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Zou Q, Wei Z, Sun S. Complications in transcatheter aortic valve replacement: A comprehensive analysis and management strategies. Curr Probl Cardiol 2024; 49:102478. [PMID: 38437930 DOI: 10.1016/j.cpcardiol.2024.102478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 03/06/2024]
Abstract
Transcatheter Aortic Valve Replacement (TAVR) marks a significant advancement in treating aortic stenosis (AS), especially for patients with high surgical risks. This concise review outlines TAVR's development, its broader application to include lower-risk patients, and innovations in the device and procedural technology. Clinical trials, notably the PARTNER series, affirm TAVR's efficacy, showing it matches or surpasses surgical aortic valve replacement (SAVR) in mortality reduction, hemodynamic benefits, and symptom alleviation, including heart failure. However, TAVR entails complications such as paravalvular leakage (PVL), conduction disorders, and increased cerebrovascular event risks. We evaluate these issues, their prevalence, causative factors, and clinical consequences, emphasizing improvements in valve design and technique that have significantly lowered PVL rates. The role of aortic valve anatomy and calcification in PVL and conduction issues is analyzed, underlining the necessity for meticulous patient selection and procedural planning. Further, the review delves into cerebrovascular event risks, their origins, and preventative strategies, including cerebral protection devices and the judicious use of anticoagulant and antiplatelet therapies. TAVR presents a less invasive, promising alternative to SAVR, but requires careful complication management to optimize patient results. Ongoing innovation and research are vital for advancing TAVR's techniques, improving valve designs, and extending its reach, thereby enhancing AS patients' quality of life.
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Affiliation(s)
- Qi Zou
- Department of Cardiology, Lanzhou University Second Hospital, Lanzhou, China
| | - Zhiliang Wei
- Department of Cardiology, Lanzhou University Second Hospital, Lanzhou, China
| | - Shougang Sun
- Department of Cardiology, Lanzhou University Second Hospital, Lanzhou, China.
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2
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Zhang M, Peng W, Yin S, Zhao Y, Lin Y. Nondual Antiplatelet Therapy Versus Dual Antiplatelet Therapy Before Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-analysis. J Cardiovasc Pharmacol 2024; 83:297-305. [PMID: 38030135 DOI: 10.1097/fjc.0000000000001512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/29/2023] [Indexed: 12/01/2023]
Abstract
ABSTRACT Transcatheter aortic valve replacement (TAVR) is an interventional procedure performed in patients with severe aortic stenosis and often required perioperative antiplatelet therapy. Most previous studies have focused on antiplatelet therapy following TAVR. However, few studies have investigated the prognostic effect of preoperative antiplatelet therapy in patients undergoing TAVR. This study aimed to compare the efficacy and safety of nondual antiplatelet therapy (non-DAPT) and DAPT before TAVR. We performed a systematic search of Embase, PubMed, and Web of Science until February 2023. Studies were eligible if they compared non-DAPT (single antiplatelet therapy or no antiplatelet therapy) with DAPT in patients before TAVR. A total of 5 studies, including 2329 patients, met the inclusion criteria and were included in the meta-analysis. Preoperative non-DAPT significantly decreased minor bleeding events compared with preoperative DAPT [odds ratio 0.58; 95% confidence interval: 0.44-0.76]. There were no significant differences in the incidence of other bleeding events, transfusions, stroke, myocardial infarction, or all-cause death. Preoperative single antiplatelet therapy significantly decreased the incidence of major bleeding compared with DAPT (odds ratio 0.14; 95% confidence interval: 0.04-0.48). Preoperative non-DAPT significantly reduced minor bleeding events in patients undergoing TAVR, without increasing the risk of stroke and myocardial infarction.
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Affiliation(s)
- Mengdi Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; and
- School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Wenxing Peng
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; and
| | - Shiqi Yin
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; and
- School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Yiru Zhao
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; and
- School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Yang Lin
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; and
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3
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Alaour B, Ferrari E, Heg D, Tueller D, Pilgrim T, Muller O, Noble S, Jeger R, Reuthebuch O, Toggweiler S, Templin C, Wenaweser P, Nietlispach F, Taramasso M, Huber C, Roffi M, Windecker S, Stortecky S. Non-Vitamin K Antagonist Versus Vitamin K Antagonist Oral Anticoagulant Agents After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2024; 17:405-418. [PMID: 38355269 DOI: 10.1016/j.jcin.2023.11.038] [Citation(s) in RCA: 1] [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: 08/30/2023] [Revised: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Studies comparing long-term outcomes between non-vitamin K antagonist (VKA) oral anticoagulant agents (direct oral anticoagulant agents [DOACs]) and VKA anticoagulant agents after transcatheter aortic valve replacement (TAVR) are scarce, with conflicting results. OBJECTIVES The aim of this study was to examine the periprocedural, short-term, and long-term safety and effectiveness of DOACs vs VKAs in patients undergoing TAVR via femoral access with concomitant indications for oral anticoagulation. METHODS Consecutive patients undergoing transfemoral TAVR in the prospective national SwissTAVI Registry between February 2011 and June 2021 were analyzed. Net clinical benefit (a composite of all-cause mortality, myocardial infarction, stroke, and life-threatening or major bleeding) and the primary safety endpoint (a composite of life-threatening and major bleeding) were compared between the VKA and DOAC groups at 30 days, 1 year, and 5 years after TAVR. RESULTS After 1:1 propensity score matching, 1,454 patients were available for analysis in each group. There was no significant difference in the rate of the net clinical benefit and the safety endpoints between the groups as assessed at 30 days and 1 and 5 years post-TAVR between VKAs and DOACs. VKAs were associated with significantly higher rates of 1- year (HR: 1.28; 95% CI: 1.01-1.62) and 5-year (HR: 1.25; 95% CI: 1.11-1.40) all-cause mortality. Long-term risk for disabling stroke was significantly lower in the VKA group after excluding periprocedural events (HR: 0.64; 95% CI: 0.46-0.90). CONCLUSIONS At 5 years after TAVR, VKAs are associated with a higher risk for all-cause mortality, a lower risk for disabling stroke, and a similar rate of life-threatening or major bleeding compared with DOACs. (SwissTAVI Registry; NCT01368250).
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Affiliation(s)
- Bashir Alaour
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Enrico Ferrari
- Department of Cardiovascular Surgery, Cardiocentro Ticino Institute-EOC, Lugano, Switzerland
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - David Tueller
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital-CHUV, Lausanne, Switzerland
| | - Stephane Noble
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Raban Jeger
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland; University of Basel, Basel, Switzerland
| | - Oliver Reuthebuch
- University of Basel, Basel, Switzerland; Department of Cardiovascular Surgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | | | - Christian Templin
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Peter Wenaweser
- Heart Clinic Hirslanden, Hirslanden Clinic Zurich, Zurich, Switzerland
| | | | | | - Christoph Huber
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Marco Roffi
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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4
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Claeys MJ, Aminian A, Bartunek J, Bennett J, Buysschaert I, Claeys M, De Bock D, Delodder L, Debonnaire P, Dewilde W, Ferdinande B, Geerinck S, Goetschalckx K, Lambrechts O, Lochy S, Paelinck BP, Rosseel L, Stroobants D, Vanderheyden M, Van der Heyden J, Verbrugghe P, Verheye S, Dubois C. Bleeding and thrombotic risk of different antiplatelet regimens posttranscatheter edge-to-edge mitral valve repair in patients with an indication for oral anticoagulation: Results from an all-comers national registry. Catheter Cardiovasc Interv 2024; 103:382-388. [PMID: 38078877 DOI: 10.1002/ccd.30931] [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: 02/27/2023] [Revised: 09/01/2023] [Accepted: 11/23/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Evidence-based recommendations for antithrombotic treatment in patients who have an indication for oral anticoagulation (OAC) after transcatheter edge-to-edge mitral valve repair (TEER) are lacking. AIMS To compare bleeding and thrombotic risk for different antithrombotic regimens post-TEER with MitraClip in an unselected population with the need for OACs. METHODS Bleeding and thrombotic complications (stroke and myocardial infarction) up to 3 months after TEER with mitraclip were evaluated in 322 consecutive pts with an indication for OACs. These endpoints were defined by the Mitral Valve Academic Research Consortium criteria and were compared between two antithrombotic regimens: single antithrombotic therapy with OAC (single ATT) and double/triple ATT with a combination of OAC and aspirin and/or clopidogrel (combined ATT). RESULTS Collectively, 108 (34%) patients received single ATT, 203 (63%) received double ATT and 11 (3%) received triple ATT. Bleeding events occurred in 67 patients (20.9%), with access site related events being the most frequent cause (37%). Bleeding complications were observed more frequently in the combined ATT group than in the single ATT group: 24% versus 14% [p = 0.03, adjusted RR: 0.55 (0.3-0.98)]. Within the combined group, the bleeding risk was 23% in the double ATT and 45% in the triple ATT group. Thrombotic complications occurred in only three patients (0.9%), and all belonged to the combined ATT group. CONCLUSIONS In patients with an indication for OACs, withholding of antiplatelet therapy post-TEER with Mitraclip was associated with a 45% reduction in bleeding and without a signal of increased thrombotic risk.
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Affiliation(s)
- Marc J Claeys
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier, Universitaire de Charleroi, Charleroi, Belgium
| | - Jozef Bartunek
- Department of Cardiology, OLV Hospital Aalst, Aalst, Belgium
| | - Johan Bennett
- Department of Cardiovascular Medicine, UZ Leuven and Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Ian Buysschaert
- Department of Cardiology, Hospital Sint-Jan Brugge, Bruges, Belgium
| | - Mathias Claeys
- Department of Cardiology, Hospital Sint-Jan Brugge, Bruges, Belgium
| | - Dina De Bock
- Deptartment of Cardiovascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Lies Delodder
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
| | | | - Willem Dewilde
- Department of Cardiology, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | - Bert Ferdinande
- Department of Cardiology, Hospital Oost-Limburg, Genk, Belgium
| | | | - Kaatje Goetschalckx
- Department of Cardiovascular Medicine, UZ Leuven and Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | - Stijn Lochy
- Department of Cardiology, Brussels University Hospital, Brussels, Belgium
| | | | | | | | | | | | - Peter Verbrugghe
- Department of Cardiovascular Medicine, UZ Leuven and Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Stefan Verheye
- Department of Cardiology, ZAS Hospital, Antwerp, Belgium
| | - Christophe Dubois
- Department of Cardiovascular Medicine, UZ Leuven and Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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5
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Dobesh PP, Goldsweig AM. Antithrombotic therapy with Transcatheter aortic valve replacement. Pharmacotherapy 2023; 43:1064-1083. [PMID: 37464970 DOI: 10.1002/phar.2847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 07/20/2023]
Abstract
Aortic valve replacement is a necessary management strategy for patients with severe aortic stenosis. The use of transaortic valve replacement (TAVR) has increased significantly over the last decade and now exceeds traditional surgical aortic valve replacement. Since the valve systems used in TAVR consist of bioprosthetic valve tissue encased in a metal stent frame, antithrombotic therapy recommendations cannot be extrapolated from prior data with differently constructed surgical bioprosthetic or mechanical valves. Data on the use of antithrombotic therapy with TAVR are a rapidly developing area of medicine. Choice of agents depends on several patient factors. Patients undergoing TAVR also have a relatively high incidence of subclinical valve thrombosis. The clinical impact of this phenomenon and the implications for antithrombotic therapy continue to evolve. It is critical for clinicians who treat patients undergoing TAVR to have a firm understanding of practice guidelines, the evolving evidence, and its implications for the use of antithrombotic therapy in these patients.
