1
|
Jain H, Pervez N, Dey D, Odat RM, Jain J, Goyal A, Saggar A, Hussein AM, Mathur A, Khanna S, Ahmed R, Shahid F. Efficacy of Sentinel Cerebral Embolic Protection Device in Transcatheter Aortic Valve Replacement: A Meta-Analysis of Randomized Controlled Trials and Propensity Score-Matched Studies. Cardiol Rev 2024:00045415-990000000-00339. [PMID: 39345145 DOI: 10.1097/crd.0000000000000797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2024]
Abstract
Transcatheter aortic valve replacement (TAVR) is frequently associated with stroke due to debris embolization. Although the risk of stroke with newer-generation devices is lower, stroke still represents a significant cause of mortality and morbidity post-TAVR. The Sentinel cerebral embolic protection device (CEPD) is a dual-embolic filter device designed to capture debris dislodged during TAVR. A systematic literature search was performed on the major bibliographic databases to retrieve studies that compared TAVR with and without Sentinel CEPD. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the DerSimonian-Laird random-effects model, with a P value of <0.05 considered statistically significant. This meta-analysis included 6 studies with 25,130 patients undergoing TAVR (12,608: Sentinel CEPD; 12,522: without Sentinel CEPD). The use of the Sentinel CEPD in TAVR was associated with a statistically significant lower risk of acute kidney injury (OR: 0.89; 95% CI: 0.81-0.97; P = 0.01]. The use of Sentinel CEPD in TAVR was associated with a statistically insignificant trend toward a reduction in stroke (OR: 0.80; 95% CI: 0.58-1.10; P = 0.18), all-cause mortality (OR: 0.74; 95% CI: 0.51-1.07; P = 0.11), and major vascular complications (OR: 0.74; 95% CI: 0.46-1.19; P = 0.21). The use of Sentinel CEPD in patients undergoing TAVR does not lead to a statistically significant reduction in stroke, all-cause mortality, or major vascular complications; however, the risk of acute kidney injury is lower. Further randomized studies are warranted to confirm these findings.
Collapse
Affiliation(s)
- Hritvik Jain
- From the Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Neha Pervez
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Debankur Dey
- Department of Internal Medicine, Medical College and Hospital, Kolkata, India
| | - Ramez M Odat
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Jyoti Jain
- From the Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Anmol Saggar
- Department of Internal Medicine, Punjab Institute of Medical Sciences, Jalandhar, India
| | - Ayham Mohammad Hussein
- Department of Internal Medicine, Faculty of Medicine, Al-Balqa' Applied University, Salt, Jordan
| | - Aniket Mathur
- Department of Internal Medicine, Jhalawar Hospital and Medical College, Jhalawar, Rajasthan, India
| | - Sukul Khanna
- Department of Internal Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India
| | - Raheel Ahmed
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Farhan Shahid
- Department of Interventional Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| |
Collapse
|
2
|
Ayyad M, Jabri A, Khalefa BB, Al-Abdouh A, Madanat L, Albandak M, Alhuneafat L, Sukhon F, Shahrori Z, Mourid MR, Mhanna M, Giustino G, Wang DD, Hanson ID, Abbas AE, AlQarqaz M, Villablanca P. Efficacy and safety of TAVR versus SAVR in patients with small aortic annuli: A systematic review and meta-analysis. Int J Cardiol 2024; 411:132243. [PMID: 38851542 DOI: 10.1016/j.ijcard.2024.132243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/05/2024] [Accepted: 06/05/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION Patients with a small aortic annulus (SAA) undergoing aortic valve replacement are at increased risk of patient-prosthesis mismatch (PPM), which adversely affects outcomes. Transcatheter aortic valve replacement (TAVR) has shown promise in mitigating PPM compared to surgical aortic valve replacement (SAVR). METHODS We conducted a systematic review and meta-analysis following PRISMA guidelines to compare clinical outcomes, mortality, and PPM between SAA patients undergoing TAVR and SAVR. Eligible studies were identified through comprehensive literature searches and assessed for quality and relevance. RESULTS Nine studies with a total of 2476 patients were included. There was no significant difference in 30-day Mortality between TAVR vs SAVR groups (OR = 0.65, 95% CI [ 0.09-4.61], P = 0.22). There was no difference between both groups regarding myocardial infarction at 30 days (OR = 0.63, 95% CI [0.1-3.89], P = 0.62). TAVR was associated with a significantly lower 30-day major bleeding and 2-year major bleeding, Pooled studies were homogeneous (OR = 0.44, 95% CI [0.31-0.64], P < 0.01, I2 = 0, P = 0.89), (OR = 0.4 ,95% CI [0.21-0.77], P = 0.03, I2 = 0%, P = 0.62) respectively. TAVR was associated with a lower rate of moderate PPM (OR = 0.6, 95% CI [ 0.44-0.84], p value = 0.01, i2 = 0%, p value = 0.44). The overall effect estimate did not favor any of the two groups regarding short-term Mild AR (OR = 5.44, 95% CI [1.02-28.91], P = 0.05) and Moderate/severe AR (OR = 4.08, 95% CI [ 0.79-21.02], P = 0.08, I2 = 0%, P = 0.59). CONCLUSION Our findings suggest that both TAVR and SAVR are viable options for treating AS in patients with a small aortic annulus. TAVR offers advantages in reducing PPM and major bleeding, while SAVR performs better in terms of pacemaker implantation. Future studies should focus on comparing newer generation TAVR techniques and devices with SAVR. Consideration of patient characteristics is crucial in selecting the optimal treatment approach for AS.
Collapse
Affiliation(s)
- Mohammed Ayyad
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Ahmad Jabri
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA; Michigan State University, College of Human Medicine, USA
| | | | - Ahmad Al-Abdouh
- Division of hospital medicine, University of Kentucky, Lexington, KY, USA
| | - Luai Madanat
- Department of Cardiovascular Medicine, William Beaumont University Hospital, Royal Oak, MI, USA; Oakland University William Beaumont School of Medicine, USA
| | - Maram Albandak
- Division of hospital medicine, University of Kentucky, Lexington, KY, USA; Department of Internal Medicine, University of Toledo, Toledo, Ohio, USA
| | - Laith Alhuneafat
- Cardiovascular Division, University of Minnesota, Minneapolis, MN, USA
| | - Fares Sukhon
- Heart and Vascular Center, Metrohealth Medical Center, Cleveland, OH, United States of America
| | - Zaid Shahrori
- Case Western Reserve University/Metrohealth Medical Center Cleveland, OH, USA
| | | | - Mohammed Mhanna
- Division of Cardiovascular Medicine, University of Iowa, IA, USA
| | - Gennaro Giustino
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA; Michigan State University, College of Human Medicine, USA
| | - Dee Dee Wang
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA; Michigan State University, College of Human Medicine, USA
| | - Ivan D Hanson
- Department of Cardiovascular Medicine, William Beaumont University Hospital, Royal Oak, MI, USA; Oakland University William Beaumont School of Medicine, USA
| | - Amr E Abbas
- Department of Cardiovascular Medicine, William Beaumont University Hospital, Royal Oak, MI, USA; Oakland University William Beaumont School of Medicine, USA
| | - Mohammad AlQarqaz
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA; Michigan State University, College of Human Medicine, USA
| | - Pedro Villablanca
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI, USA; Michigan State University, College of Human Medicine, USA.
| |
Collapse
|
3
|
Shekhar S, Isogai T, Agrawal A, Kaw R, Mahalwar G, Krishnaswamy A, Puri R, Reed G, Mentias A, Kapadia S. Outcomes and Predictors of Stroke After Transcatheter Aortic Valve Replacement in the Cerebral Protection Device Era. J Am Heart Assoc 2024; 13:e034298. [PMID: 39101495 DOI: 10.1161/jaha.124.034298] [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: 02/28/2024] [Accepted: 05/06/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Studies have shown inconclusive results on the effectiveness of cerebral protection devices (CPDs) with transcatheter aortic valve replacement. We aimed to analyze the national statistics on stroke and other outcomes with CPD use. METHODS AND RESULTS The Nationwide Readmissions Database (2017-2020) was queried to obtain data on patients undergoing transcatheter aortic valve replacement. Outcomes were compared between patients with a CPD and patients without a CPD. Of 271 804 patients undergoing transcatheter aortic valve replacement, CPD was used in 7.3% of patients. In a multivariable logistic regression analysis, CPD use was not associated with lower overall stroke rates (1.6% versus 1.9% without CPD; odds ratio, 0.95 [95% CI, 0.84-1.07]; P=0.364), but it was significantly associated with lower major stroke rates (1.2% versus 1.5% without CPD; odds ratio, 0.85 [95% CI, 0.74-0.98]; P=0.02). Patients with a CPD also had a shorter length of stay, higher routine discharges to home/self-care (74.9% versus 70.6%), and lower mortality rates (0.7% versus 1.3%). The 30-day (9.6% versus 11.7%) and 180-day (24.6% versus 28.2%) readmission rates were significantly lower in the CPD cohort. Among patients who developed stroke, patients with a CPD had more frequent routine discharges. Prior valve surgery was associated with the highest risk of overall and major stroke. CONCLUSIONS CPD use during transcatheter aortic valve replacement was not independently associated with a lower risk of overall stroke but was associated with a lower risk of major stroke in a multivariable model. Data from future randomized trials that may offset any potential confounders in our study are required to help identify patients who would benefit from the use of these devices.
