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Dandach L, Mahmoudi K, Sfeir M, Masri A. Coronary Risk in Transcatheter Aortic Valve Replacement, Overview of Data, Challenges, and Best Practices. Cardiol Clin 2024; 42:361-371. [PMID: 38910021 DOI: 10.1016/j.ccl.2024.02.016] [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] [Indexed: 06/25/2024]
Abstract
Coronary artery obstruction is a rare complication of transcatheter aortic valve replacement (TAVR). This risk increases in TAVR-valve-in-valve procedure. Several anatomic risk factors were described in many studies to identify the predictive elements of coronary artery occlusion on computed tomography cardiac scan. Rescue percutaneous coronary intervention was the first approach described to treat this complication with a high mortality rate. Later on, preventive chimney stenting technique was evaluated and results showed that is a safe and effective strategy but it leads to a difficult coronary access later. New preventive techniques are being evaluated recently (Basilica and Shorctut).
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Affiliation(s)
- Louay Dandach
- Department of Cardiology, Institut Mutualiste Montsouris, 42 boulevard, Jourdan 75014, Paris
| | - Khalil Mahmoudi
- Department of Cardiology, Institut Mutualiste Montsouris, 42 boulevard, Jourdan 75014, Paris
| | - Maroun Sfeir
- Department of Cardiology, Institut Mutualiste Montsouris, 42 boulevard, Jourdan 75014, Paris
| | - Alaa Masri
- Department of Cardiology, Institut Mutualiste Montsouris, 42 boulevard, Jourdan 75014, Paris.
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Gennari M, Biroli M, Severgnini G, Olivares P, Ferrari C, Giacari CM, Agrifoglio M, De Marco F, Taramasso M. The PIGTAIL paradigm for a fast and safe transfemoral transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2024. [PMID: 38773853 DOI: 10.1002/ccd.31090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/03/2024] [Accepted: 05/08/2024] [Indexed: 05/24/2024]
Abstract
Transfemoral transcatheter aortic valve replacement is the preferred primary access route whenever possible. Despite advancements in expertise and delivery system profiles, complications associated with the primary femoral access still significantly affect procedural morbidity and outcomes. The current standard for accurate main access planning involves proper preprocedural evaluation guided by computed tomography. Several baseline clinical and anatomical features serve as predictors for the risk of vascular injury occurring during or after transcatheter aortic valve replacement. In this paper, we aimed at reviewing the most up-to-date knowledge of the topic for a safe transfemoral access approach according to a paradigm we have called "PIGTAIL."
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Affiliation(s)
- Marco Gennari
- IRCCS Centro Cardiologico Monzino, Interventional, Valvular and Structural Heart Cardiology, Milan, Italy
| | - Matteo Biroli
- IRCCS Centro Cardiologico Monzino, Interventional, Valvular and Structural Heart Cardiology, Milan, Italy
- University of Milan, Milan, Italy
| | - Gaia Severgnini
- University of Milan, Milan, Italy
- Department of Cardiovascular Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Paolo Olivares
- IRCCS Centro Cardiologico Monzino, Interventional, Valvular and Structural Heart Cardiology, Milan, Italy
| | - Cristina Ferrari
- IRCCS Centro Cardiologico Monzino, Interventional, Valvular and Structural Heart Cardiology, Milan, Italy
| | - Carlo Maria Giacari
- IRCCS Centro Cardiologico Monzino, Interventional, Valvular and Structural Heart Cardiology, Milan, Italy
| | - Marco Agrifoglio
- University of Milan, Milan, Italy
- Department of Cardiovascular Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Federico De Marco
- IRCCS Centro Cardiologico Monzino, Interventional, Valvular and Structural Heart Cardiology, Milan, Italy
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Fogelson B, Baljepally R, Heidel E, Ferlita S, Moodie T, Coombes T, Goodwin RP, Livesay J. Rural versus urban outcomes following transcatheter aortic valve implantation: The importance of the heart team. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 62:3-8. [PMID: 38135570 DOI: 10.1016/j.carrev.2023.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Rural patients face known healthcare disparities and worse cardiovascular outcomes compared to urban residents due to inequitable access and delayed care. Few studies have assessed rural-urban differences in outcomes following Transcatheter Aortic Valve Implantation (TAVI). We compared short-term post-TAVI outcomes between rural and urban patients. METHODS We performed a retrospective analysis of n = 413 patients who underwent TAVI at our large academic medical center, between 2011 and 2020 (rural/urban patients = 93/320. Rural/urban males = 53/173). Primary outcomes were all-cause mortality and cardiovascular mortality. Secondary outcomes included stroke/transient ischemic attack, myocardial infarction, atrial fibrillation, acute kidney injury, bleeding, vascular complications, and length of stay. RESULTS The mean age in years was 77 [IQR 70-82] for rural patients and 78 [IQR 72-84] for urban patients. Baseline characteristics were similar between groups, except for a greater frequency of active smokers and diabetics as well as a greater body mass index in the rural group. There were no statistically significant differences in all-cause or cardiovascular mortality between the groups. There was also no statistically significant difference in secondary outcomes. CONCLUSION Rural and urban patients had no statistically significant difference in all-cause mortality or cardiovascular mortality following TAVI. Given its minimally invasive nature and quality-centric, multidisciplinary care provided by the TAVI Heart Teams, TAVI may be the preferred modality for the treatment of severe aortic stenosis in rural populations.
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Affiliation(s)
- Benjamin Fogelson
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA.
| | - Raj Baljepally
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Eric Heidel
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Steve Ferlita
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Travis Moodie
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Tyler Coombes
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Rachel P Goodwin
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - James Livesay
- Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
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Ammar KA, Graeber A, Ahmad AR, Zilinski J, O’Hair DP, Jain R, Allaqaband SQ, Bajwa T. Intentional Oversizing of Valve in Transcatheter Aortic Valve Replacement: Is Bigger Better? A Large, Single-Center Experience. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2024; 8:100278. [PMID: 38799807 PMCID: PMC11121734 DOI: 10.1016/j.shj.2023.100278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 05/29/2024]
Abstract
Background The current clinical practice standard is 10% to 20% oversizing of self-expanding valves in transcatheter aortic valve replacement. We aimed to determine whether >20% oversizing of self-expanding valves (Medtronic Evolut) would lead to better valve performance with similar or better outcomes. Methods From October 2011 to December 2016, we approached all transcatheter aortic valve replacement patients with a conscious attempt at large oversizing (>20%). The most common valve used, excluding those used in valve-in-valve patients, was the 29-mm Evolut R (29%). We used a retrospective chart review to compare moderate oversizing (group 1; 10% to 20%) with large oversizing (group 2; >20%). Results Of 556 patients, 45% were male; the overall mean Society of Thoracic Surgeons risk score was 5.8 ± 3.8. Eighty-five (15%) patients needed a pacemaker, and 21 (3.8%) developed significant paravalvular leak. Mean oversizing was 20.3% ± 6.0%, with 41.4% of patients included in group 1 and 54.5% in group 2. Incidences of complications in group 2 vs. group 1 were as follows: a) paravalvular leak (2.0 vs. 6.1%; odds ratio = 0.31, p = 0.01), b) pacemaker (15 vs. 14%), c) gastrointestinal bleed (n = 4 vs. 0; 1.3 vs. 0.0%; p = 0.03), d) annular dissection (n = 1 vs. 0; 0.3 vs. 0%; p = 0.29), e) mortality (n = 5 vs. 4; 1.6 vs. 1.7%). Incidence of paravalvular leak was higher in those who died than survivors (13 vs. 1.3%; p ≤ 0.0001). Conclusions These data suggest that, in current self-expanding valves, >20% oversizing delivers a significantly lower prevalence of paravalvular leak without an increase in other complications. Since paravalvular leak is associated with increased mortality, >20% oversizing may represent a superior prosthesis choice.
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Affiliation(s)
- Khawaja Afzal Ammar
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Milwaukee Clinical Campus, Milwaukee, Wisconsin, USA
| | - Alexandria Graeber
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA
| | - Abdur Rahman Ahmad
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA
| | - Jodi Zilinski
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Milwaukee Clinical Campus, Milwaukee, Wisconsin, USA
| | - Daniel P. O’Hair
- Boulder Heart at Boulder Community Health, Boulder, Colorado, USA
| | - Renuka Jain
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Milwaukee Clinical Campus, Milwaukee, Wisconsin, USA
| | - Suhail Q. Allaqaband
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Milwaukee Clinical Campus, Milwaukee, Wisconsin, USA
| | - Tanvir Bajwa
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Advocate Aurora Health, Milwaukee, Wisconsin, USA
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Milwaukee Clinical Campus, Milwaukee, Wisconsin, USA
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Usuku H, Yamamoto E, Oike F, Yoshida K, Ogata Y, Kato S, Fukushige S, Tomita A, Matsumoto S, Iwayama Y, Honda K, Tanaka S, Fukuyoshi Y, Ousaka T, Tanaka E, Misumi I, Nishigami K, Shono H, Tsujita K. Current awareness and use of transthoracic echocardiography in evaluation of valvular heart disease in Kumamoto Prefecture -a report from the Kumamoto cardiovascular echocardiography standardization project. J Echocardiogr 2024:10.1007/s12574-024-00648-w. [PMID: 38581560 DOI: 10.1007/s12574-024-00648-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/24/2024] [Accepted: 02/28/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND There are few reports on transthoracic echocardiography (TTE) for the evaluation of valvular heart disease in a specific area or region. METHODS AND RESULTS This cross-sectional questionnaire-based survey was conducted in 2023 in Kumamoto Prefecture, where 106 hospitals provide cardiology services. Ninety-three (88%) of the hospitals completed questionnaires regarding TTE. The severity of low flow/low gradient AS was evaluated by dobutamine stress echocardiography in only 7% of hospitals and exercise stress echocardiography for asymptomatic mitral regurgitation in only 5%. Multivariate logistic regression analysis revealed that participation in remote multi-institutional echocardiographic meetings and use of the Kumamoto Prefecture echocardiographic manual were significantly associated with the use of a multi-window approach (P < 0.05). CONCLUSIONS In Kumamoto Prefecture, echocardiographic measurements are performed according to the recommendations at a relatively low rate. Dissemination of recommendations through remote meetings and the use of the echocardiographic manual may increase the likelihood of TTE being performed according to the recommendations.
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Affiliation(s)
- Hiroki Usuku
- Department of Laboratory Medicine, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan.
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Fumi Oike
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenichi Yoshida
- Kumamoto Association of Medical Technologist, Kumamoto, Japan
- Department of Laboratory Medicine, Kumamoto Rosai Hospital, Kumamoto, Japan
| | - Yuji Ogata
- Kumamoto Association of Medical Technologist, Kumamoto, Japan
- Department of Laboratory Medicine, Kumamoto City Ueki Hospital, Kumamoto, Japan
| | - Saori Kato
- Kumamoto Association of Medical Technologist, Kumamoto, Japan
- Department of Laboratory Medicine, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Syota Fukushige
- Kumamoto Association of Medical Technologist, Kumamoto, Japan
- Department of Laboratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Ayako Tomita
- Kumamoto Association of Medical Technologist, Kumamoto, Japan
- Department of Laboratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Seiki Matsumoto
- Kumamoto Association of Medical Technologist, Kumamoto, Japan
- Department of Laboratory Medicine, Miyuki Hospital, Kumamoto, Japan
| | - Yoshio Iwayama
- Kumamoto Association of Medical Technologist, Kumamoto, Japan
- Department of Laboratory Medicine, Sakura Jyuji Hospital, Kumamoto, Japan
| | - Kanako Honda
- Kumamoto Association of Medical Technologist, Kumamoto, Japan
- Department of Laboratory Medicine, Kumamoto Chuo Hospital, Kumamoto, Japan
| | - Shinji Tanaka
- Kumamoto Association of Medical Technologist, Kumamoto, Japan
- Department of Laboratory Medicine, Kumamoto Health Care Center of Japanese Red Cross Society, Kumamoto, Japan
| | - Yoko Fukuyoshi
- Department of Laboratory Medicine, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
- Kumamoto Association of Medical Technologist, Kumamoto, Japan
| | - Tamami Ousaka
- Kumamoto Association of Medical Technologist, Kumamoto, Japan
- Department of Laboratory Medicine, Kumamoto Chuo Hospital, Kumamoto, Japan
| | - Eiichiro Tanaka
- Department of Internal Medicine, Tanaka Medical Clinic, Kumamoto, Japan
| | - Ikuo Misumi
- Department of Cardiovascular Medicine, Kumamoto City Hospital, Kumamoto, Japan
| | | | - Hiroyuki Shono
- Department of Cardiovascular Medicine, Saiseikai Misumi Hospital, Kumamoto, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Ippolito D, Porta M, Maino C, Riva L, Ragusi M, Giandola T, Franco PN, Cangiotti C, Gandola D, De Vito A, Talei Franzesi C, Corso R. Feasibility of Low-Dose and Low-Contrast Media Volume Approach in Computed Tomography Cardiovascular Imaging Reconstructed with Model-Based Algorithm. Tomography 2024; 10:286-298. [PMID: 38393291 PMCID: PMC10891780 DOI: 10.3390/tomography10020023] [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: 01/12/2024] [Revised: 02/02/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
Aim: To evaluate the dose reduction and image quality of low-dose, low-contrast media volume in computed tomography (CT) examinations reconstructed with the model-based iterative reconstruction (MBIR) algorithm in comparison with the hybrid iterative (HIR) one. Methods: We prospectively enrolled a total of 401 patients referred for cardiovascular CT, evaluated with a 256-MDCT scan with a low kVp (80 kVp) reconstructed with an MBIR (study group) or a standard HIR protocol (100 kVp-control group) after injection of a fixed dose of contrast medium volume. Vessel contrast enhancement and image noise were measured by placing the region of interest (ROI) in the left ventricle, ascending aorta; left, right and circumflex coronary arteries; main, right and left pulmonary arteries; aortic arch; and abdominal aorta. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were computed. Subjective image quality obtained by consensus was assessed by using a 4-point Likert scale. Radiation dose exposure was recorded. Results: HU values of the proximal tract of all coronary arteries; main, right and left pulmonary arteries; and of the aorta were significantly higher in the study group than in the control group (p < 0.05), while the noise was significantly lower (p < 0.05). SNR and CNR values in all anatomic districts were significantly higher in the study group (p < 0.05). MBIR subjective image quality was significantly higher than HIR in CCTA and CTPA protocols (p < 0.05). Radiation dose was significantly lower in the study group (p < 0.05). Conclusions: The MBIR algorithm combined with low-kVp can help reduce radiation dose exposure, reduce noise, and increase objective and subjective image quality.