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Affiliation(s)
- Paul P Dobesh
- Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andrew M Goldsweig
- Cardiac Catheterization Laboratory, Cardiovascular Clinical Research, Baystate Medical Center, Springfield, Massachusetts, USA
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6
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Sharma H, Afzal S, Leick J, Werner N, Doshi SN, Nadir MA. Antithrombotic therapy following transcatheter aortic valve intervention. Pharmacol Ther 2023; 250:108509. [PMID: 37572882 DOI: 10.1016/j.pharmthera.2023.108509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/27/2023] [Accepted: 08/08/2023] [Indexed: 08/14/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is increasingly being performed to treat symptomatic patients with aortic stenosis and annual procedure volume has overtaken surgical aortic valve replacement in the United States. However, current international guidelines were written prior to the publication of several important recent studies. Furthermore, European and American guidelines differ in their recommendations of antithrombotic therapy following TAVR. Consequently, there is a need to examine the literature to provide clinicians guidance on the optimum antithrombotic strategy, particularly as different patient populations exist. In this review, we examine the data for antiplatelet and anticoagulation therapy post-TAVR.
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Affiliation(s)
- Harish Sharma
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Shazia Afzal
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Jürgen Leick
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Nikos Werner
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Sagar N Doshi
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - M Adnan Nadir
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK.
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7
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Banga S, Abela GS, Saltiel F, Fischell T, Kalavakunta JK, Sood A, Jolly G, Najib K, Al-Ali H, Qintar M, Bazil J, Singh Y, Gupta V. Management of Atrial Fibrillation Post Transcatheter Aortic Valve Implantation. Am J Cardiol 2023; 200:171-177. [PMID: 37329837 DOI: 10.1016/j.amjcard.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 05/01/2023] [Accepted: 05/16/2023] [Indexed: 06/19/2023]
Abstract
Atrial fibrillation (AF) is a common complication in patients who underwent transcatheter aortic valve implantation. Some of these patients have preexisting AF as well. The management of these patients is complex, especially after the procedure, when there is a sudden change in hemodynamics. There are no established guidelines about the management of the patients who underwent transcatheter aortic valve replacement with preexisting or new-onset AF. This review article discusses the management of these patients with rate and rhythm control strategies with medications. This article also highlights the role of newer oral anticoagulation medications and left atrial occlusion devices to prevent stroke after the procedure. We will also discuss new advances in the care of this patient population to prevent the occurrence of AF after transcatheter aortic valve implantation. In conclusion, this article is a synopsis of both pharmacologic and device interventions for the management of AF in patients who underwent transcatheter aortic valve replacement.
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Affiliation(s)
- Sandeep Banga
- Department of Cardiology, Sparrow Hospital, Michigan State University, Lansing, Michigan.
| | - George S Abela
- Department of Cardiology, Sparrow Hospital, Michigan State University, Lansing, Michigan
| | - Frank Saltiel
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Tim Fischell
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Jagadeesh K Kalavakunta
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Abhinav Sood
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - George Jolly
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Khalid Najib
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Haya Al-Ali
- Department of Physiology, Michigan State University, Lansing, Michigan
| | - Mohammed Qintar
- Department of Cardiology, Sparrow Hospital, Michigan State University, Lansing, Michigan
| | - Jason Bazil
- Department of Physiology, Michigan State University, Lansing, Michigan
| | - Yashbir Singh
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Vishal Gupta
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
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8
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Adalja D, Zala H, Victor V, Sheth A, Willyard C, Suzuki E, Patel HP, Majmundar M, Vallabhajosyula S, Doshi R. Incidence, Current Guidelines and Management of Gastrointestinal Bleeding after Transcatheter Aortic Valve Replacement: A Systematic Review. Curr Cardiol Rev 2023; 19:e230622206351. [PMID: 35747979 PMCID: PMC10201885 DOI: 10.2174/1573403x18666220623150830] [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: 02/24/2022] [Revised: 04/10/2022] [Accepted: 04/12/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND There is a significant increase in morbidity and mortality in patients complicated by major bleeding following transcatheter aortic valve replacement (TAVR). It has become more challenging to manage such complications when the patient needs to be on anticoagulation or antiplatelet agent post-procedure to prevent thrombotic/embolic complications. METHODS We systematically reviewed all available randomized controlled trials and observational studies to identify incidence rates of gastrointestinal bleeding post-procedure. After performing a systematic search, a total of 8731 patients from 15 studies (5 RCTs and 10 non-RCTs) were included in this review. RESULTS The average rate of gastrointestinal bleeding during follow-up was 3.0% in randomized controlled trials and 1.9% among observational studies. CONCLUSION Gastrointestinal bleeding has been noted to be higher in the RCTs as compared to observational studies. This review expands knowledge of current guidelines and possible management of patients undergoing TAVR.
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Affiliation(s)
- Devina Adalja
- Department of Internal Medicine, St Joseph's University Medical Center, Paterson, NJ, USA
| | - Harshvardhan Zala
- Department of Clinical Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Varun Victor
- Department of Internal Medicine, Canton Medical Education Foundation, Canton, OH, USA
| | - Aakash Sheth
- Department of Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Charles Willyard
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, NV, USA
| | - Emi Suzuki
- Department of Pediatrics, UCSF- Fresno, Fresno, CA, USA
| | - Harsh P. Patel
- Department of Internal Medicine, Louis A Weiss Memorial Hospital, Chicago, IL, USA
| | - Monil Majmundar
- Department of Cardiology, Maimonides Medical Center, Brooklyn, New York, USA
| | | | - Rajkumar Doshi
- Department of Cardiology, St Joseph's University Medical Center, Paterson, NJ, USA
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9
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Ge J, Han W, Ma C, Maduray K, Chen T, Zhong J. Efficacy and Safety of NOACs Compared With VKAs for Patients With Atrial Fibrillation After Transcatheter Aortic Valve Implantation: A System Review and Meta-Analysis. Clin Appl Thromb Hemost 2022; 28:10760296221145168. [PMID: 36524251 PMCID: PMC9768833 DOI: 10.1177/10760296221145168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Novel oral anticoagulants (NOACs) are preferentially recommended in patients with nonvalvular atrial fibrillation (AF) for stroke prevention over vitamin K antagonists (VKAs). However, the evidence regarding the efficacy and safety of NOACs versus VKAs after transcatheter aortic valve implantation (TAVI) in patients with AF is very rare. Pubmed, Embase, Web of science, and Cochrane Databases were searched for eligible studies published before May 19, 2022. A total of 11 studies were included in this meta-analysis involving 27 107 patients. Regarding primary outcomes, there were no differences between NOACs and VKAs in all-cause mortality (RR: 0.84, 95% CI: (0.69, 1.02)) and stroke (RR: 1.00, 95% CI: (0.85, 1.19)). With respect to secondary outcomes, NOACs were associated with reduced incidence of bleeding (RR: 0.77, 95% CI: (0.71, 0.83)) and intracranial bleeding (RR: 0.57, 95% CI: (0.39, 0.83)), whereas no significant differences were found in major or life-threatening bleeding (RR: 0.98, 95% CI: (0.82, 1.17)) and myocardial infarction (RR: 1.37, 95% CI: (0.83, 2.26)). Our meta-analysis revealed the safety and efficacy of NOACs may be superior to VKAs in AF patients undergoing TAVI.
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Affiliation(s)
- Junye Ge
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wenqiang Han
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chuanzhen Ma
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kellina Maduray
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tongshuai Chen
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China,Tongshuai Chen, Department of Cardiology, Qilu Hospital Affiliated to Shandong University, 107 Wen Hua Xi Road, Jinan 250012, China.
| | - Jingquan Zhong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China,Department of Cardiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China,Jingquan Zhong, Department of Cardiology, Qilu Hospital Affiliated to Shandong University, 107 Wen Hua Xi Road, Jinan 250012, China.
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10
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Ten Berg J, Rocca B, Angiolillo DJ, Hayashida K. The search for optimal antithrombotic therapy in transcatheter aortic valve implantation: facts and uncertainties. Eur Heart J 2022; 43:4616-4634. [PMID: 36130256 DOI: 10.1093/eurheartj/ehac385] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 01/05/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure, which is used frequently in patients with symptomatic severe aortic valve stenosis. Most patients undergoing TAVI are over 80 years of age with a high bleeding as well as thrombotic risk. Despite the increasing safety of the procedure, thromboembolic events [stroke, (subclinical) valve thrombosis] remain prevalent. As a consequence, antithrombotic prophylaxis is routinely used and only recently new data on the efficacy and safety of antithrombotic drugs has become available. On the other hand, these antithrombotic drugs increase bleeding in a population with unique aortic stenosis-related bleeding characteristics (such as acquired von Willebrand factor defect and angiodysplasia). In this review, we discuss the impact of thromboembolic and bleeding events, the current optimal antithrombotic therapy based on registries and recent randomized controlled trials, as well as try to give a practical guide how to treat these high-risk patients. Finally, we discuss knowledge gaps and future research needed to fill these gaps.
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Affiliation(s)
- Jurrien Ten Berg
- Department of Cardiology and Center for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands.,The Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Bianca Rocca
- Department of Safety and Bioethics, Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Internal Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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11
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Lee GSJ, Tay HSE, Teo VXY, Goh RSJ, Chong B, Chan SP, Tay E, Lim Y, Yip J, Chew NWS, Kuntjoro I. Bayesian Meta-analysis of Direct Oral Anticoagulation Versus Vitamin K Antagonists With or Without Concomitant Antiplatelet After Transcatheter Aortic Valve Implantation in Patients With Anticoagulation Indication. Angiology 2022; 74:509-518. [DOI: 10.1177/00033197221121616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patients undergoing transcatheter aortic valve implantation (TAVI) commonly have co-morbidities requiring anticoagulation. However, the optimal post-procedural anticoagulation regimen is not well-established. This meta-analysis investigates safety and efficacy outcomes of direct oral anticoagulants (DOACs) and Vitamin K Antagonist (VKA), with or without concomitant antiplatelet therapy. We searched EMBASE and MEDLINE for appropriate studies. Subgroup analyses were performed for anticoagulant monotherapy and combined therapy with antiplatelet agents. Eleven studies (6359 patients) were included. Overall, there were no differences between DOACs and VKA for all-cause mortality (Odds Ratio [OR]: .69; Credible Interval [CrI]: .40–1.06), cardiovascular-related mortality (OR: .76; Crl: .13–3.47), bleeding (OR: .95; CrI: .75–1.17), stroke (OR: 1.04; CrI: .65–1.63), myocardial infarction (OR: 1.51; CrI: .55–3.84), and valve thrombosis (OR: .29; CrI: .01–3.54). For DOACs vs VKA monotherapy subgroup, there were no differences in outcomes. For the combined therapy subgroup, there was decreased odds of all-cause mortality in the DOACs group compared with the VKA group (OR: .13; CrI: .02–.65), but no differences for bleeding and stroke. DOACs and VKA have similar safety and efficacy profiles for post-TAVI patients with anticoagulation indication. However, if concomitant antiplatelet therapy is required, DOACs were more favorable than VKA for all-cause mortality.
