomes compared to aspirin or OAC without clopidogrel. The performance of different antithrombotic regimens in terms of long-term clinical outcomes and bioprosthesis valve function requires further investigation. Forest plots from pairwise and network meta-analyses associated with an antithrombotic therapy with or without clopidogrel Risk ratio for all outcomes of interest calculated with the pairwise meta-analysis (left side) and for main outcomes calculated with the network meta-analysis (right side) in patients allocated to an antithrombotic therapy with clopidogrel or without. The diamonds indicate the point estimate and the left and the right ends of the lines the [95% CI]. CI: Confidence intervals; OAC; oral anticoagulation.
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20
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Patel KV, Omar W, Gonzalez PE, Jessen ME, Huffman L, Kumbhani DJ, Bavry AA. Expansion of TAVR into Low-Risk Patients and Who to Consider for SAVR. Cardiol Ther 2020; 9:377-394. [PMID: 32875469 PMCID: PMC7584721 DOI: 10.1007/s40119-020-00198-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Indexed: 12/15/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of severe aortic stenosis (AS) over the last decade. The results of the Placement of Aortic Transcatheter Valves (PARTNER) 3 and Evolut Low Risk trials demonstrated the safety and efficacy of TAVR in low-surgical-risk patients and led to the approval of TAVR for use across the risk spectrum. Heart teams around the world will now be faced with evaluating a deluge of younger, healthier patients with severe AS. Prior to the PARTNER 3 and Evolut Low Risk studies, this heterogenous patient population would have undergone surgical aortic valve replacement (SAVR). It is unlikely that TAVR will completely supplant SAVR for the treatment of severe AS in patients with a low surgical risk, as SAVR has excellent short- and long-term outcomes and years of durability data. In this review, we outline the critical role that SAVR will continue to play in the treatment of severe AS in the post-PARTNER 3/Evolut Low Risk era.
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Affiliation(s)
- Kunal V Patel
- Division of Cardiology, University of Texas Southwestern Medical Center, Texas, USA
| | - Wally Omar
- Division of Cardiology, University of Texas Southwestern Medical Center, Texas, USA
| | - Pedro Engel Gonzalez
- Division of Cardiology, University of Texas Southwestern Medical Center, Texas, USA
| | - Michael E Jessen
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Texas, USA
| | - Lynn Huffman
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Texas, USA
| | - Dharam J Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Texas, USA
| | - Anthony A Bavry
- Division of Cardiology, University of Texas Southwestern Medical Center, Texas, USA.
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21
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Chen S, Chau KH, Nazif TM. The incidence and impact of cardiac conduction disturbances after transcatheter aortic valve replacement. Ann Cardiothorac Surg 2020; 9:452-467. [PMID: 33312903 PMCID: PMC7724062 DOI: 10.21037/acs-2020-av-23] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/21/2020] [Indexed: 12/29/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) has developed into an established therapy for patients with severe aortic stenosis (AS) across the spectrum of surgical risk. Despite improvements in transcatheter heart valve (THV) technologies and procedural techniques, cardiac conduction disturbances, including high degree atrioventricular block (AVB) requiring permanent pacemaker (PPM) implantation and new-onset left bundle branch block (LBBB), remain frequent complications. TAVR-related conduction disturbances occur due to injury to the conduction system from interactions with interventional equipment and the transcatheter valve stent frame. Risk factors for post-TAVR conduction disturbances have been identified and include clinical characteristics, baseline electrocardiogram findings (right bundle branch block), anatomic factors, and potentially modifiable procedural factors (type of transcatheter valve, depth of implantation, over-sizing). New-onset LBBB and PPM implantation after TAVR have been shown to be associated with adverse long-term clinical outcomes, including mortality and heart failure hospitalization. These clinical consequences are likely to be of increasing importance as TAVR is utilized in younger and lower risk population. This review provides an updated overview of the literature regarding the incidence, predictors, and clinical outcomes of TAVR-related conduction disturbances, as well as proposed strategies for the management of this frequent clinical challenge.
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Affiliation(s)
- Shmuel Chen
- Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Katherine H Chau
- Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Tamim M Nazif
- Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA
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22
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Al Said S, Kaier K, Nury E, Alsaid D, Meder B, Gibson CM, Bax J, Meerpohl JJ, Katus H. Non-vitamin K antagonist oral anticoagulants (NOACs) after transcatheter aortic valve replacement (TAVR): a network meta-analysis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Samer Al Said
- Department for Internal Medicine III Cardiology Angiology and Pneumology; University Hospital Heidelberg; Heidelberg Germany
- DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim; University of Heidelberg; Heidelberg Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics; Faculty of Medicine and Medical Center, University of Freiburg; Freiburg Germany
| | - Edris Nury
- Institute for Evidence in Medicine, Medical Center - University of Freiburg; Faculty of Medicine, University of Freiburg; Freiburg Germany
| | - Dima Alsaid
- Institute for Evidence in Medicine, Medical Center - University of Freiburg; Faculty of Medicine, University of Freiburg; Freiburg Germany
| | - Benjamin Meder
- Department for Internal Medicine III Cardiology Angiology and Pneumology; University Hospital Heidelberg; Heidelberg Germany
- DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim; University of Heidelberg; Heidelberg Germany
| | - C. Michael Gibson
- Cardiology Division, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
| | - Jeroen Bax
- Department of Cardiology; Leiden University Medical Center; Leiden Netherlands
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine; Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg; Freiburg Germany
| | - Hugo Katus
- Department for Internal Medicine III Cardiology Angiology and Pneumology; University Hospital Heidelberg; Heidelberg Germany
- DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim; University of Heidelberg; Heidelberg Germany
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23
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Trauzeddel RF, Nordine M, Balanika M, Bence J, Bouchez S, Ender J, Erb JM, Fassl J, Fletcher N, Mukherjee C, Prabhu M, van der Maaten J, Wouters P, Guarracino F, Treskatsch S. Current Anesthetic Care of Patients Undergoing Transcatheter Aortic Valve Replacement in Europe: Results of an Online Survey. J Cardiothorac Vasc Anesth 2020; 35:1737-1746. [PMID: 33036889 DOI: 10.1053/j.jvca.2020.09.088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Transcatheter aortic valve replacement (TAVR) has become an alternative treatment for patients with symptomatic aortic stenosis not eligible for surgical valve replacement due to a high periprocedural risk or comorbidities. However, there are several areas of debate concerning the pre-, intra- and post-procedural management. The standards and management for these topics may vary widely among different institutions and countries in Europe. DESIGN Structured web-based, anonymized, voluntary survey. SETTING Distribution of the survey via email among members of the European Association of Cardiothoracic Anaesthesiology working in European centers performing TAVR between September and December 2018. PARTICIPANTS Physicians. MEASUREMENTS AND MAIN RESULTS The survey consisted of 25 questions, including inquiries regarding number of TAVR procedures, technical aspects of TAVR, medical specialities present, preoperative evaluation of TAVR candidates, anesthesia regimen, as well as postoperative management. Seventy members participated in the survey. Reporting members mostly performed 151-to-300 TAVR procedures per year. In 90% of the responses, a cardiologist, cardiac surgeon, cardiothoracic anesthesiologist, and perfusionist always were available. Sixty-six percent of the members had a national curriculum for cardiothoracic anesthesia. Among 60% of responders, the decision for TAVR was made preoperatively by an interdisciplinary heart team with a cardiothoracic anesthesiologist, yet in 5 countries an anesthesiologist was not part of the decision-making. General anesthesia was employed in 40% of the responses, monitored anesthesia care in 44%, local anesthesia in 23%, and in 49% all techniques were offered to the patients. In cases of general anesthesia, endotracheal intubation almost always was performed (91%). It was stated that norepinephrine was the vasopressor of choice (63% of centers). Transesophageal echocardiography guiding, whether performed by an anesthesiologist or cardiologist, was used only ≤30%. Postprocedurally, patients were transferred to an intensive care unit by 51.43% of the respondents with a reported nurse-to-patient ratio of 1:2 or 1:3, to a post-anesthesia care unit by 27.14%, to a postoperative recovery room by 11.43%, and to a peripheral ward by 10%. CONCLUSION The results indicated that requirements and quality indicators (eg, periprocedural anesthetic management, involvement of the anesthesiologist in the heart team, etc) for TAVR procedures as published within the European guideline are largely, yet still not fully implemented in daily routine. In addition, anesthetic TAVR management also is performed heterogeneously throughout Europe.
