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Giuliani C, Zanuttini A, Salaun E, Côté N, Clavel MA, Pibarot P. Subclinical valve leaflet thrombosis following bioprosthetic aortic valve replacement. Curr Opin Cardiol 2024; 39:457-464. [PMID: 38899782 DOI: 10.1097/hco.0000000000001161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
PURPOSE OF REVIEW Subclinical leaflet thrombosis (SLT) is often an incidental finding characterized by a thin layer of thrombus involving one, two or three leaflets, with typical appearance on multi-detector computed tomography (MDCT) of hypo-attenuating defect at the aortic side of the leaflet, also called hypo-attenuating leaflet thickening (HALT). SLT may occur following both transcatheter aortic replacement (TAVR) or biological surgical aortic valve replacement (SAVR). The aim of this review is to present an overview of the current state of knowledge on the incidence, diagnosis, clinical impact, and management of SLT following TAVR or SAVR. RECENT FINDINGS SLT occurs in 10-20% of patients following TAVR and is somewhat more frequent than following SAVR (5-15%). SLT may regress spontaneously without treatment in about 50% of the cases but may also progress to clinically significant valve thrombosis in some cases. Oral anticoagulation with vitamin K antagonist is reasonable if SLT is detected by echocardiography and/or MDCT during follow-up and is generally efficient to reverse SLT. SLT is associated with mild increase in the risk of stroke but has no impact on survival. SLT has been linked with accelerated structural valve deterioration and may thus impact valve durability and long-term outcomes. SUMMARY SLT is often an incidental finding on echocardiography or MDCT that occurs in 10-20% of patients following TAVR or 5-15% following biological SAVR and is associated with a mild increase in the risk of thrombo-embolic event with no significant impact on mortality but may be associated with reduced valve durability.
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Affiliation(s)
- Carlos Giuliani
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada
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2
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Adrichem R, Rodes Cabau J, Mehran R, Park DW, Ten Berg JM, de Backer O, Hengstenberg C, Budde RPJ, Dangas GD, Makkar R, Van Mieghem NM. Treatment of Transcatheter Aortic Valve Thrombosis: JACC Review Topic of the Week. J Am Coll Cardiol 2024; 84:848-861. [PMID: 39168571 DOI: 10.1016/j.jacc.2024.05.064] [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: 03/21/2024] [Revised: 05/01/2024] [Accepted: 05/13/2024] [Indexed: 08/23/2024]
Abstract
Transcatheter aortic valve (TAV) thrombosis may manifest as subclinical leaflet thrombosis (SLT) and clinical valve thrombosis. SLT is relatively common (10%-20%) after transcatheter aortic valve replacement, but clinical implications are uncertain. Clinical valve thrombosis is rare (1.2%) and associated with bioprosthetic valve failure, neurologic or thromboembolic events, heart failure, and death. Treatment for TAV thrombosis has been understudied. In principle, anticoagulation may prevent TAV thrombosis. Non-vitamin K oral anticoagulants, as compared to antiplatelet therapy, are associated with reduced incidence of SLT, although at the cost of higher bleeding and all-cause mortality risk. We present an overview of existing literature for management of TAV thrombosis and propose a rational treatment algorithm. Vitamin K antagonists or non-vitamin K oral anticoagulants are the cornerstone of antithrombotic treatment. In therapy-resistant or clinically unstable patients, ultraslow, low-dose infusion of thrombolytics seems effective and safe and may be preferred over redo-transcatheter aortic valve replacement or explant surgery.
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Affiliation(s)
- Rik Adrichem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Josep Rodes Cabau
- Department of Cardiology, Quebec Heart and Lung Institute, Quebec, Quebec, Canada
| | - Roxana Mehran
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jurrien M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands; Department of Cardiology, University Medical Center Maastricht, and the Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Ole de Backer
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - George D Dangas
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raj Makkar
- Deparment of Cardiology, Cedars Sinai Heart Institute, Los Angeles, California, USA
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands.
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3
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Chitturi KR, Aladin AI, Braun R, Al-Qaraghuli AK, Banerjee A, Reddy P, Merdler I, Chaturvedi A, Abusnina W, Haberman D, Lupu L, Rodriguez-Weisson FJ, Case BC, Wermers JP, Ben-Dor I, Satler LF, Waksman R, Rogers T. Bioprosthetic Aortic Valve Thrombosis: Definitions, Clinical Impact, and Management: A State-of-the-Art Review. Circ Cardiovasc Interv 2024; 17:e014143. [PMID: 38853766 DOI: 10.1161/circinterventions.123.014143] [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: 06/11/2024]
Abstract
Bioprosthetic aortic valve thrombosis is frequently detected after transcatheter and surgical aortic valve replacement due to advances in cardiac computed tomography angiography technology and standardized surveillance protocols in low-surgical-risk transcatheter aortic valve replacement trials. However, evidence is limited concerning whether subclinical leaflet thrombosis leads to clinical adverse events or premature structural valve deterioration. Furthermore, there may be net harm in the form of bleeding from aggressive antithrombotic treatment in patients with subclinical leaflet thrombosis. This review will discuss the incidence, mechanisms, diagnosis, and optimal management of bioprosthetic aortic valve thrombosis after transcatheter aortic valve replacement and bioprosthetic surgical aortic valve replacement.
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Affiliation(s)
- Kalyan R Chitturi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Amer I Aladin
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Ryan Braun
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD (R.B., T.R.)
| | - Abdullah K Al-Qaraghuli
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Avantika Banerjee
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Pavan Reddy
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Ilan Merdler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Abhishek Chaturvedi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Waiel Abusnina
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Dan Haberman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Lior Lupu
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Fernando J Rodriguez-Weisson
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Jason P Wermers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD (R.B., T.R.)
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Shashank S, Balireddi LD, Inban P, Al‐ezzi SMS, Reddy NJ, Alalousi Y, Prajjwal P, John J, Shajeri MAA, Almadhoun MKIKH, Sulaimanov M, Amiri B, Marsool MDM, Amir Hussin O. Subclinical leaflet thrombosis and anticoagulation strategy following trans-catheter aortic valve replacement: A systematic review. Health Sci Rep 2024; 7:e2200. [PMID: 38933424 PMCID: PMC11199189 DOI: 10.1002/hsr2.2200] [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: 10/12/2023] [Revised: 05/30/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024] Open
Abstract
Objective Subclinical leaflet thrombosis (SLT) develops in 15% of patients undergoing trans-catheter aortic valve replacement (TAVR). TAVR is a procedure in which a faulty aortic valve is replaced with a mechanical one. An aortic valve replacement can be done with open-heart surgery; this is called surgical aortic valve replacement (SAVR). A significant problem is defining the best course of treatment for asymptomatic individuals with SLT post-TAVR, including the use of oral anticoagulation (OAC) in it. Study design Systematic review. Method The most pertinent published research (original papers and reviews) in the scientific literature were searched for and critically assessed using the online, internationally indexed databases PubMed, Medline, and Cochrane Reviews. Keywords like "Transcatheter valve replacement" and "Subclinical leaflet thrombosis" were used to search the papers. Selected studies were critically assessed for inclusion based on predefined criteria. Results The review examined the prevalence and characteristics of SLT after TAVR. To note, the incidence of SLT is seen to be higher in TAVR compared SAVR. Dual antiplatelet therapy, which is utilized in antithrombotic regimens post-TAVR, can possibly hasten SLT progression which could result in the impaired mobility of leaflets and the worsening of pressure gradients. Conclusion The use of dual antiplatelet drugs in routine antithrombotic therapy tends to accelerate initial subclinical leaflet thrombosis after TAVI, which results in a developing restriction of leaflet mobility and an increase in pressure differences.
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Affiliation(s)
| | | | | | | | | | - Yarub Alalousi
- St Joseph University Medical Center, PatersonBrooklynNew YorkUSA
| | | | - Jobby John
- Dr. Somervell Memorial CSI Medical College and Hospital, NeyyāttinkaraThiruvananthapuramIndia
| | | | | | | | - Bita Amiri
- Cardiovascular Research CenterTabriz University of Medical SciencesTabrizIran
| | | | - Omniat Amir Hussin
- Internal MedicineAl Manhal University Academy of ScienceKhartoum NorthSudan
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5
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Lu X, Kelley G, Wang M, Guo X, Han L, Kassab GS. Performance of xenogeneic pulmonary visceral pleura as bioprosthetic heart valve cusps in swine. Front Cardiovasc Med 2023; 10:1213398. [PMID: 37600031 PMCID: PMC10433919 DOI: 10.3389/fcvm.2023.1213398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/20/2023] [Indexed: 08/22/2023] Open
Abstract
Objective Bovine pericardium is common biological material for bioprosthetic heart valve. There remains a significant need, however, to improve bioprosthetic valves for longer-term outcomes. This study aims to evaluate the chronic performance of bovine pulmonary visceral pleura (PVP) as bioprosthetic valve cusps. Methods The PVP was extracted from the bovine lung and fixed in 0.625% glutaraldehyde overnight at room temperature. The PVP valve cusps for the bioprosthetic valve were tailored using a laser cutter. Three leaflets were sewn onto a nitinol stent. Six PVP bioprosthetic valves were loaded into the test chamber of the heart valve tester to complete 100 million cycles. Six other PVP bioprosthetic valves were transcardially implanted to replace pulmonary artery valve of six pigs. Fluoroscopy and intracardiac echocardiography were used for in vivo assessments. Thrombosis, calcification, inflammation, and fibrosis were evaluated in the terminal study. Histologic analyses were used for evaluations of any degradation or calcification. Results All PVP bioprosthetic valves completed 100 million cycles without significant damage or tears. In vivo assessments showed bioprosthetic valve cusps open and coaptation at four months post-implant. No calcification and thrombotic deposits, inflammation, and fibrosis were observed in the heart or pulmonary artery. The histologic analyses showed complete and compact elastin and collagen fibers in the PVP valve cusps. Calcification-specific stains showed no calcific deposit in the PVP valve cusps. Conclusions The accelerated wear test demonstrates suitable mechanical strength of PVP cusps for heart valve. The swine model demonstrates that the PVP valve cusps are promising for valve replacement.
