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Rooijakkers MJP, Versteeg GAA, Hemelrijk KI, Aarts HM, Overduin DC, van Ginkel DJ, Vlaar PJ, van Wely MH, van Nunen LX, van Geuns RJ, van Garsse LAFM, Geuzebroek GSC, Verkroost MWA, Rodwell L, Heijmen RH, Tonino PAL, Ten Berg JM, Delewi R, van Royen N. Upper extremity versus lower extremity for secondary access during transcatheter aortic valve implantation: rationale and design of the randomised TAVI XS trial. Neth Heart J 2024; 32:270-275. [PMID: 38653922 PMCID: PMC11239632 DOI: 10.1007/s12471-024-01869-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND During transcatheter aortic valve implantation (TAVI), secondary access is required for angiographic guidance and temporary pacing. The most commonly used secondary access sites are the femoral artery (angiographic guidance) and the femoral vein (temporary pacing). An upper extremity approach using the radial artery and an upper arm vein instead of the lower extremity approach using the femoral artery and femoral vein may reduce clinically relevant secondary access site-related bleeding complications, but robust evidence is lacking. TRIAL DESIGN The TAVI XS trial is a multicentre, randomised, open-label clinical trial with blinded evaluation of endpoints. A total of 238 patients undergoing transfemoral TAVI will be included. The primary endpoint is the incidence of clinically relevant bleeding (i.e. Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding) of the randomised secondary access site (either diagnostic or pacemaker access, or both) within 30 days after TAVI. Secondary endpoints include time to mobilisation after TAVI, duration of hospitalisation, any BARC type 2, 3 or 5 bleeding, and early safety at 30 days according to Valve Academic Research Consortium‑3 criteria. CONCLUSION The TAVI XS trial is the first randomised trial comparing an upper extremity approach to a lower extremity approach with regard to clinically relevant secondary access site-related bleeding complications. The results of this trial will provide important insights into the safety and efficacy of an upper extremity approach in patients undergoing transfemoral TAVI.
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Affiliation(s)
- Maxim J P Rooijakkers
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Geert A A Versteeg
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Kimberley I Hemelrijk
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Hugo M Aarts
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Daniël C Overduin
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Dirk-Jan van Ginkel
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Pieter J Vlaar
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Marleen H van Wely
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lokien X van Nunen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Robert Jan van Geuns
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Leen A F M van Garsse
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Guillaume S C Geuzebroek
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Michel W A Verkroost
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Laura Rodwell
- Department of Health Sciences, Section Biostatistics, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Robin H Heijmen
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pim A L Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Jurrien M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands.
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Alperi A, Ptaszynski R, Pascual I, Del Valle R, Hernández-Vaquero D, Almendárez M, Antuna P, Ludeña R, Morís C, Avanzas P. Late bleeding events in TAVI patients receiving vitamin K antagonists or direct oral anticoagulants. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024:S1885-5857(24)00146-4. [PMID: 38701880 DOI: 10.1016/j.rec.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/14/2024] [Indexed: 05/05/2024]
Abstract
INTRODUCTION AND OBJECTIVES The optimal chronic antithrombotic regimen for patients with atrial fibrillation undergoing transcatheter aortic valve implantation (TAVI) remains uncertain. Our aim was to compare the incidence of late bleeding events between patients on direct oral anticoagulants (DOACs) and those on vitamin-K antagonists (VKA). METHODS This single-center observational study included TAVI patients requiring oral anticoagulation at discharge between 2015 and 2021. The primary endpoint was any clinically significant bleeding event. Secondary endpoints were stroke, heart failure, and all-cause mortality. RESULTS A total of 702 TAVI procedures were performed, with 297 patients requiring oral anticoagulation at discharge. Among them, 206 (69.4%) received VKA and 91 (30.6%) received DOAC. Baseline clinical, procedural and in-hospital characteristics did not significantly differ between groups, except for better renal function among DOAC patients. The median length of follow-up was 2.8 years. The risk of bleeding events was higher in patients receiving DOACs than in those receiving VKA (HR, 2.27; 95%CI, 1.21-4.26; incidence of 9.7 and 4.2 events per 100 patient-years of follow-up for DOAC and VKA patients, respectively). There were no statistically significant differences in the rates of stroke (HR, 1.28; 95%CI, 0.4-4.3), heart failure hospitalization (HR, 0.92; 95%CI, 0.46-1.86), or all-cause mortality (HR, 1.02; 95%CI, 0.68-1.55). CONCLUSIONS In older patients undergoing TAVI and receiving anticoagulant therapy for atrial fibrillation, the use of DOAC was associated with a higher risk of late bleeding events than VKA.