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Affiliation(s)
- Ralf Felix Trauzeddel
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Michael Nordine
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Marina Balanika
- Department of Anesthesiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Johan Bence
- Department of Anaesthesia and Intensive Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Stefaan Bouchez
- Department of Anesthesiology and Perioperative Medicine, Ghent University, Gent, Belgium
| | - Jörg Ender
- Department of Anesthesiology and Intensive Care Medicine, Leipzig Heart Center, Leipzig, Germany
| | | | - Jens Fassl
- Institute of Cardiac Anesthesiology, University Heart Center Dresden, Dresden, Germany
| | - Nick Fletcher
- St Georges Hospital NHS Trust, London, United Kingdom; Cleveland Clinic, London, United Kingdom
| | - Chirojit Mukherjee
- Department of Anesthesiology and Intensive Care Medicine, HELIOS Heart Surgery Clinic Karlsruhe, Karlsruhe, Germany
| | - Mahesh Prabhu
- Cardiothoracic Anaesthesia and Intensive Care, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Joost van der Maaten
- Department of Anesthesiology, University Medical Center Groningen, Faculty of Medical Sciences, Groningen, The Netherlands
| | - Patrick Wouters
- Department of Anesthesiology and Perioperative Medicine, Ghent University, Gent, Belgium
| | - Fabio Guarracino
- Department of Anesthesiology and Critical Care Medicine, Azienda Ospedaliero-Universitatria Pisana, Pisa, Italy
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
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24
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Musuku SR, Capua CAD, Doshi I, Cherukupalli D, Byun Y, Shapeton AD. Outcomes of Transfemoral Transcatheter Aortic Valve Replacement Performed With General Anesthesia Using a Supraglottic Airway Versus Monitored Anesthesia Care. J Cardiothorac Vasc Anesth 2020; 35:1760-1768. [PMID: 32980257 DOI: 10.1053/j.jvca.2020.09.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Compare general anesthesia with a supraglottic airway versus monitored anesthesia care for transfemoral transcatheter aortic valve replacement (TF-TAVR) in patients with aortic stenosis. The authors hypothesized that the supraglottic airway group would have similar operating room and procedure times, postanesthesia care unit (PACU) and hospital stays, and similar rates of intraprocedural and postprocedural complications compared with the monitored anesthesia care group. STUDY DESIGN Retrospective chart review with 1:1 propensity score matching of supraglottic airway to monitored anesthesia care patients. SETTING Tertiary care academic medical center. PARTICIPANTS TF-TAVR patients between 2017 and 2019. INTERVENTIONS Supraglottic airway or monitored anesthesia care. MEASUREMENTS AND MAIN RESULTS One hundred forty-eight supraglottic airway patients were matched with 148 monitored anesthesia care patients. Monitored anesthesia care patients had slightly shorter operating room (p < 0.001) and procedure times (p = 0.015). No difference was observed in hospital length of stay (p = 0.34). Fewer patients in the supraglottic airway group required a PACU stay >2 hours (p < 0.001). Use of intraprocedural vasopressors (p < 0.001) and fentanyl dosage (p < 0.001) was higher in the supraglottic airway group. No differences were observed in postoperative complications or procedural success rates. CONCLUSIONS In this, the first study to compare these 2 modalities, supraglottic airway use was demonstrated to be a safe, feasible alternative to monitored anesthesia care during TF-TAVR and did not increase organ-specific morbidity, 30-day mortality, hospital length of stay, or PACU length of stay. Even though supraglottic airway was associated with slight increases in procedure and operating room times, these were not clinically significant.
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Affiliation(s)
- Sridhar R Musuku
- Department of Anesthesiology and Perioperative Medicine, Albany Medical Center, Albany, NY.
| | | | | | - Divya Cherukupalli
- Department of Anesthesiology and Perioperative Medicine, Albany Medical Center, Albany, NY
| | | | - Alexander D Shapeton
- Department of Anesthesia, Critical Care and Pain Medicine, Veterans Affairs Boston Healthcare System, West Roxbury, MA; Tufts University School of Medicine, Boston, MA
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25
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Editorial commentary: Atrial fibrillation in TAVR patients: A new therapeutic challenge. Trends Cardiovasc Med 2020; 31:368-369. [PMID: 32828894 DOI: 10.1016/j.tcm.2020.08.005] [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: 08/16/2020] [Accepted: 08/16/2020] [Indexed: 11/20/2022]
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26
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Veulemans V, Afzal S, Papadopoulos G, Maier O, Kelm M, Zeus T, Hellhammer K. TAVR-related echocardiographic assessment - status quo, challenges and perspectives. Acta Cardiol 2020; 75:275-285. [PMID: 30856056 DOI: 10.1080/00015385.2019.1579979] [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] [Indexed: 12/27/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) is an emerging and a well-established procedure for high-risk and inoperable patients worldwide. Recent studies revealed furthermore that TAVR is equal or even superior to surgical valve replacement in intermediate risk patients. Therefore, a successful procedure is not only dependent on precise preprocedural patient selection but also on careful intraprocedural multimodal imaging guidance and adequate postprocedural follow-up. Up to date, 2D/3D transthoracic and/or transoesophageal echocardiography is an easy and goal-oriented tool for periprocedural TAVR-assessment regarding annulus measurements, cardiac function and concomitant valve diseases. Further procedural success is directly related to prevention of severe early and late complications. Thus, a careful intra- and postprocedural echocardiographic guidance is crucial to evaluate prosthetic function, position and its haemodynamic implication and changes in the integrity of the left ventricle during intra- and postprocedural management. We explored the role of echocardiography for pre-, intra- and postprocedural TAVR-assessment, illustrated by cases and possible algorithms, in a comprehensive literature review. Furthermore, we describe the role of fusion imaging, that is, real-time fusion of transoesophageal echocardiography and fluoroscopy (EchoNavigator Release System® I and II) during TAVR.