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Affiliation(s)
| | - Hannah Si En Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Vanessa Xin Yi Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rachel Sze Jen Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bryan Chong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Siew Pang Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Health System, National University Heart Centre, Singapore
| | - Edgar Tay
- Department of Cardiology, National University Health System, National University Heart Centre, Singapore
| | - Yinghao Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Health System, National University Heart Centre, Singapore
| | - James Yip
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Health System, National University Heart Centre, Singapore
| | - Nicholas W. S Chew
- Department of Cardiology, National University Health System, National University Heart Centre, Singapore
| | - Ivandito Kuntjoro
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Health System, National University Heart Centre, Singapore
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12
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Transcatheter aortic valve implantation in patients with uninterrupted vitamin K antagonists. Catheter Cardiovasc Interv 2022; 100:235-242. [DOI: 10.1002/ccd.30248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/13/2022] [Accepted: 05/17/2022] [Indexed: 12/19/2022]
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13
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Camaj A, Razuk V, Dangas GD. Antithrombotic Strategies in Valvular and Structural Heart Disease Interventions. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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14
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Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement. J Clin Med 2022; 11:jcm11082190. [PMID: 35456283 PMCID: PMC9031701 DOI: 10.3390/jcm11082190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022] Open
Abstract
Due to a large technical improvement in the past decade, transcatheter aortic valve replacement (TAVR) has expanded to lower-surgical-risk patients with symptomatic and severe aortic stenosis. While mortality rates related to TAVR are decreasing, the prognosis of patients is still impacted by ischemic and bleeding complications, and defining the optimal antithrombotic regimen remains a priority. Recent randomized control trials reported lower bleeding rates with an equivalent risk in ischemic outcomes with single antiplatelet therapy (SAPT) when compared to dual antiplatelet therapy (DAPT) in patients without an underlying indication for anticoagulation. In patients requiring lifelong oral anticoagulation (OAC), the association of OAC plus antiplatelet therapy leads to a higher risk of bleeding events with no advantages on mortality or ischemic outcomes. Considering these data, guidelines have recently been updated and now recommend SAPT and OAC alone for TAVR patients without and with a long-term indication for anticoagulation. Whether a direct oral anticoagulant or vitamin K antagonist provides better outcomes in patients in need of anticoagulation remains uncertain, as recent trials showed a similar impact on ischemic and bleeding outcomes with apixaban but higher gastrointestinal bleeding with edoxaban. This review aims to summarize the most recently published data in the field, as well as describe unresolved issues.
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15
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Augoustides JG. Protecting the Central Nervous System During Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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16
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Mohammed N, Mousa T, Mahfouz A. Antithrombotic therapy after transcatheter aortic valve replacement. Heart Views 2022; 23:10-15. [PMID: 35757447 PMCID: PMC9231539 DOI: 10.4103/heartviews.heartviews_36_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/06/2022] [Indexed: 11/26/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) is a treatment option for patients with asymptomatic severe aortic stenosis who are candidates for a bioprosthesis across the entire spectrum of risk. TAVR carries a risk for thrombotic and bleeding events, focusing on the importance of defining the optimal antithrombotic regimen. Patients undergoing TAVR are mostly elderly and have many comorbidities such as atrial fibrillation (AF) requiring oral anticoagulants (OACs) or coronary artery disease requiring antiplatelet agents. After TAVR among patients without baseline indications for OAC, recent data suggest dual-antiplatelet therapy is associated with an increased risk for bleeding events, particularly early postprocedure compared with single-antiplatelet therapy with aspirin. The risk of leaflet thrombosis in patients undergoing TAVR raised concern about the use of OAC in patients without an initial indication for anticoagulation therapy. Although it showed effectiveness in modulating thrombus formation at the valve level, the bleeding hazard has shown to be unacceptably high, and the net benefit of combining antiplatelet and OAC therapy is unproven. For patients with indications for the use of long-term OAC, such as those with AF, adding antiplatelet therapy increases bleeding events. A favorable effect of new OAC agents over Vitamin K antagonists is debatable. Overall, single-antiplatelet therapy and OAC appear to be reasonable strategies in patients without and with indications for concurrent anticoagulation, respectively. This article aims to review the available published studies and recommendations in the literature regarding the use of antithrombotic therapy post-TAVR.
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17
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OUP accepted manuscript. Eur Heart J 2022; 43:2783-2797. [DOI: 10.1093/eurheartj/ehac242] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/26/2022] [Accepted: 04/26/2022] [Indexed: 11/14/2022] Open
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18
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Calabrò P, Gragnano F, Niccoli G, Marcucci R, Zimarino M, Spaccarotella C, Renda G, Patti G, Andò G, Moscarella E, Mancone M, Cesaro A, Giustino G, De Caterina R, Mehran R, Capodanno D, Valgimigli M, Windecker S, Dangas GD, Indolfi C, Angiolillo DJ. Antithrombotic Therapy in Patients Undergoing Transcatheter Interventions for Structural Heart Disease. Circulation 2021; 144:1323-1343. [PMID: 34662163 DOI: 10.1161/circulationaha.121.054305] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Contemporary evidence supports device-based transcatheter interventions for the management of patients with structural heart disease. These procedures, which include aortic valve implantation, mitral or tricuspid valve repair/implantation, left atrial appendage occlusion, and patent foramen ovale closure, profoundly differ with respect to clinical indications and procedural aspects. Yet, patients undergoing transcatheter cardiac interventions require antithrombotic therapy before, during, or after the procedure to prevent thromboembolic events. However, these therapies are associated with an increased risk of bleeding complications. To date, challenges and controversies exist regarding balancing the risk of thrombotic and bleeding complications in these patients such that the optimal antithrombotic regimens to adopt in each specific procedure is still unclear. In this review, we summarize current evidence on antithrombotic therapies for device-based transcatheter interventions targeting structural heart disease and emphasize the importance of a tailored approach in these patients.
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Affiliation(s)
- Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (P.C., F.G., E.M., A.C.).,Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy (P.C., F.G., E.M., A.C.)
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (P.C., F.G., E.M., A.C.).,Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy (P.C., F.G., E.M., A.C.)
| | - Giampaolo Niccoli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (G.N.).,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy (G.N.).,Department of Medicine, University of Parma, Italy (G.N.)
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Italy (R. Marcucci.)
| | - Marco Zimarino
- Institute of Cardiology, University "G. D'Annuzio" of Chieti-Pescara, Italy (M.Z., G.R)
| | - Carmen Spaccarotella
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy (C.S., C.I.)
| | - Giulia Renda
- Institute of Cardiology, University "G. D'Annuzio" of Chieti-Pescara, Italy (M.Z., G.R)
| | - Giuseppe Patti
- Department of Translational Medicine, "Maggiore della Carità" Hospital, University of Eastern Piedmont, Via Solaroli, Novara, Italy (G.P.)
| | - Giuseppe Andò
- Unit of Cardiology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy (G.A.)
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (P.C., F.G., E.M., A.C.).,Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy (P.C., F.G., E.M., A.C.)
| | - Massimo Mancone
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy (M.M.)
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (P.C., F.G., E.M., A.C.).,Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy (P.C., F.G., E.M., A.C.)
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.G., R. Mehran., G.D.D.)
| | - Raffaele De Caterina
- University Cardiology Division, University of Pisa, Pisa University Hospital, Italy; Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Italy (R.D.C.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.G., R. Mehran., G.D.D.)
| | - Davide Capodanno
- Cardio-Thoracic-Vascular Department, Centro Alte Specialità e Trapianti, Catania, Italy (D.C.).,Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Italy (D.C.)
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland (M.V.).,Department of Cardiology, Bern University Hospital, University of Bern, Switzerland (M.V., S.W.)
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Switzerland (M.V., S.W.)
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.G., R. Mehran., G.D.D.)
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy (C.S., C.I.).,Mediterranea Cardiocentro, Naples, Italy (C.I.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
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19
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Neurologic Complications in Transcatheter Aortic Valve Replacement. Interv Cardiol Clin 2021; 10:519-529. [PMID: 34593114 DOI: 10.1016/j.iccl.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) has become the mainstay of treatment for severe symptomatic aortic stenosis. Although many TAVR complication rates including mortality and aortic regurgitation have decreased, stroke rates have remained stable for years. TAVR-related strokes are devastating to patients and their families, and very costly for health care systems. The predictors of stroke in TAVR are not yet well defined, although older age, female gender, carotid and peripheral arterial disease, bicuspid aortic valve anatomy, and atrial fibrillation are emerging as risk factors across studies.
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20
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Capodanno D, Collet JP, Dangas G, Montalescot G, Ten Berg JM, Windecker S, Angiolillo DJ. Antithrombotic Therapy After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2021; 14:1688-1703. [PMID: 34353601 DOI: 10.1016/j.jcin.2021.06.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 12/28/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) is a treatment option for symptomatic patients with severe aortic stenosis who are candidates for a bioprosthesis across the entire spectrum of risk. However, TAVR carries a risk for thrombotic and bleeding events, underscoring the importance of defining the optimal adjuvant antithrombotic regimen. Antithrombotic considerations are convoluted by the fact that many patients undergoing TAVR are generally elderly and present with multiple comorbidities, including conditions that may require long-term oral anticoagulation (OAC) (eg, atrial fibrillation) and antiplatelet therapy (eg, coronary artery disease). After TAVR among patients without baseline indications for OAC, recent data suggest dual-antiplatelet therapy to be associated with an increased risk for bleeding events, particularly early postprocedure, compared with single-antiplatelet therapy with aspirin. Concerns surrounding the potential for thrombotic complications have raised the hypothesis of adjunctive use of OAC for patients with no baseline indications for anticoagulation. Although effective in modulating thrombus formation at the valve level, the bleeding hazard has shown to be unacceptably high, and the net benefit of combining antiplatelet and OAC therapy is unproven. For patients with indications for the use of long-term OAC, such as those with atrial fibrillation, the adjunctive use of antiplatelet therapy increases bleeding. Whether direct oral anticoagulant agents achieve better outcomes than vitamin K antagonists remains under investigation. Overall, single-antiplatelet therapy and OAC appear to be reasonable strategies in patients without and with indications for concurrent anticoagulation. The aim of the present review is to appraise the current published research and recommendations surrounding the management of antithrombotic therapy after TAVR, with perspectives on evolving paradigms and ongoing trials.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Jean-Philippe Collet
- Paris Sorbonne Université, ACTION Study Group, INSERM UMR_S 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gilles Montalescot
- Paris Sorbonne Université, ACTION Study Group, INSERM UMR_S 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (Assistance Publique-Hôpitaux de Paris), Paris, France
| | - Jurrien M Ten Berg
- Department of Cardiology and Center for Platelet Function Research, St. Antonius Hospital, Nieuwegein, the Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Stephan Windecker
- Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA.
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21
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Ten Berg J, Sibbing D, Rocca B, Van Belle E, Chevalier B, Collet JP, Dudek D, Gilard M, Gorog DA, Grapsa J, Grove EL, Lancellotti P, Petronio AS, Rubboli A, Torracca L, Vilahur G, Witkowski A, Mehilli J. Management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation: a consensus document of the ESC Working Group on Thrombosis and the European Association of Percutaneous Cardiovascular Interventions (EAPCI), in collaboration with the ESC Council on Valvular Heart Disease. Eur Heart J 2021; 42:2265-2269. [PMID: 33822924 DOI: 10.1093/eurheartj/ehab196] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/15/2020] [Accepted: 03/17/2021] [Indexed: 01/09/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is effective in older patients with symptomatic severe aortic stenosis, while the indication has recently broadened to younger patients at lower risk. Although thromboembolic and bleeding complications after TAVI have decreased over time, such adverse events are still common. The recommendations of the latest 2017 ESC/EACTS Guidelines for the management of valvular heart disease on antithrombotic therapy in patients undergoing TAVI are mostly based on expert opinion. Based on recent studies and randomized controlled trials, this viewpoint document provides updated therapeutic insights in antithrombotic treatment during and after TAVI.