Collapse
Affiliation(s)
- Shashank Shekhar
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Cleveland OH USA
| | - Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Cleveland OH USA
| | - Ankit Agrawal
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Cleveland OH USA
| | - Roop Kaw
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Cleveland OH USA
| | - Gauranga Mahalwar
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Cleveland OH USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Cleveland OH USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Cleveland OH USA
| | - Grant Reed
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Cleveland OH USA
| | - Amgad Mentias
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Cleveland OH USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Cleveland OH USA
| |
Collapse
|
4
|
Basit J, Ahmed M, Kidess G, Zaheer Z, Fatima L, Naveed H, Hamza M, Fatima M, Goyal A, Loyalka P, Alam M, Alraies MC. Cerebral embolic protection for stroke prevention during transcatheter aortic valve replacement. Expert Rev Cardiovasc Ther 2024; 22:409-420. [PMID: 39056434 DOI: 10.1080/14779072.2024.2385989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 07/05/2024] [Accepted: 07/25/2024] [Indexed: 07/28/2024]
Abstract
INTRODUCTION Cerebral Embolic Protection Device (CEPD) captures emboli during Transcatheter Aortic Valve Replacement (TAVR). With recently published pivotal trials and multiple cohort studies reporting new data, there is a need to re-calibrate available statistical evidence. METHODS A systematic literature search was conducted across databases from inception till February 2023. Dichotomous outcomes were pooled using Odds Ratio (OR), while continuous outcomes were pooled using Standardized Mean Difference (SMD) along with 95% corresponding intervals (95% CIs). RESULTS Data was included from 17 studies (7 RCTs, 10 cohorts, n = 155,829). Use of CEPD was associated with significantly reduced odds of stroke (OR = 0.60, 95% CI = 0.43-0.85, p = 0.003). There was no significant difference in disabling stroke (p = 0.25), non-disabling stroke (p = 0.72), and 30-day mortality (p = 0.10) between the two groups. There were no significant differences between the two groups for Diffusion-Weighted Magnetic Resonance Imaging (DW-MRI) findings, acute kidney injury, risk of pacemaker implantation life-threatening bleed, major bleed, minor bleed, worsening National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and vascular complications (p > 0.05). CONCLUSIONS The use of CEPD during TAVR reduced the incidence of all-stroke (p = 0.003); however, there were no significant differences in any of the other pooled outcomes (p > 0.05). REGISTRATION The protocol of this meta-analysis was registered with the Open Science framework [https://doi.org/10.17605/OSF.IO/7W564] before data acquisition was started.
Collapse
Affiliation(s)
- Jawad Basit
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Mushood Ahmed
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - George Kidess
- Department of Internal Medicine, Wayne State University, Michigan, USA
| | - Zaofashan Zaheer
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Laveeza Fatima
- Department of Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Hamza Naveed
- University of Houston/HCA kingwood Hospital, Houston, TX, USA
| | - Mohammad Hamza
- Department of Hospital Medicine, Guthrie Cortland Medical Center, Cortland, NY, USA
| | - Maurish Fatima
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Pranav Loyalka
- Department of cardiology, HCA medical Center, Houston, TX, USA
| | - Mahboob Alam
- Department of Interventional Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - M Chadi Alraies
- Cardiovascular Institute, Detroit Medical Center, Detroit, MI, USA
| |
Collapse
|
5
|
Harmouch W, Karnkowska B, Thakker R, Rasmussen P, Shalaby M, Khalife W, Alwash H, Motiwala A, Kumfa P, Gilani S, Jneid H, Rangasetty U. Cerebral Embolic Protection in Transcatheter Aortic Valve Implantation Using the Sentinel Cerebral Protection System: A Systematic Review and Meta-Analysis. Cardiol Ther 2024; 13:299-314. [PMID: 38340292 PMCID: PMC11093944 DOI: 10.1007/s40119-024-00359-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
INTRODUCTION Transcatheter aortic valve implantation (TAVI) plays a vital role in patients with symptomatic aortic stenosis. Despite the mortality benefit of TAVI, embolic stroke remains a feared complication. As a result, transcatheter cerebral embolic protection (TCEP) devices have been developed to reduce this risk. Given the ongoing debate of TCEP in TAVI, we performed a systematic review and meta-analysis of all randomized controlled trials to date to identify outcomes of periprocedural stroke using the Sentinel™ cerebral protection system (CPS). METHODS MEDLINE, Cochrane, and Scopus databases were utilized from inception until 12/2023. PRISMA criteria was utilized. Keywords included "cerebral embolic protection", "sentinel cerebral protection system", "transcatheter aortic valve implantation", and "transcatheter aortic valve replacement". Primary outcome was periprocedural stroke. Secondary outcomes included periprocedural disabling and non-disabling stroke, all-cause mortality, transient ischemic attack, delirium, acute kidney injury, vascular complications, bleeding, and pacemaker implantation. Risk ratios (RR) were measured via Mantel-Haenszel method with fixed analysis. Heterogeneity was assessed via chi-squared and Higgin's I2 test. RESULTS Four trials with 3528 patients were assessed. SAPIEN 3 was the most common bioprosthetic valve used. The average age was 79.4 years with 41.9% of the sample size being females. The most prevalent comorbidities were hypertension, diabetes mellitus, and coronary artery disease. There was no difference in periprocedural stroke in patients who underwent TAVI with the Sentinel™ CPS compared to no TCEP (RR 0.75, P = 0.12). Periprocedural disabling strokes were less likely in those who underwent TAVI with the Sentinel™ CPS compared to no TCEP (RR 0.41, P = 0.02) with a number needed to treat (NNT) of 123. All other outcomes did not reach statistical significance. CONCLUSIONS In our analysis, there was no difference between TAVI with the Sentinel™ CPS compared to TAVI without TCEP in regard to risk of periprocedural stroke; however, it was associated with a decreased risk of periprocedural disabling stroke.
Collapse
Affiliation(s)
- Wissam Harmouch
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA.
| | - Barbara Karnkowska
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Ravi Thakker
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Peter Rasmussen
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Mostafa Shalaby
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Wissam Khalife
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Haider Alwash
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Afaq Motiwala
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Paul Kumfa
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Syed Gilani
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Hani Jneid
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Umamahesh Rangasetty
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| |
Collapse
|
6
|
Boccuto F, Carabetta N, Cacia MA, Kanagala SG, Panuccio G, Torella D, De Rosa S. Clinical impact of cerebral protection during transcatheter aortic valve implantation. Eur J Clin Invest 2024; 54:e14166. [PMID: 38269600 DOI: 10.1111/eci.14166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/12/2023] [Accepted: 12/23/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Embolization of debris can complicate transcatheter aortic valve implantation (TAVI) causing stroke. Cerebral embolism protection (CEP) devices can divert or trap debris. PURPOSE To evaluate the efficacy of CEP during TAVI vs the standard procedure. DATA SOURCES PubMed, SCOPUS and DOAJ 1/01/2014-04/12/2023. STUDY SELECTION Randomized and observational studies comparing CEP versus standard TAVI, according to PRISMA. PRIMARY OUTCOME stroke. SECONDARY OUTCOMES death, bleeding, vascular access complications, acute kidney injury and infarct area. DATA EXTRACTION Two investigators independently assessed study quality and extracted data. DATA SYNTHESIS Twenty-six articles were included (540.247 patients). The primary endpoint was significantly lower (RR = 0.800 95%CI:0.682-0.940; p = 0.007) with CEP. Similarly, death rates were significantly lower with CEP (RR = 0.610 95%CI:0.482-0.771; p < 0.001). No difference was found for bleeding (RR = 1.053 95%CI:0.793-1.398; p = 0.721), vascular complications (RR = 0.937 95%CI:0.820-1.070; p = 0.334) or AKI (RR = 0.982 95%CI:0.754-1.279; p = 0.891). CONCLUSIONS Use of CEP during TAVI is associated with improved outcomes. Future studies will identify patients who benefit most from CEP.
Collapse
Affiliation(s)
- Fabiola Boccuto
- Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Nicole Carabetta
- Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Michele Antonio Cacia
- Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Sai Gautham Kanagala
- Department of Internal Medicine, Metropolitan Hospital Center, New York, NY, USA
| | - Giuseppe Panuccio
- Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Daniele Torella
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Salvatore De Rosa
- Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| |
Collapse
|
7
|
Kaur A, Dhaliwal AS, Sohal S, Gwon Y, Gupta S, Bhatia K, Dominguez AC, Basman C, Tamis‐Holland J. Role of Cerebral Embolic Protection Devices in Patients Undergoing Transcatheter Aortic Valve Replacement: An Updated Meta-Analysis. J Am Heart Assoc 2024; 13:e030587. [PMID: 38240252 PMCID: PMC11056109 DOI: 10.1161/jaha.123.030587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 12/05/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Cerebral embolic protection devices (CEPD) capture embolic material in an attempt to reduce ischemic brain injury during transcatheter aortic valve replacement. Prior reports have indicated mixed results regarding the benefits of these devices. With new data emerging, we performed an updated meta-analysis examining the effect of CEPD during transcatheter aortic valve replacement on various clinical, neurological, and safety parameters. METHODS AND RESULTS A comprehensive review of electronic databases was performed comparing CEPD and no-CEPD in transcatheter aortic valve replacement. Primary clinical outcome was all-cause stroke. Secondary clinical outcomes were disabling stroke and all-cause mortality. Neurological outcomes included worsening of the National Institutes of Health Stroke Scale score, Montreal Cognitive Assessment score from baseline at discharge, presence of new ischemic lesions, and total lesion volume on neuroimaging. Safety outcomes included major or minor vascular complications and stage 2 or 3 acute kidney injury. Seven randomized controlled trials with 4016 patients met the inclusion criteria. There was no statistically significant difference in the primary clinical outcome of all-cause stroke; secondary clinical outcomes of disabling stroke, all-cause mortality, neurological outcomes of National Institutes of Health Stroke Scale score worsening, Montreal Cognitive Assessment worsening, presence of new ischemic lesions, or total lesion volume on diffusion-weighted magnetic resonance imaging between CEPD versus control groups. There was no statistically significant difference in major or minor vascular complications or stage 2 or 3 acute kidney injury between the groups. CONCLUSIONS The use of CEPD in transcatheter aortic valve replacement was not associated with a statistically significant reduction in the risk of clinical, neurological, and safety outcomes.