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Affiliation(s)
- Verena Veulemans
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Duesseldorf, Düsseldorf, Germany
| | - Shazia Afzal
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Duesseldorf, Düsseldorf, Germany
| | - Georgios Papadopoulos
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Duesseldorf, Düsseldorf, Germany
| | - Oliver Maier
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Duesseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Duesseldorf, Düsseldorf, Germany
| | - Tobias Zeus
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Duesseldorf, Düsseldorf, Germany
| | - Katharina Hellhammer
- Division of Cardiology, Pneumology, and Vascular Medicine, Department of Medicine, University Hospital Duesseldorf, Düsseldorf, Germany
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Ammar A, Elbatran AI, Wijesuriya N, Saberwal B, Ahsan SY. Management of atrial fibrillation after transcatheter aortic valve replacement: Challenges and therapeutic considerations. Trends Cardiovasc Med 2020; 31:361-367. [PMID: 32599334 DOI: 10.1016/j.tcm.2020.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 12/20/2022]
Abstract
Atrial Fibrillation (AF) is very common among patients with severe aortic stenosis. Moreover, new onset AF (NOAF) is a frequent finding after Transcatheter Aortic Valve Replacement (TAVR). There is a significant impact of AF on outcomes in patients undergoing TAVR including mortality, thrombo-embolic and bleeding events. There is lack of clear evidence about the optimal management of AF in TAVR patients. This review aims to summarize the epidemiology, predictors, prognosis, therapeutic considerations and challenges in the management of AF in patients undergoing TAVR.
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Affiliation(s)
- Ahmed Ammar
- Barts Heart Centre, St Bartholomew's Hospital, London, UK; Department of Cardiology, Ain Shams University, Cairo, Egypt.
| | | | | | - Bunny Saberwal
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Syed Y Ahsan
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
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28
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Tovia-Brodie O, Michowitz Y, Belhassen B. Use of Electrophysiological Studies in Transcatheter Aortic Valve Implantation. Arrhythm Electrophysiol Rev 2020; 9:20-27. [PMID: 32637116 PMCID: PMC7330728 DOI: 10.15420/aer.2019.38.3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
New conduction disturbances requiring permanent pacemaker implantation remain common complications following transcatheter aortic valve implantation (TAVI). It has been suggested that electrophysiological studies could help identify patients who will require permanent pacemaker implantation after TAVI. This article summarises contemporary data on the use of electrophysiological studies in patients undergoing TAVI.
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Affiliation(s)
- Oholi Tovia-Brodie
- Department of Cardiology, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yoav Michowitz
- Department of Cardiology, Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
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29
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Capodanno D, Greco A. Stroke After Transcatheter Aortic Valve Replacement: A Multifactorial Phenomenon. JACC Cardiovasc Interv 2020; 12:1590-1593. [PMID: 31439339 DOI: 10.1016/j.jcin.2019.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/01/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Davide Capodanno
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele," University of Catania, Catania, Italy.
| | - Antonio Greco
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele," University of Catania, Catania, Italy
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30
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Chakravarty T, Patel A, Kapadia S, Raschpichler M, Smalling RW, Szeto WY, Abramowitz Y, Cheng W, Douglas PS, Hahn RT, Herrmann HC, Kereiakes D, Svensson L, Yoon SH, Babaliaros VC, Kodali S, Thourani VH, Alu MC, Liu Y, McAndrew T, Mack M, Leon MB, Makkar RR. Anticoagulation After Surgical or Transcatheter Bioprosthetic Aortic Valve Replacement. J Am Coll Cardiol 2020; 74:1190-1200. [PMID: 31466616 DOI: 10.1016/j.jacc.2019.06.058] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 06/16/2019] [Accepted: 06/18/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is paucity of evidence on the impact of anticoagulation (AC) after bioprosthetic aortic valve replacement (AVR) on valve hemodynamics and clinical outcomes. OBJECTIVES The study aimed to assess the impact of AC after bioprosthetic AVR on valve hemodynamics and clinical outcomes. METHODS Data on antiplatelet and antithrombotic therapy were collected. Echocardiograms were performed at 30 days and 1 year post-AVR. Linear regression model and propensity-score adjusted cox proportional model were used to assess the impact of AC on valve hemodynamics and clinical outcomes, respectively. RESULTS A total of 4,832 patients undergoing bioprosthetic AVR (transcatheter aortic valve replacement [TAVR], n = 3,889 and surgical AVR [SAVR], n = 943) in the pooled cohort of PARTNER2 (Placement of Aortic Transcatheter Valves) randomized trials and nonrandomized registries were studied. Following adjustment for valve size, annular diameter, atrial fibrillation, and ejection fraction at the time of assessment of hemodynamics, there was no significant difference in aortic valve mean gradients or aortic valve areas between patients discharged on AC vs. those not discharged on AC, for either TAVR or SAVR cohorts. A significantly greater proportion of patients not discharged on AC had an increase in mean gradient >10 mm Hg from 30 days to 1 year, compared with those discharged on AC (2.3% vs. 1.1%, p = 0.03). There was no independent association between AC after TAVR and adverse outcomes (death, p = 0.15; rehospitalization, p = 0.16), whereas AC after SAVR was associated with significantly fewer strokes (hazard ratio [HR]: 0.17; 95% confidence interval [CI]: 0.05-0.60; p = 0.006). CONCLUSIONS In the short term, early AC after bioprosthetic AVR did not result in adverse clinical events, did not significantly affect aortic valve hemodynamics (aortic valve gradients or area), and was associated with decreased rates of stroke after SAVR (but not after TAVR). Whether early AC after bioprosthetic AVR has impact on long-term outcomes remains to be determined. (Placement of AoRTic TraNscathetER Valves [PARTNERII A]; NCT01314313).