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Affiliation(s)
- Jurrien Ten Berg
- Department of Cardiology and Center for Platelet Function Research, St Antonius Hospital, Nieuwegein, the Netherlands.,The Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Seeshaupt, Germany.,Department of Cardiology, Ludwig-Maximilians-Universität München (LMU Munich), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Eric Van Belle
- Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, CHU Lille, Institut Coeur Poumon, Cardiology, INSERM U1011, Institut Pasteur de Lille, Lille, France
| | - Bernard Chevalier
- Ramsay Générale de Santé, ICPS, Hôpital Jacques Cartier, Massy, France
| | - Jean-Philippe Collet
- ACTION Study Group, Institut De Cardiologie, Hôpital Pitié-Salpêtrière (APHP), Sorbonne Université, Paris, France
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,Maria Cecilia Hospital, GVM Care&Research, Cotignola (RA), Italy
| | - Martine Gilard
- Department of Cardiology, La Cavale Blanche University Hospital Center, Optimization of Physiological Regulations, Science and Technical Training and Research Unit, University of Western Brittany, Brest, France
| | - Diana A Gorog
- National Heart & Lung Institute, Imperial College, London, UK.,Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK
| | - Julia Grapsa
- Department of Cardiology, Guys and St Thomas NHS Hospitals, London, UK
| | | | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, CHU Sart Tilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | | | - Andrea Rubboli
- Department of Cardiovascular Diseases-AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Ravenna, Italy
| | - Lucia Torracca
- Department of Cardiac Surgery, Humanitas University Hospital Rozzano-Milano, Italy
| | - Gemma Vilahur
- Cardiovascular Program-ICCC, IR-Hospital de la Santa Creu i Sant Pau, CiberCV, Autonomous University of Barcelona, Spain
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology Cardiology, Warsaw, Poland
| | - Julinda Mehilli
- Department of Cardiology, Ludwig-Maximilians-Universität München (LMU Munich), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany.,Department of Cardiology, Medizinische Klinik I, Landshut-Achdorf Hospital, Landshut, Germany
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22
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Is an antithrombotic strategy after transcatheter aortic valve implantation clearer now? J Thromb Thrombolysis 2021; 52:1160-1164. [PMID: 34028670 DOI: 10.1007/s11239-021-02473-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
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23
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Concomitant Aspirin and Anticoagulation Is Associated With Increased Risk for Major Bleeding in Surgical Patients Requiring Postoperative Intensive Care. Crit Care Med 2021; 48:985-992. [PMID: 32304413 DOI: 10.1097/ccm.0000000000004350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Critically ill surgical patients may receive concomitant aspirin and therapeutic anticoagulation postoperatively, yet the safety of this practice remains unknown. We evaluated the risk of major bleeding with concomitant therapy compared with anticoagulation alone. DESIGN Observational cohort study. Inverse probability of treatment weighting was used to assess the association between concomitant therapy and a primary outcome of major bleeding. SETTING Postoperative ICUs at an academic medical center. PATIENTS Adults (≥ 18 yr old) receiving anticoagulation during postoperative ICU admission between 2007 and 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Nine thousand five hundred eighteen anticoagulated patients were included, including 3,237 (34%) receiving aspirin. A total of 1,874 unique patients (19.7%) experienced a major bleeding event. In inverse probability of treatment weighting analyses, concomitant therapy was associated with increased odds for major bleeding (odds ratio, 1.20; 95% CI, 1.05-1.36; p = 0.006) compared with anticoagulation alone. An interaction test suggested a differential relationship between aspirin use and major bleeding based on aspirin use in the 7 days prior to anticoagulation, such that a strong association between aspirin and major bleeding was observed for recent initiators of aspirin (1.40; 1.13-1.72;p = 0.002) but not for those continuing prior aspirin use. Aspirin use prior to anticoagulation did not modify the relationship between concomitant therapy and new myocardial infarction or stroke (i.e., rates were not increased with aspirin discontinuation prior to anticoagulation). CONCLUSIONS Concomitant aspirin and anticoagulation in critically ill surgical patients was associated with an increased rate of major bleeding. Future investigations are warranted to further define optimal management of antiplatelet therapy during anticoagulation in surgical patients.
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Abstract
PURPOSE OF REVIEW Transcatheter aortic valve replacement (TAVR) has expanded as a treatment option for severe aortic stenosis throughout the surgical risk spectrum. Decreasing procedural risk and inclusion of lower risk population has shifted the focus to optimization of postprocedural management and balancing the thrombotic and bleeding complications. In this review, we outline various patient and procedure related factors affecting choice of antithrombotic therapy post TAVR and provide an update of recent development in this area. RECENT FINDINGS Multiple studies have confirmed the high incidence of both ischemic and bleeding complications in the early to midterm post-TAVR. In addition, new data has emerged for the role of high resolution computed tomography to detect decreased leaflet mobility and leaflet micro thrombi associated with implications for bioprosthetic valve dysfunction and cerebrovascular events post TAVR. Randomized clinical trials have reported increased bleeding with dual antiplatelet therapy (DAPT) and oral anticoagulation (OAC) plus antiplatelet therapy. These findings suggest that aspirin monotherapy or OAC monotherapy likely provides the appropriate balance for antithrombotic protection and risk of bleeding. SUMMARY Majority of patients undergoing TAVR have multiple comorbidities and are at increased risk of ischemic and bleeding complications. In the absence of robust clinical evidence, there is significant variability among guideline recommendations and antithrombotic therapy post TAVR across institutions. The available evidence confirms a high rate of bleeding with more potent and prolonged antithrombotic regimens without a documented benefit for clinical endpoints. The authors favor a conservative anti thrombotic approach and suggest monotherapy with aspirin or systemic anticoagulation based upon an individual's risk of thromboembolic complications. DAPT is reserved for patients with recent stenting and OAC plus aspirin is prescribed for patients with established CAD in the post TAVR setting.
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25
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Sherwood MW, Gupta A, Vemulapalli S, Li Z, Piccini J, Harrison JK, Dai D, Vora AN, Mack MJ, Holmes DR, Rumsfeld JS, Cohen DJ, Thourani VH, Kirtane AJ, Peterson ED. Variation in Antithrombotic Therapy and Clinical Outcomes in Patients With Preexisting Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement: Insights From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Circ Cardiovasc Interv 2021; 14:e009963. [PMID: 33877866 DOI: 10.1161/circinterventions.120.009963] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Matthew W Sherwood
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.).,Inova Heart and Vascular Institute, Falls Church, VA (M.W.S.)
| | - Aakriti Gupta
- Section of Cardiovascular Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY (A.G., A.J.K.).,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (A.G.).,Cardiovascular Research Foundation, New York, NY (A.G., A.J.K.)
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.).,Division of Cardiology, Duke University Medical Center, Durham, NC (S.V., J.P., D.D., A.N.V., E.D.P.)
| | - Zhuokai Li
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.)
| | - Jonathan Piccini
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.).,Division of Cardiology, Duke University Medical Center, Durham, NC (S.V., J.P., D.D., A.N.V., E.D.P.)
| | - J Kevin Harrison
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.)
| | - David Dai
- Division of Cardiology, Duke University Medical Center, Durham, NC (S.V., J.P., D.D., A.N.V., E.D.P.)
| | - Amit N Vora
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.).,Division of Cardiology, Duke University Medical Center, Durham, NC (S.V., J.P., D.D., A.N.V., E.D.P.)
| | - Michael J Mack
- Department of Cardiovascular Surgery, Baylor Scott & White Health, Plano, TX (M.J.M.)
| | - David R Holmes
- Department of Cardiology, Mayo Foundation, Rochester, MN (D.R.H.)
| | - John S Rumsfeld
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora (J.S.R.)
| | - David J Cohen
- Department of Cardiology, University of Missouri-Kansas City School of Medicine (D.J.C.)
| | - Vinod H Thourani
- MedStar Heart and Vascular Institute/Georgetown University, Washington, DC (V.H.T.)
| | - Ajay J Kirtane
- Section of Cardiovascular Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, NY (A.G., A.J.K.).,Cardiovascular Research Foundation, New York, NY (A.G., A.J.K.)
| | - Eric D Peterson
- Duke Clinical Research Institute, Durham, NC (M.W.S., S.V., Z.L., J.P., J.K.H., A.N.V., E.D.P.).,Division of Cardiology, Duke University Medical Center, Durham, NC (S.V., J.P., D.D., A.N.V., E.D.P.)
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Généreux P, Piazza N, Alu MC, Nazif T, Hahn RT, Pibarot P, Bax JJ, Leipsic JA, Blanke P, Blackstone EH, Finn MT, Kapadia S, Linke A, Mack MJ, Makkar R, Mehran R, Popma JJ, Reardon M, Rodes-Cabau J, Van Mieghem NM, Webb JG, Cohen DJ, Leon MB. Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research. Eur Heart J 2021; 42:1825-1857. [DOI: 10.1093/eurheartj/ehaa799] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/22/2020] [Accepted: 09/24/2020] [Indexed: 12/17/2022] Open
Abstract
Abstract
Aims
The Valve Academic Research Consortium (VARC), founded in 2010, was intended to (i) identify appropriate clinical endpoints and (ii) standardize definitions of these endpoints for transcatheter and surgical aortic valve clinical trials. Rapid evolution of the field, including the emergence of new complications, expanding clinical indications, and novel therapy strategies have mandated further refinement and expansion of these definitions to ensure clinical relevance. This document provides an update of the most appropriate clinical endpoint definitions to be used in the conduct of transcatheter and surgical aortic valve clinical research.
Methods and results
Several years after the publication of the VARC-2 manuscript, an in-person meeting was held involving over 50 independent clinical experts representing several professional societies, academic research organizations, the US Food and Drug Administration (FDA), and industry representatives to (i) evaluate utilization of VARC endpoint definitions in clinical research, (ii) discuss the scope of this focused update, and (iii) review and revise specific clinical endpoint definitions. A writing committee of independent experts was convened and subsequently met to further address outstanding issues. There were ongoing discussions with FDA and many experts to develop a new classification schema for bioprosthetic valve dysfunction and failure. Overall, this multi-disciplinary process has resulted in important recommendations for data reporting, clinical research methods, and updated endpoint definitions. New definitions or modifications of existing definitions are being proposed for repeat hospitalizations, access site-related complications, bleeding events, conduction disturbances, cardiac structural complications, and bioprosthetic valve dysfunction and failure (including valve leaflet thickening and thrombosis). A more granular 5-class grading scheme for paravalvular regurgitation (PVR) is being proposed to help refine the assessment of PVR. Finally, more specific recommendations on quality-of-life assessments have been included, which have been targeted to specific clinical study designs.
Conclusions
Acknowledging the dynamic and evolving nature of less-invasive aortic valve therapies, further refinements of clinical research processes are required. The adoption of these updated and newly proposed VARC-3 endpoints and definitions will ensure homogenous event reporting, accurate adjudication, and appropriate comparisons of clinical research studies involving devices and new therapeutic strategies.