Collapse
Affiliation(s)
- Arpanjeet Kaur
- Department of MedicineIcahn School of Medicine at Mount Sinai Morningside/West‐ New YorkNew YorkNY
| | - Arshdeep S. Dhaliwal
- Population Health Science and PolicyIcahn School of Medicine at Mount Sinai‐ New YorkNew YorkNY
| | - Sumit Sohal
- Division of Cardiovascular MedicineNewark Beth Israel Medical Center‐ NewarkNewarkNJ
| | - Yeongjin Gwon
- Department of BiostatisticsUniversity of Nebraska Medical CenterOmahaNE
| | - Soumya Gupta
- Department of MedicineIcahn School of Medicine at Mount Sinai Morningside/West‐ New YorkNew YorkNY
| | - Kirtipal Bhatia
- Division of CardiologyIcahn School of Medicine at Mount Sinai Morningside‐ New YorkNew YorkNY
| | - Abel Casso Dominguez
- Division of CardiologyIcahn School of Medicine at Mount Sinai Morningside‐ New YorkNew YorkNY
| | - Craig Basman
- Division of CardiologyLenox Hill Hospital‐ New YorkNew YorkNY
| | | |
Collapse
|
8
|
Tan N, Fei G, Rizwan Amanullah M, Lim ST, Abdul Aziz Z, Govindasamy S, Chao VTT, Ewe SH, Ho KW, Yap J. Safety and efficacy of cerebral embolic protection in transcatheter aortic valve implantation: an updated meta-analysis. ASIAINTERVENTION 2024; 10:51-59. [PMID: 38425806 PMCID: PMC10900717 DOI: 10.4244/aij-d-23-00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/23/2023] [Indexed: 03/02/2024]
Abstract
Background The use of cerebral embolic protection devices during transcatheter aortic valve implantation (TAVI) reveals conflicting data. Aims This updated meta-analysis aims to evaluate the efficacy and safety of the SENTINEL Cerebral Protection System. Methods A literature search for relevant studies up to September 2022 was performed. Study outcomes were divided based on time period - overall (up to 30 days) and short (≤7 days). The outcomes studied include stroke (disabling, non-disabling), mortality, neuroimaging findings, transient ischaemic attack, acute kidney injury and major vascular and bleeding complications. Results A total of 15 studies involving 294,134 patients were included. Regarding overall outcomes, significant reductions were noted for mortality (odds ratio [OR] 0.60, 95% confidence interval [CI]: 0.41-0.88; p=0.008), all stroke (OR 0.64, 95% CI: 0.46-0.88; p=0.006) and disabling stroke (OR 0.42, 95% CI: 0.23-0.74; p=0.003) using the SENTINEL device. No significant differences were noted for other outcomes. There was significant heterogeneity across the studies for mortality (p=0.013) and all stroke (p=0.003). Including only randomised data (n=4), there was only significant reduction in the incidence of disabling stroke (OR 0.39, 95% CI: 0.17-0.89; p=0.026) in the SENTINEL group. In studies reporting ≤7-day outcomes (n=8), use of the SENTINEL device demonstrated significantly lower rates of all stroke (p<0.001), disabling stroke (p<0.001) and major bleeding complications (p=0.02). No differences in neuroimaging outcomes were noted. Conclusions In this updated meta-analysis, use of the SENTINEL Cerebral Protection System was associated with lower rates of mortality, all stroke and disabling stroke, although significant heterogeneity was noted for mortality and all stroke. Including exclusively randomised data, there was only significant reduction in the incidence of disabling stroke. No significant adverse outcomes with device use were noted.
Collapse
Affiliation(s)
- Nicholas Tan
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Gao Fei
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | - Soo Teik Lim
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Zameer Abdul Aziz
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Sivaraj Govindasamy
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | | | - See Hooi Ewe
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Kay Woon Ho
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| |
Collapse
|
9
|
Ayala Valani L, Dion D, Daneault B, Ayala-Paredes F. Deep Septal Perforation During Left Bundle Branch Area Pacing Resulting in Left Ventricular Capture and Delayed Systemic Embolism. Can J Cardiol 2023; 39:1432-1435. [PMID: 37127065 DOI: 10.1016/j.cjca.2023.02.075] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 01/31/2023] [Accepted: 02/13/2023] [Indexed: 05/03/2023] Open
Affiliation(s)
| | - Danielle Dion
- Québec Integrated Centre for Health and Social Services, Chaudiere-Appalaches, Sherbrooke, Québec, Canada
| | - Benoit Daneault
- Sherbrooke University Hospital, Sherbrooke University Medical School, Sherbrooke, Québec, Canada
| | - Felix Ayala-Paredes
- Sherbrooke University Hospital, Sherbrooke University Medical School, Sherbrooke, Québec, Canada.
| |
Collapse
|
10
|
Jimenez Diaz VA, Kapadia SR, Linke A, Mylotte D, Lansky AJ, Grube E, Settergren M, Puri R. Cerebral embolic protection during transcatheter heart interventions. EUROINTERVENTION 2023; 19:549-570. [PMID: 37720969 PMCID: PMC10495748 DOI: 10.4244/eij-d-23-00166] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/17/2023] [Indexed: 09/19/2023]
Abstract
Stroke remains a devastating complication of transcatheter aortic valve replacement (TAVR), with the incidence of clinically apparent stroke seemingly fixed at around 3% despite TAVR's significant evolution during the past decade. Embolic showers of debris (calcium, atheroma, valve material, foreign material) are captured in the majority of patients who have TAVR using a filter-based cerebral embolic protection device (CEPD). Additionally, in systematic brain imaging studies, the majority of patients receiving TAVR exhibit new cerebral lesions. Mechanistic studies have shown reductions in the volume of new cerebral lesions using CEPDs, yet the first randomised trial powered for periprocedural stroke within 72 hours of a transfemoral TAVR failed to meet its primary endpoint of showing superiority of the SENTINEL CEPD. The present review summarises the clinicopathological rationale for the development of CEPDs, the evidence behind these devices to date and the emerging recognition of cerebral embolisation in many non-TAVR transcatheter procedures. Given the uniqueness of each of the various CEPDs under development, specific trials tailored to their designs will need to be undertaken to broaden the CEPD field, in addition to evaluating the role of CEPD in non-TAVR transcatheter heart interventions. Importantly, the cost-effectiveness of these devices will require assessment to broaden the adoption of CEPDs globally.
Collapse
Affiliation(s)
- Victor Alfonso Jimenez Diaz
- Cardiology Department, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IISGS), SERGAS-UVIGO, Vigo, Spain
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Axel Linke
- Department of Internal Medicine and Cardiology, Heart Center Dresden University Hospital, Dresden, Germany and Technische Universität Dresden, Dresden, Germany
| | - Darren Mylotte
- Department of Cardiology, University Hospital Galway, Galway, Ireland and University of Galway, Galway, Ireland
| | | | - Eberhard Grube
- Department of Medicine II, Heart Center, University Hospital Bonn, Bonn, Germany
| | - Magnus Settergren
- Heart and Vascular Unit, Karolinska University Hospital, Stockholm, Sweden and Karolinska Institutet, Stockholm, Sweden
| | - Rishi Puri
- Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
11
|
Juarez-Casso FM, Crestanello JA. The Evolving Role of Surgical Aortic Valve Replacement in the Era of Transcatheter Valvular Procedures. J Clin Med 2023; 12:5299. [PMID: 37629341 PMCID: PMC10455383 DOI: 10.3390/jcm12165299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/11/2023] [Accepted: 07/19/2023] [Indexed: 08/27/2023] Open
Abstract
Surgical aortic valve replacement (SAVR) has long been the standard treatment for severe symptomatic aortic stenosis (AS). However, transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative; it was initially intended for high-risk patients and has now expanded its use to patients of all risk groups. While TAVR has demonstrated promising outcomes in diverse patient populations, uncertainties persist regarding its long-term durability and potential complications, raising the issue of the ideal lifetime management strategy for patients with AS. Therefore, SAVR continues to play an important role in clinical practice, particularly in younger patients with longer life expectancies, those with complex aortic anatomy who are unsuitable for TAVR, and those requiring concomitant surgical procedures. The choice between TAVR and SAVR warrants personalized decision-making, considering patient characteristics, comorbidities, anatomical considerations, and overall life expectancy. A multidisciplinary approach involving an experienced heart team is crucial in the preoperative evaluation process. In this review, we aimed to explore the current role of surgical management in addressing aortic valve stenosis amidst the expanding utilization of less invasive transcatheter procedures.