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Affiliation(s)
- Tarun Chakravarty
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Akshar Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | | | | | - Yigal Abramowitz
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Wen Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Pamela S Douglas
- Duke University Medical Center/Duke Clinical Research Institute, Durham, North Carolina
| | - Rebecca T Hahn
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | | | | | | | - Sung-Han Yoon
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Susheel Kodali
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Vinod H Thourani
- Medstar Heart & Vascular Institute, Washington Hospital Center, Washington, DC
| | - Maria C Alu
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Yangbo Liu
- Cardiovascular Research Foundation, New York, New York
| | | | | | - Martin B Leon
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Raj R Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Biasco L, Cerrato E, Tersalvi G, Pedrazzini G, Wilkins B, Faletra F, Ferrari E, Demertzis S, Senatore G, Di Leo A, Varbella F, De Backer O, Nombela Franco L. WorldwIde SurvEy on Clinical and Anatomical Factors Driving the Choice of Transcatheter Aortic Valve pRostheses. Front Cardiovasc Med 2020; 7:38. [PMID: 32266292 PMCID: PMC7098951 DOI: 10.3389/fcvm.2020.00038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/27/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Following the success of the first human transcatheter aortic valve replacement (TAVR) in 2002, multiple transcatheter heart valves (THVs) have become available. However, guidelines or expert consensus on how to optimize THV choice according to patients' anatomical and clinical characteristics is missing. This survey-based study aimed to identify patient-specific characteristics deemed important in the choice of THV type. Methods and results: A web-based survey including 39 questions was completed by 71 experienced TAVR operators from 23 countries with a median TAVR volume of 88 procedures in the year prior to survey completion (IQR 61-180). The survey covered five topics: access, aortic annulus/leaflets, aortic root, left ventricular function and clinical characteristics. Factors with the most impact on THV choice were reported to be a calcified sinotubular junction, valve-in-valve procedure, annular dimension >575 mm2, femoral diameter ≤ 5.0 mm, low coronary ostia, calcification at the annular level and/or protruding into the left ventricular outflow tract, and need for post TAVR PCI. Also, in case of off-label use of THVs to treat bicuspid aortic valve disease and isolated aortic regurgitation, the choice of THV type was reported to be important. Conclusions: This survey-based study identifies key patient characteristics that impact THV selection. As such, we present a guide, based on current practice, of which THV types are best suited to these different patient-specific characteristics. A patient-tailored THV choice is likely to optimize TAVR outcomes.
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Affiliation(s)
- Luigi Biasco
- Department of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.,Division of Cardiology, Azienda Sanitaria Locale TO 4, Ciriè, Italy
| | - Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano and Rivoli Infermi Hospital, Rivoli, Italy
| | | | - Giovanni Pedrazzini
- Department of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.,Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Ben Wilkins
- Division of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Enrico Ferrari
- Division of Cardiac Surgery, Cardiocentro Ticino, Lugano, Switzerland
| | | | - Gaetano Senatore
- Division of Cardiology, Azienda Sanitaria Locale TO 4, Ciriè, Italy
| | - Angelo Di Leo
- Division of Cardiology, Azienda Sanitaria Locale TO 4, Ciriè, Italy
| | - Ferdinando Varbella
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano and Rivoli Infermi Hospital, Rivoli, Italy
| | - Ole De Backer
- Division of Cardiac Surgery, Cardiocentro Ticino, Lugano, Switzerland
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Greco A, Capodanno D. Anticoagulation after Transcatheter Aortic Valve Implantation: Current Status. Interv Cardiol 2020; 15:e02. [PMID: 32382318 PMCID: PMC7203879 DOI: 10.15420/icr.2019.24] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 01/27/2020] [Indexed: 02/07/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is the standard of care for symptomatic severe aortic stenosis. Antithrombotic therapy is required after TAVI to prevent thrombotic complications but it increases the risk of bleeding events. Current clinical guidelines are mostly driven by expert opinion and therefore yield low-grade recommendations. The optimal antithrombotic regimen following TAVI has yet to be determined and several randomised controlled trials assessing this issue are ongoing. The purpose of this article is to critically explore the impact of antithrombotic drugs, especially anticoagulants, on long-term clinical outcomes following successful TAVI.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, CAST, PO G Rodolico, Policlinico-Vittorio Emanuele University Hospital, University of Catania Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, CAST, PO G Rodolico, Policlinico-Vittorio Emanuele University Hospital, University of Catania Catania, Italy
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Junquera L, Kalavrouziotis D, Côté M, Dumont E, Paradis JM, DeLarochellière R, Rodés-Cabau J, Mohammadi S. Results of transcarotid compared with transfemoral transcatheter aortic valve replacement. J Thorac Cardiovasc Surg 2020; 163:69-77. [DOI: 10.1016/j.jtcvs.2020.03.091] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 03/20/2020] [Accepted: 03/21/2020] [Indexed: 12/01/2022]
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Stachon P, Kaier K, Oettinger V, Bothe W, Zehender M, Bode C, von Zur Mühlen C. Transapical aortic valve replacement versus surgical aortic valve replacement: A subgroup analyses for at-risk populations. J Thorac Cardiovasc Surg 2020; 162:1701-1709.e1. [PMID: 32222407 DOI: 10.1016/j.jtcvs.2020.02.078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 02/19/2020] [Accepted: 02/19/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND If the transfemoral access is not feasible, a transapical access or surgical aortic valve replacement (SAVR) are alternatives for patients with aortic valve stenosis. OBJECTIVES To identify patient groups who benefit from SAVR or transapical transcatheter aortic valve replacement (TA-TAVR), we compared in-hospital outcomes of patients in a nationwide dataset. METHODS We identified 19,016 isolated SAVR and 6432 TA-TAVR performed in Germany from 2014 to 2016. We adjusted for risk factors using a covariate- and propensity-adjusted analysis. RESULTS Patients undergoing TA-TAVR were older, had more comorbidities, and accordingly greater estimated operative risk (logistic European System for Cardiac Operative Risk Evaluation 5.3 vs 17.0, P < .001). However, adjusted risk for in-hospital complications such as stroke, acute kidney injury, relevant bleeding, and prolonged mechanical ventilation >48 hours was lower in patients undergoing TA-TAVR (all P < .001). When we compared in-hospital mortality of all patients undergoing either TA-TAVR or SAVR, neither treatment strategy had a clear advantage (covariate-adjusted odds ratio [caOR], 1.13, P = .251; propensity-adjusted OR [paOR], 1.12, P = .309). Two patient subgroups seem to benefit more from SAVR than TA-TAVR: patients <75 years (caOR, 1.29, P = .237; paOR, 2.12, P = .001) and those with European System for Cardiac Operative Risk Evaluation 4-9 (caOR, 1.32, P = .114; paOR, 1.43, P = .041). Female patients had a tendency toward lower risk for in-hospital mortality when undergoing SAVR (caOR, 1.42, P = .030). In patients with chronic renal failure, TA-TAVR was superior (caOR, 0.56, P = .039, P = .040). CONCLUSIONS Patients <75 years and those at low operative risk who underwent SAVR had lower in-hospital mortality than those undergoing TA-TAVR. Patients with chronic renal failure who underwent TA-TAVR had lower in hospital mortality than those that underwent SAVR.