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Affiliation(s)
- Davide Ippolito
- Departement of Medicine and Surgery, University of Milano-Bicocca, Piazza OMS 1, 20100 Milano, Italy;
- Department of Diagnostic Radiology, Fondazione IRCCS Fondazione San Gerardo dei Tintori, Via Pergolesi 33, 20900 Monza, Italy; (M.P.); (L.R.); (M.R.); (T.G.); (P.N.F.); (C.C.); (D.G.); (A.D.V.); (C.T.F.); (R.C.)
| | - Marco Porta
- Department of Diagnostic Radiology, Fondazione IRCCS Fondazione San Gerardo dei Tintori, Via Pergolesi 33, 20900 Monza, Italy; (M.P.); (L.R.); (M.R.); (T.G.); (P.N.F.); (C.C.); (D.G.); (A.D.V.); (C.T.F.); (R.C.)
| | - Cesare Maino
- Department of Diagnostic Radiology, Fondazione IRCCS Fondazione San Gerardo dei Tintori, Via Pergolesi 33, 20900 Monza, Italy; (M.P.); (L.R.); (M.R.); (T.G.); (P.N.F.); (C.C.); (D.G.); (A.D.V.); (C.T.F.); (R.C.)
| | - Luca Riva
- Department of Diagnostic Radiology, Fondazione IRCCS Fondazione San Gerardo dei Tintori, Via Pergolesi 33, 20900 Monza, Italy; (M.P.); (L.R.); (M.R.); (T.G.); (P.N.F.); (C.C.); (D.G.); (A.D.V.); (C.T.F.); (R.C.)
| | - Maria Ragusi
- Department of Diagnostic Radiology, Fondazione IRCCS Fondazione San Gerardo dei Tintori, Via Pergolesi 33, 20900 Monza, Italy; (M.P.); (L.R.); (M.R.); (T.G.); (P.N.F.); (C.C.); (D.G.); (A.D.V.); (C.T.F.); (R.C.)
| | - Teresa Giandola
- Department of Diagnostic Radiology, Fondazione IRCCS Fondazione San Gerardo dei Tintori, Via Pergolesi 33, 20900 Monza, Italy; (M.P.); (L.R.); (M.R.); (T.G.); (P.N.F.); (C.C.); (D.G.); (A.D.V.); (C.T.F.); (R.C.)
| | - Paolo Niccolò Franco
- Department of Diagnostic Radiology, Fondazione IRCCS Fondazione San Gerardo dei Tintori, Via Pergolesi 33, 20900 Monza, Italy; (M.P.); (L.R.); (M.R.); (T.G.); (P.N.F.); (C.C.); (D.G.); (A.D.V.); (C.T.F.); (R.C.)
| | - Cecilia Cangiotti
- Department of Diagnostic Radiology, Fondazione IRCCS Fondazione San Gerardo dei Tintori, Via Pergolesi 33, 20900 Monza, Italy; (M.P.); (L.R.); (M.R.); (T.G.); (P.N.F.); (C.C.); (D.G.); (A.D.V.); (C.T.F.); (R.C.)
| | - Davide Gandola
- Department of Diagnostic Radiology, Fondazione IRCCS Fondazione San Gerardo dei Tintori, Via Pergolesi 33, 20900 Monza, Italy; (M.P.); (L.R.); (M.R.); (T.G.); (P.N.F.); (C.C.); (D.G.); (A.D.V.); (C.T.F.); (R.C.)
| | - Andrea De Vito
- Department of Diagnostic Radiology, Fondazione IRCCS Fondazione San Gerardo dei Tintori, Via Pergolesi 33, 20900 Monza, Italy; (M.P.); (L.R.); (M.R.); (T.G.); (P.N.F.); (C.C.); (D.G.); (A.D.V.); (C.T.F.); (R.C.)
| | - Cammillo Talei Franzesi
- Department of Diagnostic Radiology, Fondazione IRCCS Fondazione San Gerardo dei Tintori, Via Pergolesi 33, 20900 Monza, Italy; (M.P.); (L.R.); (M.R.); (T.G.); (P.N.F.); (C.C.); (D.G.); (A.D.V.); (C.T.F.); (R.C.)
| | - Rocco Corso
- Department of Diagnostic Radiology, Fondazione IRCCS Fondazione San Gerardo dei Tintori, Via Pergolesi 33, 20900 Monza, Italy; (M.P.); (L.R.); (M.R.); (T.G.); (P.N.F.); (C.C.); (D.G.); (A.D.V.); (C.T.F.); (R.C.)
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7
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Fountotos R, Lauck S, Piazza N, Martucci G, Arora R, Asgar A, Forcillo J, Kouz R, Labinaz M, Lamy A, Peterson M, Wijeysundera H, Masse L, Ouimet MC, Polderman J, Webb J, Afilalo J. Protein and Exercise to Reverse Frailty in Older Men and Women Undergoing Transcatheter Aortic Valve Replacement: Design of the PERFORM-TAVR Trial. Can J Cardiol 2024; 40:267-274. [PMID: 38052302 DOI: 10.1016/j.cjca.2023.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023] Open
Abstract
Despite the high procedural success of transcatheter aortic valve replacement (TAVR), 2 out of 5 older adults report poor physical performance and health-related quality of life (HRQOL) in the ensuing months, particularly those with frailty. There has yet to be a trial examining the synergistic effects of exercise and protein supplementation to counteract frailty and improve patient-centred outcomes following TAVR. The PERFORM-TAVR trial is a multicentre parallel-group randomised clinical trial that is enrolling 200 frail older adults ≥ 70 years of age undergoing TAVR. Patients will be randomly allocated to 1 of 2 treatment groups: standard-of-care lifestyle education (control group) or protein-rich oral nutritional supplement for 4 weeks before TAVR with the addition of home-based supervised exercise sessions for 12 weeks after TAVR (intervention group). The primary outcome will be physical performance as measured by a blinded observer using the Short Physical Performance Battery at 3 months. Secondary outcomes at 3, 6, and 12 months will include HRQOL, as measured by the Short-Form 36 Physical and Mental Component summary scores, and a composite safety end point. The PERFORM-TAVR trial is testing a novel frailty intervention in older adults undergoing TAVR to optimise recovery and downstream HRQOL. This represents a potential paradigm shift that highlights the value of assessing and treating patients' frailty in parallel with their underlying heart valve disease. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03522454.
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8
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Pitoulis F, Pamias-Lopez B, Fraser C, Rao A, Mangino-Blanchard L, Vernick W, Shah R, Kukafka J, Spelde A, Acker M, Szeto W, Ibrahim M. Transaortic TAVR and Mitral Repair Under Deep Hypothermic Circulatory Arrest in a Porcelain Aorta Patient. JACC Case Rep 2024; 29:102144. [PMID: 38223268 PMCID: PMC10784599 DOI: 10.1016/j.jaccas.2023.102144] [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: 07/28/2023] [Revised: 09/18/2023] [Accepted: 10/06/2023] [Indexed: 01/16/2024]
Abstract
Vascular and valvular calcifications, commonly seen in renal patients, increase operative mortality and can preclude conventional valvular management. We show a novel approach to treat aortic stenosis and degenerative mitral regurgitation under hypothermic circulatory arrest in a hemodialysis patient with aortic, mitral disease and porcelain aorta with surgical and transcatheter contraindications.
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Affiliation(s)
- Fotios Pitoulis
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
- Imperial College London, National Heart and Lung Institute, London, United Kingdom
| | - Blanca Pamias-Lopez
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
- Imperial College London, National Heart and Lung Institute, London, United Kingdom
| | - Charlie Fraser
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Akhil Rao
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Lisa Mangino-Blanchard
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - William Vernick
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Ronak Shah
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Jeremy Kukafka
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Audrey Spelde
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Michael Acker
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Wilson Szeto
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
| | - Michael Ibrahim
- University of Pennsylvania Cardiovascular Surgery, Penn Presbyterian Hospital, Philadelphia, Pennsylvania, USA
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9
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Sorrentino S, Di Costanzo A, Salerno N, Caracciolo A, Bruno F, Panarello A, Bellantoni A, Mongiardo A, Indolfi C. Strategies to Minimize Access Site-related Complications in Patients Undergoing Transfemoral Artery Procedures with Large-bore Devices. Curr Vasc Pharmacol 2024; 22:79-87. [PMID: 38073100 DOI: 10.2174/0115701611233184231206100222] [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: 08/30/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 06/14/2024]
Abstract
Large bore accesses refer to accesses with a diameter of 10 French or greater and are necessary for various medical devices, including those used in transcatheter aortic valve replacement, endovascular aneurysm repair stent-grafts, and percutaneous mechanical support devices. Notably, the utilization of these devices via femoral access is steadily increasing due to advancements in technology and implantation techniques, which are expanding the pool of patients suitable for percutaneous procedures. However, procedures involving large bore devices carry a high risk of bleeding and vascular complications (VCs), impacting both morbidity and long-term mortality. In this review article, we will first discuss the incidence, determinants, and prognostic impact of VCs in patients undergoing large bore access procedures. Subsequently, we will explore the strategies developed in recent years to minimize VCs, including techniques for optimizing vascular puncture through femoral cannulation, such as the use of echo-guided access cannulation and fluoroscopic guidance. Additionally, we will evaluate existing vascular closure devices designed for large bore devices. Finally, we will consider new pharmacological strategies aimed at reducing the risk of periprocedural access-related bleeding.
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Affiliation(s)
- Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, 8810, Italy
| | - Assunta Di Costanzo
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, 8810, Italy
| | - Nadia Salerno
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, 8810, Italy
| | - Alessandro Caracciolo
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, 8810, Italy
| | - Federica Bruno
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, 8810, Italy
| | - Alessandra Panarello
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, 8810, Italy
| | - Antonio Bellantoni
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, 8810, Italy
| | - Annalisa Mongiardo
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, 8810, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, 8810, Italy
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10
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Srinivasan A, Wong F, Wang B. Transcatheter aortic valve replacement: Past, present, and future. Clin Cardiol 2024; 47:e24209. [PMID: 38269636 PMCID: PMC10788655 DOI: 10.1002/clc.24209] [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: 10/21/2023] [Revised: 12/15/2023] [Accepted: 12/20/2023] [Indexed: 01/26/2024] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has emerged as a ground-breaking, minimally invasive alternative to traditional open-heart surgery, primarily designed for elderly patients initially considered unsuitable for surgical intervention due to severe aortic stenosis. As a result of successful large-scale trials, TAVR is now being routinely applied to a broader spectrum of patients. In deciding between TAVR and surgical aortic valve replacement, clinicians evaluate various factors, including patient suitability and anatomy through preprocedural imaging, which guides prosthetic valve sizing and access site selection. Patient surgical risk is a pivotal consideration, with a multidisciplinary team making the ultimate decision in the patient's best interest. Periprocedural imaging aids real-time visualization but is influenced by anaesthesia choices. A comprehensive postprocedural assessment is critical due to potential TAVR-related complications. Numerous trials have demonstrated that TAVR matches or surpasses surgery for patients with diverse surgical risk profiles, ranging from extreme to low risk. However, long-term follow-up data, particularly in low-risk cases, remains limited, and the applicability of published results to younger patients is uncertain. This review delves into key TAVR studies, pinpointing areas for potential improvement while delving into the future of this innovative procedure. Furthermore, it explores the expanding role of TAVR technology in addressing other heart valve replacement procedures.