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Affiliation(s)
- Xiao Lu
- Department of Bioengineering, California Medical Innovations Institute, San Diego, CA, United States
| | - Greg Kelley
- Department of Research and Development, 3 DT Holdings, LLC, San Diego, CA, United States
| | - Mengjun Wang
- Department of Research and Development, 3 DT Holdings, LLC, San Diego, CA, United States
| | - Xiaomei Guo
- Department of Bioengineering, California Medical Innovations Institute, San Diego, CA, United States
| | - Ling Han
- Department of Bioengineering, California Medical Innovations Institute, San Diego, CA, United States
| | - Ghassan S. Kassab
- Department of Bioengineering, California Medical Innovations Institute, San Diego, CA, United States
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6
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Subclinical Leaflet Thrombosis After Balloon versus Self-Expandable Transcatheter Aortic Valve Implantation. Am J Cardiol 2023; 192:88-97. [PMID: 36758269 DOI: 10.1016/j.amjcard.2023.01.015] [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: 11/11/2022] [Revised: 12/23/2022] [Accepted: 01/07/2023] [Indexed: 02/10/2023]
Abstract
Hypoattenuated leaflet thickening (HALT) has been recognized as one of the complications after transcatheter aortic valve implantation and may promote structural valve degeneration and increase the risk of cerebrovascular events. The 2 main types of available transcatheter heart valves (THVs), the balloon-expandable (BE) and the self-expanding (SE), are interchangeably used in clinical practice despite substantial design differences. There is unclear evidence on whether these 2 different THV models are achieving similar or different rates of subclinical leaflet thrombosis/HALT. A systematic search of electronic databases was conducted to identify studies that reported the incidence of HALT between SE THVs and BE THVs. The Mantel-Haenszel method was used to calculate the 95% confidence interval and pooled risk ratio with a random-effects model. A total of 126 records were identified, of which 22 studies comprising 14,401 patients were included in our final analysis. Among 5,951 patients receiving SE THVs, 194 (3.2%) developed HALT, compared with 8,450 patients receiving BE THVs, of whom 484 (5.7%) developed HALT. There was a statistically significant decrease in the risk of developing HALT in patients receiving SE THVs compared with those receiving BE THVs (risk ratio 0.75, 95% confidence interval 0.59 to 0.95, I2 32%, p = 0.02). In conclusion, could potentially reduce the risk of HALT/subclinical leaflet thrombosis.
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7
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Al Abri Q, El Nihum LI, Hinohara T, Chang SM, Faza NN, Goel SS, Kleiman NS, Wyler von Ballmoos MC, Atkins MD, Reardon MJ. Late Transcatheter Aortic Valve Thrombosis Leading to Cardiogenic Shock. JACC Case Rep 2022; 4:1459-1463. [PMID: 36444179 PMCID: PMC9700056 DOI: 10.1016/j.jaccas.2022.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/18/2022] [Accepted: 07/27/2022] [Indexed: 06/16/2023]
Abstract
A 67-year-old woman with prior transcatheter aortic valve replacement presented with worsening dyspnea. Imaging revealed transcatheter aortic valve thrombosis and aortic stenosis. Despite oral anticoagulation, she progressively deteriorated and developed cardiogenic shock. We highlight the Heart Team's role in treating this unusual late thrombosis. (Level of Difficulty: Intermediate.).
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Key Words
- CT, computed tomography
- DAPT, dual antiplatelet therapy
- HALT, hypoattenuated leaflet thrombosis
- IABP, intra-aortic balloon pump
- LVEF, left ventricular ejection fraction
- OAC, oral anticoagulation
- SAPT, single antiplatelet therapy
- SAVR, surgical aortic valve replacement
- TAV, transcatheter aortic valve
- TAVR, transcatheter aortic valve replacement
- TEE, transesophageal echocardiography
- TTE, transthoracic echocardiography
- hypoattenuated leaflet thrombosis
- transcatheter heart valve
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Affiliation(s)
- Qasim Al Abri
- DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Lamees I. El Nihum
- DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
- Texas A&M College of Medicine, Bryan, Texas, USA
| | - Tomoya Hinohara
- DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Su Min Chang
- DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Nadeen N. Faza
- DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Sachin S. Goel
- DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Neal S. Kleiman
- DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | | | - Marvin D. Atkins
- DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Michael J. Reardon
- DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
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8
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Inflammation-triggered dual release of nitroxide radical and growth factor from heparin mimicking hydrogel-tissue composite as cardiovascular implants for anti-coagulation, endothelialization, anti-inflammation, and anti-calcification. Biomaterials 2022; 289:121761. [DOI: 10.1016/j.biomaterials.2022.121761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/15/2022] [Accepted: 08/21/2022] [Indexed: 11/20/2022]
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9
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van Ginkel DJ, Bor WL, Veenstra L, van 't Hof AWJ, Fabris E. Evolving concepts in the management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation. Eur J Intern Med 2022; 101:14-20. [PMID: 35623935 DOI: 10.1016/j.ejim.2022.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/22/2022]
Abstract
Thromboembolic and bleeding complications negatively impact recovery and survival after transcatheter aortic valve implantation (TAVI). Particularly, there is a considerable risk of ischaemic stroke and vascular access related bleeding, as well as spontaneous gastro-intestinal bleeding. Therefore, benefit and harm of antithrombotic therapy should be carefully balanced. This review summarizes current evidence on peri- and post-procedural antithrombotic treatment. Indeed, in recent years, the management of antithrombotic therapy after TAVI has evolved from intensive, expert opinion-based strategies, towards a deescalated, evidence-based approach. Besides per procedural administration of unfractionated heparin, this encompasses single antiplatelet therapy in patients without a concomitant indication for oral anticoagulation (OAC); and OAC monotherapy in patients with such indication, mainly being atrial fibrillation. Combination therapy should generally be avoided to reduce bleeding risk, except after recent coronary stenting where a period of dual antiplatelet therapy (aspirin plus P2Y12-inhibitor) or P2Y12-inhibitor plus OAC (in patients with an independent indication for OAC) is recommended to prevent stent thrombosis. This new paradigm in which reduced antithrombotic intensity leads to improved patient safety, without a loss of efficacy, may be particularly suitable for elderly and fragile patients. Whether this holds in upcoming populations of younger and lower-risk patients and in specific populations as patients with subclinical valve thrombosis, is yet to be proven. Finally, whether less intensive or alternative approaches should be also applied for the periprocedural management of the antithrombotic therapy, has to be determined by ongoing and future studies.
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Affiliation(s)
- Dirk Jan van Ginkel
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Willem L Bor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Leo Veenstra
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Arnoud W J van 't Hof
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Enrico Fabris
- Cardiothoracovascular Department, University of Trieste, Trieste, Italy.
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10
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van Wiechen MP, el Azzouzi I, Knol WG, Adrichem R, Hokken TW, Ooms JF, de Ronde-Tillmans MJ, Daemen J, de Jaegere PP, Hirsch A, Budde RP, Van Mieghem NM. Leaflet thickening and motion after transcatheter aortic valve replacement: Design and rationale of the Rotterdam edoxaban trial. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:67-70. [DOI: 10.1016/j.carrev.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 06/06/2022] [Accepted: 06/10/2022] [Indexed: 11/03/2022]
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11
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Shojaeifard M, Rahnamoun Z, Firouzi A, Sadeghipour P. A case of early thrombosis following a percutaneous tricuspid valve in valve implantation managed by thrombolysis. Echocardiography 2022; 39:844-848. [PMID: 35524711 DOI: 10.1111/echo.15362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/29/2022] [Accepted: 04/23/2022] [Indexed: 01/09/2023] Open
Abstract
Bioprosthetic valve thrombosis (BPVT) is a growing recognized entity, especially with the increasing use of the valve in vale procedures and the advent of new detection technologies (e.g., 4D CT and 4D echocardiography). The incidence of BPVT is higher in transcatheter valves than surgically implanted bioprosthetic valves. However, the best thromboprophylaxis regimen and optimal management strategy in the acute context remain unknown. This paper presents a case of early thrombosis following the percutaneous tricuspid valve in vale procedure that was successfully managed with thrombolysis.
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Affiliation(s)
- Maryam Shojaeifard
- Echocardiography Department, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Zahra Rahnamoun
- Tehran Heart Center, Tehran University of Medical Science, Tehran, Iran
| | - Ata Firouzi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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12
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Bogyi M, Schernthaner RE, Loewe C, Gager GM, Dizdarevic AM, Kronberger C, Postula M, Legutko J, Velagapudi P, Hengstenberg C, Siller-Matula JM. Subclinical Leaflet Thrombosis After Transcatheter Aortic Valve Replacement: A Meta-Analysis. JACC Cardiovasc Interv 2021; 14:2643-2656. [PMID: 34949391 DOI: 10.1016/j.jcin.2021.09.019] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022]
Abstract
This meta-analysis and systematic review was performed to evaluate the clinical relevance of subclinical leaflet thrombosis (SLT) following transcatheter aortic valve replacement. PubMed, Web of Science, and CENTRAL were searched for eligible randomized and nonrandomized studies until November 2020. Risk ratios (RRs) or odds ratios and 95% CIs were calculated, using a random-effects model. Overall, 25 studies were eligible for the analysis and comprised a total of 11,098 patients. The median incidence of SLT was 6% at a median follow-up of 30 days. Use of intra-annular valves was associated with 2-fold greater risk for the development of SLT compared with use of supra-annular valves. There was no difference in the risk for SLT (RR: 0.97; 95% CI: 0.72-1.29; P = 0.83) between single-antiplatelet therapy (SAPT) and dual-antiplatelet therapy (DAPT), whereas oral anticoagulation (OAC) was associated with a 58% relative risk reduction for SLT (RR: 0.42; 95% CI: 0.29-0.61; P < 0.00001) compared with SAPT and DAPT. In patients with diagnosed leaflet thrombosis at follow-up, the risk for stroke or transient ischemic attack was increased by 2.6-fold (RR: 2.56; 95% CI: 1.60-4.09; P < 0.00001) compared with patients without leaflet thrombosis. In patients diagnosed with SLT, the odds of SLT resolution increased by 99% after switch from antiplatelet agents to OAC (odds ratio: 0.01; 95% CI: 0.00-0.06; P < 0.00001). To summarize, indication-based use of OAC after transcatheter aortic valve replacement is associated with a lower risk for SLT compared with SAPT and DAPT. Switching to OAC seems to be effective for SLT resolution. As SLT increased the odds of stroke or transient ischemic attack in the included population, further studies are needed to investigate whether screening tests for SLT and appropriate antithrombotic therapy improve long-term valve functionality and clinical prognosis.