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Affiliation(s)
- Peter Stachon
- Faculty of Medicine, Department of Cardiology and Angiology I, Heart Center Freiburg, University of Freiburg, Freiburg, Germany.
| | - Klaus Kaier
- Faculty of Medicine, Institute of Medical Biometry and Statistics, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Vera Oettinger
- Faculty of Medicine, Department of Cardiology and Angiology I, Heart Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Wolfgang Bothe
- Faculty of Medicine, Department of Cardiac and Vascular Surgery, Heart Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Faculty of Medicine, Department of Cardiology and Angiology I, Heart Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Faculty of Medicine, Department of Cardiology and Angiology I, Heart Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Mühlen
- Faculty of Medicine, Department of Cardiology and Angiology I, Heart Center Freiburg, University of Freiburg, Freiburg, Germany
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35
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Lugo LM, Romaguera R, Gómez-Hospital JA, Ferreiro JL. Antithrombotic Therapy After Transcatheter Aortic Valve Implantation. Eur Cardiol 2020; 15:1-8. [PMID: 32180830 PMCID: PMC7066806 DOI: 10.15420/ecr.2019.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/10/2019] [Indexed: 12/25/2022] Open
Abstract
The development of transcatheter aortic valve implantation has represented one of the greatest advances in the cardiology field in recent years and has changed clinical practice for patients with aortic stenosis. Despite the continuous improvement in operators’ experience and techniques, and the development of new generation devices, thromboembolic and bleeding complications after transcatheter aortic valve implantation remain frequent, and are a major concern due to their negative impact on prognosis in this vulnerable population. In addition, the optimal antithrombotic regimen in this scenario is not known, and current recommendations are mostly empirical and not evidence based. The present review aims to provide an overview of the current status of knowledge, including relevant on-going randomised trials, on antithrombotic treatment strategies after transcatheter aortic valve implantation.
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Affiliation(s)
- Leslie Marisol Lugo
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit/Medical Research Foundation, University of Western Australia, Perth, Australia
| | - Rafael Romaguera
- Heart Diseases Institute, Hospital Universitario de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Joan Antoni Gómez-Hospital
- Department of Cardiology, Hospital Universitario de Bellvitge - IDIBELL, CIBER-CV, L'Hospitalet de Llobregat, Barcelona, Spain
| | - José Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge - IDIBELL, CIBER-CV, L'Hospitalet de Llobregat, Barcelona, Spain
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36
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Guedeney P, Mehran R, Collet JP, Claessen BE, Ten Berg J, Dangas GD. Antithrombotic Therapy After Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2020; 12:e007411. [PMID: 30630354 DOI: 10.1161/circinterventions.118.007411] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The performance of transcatheter aortic valve replacement has expanded considerably during the past decade. Technological advances and refinement in implantation techniques have resulted in improved procedural outcomes, whereas indications are progressively extending toward lower-risk patients. Ischemic/embolic complications and major bleeding remain important and strongly correlate to mortality. In this regard, the optimal antithrombotic regimen after successful transcatheter aortic valve replacement remains unclear, in the absence of randomized trials. For patients without an indication for oral anticoagulation, empirical treatment with dual antiplatelet therapy (aspirin plus clopidogrel) for 3 to 6 months is currently recommended. However, dual antiplatelet therapy has been preliminarily associated with increased risk of bleeding compared with single antiplatelet therapy without significant ischemic benefit. Non-vitamin K oral anticoagulants and warfarin have also entered clinical investigation, to address the issue of preexisting or new-onset of atrial fibrillation and potentially attenuate subclinical leaflet thrombosis. Clinical trials are necessary to systematically address the risks and benefits of these approaches. In this review, we present the pathophysiological mechanisms of post-transcatheter aortic valve replacement complications and provide updated insights on the rationale behind the various antithrombotic regimens being currently evaluated in large randomized trials.
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Affiliation(s)
- Paul Guedeney
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, NY (P.G., R.M., B.E.C., G.D.D.).,ACTION Study Group, Sorbonne Université, INSERM UMR_S 1166, Institut de Cardiologie, Hôpital Pitié Salpêtrière, Paris, France (P.G., J.-P.C.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, NY (P.G., R.M., B.E.C., G.D.D.)
| | - Jean-Philippe Collet
- ACTION Study Group, Sorbonne Université, INSERM UMR_S 1166, Institut de Cardiologie, Hôpital Pitié Salpêtrière, Paris, France (P.G., J.-P.C.)
| | - Bimmer E Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, NY (P.G., R.M., B.E.C., G.D.D.)
| | - Jurriën Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands (J.t.B.)
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, New York, NY (P.G., R.M., B.E.C., G.D.D.)
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Yu S, Fabbro M, Aljure O. Expert Consensus Systems of Care Proposal to Optimize Care for Patients With Valvular Heart Disease Review of the 2019 Document for the Cardiac Anesthesiologist. J Cardiothorac Vasc Anesth 2020; 34:2476-2483. [PMID: 31917079 DOI: 10.1053/j.jvca.2019.11.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/09/2019] [Accepted: 11/28/2019] [Indexed: 11/11/2022]
Abstract
Valvular heart disease requiring intervention is increasing in prevalence in the adult population. With advancement in transcatheter and surgical procedures for valvular heart disease, optimization of patient selection, availability of resources and personnel, appropriate training and certification, and optimal periprocedural management rely on clinical evaluation, accurate echocardiographic interpretation, and understanding of valvular pathophysiology by the cardiac anesthesiologist. To optimize care and improve access for patients with valvular heart disease the Expert Consensus Systems of Care Document by Nishimura et al.1 was recently published. The authors propose a protocol with guidelines and performance metrics to create tiered-level valve centers. This review focuses and expands on aspects discussed in Nishimura et al.'s Expert Consensus Systems of Care Document that are relevant to the cardiac anesthesiologist in the periprocedural setting.
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Affiliation(s)
- Soojie Yu
- University of Miami Miller School of Medicine, Department of Anesthesiology, Miami, FL.
| | - Michael Fabbro
- University of Miami Miller School of Medicine, Department of Anesthesiology, Miami, FL
| | - Oscar Aljure
- University of Miami Miller School of Medicine, Department of Anesthesiology, Miami, FL
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Roca F, Durand E, Eltchaninoff H, Chassagne P. Predictive Value for Outcome and Evolution of Geriatric Parameters after Transcatheter Aortic Valve Implantation. J Nutr Health Aging 2020; 24:598-605. [PMID: 32510112 DOI: 10.1007/s12603-020-1375-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify parameters of comprehensive geriatric assessment (CGA) CGA including ABCDEF score, a multidomain frailty assessment, associated with poor outcome after TAVI and to assess the evolution of CGA parameters at 6-months follow-up. DESIGN one-year monocentric prospective cohort study. SETTING Departments of geriatric medicine and cardiology in Rouen University Hospital, Normandy, France. PARTICIPANTS all patients over 70, selected for TAVI by a multidisciplinary "heart team". MEASUREMENTS 8-areas CGA was performed before TAVI and at 6-months follow-up. Poor outcome was defined as decrease in 1 BADL or unplanned readmission at 6 months or death within the first year after TAVI. Geriatric characteristics associated with poor outcome were assessed by logistic regression with surgical scores as bivariable. Geriatric characteristics were compared between baseline and 6-months follow-up. RESULTS 114 patients (mean age 85.8±5.3 years) were included. Mean EuroSCORE was 19.1±10.6%. Poor outcome occurred in 57(50.0%) patients. Loss of one BADL (OR:1.66, 95CI[1.11-2.48]), decrease in IADL (OR:1.41, 95CI[1.14-1.74]), in plasmatic albumin (OR:1.10, 95CI[1.01-1.20]), in MMSe (OR:1.13, 95CI[1.02-1.26]), low walking speed (OR:1.53, 95CI[1.01-2.33]) and ABCDEF score ≥2 (OR:1.63, 95CI[1.09-2.42]) were independently associated with poor outcome. In survivors with complete follow-up (n=80), most geriatric parameters were maintained 6 months after TAVI, but IADL decreased (5.6±1.9 to 4.9±2.2, p<0.001). MMSe increased in patients with previous cognitive impairments whereas it decreased in those without (p<0.001). CONCLUSION CGA parameters are independently associated with poor outcome after TAVI. These parameters, but IADL, are maintained at 6 months and course of the MMSe depends on previous cognitive status.