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Affiliation(s)
- Akash Srinivasan
- Division of Medical Sciences, Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Felyx Wong
- Guy's and St Thomas’ NHS Foundation TrustLondonUK
| | - Brian Wang
- Department of Metabolism, Digestion and Reproduction, Faculty of MedicineImperial College LondonLondonUK
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11
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de Agustin JA, Pozo Osinalde E, Olmos C, Mahia Casado P, Marcos-Alberca P, Luaces M, Gomez de Diego JJ, Nombela-Franco L, Jimenez-Quevedo P, Tirado-Conte G, Collado Yurrita L, Fernandez-Ortiz A, Perez-Villacastin J. Current Usefulness of Transesophageal Echocardiography in Patients Undergoing Transcatheter Aortic Valve Replacement. J Clin Med 2023; 12:7748. [PMID: 38137816 PMCID: PMC10743683 DOI: 10.3390/jcm12247748] [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: 11/05/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
This review article describes in depth the current usefulness of transesophageal echocardiography in patients who undergo transcatheter aortic valve replacement. Pre-intervention, 3D-transesophageal echocardiography allows us to accurately evaluate the aortic valve morphology and to measure the valve annulus, helping us to choose the appropriate size of the prosthesis, especially useful in cases where the computed tomography is not of adequate quality. Although it is not currently used routinely during the intervention, it remains essential in those cases of greater complexity, such as for patients with greater calcification and bicuspid valve, mechanical mitral prosthesis, and "valve in valve" procedures. Three-dimensional transesophageal echocardiography is the best technique to detect and quantify paravalvular regurgitation, a fundamental aspect to decide whether immediate valve postdilation is needed. It also allows to detect early any immediate complications such as cardiac tamponade, aortic hematoma or dissection, migration of the prosthesis, malfunction of the prosthetic leaflets, or the appearance of segmental contractility disorders due to compromise of the coronary arteries ostium. Transesophageal echocardiography is also very useful in follow-up, to check the proper functioning of the prosthesis and to rule out complications such as thrombosis of the leaflets, endocarditis, or prosthetic degeneration.
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Affiliation(s)
- Jose Alberto de Agustin
- Unidad de Imagen Cardiaca, Hospital Clínico San Carlos, 28040 Madrid, Spain; (E.P.O.); (P.M.C.); (P.M.-A.); (M.L.); (J.J.G.d.D.)
| | - Eduardo Pozo Osinalde
- Unidad de Imagen Cardiaca, Hospital Clínico San Carlos, 28040 Madrid, Spain; (E.P.O.); (P.M.C.); (P.M.-A.); (M.L.); (J.J.G.d.D.)
| | - Carmen Olmos
- Unidad de Imagen Cardiaca, Hospital Clínico San Carlos, 28040 Madrid, Spain; (E.P.O.); (P.M.C.); (P.M.-A.); (M.L.); (J.J.G.d.D.)
| | - Patricia Mahia Casado
- Unidad de Imagen Cardiaca, Hospital Clínico San Carlos, 28040 Madrid, Spain; (E.P.O.); (P.M.C.); (P.M.-A.); (M.L.); (J.J.G.d.D.)
| | - Pedro Marcos-Alberca
- Unidad de Imagen Cardiaca, Hospital Clínico San Carlos, 28040 Madrid, Spain; (E.P.O.); (P.M.C.); (P.M.-A.); (M.L.); (J.J.G.d.D.)
| | - María Luaces
- Unidad de Imagen Cardiaca, Hospital Clínico San Carlos, 28040 Madrid, Spain; (E.P.O.); (P.M.C.); (P.M.-A.); (M.L.); (J.J.G.d.D.)
| | - Jose Juan Gomez de Diego
- Unidad de Imagen Cardiaca, Hospital Clínico San Carlos, 28040 Madrid, Spain; (E.P.O.); (P.M.C.); (P.M.-A.); (M.L.); (J.J.G.d.D.)
| | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clínico San Carlos, 28040 Madrid, Spain; (L.N.-F.); (P.J.-Q.); (G.T.-C.); (A.F.-O.); (J.P.-V.)
| | - Pilar Jimenez-Quevedo
- Cardiovascular Institute, Hospital Clínico San Carlos, 28040 Madrid, Spain; (L.N.-F.); (P.J.-Q.); (G.T.-C.); (A.F.-O.); (J.P.-V.)
| | - Gabriela Tirado-Conte
- Cardiovascular Institute, Hospital Clínico San Carlos, 28040 Madrid, Spain; (L.N.-F.); (P.J.-Q.); (G.T.-C.); (A.F.-O.); (J.P.-V.)
| | | | - Antonio Fernandez-Ortiz
- Cardiovascular Institute, Hospital Clínico San Carlos, 28040 Madrid, Spain; (L.N.-F.); (P.J.-Q.); (G.T.-C.); (A.F.-O.); (J.P.-V.)
| | - Julian Perez-Villacastin
- Cardiovascular Institute, Hospital Clínico San Carlos, 28040 Madrid, Spain; (L.N.-F.); (P.J.-Q.); (G.T.-C.); (A.F.-O.); (J.P.-V.)
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12
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Peña AD, Moreno-Angarita A, Estacio M, Bautista DF, Quintero IF, Olaya S, Cadavid EA. Veno-arterial extracorporeal membrane oxygenation as a perioperative support to redo cardiac surgery for inoperable adult patients: a case series. Eur Heart J Case Rep 2023; 7:ytad569. [PMID: 38130866 PMCID: PMC10733174 DOI: 10.1093/ehjcr/ytad569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/01/2023] [Accepted: 11/14/2023] [Indexed: 12/23/2023]
Abstract
Background The present article describes three cases of patients in cardiogenic shock (CS) with previous cardiac surgery that made them initially inoperable. Perioperative support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) improved haemodynamic status and results in these high-risk patients. Case summary Case 1 is a 57-year-old male morbidly obese with previous aortic valve replacement (AVR) who presented with chest pain and developed cardiac arrest. Cardiopulmonary resuscitation and femoral VA-ECMO were initiated. Three days later, a redo AVR was performed. Veno-arterial extracorporeal membrane oxygenation was maintained for 12 days, followed by 7 days of veno-venous ECMO for complete recovery. Case 2 features a 39-year-old male with two previous mitral valve replacements (MVRs). The first is due to papillary muscle rupture, and the second is due to endocarditis of the mitral prosthesis. He presented with CS and pulmonary oedema. Emergency surgery was performed and the patient was then placed in VA-ECMO. Weaning off was achieved 3 days after surgery. Case 3 is a 21-year-old female with a previous MVR due to rheumatic disease. She presented with CS, severe mitral prosthesis stenosis, and a pulmonary embolism. Femoral VA-ECMO was initiated, and one day later, she underwent a redo MVR operation. Extracorporeal membrane oxygenation was discontinued 4 days later. Discussion Dysfunctional prosthetic valves leading to CS may benefit from a redo cardiac operation supported by a perioperative VA-ECMO to optimize haemodynamic status. Despite the results from risk prediction scores, this approach has the potential to reduce operative mortality in initial inoperable patients and allow a definitive redo cardiac surgery.
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Affiliation(s)
- Alvaro Diego Peña
- Departamento de Cirugía, Servicio de Cardiovascular, Fundación Valle del Lili, Cali, Colombia
| | - Alejandro Moreno-Angarita
- Departamento de Cirugía, Servicio de Cardiovascular, Fundación Valle del Lili, Cali, Colombia
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Mayra Estacio
- Departamento de Medicina Interna, Fundación Valle del Lili, Cali, Colombia
| | | | | | - Stephany Olaya
- Departamento de Cirugía, Servicio de Cardiovascular, Fundación Valle del Lili, Cali, Colombia
| | - Eduardo Alberto Cadavid
- Departamento de Cirugía, Servicio de Cardiovascular, Fundación Valle del Lili, Cali, Colombia
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13
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Fanning JP, Roberts S, Anstey C, Yerkovich S, Lu LY, Poon K, Incani A, Natani S, McCullough J, Winearls J, Fraser JF. Hemostatic Profiles of Patients Who Underwent Transcatheter Versus Surgical Aortic Valve Replacement Versus Percutaneous Coronary Intervention. Am J Cardiol 2023; 207:260-270. [PMID: 37769569 DOI: 10.1016/j.amjcard.2023.08.100] [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: 07/18/2023] [Revised: 08/09/2023] [Accepted: 08/17/2023] [Indexed: 10/03/2023]
Abstract
Guidelines for transcatheter aortic valve replacement (TAVR) antithrombotic prophylaxis are extrapolated predominantly from percutaneous coronary intervention (PCI) data. Here, we examined temporal coagulation changes occurring in the early perioperative period to determine the pathobiologic validity of this supposition. This was a prospective observational study of consecutive patients who underwent transfemoral TAVR (n = 27), PCI (n = 12), or surgical aortic valve replacement (SAVR) requiring cardiopulmonary bypass and cross-clamping (n = 12). Blood samples were taken at 4 time points: T1 (baseline), after general anesthesia or sedation; T2, after heparin administration; T3, at the end of the procedure; and T4, 6 hours after the procedure. The samples were assessed concurrently using standard laboratory coagulation tests and viscoelastic tests of whole blood clotting, including the latest generation thromboelastometry (ROTEM sigma) and thromboelastometry (TEG 6s). Patients in the TAVR cohort were older and a had lower baseline hemoglobin level than patients in the PCI and SAVR cohorts. The baseline platelet function was similar between the TAVR and PCI cohorts and impaired in the SAVR cohort Figure S1. The baseline hemostatic measures were comparable among cohorts. Regarding the per-patient change from baseline, the TAVR cohort showed an overall more prothrombotic state than the other cohorts, with the most marked differences from the SAVR cohort after intraoperative heparin administration and from the PCI cohorts 6 hours after the procedure. In addition, the ROTEM and TEG parameters were well correlated but not interchangeable. In conclusion, patients who underwent TAVR have a more prothrombotic hemostatic profile than PCI and SAVR patients. These findings question the current guidelines that extrapolate antithrombotic regimens from PCI to TAVR settings.
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Affiliation(s)
- Jonathon Paul Fanning
- Intensive Care Services, St. Andrew's War Memorial Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia.
| | - Shaun Roberts
- Faculty of Medicine, The University of Queensland, Queensland, Australia; Department of Anaesthesia and Perioperative Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Chris Anstey
- Faculty of Medicine, The University of Queensland, Queensland, Australia; School of Medicine, Griffith University, Queensland, Australia
| | - Stephanie Yerkovich
- Faculty of Medicine, The University of Queensland, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia
| | - Lawrence Yanxi Lu
- Faculty of Medicine, The University of Queensland, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia; Department of Anaesthesia and Perioperative Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Karl Poon
- Intensive Care Services, St. Andrew's War Memorial Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia
| | - Alexander Incani
- Intensive Care Services, St. Andrew's War Memorial Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia
| | - Sarvesh Natani
- Intensive Care Services, St. Andrew's War Memorial Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia
| | - James McCullough
- School of Medicine, Griffith University, Queensland, Australia; Department of Intensive Care, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - James Winearls
- Intensive Care Services, St. Andrew's War Memorial Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia; Department of Intensive Care, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - John Francis Fraser
- Intensive Care Services, St. Andrew's War Memorial Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia; School of Medicine, Griffith University, Queensland, Australia
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14
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Gorla R, Tua L, D'Errigo P, Barbanti M, Biancari F, Tarantini G, Badoni G, Ussia GP, Ranucci M, Bedogni F, Baglio G, Rosato S. Incidence and predictors of 30-day and 6-month stroke after TAVR: Insights from the multicenter OBSERVANT II study. Catheter Cardiovasc Interv 2023; 102:1122-1131. [PMID: 37794734 DOI: 10.1002/ccd.30848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 09/13/2023] [Accepted: 09/17/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND The incidence and predictors of 30-day stroke after transcatheter aortic valve replacement (TAVR) were derived from early studies investigating first-generation devices. The incidence of 6-month stroke and its related predictors are unknown. AIMS To investigate the incidence and to identify procedural and patient-related predictors of 30-day and 6-month stroke after TAVR. METHODS Data from 2753 consecutive patients with severe aortic stenosis undergoing TAVR were obtained from the OBSERVANT-II study, an observational, prospective, multicenter cohort study. The study endpoints were symptomatic 30-day and 6-month stroke after TAVR. RESULTS The occurrence of a 30-day and 6-month stroke was low (1.3% and 2.4%, respectively) but with significant impact on survival. Aortic valve predilatation (odds ratio [OR]: 2.28, 95% confidence interval [CI]: 1.12-4.65, p = 0.023), diabetes (OR: 3.10, 95% CI: 1.56-6.18, p = 0.001), and left ventricle ejection fraction < 50% (OR: 2.15, 95% CI: 1.04-4.47, p = 0.04) were independent predictors of 30-day stroke, whereas diabetes (sub-distribution hazard ratio [SHR]: 2.07, 95% CI: 1.25-3.42, p = 0.004), pre-existing neurological dysfunction (SHR: 3.92, 95% CI: 1.54-10, p = 0.004), bicuspid valve (SHR: 4.75, 95% CI: 1.44-15.7, p = 0.011), and critical status (SHR: 3.05, 95% CI: 1.21-7.72, p = 0.018) were predictive of 6-month stroke. Conversely, antiplatelet therapy and anticoagulation were protective factors at both 30 days and 6 months. CONCLUSIONS Stroke after TAVR was rare. Predilatation was the only procedural factor predictive of 30-day stroke, whereas the remaining were patient-related risk factors, suggesting appropriate risk stratification preoperatively.