Collapse
Affiliation(s)
| | - Juan A. Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| |
Collapse
|
12
|
Shrestha DB, Shtembari J, Lamichhane S, Baniya A, Shahi M, Dhungel S, Pant K, Sutton NR, Villablanca P, Mungee S. Safety and efficacy of cerebral embolic protection devices for patients undergoing transcatheter aortic valve replacement: An updated meta-analysis. Health Sci Rep 2023; 6:e1391. [PMID: 37404451 PMCID: PMC10314975 DOI: 10.1002/hsr2.1391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/18/2023] [Accepted: 06/20/2023] [Indexed: 07/06/2023] Open
Abstract
Background and Aims Cerebral embolic protection (CEP) devices are employed to capture embolic debris and reduce the risk of stroke during transcatheter aortic valve replacement (TAVR). Evidence is mixed regarding the safety and efficacy of CEP. We aimed to summarize the safety and effectiveness of CEP use during TAVR. Methods Electronic databases, including PubMed, PubMed Central, Scopus, Cochrane Library, and Embase, were searched using relevant search terms for articles relating to CEP. All relevant data from 20 studies were extracted into a standardized form. Statistical analyses were performed using Revman 5.4. Odds ratio (OR) or mean differences (MDs) were used to estimate the desired outcome with a 95% confidence interval (CI). Results Twenty studies (eight randomized controlled trials [RCTs]) involving 210,871 patients (19,261 in the CEP group and 191,610 in TAVR without the CEP group) were included. The use of CEP was associated with a lower odds of 30-day mortality by 39% (OR: 0.61, 95% CI: 0.53-0.70) and stroke by 31% (OR: 0.69, 95% CI: 0.52-0.92). Comparing devices, benefit in terms of mortality and stroke was observed with the use of the Sentinel device (Boston Scientific), but not among other devices. No differences were observed in the outcomes of acute kidney injury, major or life-threatening bleeding events, or major vascular complications between groups. When only RCTs were included, there were no observed differences in the primary or secondary outcomes for CEP versus no CEP use during TAVR. Conclusions The totality of evidence suggests a net benefit for the use of CEP, weighted by studies in which the Sentinal device was used. However, given the RCT subanalysis, additional evidence is needed to identify patients at the highest risk of stroke for optimal decision-making.
Collapse
Affiliation(s)
| | - Jurgen Shtembari
- Department of Internal MedicineMount Sinai HospitalChicagoIllinoisUSA
| | - Sandesh Lamichhane
- Department of Internal MedicineChitwan Medical College Teaching HospitalBharatpurNepal
| | - Abinash Baniya
- Department of Internal MedicineChitwan Medical College Teaching HospitalBharatpurNepal
| | - Manoj Shahi
- Department of Internal MedicineChitwan Medical College Teaching HospitalBharatpurNepal
| | - Swati Dhungel
- Division of Cardiovascular Medicine, Department of Internal Medicine, John H. StrogerJr. Hospital of Cook CountyChicagoIllinoisUSA
| | - Kailash Pant
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of Illinois College of Medicine, OSF HealthcarePeoriaIllinoisUSA
| | - Nadia R. Sutton
- Division of Cardiovascular Medicine, Department of Internal MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Department of Biomedical EngineeringVanderbilt UniversityNashvilleTennesseeUSA
| | - Pedro Villablanca
- Division of Interventional Cardiology and Structural Heart Disease, Department of Internal MedicineThe Center for Structural Heart Disease Henry Ford HospitalDetroitMichiganUSA
| | - Sudhir Mungee
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of Illinois College of Medicine, OSF HealthcarePeoriaIllinoisUSA
| |
Collapse
|
13
|
Wolfrum M, Handerer IJ, Moccetti F, Schmeisser A, Braun-Dullaeus RC, Toggweiler S. Cerebral embolic protection during transcatheter aortic valve replacement: a systematic review and meta-analysis of propensity score matched and randomized controlled trials using the Sentinel cerebral embolic protection device. BMC Cardiovasc Disord 2023; 23:306. [PMID: 37330463 PMCID: PMC10276451 DOI: 10.1186/s12872-023-03338-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 06/08/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND The Sentinel cerebral embolic protection device (CEP) aims to reduce the risk of stroke during transcatheter aortic valve replacement (TAVR). We performed a systematic review and meta-analysis of propensity score matched (PSM) and randomized controlled trials (RCT) investigating the effect of the Sentinel CEP to prevent strokes during TAVR. METHODS Eligible trials were searched through PubMed, ISI Web of science databases, Cochrane database, and proceedings of major congresses. Primary outcome was stroke. Secondary outcomes included all-cause mortality, major or life-threatening bleeding, major vascular complications and acute kidney injury at discharge. Fixed and random effect models were used to calculate the pooled risk ratio (RR) with 95% confidence intervals (CI) and absolute risk difference (ARD). RESULTS A total of 4066 patients from 4 RCTs (3'506 patients) and 1 PSM study (560 patients) were included. Use of Sentinel CEP was successful in 92% of patients and was associated with a significantly lower risk of stroke (RR: 0.67, 95% CI: 0.48-0.95, p = 0.02. ARD: -1.3%, 95% CI: -2.3 - -0.2, p = 0.02, number needed to treat (NNT) = 77), and a reduced risk of disabling stroke (RR: 0.33, 95% CI: 0.17-0.65. ARD: -0.9%, 95% CI: -1.5 - -0.3, p = 0.004, NNT = 111). Use of Sentinel CEP was associated with a lower risk of major or life-threatening bleeding (RR: 0.37, 95% CI: 0.16-0.87, p = 0.02). Risk for nondisabling stroke (RR: 0.93, 95% CI: 0.62-1.40, p = 0.73), all-cause mortality (RR: 0.70, 95% CI: 0.35-1.40, p = 0.31), major vascular complications (RR: 0.74, 95% CI: 0.33-1.67, p = 0.47) and acute kidney injury (RR: 0.74, 95% CI: 0.37-1.50, p = 0.40) were similar. CONCLUSIONS The use of CEP during TAVR was associated with lower risks of any stroke and disabling stroke with an NNT of 77 and 111, respectively.
Collapse
Affiliation(s)
- Mathias Wolfrum
- Heart Center Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland.
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany.
| | - Immanuel Justus Handerer
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
| | | | - Alexander Schmeisser
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
| | - Ruediger C Braun-Dullaeus
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
| | | |
Collapse
|
14
|
Kharbanda RK, Perkins AD, Kennedy J, Banning AP, Baumbach A, Blackman DJ, Dodd M, Evans R, Hildick-Smith D, Jamal Z, Ludman P, Palmer S, Stables R, Clayton T. Routine cerebral embolic protection in transcatheter aortic valve implantation: rationale and design of the randomised British Heart Foundation PROTECT-TAVI trial. EUROINTERVENTION 2023; 18:1428-1435. [PMID: 36706009 PMCID: PMC10111121 DOI: 10.4244/eij-d-22-00713] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 12/14/2022] [Indexed: 01/28/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) is an established treatment for aortic stenosis. Cerebral embolic protection (CEP) devices may impact periprocedural stroke by capturing debris destined for the brain. However, there is a lack of high-quality randomised trial evidence supporting the use of CEP during TAVI. The British Heart Foundation (BHF) PROTECT-TAVI trial will address whether the routine use of CEP reduces the incidence of stroke in patients undergoing TAVI. BHF PROTECT-TAVI is a prospective, open-label, outcome-adjudicated, multicentre randomised controlled trial. The trial is open to all adult patients scheduled for TAVI at participating specialist cardiac centres across the United Kingdom who are able to receive the CEP device. The trial will recruit 7,730 participants. Participants will be randomised in a 1:1 ratio to undergo TAVI with CEP or TAVI without CEP (standard of care). The primary outcome is the incidence of stroke at 72 hours post-TAVI. Key secondary outcomes include the incidence of stroke and all-cause mortality up to 12 months post-TAVI, disability and cognitive outcomes, stroke severity, access site complications and a health economics analysis. The sample size of 7,730 participants has 80% power to detect a 33% relative risk reduction from a 3% incidence of the primary outcome in the controls. Trial recruitment commenced in October 2020. As of October 2022, 3,068 patients have been enrolled. BHF PROTECT-TAVI is designed to provide definitive evidence on the clinical efficacy and cost-effectiveness of using routine CEP with the SENTINEL device to reduce stroke in TAVI.