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Affiliation(s)
- F Roca
- Dr Roca Frédéric, Service de Médecine Gériatrique, CHU de Rouen, 76031 Rouen Cedex, France. Tel: +33 2 32 88 93 67, Fax: +33 2 32 88 06 01;
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Jimenez Diaz VA, Tello-Montoliu A, Moreno R, Cruz Gonzalez I, Baz Alonso JA, Romaguera R, Molina Navarro E, Juan Salvadores P, Paredes Galan E, De Miguel Castro A, Bastos Fernandez G, Ortiz Saez A, Fernandez Barbeira S, Raposeiras Roubin S, Ocampo Miguez J, Serra Peñaranda A, Valdes Chavarri M, Cequier Fillat A, Calvo Iglesias F, Iñiguez Romo A. Assessment of Platelet REACtivity After Transcatheter Aortic Valve Replacement: The REAC-TAVI Trial. JACC Cardiovasc Interv 2019; 12:22-32. [PMID: 30621974 DOI: 10.1016/j.jcin.2018.10.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/17/2018] [Accepted: 10/02/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The REAC-TAVI (Assessment of platelet REACtivity after Transcatheter Aortic Valve Implantation) trial enrolled patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) pre-treated with aspirin + clopidogrel, aimed to compare the efficacy of clopidogrel and ticagrelor in suppressing high platelet reactivity (HPR) after TAVI. BACKGROUND Current recommendations support short-term use of aspirin + clopidogrel for patients with severe AS undergoing TAVR despite the lack of compelling evidence. METHODS This was a prospective, randomized, multicenter investigation. Platelet reactivity was measured at 6 different time points with the VerifyNow assay (Accriva Diagnostics, San Diego, California). HPR was defined as (P2Y12 reaction units (PRU) ≥208. Patients with HPR before TAVR were randomized to either aspirin + ticagrelor or aspirin + clopidogrel for 3 months. Patients without HPR continued with aspirin + clopidogrel (registry cohort). The primary endpoint was non-HPR status (PRU <208) in ≥70% of patients treated with ticagrelor at 90 days post-TAVR. RESULTS A total of 68 patients were included. Of these, 48 (71%) had HPR (PRU 273 ± 09) and were randomized to aspirin + ticagrelor (n = 24, PRU 277 ± 08) or continued with aspirin + clopidogrel (n = 24, PRU 269 ± 49). The remaining 20 patients (29%) without HPR (PRU 133 ± 12) were included in the registry. Overall, platelet reactivity across all the study time points after TAVR was lower in patients randomized to ticagrelor compared with those treated with clopidogrel, including those enrolled in the registry (p < 0.001). The primary endpoint was achieved in 100% of patients with ticagrelor compared with 21% with clopidogrel (p < 0.001). Interestingly, 33% of clopidogrel responder patients at baseline developed HPR status during the first month after TAVR. CONCLUSIONS HPR to clopidogrel is present in a considerable number of patients with AS undergoing TAVR. Ticagrelor achieves a better and faster effect, providing sustained suppression of HPR to these patients. (Platelet Reactivity After TAVI: A Multicenter Pilot Study [REAC-TAVI]; NCT02224066).
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Affiliation(s)
- Victor Alfonso Jimenez Diaz
- Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain; Cardiovascular Research Unit, Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain.
| | - Antonio Tello-Montoliu
- Cardiology Department, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (Network Research Center for Cardiovascular Diseases), CIBER-CV, Madrid, Spain
| | - Raul Moreno
- Cardiology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Ignacio Cruz Gonzalez
- Centro de Investigación en Red de Enfermedades Cardiovasculares (Network Research Center for Cardiovascular Diseases), CIBER-CV, Madrid, Spain; Cardiology Department, Hospital Universitario de Salamanca, Salamanca, Spain
| | | | - Rafael Romaguera
- Cardiology Department, Hospital Universitario de Bellvitge, Barcelona, Spain
| | | | - Pablo Juan Salvadores
- Cardiovascular Research Unit, Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain; Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain
| | - Emilio Paredes Galan
- Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
| | | | | | - Alberto Ortiz Saez
- Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
| | | | | | - Juan Ocampo Miguez
- Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
| | | | - Mariano Valdes Chavarri
- Cardiology Department, Hospital Universitario Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (Network Research Center for Cardiovascular Diseases), CIBER-CV, Madrid, Spain
| | - Angel Cequier Fillat
- Centro de Investigación en Red de Enfermedades Cardiovasculares (Network Research Center for Cardiovascular Diseases), CIBER-CV, Madrid, Spain; Cardiology Department, Hospital Universitario de Bellvitge, Barcelona, Spain
| | | | - Andres Iñiguez Romo
- Cardiology Department, Hospital Alvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (Network Research Center for Cardiovascular Diseases), CIBER-CV, Madrid, Spain
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Abstract
New developments in transcatheter valve technologies including aortic valve replacement and mitral valve and tricuspid valve interventions are described. Recent studies evaluating the success rate, patient outcomes, and anesthesiologic management of the procedures are discussed.
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Affiliation(s)
- Michael A Ackermann
- Department of Anesthesiology and Intensive Care Medicine, Heart Centre Leipzig, Struempellstr 39, Leipzig 04289, Germany
| | - Jörg K Ender
- Department of Anesthesiology and Intensive Care Medicine, Heart Centre Leipzig, Struempellstr 39, Leipzig 04289, Germany.
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41
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Cook SA, Navas-Blanco JR, Acho C, Han X, Wyman J, Szymanski TJ. Comparison of Patient Outcomes of Transfemoral Transcatheter Aortic Valve Replacement Using Pre-Sedation Radial Versus Post-Sedation Femoral Arterial Sites for Blood Pressure Monitoring. J Cardiothorac Vasc Anesth 2019; 33:3303-3308. [DOI: 10.1053/j.jvca.2019.01.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 11/11/2022]
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Shirakawa K, Murata M. Significance of echocardiographic evaluation for transcatheter aortic valve implantation. Cardiovasc Interv Ther 2019; 35:85-95. [PMID: 31502235 DOI: 10.1007/s12928-019-00617-6] [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] [Received: 08/19/2019] [Accepted: 08/29/2019] [Indexed: 10/26/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is widely accepted as an alternative to surgical aortic valve replacement (SAVR) for the treatment of severe aortic stenosis (AS). Existing scientific evidence demonstrates that TAVI is superior to SAVR, and it is expected that indications for the clinical applications of TAVI will be expanded in the future. Echocardiography plays a key role in perioperative assessment of patients undergoing TAVI. Preprocedural echocardiographic evaluation is important to determine the severity of AS in addition to patients' anatomical suitability for TAVI. Furthermore, echocardiography is essential for intraoperative guidance, assessment of complications, postoperative evaluation, and prognostic prediction. Inaccurate echocardiographic measurements and evaluation can lead to less-than-optimal/inappropriate treatment strategies in patients with AS. Therefore, a thorough understanding of the limitations of echocardiographic evaluation is important. This review summarizes the role of echocardiographic evaluation in patients undergoing TAVI.