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Affiliation(s)
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA
| | - Nicolo Piazza
- McGill University Health Centre, Montreal, QC, Canada
| | - Maria C Alu
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, NY, USA
| | - Tamim Nazif
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, NY, USA
| | - Rebecca T Hahn
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, NY, USA
| | - Philippe Pibarot
- Quebec Heart & Lung Institute, Laval University, Quebec, QC, Canada
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jonathon A Leipsic
- Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Philipp Blanke
- Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic and Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew T Finn
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, NY, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | | | - Michael J Mack
- Baylor Scott & White Heart Hospital Plano, Plano, TX, USA
| | - Raj Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | - John G Webb
- Department of Cardiology, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - David J Cohen
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Martin B Leon
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, NY, USA
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27
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Généreux P, Piazza N, Alu MC, Nazif T, Hahn RT, Pibarot P, Bax JJ, Leipsic JA, Blanke P, Blackstone EH, Finn MT, Kapadia S, Linke A, Mack MJ, Makkar R, Mehran R, Popma JJ, Reardon M, Rodes-Cabau J, Van Mieghem NM, Webb JG, Cohen DJ, Leon MB. Valve Academic Research Consortium 3: Updated Endpoint Definitions for Aortic Valve Clinical Research. J Am Coll Cardiol 2021; 77:2717-2746. [PMID: 33888385 DOI: 10.1016/j.jacc.2021.02.038] [Citation(s) in RCA: 475] [Impact Index Per Article: 158.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIMS The Valve Academic Research Consortium (VARC), founded in 2010, was intended to (i) identify appropriate clinical endpoints and (ii) standardize definitions of these endpoints for transcatheter and surgical aortic valve clinical trials. Rapid evolution of the field, including the emergence of new complications, expanding clinical indications, and novel therapy strategies have mandated further refinement and expansion of these definitions to ensure clinical relevance. This document provides an update of the most appropriate clinical endpoint definitions to be used in the conduct of transcatheter and surgical aortic valve clinical research. METHODS AND RESULTS Several years after the publication of the VARC-2 manuscript, an in-person meeting was held involving over 50 independent clinical experts representing several professional societies, academic research organizations, the US Food and Drug Administration (FDA), and industry representatives to (i) evaluate utilization of VARC endpoint definitions in clinical research, (ii) discuss the scope of this focused update, and (iii) review and revise specific clinical endpoint definitions. A writing committee of independent experts was convened and subsequently met to further address outstanding issues. There were ongoing discussions with FDA and many experts to develop a new classification schema for bioprosthetic valve dysfunction and failure. Overall, this multi-disciplinary process has resulted in important recommendations for data reporting, clinical research methods, and updated endpoint definitions. New definitions or modifications of existing definitions are being proposed for repeat hospitalizations, access site-related complications, bleeding events, conduction disturbances, cardiac structural complications, and bioprosthetic valve dysfunction and failure (including valve leaflet thickening and thrombosis). A more granular 5-class grading scheme for paravalvular regurgitation (PVR) is being proposed to help refine the assessment of PVR. Finally, more specific recommendations on quality-of-life assessments have been included, which have been targeted to specific clinical study designs. CONCLUSIONS Acknowledging the dynamic and evolving nature of less-invasive aortic valve therapies, further refinements of clinical research processes are required. The adoption of these updated and newly proposed VARC-3 endpoints and definitions will ensure homogenous event reporting, accurate adjudication, and appropriate comparisons of clinical research studies involving devices and new therapeutic strategies.
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Affiliation(s)
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - Nicolo Piazza
- McGill University Health Centre, Montreal, Quebec, Canada
| | - Maria C Alu
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, New York, USA
| | - Tamim Nazif
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, New York, USA
| | - Rebecca T Hahn
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, New York, USA
| | - Philippe Pibarot
- Quebec Heart & Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jonathon A Leipsic
- Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Philipp Blanke
- Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic and Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew T Finn
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, New York, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Michael J Mack
- Baylor Scott & White Heart Hospital Plano, Plano, Texas, USA
| | - Raj Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jeffrey J Popma
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michael Reardon
- Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Josep Rodes-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec, Quebec, Canada
| | | | - John G Webb
- Department of Cardiology, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - David J Cohen
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Martin B Leon
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, New York, USA.
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28
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Durand E, Penso M, Hemery T, Levesque T, Moles G, Tron C, Bouhzam N, Bettinger N, Wong S, Dacher JN, Eltchaninoff H. Standardized Measurement of Femoral Artery Depth by Computed Tomography to Predict Vascular Complications After Transcatheter Aortic Valve Implantation. Am J Cardiol 2021; 145:119-127. [PMID: 33460601 DOI: 10.1016/j.amjcard.2020.12.089] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 12/20/2022]
Abstract
Vascular complications (VCs) are difficult to predict and remain an important issue after transfemoral (TF) transcatheter aortic valve implantation (TAVI) although their incidence has decreased with size reduction of introducers. We aimed to evaluate a standardized measurement of femoral artery depth (FAD) using computed tomography (CT) to predict VCs after TAVI. We performed a retrospective study of 679 TF TAVI patients. We evaluated a standardized CT method to measure FAD immediately above the bifurcation. Sheath-to-femoral-artery ratio (SFAR), calcification, and tortuosity were also evaluated. VCs were defined by the Valve Academic Research Consortium (VARC)-2. Receiver operating characteristic (ROC) curves were used to predict major VCs and the need for a stent-graft. The median values of FAD and SFAR were 49.0 (36.2 to 66.7) mm and 0.95 (0.81 to 1.18), respectively. Major VCs occurred in 37 (5.4%) patients and a stent-graft was required in 49 (7.1%) patients. FAD predicted the need for a stent-graft [0.61 (0.51 to 0.70), p = 0.04] but not major VCs [0.52 (0.40 to 0.63), p = 0.76]. In contrast, SFAR did not predict the need for a stent-graft [0.53 (0.43 to 0.62), p = 0.61] but predicted major VCs [0.70 (0.58 to 0.81), p = 0.001]. Calcification and tortuosity predicted neither major VCs nor the need for a stent-graft. In conclusion, the results of our study suggest that CT measurements of FAD and SFAR provide additional information to predict major VCs and the need for a femoral stent-graft after TF TAVI.
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Affiliation(s)
- Eric Durand
- Normandie Univ, UNIROUEN, Inserm U1096, CHU Rouen, Department of Cardiology, FHU CARNAVAL, F-76000 Rouen, France.
| | - Maryline Penso
- Normandie Univ, UNIROUEN, Inserm U1096, CHU Rouen, Department of Cardiology, FHU CARNAVAL, F-76000 Rouen, France
| | - Thibault Hemery
- Normandie Univ, UNIROUEN, Inserm U1096, CHU Rouen, Department of Cardiology, FHU CARNAVAL, F-76000 Rouen, France
| | - Thomas Levesque
- Normandie Univ, UNIROUEN, Inserm U1096, CHU Rouen, Department of Cardiology, FHU CARNAVAL, F-76000 Rouen, France
| | - Gustavo Moles
- Normandie Univ, UNIROUEN, Inserm U1096, CHU Rouen, Department of Cardiology, FHU CARNAVAL, F-76000 Rouen, France
| | - Christophe Tron
- Normandie Univ, UNIROUEN, Inserm U1096, CHU Rouen, Department of Cardiology, FHU CARNAVAL, F-76000 Rouen, France
| | - Najime Bouhzam
- Normandie Univ, UNIROUEN, Inserm U1096, CHU Rouen, Department of Cardiology, FHU CARNAVAL, F-76000 Rouen, France
| | - Nicolas Bettinger
- Normandie Univ, UNIROUEN, Inserm U1096, CHU Rouen, Department of Cardiology, FHU CARNAVAL, F-76000 Rouen, France
| | - Stephanie Wong
- Normandie Univ, UNIROUEN, Inserm U1096, CHU Rouen, Department of Radiology, FHU CARNAVAL, F-76000 Rouen, France
| | - Jean-Nicolas Dacher
- Normandie Univ, UNIROUEN, Inserm U1096, CHU Rouen, Department of Radiology, FHU CARNAVAL, F-76000 Rouen, France
| | - Hélène Eltchaninoff
- Normandie Univ, UNIROUEN, Inserm U1096, CHU Rouen, Department of Cardiology, FHU CARNAVAL, F-76000 Rouen, France
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29
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Wang M, Zeraatkar D, Obeda M, Lee M, Garcia C, Nguyen L, Agarwal A, Al-Shalabi F, Benipal H, Ahmad A, Abbas M, Vidug K, Holbrook A. Drug-drug Interactions with Warfarin: A Systematic Review and Meta-analysis. Br J Clin Pharmacol 2021; 87:4051-4100. [PMID: 33769581 DOI: 10.1111/bcp.14833] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 12/13/2022] Open
Abstract
AIM The objective of this paper is to systematically review the literature on drug-drug interactions with warfarin, with a focus on patient-important clinical outcomes. METHODS MEDLINE, EMBASE, and the International Pharmaceutical Abstract (IPA) databases were searched from January 2004 to August 2019. We included studies describing drug-drug interactions between warfarin and other drugs. Screening and data extraction were conducted independently and in duplicate. We synthesized pooled odds ratios (OR) with 95% confidence intervals (CIs), comparing warfarin plus another medication to warfarin alone. We assessed the risk of bias at the study level and evaluated the overall certainty of evidence using GRADE. RESULTS Of 42,013 citations identified, a total of 72 studies reporting on 3,735,775 patients were considered eligible, including 11 randomized clinical trials and 61 observational studies. Increased risk of clinically relevant bleeding when added to warfarin therapy was observed for antiplatelet (AP) regimens (OR=1.74; 95% CI 1.56, 1.94), many antimicrobials (OR=1.63; 95% CI 1.45, 1.83), NSAIDs including COX-2 NSAIDs (OR=1.83; 95% CI 1.29, 2.59), SSRIs (OR=1.62; 95% CI 1.42, 1.85), mirtazapine (OR=1.75; 95% CI 1.30, 2.36), loop diuretics (OR=1.92; 95% CI 1.29, 2.86), and others. We found a protective effect of proton pump inhibitors (PPIs) against warfarin-related gastrointestinal (GI) bleedings (OR=0.69; 95% CI 0.64, 0.73). No significant effect on thromboembolic events or mortality of any drug group used with warfarin was found, including single or dual AP regimens. CONCLUSIONS This review found low to moderate certainty evidence supporting the interaction between warfarin and a small group of medications, which result in increased bleeding risk. PPIs are associated with reduced hospitalization for upper GI bleeding for patients taking warfarin. Further studies are required to better understand drug-drug interactions leading to thromboembolic outcomes or death.
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Affiliation(s)
- Mei Wang
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada.,Clinical Pharmacology & Toxicology, Research Institute, St Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, L8N 4A6, Ontario, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Michael Obeda
- Department of Family Medicine, Queen's University, 220 Bagot St, Kingston, K7L 3G2, Ontario, Canada
| | - Munil Lee
- Schulich School of Medicine and Dentistry, Western University, London, N6A 3K7, Ontario, Canada
| | - Cristian Garcia
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Laura Nguyen
- Faculty of Medicine, University of Ottawa, 451 Smyth Rd, Ottawa, K1H 8M5, Ontario, Canada
| | - Arnav Agarwal
- Department of Medicine, University of Toronto, 27 King's College Circle, Toronto, M5S 1A, Ontario, Canada
| | - Farah Al-Shalabi
- Clinical Pharmacology & Toxicology, Research Institute, St Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, L8N 4A6, Ontario, Canada
| | - Harsukh Benipal
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Afreen Ahmad
- Bachelor Health Sciences Program, Faculty of Health Sciences, McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Momina Abbas
- Bachelor Arts & Science Program, Faculty of Arts & Science, McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
| | - Kristina Vidug
- Clinical Pharmacology & Toxicology, Research Institute, St Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, L8N 4A6, Ontario, Canada
| | - Anne Holbrook
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada.,Clinical Pharmacology & Toxicology, Research Institute, St Joseph's Healthcare Hamilton, 50 Charlton Avenue East, Hamilton, L8N 4A6, Ontario, Canada.,Division of Clinical Pharmacology & Toxicology, Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, Ontario, Canada
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30
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Saito Y, Nazif T, Baumbach A, Tchétché D, Latib A, Kaple R, Forrest J, Prendergast B, Lansky A. Adjunctive Antithrombotic Therapy for Patients With Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement. JAMA Cardiol 2021; 5:92-101. [PMID: 31721980 DOI: 10.1001/jamacardio.2019.4367] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Transcatheter aortic valve replacement (TAVR) is an established alternative to surgery for patients with severe symptomatic aortic stenosis. Adjunctive antithrombotic therapy used to mitigate thrombotic risks in patients undergoing TAVR must be balanced against bleeding complications, since both are associated with increased mortality. Observation Stroke risk associated with TAVR is lower than that associated with surgical aortic valve replacement in recent trials including patients at intermediate or low risk, but it is constant beginning at the time of implant and accrues over time based on patient risk factors. Patients with aortic stenosis undergoing TAVR also have a sizable risk of life-threatening or major bleeding. Although dual antiplatelet therapy for 3 to 6 months after TAVR is the guideline-recommended regimen, this practice is not well supported by current evidence. In patients with no indication for oral anticoagulation, current registry-based evidence suggests that single antiplatelet therapy may be safer than dual antiplatelet therapy. Similarly, oral anticoagulation monotherapy appears superior to anticoagulation plus antiplatelet therapy in those where oral anticoagulant use is indicated. To date, no risk prediction models have been established to guide antithrombotic therapy. Conclusions and Relevance Despite the growing volume of TAVR procedures to treat patients with severe aortic stenosis, evidence for adjunctive antithrombotic therapy remains rather scarce. Ongoing clinical trials will provide better understanding to guide antithrombotic therapy.