Collapse
Affiliation(s)
- Rajesh K Kharbanda
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Alexander David Perkins
- Clinical Trials Unit and Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - James Kennedy
- Acute Vascular Imaging Centre, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Adrian P Banning
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK and Barts Heart Centre, London, UK
| | - Daniel J Blackman
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthew Dodd
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Richard Evans
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - David Hildick-Smith
- Cardiac Surgery, Cardiac Center, Royal Sussex County Hospital, Brighton, UK and Sussex University Hospitals Trust, Brighton, UK
| | - Zahra Jamal
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Peter Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, UK
| | - Rodney Stables
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Tim Clayton
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
15
|
Baloch ZQ, Haider SJ, Siddiqui HF, Shaikh FN, Shah BUD, Ansari MM, Qintar M. Utility of Cerebral Embolic Protection Devices in Transcatheter Procedures: A Systematic Review and Meta-Analysis. Curr Probl Cardiol 2023; 48:101675. [PMID: 36870550 DOI: 10.1016/j.cpcardiol.2023.101675] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND With the emergence of the largest randomized control trial to date - the Stroke Protection With Sentinel During Transcatheter Aortic Valve Replacement (PROTECTED TAVR) study- we sought to conduct an updated meta-analyses to evaluate the utility of CEP devices on both clinical outcomes and neuroimaging parameters. METHODS Electronic databases were queried through November 2022 for clinical trials comparing the utility of Cerebral Embolic Protection (CEP) devices in Transcatheter Aortic Valve Replacement (TAVR) with non-CEP TAVR procedures. Meta-analyses were performed using the generic inverse variance technique, and a random-effects model, and results are presented as weighted mean differences (WMD) for continuous outcomes, and hazard ratios (HR) for dichotomous outcomes. Outcomes of interest included stroke, disabling stroke, non-disabling stroke, bleeding, mortality, vascular complications, new ischemic lesions, acute kidney injury (AKI) and total lesion volume. RESULTS 13 studies (8 RCTs, 5 observational studies) consisting of 128,471 patients were included in the analysis. Results from our meta-analyses showed a significant reduction in stroke (OR: 0.84 [0.74 - 0.95]; P < 0.01; I2 = 0%), disabling stroke (OR: 0.37 [0.21 - 0.67]; P < 0.01; I2 = 0%) and bleeding events (OR: 0.91 [0.83 - 0.99]; P = 0.04; I2 = 0%) through CEP device use in TAVR. The use of CEP devices had no significant impact on non-disabling stroke (OR: 0.94 [0.65 - 1.37]; P < 0.01; I2 = 0%), mortality (OR: 0.78 [0.53 - 1.14]; P < 0.01; I2 = 17%), vascular complications (OR: 0.99 [0.63 - 1.57]; P < 0.01; I2 = 28%), AKI (OR: 0.78 [0.46 - 1.32]; P < 0.01; I2 = 0%), new ischemic lesions (MD: -1.72 [-4.01, 0.57]; p < 0.001; I2 = 95%) and total lesion volume (MD: -46.11 [-97.38, 5.16]; p < 0.001; I2 = 81%). CONCLUSIONS The results suggest that CEP device use was associated with a lower risk of disabling stroke and bleeding events in patients undergoing TAVR.
Collapse
|
16
|
A Referral Center Experience with Cerebral Protection Devices: Challenging Cardiac Thrombus in the EP Lab. J Clin Med 2023; 12:jcm12041549. [PMID: 36836084 PMCID: PMC9967427 DOI: 10.3390/jcm12041549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/30/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Cerebral protection devices (CPD) are designed to prevent cardioembolic stroke and most evidence that exists relates to TAVR procedures. There are missing data on the benefits of CPD in patients that are considered high risk for stroke undergoing cardiac procedures like left atrial appendage (LAA) closure or catheter ablation of ventricular tachycardia (VT) when cardiac thrombus is present. PURPOSE This work aimed to examine the feasibility and safety of the routine use of CPD in patients with cardiac thrombus undergoing interventions in the electrophysiology (EP) lab of a large referral center. METHODS The CPD was placed under fluoroscopic guidance in all procedures in the beginning of the intervention. Two different CPDs were used according to the physician's discretion: (1) a capture device consisting of two filters for the brachiocephalic and left common carotid arteries placed over a 6F sheath from a radial artery; or (2) a deflection device covering all three supra-aortic vessels placed over an 8F femoral sheath. Retrospective periprocedural and safety data were obtained from procedural reports and discharge letters. Long-term safety data were obtained by clinical follow-up in our institution and telephone consultations. RESULTS We identified 30 consecutive patients in our EP lab who underwent interventions (21 LAA closure, 9 VT ablation) with placement of a CPD due to cardiac thrombus. Mean age was 70 ± 10 years and 73% were male, while mean LVEF was 40 ± 14%. The location of the cardiac thrombus was the LAA in all 21 patients (100%) undergoing LAA-closure, whereas, in the 9 patients undergoing VT ablation, thrombus was present in the LAA in 5 cases (56%), left ventricle (n = 3, 33%) and aortic arch (n = 1, 11%). The capture device was used in 19 out of 30 (63%) and the deflection device in 11 out of 30 cases (37%). There were no periprocedural strokes or transitory ischemic attacks (TIA). CPD-related complications comprised the vascular access and were as follows: two cases of pseudoaneurysm of the femoral artery not requiring surgery (7%), 1 hematoma at the arterial puncture site (3%) and 1 venous thrombosis (3%) resolved by warfarin. At long-term follow-up, 1 TIA and 2 non-cardiovascular deaths occurred, with a mean follow-up time of 660 days. CONCLUSIONS Placement of a cerebral protection device prior to LAA closure or VT ablation in patients with cardiac thrombus proved feasible, but possible vascular complications needed to be taken into account. A benefit in periprocedural stroke prevention for these interventions seemed plausible but has yet to be proven in larger and randomized trials.
Collapse
|
17
|
von Kemp MJ, Floré V, Lau CW, De Sutter J, Provenier F, Cornelis K. Impact of routine use of a cerebral protection device on the TAVR procedure and its short-term outcomes: a single-centre experience. Acta Cardiol 2022; 77:922-929. [PMID: 36044035 DOI: 10.1080/00015385.2022.2111128] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Stroke is a major concern in transcatheter aortic valve replacement (TAVR). The introduction of a cerebral protection devices may counteract the evolution towards minimally invasive TAVR. At this time, there is insufficient data to support the routine use of these devices. METHODS We aimed to evaluate the outcome of the routine use of the Sentinel Cerebral protection system® (CPS) in patients undergoing TAVR, after completing a CT-based screening process for feasibility of Sentinel implantation. We report our initial experience with the routine implementation of the Sentinel CPS in all anatomically suitable patients undergoing TAVR. We retrospectively compared the procedural characteristics and outcomes between all TAVR patients treated with (n = 78) and without (n = 79) intended Sentinel. RESULTS The Sentinel CPS could successfully be deployed in 99% of intended cases after CT feasibility screening. TAVR procedures with Sentinel CPS were not longer than procedures without Sentinel use (89 ± 20 versus 120 ± 50 min, p = 0.007). Sentinel CPS use was not associated with an increased risk of procedural complications. Stroke was observed in none (0%) of the Sentinel CPS patients, and in 6.3% of the non-Sentinel CPS patients (p = 0.05). The finding of stroke was associated with a high risk of early postprocedural mortality: 60% of stroke patients died within 3 months. CONCLUSION Routine use of the Sentinel CPS in CT-screened TAVR patients is feasible with high procedural success, without significant adverse events and without counteracting the evolution towards minimally invasive TAVR. Clinically relevant stroke was observed in none of the Sentinel CPS patients.
Collapse
Affiliation(s)
- Marnix J von Kemp
- Cardiology Department, Hartcentrum, AZ Maria Middelares, Ghent, Belgium.,Vrije Universiteit Brussel (VUB) Departement Cardiologie, Brussel, Belgium
| | - Vincent Floré
- Cardiology Department, Hartcentrum, AZ Maria Middelares, Ghent, Belgium
| | - Chirik Wah Lau
- Cardiology Department, Hartcentrum, AZ Maria Middelares, Ghent, Belgium
| | - Johan De Sutter
- Cardiology Department, Hartcentrum, AZ Maria Middelares, Ghent, Belgium
| | - Frank Provenier
- Cardiology Department, Hartcentrum, AZ Maria Middelares, Ghent, Belgium
| | - Kristoff Cornelis
- Cardiology Department, Hartcentrum, AZ Maria Middelares, Ghent, Belgium
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
Kalogeropoulos AS, Redwood SR, Allen CJ, Hurrell H, Chehab O, Rajani R, Prendergast B, Patterson T. A 20-year journey in transcatheter aortic valve implantation: Evolution to current eminence. Front Cardiovasc Med 2022; 9:971762. [PMID: 36479570 PMCID: PMC9719928 DOI: 10.3389/fcvm.2022.971762] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/31/2022] [Indexed: 07/26/2023] Open
Abstract
Since the first groundbreaking procedure in 2002, transcatheter aortic valve implantation (TAVI) has revolutionized the management of aortic stenosis (AS). Through striking developments in pertinent equipment and techniques, TAVI has now become the leading therapeutic strategy for aortic valve replacement in patients with severe symptomatic AS. The procedure streamlining from routine use of conscious sedation to a single arterial access approach, the newly adapted implantation techniques, and the introduction of novel technologies such as intravascular lithotripsy and the refinement of valve-bioprosthesis devices along with the accumulating experience have resulted in a dramatic reduction of complications and have improved associated outcomes that are now considered comparable or even superior to surgical aortic valve replacement (SAVR). These advances have opened the road to the use of TAVI in younger and lower-risk patients and up-to-date data from landmark studies have now established the outstanding efficacy and safety of TAVI in patients with low-surgical risk impelling the most recent ESC guidelines to propose TAVI, as the main therapeutic strategy for patients with AS aged 75 years or older. In this article, we aim to summarize the most recent advances and the current clinical aspects involving the use of TAVI, and we also attempt to highlight impending concerns that need to be further addressed.