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Affiliation(s)
- Kohsuke Shirakawa
- Japan Society for the Promotion of Science, Tokyo, Japan.,Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Mitsushige Murata
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan. .,School of Medicine, Center for Preventive Medicine, Keio University, Tokyo, Japan.
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Rodés-Cabau J. Optimizing Valve Implantation Depth to Win the Battle Against Conduction Disturbances Post-TAVR. JACC Cardiovasc Interv 2019; 12:1808-1810. [DOI: 10.1016/j.jcin.2019.06.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
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44
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Rodés-Cabau J, Ellenbogen KA, Krahn AD, Latib A, Mack M, Mittal S, Muntané-Carol G, Nazif TM, Sondergaard L, Urena M, Windecker S, Philippon F. Management of Conduction Disturbances Associated With Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2019; 74:1086-1106. [DOI: 10.1016/j.jacc.2019.07.014] [Citation(s) in RCA: 171] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/05/2019] [Accepted: 07/07/2019] [Indexed: 12/12/2022]
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45
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Greco A, Capranzano P, Barbanti M, Tamburino C, Capodanno D. Antithrombotic pharmacotherapy after transcatheter aortic valve implantation: an update. Expert Rev Cardiovasc Ther 2019; 17:479-496. [PMID: 31198065 DOI: 10.1080/14779072.2019.1632189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Transcatheter aortic valve implantation (TAVI) is the treatment of choice for a large proportion of patients with severe aortic stenosis. Despite numerous technological and clinical advances, TAVI remains associated with thrombotic complications requiring antithrombotic pharmacotherapy, which exposes to the risk of bleeding, especially in elderly individuals. The optimal antithrombotic regimen following TAVI is uncertain and several investigations are ongoing. Areas covered: Clinical guidelines are mostly driven by observational trials and experts' opinions, thus resulting into low-grade level of evidence. The aim of the current review is to critically explore the epidemiology, pathophysiology and prognostic value of thrombotic and bleeding events after TAVI, and to review the current literature on antithrombotic strategies following the procedure. Expert opinion: Thrombotic and bleeding events remain major complications occurring in the frail population that is currently offered TAVI. Waiting for upcoming evidence from ongoing randomized clinical trials, tailoring antithrombotic therapies based on patients' characteristics, values and circumstances is a preferable approach.
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Affiliation(s)
- Antonio Greco
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Piera Capranzano
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Marco Barbanti
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Corrado Tamburino
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Davide Capodanno
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
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46
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Valvo R, Costa G, Tamburino C, Barbanti M. Antithrombotic Therapy in Transcatheter Aortic Valve Replacement. Front Cardiovasc Med 2019; 6:73. [PMID: 31214599 PMCID: PMC6554284 DOI: 10.3389/fcvm.2019.00073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 05/15/2019] [Indexed: 11/13/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has recently emerged as an effective alternative to medical treatment or surgical aortic valve replacement in all symptomatic patients with severe aortic stenosis and high or prohibitive risk and in intermediate risk when transfemoral access is feasible. Patients undergoing TAVR are often at high risk for either bleeding or cerebrovascular complications, or both, so adjuvant antithrombotic therapies are commonly used before, during and after the procedure. Today, there is no clear evidence on the best antithrombotic regimen in this context. In this review, we will try to go through the mechanisms involved in bleeding and embolic complications and we will discuss the current points of antithrombotic treatment in patients during and after TAVR, with or without oral anticoagulation (OAC) indication.
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Affiliation(s)
| | | | | | - Marco Barbanti
- Division of Cardiology, Policlinico–Vittorio Emanuele Hospital, University of Catania, Catania, Italy
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Mäkikallio T, Jalava MP, Husso A, Virtanen M, Laakso T, Ahvenvaara T, Tauriainen T, Maaranen P, Kinnunen EM, Dahlbacka S, Jaakkola J, Airaksinen J, Anttila V, Savontaus M, Laine M, Juvonen T, Valtola A, Raivio P, Eskola M, Niemelä M, Biancari F. Ten-year experience with transcatheter and surgical aortic valve replacement in Finland. Ann Med 2019; 51:270-279. [PMID: 31112060 PMCID: PMC7880078 DOI: 10.1080/07853890.2019.1614657] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Aim: We investigated the outcomes of transcatheter (TAVR) and surgical aortic valve replacement (SAVR) in Finland during the last decade. Methods: The nationwide FinnValve registry included data from 6463 patients who underwent TAVR or SAVR with a bioprosthesis for aortic stenosis from 2008 to 2017. Results: The annual number of treated patients increased three-fold during the study period. Thirty-day mortality declined from 4.8% to 1.2% for TAVR (p = .011) and from 4.1% to 1.8% for SAVR (p = .048). Two-year survival improved from 71.4% to 83.9% for TAVR (p < .001) and from 87.2% to 91.6% for SAVR (p = .006). During the study period, a significant reduction in moderate-to-severe paravalvular regurgitation was observed among TAVR patients and a reduction of the rate of acute kidney injury was observed among both SAVR and TAVR patients. Similarly, the rate of red blood cell transfusion and severe bleeding decreased significantly among SAVR and TAVR patients. Hospital stay declined from 10.4 ± 8.4 to 3.7 ± 3.4 days after TAVR (p < .001) and from 9.0 ± 5.9 to 7.8 ± 5.1 days after SAVR (p < .001). Conclusions: In Finland, the introduction of TAVR has led to an increase in the invasive treatment of severe aortic stenosis, which was accompanied by improved early outcomes after both SAVR and TAVR. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT03385915 Key Messages This study demonstrated that the introduction of transcatheter aortic valve replacement has led to its widespread use as an invasive treatment for severe aortic stenosis. Early and 2-year survival after transcatheter and surgical aortic valve replacement has improved during past decade. Transcatheter aortic valve replacement has fulfilled its previously unmet clinical needs and has surpassed surgical aortic valve replacement as the most common invasive treatment for aortic stenosis.