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Affiliation(s)
- Yuichi Saito
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Tamim Nazif
- Columbia University Medical Center, New York, New York
| | - Andreas Baumbach
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.,Barts Heart Centre, London and Queen Mary University of London, London, United Kingdom
| | | | - Azeem Latib
- Montefiore Medical Center, New York, New York
| | - Ryan Kaple
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - John Forrest
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Alexandra Lansky
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.,Barts Heart Centre, London and Queen Mary University of London, London, United Kingdom
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31
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Rogers T, Shults C, Torguson R, Shea C, Parikh P, Bilfinger T, Cocke T, Brizzio ME, Levitt R, Hahn C, Hanna N, Comas G, Mahoney P, Newton J, Buchbinder M, Moreno R, Zhang C, Craig P, Asch FM, Weissman G, Garcia-Garcia HM, Ben-Dor I, Satler LF, Waksman R. Randomized Trial of Aspirin Versus Warfarin After Transcatheter Aortic Valve Replacement in Low-Risk Patients. Circ Cardiovasc Interv 2021; 14:e009983. [PMID: 33423540 DOI: 10.1161/circinterventions.120.009983] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The optimal antithrombotic regimen after transcatheter aortic valve replacement remains unclear. METHODS In this randomized open-label study, low-risk patients undergoing transfemoral transcatheter aortic valve replacement at 7 centers in the United States were randomized 1:1 to low-dose aspirin or warfarin plus low-dose aspirin for 30 days. Patients who could not be randomized were enrolled in a separate registry. Computed tomography or transesophageal echocardiography was performed at 30 days. The primary effectiveness end point was a composite of the following at 30 days: hypoattenuated leaflet thickening, at least moderately reduced leaflet motion, hemodynamic dysfunction (mean aortic valve gradient ≥20 mm Hg, effective orifice area ≤1.0 cm2, dimensionless valve index <0.35, or moderate or severe aortic regurgitation), stroke, or transient ischemic attack. RESULTS Between July 2018 and October 2019, 94 patients were randomly assigned, 50 to aspirin and 44 to warfarin plus aspirin, and 30 were enrolled into the registry. In the intention-to-treat analysis of the randomized cohort, the composite primary effectiveness end point was met in 26.5% for aspirin versus 7.0% for warfarin plus aspirin (P=0.014; odds ratio, 4.8 [95% CI, 1.3-18.3]). The rate of hypoattenuated leaflet thickening was 16.3% for aspirin versus 4.7% for warfarin plus aspirin (P=0.07; odds ratio, 4.0 [95% CI, 0.8-20.0]). There was no excess bleeding at 30 days with anticoagulation. In the as-treated analysis of pooled randomized and registry cohorts, the rate of hypoattenuated leaflet thickening was 16.7% for aspirin versus 3.1% for warfarin plus aspirin (P=0.011; odds ratio, 6.3 [95% CI, 1.3-30.6]). CONCLUSIONS In low-risk transcatheter aortic valve replacement patients, anticoagulation with warfarin may prevent transcatheter heart valve dysfunction in the short term without excess bleeding. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03557242.
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Affiliation(s)
- Toby Rogers
- Section of Interventional Cardiology (T.R., R.T., C. Shea, C.Z., P.C., I.B.-D., L.F.S., R.W.), MedStar Washington Hospital Center, WA.,Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (T.R.)
| | - Christian Shults
- Department of Cardiac Surgery (C. Shults), MedStar Health Research Institute (F.M.A.), MedStar Washington Hospital Center, WA
| | - Rebecca Torguson
- Section of Interventional Cardiology (T.R., R.T., C. Shea, C.Z., P.C., I.B.-D., L.F.S., R.W.), MedStar Washington Hospital Center, WA
| | - Corey Shea
- Section of Interventional Cardiology (T.R., R.T., C. Shea, C.Z., P.C., I.B.-D., L.F.S., R.W.), MedStar Washington Hospital Center, WA
| | - Puja Parikh
- Department of Cardiology (P.P.), Stony Brook University Hospital, NY
| | - Thomas Bilfinger
- Department of Cardiothoracic Surgery (T.B.), Stony Brook University Hospital, NY
| | - Thomas Cocke
- Department of Cardiology (T.C.), The Valley Hospital, Ridgewood, NJ
| | - Mariano E Brizzio
- Department of Cardiothoracic Surgery (M.E.B.), The Valley Hospital, Ridgewood, NJ
| | - Robert Levitt
- Henrico Cardiology Associates (R.L.), HCA Virginia Health System
| | - Chiwon Hahn
- Cardiothoracic Surgical Associates - Richmond (C.H.), HCA Virginia Health System
| | - Nicholas Hanna
- Department of Cardiology (N.H.), St. John Health System, Tulsa, OK
| | - George Comas
- Department of Cardiothoracic Surgery (G.C.), St. John Health System, Tulsa, OK
| | - Paul Mahoney
- Department of Cardiology (P.M.), Sentara Norfolk General Hospital, VA
| | - Joseph Newton
- Department of Cardiothoracic Surgery (J.N.), Sentara Norfolk General Hospital, VA
| | - Maurice Buchbinder
- Department of Cardiology (M.B.), Foundation for Cardiovascular Medicine, San Diego, CA
| | - Ricardo Moreno
- Department of Cardiothoracic Surgery (R.M.), Foundation for Cardiovascular Medicine, San Diego, CA
| | - Cheng Zhang
- Section of Interventional Cardiology (T.R., R.T., C. Shea, C.Z., P.C., I.B.-D., L.F.S., R.W.), MedStar Washington Hospital Center, WA
| | - Paige Craig
- Section of Interventional Cardiology (T.R., R.T., C. Shea, C.Z., P.C., I.B.-D., L.F.S., R.W.), MedStar Washington Hospital Center, WA
| | | | - Gaby Weissman
- Department of Cardiology (G.W., H.M.G.-G.), MedStar Washington Hospital Center, WA
| | | | - Itsik Ben-Dor
- Section of Interventional Cardiology (T.R., R.T., C. Shea, C.Z., P.C., I.B.-D., L.F.S., R.W.), MedStar Washington Hospital Center, WA
| | - Lowell F Satler
- Section of Interventional Cardiology (T.R., R.T., C. Shea, C.Z., P.C., I.B.-D., L.F.S., R.W.), MedStar Washington Hospital Center, WA
| | - Ron Waksman
- Section of Interventional Cardiology (T.R., R.T., C. Shea, C.Z., P.C., I.B.-D., L.F.S., R.W.), MedStar Washington Hospital Center, WA
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Lai JK, Willenborg KL, Berei T, Rose AE. Antithrombotic selection in patients undergoing transcatheter aortic valve replacement. Am J Health Syst Pharm 2021; 78:22-35. [PMID: 33119752 DOI: 10.1093/ajhp/zxaa329] [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: 01/09/2023] Open
Abstract
PURPOSE Clinical controversy regarding the most appropriate antithrombotic regimen after transcatheter aortic valve replacement remains. Current evidence, guidelines, and recommendations are discussed. SUMMARY Antithrombotic selection following transcatheter aortic valve replacement depends on a variety of patient-specific factors. For patients without a preexisting indication for anticoagulation, initial trials employed dual antiplatelet therapy as the postprocedural therapy of choice. Newer studies in this patient population, however, suggest single antiplatelet therapy reduces bleeding events without sacrificing ischemic protection. In patients with a preexisting indication for anticoagulation, warfarin plus single antiplatelet therapy, as opposed to triple antithrombotic therapy, offered similar ischemic protection while reducing clinically significant bleeding. Warfarin monotherapy was associated with a further reduction in bleeding events. One trial demonstrated the safety and efficacy of using apixaban in patients with concomitant atrial fibrillation; however, routine use of rivaroxaban increased adverse cardiac and bleeding events, leaving the utility of direct-acting oral anticoagulants in question. CONCLUSION Available evidence and current guidelines point to a lack of consensus regarding antithrombotic selection after transcatheter aortic valve replacement. Patient-specific factors and comorbidities must be considered when tailoring therapy, with an emphasis on balancing thrombotic and bleeding risks.
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Affiliation(s)
- Jennifer K Lai
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Katie L Willenborg
- Department of Pharmacy, William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Theodore Berei
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Anne E Rose
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI
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McFadyen JD, Peter K. Transcatheter Aortic Valve Implantation, Atrial Fibrillation, and Bleeding: A Surprisingly Fatal Attraction. Thromb Haemost 2020; 120:1479-1482. [PMID: 33070302 DOI: 10.1055/s-0040-1718533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- James D McFadyen
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Department of Clinical Hematology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
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34
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Zeng Q, Cheng Z, Xia Y, Cheng R, Ou A, Li X, Xu X, Huang Y, Xu D. Optimal antithrombotic therapy after transcatheter aortic valve replacement in patients with atrial fibrillation. Ther Adv Chronic Dis 2020; 11:2040622320949068. [PMID: 33133475 PMCID: PMC7576914 DOI: 10.1177/2040622320949068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 07/20/2020] [Indexed: 11/16/2022] Open
Abstract
Atrial fibrillation (AF) is prevalent in patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). Depending on the timing of AF detection, it is usually categorized as pre-existing AF or new-onset AF. Antiplatelet therapy, rather than a vitamin K antagonist, may be considered as the primary treatment for patients without an indication for oral anticoagulants who undergo TAVR. However, the optimal postprocedural antithrombotic regimen for patients with AF undergoing TAVR remains unknown. In this review, we briefly introduce the management strategies of antithrombotic therapy and list the evidence from related studies to elucidate the optimal antithrombotic management for patients with AF undergoing TAVR.
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Affiliation(s)
- Qingchun Zeng
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou , China
- Guangdong Provincial Key Laboratory of Shock and Microcirculation, Southern Medical University, Guangzhou, China
- Bioland Laboratory (Guangzhou Regenerative Medicine and Health Guangdong Laboratory), Guangzhou, China
| | - Zhendong Cheng
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yi Xia
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Rui Cheng
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ailian Ou
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xinrui Li
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xingbo Xu
- Department of Cardiology and Pneumology, University Medical Center of Göttingen, Georg-August-University, Göttingen, Germany
| | - Yuli Huang
- Department of Cardiology, Shunde Hospital, Southern Medical University, Foshan, China
| | - Dingli Xu
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, 1838 Northern Guangzhou Ave, Guangzhou 510515, China
- Guangdong Provincial Key Laboratory of Shock and Microcirculation, Southern Medical University, Guangzhou, China
- Bioland Laboratory (Guangzhou Regenerative Medicine and Health Guangdong Laboratory), Guangzhou, China
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35
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Zhu Y, Meng S, Chen M, Jia R, Nan J, Li H, Zhu H, Li L, Jin Z. Comparing anticoagulation therapy alone versus anticoagulation plus single antiplatelet drug therapy after transcatheter aortic valve implantation in patients with an indication for anticoagulation: a systematic review and meta-analysis. Cardiovasc Drugs Ther 2020; 35:995-1002. [PMID: 33030686 DOI: 10.1007/s10557-020-07081-y] [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] [Accepted: 09/16/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE This meta-analysis compared the efficacy and safety of oral anticoagulation (OAC) therapy alone versus OAC plus single antiplatelet therapy (SAPT) in patients with an indication for chronic OAC (mostly due to atrial fibrillation) after transcatheter aortic valve implantation (TAVI). METHODS A systematic literature search was performed in the PubMed, Embase, and Cochrane Library databases to identify relevant studies. Data was extracted from the eligible studies and outcomes expressed as relative risks (RRs) with 95% confidence intervals (CIs). RESULTS Five studies comprising 1344 patients with an indication for chronic OAC and undergoing TAVI were included. Of the 1344 patients, 480 patients received OAC therapy alone and 864 patients received OAC plus SAPT. There were no significant differences between OAC alone versus OAC plus SAPT in all-cause mortality (RR = 1.05, 95% CI 0.84-1.30, p = 0.69) and ischemic stroke (RR = 0.95, 95% CI 0.95-1.61, p = 0.86). However, OAC alone was associated with significantly lower risks of all bleeding events (RR = 0.62, 95% CI 0.49-0.69, p < 0.0001) and major and/ life-threatening bleeding events (RR = 0.57, 95% CI 0.42-0.76, p = 0.0002) compared to OAC plus SAPT. CONCLUSION In patients with an indication for chronic anticoagulation, post-TAVI antithrombotic therapy with OAC alone compared to OAC plus SAPT may be not significantly different in reducing all-cause mortality and ischemic stroke, but has an important benefit in a significantly lower risk of all bleeding and major and/life-threatening bleeding events.