Collapse
Affiliation(s)
- Andreas S. Kalogeropoulos
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
- Department of Cardiology, MITERA General Hospital, Hygeia Healthcare Group, Athens, Greece
| | - Simon R. Redwood
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Christopher J. Allen
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Harriet Hurrell
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Omar Chehab
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Ronak Rajani
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
- School of Bioengineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Bernard Prendergast
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Tiffany Patterson
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
20
|
Kapadia SR, Makkar R, Leon M, Abdel-Wahab M, Waggoner T, Massberg S, Rottbauer W, Horr S, Sondergaard L, Karha J, Gooley R, Satler L, Stoler RC, Messé SR, Baron SJ, Seeger J, Kodali S, Krishnaswamy A, Thourani VH, Harrington K, Pocock S, Modolo R, Allocco DJ, Meredith IT, Linke A. Cerebral Embolic Protection during Transcatheter Aortic-Valve Replacement. N Engl J Med 2022; 387:1253-1263. [PMID: 36121045 DOI: 10.1056/nejmoa2204961] [Citation(s) in RCA: 103] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transcatheter aortic-valve replacement (TAVR) for the treatment of aortic stenosis can lead to embolization of debris. Capture of debris by devices that provide cerebral embolic protection (CEP) may reduce the risk of stroke. METHODS We randomly assigned patients with aortic stenosis in a 1:1 ratio to undergo transfemoral TAVR with CEP (CEP group) or without CEP (control group). The primary end point was stroke within 72 hours after TAVR or before discharge (whichever came first) in the intention-to-treat population. Disabling stroke, death, transient ischemic attack, delirium, major or minor vascular complications at the CEP access site, and acute kidney injury were also assessed. A neurology professional examined all the patients at baseline and after TAVR. RESULTS A total of 3000 patients across North America, Europe, and Australia underwent randomization; 1501 were assigned to the CEP group and 1499 to the control group. A CEP device was successfully deployed in 1406 of the 1489 patients (94.4%) in whom an attempt was made. The incidence of stroke within 72 hours after TAVR or before discharge did not differ significantly between the CEP group and the control group (2.3% vs. 2.9%; difference, -0.6 percentage points; 95% confidence interval, -1.7 to 0.5; P = 0.30). Disabling stroke occurred in 0.5% of the patients in the CEP group and in 1.3% of those in the control group. There were no substantial differences between the CEP group and the control group in the percentage of patients who died (0.5% vs. 0.3%); had a stroke, a transient ischemic attack, or delirium (3.1% vs. 3.7%); or had acute kidney injury (0.5% vs. 0.5%). One patient (0.1%) had a vascular complication at the CEP access site. CONCLUSIONS Among patients with aortic stenosis undergoing transfemoral TAVR, the use of CEP did not have a significant effect on the incidence of periprocedural stroke, but on the basis of the 95% confidence interval around this outcome, the results may not rule out a benefit of CEP during TAVR. (Funded by Boston Scientific; PROTECTED TAVR ClinicalTrials.gov number, NCT04149535.).
Collapse
Affiliation(s)
- Samir R Kapadia
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Raj Makkar
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Martin Leon
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Mohamed Abdel-Wahab
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Thomas Waggoner
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Steffen Massberg
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Wolfgang Rottbauer
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Samuel Horr
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Lars Sondergaard
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Juhana Karha
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Robert Gooley
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Lowell Satler
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Robert C Stoler
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Steven R Messé
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Suzanne J Baron
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Julia Seeger
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Susheel Kodali
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Amar Krishnaswamy
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Vinod H Thourani
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Katherine Harrington
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Stuart Pocock
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Rodrigo Modolo
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Dominic J Allocco
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Ian T Meredith
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Axel Linke
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| |
Collapse
|
21
|
Isogai T, Vanguru HR, Krishnaswamy A, Agrawal A, Spilias N, Shekhar S, Saad AM, Verma BR, Puri R, Reed GW, Popović ZB, Unai S, Yun JJ, Uchino K, Kapadia SR. Feasibility of Sentinel Cerebral Embolic Protection Device Deployment During Transfemoral Transcatheter Aortic Valve Replacement. Am J Cardiol 2022; 184:157-159. [PMID: 36192198 DOI: 10.1016/j.amjcard.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/17/2022] [Accepted: 09/02/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | | | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Ankit Agrawal
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Nikolaos Spilias
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Shashank Shekhar
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Anas M Saad
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Beni Rai Verma
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Grant W Reed
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Zoran B Popović
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - James J Yun
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute.
| |
Collapse
|
22
|
Haseeb ul Rasool M, Saleem M, Nadeem M, Maqbool M, Aziz AA, Fox JM, Suleiman A. The Role of Transcatheter Aortic Valve Replacement in Asymptomatic Aortic Stenosis: A Feasibility Analysis. Cureus 2022; 14:e29522. [PMID: 36312695 PMCID: PMC9589522 DOI: 10.7759/cureus.29522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 11/26/2022] Open
Abstract
Surgical aortic valve replacement (SAVR) is the current treatment of choice for good surgical candidates with moderate to severe symptomatic aortic stenosis (AS). As transcatheter aortic valvular replacement (TAVR) has shown an improved one and two-year all-cause mortality, it has been chosen for moderately symptomatic severe AS patients. The purpose of this review was to perform a clinical comparison of TAVR vs. SAVR and to analyze the Health Index Factor (HIF) that makes TAVR a treatment of choice in asymptomatic AS patients. An extensive literature search of PubMed, Cochrane, and Embase databases was performed using the keywords “Aortic stenosis”, “SAVR”, “TAVR”, and “Asymptomatic”. A total of 45 prospective randomized clinical trials in the English language that were published from the year 2000 onwards were included in the final analysis. It has been found that 59.3% of asymptomatic AS patients are likely to die in the next five years without proactive treatment. Multiple studies have proven that early intervention with aortic valve replacement is superior to conservative treatment in severe asymptomatic AS; however, the choice between SAVR and TAVR is not well established. The NOTION Trial, SURTAVI Trail, and PARTNER 3 study have shown the non-inferiority of TAVR over SAVR, during one-year follow-up for low surgical risk patients. Evolut Low-Risk study and Early TAVR are the only two prospective studies performed to date that have enrolled patients with asymptomatic severe AS. The Evolut Trial demonstrated no difference in all-cause mortality at 30 days (1.3% vs. 4.8%. p=0.23), and 12 days (1.3% vs. 6.5%, p=0.11). Additionally, TAVR also decreases the risk of post-procedural atrial fibrillation, acute kidney injury (AKI), and rehospitalization, and leads to significant improvement in the mean trans-aortic pressure gradient. TAVR also showed marked improvement in the 30-day Quality of Life (QOL) index, where SAVR did not report any significant change in the QOL index. However, the official recommendations of Early TAVR are still awaited. TAVR has consistently shown a statistically non-significant difference in case mortality, risk of stroke, and rehospitalization with moderate to high surgical risk patients whereby recent initial trials have shown significant improvement in the QOL index and hemodynamic index for patients with asymptomatic disease. More extensive studies are required to prove the risk stratifications, long-term outcomes, and clinical characteristics that would make TAVR a preferred intervention in asymptomatic patients.
Collapse
|
23
|
Bjursten H, Koul S, Duvernoy O, Fagman E, Samano N, Nilsson J, Nielsen NE, Rück A, Johansson J, James S, Settergren M, Götberg M, Pistea A. Calcium Load in the Aortic Valve, Aortic Root, and Left Ventricular Outflow Tract and the Risk for a Periprocedural Stroke. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100070. [PMID: 37288334 PMCID: PMC10242559 DOI: 10.1016/j.shj.2022.100070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/07/2022] [Accepted: 06/17/2022] [Indexed: 06/09/2023]
Abstract
Background Periprocedural stroke during transcatheter aortic valve implantation is a rare but devastating complication. The calcified aortic valve is the most likely source of the emboli in a periprocedural stroke. The total load and distribution of calcium in the leaflets, aortic root, and left ventricular outflow tract varies from patient to patient. Consequently, there could be patterns of calcification that are associated with a higher risk of stroke. This study aimed to explore whether the pattern of calcification in the left ventricular outflow tract, annulus, aortic valve, and ascending aorta can be used to predict a periprocedural stroke. Methods Among the 3282 consecutive patients who received a transcatheter aortic valve implantation in the native valve in Sweden from 2014 to 2018, we identified 52 who had a periprocedural stroke. From the same cohort, a control group of 52 patients was constructed by propensity score matching. Both groups had one missing cardiac computed tomography, and 51 stroke and 51 control patients were blindly reviewed by an experienced radiologist. Results The groups were well balanced in terms of demographics and procedural data. Of the 39 metrics created to describe calcium pattern, only one differed between the groups. The length of calcium protruding above the annulus was 10.6 mm (interquartile range 7-13.6) for patients without stroke and 8 mm (interquartile range 3-10) for stroke patients. Conclusions This study could not find any pattern of calcification that predisposes for a periprocedural stroke.