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Affiliation(s)
- Matthias Bogyi
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Rüdiger E Schernthaner
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Gloria M Gager
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria; Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Al Medina Dizdarevic
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Christina Kronberger
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Marek Postula
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Center for Preclinical Research and Technology CEPT, Warsaw, Poland
| | - Jacek Legutko
- Jagiellonian University Medical College, Faculty of Medicine, Institute of Cardiology, Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Poonam Velagapudi
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Christian Hengstenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Jolanta M Siller-Matula
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria; Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Center for Preclinical Research and Technology CEPT, Warsaw, Poland.
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13
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Transcatheter Aortic Valve Leaflet Thrombosis: Prevalence, Management, and Future Directions. Curr Cardiol Rep 2021; 23:186. [PMID: 34762219 DOI: 10.1007/s11886-021-01614-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW We review the pathology, prevalence, diagnosis, hemodynamics, risk factors, prognosis, and treatment of leaflet thrombosis (LT), and suggest future directions in this field. RECENT FINDINGS The latest meta-analysis showed the prevalence of overall LT is 5.4% (clinical LT of 1.2% and subclinical LT of 15.1%). Either subclinical or clinical LT is not associated with risk of mortality; however, clinical LT is associated with increased risk of stroke. Although LT can be reduced by oral anticoagulation therapy (OAT), routine use of OAT as primary prevention for high-risk patients is not recommended due to increased risk of mortality. Four-dimensional computed tomography plays an important role in the diagnosis of LT and the accumulation of qualitative or qualitative assessments of hypoattenuated leaflet thickening would provide more clues to clarify effective OAT strategies. In addition, further studies are warranted to evaluate the efficacy of other anticoagulants in low-intermediate risk patients.
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14
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Woldendorp K, Doyle MP, Black D, Ng M, Keech A, Grieve SM, Bannon PG. Subclinical valve thrombosis in transcatheter aortic valve implantation: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2021; 162:1491-1499.e2. [DOI: 10.1016/j.jtcvs.2020.01.084] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 12/21/2019] [Accepted: 01/16/2020] [Indexed: 11/27/2022]
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15
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Wunderlich NC, Honold J, Swaans MJ, Siegel RJ. How to Image and Manage Prosthesis-Related Complications After Transcatheter Aortic Valve Replacement. Curr Cardiol Rep 2021; 23:94. [PMID: 34196775 DOI: 10.1007/s11886-021-01522-2] [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] [Accepted: 05/14/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW In this review, we provide an overview of potential prosthesis - related complications after transcatheter aortic valve replacement, their incidences, the imaging modalities best suited for detection, and possible strategies to manage these complications. RECENT FINDINGS Therapy for severe aortic valve stenosis requiring intervention has increasingly evolved toward transcatheter aortic valve replacement over the past decade, and the number of procedures performed has increased steadily in recent years. As more and more centers favor a minimalistic approach and largely dispense with general anesthesia and intra-procedural imaging by transesophageal echocardiography, post-procedural imaging is becoming increasingly important to promptly detect dysfunction of the transcatheter valve and potential complications. Complications after transcatheter aortic valve replacement must be detected immediately in order to initiate adequate therapeutic measures, which require a profound knowledge of possible complications that may occur after transcatheter aortic valve replacement, the imaging modalities best suited for detection, and available treatment options.
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Affiliation(s)
| | - Jörg Honold
- Cardiovascular Center Darmstadt, Darmstadt, Germany
| | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Robert J Siegel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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16
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Bailoor S, Seo JH, Dasi L, Schena S, Mittal R. Prosthetic Valve Monitoring via In Situ Pressure Sensors: In Silico Concept Evaluation using Supervised Learning. Cardiovasc Eng Technol 2021; 13:90-103. [PMID: 34145555 DOI: 10.1007/s13239-021-00553-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/02/2021] [Indexed: 01/20/2023]
Abstract
PURPOSE Patients receiving transcatheter aortic valve replacement (TAVR) can benefit from continuous, longitudinal monitoring of valve prosthesis to prevent leaflet thrombosis-related complications. We present a computational proof-of-concept study of a novel, non-invasive and non-toxic valve monitoring technique for TAVs which uses pressure measurements from microsensors embedded on the valve stent. We perform a data-driven analysis to determine the signal processing and machine learning required to detect reduced mobility in individual leaflets. METHODS We use direct numerical simulations to describe hemodynamic differences in transvalvular flow in ascending aorta models with healthy and stenotic valves. A Cartesian-grid flow solver and a reduced-order valve model simulate the complex dynamics of blood flow and leaflet motion, respectively. The two-way fluid-structure interaction coupling is achieved using a sharp interface immersed boundary method. RESULTS From a dataset of 21 simulations, we show leaflets with reduced mobility result in large, asymmetric pressure fluctuations in their vicinity, particularly in the region extending from the aortic sinus to the sino-tubular junction (STJ). We train a linear classifier algorithm by correlating sinus and STJ pressure measurements on the stent surface to individual leaflet status. The algorithm was shown to have >90% accuracy for prospective detection of individual leaflet dysfunction. CONCLUSIONS We demonstrate that using only two discrete pressure measurements, per leaflet, on the TAV stent, individual leaflet status can be accurately predicted. Such a sensorized TAV system could enable safe and inexpensive detection of prosthetic valve dysfunction.
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Affiliation(s)
- Shantanu Bailoor
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Jung-Hee Seo
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Lakshmi Dasi
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Stefano Schena
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rajat Mittal
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA.
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17
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Rheude T, Pellegrini C, Stortecky S, Marwan M, Xhepa E, Ammon F, Pilgrim T, Mayr NP, Husser O, Achenbach S, Windecker S, Cassese S, Joner M. Meta-Analysis of Bioprosthetic Valve Thrombosis After Transcatheter Aortic Valve Implantation. Am J Cardiol 2021; 138:92-99. [PMID: 33065085 DOI: 10.1016/j.amjcard.2020.10.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 09/26/2020] [Accepted: 10/05/2020] [Indexed: 12/22/2022]
Abstract
Bioprosthetic valve thrombosis may complicate transcatheter aortic valve implantation (TAVI). This meta-analysis sought to evaluate the prevalence and clinical impact of subclinical leaflet thrombosis (SLT) and clinical valve thrombosis (CVT) after TAVI. We summarized diagnostic strategies, prevalence of SLT and/or CVT and estimated their impact on the risk of all-cause death and stroke. Twenty studies with 12,128 patients were included. The prevalence of SLT and CVT was 15.1% and 1.2%, respectively. The risk of all-cause death was not significantly different between patients with SLT (relative risk [RR] 0.77; p = 0.22) and CVT (RR 1.29; p = 0.68) compared with patients without. The risk of stroke was higher in patients with CVT (RR 7.51; p <0.001) as compared with patients without, while patients with SLT showed no significant increase in the risk of stroke (RR 1.81; p = 0.17). Reduced left ventricular function was associated with increased prevalence, while oral anticoagulation was associated with reduced prevalence of bioprosthetic valve thrombosis. Bioprosthetic valve thrombosis is frequent after TAVI, but does not increase the risk of death. Clinical valve thrombosis is associated with a significantly increased risk of stroke. Future studies should focus on prevention and treatment of bioprosthetic valve thrombosis.
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Affiliation(s)
- Tobias Rheude
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Costanza Pellegrini
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Stefan Stortecky
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mohamed Marwan
- Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Erion Xhepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Fabian Ammon
- Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - N Patrick Mayr
- Institut für Anästhesiologie, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Oliver Husser
- Klinik für Innere Medizin I, Kardiologie, St. Johannes-Hospital Dortmund, Dortmund, Germany
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Salvatore Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michael Joner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Munich, Germany.
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18
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Karády J, Apor A, Nagy AI, Kolossváry M, Bartykowszki A, Szilveszter B, Simon J, Molnár L, Jermendy ÁL, Panajotu A, Suhai FI, Varga A, Rajani R, Maurovich-Horvat P, Merkely B. Quantification of hypo-attenuated leaflet thickening after transcatheter aortic valve implantation: clinical relevance of hypo-attenuated leaflet thickening volume. Eur Heart J Cardiovasc Imaging 2020; 21:1395-1404. [PMID: 32756984 DOI: 10.1093/ehjci/jeaa184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/13/2020] [Accepted: 06/03/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Our aim was to establish an objective, quantitative methodology for volumetric hypo-attenuated leaflet thickening (HALT) diagnosis and evaluate its clinical significance. METHODS AND RESULTS We prospectively enrolled 144 patients who underwent transcatheter aortic valve implantation (TAVI) between 2011 and 2016. At inclusion, cardiac computed tomography angiography (CTA), transthoracic echocardiography, and brain magnetic resonance imaging (MRI) were performed. We quantified HALT on CTA datasets by segmenting the inner volume of TAVI frame at the level of leaflets and extracted voxels between a threshold of -200 to 200 HU based on prior recommendation. The median HALT volume was 72 [inter-quartile range (IQR): 1-154] mm3 (intra- and inter-reader agreement: intra-class correlation coefficient = 0.92 and 0.94, respectively) and 79% (n = 87/111) of the patients had HALT >0 mm3. In multivariate linear regression, oral anti-coagulation (β: -0.32; 95% CI: -0.62 to -0.01; P = 0.004) and history of myocardial infarction (β: 0.32; 95% CI: 0.01-0.63; P = 0.043) were associated with HALT quantity. Log-transformed HALT volume was associated with elevated (>13 mmHg) aortic mean gradient (AMG, OR: 12.85; 95% CI: 1.96-152.93; P = 0.021) and moderate-to-severe valvular degeneration (AMG ≥ 20 mmHg or ΔAMG ≥ 10 mmHg; OR: 10.56; 95% CI: 1.44-148.71; P = 0.046) but did not predict ischaemic brain lesions on MRI or all-cause death after a median follow-up of 29 (IQR: 11-29) months (all P > 0.05). CONCLUSION Through systematic analysis of asymptomatic patients with TAVI, an objective and reproducible methodology was feasible for volumetric measurement of HALT. Anti-coagulation might have a protective effect against HALT. Ischaemic brain lesions and all-cause death were not associated with HALT; nevertheless, it might deteriorate prosthesis function due to its association with elevated AMG. CLINICAL TRIAL REGISTRATION http//:www.ClinicalTrials.gov; NCT02826200.