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Affiliation(s)
- Alberto Alperi
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Asturias, Spain
| | - Raul Ptaszynski
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Isaac Pascual
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Asturias, Spain; Universidad de Oviedo, Oviedo, Asturias, Spain
| | - Raquel Del Valle
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Asturias, Spain
| | - Daniel Hernández-Vaquero
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Asturias, Spain; Universidad de Oviedo, Oviedo, Asturias, Spain
| | - Marcel Almendárez
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Paula Antuna
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Raul Ludeña
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - César Morís
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Asturias, Spain; Universidad de Oviedo, Oviedo, Asturias, Spain
| | - Pablo Avanzas
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Asturias, Spain; Universidad de Oviedo, Oviedo, Asturias, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
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Chen Y, Xiao Y, Huang R, Jiang F, Zhou J, Su C, Yang T. Association between hospital racial composition and aortic valve replacement outcomes: A national inpatients sample database analysis. Catheter Cardiovasc Interv 2024; 103:637-649. [PMID: 38353494 DOI: 10.1002/ccd.30970] [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: 10/30/2023] [Revised: 01/13/2024] [Accepted: 01/31/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Racial and ethnic disparities exist in the outcomes following surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI). However, it is unclear whether hospital racial composition contributes to these racial disparities. METHODS We analyzed the National Inpatient Sample (NIS) database from 2015 to 2019 to identify patients with aortic stenosis (AS) who received SAVR and TAVI. The Racial/Ethnic Diversity Index (RDI) was used to assess hospital racial composition as the proportion of nonwhite patients to total hospital admissions. Hospitals were categorized into RDI quintiles. Textbook outcome (TO) was defined as no in-hospital mortality, no postoperative complications and no prolonged length of stay (LOS). Multivariable mixed generalized linear models were conducted to assess the association between RDI and post-SAVR and post-TAVI outcomes. Moreover, quantile regression was used to assess the additional cost and length of stay associated with the RDI quintile. RESULTS The study included 82,502 SAVR or TAVI performed across 3285 hospitals, with 47.4% isolated SAVR and 52.5% isolated TAVI. After adjustment, quintiles 4 and 5 demonstrated significantly lower odds of TO than the lowest RDI quintile in both the SAVR cohort (quintile 4, 0.79 [95% CI, 0.73-0.85]; quintile 5, 0.79 [95% CI, 0.73-0.86]) and TAVI cohort (quintile 4, 0.88 [95% CI, 0.82-0.95]; quintile 5, 0.80 [95% CI, 0.74-0.86]). Despite non-observable differences in in-hospital mortality across all RDI quintiles, the rate of AKI and blood transfusion increased with increasing RDI for both cohorts. Further, Higher RDI quintiles were associated with increased costs and longer LOS. From 2015 to 2019, post-TAVI outcomes improved across all RDI quintiles. CONCLUSIONS Hospitals with a higher RDI experienced lower TO achievements, increased AKI, and blood transfusion, along with extended LOS and higher costs. Importantly, post-TAVI outcomes improved from 2015 to 2019 across all RDI groups.