Collapse
Affiliation(s)
- Henrik Bjursten
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Sasha Koul
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Olov Duvernoy
- Section of Radiology, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Erika Fagman
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ninos Samano
- Faculty of Medicine and Health, University Health Care Research Centre, Örebro University, Örebro, Sweden
| | - Johan Nilsson
- Institution of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Niels Erik Nielsen
- Department of Cardiology, Heart Centre, University Hospital, Linköping, Sweden
| | - Andreas Rück
- Department of Cardiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
| | - Jan Johansson
- Department of Cardiology, Blekinge Hospital, Karlskrona, Sweden
| | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Magnus Settergren
- Department of Cardiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
| | - Matthias Götberg
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Adrian Pistea
- Department of Radiology, Skåne University Hospital, Lund University, Lund, Sweden
| |
Collapse
|
24
|
Pérez-Camargo D, Travieso A, Carnero-Alcázar M, Taramasso M, Cobiella-Carnicer J, Maroto-Castellanos LC. Neurological outcomes of transcatheter aortic valve implantation with or without cerebral embolic protection devices: A meta-analysis. J Stroke Cerebrovasc Dis 2022; 31:106605. [PMID: 35843052 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106605] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/20/2022] [Accepted: 06/12/2022] [Indexed: 10/17/2022] Open
Abstract
INTRODUCTION Cerebral embolic protection devices (CEPDs) are designed to prevent embolization of debris during transcatheter aortic valve implantation (TAVI). Current evidence from randomized clinical trials (RCTs) and observational studies is controversial. AIMS The purpose of this meta-analysis was to study the influence of CEPDs on stroke, silent ischemic lesions and neurocognitive function. METHODS A systematic search was conducted including RCTs or adjusted observational studies comparing TAVI with or without CEPDs. Pooled odds ratios, risk ratios or standardized mean differences with 95% confidence intervals were calculated using the inverse of variance method. Risk of bias sensitivity analyses and meta regression for CEPD type were also conducted. RESULTS Five RCTs and five adjusted observational studies were included (n= 159,865). Mean age of the patients was 81.1 (SD 1.04) years in CEPDs and 81 (SD 1.86) in non-CEPD. The overall quality of evidence using the GRADE system for each endpoint was low to very low, mainly due to serious risk of bias, inconsistency and imprecision. Random effects meta-analysis detected no significant differences between CEPD and non-CEPD (OR= 0.74; 95% CI 0.51-1.07; P= 0.105; I2= 82.1%) for 30-day stroke. This finding was consistent in meta regression for CEPD type and subgroup analyses by study type and CEPD type. No significant differences between groups were observed in cerebral DW-MRI assessment and neurocognitive function evaluation. CONCLUSION In the present meta- analysis of five RCTs and five adjusted observational studies, the use of a CEPD during TAVI was not associated with a significant benefit on 30- day stroke, total lesion volume per patient, number of ischemic lesions per patient and neurocognitive function assessments.
Collapse
Affiliation(s)
- Daniel Pérez-Camargo
- Cardiac Surgery Department, Hospital Universitario Clínico San Carlos, Madrid, Spain.
| | - Alejandro Travieso
- Cardiology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | | | | | | |
Collapse
|
25
|
A Novel Computed Tomographic Angiography Tortuosity Index to Predict Successful Sentinel Cerebral Embolic Protection Delivery for Transcatheter Aortic Valve Replacement. STRUCTURAL HEART 2022. [DOI: 10.1016/j.shj.2022.100021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
26
|
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
|
27
|
Khokhar AA, Giannini F, Colombo A. Peri‐procedural Complications of Transcatheter Aortic Valve Replacement (TAVR). Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
|
28
|
Deveci OS, Okutucu S, Fatihoglu SG, Oto A. Cerebral embolic protection devices during transcatheter aortic valve implantation, the current state of the art. Acta Cardiol 2022; 77:196-203. [PMID: 33827380 DOI: 10.1080/00015385.2021.1909276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Stroke after transcatheter aortic valve (TAVI) is a devastating adverse event. The majority of these occur in the acute phase following TAVI where cerebral embolic events are frequent. Cerebral embolic protection devices (CEPD) have been developed to minimise the risk of peri-procedural ischaemic stroke during TAVI. CEPD have the potential to lower intraprocedural burden of new silent ischaemic brain injury. Several CEPD have been developed, but their clinical benefit remains unknown. Herein, we aimed to review the impact of the use of CEPD, in patients undergoing TAVI, on the reduction of strokes or the onset of new ischaemic lesions.
Collapse
Affiliation(s)
- Onur Sinan Deveci
- Department of Cardiology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Sercan Okutucu
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
| | | | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
| |
Collapse
|
29
|
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.
Collapse
|
30
|
Embolic Protection with the TriGuard 3 System in Nonagenarian Patients Undergoing Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis. J Clin Med 2022; 11:jcm11072003. [PMID: 35407611 PMCID: PMC8999484 DOI: 10.3390/jcm11072003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/21/2022] [Accepted: 03/28/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Transcatheter aortic valve replacement (TAVR) improves the survival and life quality of nonagenarian patients with aortic stenosis. Stroke remains one of the most worrisome complications following TAVR. Cerebral embolic protection devices (CEPDs) may reduce neurological complications after TAVR. This study evaluated the safety and efficacy of CEPDs during TAVR in nonagenarian patients. Methods: Between January 2018 and October 2021, 869 patients underwent transfemoral TAVR (TF-TAVR) at our center. Of these, 51 (5.9%) patients were older than ninety years. In 33 consecutive nonagenarian patients, TF-TAVR was implanted without CEPDs using balloon-expandable valves (BEVs) and self-expandable valves (SEVs). Eighteen consecutive nonagenarians underwent TF-TAVR using a CEPD (CP group). Follow up period was in-hospital or 30 days after the procedure, respectively. Results: Minor access site complications occurred in two patients (3.9%) and were not CEPD-associated. Postinterventional delirium occurred in nine patients (17.6%). Periprocedural minor non-disabling stroke and delirium occurred in ten patients (19.6%). Periprocedural major fatal stroke occurred in two patients in the BEV group (3.9%). Two patients in the BEV group died due to postinterventional pneumonia with sepsis. The mortality rate was 7.8%. The results did not differ between the groups. Conclusions: Age alone is no longer a contraindication for TAVR. CEPD using the Triguard 3 system in nonagenarian TAVR patients was feasible and safe and did not increase access site complications.
Collapse
|
31
|
Outcomes in Patients With Asymptomatic Aortic Stenosis (from the Evolut Low Risk Trial). Am J Cardiol 2022; 168:110-116. [PMID: 35101271 DOI: 10.1016/j.amjcard.2021.12.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 01/04/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) has comparable outcomes with surgical aortic valve replacement (SAVR) in symptomatic patients with severe aortic stenosis, including those at low risk for surgery. Less is known about TAVI outcomes in asymptomatic patients. This analysis compares clinical, hemodynamic, and quality of life (QOL) outcomes after TAVI or SAVR for low-risk asymptomatic patients. The randomized Evolut Low Risk trial enrolled asymptomatic patients treated with TAVI (n = 76) and SAVR (n = 62). New York Heart Association functional class I identified patients without symptoms. Clinical outcomes, echocardiographic findings, and QOL in both groups were compared 30 days and 12 months after AVR. Asymptomatic patients had a mean Society of Thoracic Surgeons score of 1.7 ± 0.6, 73% were men, and mean age was 74.2 ± 5.8 years. The composite end point of all-cause mortality or disabling stroke was similar at 12 months in patients with TAVI (1.3%) and SAVR (6.5%; p = 0.11), although patients with SAVR tended to have higher rates of all-cause mortality (4.8%) compared with patients with TAVI (0.0%, p = 0.05). Patients with TAVI had lower mean aortic valve gradients (8.1 ± 3.2 mm Hg) and larger mean effective orifice area (2.3 ± 0.6 mm Hg) than patients with SAVR (10.8 ± 3.8; p <0.001 and 1.9 ± 0.6; p = 0.001, respectively), and showed significant improvement in Kansas City Cardiomyopathy Questionnaire scores from baseline to 30 days (∆12.1 ± 23.6; p <0.001), whereas patients with SAVR did not (∆2.2 ± 20.3; p = 0.398). Patients with TAVI and SAVR had a significant improvement in QOL by 12 months compared with baseline. In conclusion, low risk asymptomatic patients with severe aortic stenosis who underwent TAVI had comparable clinical outcomes to SAVR, with superior valve performance and faster QOL improvement.
Collapse
|
32
|
Prevalence and Prognostic Impact of Carotid Artery Disease in Patients Undergoing TAVI. Ann Vasc Surg 2022; 84:61-68. [PMID: 35341937 DOI: 10.1016/j.avsg.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the prevalence of atherosclerotic carotid artery disease (ACAD) in patients undergoing transcatheter aortic valve implantation (TAVI) and postoperative cerebrovascular and evaluate its prognostic impact on post-operative cerebrovascular incidents (CVA). METHODS Retrospective review of all consecutive patients with severe symptomatic aortic valve stenosis (AVS) who underwent TAVI at a single tertiary university hospital (January 2008-December 2018). Patients with AVS scheduled for TAVI and concomitant carotid stenosis were evaluated for prophylactic carotid revascularization (carotid endarterectomy, CEA or carotid artery stenting, CAS). RESULTS 771 consecutive patients (mean age 80 years, 52% males), were treated by TAVI procedures. Carotid stenosis >70% was detected in 69 patients (9%); it was unilateral in 47 (68%) and bilateral in 22 (32%). Prophylactic carotid revascularization was performed before TAVI in 45 patients (31%): in 63.1% of patients (30/47) with unilateral carotid stenosis >70%, and in 68.1% (15/22) with bilateral carotid stenosis >70%. Postoperative CVA following TAVI procedures were recorded in 25 patients (3.2%): 22 cases of stroke (2.8%) and 3 cases of transient ischemic attack (0.4%). At multiple logistic regression, only bilateral carotid stenosis >70% (OR 1.16, CI 95% 1.03-1.31; p=.0009) was found as independent predictors of periprocedural CVA. CONCLUSIONS In patients with severe symptomatic AVS undergoing TAVI, carotid stenosis was frequently observed. Unilateral carotid stenosis >70% did not show a significant association with early CVA following TAVI. However, in the cohort of patients with bilateral carotid stenosis >70%, a significant association with postoperative CVA was observed.