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Affiliation(s)
- Riccardo Gorla
- Department of Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Lorenzo Tua
- Department of Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
- Department of Cardiology, IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Paola D'Errigo
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Marco Barbanti
- Division of Cardiology, A.O.U. Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Fausto Biancari
- Department of Medicine, South Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gabriella Badoni
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Francesco Bedogni
- Department of Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Giovanni Baglio
- Italian National Agency for Regional Healthcare Services, Rome, Italy
| | - Stefano Rosato
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
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15
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Kulkarni A, Arafat M, Hou L, Liang S, Kassotis J. Racial Disparity Among Patients Undergoing Surgical Aortic Valve Replacement and Transcatheter Aortic Valve Replacement in the United States. Angiology 2023; 74:812-821. [PMID: 36426842 DOI: 10.1177/00033197221137025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative to surgical aortic valve replacement (SAVR). However, racial disparities in the utilization of TAVR persist. This meta-analysis attempts to determine whether the prevalence of adverse outcomes (procedure-related complications) represent barriers to the use of TAVR among African Americans (AA). The TAVR cohort consisted of 89.6% Caucasian (C) and 4.7% AA, while the SAVR cohort included 86.9% C and 6.4% AA. The utilization rate (UR) of TAVR was 1.48 and .35 among C and AA, respectively, while the UR of SAVR was 1.44 and .48 among C and AA, respectively. Following TAVR, for AA the odds ratio (OR) was greater for stroke (OR = 1.22, P = .02) and transient ischemic attack (TIA) (OR = 1.57, P < .001) and lower for undergoing the insertion of a permanent pacemaker (OR = .81, P < .001). While there was a significant difference between C and AA in TAVR and SAVR utilization, outcomes between groups following TAVR are comparable; therefore, adverse outcomes do not appear to be a barrier to the use of TAVR among eligible AA.
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Affiliation(s)
- Abha Kulkarni
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Mohammod Arafat
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Linle Hou
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Shiochee Liang
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - John Kassotis
- Department of Cardiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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16
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Krittanawong C, Virk HUH, Hahn J, Wang Z, Al-Azzam F, Alam M, Sharma S, Jneid H. Clinical Outcome of TAVI vs. SAVR in Patients with Severe Aortic Stenosis. J Clin Med 2023; 12:5236. [PMID: 37629278 PMCID: PMC10455769 DOI: 10.3390/jcm12165236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
The utilization of transcatheter aortic valve implantation (TAVI) has become the treatment of choice in patients with severe aortic stenosis (AS) with intermediate-to-high surgical risk for surgical aortic valve replacement (SAVR) [...].
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Affiliation(s)
- Chayakrit Krittanawong
- Cardiology Division, New York University Langone Health and New York University School of Medicine, New York, NY 10016, USA
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Joshua Hahn
- Division of Cardiology, University of Texas Medical Branch, Houston, TX 77059, USA
| | - Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA
| | - Fu’ad Al-Azzam
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Mahboob Alam
- The Texas Heart Institute, Baylor College of Medicine, Houston, TX 77030, USA
| | - Samin Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY 10029, USA
| | - Hani Jneid
- Division of Cardiology, University of Texas Medical Branch, Houston, TX 77059, USA
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17
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Selvaraj V, Khan MS, Mufarrih SH, Kazimuddin M, Waheed MA, Tripathi A, Bavishi C, Hyder ON, Aronow HD, Saad M, Abbott JD. Meta-Analysis Assessing Efficacy and Safety of Vitamin K Antagonists Versus Direct Oral Anticoagulants for Atrial Fibrillation After Transcatheter Aortic Valve Implantation. Am J Cardiol 2023; 201:260-267. [PMID: 37393728 DOI: 10.1016/j.amjcard.2023.06.049] [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: 03/14/2023] [Revised: 05/26/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023]
Abstract
Patients who underwent transcatheter aortic valve implantation (TAVI) with concomitant atrial fibrillation (AF) are at a higher risk for thromboembolic and bleeding events. The optimal antithrombotic strategy for patients with AF after TAVI remains unclear. We sought to determine the comparative efficacy and safety of direct oral anticoagulants (DOAC) versus oral vitamin K antagonists (VKAs) in these patients. Electronic databases such as PubMed, Cochrane, and Embase databases were searched till January 31, 2023, for relevant studies evaluating clinical outcomes of VKA versus DOAC in patients with AF after TAVI. Outcomes assessed were (1) all-cause mortality, (2) stroke, (3) major/life-threatening bleeding, and (4) any bleeding. Hazard ratios (HRs) were pooled in meta-analysis using random effect model. Nine studies (2 randomized and 7 observational) were included in systematic review, and 8 studies with 25,769 patients were eligible to be included in the meta-analysis. The mean age of the patients was 82.1 years, and 48.3% were male. Pooled analysis using random-effects model showed no statistically significant difference in all-cause mortality (HR 0.91, 95% confidence interval [CI] 0.76 to 1.10, p = 0.33), stroke (HR 0.96, 95% CI 0.80 to 1.16, p = 0.70), and major/life-threatening bleeding (HR 1.05, 95% CI 0.82 to 1.35, p = 0.70) in patients that received DOAC compared with oral VKA. Risk of any bleeding was lower in the DOAC group compared with oral VKA (HR 0.83, 95% CI 0.76 to 0.91, p = 0.0001). In patients with AF, DOACs appear to be a safe alternative oral anticoagulation strategy to oral VKA after TAVI. Further randomized studies are required to confirm the role of DOACs in those patients.
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Affiliation(s)
- Vijairam Selvaraj
- Department of Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Mohammad Saud Khan
- Division of Cardiology, University of Kentucky College of Medicine - Bowling Green Campus, Bowling Green, Kentucky
| | - Syed Hamzah Mufarrih
- Department of Internal Medicine, University of Kentucky College of Medicine - Bowling Green Campus, Bowling Green, Kentucky
| | - Mohammed Kazimuddin
- Division of Cardiology, University of Kentucky College of Medicine - Bowling Green Campus, Bowling Green, Kentucky
| | - Mohammad Abdul Waheed
- Division of Cardiology, University of Kentucky College of Medicine - Bowling Green Campus, Bowling Green, Kentucky
| | - Avnish Tripathi
- Division of Cardiology, CHI St. Vincent Heart Clinic Arkansas, Searcy, Arkansas
| | - Chirag Bavishi
- Division of Cardiology, University of Missouri School of Medicine, Columbia, Missouri
| | - Omar N Hyder
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Marwan Saad
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - J Dawn Abbott
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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Kneizeh K, Milzi A, Vogt F, Witte K, Marx N, Lehrke M, Almalla M, Schröder J. Efficacy and Safety of Low-Dose Protamine in Reducing Bleeding Complications during TAVI: A Propensity-Matched Comparison. J Clin Med 2023; 12:4243. [PMID: 37445282 DOI: 10.3390/jcm12134243] [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: 05/02/2023] [Revised: 06/09/2023] [Accepted: 06/21/2023] [Indexed: 07/15/2023] Open
Abstract
OBJECTIVES We aimed to evaluate the efficacy and safety of low-dose protamine in reducing access site-related complications during Transcatheter Aortic Valve Implantation (TAVI) as compared to full-dose protamine. BACKGROUND Access site-related complications represent an independent predictor of poor outcomes of TAVI. Data regarding heparin reversal with protamine and the dosage needed to prevent bleeding complications are scarce among patients undergoing TAVI. METHODS A total of 897 patients were retrospectively included in the study. Patients who underwent percutaneous coronary intervention within 4 weeks before or concomitantly with TAVI (n = 191) were given 0.5 mg protamine for each 100 units of unfractionated heparin. All other patients (n = 706) were considered as a control group and 1 mg protamine for each 100 units of heparin was administered. RESULTS The combined intra-hospital endpoint of death, life-threatening major bleeding, and major vascular complications were significantly more frequent in patients receiving low-dose protamine [29 (15.2%) vs. 50 (7.1%), p < 0.001]. After propensity matching (n = 130 for each group) for relevant clinical characteristics including anti-platelet therapy [19 (14.6%) vs. 6 (4.6%), p = 0.006], low-dose protamine predicted the combined endpoint (OR 3.54, 95%-CI 1.36-9.17, p = 0.009), and even in multivariable analysis, low-dose protamine continued to be a predictor of the combined endpoint in the matched model (OR 3.07, 95%-CI 1.17-8.08, p = 0.023) alongside baseline hemoglobin. CONCLUSIONS In this propensity-matched retrospective analysis, a low-dose protamine regime is associated with a higher rate of major adverse events compared to a full-dose protamine regime following transfemoral TAVI.
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Affiliation(s)
- Kinan Kneizeh
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Andrea Milzi
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Felix Vogt
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Klaus Witte
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Michael Lehrke
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Mohammad Almalla
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Jörg Schröder
- Department of Cardiology, Angiology and Critical Care (Medical Clinic 1), University Hospital RWTH Aachen, 52074 Aachen, Germany
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19
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Chi H, Shao Y, Xie F, Zhang J, Zhang G, Jiang G, Tong D, Li J. Procoagulant effect of extracellular vesicles in patients after transcatheter aortic valve replacement or transcatheter aortic valve replacement with percutaneous coronary intervention. J Thromb Thrombolysis 2023:10.1007/s11239-023-02835-5. [PMID: 37284999 DOI: 10.1007/s11239-023-02835-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 06/08/2023]
Abstract
Patients with severe aortic stenosis (AS) after replacement of the transcatheter aortic valve (TAVR) are more likely to develop thrombotic complications such as cerebral embolism and artificial valve thrombosis. However, the mechanism is not yet well defined. We aimed to explore the plasma extracellular vesicles (EVs) levels and their role in the induction of procoagulant activity (PCA) in patients receiving TAVR alone or TAVR with percutaneous coronary intervention (PCI). EVs were analyzed with flow cytometer. Markers of platelet and endothelial cell activation were quantified using selective enzyme-linked immunosorbent assay (ELISA) kits. Procoagulant activity (PCA) was assessed by clotting time, purified clotting complex assays, and fibrin production assays. Our results confirmed that EVs with positive phosphatedylserin (PS+EV), platelet EVs (PEVs) and positive tissue factor EVs (TF+EVs) were higher in patients following TAVR than before TAVR, particularly in TAVR with PCI. Furthermore, endothelial-derived EVs (EEVs) were also higher in patients after TAVR with PCI than pre-TAVR, however, the EEVs levels in TAVR alone patients were gradually reduce than pre-TAVR. In addition, we further proved that total EVs contributed to dramatically shortened coagulation time, increased intrinsic/extrinsic factor Xa and thrombin generation in patients after TAVR, especially in TAVR with PCI. The PCA was markedly attenuated by approximately 80% with lactucin. Our study reveals a previously unrecognized link between plasma EV levels and hypercoagulability in patients after TAVR, especially TAVR with PCI. Blockade of PS+EVs may improve the hypercoagulable state and prognosis of patients.
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Affiliation(s)
- Hang Chi
- Department of emergency, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Yibing Shao
- Department of Cardiology, School of Medicine, Qingdao Municipal Hospital, Qingdao University, NO. 5 Donghai Middle Road, Qingdao, 266071, Shandong, China
| | - Fangyu Xie
- Department of Cardiology, School of Medicine, Qingdao Municipal Hospital, Qingdao University, NO. 5 Donghai Middle Road, Qingdao, 266071, Shandong, China
| | - Jian Zhang
- Department of General Practice, People's Hospital of Longhua, Shenzhen, China
| | - Guixin Zhang
- Department of General Surgery, Qingdao FUWAI Cardiovascular Hospital, Qingdao, Shandong Province, China
| | - Guihua Jiang
- Department of Infectious Diseases, People's Hospital of Longhua, Shenzhen, China
| | - Dongxia Tong
- Department of Oncology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, NO. 1 Jiaozhou Road, Qingdao, 266071, Shandong, China.
| | - Jihe Li
- Department of Cardiology, School of Medicine, Qingdao Municipal Hospital, Qingdao University, NO. 5 Donghai Middle Road, Qingdao, 266071, Shandong, China.