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Affiliation(s)
- Yanfei Chen
- School of International Business, China Pharmaceutical University, Nanjing, China
| | - Yue Xiao
- School of International Business, China Pharmaceutical University, Nanjing, China
| | - Ruijian Huang
- School of International Business, China Pharmaceutical University, Nanjing, China
| | - Feng Jiang
- School of International Business, China Pharmaceutical University, Nanjing, China
| | - Jifang Zhou
- School of International Business, China Pharmaceutical University, Nanjing, China
| | - Cunhua Su
- Department of Thoracic and Cardiovascular Surgery, Nanjing Medical University, Nanjing, China
| | - Tianchi Yang
- Immunization Center, Ningbo Municipal Centre for Disease Control and Prevention, Ningbo, China
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Petrovic M, Spirito A, Sartori S, Vogel B, Tchetche D, Petronio AS, Mehilli J, Lefevre T, Presbitero P, Capranzano P, Pileggi B, Iadanza A, Sardella G, van Mieghem NM, Meliga E, Feng Y, Dumonteil N, Cohen R, Fraccaro C, Trabattoni D, Mikhail G, Ferrer-Gracia MC, Naber C, Sharma SK, Watanabe Y, Morice MC, Dangas GD, Chieffo A, Mehran R. Prognostic Impact of Prefrailty and Frailty in Women Undergoing TAVR: Insights From the WIN-TAVI Registry. Can J Cardiol 2024; 40:457-467. [PMID: 37923124 DOI: 10.1016/j.cjca.2023.10.024] [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: 04/16/2023] [Revised: 10/20/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND The risks of prefrail and frail women undergoing transcatheter aortic valve replacement (TAVR) have not been fully examined. The aim of the analysis was to assess the prognostic impact of prefrailty and frailty in women undergoing TAVR. METHODS Women at intermediate or high surgical risk with severe aortic stenosis undergoing TAVR from the prospective multicentre WIN-TAVI (Women's International Transcatheter Aortic Valve Implantation) registry were stratified based on the number of Fried frailty criteria (weight loss, exhaustion, low physical activity, slow gait, weakness) met: nonfrail (no criteria), prefrail (1 or 2 criteria), or frail (3 or more criteria). The primary outcome at 1 year was the Valve Academic Research Consortium 2 (VARC-2) efficacy end point, a composite of mortality, stroke, myocardial infarction, hospitalisation for valve-related symptoms or heart failure, and valve-related dysfunction; secondary outcomes included the composite of VARC-2 life-threatening or major bleeding. RESULTS Out of 1019 women, 297 (29.1%) met at least 1 frailty criterion: 264 (25.9%) had prefrailty and 33 (3.2%) frailty. The 1-year risk of the primary outcome was significantly higher in prefrail and frail (20.2%) than in nonfrail (14.9%) women (adjusted hazard ratio [aHR] 1.51, 95% confidence interval [CI] 1.07-2.12). The risk of VARC-2 life-threatening or major bleeding was higher in prefrail or frail (19.9%) than in nonfrail (10.0%) women (aHR 2.06, 95% CI 1.42-2.97). These risks were consistently increased in the prefrail and frail groups assessed separately. CONCLUSIONS In women undergoing TAVR, the presence of prefrailty or frailty conferred an increased risk of the VARC-2 efficacy end point and of VARC-2 life-threatening or major bleeding.
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Affiliation(s)
- Marija Petrovic
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Samantha Sartori
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Birgit Vogel
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Julinda Mehilli
- Munich University Clinic, Ludwig-Maximilians University and German Centre for Cardiovascular Research, Munich Heart Alliance, Munich, Germany
| | - Thierry Lefevre
- Institut Hospitalier Jacques Cartier, Ramsay Générale de Santé, Massy, France
| | | | - Piera Capranzano
- Cardiology, Policlinico Hospital, University of Catania, Catania, Italy
| | - Brunna Pileggi
- Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Cardiopneumonology, Heart Institute of the University of São Paulo, São Paulo, Brazil
| | - Alessandro Iadanza
- Azienda Ospedaliera Universitaria Senese, Policlinico Le Scotte, Siena, Italy
| | - Gennaro Sardella
- Policlinico Umberto I "Sapienza," University of Rome, Rome, Italy
| | | | | | - Yihan Feng
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Rebecca Cohen
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ghada Mikhail
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | | | - Christoph Naber
- Contilia Heart and Vascular Centre, Elisabeth Krankenhaus, Essen, Germany
| | - Samin K Sharma
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Marie-Claude Morice
- Institut Hospitalier Jacques Cartier, Ramsay Générale de Santé, Massy, France
| | - George D Dangas
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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Benjamin MM, Rabbat MG. Artificial Intelligence in Transcatheter Aortic Valve Replacement: Its Current Role and Ongoing Challenges. Diagnostics (Basel) 2024; 14:261. [PMID: 38337777 PMCID: PMC10855497 DOI: 10.3390/diagnostics14030261] [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: 12/15/2023] [Revised: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 02/12/2024] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has emerged as a viable alternative to surgical aortic valve replacement, as accumulating clinical evidence has demonstrated its safety and efficacy. TAVR indications have expanded beyond high-risk or inoperable patients to include intermediate and low-risk patients with severe aortic stenosis. Artificial intelligence (AI) is revolutionizing the field of cardiology, aiding in the interpretation of medical imaging and developing risk models for at-risk individuals and those with cardiac disease. This article explores the growing role of AI in TAVR procedures and assesses its potential impact, with particular focus on its ability to improve patient selection, procedural planning, post-implantation monitoring and contribute to optimized patient outcomes. In addition, current challenges and future directions in AI implementation are highlighted.