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Affiliation(s)
- Timo Mäkikallio
- a Department of Internal Medicine , Oulu University Hospital , Oulu , Finland
| | - Maina P Jalava
- b Heart Center , Turku University Hospital and University of Turku , Turku , Finland
| | | | - Marko Virtanen
- d Heart Hospital , Tampere University Hospital , Tampere , Finland
| | - Teemu Laakso
- e Heart Center , Helsinki University Hospital , Helsinki , Finland
| | - Tuomas Ahvenvaara
- f Department of Surgery , Oulu University Hospital and University of Oulu , Finland
| | - Tuomas Tauriainen
- f Department of Surgery , Oulu University Hospital and University of Oulu , Finland
| | - Pasi Maaranen
- d Heart Hospital , Tampere University Hospital , Tampere , Finland
| | | | | | - Jussi Jaakkola
- b Heart Center , Turku University Hospital and University of Turku , Turku , Finland
| | - Juhani Airaksinen
- b Heart Center , Turku University Hospital and University of Turku , Turku , Finland
| | - Vesa Anttila
- b Heart Center , Turku University Hospital and University of Turku , Turku , Finland
| | - Mikko Savontaus
- b Heart Center , Turku University Hospital and University of Turku , Turku , Finland
| | - Mika Laine
- e Heart Center , Helsinki University Hospital , Helsinki , Finland
| | - Tatu Juvonen
- e Heart Center , Helsinki University Hospital , Helsinki , Finland
| | - Antti Valtola
- c Heart Center , Kuopio University Hospital , Kuopio , Finland
| | - Peter Raivio
- e Heart Center , Helsinki University Hospital , Helsinki , Finland
| | - Markku Eskola
- d Heart Hospital , Tampere University Hospital , Tampere , Finland
| | - Matti Niemelä
- a Department of Internal Medicine , Oulu University Hospital , Oulu , Finland
| | - Fausto Biancari
- b Heart Center , Turku University Hospital and University of Turku , Turku , Finland.,f Department of Surgery , Oulu University Hospital and University of Oulu , Finland.,g Department of Surgery , University of Turku, Turku , Finland
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48
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Renner J, Tesdorpf A, Freitag‐Wolf S, Francksen H, Petzina R, Lutter G, Frey N, Frank D. A retrospective study of conscious sedation versus general anaesthesia in patients scheduled for transfemoral aortic valve implantation: A single center experience. Health Sci Rep 2019; 2:e95. [PMID: 30697594 PMCID: PMC6346987 DOI: 10.1002/hsr2.95] [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: 06/30/2018] [Revised: 09/04/2018] [Accepted: 09/17/2018] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES The current 2017 ESC/EACTS guidelines recommend transcatheter aortic valve implantations (TAVIs) as the therapy of choice for inoperable patients with severe symptomatic aortic stenosis. Most of the TAVIs worldwide are performed under general anaesthesia (GA). Although conscious sedation (CS) concepts are increasingly applied in Europe, it is still a matter of debate which concept is associated with highest amount of safety for this high-risk patient population. The aim of this single center, before-and-after study was to investigate feasibility and safety of CS compared with GA with respect to peri-procedural complications and 30-day mortality in patients scheduled for transfemoral TAVI (TF-TAVI). METHODS From March 2012 until September 2014, patients scheduled for the TF-TAVI procedure were included in a prospective, observational manner. From the 200 patients finally included, 107 procedures were performed under GA, using either an endotracheal tube or a laryngeal mask, and balanced anaesthesia. CS was performed in 93 patients using low-dose propofol and remifentanil. RESULTS Conversion to GA was needed 4 times due to procedural-related complications (4.3%), in one patient due to ongoing agitation (1.1%). The CS-group showed significantly shorter key time courses: anaesthesia time (105 [95-120] minutes vs 115 [105-140] minutes, P-value = 0.009, Mann-Whitney-U-test) and length of stay in the intensive care unit (1.6 [1.0-1.5] d vs 2.1 [1.0-2.0] d, P-value = 0.002, Mann-Whitney-U-test). The lowest mean arterial pressure was significantly higher in the CS-group compared with the GA-group (74.3 mmHg vs 55.2 mmHg, P-value <0.0001, t-test). CS was associated with less requirements of norepinephrine (0.1 μg/kg vs 2.3 μg/kg, P-value <0.0001, Mann-Whitney-U-test). CONCLUSIONS Our single-center data demonstrate that CS is a feasible and safe alternative, especially with respect to a higher degree of intra-procedural haemodynamic stability, and a reduced length of stay in the intensive care unit.
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Affiliation(s)
- Jochen Renner
- Department of Anaesthesiology and Intensive Care MedicineUniversity Hospital Schleswig‐HolsteinGermany
| | - Anna Tesdorpf
- Department of Trauma SurgeryUniversity Hospital Schleswig‐HolsteinGermany
| | | | - Helga Francksen
- Department of Anaesthesiology and Intensive Care MedicineUniversity Hospital Schleswig‐HolsteinGermany
| | - Rainer Petzina
- Department for Cardiovascular SurgeryUniversity Hospital Schleswig‐HolsteinGermany
| | - Georg Lutter
- Department for Cardiovascular SurgeryUniversity Hospital Schleswig‐HolsteinGermany
| | - Norbert Frey
- Department of Cardiology and AngiologyUniversity Hospital Schleswig‐HolsteinGermany
| | - Derk Frank
- Department of Cardiology and AngiologyUniversity Hospital Schleswig‐HolsteinGermany
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Rodés-Cabau J, Urena M, Pelletier-Beaumont E, Philippon F. Reply: What Is the Value of Continuous Monitoring Post-Transcatheter Aortic Valve Replacement? JACC Cardiovasc Interv 2018; 11:2235-2236. [PMID: 30409285 DOI: 10.1016/j.jcin.2018.09.030] [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: 09/10/2018] [Accepted: 09/25/2018] [Indexed: 10/27/2022]
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50
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McHugh F, Ahmed K, Neylon A, Sharif F, Mylotte D. Antithrombotic management after transcatheter aortic valve implantation. J Thorac Dis 2018; 10:S3620-S3628. [PMID: 30505544 DOI: 10.21037/jtd.2018.10.59] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is now the accepted standard of care for patients with symptomatic severe aortic stenosis at elevated risk for conventional surgical valve replacement. Currently, societal guidelines propose the use of dual antiplatelet therapy for the prevention of thromboembolic events after TAVI in patients without an indication for oral anticoagulation. This strategy is empiric and largely based on expert consensus extrapolated from the arena of percutaneous coronary intervention. In this review, we explore the rational for using antiplatelet and/or anticoagulant strategies after TAVI, review current guidelines and the evidence underpinning them, and detail the on-going randomized trials that will shape future recommendations on this important issue.
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Affiliation(s)
- Fiachra McHugh
- Department of Cardiology, University Hospital of Galway, Galway, Ireland
| | - Khalid Ahmed
- Department of Cardiology, University Hospital of Galway, Galway, Ireland
| | - Antoinette Neylon
- Department of Cardiology, University Hospital of Galway, Galway, Ireland
| | - Faisal Sharif
- Department of Cardiology, University Hospital of Galway, Galway, Ireland.,National University of Ireland, Galway, Ireland
| | - Darren Mylotte
- Department of Cardiology, University Hospital of Galway, Galway, Ireland.,National University of Ireland, Galway, Ireland
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