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20
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Guedeney P, Chevrot G, Collet JP. VARC-3 Criteria: Adding Prognosis to Injury. JACC Cardiovasc Interv 2023; 16:1233-1235. [PMID: 37225295 DOI: 10.1016/j.jcin.2023.04.012] [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: 04/03/2023] [Accepted: 04/11/2023] [Indexed: 05/26/2023]
Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie, Assistance Publique - Hôpitaux de Paris, Paris, France.
| | - Gabriel Chevrot
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie, Assistance Publique - Hôpitaux de Paris, Paris, France
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21
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Matsumoto Y, Fujioka C, Yokomachi K, Kitera N, Nishimaru E, Kiguchi M, Higaki T, Kawashita I, Tatsugami F, Nakamura Y, Awai K. Evaluation of the second-generation whole-heart motion correction algorithm (SSF2) used to demonstrate the aortic annulus on cardiac CT. Sci Rep 2023; 13:3636. [PMID: 36869155 PMCID: PMC9984533 DOI: 10.1038/s41598-023-30786-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 03/01/2023] [Indexed: 03/05/2023] Open
Abstract
The main purpose of pre-transcatheter aortic valve implantation (TAVI) cardiac computed tomography (CT) for patients with severe aortic stenosis is aortic annulus measurements. However, motion artifacts present a technical challenge because they can reduce the measurement accuracy of the aortic annulus. Therefore, we applied the recently developed second-generation whole-heart motion correction algorithm (SnapShot Freeze 2.0, SSF2) to pre-TAVI cardiac CT and investigated its clinical utility by stratified analysis of the patient's heart rate during scanning. We found that SSF2 reconstruction significantly reduced aortic annulus motion artifacts and improved the image quality and measurement accuracy compared to standard reconstruction, especially in patients with high heart rate or a 40% R-R interval (systolic phase). SSF2 may contribute to improving the measurement accuracy of the aortic annulus.
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Affiliation(s)
- Yoriaki Matsumoto
- Department of Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan.
| | - Chikako Fujioka
- Department of Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Kazushi Yokomachi
- Department of Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Nobuo Kitera
- Department of Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Eiji Nishimaru
- Department of Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Masao Kiguchi
- Department of Radiology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Toru Higaki
- Department of Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Ikuo Kawashita
- Department of Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Fuminari Tatsugami
- Department of Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Yuko Nakamura
- Department of Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
| | - Kazuo Awai
- Department of Diagnostic Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, Japan
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22
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Conzelmann L, Grotherr P, Dapeng L, Würth A, Widder J, Jacobshagen C, Mehlhorn U. Valve-Related Complications in TAVI Leading to Emergent Cardiac Surgery. Thorac Cardiovasc Surg 2023; 71:107-117. [PMID: 36446625 DOI: 10.1055/s-0042-1758073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is now a standard procedure for the treatment of symptomatic aortic valve stenosis in many patients. In Germany, according to the annual reports from the German Institute for Quality Assurance and Transparency in Healthcare (Institut für Qualitätssicherung und Transparenz im Gesundheitswesen), the rate of serious intraprocedural complications, such as valve malpositioning or embolization, coronary obstruction, aortic dissection, annular rupture, pericardial tamponade, or severe aortic regurgitation requiring emergency cardiac surgery has decreased markedly in recent years from more than 5.5% in 2012 to 2.0% in 2019. However, with increased use, the total number of adverse events remains about 500 per year, about 100 of which require conversion to sternotomy. These, sometimes, fatal events can occur at any time and are still challenging. Therefore, the interdisciplinary TAVI heart team should be prepared and aware of possible rescue strategies.
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Affiliation(s)
- Lars Conzelmann
- Department of Cardiac Surgery, HELIOS Clinic for Cardiac Surgery Karlsruhe, Karlsruhe, Germany
| | - Philipp Grotherr
- Department of Cardiology, Medical Clinic IV, Municipal Hospital Karlsruhe, Karlsruhe, Germany
| | - Lu Dapeng
- Department of Cardiology, Intensive Care Medicine and Angiology, Vincentius-Diakonissen Hospital Karlsruhe, Karlsruhe, Germany
| | - Alexander Würth
- Department of Cardiology, Medical Clinic IV, Municipal Hospital Karlsruhe, Karlsruhe, Germany
| | - Julian Widder
- Department of Cardiology, Medical Clinic IV, Municipal Hospital Karlsruhe, Karlsruhe, Germany
| | - Claudius Jacobshagen
- Department of Cardiology, Intensive Care Medicine and Angiology, Vincentius-Diakonissen Hospital Karlsruhe, Karlsruhe, Germany
| | - Uwe Mehlhorn
- Department of Cardiac Surgery, HELIOS Clinic for Cardiac Surgery Karlsruhe, Karlsruhe, Germany
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23
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Erdem S, An SY, McAlister CA, Basra SS. Suicide left ventricle following protamine: A case report. Catheter Cardiovasc Interv 2023; 101:592-595. [PMID: 36626268 DOI: 10.1002/ccd.30528] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/31/2022] [Accepted: 12/10/2022] [Indexed: 01/11/2023]
Abstract
A patient with severe aortic stenosis and left ventricular hypertrophy underwent a transcatheter aortic valve replacement. The patient's blood pressure significantly dropped after protamine administration. A diagnosis of suicide left ventricle post-valve replacement was made. The diagnosis and management of the protamine reaction are detailed. This case highlights the need to slowly infuse protamine sulfate and monitor for adverse events.
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Affiliation(s)
- Saliha Erdem
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sin Y An
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Courtney A McAlister
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sukhdeep S Basra
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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24
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Del Val D, Panagides V, Mestres CA, Miró JM, Rodés-Cabau J. Infective Endocarditis After Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 81:394-412. [PMID: 36697140 DOI: 10.1016/j.jacc.2022.11.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 01/25/2023]
Abstract
Infective endocarditis (IE) is a rare but serious complication following transcatheter aortic valve replacement (TAVR). Despite substantial improvements in the TAVR procedure (less invasive) and its expansion to younger and healthier patients, the incidence of IE after TAVR remains stable, with incidence rates similar to those reported after surgical aortic valve replacement. Although IE after TAVR is recognized as a subtype of prosthetic valve endocarditis, this condition represents a particularly challenging scenario given its unique clinical and microbiological profile, the high incidence of IE-related complications, the uncertain role of cardiac surgery, and the dismal prognosis in most patients with TAVR-IE. The number of TAVR procedures is expected to grow exponentially in the coming years, increasing the number of patients at risk of developing this life-threatening complication. Therefore, a detailed understanding of this disease and its complications will be essential to improve clinical outcomes.
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Affiliation(s)
- David Del Val
- Hospital Universitario de La Princesa, Madrid, Spain; Instituto de Investigación Sanitaria, Hospital Universitario de La Princesa, CIBERCV, Madrid, Spain; Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Vassili Panagides
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Carlos A Mestres
- Department of Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
| | - José M Miró
- Infectious Diseases Service, Hospital Clinic-L'Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Clínic Barcelona, Barcelona, Spain.
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25
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Lacy SC, Benjamin MM, Osman M, Syed MA, Kinno M. Low Contrast and Low kV CTA Before Transcatheter Aortic Valve Replacement: A Systematic Review. J Cardiovasc Imaging 2023; 31:108-115. [PMID: 37096677 PMCID: PMC10133812 DOI: 10.4250/jcvi.2022.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 12/23/2022] [Accepted: 01/03/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Minimizing contrast dose and radiation exposure while maintaining image quality during computed tomography angiography (CTA) for transcatheter aortic valve replacement (TAVR) is desirable, but not well established. This systematic review compares image quality for low contrast and low kV CTA versus conventional CTA in patients with aortic stenosis undergoing TAVR planning. METHODS We performed a systematic literature review to identify clinical studies comparing imaging strategies for patients with aortic stenosis undergoing TAVR planning. The primary outcomes of image quality as assessed by the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were reported as random effects mean difference with 95% confidence interval (CI). RESULTS We included 6 studies reporting on 353 patients. There was no difference in cardiac SNR (mean difference, -1.42; 95% CI, -5.71 to 2.88; p = 0.52), cardiac CNR (mean difference, -3.83; 95% CI, -9.98 to 2.32; p = 0.22), aortic SNR (mean difference, -0.23; 95% CI, -7.83 to 7.37; p = 0.95), aortic CNR (mean difference, -3.95; 95% CI, -12.03 to 4.13; p = 0.34), and ileofemoral SNR (mean difference, -6.09; 95% CI, -13.80 to 1.62; p = 0.12) between the low dose and conventional protocols. There was a difference in ileofemoral CNR between the low dose and conventional protocols with a mean difference of -9.26 (95% CI, -15.06 to -3.46; p = 0.002). Overall, subjective image quality was similar between the 2 protocols. CONCLUSIONS This systematic review suggests that low contrast and low kV CTA for TAVR planning provides similar image quality to conventional CTA.
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Affiliation(s)
- Spencer C. Lacy
- Department of Internal Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Mina M. Benjamin
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Mohammed Osman
- Knight & Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Mushabbar A. Syed
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Menhel Kinno
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, IL, USA
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26
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Asher S, Maslow A, Mishra V, Flaherty D, Hayward G, Whiteneck S, Cheves T, Sweeney J. A Pilot Study to Assess the Clinical Onset of IV Heparin in Interventional Cardiology and Cardiac Surgery. J Cardiothorac Vasc Anesth 2022; 36:4281-4288. [PMID: 36100498 DOI: 10.1053/j.jvca.2022.07.030] [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: 04/20/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine the onset of heparin anticoagulation, using 2 different measures of activated clotting times (ACT), thromboelastography (TEG; R-time), and anti-Xa levels, after administering low- (100 U/kg) and high- (300 U/kg) dose intravenous (IV) heparin to patients undergoing transcatheter aortic valve replacement (TAVR) and cardiac surgery, respectively. DESIGN Prospective study. SETTING Single academic institution. PARTICIPANTS Patients with normal baseline coagulation presenting for TAVR or cardiac valve surgery. INTERVENTIONS Coagulation studies were performed at baseline, 30 seconds, 90 seconds, and 180 seconds after IV heparin administration. The tests included iSTAT (iACT) and Hemochron ACT (hACT), TEG R-Time, and anti-Xa levels. At the authors' institution, anti-Xa is the preferred measure of heparin anticoagulation when time permits. ACT, a rapid point- of-care test, is used to assess intraprocedural anticoagulation. MEASUREMENTS AND MAIN RESULTS After both low- and high-dose heparin, there are peak increases in ACT and anti-Xa at 30 seconds, followed by a decline at 90 seconds and plateau at 180 seconds. The TEG R-time remained elevated (>80 minutes) throughout. For TAVR cases, all anti-Xa was >1.5 IU/mL, and was associated with an iACT >180 seconds and an hACT >200 seconds. For cardiac valve surgery cases, all anti-Xa was >2.4 and associated with an iACT >420 seconds and and hACT >340 seconds. Compared with hACT, iACTs were significantly lower at all time points after low-dose heparin, but not after high-dose heparin. CONCLUSIONS In this pilot study, heparin anticoagulation was detected as early as 30 seconds after IV administration, based on ACT, anti-Xa levels, and TEG R-time.
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Affiliation(s)
- Shyamal Asher
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI.
| | - Andrew Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Vikas Mishra
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Devon Flaherty
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - Geoffrey Hayward
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | | | - Tracey Cheves
- Department of Hematology, Rhode Island Hospital, Providence, RI
| | - Joseph Sweeney
- Department of Hematology, Rhode Island Hospital, Providence, RI
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27
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Al‐Kassou B, Veulemans V, Shamekhi J, Maier O, Piayda K, Zeus T, Aksoy A, Zietzer A, Meertens M, Mauri V, Weber M, Sinning J, Grube E, Adam M, Bakhtiary F, Zimmer S, Baldus S, Kelm M, Nickenig G, Sedaghat A. Optimal protamine-to-heparin dosing ratio for the prevention of bleeding complications in patients undergoing TAVR-A multicenter experience. Clin Cardiol 2022; 46:67-75. [PMID: 36259730 PMCID: PMC9849438 DOI: 10.1002/clc.23936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Despite major advances, transcatheter aortic valve replacement (TAVR) is still associated with procedure-specific complications. Although previous studies reported lower bleeding rates in patients receiving protamine for heparin reversal, the optimal protamine-to-heparin dosing ratio is unknown. HYPOTHESIS The aim of this study was a comparison of two different heparin antagonization regimens for the prevention of bleeding complications after TAVR. METHODS The study included 1446 patients undergoing TAVR, of whom 623 received partial and 823 full heparin antagonization. The primary endpoint was a composite of 30-day mortality, life-threatening, and major bleeding. Safety endpoints included stroke and myocardial infarction at 30 days. RESULTS Full antagonization of heparin resulted in lower rates of the primary endpoint as compared to partial heparin reversal (5.6% vs. 10.4%, p < .01), which was mainly driven by lower rates of life-threatening (0.5% vs. 1.6%, p = .05) and major bleeding (3.2% vs. 7.5%, p < .01). Moreover, the incidence of major vascular complications was significantly lower in patients with full heparin reversal (3.5% vs. 7.5%, p < .01). The need for red-blood-cell transfusion was lower in patients receiving full as compared to partial heparin antagonization (10.4% vs. 15.9%, p < .01). No differences were observed in the incidence of stroke and myocardial infarction between patients with full and partial heparin reversal (2.2% vs. 2.6%, p = .73 and 0.2% vs. 0.4%, p = .64, respectively). CONCLUSIONS Full heparin antagonization resulted in significantly lower rates of life-threatening and major bleeding after TAVR as compared to partial heparin reversal. The occurrence of stroke and myocardial infarction was low and comparable between both groups.