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Affiliation(s)
- Mina M. Benjamin
- Division of Cardiovascular Medicine, SSM—Saint Louis University Hospital, Saint Louis University, Saint Louis, MO 63104, USA
| | - Mark G. Rabbat
- Department of Cardiovascular Medicine, Loyola University Medical Center, Maywood, IL 60153, USA;
- Department of Cardiology, Edward Hines Jr. VA Hospital, Hines, IL 60141, USA
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6
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Rooijakkers MJP, Versteeg GAA, van Wely MH, Rodwell L, van Nunen LX, van Geuns RJ, van Garsse LAFM, Geuzebroek GSC, Verkroost MWA, Heijmen RH, van Royen N. Using Upper Arm Vein as Temporary Pacemaker Access Site: A Next Step in Minimizing the Invasiveness of Transcatheter Aortic Valve Replacement. J Clin Med 2024; 13:651. [PMID: 38337345 PMCID: PMC10855945 DOI: 10.3390/jcm13030651] [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: 11/09/2023] [Revised: 01/15/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
Background The femoral vein is commonly used as a pacemaker access site during transcatheter aortic valve replacement (TAVR). Using an upper arm vein as an alternative access site potentially causes fewer bleeding complications and shorter time to mobilization. We aimed to assess the safety and efficacy of an upper arm vein as a temporary pacemaker access site during TAVR. Methods We evaluated all patients undergoing TAVR in our center between January 2020 and January 2023. Upper arm, femoral, and jugular vein pacemaker access was used in 255 (45.8%), 191 (34.3%), and 111 (19.9%) patients, respectively. Clinical outcomes were analyzed according to pacemaker access in the overall population and in a propensity-matched population involving 165 upper arm and 165 femoral vein patients. Primary endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 pacemaker access site-related bleeding. Results In the overall population, primary endpoint was lowest for upper arm, followed by femoral and jugular vein access (2.4% vs. 5.8% vs. 10.8%, p = 0.003). Time to mobilization was significantly longer (p < 0.001) in the jugular cohort compared with the other cohorts. In the propensity-matched cohort, primary endpoint showed a trend toward lower occurrence in the upper arm compared with the femoral cohort (2.4% vs. 6.1%, p = 0.10). Time to mobilization was significantly shorter (480 vs. 1140 min, p < 0.001) in the upper arm cohort, with a comparable skin-to-skin time (83 vs. 85 min, p = 0.75). Cross-over from upper arm pacemaker access was required in 17 patients (6.3% of attempted cases via an upper arm vein). Conclusions Using an upper arm vein as a temporary pacemaker access site is safe and feasible. Its use might be associated with fewer bleeding complications and shorter time to mobilization compared with the femoral vein.
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Affiliation(s)
- Maxim J. P. Rooijakkers
- Department of Cardiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (M.J.P.R.); (G.A.A.V.); (M.H.v.W.); (L.X.v.N.); (R.J.v.G.)
| | - Geert A. A. Versteeg
- Department of Cardiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (M.J.P.R.); (G.A.A.V.); (M.H.v.W.); (L.X.v.N.); (R.J.v.G.)
| | - Marleen H. van Wely
- Department of Cardiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (M.J.P.R.); (G.A.A.V.); (M.H.v.W.); (L.X.v.N.); (R.J.v.G.)
| | - Laura Rodwell
- Section Biostatistics, Department of Health Sciences, Radboud Institute for Health Sciences, 6525 EZ Nijmegen, The Netherlands;
| | - Lokien X. van Nunen
- Department of Cardiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (M.J.P.R.); (G.A.A.V.); (M.H.v.W.); (L.X.v.N.); (R.J.v.G.)
| | - Robert Jan van Geuns
- Department of Cardiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (M.J.P.R.); (G.A.A.V.); (M.H.v.W.); (L.X.v.N.); (R.J.v.G.)
| | - Leen A. F. M. van Garsse
- Department of Cardiothoracic Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (L.A.F.M.v.G.); (G.S.C.G.); (M.W.A.V.); (R.H.H.)
| | - Guillaume S. C. Geuzebroek
- Department of Cardiothoracic Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (L.A.F.M.v.G.); (G.S.C.G.); (M.W.A.V.); (R.H.H.)
| | - Michel W. A. Verkroost
- Department of Cardiothoracic Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (L.A.F.M.v.G.); (G.S.C.G.); (M.W.A.V.); (R.H.H.)
| | - Robin H. Heijmen
- Department of Cardiothoracic Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (L.A.F.M.v.G.); (G.S.C.G.); (M.W.A.V.); (R.H.H.)