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Affiliation(s)
- Júlia Karády
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary.,Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
| | - Astrid Apor
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Anikó I Nagy
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary.,Department of Medicine, Karolinska Institutet, 1 Solnavägen, Solna 171 77, Stockholm, Sweden
| | - Márton Kolossváry
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Andrea Bartykowszki
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Bálint Szilveszter
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Judit Simon
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Levente Molnár
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Ádám L Jermendy
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Alexisz Panajotu
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Ferenc I Suhai
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Andrea Varga
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Ronak Rajani
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary.,Department of Radiology, Medical Imaging Centre, Semmelweis University, 78 Ulloi St, Budapest 1082, Hungary
| | - Béla Merkely
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
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19
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Quin JA. Commentary: Putting the personal back in precision medicine. J Thorac Cardiovasc Surg 2020; 164:e125-e126. [PMID: 33339602 DOI: 10.1016/j.jtcvs.2020.11.030] [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: 11/06/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Jacquelyn A Quin
- Cardiac Division, Department of Surgery, VA Boston Healthcare System, West Roxbury, Mass.
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20
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Szilveszter B, Oren D, Molnár L, Apor A, Nagy AI, Molnár A, Vattay B, Kolossváry M, Karády J, Bartykowszki A, Jermendy ÁL, Suhai FI, Panajotu A, Maurovich-Horvat P, Merkely B. Subclinical leaflet thrombosis is associated with impaired reverse remodelling after transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging 2020; 21:1144-1151. [PMID: 31665257 DOI: 10.1093/ehjci/jez256] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 07/12/2019] [Accepted: 10/24/2019] [Indexed: 01/19/2023] Open
Abstract
AIMS Cardiac CT is increasingly applied for planning and follow-up of transcatheter aortic valve implantation (TAVI). However, there are no data available on reverse remodelling after TAVI assessed by CT. Therefore, we aimed to evaluate the predictors and the prognostic value of left ventricular (LV) reverse remodelling following TAVI using CT angiography. METHODS AND RESULTS We investigated 117 patients with severe, symptomatic aortic stenosis (AS) who underwent CT scanning before and after TAVI procedure with a mean follow-up time of 2.6 years after TAVI. We found a significant reduction in LV mass (LVM) and LVM indexed to body surface area comparing pre- vs. post-TAVI images: 180.5 ± 53.0 vs. 137.1 ± 44.8 g and 99.7 ± 25.4 vs. 75.4 ± 19.9 g/m2, respectively, both P < 0.001. Subclinical leaflet thrombosis (SLT) was detected in 25.6% (30/117) patients. More than 20% reduction in LVM was defined as reverse remodelling and was detected in 62.4% (73/117) of the patients. SLT, change in mean pressure gradient on echocardiography and prior myocardial infarction was independently associated with LV reverse remodelling after adjusting for age, gender, and traditional risk factors (hypertension, body mass index, diabetes mellitus, and hyperlipidaemia): OR = 0.27, P = 0.022 for SLT and OR = 0.22, P = 0.006 for prior myocardial infarction, OR = 1.51, P = 0.004 for 10 mmHg change in mean pressure gradient. Reverse remodelling was independently associated with favourable outcomes (HR = 0.23; P = 0.019). CONCLUSION TAVI resulted in a significant LVM regression on CT. The presence of SLT showed an inverse association with LV reverse remodelling and thus it may hinder the beneficial LV structural changes. Reverse remodelling was associated with improved long-term prognosis.
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Affiliation(s)
- Bálint Szilveszter
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Daniel Oren
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Levente Molnár
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Astrid Apor
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Anikó I Nagy
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Andrea Molnár
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Borbála Vattay
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Márton Kolossváry
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Júlia Karády
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Andrea Bartykowszki
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Ádám L Jermendy
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Ferenc I Suhai
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Alexisz Panajotu
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary.,Medical Imaging Center, Semmelweis University, Üllői Street, 1082 Budapest, Hungary
| | - Béla Merkely
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
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21
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Sannino A, Hahn RT, Leipsic J, Mack MJ, Grayburn PA. Meta-analysis of Incidence, Predictors and Consequences of Clinical and Subclinical Bioprosthetic Leaflet Thrombosis After Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 132:106-113. [PMID: 32773221 DOI: 10.1016/j.amjcard.2020.07.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 01/17/2023]
Abstract
Leaflet thrombosis (LT) has been claimed as a potential cause of hemodynamic dysfunction or bioprosthetic valve degeneration of transcatheter heart valves. Sparse and contrasting evidence exists, however, regarding LT occurrence, prevention and treatment. MEDLINE, ISI Web of Science and SCOPUS databases were searched for studies published up to January 2020. Only studies reporting data on incidence and outcomes associated to the presence/absence of clinical or subclinical LT, detected or confirmed with a multidetector computed tomography exam were included. The study was designed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) requirements. Two reviewers independently screened articles for fulfillment of inclusion criteria. Data were pooled using a random-effect model. The primary end point was the incidence of LT. Secondary outcomes included: stroke and transient ischemic attacks and mean transvalvular gradients at different time-points in patients with and without LT. Of the initial 200 studies, 22 were finally included with a total of 11,567 patients. LT overall incidence was 8% (95% Confidence Interval [CI]: 5% to 13%, I2 = 96.4%). LT incidence in patients receiving only antiplatelets was 13% (95% CI: 7% to 23%, p <0.0001); patients discharged on oral anticoagulants had a reported incidence of 4% (95% CI: 2% to 8%, p <0.0001). Patients with LT, either clinical or subclinical, were not at increased risk of stroke (OR 1.06, 95% CI: 0.75 to 1.50, p = 0.730, I2 = 0.0%) or transient ischemic attacks (Odds Ratio 1.01, 95% CI: 0.40 to 2.57, p = 0.989, I2 = 0.0%). LT was associated with higher mean transvalvular gradients compared with patients without LT at 30 days post-transcatheter implantation, but not at discharge or at 1 year. LT is a relatively common event that, even when clinically manifest, is not associated with an increased risk of cerebrovascular events. Although patients on anticoagulants appear to be at lower risk of LT, the available evidence does not allow formulation of recommendations for prophylactical anticoagulation nor routine computed tomography after transcatheter aortic valve replacement.
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Aktuerk D, Mirsadraee S, Quarto C, Davies S, Duncan A. Leaflet thrombosis after valve-in-valve transcatheter aortic valve implantation: a case series. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-6. [PMID: 32974465 DOI: 10.1093/ehjcr/ytaa221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/14/2020] [Accepted: 06/19/2020] [Indexed: 01/09/2023]
Abstract
Background Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) in degenerated surgical aortic valve replacement (SAVR) is an alternative to redo-SAVR. However, reports on leaflet thrombosis following ViV-TAVI are emerging and subclinical thrombosis has gained recent attention. Although the incidence of transcatheter heart valve (THV) thrombosis after TAVI for native aortic valve disease is low, current imaging studies suggest the incidence of subclinical THV thrombosis may be significantly higher. While anticoagulation strategies for THV patients for native aortic stenosis presenting with symptomatic obstructive thrombosis has been described, the optimal management and anticoagulation therapy of patients with THV thrombosis following ViV-TAVI are less evident. Case summary We report a case series of three patients presenting with early and late THV thrombosis after ViV-TAVI. Two patients presented clinically on single antiplatelet therapy and one patient presented with subclinical valve thrombosis whilst taking a non-vitamin K oral anticoagulation agent. Discussion Leaflet thrombosis after ViV-TAVI is an important cause of THV degeneration and may present subclinically. Imaging modalities such as serial transthoracic echocardiograms and multidetector computerized tomography aid diagnosis and guide management. Patient-individualized risk- vs. -benefit prophylactic post-procedural oral anticoagulation may be indicated.
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Affiliation(s)
- Dincer Aktuerk
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, Sydney Street, Chelsea, London SW36NP, UK
| | - Saeed Mirsadraee
- Department of Radiology, Royal Brompton Hospital, Sydney Street, Chelsea, London SW36NP, UK
| | - Cesare Quarto
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, Sydney Street, Chelsea, London SW36NP, UK
| | - Simon Davies
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, Chelsea, London SW36NP, UK
| | - Alison Duncan
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, Chelsea, London SW36NP, UK
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In Vitro Durability and Stability Testing of a Novel Polymeric Transcatheter Aortic Valve. ASAIO J 2020; 66:190-198. [PMID: 30845067 DOI: 10.1097/mat.0000000000000980] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has emerged as an effective therapy for the unmet clinical need of inoperable patients with severe aortic stenosis (AS). Current clinically used tissue TAVR valves suffer from limited durability that hampers TAVR's rapid expansion to younger, lower risk patients. Polymeric TAVR valves optimized for hemodynamic performance, hemocompatibility, extended durability, and resistance to calcific degeneration offer a viable solution to this challenge. We present extensive in vitro durability and stability testing of a novel polymeric TAVR valve (PolyNova valve) using 1) accelerated wear testing (AWT, ISO 5840); 2) calcification susceptibility (in the AWT)-compared with clinically used tissue valves; and 3) extended crimping stability (valves crimped to 16 Fr for 8 days). Hydrodynamic testing was performed every 50M cycles. The valves were also evaluated visually for structural integrity and by scanning electron microscopy for evaluation of surface damage in the micro-scale. Calcium and phosphorus deposition was evaluated using micro-computed tomography (μCT) and inductive coupled plasma spectroscopy. The valves passed 400M cycles in the AWT without failure. The effective orifice area kept stable at 1.8 cm with a desired gradual decrease in transvalvular pressure gradient and regurgitation (10.4 mm Hg and 6.9%, respectively). Calcium and phosphorus deposition was significantly lower in the polymeric valve: down by a factor of 85 and 16, respectively-as compared to a tissue valve. Following the extended crimping testing, no tears nor surface damage were evident. The results of this study demonstrate the potential of a polymeric TAVR valve to be a viable alternative to tissue-based TAVR valves.