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Affiliation(s)
- Baravan Al‐Kassou
- Department of Medicine IIHeart Center, University Hospital BonnBonnGermany
| | - Verena Veulemans
- Division of CardiologyUniversity Hospital of DuesseldorfDuesseldorfGermany,Division of CardiologyCardiovascular Research Institute DuesseldorfDüsseldorfGermany
| | - Jasmin Shamekhi
- Department of Medicine IIHeart Center, University Hospital BonnBonnGermany
| | - Oliver Maier
- Division of CardiologyUniversity Hospital of DuesseldorfDuesseldorfGermany
| | - Kerstin Piayda
- Division of CardiologyUniversity Hospital of DuesseldorfDuesseldorfGermany
| | - Tobias Zeus
- Division of CardiologyUniversity Hospital of DuesseldorfDuesseldorfGermany
| | - Adem Aksoy
- Department of Medicine IIHeart Center, University Hospital BonnBonnGermany
| | - Andreas Zietzer
- Department of Medicine IIHeart Center, University Hospital BonnBonnGermany
| | - Max Meertens
- Department of Cardiology, Heart CenterUniversity of CologneCologneGermany
| | - Victor Mauri
- Department of Cardiology, Heart CenterUniversity of CologneCologneGermany
| | - Marcel Weber
- Department of Medicine IIHeart Center, University Hospital BonnBonnGermany
| | - Jan‐Malte Sinning
- Department of Medicine IIHeart Center, University Hospital BonnBonnGermany
| | - Eberhard Grube
- Department of Medicine IIHeart Center, University Hospital BonnBonnGermany
| | - Matti Adam
- Department of Cardiology, Heart CenterUniversity of CologneCologneGermany
| | - Farhad Bakhtiary
- Department of Cardiac SurgeryHeart Center, University Hospital BonnBonnGermany
| | - Sebastian Zimmer
- Department of Medicine IIHeart Center, University Hospital BonnBonnGermany
| | - Stephan Baldus
- Department of Cardiology, Heart CenterUniversity of CologneCologneGermany
| | - Malte Kelm
- Division of CardiologyUniversity Hospital of DuesseldorfDuesseldorfGermany,Division of CardiologyCardiovascular Research Institute DuesseldorfDüsseldorfGermany
| | - Georg Nickenig
- Department of Medicine IIHeart Center, University Hospital BonnBonnGermany
| | - Alexander Sedaghat
- Department of Medicine IIHeart Center, University Hospital BonnBonnGermany
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28
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Nascimbene A, McAlister C, Yo D, Matejin S, Jezovnik M, Gregoric ID, Kar B. Use of the SAPIEN 3 Transcatheter Heart Valve in High-Risk Scenarios. Tex Heart Inst J 2022; 49:487438. [DOI: 10.14503/thij-21-7579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The transcatheter aortic valve replacement procedure is used in patients with aortic stenosis. Transcatheter aortic valve replacement devices are quite versatile; thus, they are increasingly being used for nonaortic applications, such as tricuspid valve-in-valve implantation. This case series describes a transcatheter aortic valve replacement procedure in 4 patients with anatomic challenges (eg, aortic tortuosity, high valvular calcium burden, highly calcified bicuspid valve, low coronary artery takeoff, left main coronary artery occlusion, and large aortic annulus) and a fifth patient who had a failed tricuspid bioprosthesis and underwent a tricuspid valve-in-valve implantation with the Edwards SAPIEN 3 transcatheter heart valve (Edwards Lifesciences). All procedures required adjustments to the standard protocol, and each procedure was successful. The critical, technical adjustments in the deployment technique and preprocedural planning of the procedures are detailed to provide a road map for other cardiologists who encounter similar challenges.
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Affiliation(s)
- Angelo Nascimbene
- 1 Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, Houston, Texas
| | - Courtney McAlister
- 1 Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, Houston, Texas
| | - Daniel Yo
- 1 Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, Houston, Texas
| | - Stanislava Matejin
- 1 Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, Houston, Texas
| | - Mateja Jezovnik
- 1 Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, Houston, Texas
| | - Igor D. Gregoric
- 1 Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, Houston, Texas
| | - Biswajit Kar
- 1 Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, University of Texas Health Science Center at Houston, Houston, Texas
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Widmer D, Widmer AF, Jeger R, Dangel M, Stortecky S, Frei R, Conen A. Prevalence of enterococcal groin colonization in patients undergoing cardiac interventions: Challenging antimicrobial prophylaxis with cephalosporins in TAVR patients. J Hosp Infect 2022; 129:198-202. [DOI: 10.1016/j.jhin.2022.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/17/2022] [Accepted: 07/25/2022] [Indexed: 11/29/2022]
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Alman K, Sadd CJ, Ravel A, Raza F, Chybowski A, Runo JR. Prevalence of Aortic Stenosis and TAVR outcomes in Patients with Systemic Sclerosis associated Pulmonary Hypertension. Pulm Circ 2022; 12:e12118. [PMID: 36034401 PMCID: PMC9400580 DOI: 10.1002/pul2.12118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 05/15/2022] [Accepted: 07/07/2022] [Indexed: 11/20/2022] Open
Abstract
There is little known about performing transcatheter aortic valve replacement (TAVR) in patients with group 1 pulmonary arterial hypertension (PAH) on advanced pulmonary vasodilator therapy. Retrospective cohort study among 90 patients with systemic sclerosis‐associated pulmonary arterial hypertension and systemic sclerosis‐associated pulmonary hypertension (SSc‐PAH/PH) evaluated at a tertiary PH center. The SSc‐PAH/PH cohort was stratified by the presence or absence of aortic stenosis (AS) to identify differences in baseline characteristics, hemodynamics, and long‐term outcomes. Of the 90 SSc‐PAH/PH patients, 13 patients were diagnosed with AS at PH diagnosis and another 6 patients developed AS during the study period. The period prevalence of AS was 21.1% (19/90, 95% confidence interval: 13.2%–30.1%) of which 94.7% was mild (18/19) at diagnosis with mean age at AS diagnosis of 66.3 + 2.2 years. Among AS patients, 31.6% (6/19) progressed to severe AS, five of which underwent TAVR (median age: 70 years) while on advanced PAH therapy. One of the five TAVR patients developed worsening pulmonary hypertension post‐TAVR. The 5‐year survival rate for all AS patients from diagnosis date was 37.2%. There was a high prevalence of AS in this cohort of SSc‐PAH/PH patients, with mean age of onset younger than patients with nonbicuspid aortic valve stenosis. This is the largest series of SSc‐PAH/PH patients on advanced pulmonary vasodilator therapy who underwent TAVR with acceptable early outcomes.
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Affiliation(s)
- Kirsten Alman
- Department of Medicine, School of Medicine and Public Health University of Wisconsin‐Madison Madison WI USA
| | - Corey J Sadd
- Department of Medicine, School of Medicine and Public Health University of Wisconsin‐Madison Madison WI USA
| | - Amish Ravel
- Department of Cardiology, School of Medicine and Public Health University of Wisconsin‐Madison Madison WI USA
| | - Farhan Raza
- Department of Cardiology, School of Medicine and Public Health University of Wisconsin‐Madison Madison WI USA
| | - Amy Chybowski
- Department of Pulmonary and Critical Care Medicine, School of Medicine and Public Health University of Wisconsin‐Madison Madison WI USA
| | - James R Runo
- Department of Pulmonary and Critical Care Medicine, School of Medicine and Public Health University of Wisconsin‐Madison Madison WI USA
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Guduguntla V, Yaser JM, Keteyian SJ, Pagani FD, Likosky DS, Sukul D, Thompson MP. Variation in Cardiac Rehabilitation Participation During Aortic Valve Replacement Episodes of Care. Circ Cardiovasc Qual Outcomes 2022; 15:e009175. [PMID: 35559710 PMCID: PMC10068673 DOI: 10.1161/circoutcomes.122.009175] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite reported benefit in the setting of aortic valve replacement (AVR), cardiac rehabilitation (CR) utilization remains low, with few studies evaluating hospital and patient-level variation in CR participation. We explored determinants of CR variability during AVR episodes of care: transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). METHODS A cohort of 10 124 AVR episodes of care (TAVR n=5121 from 24 hospitals; SAVR n=5003 from 32 hospitals) were identified from the Michigan Value Collaborative statewide multipayer registry (2015-2019). CR enrollment was defined as the presence of a single professional or facility claim within 90 days of discharge: 93 797, 93 798, G0422, G0423. Annual trends and hospital variation in CR were described for TAVR, SAVR, and all AVR. Multilevel logistic regression was used to estimate effects of predictors and hospital risk-adjusted rates of CR enrollment. RESULTS Overall, 4027 (39.8%) patients enrolled in CR, with significant differences by treatment strategy: SAVR=50.9%, TAVR=28.9% (P<0.001). CR use after SAVR was significantly higher than after TAVR and increased over time for both modalities (P<0.001). There were significant differences in CR enrollment across age, gender, payer, and some comorbidities (P<0.05). At the hospital level, CR participation rates for all AVR varied 10-fold (4.8% to 68.7%) and were moderately correlated between SAVR and TAVR (Pearson r=0.56, P<0.01). CONCLUSIONS Substantial variation exists in CR participation during AVR episodes of care across hospitals. However, within-hospital CR participation rates were significantly correlated across treatment strategies. These findings suggest that CR participation is the product of hospital-specific practice patterns. Identifying hospital practices associated with higher CR participation can help assist future quality improvement efforts to increase CR use after AVR.
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Affiliation(s)
- Vinay Guduguntla
- Department of Internal Medicine, University of California, San Francisco (V.G.)
- Michigan Value Collaborative, University of Michigan, Ann Arbor (V.G., J.M.Y., M.P.T.)
| | - Jessica M Yaser
- Michigan Value Collaborative, University of Michigan, Ann Arbor (V.G., J.M.Y., M.P.T.)
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Health, Detroit, MI (S.J.K.)
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor (F.D.P., D.S.L., M.P.T.)
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI (F.D.P., D.S.L., M.P.T.)
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor (F.D.P., D.S.L., M.P.T.)
| | - Devraj Sukul
- Department of Internal Medicine, University of California, San Francisco (V.G.)
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor (D.S.)
| | - Michael P Thompson
- Michigan Value Collaborative, University of Michigan, Ann Arbor (V.G., J.M.Y., M.P.T.)
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor (F.D.P., D.S.L., M.P.T.)
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, MI (F.D.P., D.S.L., M.P.T.)
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Tomey MI, Camaj A, Kini AS, Sharma SK. Aortic Valvuloplasty and Large‐Bore Percutaneous Arterial Access. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Ranjan P, Ro R, Lerakis S. Multislice Computed Tomography (MSCT) and Cardiovascular Magnetic Resonance (CMR) Imaging for Coronary and Structural Heart Disease. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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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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35
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Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement. J Clin Med 2022; 11:jcm11082190. [PMID: 35456283 PMCID: PMC9031701 DOI: 10.3390/jcm11082190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022] Open
Abstract
Due to a large technical improvement in the past decade, transcatheter aortic valve replacement (TAVR) has expanded to lower-surgical-risk patients with symptomatic and severe aortic stenosis. While mortality rates related to TAVR are decreasing, the prognosis of patients is still impacted by ischemic and bleeding complications, and defining the optimal antithrombotic regimen remains a priority. Recent randomized control trials reported lower bleeding rates with an equivalent risk in ischemic outcomes with single antiplatelet therapy (SAPT) when compared to dual antiplatelet therapy (DAPT) in patients without an underlying indication for anticoagulation. In patients requiring lifelong oral anticoagulation (OAC), the association of OAC plus antiplatelet therapy leads to a higher risk of bleeding events with no advantages on mortality or ischemic outcomes. Considering these data, guidelines have recently been updated and now recommend SAPT and OAC alone for TAVR patients without and with a long-term indication for anticoagulation. Whether a direct oral anticoagulant or vitamin K antagonist provides better outcomes in patients in need of anticoagulation remains uncertain, as recent trials showed a similar impact on ischemic and bleeding outcomes with apixaban but higher gastrointestinal bleeding with edoxaban. This review aims to summarize the most recently published data in the field, as well as describe unresolved issues.