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; (M.J.P.R.); (G.A.A.V.); (M.H.v.W.); (L.X.v.N.); (R.J.v.G.)
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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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Avvedimento M, Rodés-Cabau J. Reply: Extensive Impairment of the Hemostatic System Increases Bleeding Events: The Potential of CT-ADP. JACC Cardiovasc Interv 2023; 16:2934. [PMID: 38092502 DOI: 10.1016/j.jcin.2023.10.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 12/18/2023]
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9
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Franzone A, Esposito G. VARC-3 Criteria for Bleeding Events: Integrating Theory Into Practice. JACC Cardiovasc Interv 2023; 16:2275-2276. [PMID: 37676227 DOI: 10.1016/j.jcin.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/07/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Anna Franzone
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy.
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
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Avvedimento M, Real C, Nuche J, Farjat-Pasos J, Galhardo A, Trinh KH, Robichaud M, Delarochellière R, Paradis JM, Poulin A, Dumont E, Kalavrouziotis D, Mohammadi S, Côté M, Rodés-Cabau J. Incidence, Predictors, and Prognostic Impact of Bleeding Events After TAVR According to VARC-3 Criteria. JACC Cardiovasc Interv 2023; 16:2262-2274. [PMID: 37676226 DOI: 10.1016/j.jcin.2023.07.005] [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: 05/01/2023] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND The updated Valve Academic Research Consortium (VARC) definition for bleeding events after transcatheter aortic valve replacement (TAVR) lacks of clinical validation. OBJECTIVES The aim of this study was to determine the incidence, predictors, and clinical impact of bleeding events following TAVR as defined by recent VARC-3 criteria. METHODS A total of 2,384 consecutive patients with severe symptomatic aortic stenosis undergoing TAVR were included. Early (at index hospitalization) and late (after hospital discharge) bleeding complications were defined according to VARC-3 criteria as type 1, 2, 3, or 4. Baseline, procedural, and follow-up (24 [IQR: 12-43] months) data were prospectively collected. RESULTS Bleeding events occurred in 761 patients (31.9%): types 1, 2, 3, and 4 in 169 (22.2%), 399 (52.4%), 149 (19.6%), and 44 (5.8%) patients, respectively. The primary vascular access site and gastrointestinal locations were the most common bleeding sources among early and late bleeding events, respectively. Female sex, thoracotomy access, larger (14-F) sheath use, and dual antiplatelet therapy determined an increased risk of early bleeding events (P < 0.02 for all). The use of the radial artery for secondary access was associated with a significant risk reduction of early bleeding (P < 0.001). Type 2 and type 3 events were associated with an increased mortality risk at 30-day (HR: 2.94 [95% CI: 1.43-6.03; P = 0.003] and HR: 4.91 [95% CI: 2.19-11.03; P < 0.001], respectively) and 1-year (HR: 1.86 [95% CI: 1.28-2.69; P = 0.001] and HR: 2.28 [95% CI: 1.41-3.66; P = 0.001], respectively) follow-up. A similar prognostic pattern was observed when applying VARC-2 criteria but with a much lower global incidence of early bleeding events (19% vs 27%; P < 0.001). CONCLUSIONS Bleeding events after TAVR were associated with poorer short- and long-term survival. The magnitude of this correlation was proportional to bleeding severity defined according to VARC-3 criteria. Further studies on bleeding prevention following TAVR are warranted to improve procedural safety and patient prognosis.
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Affiliation(s)
- Marisa Avvedimento
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Carlos Real
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada; Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Jorge Nuche
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Julio Farjat-Pasos
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Attilio Galhardo
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Kim-Hoang Trinh
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Mathieu Robichaud
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Jean-Michel Paradis
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Anthony Poulin
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Eric Dumont
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Siamak Mohammadi
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Mélanie Côté
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada; Clínic Barcelona, Barcelona, Spain.