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Brown RA, Reid AB, Turaga M, Huang AL, Maggiore PL, Sellers SL, Kiritchkov L, Tarazi SC, Blanke P, Leipsic JA. Subclinical Leaflet Thrombosis Post Transcatheter Aortic Valve Replacement – An Update for 2020. STRUCTURAL HEART 2020. [DOI: 10.1080/24748706.2020.1805534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Kalra DK. Cardiac CT: A Sine Qua Non for Structural Heart Interventions. Cardiology 2020; 145:663-665. [PMID: 32829334 DOI: 10.1159/000509466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Dinesh K Kalra
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA,
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Tian Z, Li T, Ma S. Impact of leaflet thrombosis on hemodynamics and clinical outcomes after bioprosthetic aortic valve replacement: A meta-analysis. Clin Cardiol 2020; 43:468-474. [PMID: 31957895 PMCID: PMC7244303 DOI: 10.1002/clc.23331] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/05/2019] [Accepted: 01/02/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Leaflet thrombosis (LT, also called cusp thrombosis) detected by multidetector computed tomography (MDCT) is common in bioprosthetic aortic valve replacement (bAVR). However, it remains contradictory whether MDCT-defined LT following bAVR is associated with hemodynamic deterioration and stroke. Thus, we performed the first meta-analysis to assess hemodynamic outcomes and updated the latest researches on the clinical outcomes of MDCT-defined LT after bAVR. HYPOTHESIS MDCT-defined LT might be associated with worse hemodynamic and clinical outcomes after bAVR. METHOD MEDLINE, EMBASE, Cochrane Library, and ClinicalTrial.gov were searched from inception to 15th April 2019. The fix-effect model was utilized to calculate odds ratio (OR) and 95% confidence interval (CI). The primary outcomes were hemodynamic stability indexes, including mean pressure gradient (MPG), left ventricular ejection fraction (LVEF), paravalvular leak (PVL), and clinical heart failure. The secondary endpoints were major adverse cardiovascular and cerebrovascular events (MACCEs), which consisted of myocardial infarction, all-cause death, stroke, and transient ischemic attack (TIA). RESULTS Twelve studies with 4820 patients were included. The total prevalence of MDCT-defined LT was 9.7%. MDCT-defined LT was associated with a significantly increased risk of MPG (inverse variance 0.43, 95% CI: [0.30, 0.57]), MACCEs (OR 2.43, 95% CI: [1.45, 4.06]), stroke (OR 1.79, 95% CI: [1.03, 3.11]), and TIA (OR 4.09, 95% CI: [1.59, 10.54]). There were no differences for other outcomes. CONCLUSIONS MDCT-defined LT after bAVR is associated with increased MPG and increased risk of adverse cerebrovascular events, including TIA and stroke. While LVEF, PVL, and clinical heart failure were similar between patient with and without LT.
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Affiliation(s)
- Zixin Tian
- Department of Cardiology, Shengjing Hospital of China Medical University, Shengyang, Liaoning Province, People's Republic of China
| | - Tiejun Li
- Department of Cardiology, Shengjing Hospital of China Medical University, Shengyang, Liaoning Province, People's Republic of China
| | - Shumei Ma
- Department of Cardiology, Shengjing Hospital of China Medical University, Shengyang, Liaoning Province, People's Republic of China
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Valvo R, Criscione E, Reddavid C, Barbanti M. Early detection of transcatheter heart valve dysfunction. Expert Rev Cardiovasc Ther 2019; 17:863-872. [PMID: 31829050 DOI: 10.1080/14779072.2019.1703673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction: Transcatheter aortic valve implantation therapy is spreading rapidly, representing the standard of care in inoperable and high-risk patients, and a valid alternative in intermediate- and low-risk patients with severe symptomatic aortic stenosis. In this subset, the development and validation of noninvasive, quantitative, in vivo imaging modality, to monitor possible valve dysfunction is mandatory, in order to plan timely therapeutic interventions before the onset of symptoms.Areas covered: The implantation of transcatheter heart valves (THV) is increasing rapidly. As a consequence, THV dysfunction will become a major cause of cardiovascular morbidity after TAVI. Emergency repeat aortic valve replacement surgery is associated with a high rate of mortality compared with elective repeat surgery. In this context, early detection of THV dysfunction is therefore highly desirable. The review aims to examine the different diagnostic method to early detect THV dysfunction.Expert opinion: Most promising innovations in the diagnosis of early detection of THV dysfunction are evaluated, and the future outlook is explored. Waiting for upcoming evidence about the utility of CT, CMR, and PET on early detection of THV dysfunction, tailoring echocardiogram follow-up based on patients' characteristics is the desirable approach.
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Affiliation(s)
- Roberto Valvo
- A.O.U. Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Enrico Criscione
- A.O.U. Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Claudia Reddavid
- A.O.U. Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Marco Barbanti
- A.O.U. Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
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Núñez-Gil IJ, Alkhouli M, Centola M, Feltes G, Villablanca P, Ramakrishna H. Analysis of Bioprosthetic Aortic Valve Thrombosis—Implications and Management Strategies. J Cardiothorac Vasc Anesth 2019; 33:2853-2860. [DOI: 10.1053/j.jvca.2018.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Indexed: 01/14/2023]
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D’Ascenzo F, Salizzoni S, Saglietto A, Cortese M, Latib A, Franzone A, Barbanti M, Nietlispach F, Holy EW, Burriesci G, De Paoli A, Fonio P, Atzeni F, Moretti C, Perl L, D’Amico M, Rinaldi M, Conrotto F. Incidence, predictors and cerebrovascular consequences of leaflet thrombosis after transcatheter aortic valve implantation: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2019; 56:488-494. [DOI: 10.1093/ejcts/ezz099] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
OBJECTIVES
We examined the incidence, the impact of subsequent cerebrovascular events and the clinical or procedural predictors of leaflet thrombosis (LT) in patients undergoing transcatheter aortic valve implantation (TAVI).
METHODS
MEDLINE/PubMed was systematically screened for studies reporting on LT in TAVI patients. Incidence [both clinical and subclinical, i.e. detected with computed tomography (CT)] of LT was the primary end point of the study. Predictors of LT evaluated at multivariable analysis and impact of LT on stroke were the secondary ones.
RESULTS
Eighteen studies encompassing 11 124 patients evaluating incidence of LT were included. Pooled incidence of LT was 0.43% per month [5.16% per year, 95% confidence interval (CI) 0.21–0.72, I2 = 98%]. Pooled incidence of subclinical LT was 1.36% per month (16.32% per year, 95% CI 0.71–2.19, I2 = 94%). Clinical LT was less frequent (0.04% per month, 0.48% per year, 95% CI 0.00–0.19, I2 = 93%). LT increased the risk of stroke [odds ratio (OR) 4.21, 95% CI 1.27–13.98], and was more frequent in patients with a valve diameter of 28-mm (OR 2.89: 1.55–5.8), for balloon-expandable (OR 8: 2.1–9.7) or after valve-in-valve procedures (OR 17.1: 3.1–84.9). Oral anticoagulation therapy reduced the risk of LT (OR 0.43, 95% CI: 0.22–0.84, I2 = 64%), as well as the mean transvalvular gradient.
CONCLUSIONS
LT represents an infrequent event after TAVI, despite increasing risk of stroke. Given its full reversal with warfarin, in high-risk patients (those with valve-in-valve procedures, balloon expandable or large-sized devices), a protocol which includes a control CT appears reasonable.
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Affiliation(s)
- Fabrizio D’Ascenzo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Stefano Salizzoni
- Division of Cardiac Surgery, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Andrea Saglietto
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Martina Cortese
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Azeem Latib
- Interventional Cardiology Unit, Cardiothoracic and Vascular Department, San Raffaele Scientific Institute, Milan, Italy
| | - Anna Franzone
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Marco Barbanti
- Division of Cardiology, Ferrarotto Hospital, University of Catania, Catania, Italy
| | | | - Erik W Holy
- Cardiology Clinic, University Hospital of Zurich, Zurich, Switzerland
| | - Gaetano Burriesci
- UCL Mechanical Engineering, University College London, London, UK
- Ri.MED Foundation, Palermo, Italy
| | - Alessandro De Paoli
- Radiology Unit, Department of Surgical Science, University of Turin, Turin, Italy
| | - Paolo Fonio
- Radiology Unit, Department of Surgical Science, University of Turin, Turin, Italy
| | - Francesco Atzeni
- Division of Cardiac Surgery, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Claudio Moretti
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Leor Perl
- Department of Cardiology, Rabin Medical Center, Petach-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maurizio D’Amico
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Mauro Rinaldi
- Division of Cardiac Surgery, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Federico Conrotto
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
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Luraghi G, Migliavacca F, García-González A, Chiastra C, Rossi A, Cao D, Stefanini G, Rodriguez Matas JF. On the Modeling of Patient-Specific Transcatheter Aortic Valve Replacement: A Fluid-Structure Interaction Approach. Cardiovasc Eng Technol 2019; 10:437-455. [PMID: 31309527 DOI: 10.1007/s13239-019-00427-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 07/04/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Transcatheter aortic valve replacement (TAVR) is a minimally invasive treatment for high-risk patients with aortic diseases. Despite its increasing use, many influential factors are still to be understood and require continuous investigation. The best numerical approach capable of reproducing both the valves mechanics and the hemodynamics is the fluid-structure interaction (FSI) modeling. The aim of this work is the development of a patient-specific FSI methodology able to model the implantation phase as well as the valve working conditions during cardiac cycles. METHODS The patient-specific domain, which included the aortic root, native valve and calcifications, was reconstructed from CT images, while the CAD model of the device, metallic frame and pericardium, was drawn from literature data. Ventricular and aortic pressure waveforms, derived from the patient's data, were used as boundary conditions. The proposed method was applied to two real clinical cases, which presented different outcomes in terms of paravalvular leakage (PVL), the main complication after TAVR. RESULTS The results confirmed the clinical prognosis of mild and moderate PVL with coherent values of regurgitant volume and effective regurgitant orifice area. Moreover, the final release configuration of the device and the velocity field were compared with postoperative CT scans and Doppler traces showing a good qualitative and quantitative matching. CONCLUSION In conclusion, the development of realistic and accurate FSI patient-specific models can be used as a support for clinical decisions before the implantation.