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TAVR 20 Years Later. J Am Coll Cardiol 2022; 79:1314-1316. [DOI: 10.1016/j.jacc.2022.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Galusko V, Thornton G, Jozsa C, Sekar B, Aktuerk D, Treibel TA, Petersen SE, Ionescu A, Ricci F, Khanji MY. Aortic regurgitation management: a systematic review of clinical practice guidelines and recommendations. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:113-126. [PMID: 35026012 DOI: 10.1093/ehjqcco/qcac001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/05/2022] [Indexed: 11/13/2022]
Abstract
Guidelines for the diagnosis and management of aortic regurgitation (AR) contain recommendations that do not always match. We systematically reviewed clinical practice guidelines and summarized similarities and differences in the recommendations as well as gaps in evidence on the management of AR. We searched MEDLINE and Embase (1 January 2011 to 1 September 2021), Google Scholar, and websites of relevant organizations for contemporary guidelines that were rigorously developed as assessed by the Appraisal of Guidelines for Research and Evaluation II tool. Three guidelines met our inclusion criteria. There was consensus on the definition of severe AR and use of echocardiography and of multimodality imaging for diagnosis, with emphasis on comprehensive assessment by the heart valve team to assess suitability and choice of intervention. Surgery is indicated in all symptomatic patients and aortic valve replacement is the cornerstone of treatment. There is consistency in the frequency of follow-up of patients, and safety of non-cardiac surgery in patients without indications for surgery. Discrepancies exist in recommendations for 3D imaging and the use of global longitudinal strain and biomarkers. Cut-offs for left ventricular ejection fraction and size for recommending surgery in severe asymptomatic AR also vary. There are no specific AR cut-offs for high-risk surgery and the role of percutaneous intervention is yet undefined. Recommendations on the treatment of mixed valvular disease are sparse and lack robust prospective data.
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Affiliation(s)
- Victor Galusko
- Department of Cardiology, King's College Hospital, London SE5 9RS, UK
| | - George Thornton
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, London WC1E 6DD, UK
| | - Csilla Jozsa
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
| | - Baskar Sekar
- Department of Cardiology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester GL1 3NN, UK
| | - Dincer Aktuerk
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
| | - Thomas A Treibel
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Institute of Cardiovascular Science, University College London, London WC1E 6DD, UK
| | - Steffen E Petersen
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London EC1A 7BE, UK
| | - Adrian Ionescu
- Morriston Hospital, UK Cardiac Regional Centre, Swansea Bay Health Board, Swansea SA6 6NL, UK
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, 'G.d'Annunzio' University of Chieti-Pescara, 66100 Chieti, Italy
- Department of Clinical Sciences, Lund University, Jan Waldenströms gata 35, -205 02, Malmö, Sweden
- Casa di Cura Villa Serena, 65013 Città Sant'Angelo, Pescara, Italy
| | - Mohammed Y Khanji
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- Department of Cardiology, Newham University Hospital, Barts Health NHS Trust, Glen Road, London E13 8SL, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London EC1A 7BE, UK
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Robbins AJ, Grande SW, Alwan F, Soule MR, Raveendran G, Helmer G, Andrade R, Perry T. Physicians' perspectives and attitudes toward surgical bailout in transcatheter aortic valve replacement. JTCVS OPEN 2022; 9:74-81. [PMID: 36003484 PMCID: PMC9390286 DOI: 10.1016/j.xjon.2022.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 01/12/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES The incidence of surgical bailout during transcatheter aortic valve replacement (TAVR) is ∼1%, with an associated 50% in-hospital mortality. We performed an exploratory qualitative study of TAVR team perceptions regarding routine surgical bailout planning with patients. METHODS We developed a semistructed interview guide to explore clinician perspectives on the TAVR consent process, managing intraoperative emergencies, and involving patients in surgical contingency planning. We interviewed surgeons, cardiologists, and anesthesiologists involved with TAVR in 4 hospitals. We performed qualitative thematic analysis via independent coding of salient quotations from the transcribed texts. Codes were categorized based on shared meaning and the final themes were derived by identifying key content, and examining its relational nature. RESULTS Thirteen interviews were conducted, identifying 4 major themes. Participants agreed that eliciting patient preference for bailout is crucial, particularly when surgical outcome is ambiguous. In those cases, participants offered criteria for determining which patients should be engaged in a more nuanced discussion. The ethos of specialty clinicians impacted anticipation and response to procedural emergencies. Finally, physician attitudes reflected strong emotional responses to patient death/morbidity, particularly in iatrogenic injury. Participants expressed anxiety with performing TAVR without surgical backup, while also demonstrating willingness to respect patients' wishes. CONCLUSIONS The TAVR team supports engaging patients regarding potential surgical bailout and honoring their preferences in the event of complication. However, clinical judgment about the expected outcome of bailout would frame that discussion. Participants described the emotional weight of not pursuing bailout if indicated and the importance of good coping mechanisms.
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Affiliation(s)
- Alexandria J. Robbins
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
- Hospice and Palliative Care, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minn
| | - Stuart W. Grande
- Division of Health Policy and Management, School of Public Health, University of Minnesota Medical School, Minneapolis, Minn
| | - Fatima Alwan
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
| | - Matthew R. Soule
- Division of Cardiothoracic Surgery, Minneapolis VA Health Care System, Minneapolis, Minn
| | - Ganesh Raveendran
- Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minn
| | - Gregory Helmer
- Division of Cardiology, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minn
| | - Rafael Andrade
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
| | - Tjorvi Perry
- Department of Anesthesia, University of Minnesota Medical School, Minneapolis, Minn
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Validation of the VARC-3 Technical Success Definition in Patients Undergoing TAVR. JACC Cardiovasc Interv 2022; 15:353-364. [PMID: 35093281 DOI: 10.1016/j.jcin.2021.11.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The authors aimed to investigate the rates, predictors, and prognostic impact of technical success in patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND The Valve Academic Research Consortium-3 (VARC-3) has introduced a composite endpoint to assess the immediate technical success of TAVR. METHODS In the prospective Bern TAVR registry, patients were stratified according to VARC-3 technical success. Technical failure differentiated between vascular and cardiac complications. RESULTS In a total of 1,624 patients undergoing TAVR between March 2012 and December 2019, 1,435 (88.4%) patients had technical success. Among 189 patients with technical failure, 140 (8.6%) had vascular and 49 (3.0%) had cardiac technical failure. Female, larger device landing zone calcium volume, and the early term of the study period were associated with an increased risk for cardiac technical failure, whereas higher body mass index and the use of the Prostar (Abbott Vascular Inc) MANTA (Teleflex) (compared with the ProGlide [Abbott Vascular Inc]) were predictors of vascular technical failure. In multivariable analysis, technical failure conferred an increased risk for cardiovascular death or stroke (HR: 2.01; 95% CI: 1.37-2.95). The adverse effect remained when stratified to cardiac (HR: 2.62; 95% CI: 1.38-4.97) or vascular technical failure (HR: 1.95; 95% CI: 1.28-2.95) and limited to the periprocedural period (0-30 days: HR: 3.42 [95% CI: 2.05-5.69]; 30-360 days: HR: 1.36 [95% CI: 0.79-2.35]; P for interaction = 0.002). CONCLUSIONS Technical failure according to VARC-3 was observed in 1 of 10 patients undergoing TAVR and was associated with a 2-fold increased risk of the composite outcome at 1 year after TAVR. (Swiss TAVI Registry; NCT01368250).
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Hirose S, Enta Y, Ishii K, Inoue A, Nakashima M, Nomura T, Saigan M, Tada N. En face view of the transcatheter heart valve from deep right-anterior-oblique cranial position for coronary access after transcatheter aortic valve implantation: a case series. Eur Heart J Case Rep 2022; 6:ytac059. [PMID: 35233498 PMCID: PMC8874809 DOI: 10.1093/ehjcr/ytac059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/14/2021] [Accepted: 01/21/2022] [Indexed: 11/14/2022]
Abstract
Background Coronary access after transcatheter aortic valve implantation (TAVI) is challenging due to the changes in aortic geometry. The perpendicular (long-axis) view of the transcatheter heart valve (THV) is usually used as the primary fluoroscopic angle. However, it does not always provide sufficient information on the rotational axis needed for selective coronary ostia engagement. The en face (short-axis) view from the deep right-anterior-oblique cranial position gives us additional information about three-dimensional spatial relationship of the THV and coronary ostia. Case summary We present three cases of coronary access after TAVI. We were successful in the use of the ‘en face’ view along with the perpendicular view in these cases. Discussion The use of the en face view complements that of the perpendicular long-axis view since it allows the understanding of the three-dimensional spatial relationship of the THV and the coronary ostia during fluoroscopy and control of catheter manipulation in two directions (up/down for perpendicular and clockwise/counterclockwise for en face view). We believe that the en face view helps improve the technical success of coronary access after TAVI.
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Affiliation(s)
- Suguru Hirose
- Department of Cardiology, Sendai Kousei Hospital, 4-15 Hirosemachi Aoba Sendai, Miyagi 980-0873, Japan
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, Tochigi, Japan
| | - Yusuke Enta
- Department of Cardiology, Sendai Kousei Hospital, 4-15 Hirosemachi Aoba Sendai, Miyagi 980-0873, Japan
| | - Kazunori Ishii
- Department of Cardiology, Sendai Kousei Hospital, 4-15 Hirosemachi Aoba Sendai, Miyagi 980-0873, Japan
| | - Arata Inoue
- Department of Cardiology, Sendai Kousei Hospital, 4-15 Hirosemachi Aoba Sendai, Miyagi 980-0873, Japan
| | - Masaki Nakashima
- Department of Cardiology, Sendai Kousei Hospital, 4-15 Hirosemachi Aoba Sendai, Miyagi 980-0873, Japan
| | - Takehiro Nomura
- Department of Cardiology, Sendai Kousei Hospital, 4-15 Hirosemachi Aoba Sendai, Miyagi 980-0873, Japan
| | - Makoto Saigan
- Department of Cardiology, Sendai Kousei Hospital, 4-15 Hirosemachi Aoba Sendai, Miyagi 980-0873, Japan
| | - Norio Tada
- Department of Cardiology, Sendai Kousei Hospital, 4-15 Hirosemachi Aoba Sendai, Miyagi 980-0873, Japan
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, Tochigi, Japan
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Hashimoto N, Tamura H, Otaki Y, Takahata A, Tsuchiya H, Sugai T, Yamashita A, Wanezaki M, Nishiyama S, Watanabe T, Uchida T, Watanabe M. Perfusion Balloon Is Useful for Preventing Obstruction of Left Main Coronary Artery During Transcatheter Aortic Valve Implantation. Int Heart J 2022; 63:163-167. [DOI: 10.1536/ihj.21-275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Naoto Hashimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Harutoshi Tamura
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Yoichiro Otaki
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Aoi Takahata
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Hayato Tsuchiya
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Takayuki Sugai
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Atsushi Yamashita
- Department of Cardiovascular, Thoracic, and Pediatric Surgery, Yamagata University School of Medicine
| | - Masahiro Wanezaki
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Satoshi Nishiyama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Tetsuro Uchida
- Department of Cardiovascular, Thoracic, and Pediatric Surgery, Yamagata University School of Medicine
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
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Busto L, Veiga C, González-Nóvoa JA, Loureiro-Ga M, Jiménez V, Baz JA, Íñiguez A. Automatic Identification of Bioprostheses on X-ray Angiographic Sequences of Transcatheter Aortic Valve Implantation Procedures Using Deep Learning. Diagnostics (Basel) 2022; 12:diagnostics12020334. [PMID: 35204425 PMCID: PMC8870761 DOI: 10.3390/diagnostics12020334] [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: 12/22/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/23/2022] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has become the treatment of choice for patients with severe aortic stenosis and high surgical risk. Angiography has been established as an essential tool in TAVI, as this modality provides real-time images required to support the intervention. The automatic interpretation and parameter extraction on such images can lead to significative improvements and new applications in the procedure that, in most cases, rely on a prior identification of the transcatheter heart valve (THV). In this paper, U-Net architecture is proposed for the automatic segmentation of THV on angiographies, studying the role of its hyperparameters in the quality of the segmentations. Several experiments have been conducted, testing the methodology using multiple configurations and evaluating the results on different types of frames captured during the procedure. The evaluation has been performed in terms of conventional classification metrics, complemented with two new metrics, specifically defined for this problem. Those new metrics provide a more appropriate assessment of the quality of the results, given the class imbalance in the dataset. From an analysis of the evaluation results, it can be concluded that the method provides appropriate segmentation results for this dataset.