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Affiliation(s)
- Yong Zhu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Shuai Meng
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Maolin Chen
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Ruofei Jia
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Nan
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hong Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Huagang Zhu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China
| | - Long Li
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zening Jin
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China. .,Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Al Said S, Kaier K, Nury E, Alsaid D, Meder B, Gibson CM, Bax J, Meerpohl JJ, Katus H. Non-vitamin K antagonist oral anticoagulants (NOACs) after transcatheter aortic valve replacement (TAVR): a network meta-analysis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Samer Al Said
- Department for Internal Medicine III Cardiology Angiology and Pneumology; University Hospital Heidelberg; Heidelberg Germany
- DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim; University of Heidelberg; Heidelberg Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics; Faculty of Medicine and Medical Center, University of Freiburg; Freiburg Germany
| | - Edris Nury
- Institute for Evidence in Medicine, Medical Center - University of Freiburg; Faculty of Medicine, University of Freiburg; Freiburg Germany
| | - Dima Alsaid
- Institute for Evidence in Medicine, Medical Center - University of Freiburg; Faculty of Medicine, University of Freiburg; Freiburg Germany
| | - Benjamin Meder
- Department for Internal Medicine III Cardiology Angiology and Pneumology; University Hospital Heidelberg; Heidelberg Germany
- DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim; University of Heidelberg; Heidelberg Germany
| | - C. Michael Gibson
- Cardiology Division, Beth Israel Deaconess Medical Center; Harvard Medical School; Boston MA USA
| | - Jeroen Bax
- Department of Cardiology; Leiden University Medical Center; Leiden Netherlands
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine; Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg; Freiburg Germany
| | - Hugo Katus
- Department for Internal Medicine III Cardiology Angiology and Pneumology; University Hospital Heidelberg; Heidelberg Germany
- DZHK (German Centre for Cardiovascular Research), partner site Heidelberg/Mannheim; University of Heidelberg; Heidelberg Germany
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Aikins J, Koomson A, Ladele M, Al-Nusair L, Ahmed A, Ashry A, Harky A. Anticoagulation and antiplatelet therapy in patients with prosthetic heart valves. J Card Surg 2020; 35:3521-3529. [PMID: 32939828 DOI: 10.1111/jocs.15034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The choice of antithrombotic therapy, anticoagulants or antiplatelets, after prosthetic heart valve replacement or repair, remains a disputed topic in the literature. Antithrombotic therapies are used after heart valve intervention to reduce the rates of thromboembolic events, therefore improving patient outcomes. Different interventions may require different therapeutic regimens to achieve the most efficacious clinical outcome for patients. METHODS AND DISCUSSION This review aims to summarize and critique the available literature concerning therapeutic agents used for bioprosthetic and mechanical valves as well as for valve repair, so as to assist clinicians and researchers in making decisions with regard to their patients and research endeavors.
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Affiliation(s)
- Joel Aikins
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Abeku Koomson
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Mofolaoluwami Ladele
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Lana Al-Nusair
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Amna Ahmed
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Amr Ashry
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.,Department of Cardiothoracic Surgery, Assiut University Hospital, Assiut, Egypt
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.,Department of Integrative Biology, Faculty of Life Science, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, UK
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38
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Yokoyama Y, Briasoulis A, Takagi H, Kuno T. Anticoagulation With or Without Antiplatelet Therapy Following Transcatheter Aortic Valve Replacement for Patients With Atrial Fibrillation: A Meta-Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 24:42-47. [PMID: 32830088 DOI: 10.1016/j.carrev.2020.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/09/2020] [Accepted: 08/10/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although current guidelines recommend oral anticoagulants (OAC) with or without antiplatelet therapy (APT) following transcatheter aortic valve replacement (TVAR) in patients with an indication for long-term anticoagulation therapy, the optimal antithrombotic strategy remains unknown in these population. Herein, we conducted a meta-analysis comparing the outcome of OAC alone versus OAC with APT following TAVR in patients with atrial fibrillation (AF). METHODS MEDLINE and EMBASE were searched through May 2020 to identify clinical trials that investigated OAC alone versus OAC with APT following TAVR in patients with AF. From each study, we extracted the hazard ratios (HRs) or risk ratios of major or life threatening bleeding, stroke, all-cause mortality and cardiovascular mortality. RESULTS 1 randomized controlled trial and 3 observational studies were identified, which enrolled a total of 2032 patients with AF who underwent TAVR assigned to the OAC group (n = 722) or OAC with APT group (n = 1310). Pooled analyses demonstrated the rate of major or life threatening bleeding was significantly lower in the OAC group compared to the OAC with APT group (HR [95% Confidence Interval [CI] = 0.54 [0.38-0.77], P = .0006]). However, the rate of stroke was similar in both groups (HR [95% CI] = 1.22 [0.80-1.87], P = .36). All-cause and cardiovascular mortalities were also similar in both groups. CONCLUSIONS We observed that OAC with APT following TAVR in patients with AF increased the risk of bleeding compared to OAC alone without decreasing the risk of stroke.
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Affiliation(s)
- Yujiro Yokoyama
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Alexandros Briasoulis
- Division of Cardiology, Heart failure and Transplantation, University of Iowa, IA, USA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, NY, USA.
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Lother A, Kaier K, Ahrens I, Bothe W, Wolf D, Zehender M, Bode C, von zur Mühlen C, Stachon P. Bleeding Complications Drive In-Hospital Mortality of Patients with Atrial Fibrillation after Transcatheter Aortic Valve Replacement. Thromb Haemost 2020; 120:1580-1586. [DOI: 10.1055/s-0040-1715833] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Abstract
Background Atrial fibrillation (AF) is a risk factor for poor postoperative outcome after transfemoral transcatheter aortic valve replacement (TF-TAVR). The present study analyses the outcomes after TF-TAVR in patients with or without AF and identifies independent predictors for in-hospital mortality in clinical practice.
Methods and Results Among all 57,050 patients undergoing isolated TF-TAVR between 2008 and 2016 in Germany, 44.2% of patients (n = 25,309) had AF. Patients with AF were at higher risk for unfavorable in-hospital outcome after TAVR. Including all baseline characteristics for a risk-adjusted comparison, AF was an independent risk factor for in-hospital mortality after TAVR. Among patients with AF, EuroSCORE, New York Heart Association classification class, or renal disease had only moderate effects on mortality, while the occurrence of postprocedural stroke or moderate to major bleeding substantially increased in-hospital mortality (odds ratio [OR] 3.35, 95% confidence interval [CI] 2.61–4.30, p < 0.001 and OR 3.12, 95% CI 2.68–3.62, p < 0.001). However, the strongest independent predictor for in-hospital mortality among patients with AF was severe bleeding (OR 18.00, 95% CI 15.22–21.30, p < 0.001).
Conclusion The present study demonstrates that the incidence of bleeding defines the in-hospital outcome of patients with AF after TF-TAVR. Thus, the periprocedural phase demands particular care in bleeding prevention.
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Affiliation(s)
- Achim Lother
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Ingo Ahrens
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Augustinerinnen Hospital, Academic Teaching Hospital, University of Cologne, Cologne, Germany
| | - Wolfgang Bothe
- Department of Cardiac and Vascular Surgery, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dennis Wolf
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von zur Mühlen
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Drakopoulou M, Soulaidopoulos S, Oikonomou G, Stathogiannis K, Latsios G, Synetos A, Tousoulis D, Toutouzas K. Novel Perspective for Antithrombotic Therapy in TAVI. Curr Pharm Des 2020; 26:2789-2803. [DOI: 10.2174/1381612826666200413083746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/16/2020] [Indexed: 12/29/2022]
Abstract
:
While surgical aortic valve replacement (SAVR) was for years the only available treatment for symptomatic
aortic stenosis, the introduction of transcatheter aortic valve implantation (TAVI) in 2002 and the improvement
of its technical aspects in the following years, has holistically changed the synchronous therapeutic
approach of aortic valve stenosis. Recent evidence has expanded the indication of TAVI from high to lower surgical
risk populations with symptomatic aortic stenosis. The administration of antithrombotic therapy periprocedurally
and its maintenance after a successful TAVI is crucial for the prevention of complications and affects
postprocedural survival. Randomized controlled trials investigating the appropriate combination and the
duration of antithrombotic treatment after TAVI are for the moment scarce. This review article sheds light on the
underlying pathogenetic mechanisms contributing in periprocedural TAVI thrombotic complications and discuss
the efficacy of current antithrombotic policies as evaluated in randomized trials.
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Affiliation(s)
- Maria Drakopoulou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - George Oikonomou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Stathogiannis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - George Latsios
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Andreas Synetos
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
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Ammar A, Elbatran AI, Wijesuriya N, Saberwal B, Ahsan SY. Management of atrial fibrillation after transcatheter aortic valve replacement: Challenges and therapeutic considerations. Trends Cardiovasc Med 2020; 31:361-367. [PMID: 32599334 DOI: 10.1016/j.tcm.2020.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 12/20/2022]
Abstract
Atrial Fibrillation (AF) is very common among patients with severe aortic stenosis. Moreover, new onset AF (NOAF) is a frequent finding after Transcatheter Aortic Valve Replacement (TAVR). There is a significant impact of AF on outcomes in patients undergoing TAVR including mortality, thrombo-embolic and bleeding events. There is lack of clear evidence about the optimal management of AF in TAVR patients. This review aims to summarize the epidemiology, predictors, prognosis, therapeutic considerations and challenges in the management of AF in patients undergoing TAVR.