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Affiliation(s)
- Giulia Luraghi
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Piazza L. da Vinci 32, 20133, Milan, Italy.
| | - Francesco Migliavacca
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Piazza L. da Vinci 32, 20133, Milan, Italy
| | - Alberto García-González
- Laboratori de Càlcul Numèric (LaCàN), E.T.S. de Ingenieros de Caminos, Canales y Puertos, Universitat Politècnica de Catalunya (UPC), Jordi Girona 1-3, 08034, Barcelona, Spain
| | - Claudio Chiastra
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Piazza L. da Vinci 32, 20133, Milan, Italy.,PoliToBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Corso Duca degli Abruzzi 24, 10129, Turin, Italy
| | - Alexia Rossi
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090, Pieve Emanuele, MI, Italy
| | - Davide Cao
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090, Pieve Emanuele, MI, Italy
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, via Rita Levi Montalcini 4, 20090, Pieve Emanuele, MI, Italy
| | - Jose Felix Rodriguez Matas
- Laboratory of Biological Structure Mechanics (LaBS), Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Piazza L. da Vinci 32, 20133, Milan, Italy
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Greco A, Capranzano P, Barbanti M, Tamburino C, Capodanno D. Antithrombotic pharmacotherapy after transcatheter aortic valve implantation: an update. Expert Rev Cardiovasc Ther 2019; 17:479-496. [PMID: 31198065 DOI: 10.1080/14779072.2019.1632189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Transcatheter aortic valve implantation (TAVI) is the treatment of choice for a large proportion of patients with severe aortic stenosis. Despite numerous technological and clinical advances, TAVI remains associated with thrombotic complications requiring antithrombotic pharmacotherapy, which exposes to the risk of bleeding, especially in elderly individuals. The optimal antithrombotic regimen following TAVI is uncertain and several investigations are ongoing. Areas covered: Clinical guidelines are mostly driven by observational trials and experts' opinions, thus resulting into low-grade level of evidence. The aim of the current review is to critically explore the epidemiology, pathophysiology and prognostic value of thrombotic and bleeding events after TAVI, and to review the current literature on antithrombotic strategies following the procedure. Expert opinion: Thrombotic and bleeding events remain major complications occurring in the frail population that is currently offered TAVI. Waiting for upcoming evidence from ongoing randomized clinical trials, tailoring antithrombotic therapies based on patients' characteristics, values and circumstances is a preferable approach.
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Affiliation(s)
- Antonio Greco
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Piera Capranzano
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Marco Barbanti
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Corrado Tamburino
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Davide Capodanno
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
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Kueri S, Kari FA, Fuentes RA, Sievers HH, Beyersdorf F, Bothe W. The Use of Biological Heart Valves. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:423-430. [PMID: 31423972 DOI: 10.3238/arztebl.2019.0423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 04/15/2019] [Accepted: 04/15/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Biological heart-valve prostheses have undergone continuous devel- opment up to the present, and technological advances have been made in catheter- assisted valve systems (transcatheter aortic valve implantation, TAVI) and minimally invasive routes of application. These parallel trends have led to major changes in therapeutic strategies, widening the spectrum of patients who are candidates for biological aortic valve implantation. METHODS This review is based on pertinent publications retrieved by a systematic search in PubMed employing the search terms "conventional biological aortic pros- thesis," "rapid deployment prosthesis," and "transcatheter aortic valve implantation/ replacement." RESULTS Among biological heart-valve prostheses, a distinction is drawn between stented (conventional, rapid-deployment, and catheter-assisted) and non-stented types. The long-term durability of conventional, surgically implantable biological valve protheses is by far the best documented: the reported 5-year reoperation rates range from 13.4% to 36.6%, and the pacemaker implantation rate is ca. 4%. Rapid-deployment prostheses combine the advantages of conventional and ca- theter-assisted techniques and facilitate minimally invasive approaches. The TAVI method is currently recommended for high- and intermediate-risk patients, while conventional valve replacement remains the method of choice for those at low risk. Rapid-deployment and TAVI prostheses is associated with a higher pacemaker im- plantation rate than conventional prostheses: these rates are 8.5-15.3% for TAVI and 6.0-8.8% for rapid-deployment valves. The intermediate-term durability of catheter-assisted and rapid-deployment prostheses appears promising, but their long-term durability is still unclear. CONCLUSION The further development of biological heart-valve prostheses in the form of improved conventional, transcatheter, and rapid-deployment prostheses now enables individualized treatment. Before any such procedure is performed, the car- diac team must assess the patient's risk profile and the advantages and disadvan- tages of each type of prosthesis to determine which is best.
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Affiliation(s)
- Sami Kueri
- Department of Cardiovascular Surgery, University Heart Center, Albert-Ludwigs-Universität Freiburg, Bad Krozingen; University Heart Center Lübeck, Department of Cardiac and Thoracic Vascular Surgery
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Oezpeker UC, Feuchtner G, Bonaros N. Cusp thrombosis of a self-expandable sutureless aortic valve treated by valve-in-valve transcatheter aortic valve implantation procedure: case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2019; 2:yty117. [PMID: 31020193 PMCID: PMC6426046 DOI: 10.1093/ehjcr/yty117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 11/30/2018] [Indexed: 11/18/2022]
Abstract
Background Surgical implantation rates of bioprosthetic valves, especially the use of sutureless or rapid deployment valves, as well as the advent of transcatheter valve implantation (TAVR) have increased during the last decades mainly due to their excellent haemodynamic and clinical results. One common characteristic of all bioprosthetic types of surgical aortic valve replacement (SAVR) and TAVR is the risk of early degeneration, which leads to valve-dysfunction and is associated with higher rates of valve reinterventions. Recent studies have demonstrated that cusp thrombosis may play a role in early valve dysfunction. This case report is, to our knowledge, the first documentation on a successful treatment of early aortic valve (AV) degeneration of a sutureless AV thrombosis with a valve-in-valve (ViV) TAVR implantation. Case summary A 77 years old woman was re-evaluated from the heart-team, which considered the following characteristics: severe impairment of mobility and frailty with an STS-score of 10.01% and a EuroSCORE II of 6.9%. Due to the high surgical risk for SAVR, we decided to perform a ViV-TAVR using a balloonexpandable bioprosthesis. The procedure was performed via transfemoral access under general anaesthesia using a 23 mm Edwards-Sapien 3 bioprosthesis without balloon-valvuloplasty and with nominal-volume dilation under rapid-pacing. Discussion The differentiation of bioprosthesis valve thrombosis, and hypoattenuating leaflet thickening vs. structural valve degeneration can be difficult, and a multimodality imaging approach, comprising trans-thoracic echocardiogram, transoesophageal echocardiography and computed tomography, useful. These investigations are very important to decide the right strategy of surgical valve replacement vs. TAVR.
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Affiliation(s)
- Ulvi Cenk Oezpeker
- University Clinic of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, Austria
| | - Gudrun Feuchtner
- University Clinic of Radiology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, Austria
| | - Nikolaos Bonaros
- University Clinic of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, Austria
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Rosseel L, De Backer O, Søndergaard L. Clinical Valve Thrombosis and Subclinical Leaflet Thrombosis Following Transcatheter Aortic Valve Replacement: Is There a Need for a Patient-Tailored Antithrombotic Therapy? Front Cardiovasc Med 2019; 6:44. [PMID: 31058168 PMCID: PMC6482296 DOI: 10.3389/fcvm.2019.00044] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 03/25/2019] [Indexed: 11/13/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has become an established therapeutic option for patients with symptomatic, severe aortic valve stenosis at increased surgical risk. Antithrombotic therapy after TAVR aims to prevent transcatheter heart valve (THV) thrombosis, in which two different entities have to be recognized: clinical valve thrombosis and subclinical leaflet thrombosis. In clinical valve thrombosis, obstructive thrombus formation leads to an increased transvalvular gradient, often provoking heart failure symptoms. Subclinical leaflet thrombosis is most often an incidental finding, characterized by a thin layer of thrombus covering the aortic side of one or more leaflets; it is also referred to as Hypo-Attenuating Leaflet Thickening (HALT) as described on multi-detector computed tomography (MDCT) imaging. This phenomenon may also affect leaflet motion and is then classified as Hypo-Attenuation affecting Motion (HAM). Even in case of HAM, the transvalvular pressure gradient remains within normal range and does not provoke heart failure symptoms. Whereas, clinical valve thrombosis requires treatment, the clinical impact and need for intervention in subclinical leaflet thrombosis is still uncertain. Oral anticoagulant therapy protects against and resolves both clinical valve thrombosis and subclinical leaflet thrombosis; however, large-scale randomized clinical trials studying different antithrombotic strategies after TAVR are still under way. This review article summarizes the currently available data within the field of transcatheter aortic valve/leaflet thrombosis and discusses the need for a patient tailored antithrombotic approach.
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Ranasinghe MP, Peter K, McFadyen JD. Thromboembolic and Bleeding Complications in Transcatheter Aortic Valve Implantation: Insights on Mechanisms, Prophylaxis and Therapy. J Clin Med 2019; 8:jcm8020280. [PMID: 30823621 PMCID: PMC6406714 DOI: 10.3390/jcm8020280] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 01/09/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has emerged as an important alternative to surgical aortic valve repair (SAVR) for patients with severe aortic stenosis. This rapidly advancing field has produced new-generation devices being delivered with small delivery sheaths, embolic protection devices and improved retrieval features. Despite efforts to reduce the rate of thrombotic complications associated with TAVI, valve thrombosis and cerebral ischaemic events post-TAVI continue to be a significant issue. However, the antithrombotic treatments utilised to prevent these dreaded complications are based on weak evidence and are associated with high rates of bleeding, which in itself is associated with adverse clinical outcomes. Recently, experimental data has shed light on the unique mechanisms, particularly the complex haemodynamic changes at sites of TAVI, that underpin the development of post-TAVI thrombosis. These new insights regarding the drivers of TAVI-associated thrombosis, coupled with the ongoing development of novel antithrombotics which do not cause bleeding, hold the potential to deliver newer, safer therapeutic paradigms to prevent post-TAVI thrombotic and bleeding complications. This review highlights the major challenge of post-TAVI thrombosis and bleeding, and the significant issues surrounding current antithrombotic approaches. Moreover, a detailed discussion regarding the mechanisms of post-TAVI thrombosis is provided, in addition to an appraisal of current antithrombotic guidelines, past and ongoing clinical trials, and how novel therapeutics offer the hope of optimizing antithrombotic strategies and ultimately improving patient outcomes.