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Affiliation(s)
- Laura Busto
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), 36213 Vigo, Spain; (J.A.G.-N.); (M.L.-G.)
- Correspondence: (L.B.); (C.V.)
| | - César Veiga
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), 36213 Vigo, Spain; (J.A.G.-N.); (M.L.-G.)
- Correspondence: (L.B.); (C.V.)
| | - José A. González-Nóvoa
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), 36213 Vigo, Spain; (J.A.G.-N.); (M.L.-G.)
| | - Marcos Loureiro-Ga
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), 36213 Vigo, Spain; (J.A.G.-N.); (M.L.-G.)
| | - Víctor Jiménez
- Cardiology Department, Complexo Hospitalario Universitario de Vigo (SERGAS), Álvaro Cunqueiro Hospital, 36213 Vigo, Spain; (V.J.); (J.A.B.); (A.Í.)
| | - José Antonio Baz
- Cardiology Department, Complexo Hospitalario Universitario de Vigo (SERGAS), Álvaro Cunqueiro Hospital, 36213 Vigo, Spain; (V.J.); (J.A.B.); (A.Í.)
| | - Andrés Íñiguez
- Cardiology Department, Complexo Hospitalario Universitario de Vigo (SERGAS), Álvaro Cunqueiro Hospital, 36213 Vigo, Spain; (V.J.); (J.A.B.); (A.Í.)
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OUP accepted manuscript. Eur Heart J 2022; 43:1008-1011. [DOI: 10.1093/eurheartj/ehab896] [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: 08/09/2021] [Revised: 12/17/2021] [Accepted: 12/20/2021] [Indexed: 11/14/2022] Open
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Payabyab EC, Elbaum LS, Sharma N, George I, Mick SL. Shockwave and Non-transfemoral Transcatheter Aortic Valve Replacement. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has become a widely adopted treatment modality for severe aortic stenosis. Transfemoral access is the approach of choice; however, approximately 25% of patients undergoing TAVR also have concomitant peripheral arterial disease. The recent advent of intravascular lithotripsy has enabled preservation of transfemoral access in some patients; although, a proportion still require alternative, non-femoral access. Alternative access sites can be broadly categorized into transthoracic and peripheral, facilitated by surgical or percutaneous techniques. In this review, the technical details and clinical outcomes of various TAVR accesses are discussed. Initially, transthoracic approaches were most common, but recently, the trend has been toward alternative peripheral access due to superior outcomes. Although there are no randomized data to support all the alternative access sites, the experiences reported provide available options for a large portion of patients to be candidates for TAVR. The intervention site should be selected by a multidisciplinary heart team based on patient anatomical factors and institutional expertise.
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Affiliation(s)
- Eden C Payabyab
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY
| | - Lindsay S Elbaum
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York City, NY
| | - Navneet Sharma
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York City, NY
| | - Isaac George
- NewYork-Presbyterian Hospital, Columbia University Medical Center, New York City, NY
| | - Stephanie L Mick
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY
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Salgado R, El Addouli H, Budde RPJ. Transcatheter Aortic Valve Implantation: The Evolving Role of the Radiologist in 2021. ROFO-FORTSCHR RONTG 2021; 193:1411-1425. [PMID: 34814198 DOI: 10.1055/a-1645-1873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) has gained worldwide acceptance and implementation as an alternative therapeutic option in patients with severe aortic valve stenosis unable to safely undergo surgical aortic valve replacement. This transformative technique places the radiologist in a key position in the pre-procedural assessment of potential candidates for this technique, delivering key anatomical information necessary for patient eligibility and procedural safety. Recent trials also provide encouraging results to potentially extend the indication to patients with safer risk profiles. METHOD The review is based on a PubMed literature search using the search terms "transcatheter heart valve", "TAVI", "TAVR", "CT", "imaging", "MR" over a period from 2010-2020, combined with personal comments based on the author's experience. RESULTS AND CONCLUSION CT plays a prominent role in the pre-procedural workup, delivering as a true 3D imaging modality optimal visualization of the complex anatomy of the aortic root with simultaneous evaluation of the patency of the different access routes. As such, the contribution of CT is key for the determination of patient eligibility and procedural safety. This input is supplementary to the contributions of other imaging modalities and forms an important element in the discussions of the Heart Valve Team. Knowledge of the procedure and its characteristics is necessary in order to provide a comprehensive and complete report. While the role of CT in the pre-procedural evaluation is well established, the contribution of CT and MR and the clinical significance of their findings in the routine follow-up after the intervention are less clear and currently the subject of intense investigation. Important issues remain, including the occurrence and significance of subclinical leaflet thrombosis, prosthetic heart valve endocarditis, and long-term structural valve degeneration. KEY POINTS · CT plays a crucial role in evaluating transcatheter heart valve candidates. · Evaluation must include the dimensions of the aortic root and access paths. · The exact post-procedural role of CT and MRI has not yet been determined.. CITATION FORMAT · Salgado R, El Addouli H, Budde RP. Transcatheter Aortic Valve Implantation: The Evolving Role of the Radiologist in 2021. Fortschr Röntgenstr 2021; 193: 1411 - 1425.
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Affiliation(s)
- Rodrigo Salgado
- Radiology, UZA, Edegem, Belgium.,Radiology, Holy Heart Hospital Lier, Belgium
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Razuk V, Camaj A, Cao D, Nicolas J, Hengstenberg C, Sartori S, Zhang Z, Power D, Beerkens F, Chiarito M, Meneveau N, Tron C, Dumonteil N, Widder JD, Ferrari M, Violini R, Stella PR, Jeger R, Anthopoulos P, Mehran R, Dangas GD. Impact of anemia on short-term outcomes after TAVR: A subgroup analysis from the BRAVO-3 randomized trial. Catheter Cardiovasc Interv 2021; 98:E870-E880. [PMID: 33909348 DOI: 10.1002/ccd.29753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 04/26/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To determine the prognostic impact of anemia in patients randomized to bivalirudin or unfractionated heparin (UFH) during transcatheter aortic valve replacement (TAVR). BACKGROUND Whether the periprocedural use of bivalirudin as compared with UFH in anemic patients undergoing TAVR has an impact on outcomes remains unknown. METHODS The BRAVO-3 trial compared the use of bivalirudin versus UFH in 802 high risk patients undergoing transfemoral TAVR for severe symptomatic aortic stenosis. Patients were stratified according to the presence (defined as hemoglobin levels <13 g/dl in men and <12 g/dl in women) or absence of anemia. The primary outcomes were net adverse cardiac events (NACE; a composite of all-cause mortality, myocardial infarction, stroke, or bleeding) and major bleeding (Bleeding Academic Research Consortium ≥3b) at 30 days. RESULTS Among 798 patients with available baseline hemoglobin levels, 427 (54%) were anemic of whom 221 (52%) received bivalirudin. There were no significant differences in NACE and major bleeding at 30 days between patients with and without anemia, irrespective of the type of anticoagulant used (pinteraction = 0.71 for NACE, pinteraction = 1.0 for major bleeding). However, anemic patients had a higher risk of major vascular complications (adjusted OR 2.43, 95% CI 1.42-4.16, p = 0.001), and acute kidney injury (adjusted OR 1.74, 95% CI 1.16-2.59, p = 0.007) compared to non-anemic patients at 30 days. CONCLUSIONS Anemia was not associated with a higher risk of NACE or major bleeding at 30 days after TAVR without modification of the treatment effects of periprocedural anticoagulation with bivalirudin versus UFH.
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Affiliation(s)
- Victor Razuk
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anton Camaj
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christian Hengstenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David Power
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Frans Beerkens
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mauro Chiarito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
| | - Christophe Tron
- Division of Cardiology, Rouen University Hospital, Rouen, France
| | - Nicolas Dumonteil
- Groupe CardioVasculaire Interventionnel, Clinique Pasteur, Toulouse, France
| | - Julian D Widder
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Markus Ferrari
- Interventional Cardiology, Helios Dr. Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Germany
| | - Roberto Violini
- Interventional Cardiology Unit, San Camillo Hospital, Rome, Italy
| | - Pieter R Stella
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Raban Jeger
- Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | | | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Majmundar M, Kumar A, Kalra A. Impact of Embolic Protection Device Placed During Transcatheter Aortic Valve Implantation on Postdischarge Stroke Prevention. Am J Cardiol 2021; 158:150-152. [PMID: 34465461 DOI: 10.1016/j.amjcard.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 08/03/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Monil Majmundar
- Department of Cardiology, Maimonides Medical Center, Brooklyn, New York; Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, Ohio
| | - Ashish Kumar
- Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, Ohio; Department of Internal Medicine, Cleveland Clinic Akron General, Akron, Ohio
| | - Ankur Kalra
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, Ohio; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Comparing Single- and Dual Antiplatelet Therapies Following Transcatheter Aortic Valve Implantation. Ann Thorac Surg 2021; 114:1951-1964. [PMID: 34715082 DOI: 10.1016/j.athoracsur.2021.09.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/24/2021] [Accepted: 09/20/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Transcatheter aortic valve implantation has been an established treatment in patients with symptomatic severe aortic stenosis. However, the postoperative antiplatelet regimen after transcatheter aortic valve implantation was not established certainly. The aim of this meta-analysis is to compare the safety and efficacy of single- (SAPT) and dual-antiplatelet therapies (DAPT) in patients undergoing transcatheter aortic valve implantation. METHODS Eligible randomized controlled trials and cohort studies published before February 2021 were retrieved from PubMed, Embase, and the Cochrane Library. We calculated odds ratios with 95% confidence intervals. RESULTS Nine articles, involving 19,277 patients, met the selection criteria. In the short-term outcome, compared with SAPT, DAPT was associated with a significantly higher rate of bleeding (odds ratios, 95% confidence intervals: 3.00, 1.67-5.38) and showed no significant differences in thrombotic events (odds ratios, 95% confidence intervals: 1.25, 0.74-2.11) and all-cause mortality (odds ratios, 95% confidence intervals: 0.84; 0.42-1.69). In the long-term outcome, DAPT was associated with a significantly higher bleeding rate (odds ratios, 95% confidence intervals: 1.85, 1.24-2.78) and showed no differences in thrombotic events (odds ratios, 95% confidence intervals: 1.13, 0.86-1.48) and all-cause mortality (odds ratios, 95% confidence intervals: 1.12, 0.95-1.32). Our trial sequential analysis confirmed DAPT didn't confer any benefit for reducing all-cause mortality and thrombotic events, and carried a higher risk of bleeding than SAPT. CONCLUSIONS SAPT should be a sufficient antiplatelet strategy in post- transcatheter aortic valve implantation patients without indications for oral anticoagulation medication, especially in the long-term follow-up period.
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Saia F, Orzalkiewicz M. How to reduce uncommon but severe transcatheter aortic valve implantation complications: stroke, thrombosis, endocarditis, cognitive decline? Eur Heart J Suppl 2021; 23:E142-E146. [PMID: 34650374 PMCID: PMC8503386 DOI: 10.1093/eurheartj/suab110] [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] [Indexed: 11/12/2022]
Abstract
Transcatheter aortic valve implantation has become a valid alternative to surgical aortic valve replacement for patients with symptomatic severe aortic stenosis, regardless of baseline surgical risk. The incidence of periprocedural complications has steadily declined over the years, thanks to technical advancement of transcatheter heart valves, delivery systems, and increased operators' experience. Beyond the most common periprocedural complications, there are a few uncommon but potentially severe complications that more often occur during follow-up, although they may also arise in the periprocedural phase. Stroke, infective endocarditis, valve thrombosis, and cognitive decline are among them. In this brief review, we describe the incidence, predictive factors, and potential preventive measures for those events.
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Affiliation(s)
- Francesco Saia
- Cardiac Unit, Cardio-Thoracic-Vascular Department, IRCCS University Hospital of Bologna, Policlinico S. Orsola (Pav. 23), Via Massarenti, 9, 40138 Bologna, Italy
| | - Mateusz Orzalkiewicz
- Cardiac Unit, Cardio-Thoracic-Vascular Department, IRCCS University Hospital of Bologna, Policlinico S. Orsola (Pav. 23), Via Massarenti, 9, 40138 Bologna, Italy
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Neurologic Complications in Transcatheter Aortic Valve Replacement. Interv Cardiol Clin 2021; 10:519-529. [PMID: 34593114 DOI: 10.1016/j.iccl.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) has become the mainstay of treatment for severe symptomatic aortic stenosis. Although many TAVR complication rates including mortality and aortic regurgitation have decreased, stroke rates have remained stable for years. TAVR-related strokes are devastating to patients and their families, and very costly for health care systems. The predictors of stroke in TAVR are not yet well defined, although older age, female gender, carotid and peripheral arterial disease, bicuspid aortic valve anatomy, and atrial fibrillation are emerging as risk factors across studies.
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