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Affiliation(s)
- Ahmed Ammar
- Barts Heart Centre, St Bartholomew's Hospital, London, UK; Department of Cardiology, Ain Shams University, Cairo, Egypt.
| | | | | | - Bunny Saberwal
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Syed Y Ahsan
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
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Ziviello F, Pilgrim T, Kroon H, Ooms JF, van Wiechen MP, El Azzouzi I, Stortecky S, Asami M, Daemen J, de Jaegere PP, Windecker S, van Mieghem NM. HAS-BLED score and actual bleeding in elderly patients undergoing transcatheter aortic valve implantation. Minerva Med 2020; 111:203-212. [DOI: 10.23736/s0026-4806.19.06154-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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43
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Capodanno D, Greco A. Stroke After Transcatheter Aortic Valve Replacement: A Multifactorial Phenomenon. JACC Cardiovasc Interv 2020; 12:1590-1593. [PMID: 31439339 DOI: 10.1016/j.jcin.2019.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 07/01/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Davide Capodanno
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele," University of Catania, Catania, Italy.
| | - Antonio Greco
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele," University of Catania, Catania, Italy
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Pibarot P, Mazer CD, Verma S. Should Bioprosthetic Aortic Valves Be Routinely Anticoagulated?: Insights From PARTNER and Beyond. J Am Coll Cardiol 2020; 74:1201-1204. [PMID: 31466617 DOI: 10.1016/j.jacc.2019.07.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, Quebec, Canada.
| | - C David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute of St. Michael's Hospital, and Departments of Anesthesia and Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Departments of Surgery, and Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
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Guedeney P, Huchet F, Manigold T, Overtchouk P, Rouanet S, Balagny P, Leprince P, Lebreton G, Letocart V, Barthelemy O, Vicaut E, Montalescot G, Guerin P, Collet JP. Effect of oral anticoagulation on clinical outcomes and haemodynamic variables after successful transcatheter aortic valve implantation. Arch Cardiovasc Dis 2020; 113:341-349. [DOI: 10.1016/j.acvd.2019.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/11/2019] [Accepted: 12/19/2019] [Indexed: 11/27/2022]
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Nijenhuis VJ, Brouwer J, Delewi R, Hermanides RS, Holvoet W, Dubois CLF, Frambach P, De Bruyne B, van Houwelingen GK, Van Der Heyden JAS, Toušek P, van der Kley F, Buysschaert I, Schotborgh CE, Ferdinande B, van der Harst P, Roosen J, Peper J, Thielen FWF, Veenstra L, Chan Pin Yin DRPP, Swaans MJ, Rensing BJWM, van 't Hof AWJ, Timmers L, Kelder JC, Stella PR, Baan J, Ten Berg JM. Anticoagulation with or without Clopidogrel after Transcatheter Aortic-Valve Implantation. N Engl J Med 2020; 382:1696-1707. [PMID: 32223116 DOI: 10.1056/nejmoa1915152] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The roles of anticoagulation alone or with an antiplatelet agent after transcatheter aortic-valve implantation (TAVI) have not been well studied. METHODS We performed a randomized trial of clopidogrel in patients undergoing TAVI who were receiving oral anticoagulation for appropriate indications. Patients were assigned before TAVI in a 1:1 ratio not to receive clopidogrel or to receive clopidogrel for 3 months. The two primary outcomes were all bleeding and non-procedure-related bleeding over a period of 12 months. Procedure-related bleeding was defined as Bleeding Academic Research Consortium type 4 severe bleeding, and therefore most bleeding at the puncture site was counted as non-procedure-related. The two secondary outcomes were a composite of death from cardiovascular causes, non-procedure-related bleeding, stroke, or myocardial infarction at 12 months (secondary composite 1) and a composite of death from cardiovascular causes, ischemic stroke, or myocardial infarction (secondary composite 2), both tested for noninferiority (noninferiority margin, 7.5 percentage points) and superiority. RESULTS Bleeding occurred in 34 of the 157 patients (21.7%) receiving oral anticoagulation alone and in 54 of the 156 (34.6%) receiving oral anticoagulation plus clopidogrel (risk ratio, 0.63; 95% confidence interval [CI], 0.43 to 0.90; P = 0.01); most bleeding events were at the TAVI access site. Non-procedure-related bleeding occurred in 34 patients (21.7%) and in 53 (34.0%), respectively (risk ratio, 0.64; 95% CI, 0.44 to 0.92; P = 0.02). Most bleeding occurred in the first month and was minor. A secondary composite 1 event occurred in 49 patients (31.2%) receiving oral anticoagulation alone and in 71 (45.5%) receiving oral anticoagulation plus clopidogrel (difference, -14.3 percentage points; 95% CI for noninferiority, -25.0 to -3.6; risk ratio, 0.69; 95% CI for superiority, 0.51 to 0.92). A secondary composite 2 event occurred in 21 patients (13.4%) and in 27 (17.3%), respectively (difference, -3.9 percentage points; 95% CI for noninferiority, -11.9 to 4.0; risk ratio, 0.77; 95% CI for superiority, 0.46 to 1.31). CONCLUSIONS In patients undergoing TAVI who were receiving oral anticoagulation, the incidence of serious bleeding over a period of 1 month or 1 year was lower with oral anticoagulation alone than with oral anticoagulation plus clopidogrel. (Funded by the Netherlands Organization for Health Research and Development; POPular TAVI EU Clinical Trials Register number, 2013-003125-28; ClinicalTrials.gov number, NCT02247128.).
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Affiliation(s)
- Vincent J Nijenhuis
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Jorn Brouwer
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Ronak Delewi
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Renicus S Hermanides
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Wouter Holvoet
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Christophe L F Dubois
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Peter Frambach
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Bernard De Bruyne
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Gert K van Houwelingen
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Jan A S Van Der Heyden
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Petr Toušek
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Frank van der Kley
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Ian Buysschaert
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Carl E Schotborgh
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Bert Ferdinande
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Pim van der Harst
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - John Roosen
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Joyce Peper
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Frederick W F Thielen
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Leo Veenstra
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Dean R P P Chan Pin Yin
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Martin J Swaans
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Benno J W M Rensing
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Arnoud W J van 't Hof
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Leo Timmers
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Johannes C Kelder
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Pieter R Stella
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Jan Baan
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
| | - Jurriën M Ten Berg
- From the Department of Cardiology, St. Antonius Hospital, Nieuwegein (V.J.N., J. Brouwer, J.P., D.R.P.P.C.P.Y., M.J.S., B.J.W.M.R., L.T., J.C.K., J.M.B.), the Department of Cardiology, Amsterdam University Medical Centers, Location AMC, Amsterdam (R.D., J. Baan), the Department of Cardiology, Isala Hospital, Zwolle (R.S.H.), the Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute, Maastricht (W.H., L.V., A.W.J.H.), the Department of Cardiology, Medisch Spectrum Twente, Enschede (G.K.H.), the Department of Cardiology, Leiden University Medical Center, Leiden (F.K.), the Department of Cardiology, Haga Hospital, The Hague (C.E.S.), the Department of Cardiology, University Medical Center Groningen, Groningen (P.H.), Erasmus School of Health Policy and Management, Erasmus University, Rotterdam (F.W.F.T.), the Department of Cardiology, Zuyderland Medical Center, Heerlen (A.W.J.H.), and the Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, Utrecht University, Utrecht (P.R.S.) - all in the Netherlands; the Department of Cardiology, University Hospital Leuven, Leuven (C.L.F.D.), the Department of Cardiology, Onze Lieve Vrouwe Hospital (B.D.B.), and the Department of Cardiology, Algemeen Stedelijk Hospital Aalst (I.B.), Aalst, the Department of Cardiology, Sint-Jan Hospital, Brugge (J.A.S.V.D.H.), the Department of Cardiology, Hospital Oost-Limburg, Genk (B.F.), and the Department of Cardiology, Imelda Hospital, Bonheiden (J.R.) - all in Belgium; the Department of Cardiology, Institut National de Chirurgie Cardiaque et de Cardiologie Interventionnelle, Luxembourg, Luxembourg (P.F.); and the Department of Cardiology, University Hospital Královské Vinohrady and Third Medical Faculty, Charles University, Prague, Czech Republic (P.T.)
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Greco A, Capodanno D. Anticoagulation after Transcatheter Aortic Valve Implantation: Current Status. Interv Cardiol 2020; 15:e02. [PMID: 32382318 PMCID: PMC7203879 DOI: 10.15420/icr.2019.24] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 01/27/2020] [Indexed: 02/07/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is the standard of care for symptomatic severe aortic stenosis. Antithrombotic therapy is required after TAVI to prevent thrombotic complications but it increases the risk of bleeding events. Current clinical guidelines are mostly driven by expert opinion and therefore yield low-grade recommendations. The optimal antithrombotic regimen following TAVI has yet to be determined and several randomised controlled trials assessing this issue are ongoing. The purpose of this article is to critically explore the impact of antithrombotic drugs, especially anticoagulants, on long-term clinical outcomes following successful TAVI.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, CAST, PO G Rodolico, Policlinico-Vittorio Emanuele University Hospital, University of Catania Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, CAST, PO G Rodolico, Policlinico-Vittorio Emanuele University Hospital, University of Catania Catania, Italy
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48
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Late Cerebrovascular Events Following Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2020; 13:872-881. [DOI: 10.1016/j.jcin.2019.11.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/04/2019] [Accepted: 11/12/2019] [Indexed: 11/23/2022]
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Little C, Szydlo R, Aw TC, Laffan M, Arachchillage DRJ. Effect of direct-acting oral anticoagulants (DOACs) on bleeding and blood product usage in cardiac surgery compared to warfarin and controls. Br J Haematol 2020; 190:284-293. [PMID: 32128791 DOI: 10.1111/bjh.16521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 01/12/2020] [Indexed: 11/30/2022]
Abstract
In this retrospective, single-centre, observational study, we assessed (i) use of anticoagulant and antiplatelet (AP) therapy, (ii) the duration of direct-acting oral anticoagulant (DOAC) discontinuation, (iii) renal function and (iv) PT and APTT as predictors of bleeding and blood product usage; in adults (>18 years) undergoing major cardiac surgery from 01.01.2015 to 31.12.2018. Comparisons were made between each treatment group (warfarin, DOAC and DOAC + AP) and untreated controls, and between warfarin and DOAC. A total of 2928 patients were included for analysis. Median (range) of DOAC discontinuation prior to surgery was five days (1-22) for DOAC and five days (2-7) for DOAC + AP. There were no differences in bleeding between anticoagulant groups versus control, or DOAC versus warfarin. There were no differences in blood product use between DOAC and warfarin patients. The duration of DOAC discontinuation but not the creatinine clearance influenced bleeding and blood products use. Thrombosis occurred in 0·7% and 3·1% in controls and patients on warfarin respectively (P = 0·099) with none among patients on DOAC or DOAC + AP. The PT/APTT had no predictive value. Median five-day discontinuation of DOAC +/- AP irrespective of renal function prevents an increase in bleeding compared to patients on warfarin or controls with no increase in thrombosis.
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Affiliation(s)
- Christopher Little
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Richard Szydlo
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - T C Aw
- Department of Anaesthesia, Royal Brompton Hospital & Harefield NHS Foundation Trust, London, UK
| | - Mike Laffan
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK.,Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Deepa R J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK.,Department of Haematology, Imperial College Healthcare NHS Trust, London, UK.,Department of Haematology, Royal Brompton Hospital & Harefield NHS Foundation Trust, London, UK
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50
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Lugo LM, Romaguera R, Gómez-Hospital JA, Ferreiro JL. Antithrombotic Therapy After Transcatheter Aortic Valve Implantation. Eur Cardiol 2020; 15:1-8. [PMID: 32180830 PMCID: PMC7066806 DOI: 10.15420/ecr.2019.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/10/2019] [Indexed: 12/25/2022] Open
Abstract
The development of transcatheter aortic valve implantation has represented one of the greatest advances in the cardiology field in recent years and has changed clinical practice for patients with aortic stenosis. Despite the continuous improvement in operators’ experience and techniques, and the development of new generation devices, thromboembolic and bleeding complications after transcatheter aortic valve implantation remain frequent, and are a major concern due to their negative impact on prognosis in this vulnerable population. In addition, the optimal antithrombotic regimen in this scenario is not known, and current recommendations are mostly empirical and not evidence based. The present review aims to provide an overview of the current status of knowledge, including relevant on-going randomised trials, on antithrombotic treatment strategies after transcatheter aortic valve implantation.
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Affiliation(s)
- Leslie Marisol Lugo
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit/Medical Research Foundation, University of Western Australia, Perth, Australia
| | - Rafael Romaguera
- Heart Diseases Institute, Hospital Universitario de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Joan Antoni Gómez-Hospital
- Department of Cardiology, Hospital Universitario de Bellvitge - IDIBELL, CIBER-CV, L'Hospitalet de Llobregat, Barcelona, Spain
| | - José Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge - IDIBELL, CIBER-CV, L'Hospitalet de Llobregat, Barcelona, Spain
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