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Affiliation(s)
- Mark P Ranasinghe
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, 75 Commercial Road, PO Box 6492, Melbourne, Victoria 3004, Australia.
- Department of Medicine, Monash University, Melbourne, Victoria 3800, Australia.
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, 75 Commercial Road, PO Box 6492, Melbourne, Victoria 3004, Australia.
- Department of Medicine, Monash University, Melbourne, Victoria 3800, Australia.
- Heart Centre, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.
| | - James D McFadyen
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, 75 Commercial Road, PO Box 6492, Melbourne, Victoria 3004, Australia.
- Department of Medicine, Monash University, Melbourne, Victoria 3800, Australia.
- Department of Clinical Haematology, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.
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Tang L, Lesser JR, Schneider LM, Burns MR, Gössl M, Garberich R, Niikura H, Witt D, Sorajja P. Prospective Evaluation for Hypoattenuated Leaflet Thickening Following Transcatheter Aortic Valve Implantation. Am J Cardiol 2019; 123:658-666. [PMID: 30528421 DOI: 10.1016/j.amjcard.2018.11.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/05/2018] [Accepted: 11/12/2018] [Indexed: 12/31/2022]
Abstract
Prospective investigations for the frequency of hypoattenuated leaflet thickening (HALT) and its clinical implications in transcatheter aortic valve implantation (TAVI) patients are limited. We initiated a prospective screening program of TAVI patients for HALT beginning in July 2015. Eligible patients were evaluated with gated, contrast-enhanced multidetector computed tomography within 30 days of TAVI, and examined for HALT and clinical outcomes. During the study period, 287 patients (81 ± 8 years; 53% men) who underwent TAVI with commercially approved devices were examined. Overall, 26 patients (9.1%) had occurrence of HALT, and only one of these patients had detectable hemodynamic changes on echocardiography at diagnosis. Notably, 9 of 26 HALT patients had been receiving warfarin, however, the HALT patients more often had subtherapeutic international normalized ratio whereas using warfarin than patients without HALT on index multidetector computed tomography imaging (p = 0.01). Patients who developed HALT had lower baseline aortic gradient, valvuloarterial impedance, and peak aortic velocity, and more commonly had been treated with balloon-expandable valves (73% of all HALT cases) with a higher incidence among those who received larger prostheses. All patients with HALT were placed on anticoagulation at diagnosis, and valvular function remained unchanged at follow-up. Two patients with HALT (7.7%) experienced ischemic stroke. A statistical trend for more major adverse clinical events was present in HALT patients. In conclusion, HALT was detected in 9% of TAVI cases in this prospective observational cohort, with a greater frequency in patients with large, balloon-expandable prostheses. Prospective screening may be considered as early HALT is reversible by timely therapeutic anticoagulation.
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Tsuda M, Mizote I, Ichibori Y, Mukai T, Maeda K, Onishi T, Kuratani T, Sawa Y, Sakata Y. Outcomes of Redo Transcatheter Aortic Valve Implantation for Structural Valve Degeneration of Transcatheter Aortic Valve. Circ Rep 2019; 1:142-148. [PMID: 33693129 PMCID: PMC7890286 DOI: 10.1253/circrep.cr-18-0025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 11/09/2022] Open
Abstract
Background: The outcome of redo transcatheter aortic valve (TAV) implantation (TAVI) is unknown for TAV structural valve degeneration (SVD). This paper reports the initial results of redo TAVI for TAV-SVD in Japanese patients. Methods and Results: Of 630 consecutive patients, 6 (1.0%) underwent redo TAVI for TAV-SVD (689-1,932 days after the first TAVI). The first TAV were 23-mm balloon-expandable valves (BEV, n=5) and a 26-mm self-expandable valve (SEV, n=1). All patients underwent multidetector computed tomography (MDCT) before redo TAVI, which showed first-TAV under-expansion (range, 19.1-21.0 mm) compared with the label size. Two BEV and 4 SEV were successfully implanted as second TAV, without moderate/severe regurgitation or 30-day mortality. One of 2 patients with a BEV-inside-BEV implantation had a high transvalvular mean pressure gradient post-procedurally (34 mmHg) and required surgical valve replacement 248 days after the redo TAVI. This, however, was unnoted in patients with SEV implantation during redo TAVI. Planned coronary artery bypass grafting was concomitantly performed in 1 patient with a small sino-tubular junction and SEV-inside-SEV implantation because of the risk of coronary malperfusion caused by the first TAV leaflets. Five of the 6 patients survived during the follow-up period (range, 285-1,503 days). Conclusions: Redo TAVI for TAV-SVD appears safe and feasible, while specific strategies based on MDCT and device selection seem important for better outcomes.
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Affiliation(s)
- Masaki Tsuda
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Isamu Mizote
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Yasuhiro Ichibori
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Takashi Mukai
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Koichi Maeda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine Suita Japan
| | - Toshinari Onishi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Toru Kuratani
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine Suita Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine Suita Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
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Meng S, Mao J, Rouse EN, Le-Bel G, Bourget JM, Reed RR, Philippe E, How D, Zhang Z, Germain L, Guidoin R. The Red Kangaroo pericardium as a material source for the manufacture of percutaneous heart valves. Morphologie 2019; 103:37-47. [PMID: 30638803 DOI: 10.1016/j.morpho.2018.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/06/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The kangaroo pericardium might be considered to be a good candidate material for use in the manufacture of the leaflets of percutaneous heart valves based upon the unique lifestyle. The diet consists of herbs, forbs and strubs. The kangaroo pericardium holds an undulated structure of collagen. MATERIAL AND METHOD A Red Kangaroo was obtained after a traffic fatality and the pericardium was dissected. Four compasses were cut from four different sites: auricular (AUR), atrial (ATR), sternoperitoneal (SPL) and phrenopericardial (PPL). They were investigated by means of scanning electron microscopy, light microscopy and transmission electron microscopy. RESULTS All the samples showed dense and wavy collagen bundles without vascularisation from both the epicardium and the parietal pericardium. The AUR and the ATR were 150±25μm thick whereas the SPL and the PPL were thinner at 120±20μm. The surface of the epicardium was smooth and glistening. The filaments of collagen were well individualized without any aggregation, but the banding was poorly defined and somewhat blurry. CONCLUSION This detailed morphological analysis of the kangaroo pericardium illustrated a surface resistant to thrombosis and physical characteristics resistant to fatigue. The morphological characteristics of the kangaroo pericardium indicate that it represents an outstanding alternative to the current sources e.g., bovine and porcine. However, procurement of tissues from the wild raises supply and sanitary issues. Health concerns based upon sanitary uncertainty and reliability of supply of wild animals remain real problems.
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Affiliation(s)
- S Meng
- Chongqing Key Lab of Catalysis and Functional Organic Molecules; College of Environment and Biotechnology, Chongqing Technology and Business University, Chongqing, PR China
| | - J Mao
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada
| | - E N Rouse
- Department of Comparative Medicine, College of Veterinary of Tennessee, Knoxville, TN, USA
| | - G Le-Bel
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada
| | - J M Bourget
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada
| | - R R Reed
- Department of Comparative Medicine, College of Veterinary of Tennessee, Knoxville, TN, USA
| | - E Philippe
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada
| | - D How
- Peninsula College of Medicine and Dentistry (PCMD), Plymouth, Devon, UK
| | - Z Zhang
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada
| | - L Germain
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada
| | - R Guidoin
- Axe Médecine Régénératrice, Centre de Recherche du CHU and Département de Chirurgie, Faculté de Médecine, Université Laval, Québec Canada.
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Marcelli E, Bortolani B, Corazza I, Cercenelli L. A Novel Sensorized Heart Valve Prosthesis: Preliminary In Vitro Evaluation. SENSORS 2018; 18:s18113905. [PMID: 30428516 PMCID: PMC6263652 DOI: 10.3390/s18113905] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 10/30/2018] [Accepted: 11/07/2018] [Indexed: 12/16/2022]
Abstract
Background: Recent studies have shown that subclinical valve thrombosis in heart valve prosthesis (HVP) can be responsible for reduced leaflet motion detectable only by advanced imaging diagnostics. We conceived a novel sensorized HVP able to detect earlier any thrombus formation that may alter the leaflets motion using an electric impedance measurement, IntraValvular Impedance (IVI). Methods: For IVI measurement, dedicated electrodes are embedded in the structure of the HVP to generate a local electric field that is altered by the moving valve leaflets during their cyclic opening/closing. We present preliminary in vitro results using a first prototype of sensorized mechanical heart valve connected to an external impedance measurement system. The prototype was tested on a circulatory mock loop system and the IVI signals were recorded during both normal dynamics and experimentally induced altered working of the leaflets. Results: Recordings showed a very repetitive and stable IVI signal during the normal cyclic opening/closing of the HVP. The induced alterations in leaflet motion were reflected in the IVI signal. Conclusions: The novel sensorized HVP has great potential to give early warning of possible subclinical valve thrombosis altering the valve leaflet motion, and to help in tailoring the anticoagulation therapy.
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Affiliation(s)
- Emanuela Marcelli
- Laboratory of Bioengineering, DIMES Department, University of Bologna, S. Orsola-Malpighi Hospital, 40138 Bologna, Italy.
| | - Barbara Bortolani
- Laboratory of Bioengineering, DIMES Department, University of Bologna, S. Orsola-Malpighi Hospital, 40138 Bologna, Italy.
| | - Ivan Corazza
- Medical Physics Activities Coordination Center, DIMES Department, University of Bologna, 40138 Bologna, Italy.
| | - Laura Cercenelli
- Laboratory of Bioengineering, DIMES Department, University of Bologna, S. Orsola-Malpighi Hospital, 40138 Bologna, Italy.