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Avvedimento M, Campelo-Parada F, Munoz-Garcia E, Nombela-Franco L, Fischer Q, Donaint P, Serra V, Veiga G, Gutiérrez E, Esposito G, Vilalta V, Alperi A, Regueiro A, Asmarats L, Ribeiro HB, Matta A, Munoz-Garcia A, Tirado-Conte G, Urena M, Metz D, Rodenas-Alesina E, de la Torre Hernandez JM, Fernandez-Nofrerias E, Pascual I, Vidal-Cales P, Arzamendi D, Campanha-Borges DC, Trinh KH, Côté M, Faroux L, Rodés-Cabau J. Late Bleeding Events in Patients Undergoing Percutaneous Coronary Intervention in the Workup Pre-TAVR. JACC Cardiovasc Interv 2023; 16:2153-2164. [PMID: 37704301 DOI: 10.1016/j.jcin.2023.06.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND In patients undergoing percutaneous coronary intervention (PCI) in the work-up pre-transcatheter aortic valve replacement (TAVR), the incidence and clinical impact of late bleeding events (LBEs) remain largely unknown. OBJECTIVES This study sought to determine the incidence, clinical characteristics, associated factors, and outcomes of LBEs in patients undergoing PCI in the work-up pre-TAVR. METHODS This was a multicenter study including 1,457 consecutive patients (mean age 81 ± 7 years; 41.5% women) who underwent TAVR and survived beyond 30 days. LBEs (>30 days post-TAVR) were defined according to the Valve Academic Research Consortium-2 criteria. RESULTS LBEs occurred in 116 (7.9%) patients after a median follow-up of 23 (IQR: 12-40) months. Late bleeding was minor, major, and life-threatening or disabling in 21 (18.1%), 63 (54.3%), and 32 (27.6%) patients, respectively. Periprocedural (<30 days post-TAVR) major bleeding and the combination of antiplatelet and anticoagulation therapy at discharge were independent factors associated with LBEs (P ≤ 0.02 for all). LBEs conveyed an increased mortality risk at 4-year follow-up compared with no bleeding (43.9% vs 36.0; P = 0.034). Also, LBE was identified as an independent predictor of all-cause mortality after TAVR (HR: 1.39; 95% CI: 1.05-1.83; P = 0.020). CONCLUSIONS In TAVR candidates with concomitant significant coronary artery disease requiring percutaneous treatment, LBEs after TAVR were frequent and associated with increased mortality. Combining antiplatelet and anticoagulation regimens and the occurrence of periprocedural bleeding determined an increased risk of LBEs. Preventive strategies should be pursued for preventing late bleeding after TAVR, and further studies are needed to provide more solid evidence on the most safe and effective antithrombotic regimen post-TAVR in this challenging group of patients.
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Affiliation(s)
- Marisa Avvedimento
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Erika Munoz-Garcia
- Cardiology Department, Hospital Universitario Virgen de la Victoria, Málaga, CIBERCV, Spain
| | - Luis Nombela-Franco
- Cardiology Department, Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico de San Carlos, Madrid, Spain
| | - Quentin Fischer
- Cardiology Department, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pierre Donaint
- Cardiology Department, Reims University Hospital, Reims, France
| | - Vicenç Serra
- Cardiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Gabriela Veiga
- Cardiology Department, Hospital Universitario Marques de Valdecilla, IDIVAL, Santander, Spain
| | | | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Victoria Vilalta
- Cardiology Department, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Alberto Alperi
- Cardiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Ander Regueiro
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | - Lluis Asmarats
- Cardiology Department, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Henrique B Ribeiro
- Cardiology Department, Heart Institute, University of São Paulo, São Paulo, Brazil
| | - Anthony Matta
- Cardiology Department, Hôpital Rangueil, CHU Toulouse, Toulouse, France
| | - Antonio Munoz-Garcia
- Cardiology Department, Hospital Universitario Virgen de la Victoria, Málaga, CIBERCV, Spain
| | - Gabriela Tirado-Conte
- Cardiology Department, Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico de San Carlos, Madrid, Spain
| | - Marina Urena
- Cardiology Department, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Damien Metz
- Cardiology Department, Reims University Hospital, Reims, France
| | | | | | | | - Isaac Pascual
- Cardiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Pablo Vidal-Cales
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | - Dabit Arzamendi
- Cardiology Department, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Kim Hoang Trinh
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Mélanie Côté
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Laurent Faroux
- Cardiology Department, Reims University Hospital, Reims, France
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain.
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