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41
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Long A, Mahoney P. Fulminant Presentation of a Failed TAVR Valve: Successful Revision with a Transcatheter Approach - Case Report and Review of the Literature. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:720-723. [PMID: 30391212 DOI: 10.1016/j.carrev.2018.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/16/2018] [Accepted: 10/16/2018] [Indexed: 11/15/2022]
Abstract
Transcatheter Aortic Valve Replacement (TAVR) has evolved as a strategy for managing aortic stenosis in a growing proportion of patients considered at high or intermediate surgical risk. Though early data has demonstrated excellent durability and life span of transcatheter valves up to five years, there is an absence of case based studies in the literature regarding transcatheter valve failure after TAVR, and outcomes of subsequent redo TAVR Valve-in-Valve (VIV) procedures. We report here a successful case of emergent, catheter-based treatment for severe, highly symptomatic valve in valve restenosis of a 5 year old Sapien valve.
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Affiliation(s)
- Ashleigh Long
- Sentara Heart Valve and Structural Disease Center, 600 Gresham Drive, Norfolk, VA 23507, United States of America
| | - Paul Mahoney
- Sentara Heart Valve and Structural Disease Center, 600 Gresham Drive, Norfolk, VA 23507, United States of America.
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42
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Al’Aref SJ, Mrsic Z, Feuchtner G, Min JK, Villines TC. The Journal of Cardiovascular Computed Tomography year in review - 2018. J Cardiovasc Comput Tomogr 2018; 12:529-538. [DOI: 10.1016/j.jcct.2018.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/18/2018] [Indexed: 12/24/2022]
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43
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Rotman OM, Bianchi M, Ghosh RP, Kovarovic B, Bluestein D. Principles of TAVR valve design, modelling, and testing. Expert Rev Med Devices 2018; 15:771-791. [PMID: 30318937 PMCID: PMC6417919 DOI: 10.1080/17434440.2018.1536427] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Transcatheter aortic valve replacement (TAVR) has emerged as an effective minimally-invasive alternative to surgical valve replacement in medium- to high-risk, elderly patients with calcific aortic valve disease and severe aortic stenosis. The rapid growth of the TAVR devices market has led to a high variety of designs, each aiming to address persistent complications associated with TAVR valves that may hamper the anticipated expansion of TAVR utility. AREAS COVERED Here we outline the challenges and the technical demands that TAVR devices need to address for achieving the desired expansion, and review design aspects of selected, latest generation, TAVR valves of both clinically-used and investigational devices. We further review in detail some of the up-to-date modeling and testing approaches for TAVR, both computationally and experimentally, and additionally discuss those as complementary approaches to the ISO 5840-3 standard. A comprehensive survey of the prior and up-to-date literature was conducted to cover the most pertaining issues and challenges that TAVR technology faces. EXPERT COMMENTARY The expansion of TAVR over SAVR and to new indications seems more promising than ever. With new challenges to come, new TAV design approaches, and materials used, are expected to emerge, and novel testing/modeling methods to be developed.
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Affiliation(s)
- Oren M. Rotman
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA
| | - Matteo Bianchi
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA
| | - Ram P. Ghosh
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA
| | - Brandon Kovarovic
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY 11794, USA
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44
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Rashid HN, Nasis A, Gooley RP, Cameron JD, Brown AJ. The prevalence of computed tomography-defined leaflet thrombosis in intra- versus supra-annular transcatheter aortic valve prostheses. Catheter Cardiovasc Interv 2018; 92:1414-1416. [DOI: 10.1002/ccd.27702] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 05/30/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Hashrul N. Rashid
- Monash Cardiovascular Research Centre; MonashHEART, Monash Health, and Monash University; Clayton Victoria Australia
| | - Arthur Nasis
- Monash Cardiovascular Research Centre; MonashHEART, Monash Health, and Monash University; Clayton Victoria Australia
| | - Robert P. Gooley
- Monash Cardiovascular Research Centre; MonashHEART, Monash Health, and Monash University; Clayton Victoria Australia
| | - James D. Cameron
- Monash Cardiovascular Research Centre; MonashHEART, Monash Health, and Monash University; Clayton Victoria Australia
| | - Adam J. Brown
- Monash Cardiovascular Research Centre; MonashHEART, Monash Health, and Monash University; Clayton Victoria Australia
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45
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Rotman OM, Kovarovic B, Chiu WC, Bianchi M, Marom G, Slepian MJ, Bluestein D. Novel Polymeric Valve for Transcatheter Aortic Valve Replacement Applications: In Vitro Hemodynamic Study. Ann Biomed Eng 2018; 47:113-125. [PMID: 30194551 DOI: 10.1007/s10439-018-02119-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/17/2018] [Indexed: 11/30/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) is a minimally-invasive approach for treating severe aortic stenosis. All clinically-used TAVR valves to date utilize chemically-fixed xenograft as the leaflet material. Inherent limitation of the tissue (e.g., calcific degeneration) motivates the search for alternative leaflet material. Here we introduce a novel polymeric TAVR valve that was designed to address the limitations of tissue-valves. In this study, we experimentally evaluated the hemodynamic performance of the valve and compared its performance to clinically-used valves: a gold standard surgical tissue valve, and a TAVR valve. Our comparative testing protocols included: (i) baseline hydrodynamics (ISO:5840-3), (ii) complementary patient-specific hydrodynamics in a dedicated system, and (iii) thrombogenicity. The patient-specific testing system facilitated comparing TAVR valves performance under more realistic conditions. Baseline hydrodynamics results at CO 4-7 L/min showed superior effective orifice area (EOA) for the polymer valve, most-notably as compared to the reference TAVR valve. Regurgitation fraction was higher in the polymeric valve, but within the ISO minimum requirements. Thrombogenicity trends followed the EOA results with the polymeric valve being the least thrombogenic, and clinical TAVR being the most. Hemodynamic-wise, the results strongly indicate that our polymeric TAVR valve can outperform tissue valves.
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Affiliation(s)
- Oren M Rotman
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, 11794-8151, USA
| | - Brandon Kovarovic
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, 11794-8151, USA
| | - Wei-Che Chiu
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, 11794-8151, USA
| | - Matteo Bianchi
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, 11794-8151, USA
| | - Gil Marom
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, 11794-8151, USA.,School of Mechanical Engineering, Tel Aviv University, 6997801, Tel Aviv, Israel
| | - Marvin J Slepian
- Department of Biomedical Engineering, University of Arizona, Tucson, AZ, 85721, USA
| | - Danny Bluestein
- Department of Biomedical Engineering, Stony Brook University, Stony Brook, NY, 11794-8151, USA.
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46
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Sierra P, Gómez-Luque A, Llau JV, Ferrandis R, Cassinello C, Hidalgo F. Recommendations for perioperative antiplatelet treatment in non-cardiac surgery. Working Group of the Spanish Society of Anaesthesiology-Resuscitation and Pain Therapy, Division of Haemostasis, Transfusion Medicine, and Perioperative Fluid Therapy. Update of the Clinical practice guide 2018. ACTA ACUST UNITED AC 2018; 66:18-36. [PMID: 30166124 DOI: 10.1016/j.redar.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 12/24/2022]
Affiliation(s)
- P Sierra
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Fundación Puigvert (IUNA), Barcelona, España.
| | - A Gómez-Luque
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, España
| | - J V Llau
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Dr. Peset, Universitat de València, Valencia, España
| | - R Ferrandis
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hopital Clínic i Universitari La Fe, Universitat de València, Valencia, España
| | - C Cassinello
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Miguel Servet, Zaragoza, España
| | - F Hidalgo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Clínica Universidad de Navarra, Pamplona, España
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47
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Alkhouli M, Winkler L, Tallaksen RJ. Computed Tomography Assessment for Transcatheter Aortic Valve Replacement. Interv Cardiol Clin 2018; 7:301-313. [PMID: 29983143 DOI: 10.1016/j.iccl.2018.03.004] [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: 10/28/2022]
Abstract
Transcatheter aortic valve replacement has become a mainstream therapeutic option for patients with severe aortic stenosis who are at intermediate risk or high risk for surgical valve replacement. Computed tomography (CT) is now the standard imaging modality for preoperative vascular access planning an aortic annular sizing. This article reviews the established and potential future roles of CT in transcatheter aortic valve replacement.
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Affiliation(s)
- Mohamad Alkhouli
- Division of Cardiovascular Disease, Structural Heart Interventions, West Virginia University School of Medicine, West Virginia University, 1 Medical Center Drive, Morgantown, WV 26505-8059, USA.
| | - Lana Winkler
- Department of Radiology, West Virginia University, 1 medical drive, Morgantown, WV 26505, USA
| | - Robert J Tallaksen
- Department of Radiology, West Virginia University, 1 medical drive, Morgantown, WV 26505, USA
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48
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Rashid HN, Brown AJ, McCormick LM, Amiruddin AS, Be KK, Cameron JD, Nasis A, Gooley RP. Subclinical Leaflet Thrombosis in Transcatheter Aortic Valve Replacement Detected by Multidetector Computed Tomography ― A Review of Current Evidence ―. Circ J 2018; 82:1735-1742. [DOI: 10.1253/circj.cj-17-1363] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hashrul N. Rashid
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health
| | - Adam J. Brown
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health
| | - Liam M. McCormick
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health
| | - Ameera S. Amiruddin
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health
| | - Kim K. Be
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health
| | - James D. Cameron
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health
| | - Arthur Nasis
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health
| | - Robert P. Gooley
- Monash Cardiovascular Research Centre, Monash University and MonashHeart, Monash Health
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49
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Kanjanauthai S, Pirelli L, Nalluri N, Kliger CA. Subclinical leaflet thrombosis following transcatheter aortic valve replacement. J Interv Cardiol 2018; 31:640-647. [DOI: 10.1111/joic.12521] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/22/2018] [Accepted: 04/26/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
| | | | - Nikhil Nalluri
- Staten Island University Hospital; Valve and Structural Heart Center; New York New York
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Marwan M. Reply: Leaflet thrombosis following transcatheter aortic valve implantation. J Cardiovasc Comput Tomogr 2018; 12:e3. [PMID: 29598928 DOI: 10.1016/j.jcct.2018.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 03/14/2018] [Indexed: 10/17/2022]
Affiliation(s)
- M Marwan
- Department of Internal Medicine 2 (Cardiology), University of Erlangen, Ulmenweg 18, D-91054 Erlangen, Germany.
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