Collapse
|
33
|
Donà C, Koschutnik M, Nitsche C, Winter MP, Seidl V, Siller-Matula J, Mach M, Andreas M, Bartko P, Kammerlander AA, Goliasch G, Lang I, Hengstenberg C, Mascherbauer J. Cerebral Protection in TAVR-Can We Do Without? A Real-World All-Comer Intention-to-Treat Study-Impact on Stroke Rate, Length of Hospital Stay, and Twelve-Month Mortality. J Pers Med 2022; 12:jpm12020320. [PMID: 35207808 PMCID: PMC8878932 DOI: 10.3390/jpm12020320] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Stroke associated with transcatheter aortic valve replacement (TAVR) is a potentially devastating complication. Until recently, the Sentinel™ Cerebral Protection System (CPS; Boston Scientific, Marlborough, MA, USA) has been the only commercially available device for mechanical prevention of TAVR-related stroke. However, its effectiveness is still undetermined. Objectives: To explore the impact of Sentinel™ on stroke rate, length of hospital stay (LOS), and twelve-month mortality in a single-center, real-world, all-comers TAVR cohort. Material and Methods: Between January 2019 and August 2020 consecutive patients were assigned to TAVR with or without Sentinel™ in a 1:1 fashion according to the treating operator. We defined as primary endpoint clinically detectable cerebrovascular events within 72 h after TAVR and as secondary endpoints LOS and 12-month mortality. Logistic and linear regression analyses were used to assess associations of Sentinel™ use with endpoints. Results: Of 411 patients (80 ± 7 y/o, 47.4% female, EuroSCORE II 6.3 ± 5.9%), Sentinel™ was used in 213 (51.8%), with both filters correctly deployed in 189 (46.0%). Twenty (4.9%) cerebrovascular events were recorded, ten (2.4%) of which were disabling strokes. Patients with Sentinel™ suffered 71% less (univariate analysis; OR 0.29, 95%CI 0.11–0.82; p = 0.02) and, respectively, 76% less (multivariate analysis; OR 0.24, 95%CI 0.08–0.76; p = 0.02) cerebrovascular events compared to patients without Sentinel™. Sentinel™ use was also significantly associated with shorter LOS (Regression coefficient −2.47, 95%CI −4.08, −0.87; p < 0.01) and lower 12-month all-cause mortality (OR 0.45; 95%CI 0.22–0.93; p = 0.03). Conclusion: In the present prospective all-comers TAVR cohort, patients with Sentinel™ use showed (1) lower rates of cerebrovascular events, (2) shortened LOS, and (3) improved 12-month survival. These data promote the use of a CPS when implanting TAVR valves.
Collapse
Affiliation(s)
- Carolina Donà
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Matthias Koschutnik
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Christian Nitsche
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Max-Paul Winter
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Veronika Seidl
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Jolanta Siller-Matula
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Markus Mach
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.M.); (M.A.)
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.M.); (M.A.)
| | - Philipp Bartko
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Andreas Anselm Kammerlander
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Georg Goliasch
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Irene Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Christian Hengstenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Julia Mascherbauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
- Department of Internal Medicine 3, University Hospital St. Poelten, Karl Landsteiner University of Health Sciences, 3500 Krems, Austria
- Correspondence: ; Tel.: +43-1-40400-46140; Fax: +43-1-40400-42160
| |
Collapse
|
34
|
Gill D, Jaber WA, Keeling WB, Thames MD. Thrombi straddling patent foramen ovale: A case series with various management strategies. Catheter Cardiovasc Interv 2022; 99:1683-1686. [PMID: 35170845 DOI: 10.1002/ccd.30131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 11/10/2022]
Abstract
This case series explores four cases of thrombi straddling patent foramen ovale (TSFO), an exceedingly rare event. The cases are compared regarding their presentations, evaluations, and management strategies including the first documented uses of percutaneous thromboembolectomy for the removal of a TSFO.
Collapse
Affiliation(s)
- Deanna Gill
- Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Wissam A Jaber
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - William B Keeling
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Marc D Thames
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
35
|
Zahid S, Ullah W, Zia Khan M, Faisal Uddin M, Rai D, Abbas S, Usman Khan M, Hussein A, Salama A, Bandyopadhyay D, Bhaibhav B, Rao M, Alam M, Alraies C, Balla S, Alkhouli M, Depta JP. Cerebral Embolic Protection during Transcatheter Aortic Valve Implantation: Updated Systemic Review and Meta-Analysis. Curr Probl Cardiol 2022; 48:101127. [PMID: 35124076 DOI: 10.1016/j.cpcardiol.2022.101127] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/25/2022] [Indexed: 11/03/2022]
Abstract
In patient undergoing transcatheter aortic valve implantation (TAVI), stroke remains a potentially devastating complication associated with significant morbidity, and mortality. To reduce the risk of stroke, cerebral protection devices (CPD) were developed to prevent debris from embolizing to the brain during TAVI. We performed a systematic review and meta-analysis to determine the safety and efficacy of CPD in TAVI. The MEDLINE (PubMed, Ovid) and Cochrane databases were queried with various combinations of medical subject headings to identify relevant articles. Statistical analysis was performed using a random-effects model to calculate unadjusted odds ratio (OR), including subgroup analyses based on follow-up duration, study design, and type of CPD. Using a pooled analysis, CPD was associated with a significant reduction in major adverse cardiovascular events MACE (OR 0.75, 95% CI 0.70-0.81, P < 0.01), mortality (OR 0.65, 95% CI 0.58-0.74, P < 0.01) and stroke (OR 0.84, 95% CI 0.76-0.93, P < 0.01) in patients undergoing TAVI. Similarly, on MRI volume per lesion were lower for patients with CPD use. No significant difference was observed in acute kidney injury (OR 0.75, 95% CI 0.42-1.37, P = 0.68), bleeding (OR 0.92, 95% CI 0.71-1.20, P = 0.55) or vascular complications (OR 0.90, 95% CI 0.62-1.31, P = 0.6) for patients undergoing TAVI with CPD. In conclusion, CPD device use in TAVI is associated with a reduction of MACE, mortality, and stroke compared with patients undergoing TAVI without CPD. However, the significant reduction in mortality is driven mainly by observational studies.
Collapse
|
36
|
Atherosclerotic Disease of the Proximal Aorta. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00033-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
37
|
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
|
38
|
Riley KJ, Kao LW, Low YH, Card S, Manalo G, Fleming JP, Essandoh MK, Dalia AA, Qu JZ. Neurologic Dysfunction and Neuroprotection in Transcatheter Aortic Valve Implantation. J Cardiothorac Vasc Anesth 2021; 36:3224-3236. [PMID: 34903454 DOI: 10.1053/j.jvca.2021.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/07/2021] [Accepted: 11/08/2021] [Indexed: 11/11/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is a fast-growing procedure. Expanding to low-risk patients, it has surpassed surgical aortic valve implantation in frequency and has been associated with excellent outcomes. Stroke is a devastating complication after transcatheter aortic valve implantation. Silent brain infarcts identified by diffusion-weighted magnetic resonance imaging are present in most patients following TAVI. Postoperative delirium and cognitive dysfunction are common neurologic complications. The stroke and silent brain infarcts are likely caused by particulate emboli released during the procedure. Intravascularly positioned cerebral embolic protection devices are designed to prevent debris from entering the aortic arch vessels to avoid stroke. Despite promising design, randomized clinical trials have not demonstrated a reduction in stroke in patients receiving cerebral embolic protection devices. Similarly, the association of cerebral embolic protection devices with silent brain infarcts, postoperative delirium, and cognitive dysfunction is uncertain. Monitored anesthesia care or conscious sedation is as safe as general anesthesia and is associated with lower cost, but different anesthetic techniques have not been shown to decrease stroke risk, postoperative delirium, or cognitive dysfunction. Anesthesiologists play important roles in providing perioperative care including management of neurologic events in patients undergoing TAVI. Large randomized clinical trials are needed that focus on the correlation between perioperative interventions and neurologic outcomes.
Collapse
Affiliation(s)
- Kyle J Riley
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lee-Wei Kao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ying H Low
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Shika Card
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Gem Manalo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey P Fleming
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael K Essandoh
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jason Z Qu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
39
|
Shimamura J, Kuno T, Malik A, Yokoyama Y, Gupta R, Ahmad H, Briasoulis A. Safety and efficacy of cerebral embolic protection devices in patients undergoing transcatheter aortic valve replacement: a meta-analysis of in-hospital outcomes. Cardiovasc Interv Ther 2021; 37:549-557. [PMID: 34773568 DOI: 10.1007/s12928-021-00823-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 11/01/2021] [Indexed: 12/19/2022]
Abstract
The evidence regarding the impact of cerebral embolic protection devices (EPDs) on outcomes following transcatheter aortic valve replacement (TAVR) is limited. The objective of this study was to evaluate in-hospital outcomes with the use of cerebral EPDs in TAVR. We performed a comprehensive EMBASE and PUBMED search to investigate randomized control studies or propensity score-matched retrospective studies which assessed patients undergoing TAVR with or without EPD up to April 2021. Endpoints of interest were in-hospital mortality, stroke, acute kidney injury, pacemaker implantation, major bleeding, vascular complication, length of stay. Ten studies involving 173,002 patients with EPD (n = 16,898, 9.8%) and those without (n = 156,104, 90.2%) fulfilled the inclusion criteria. The use of EPD was associated with significantly lower risk of in-hospital stroke (odds ratio [95% confidential interval]: 0.64 [0.46; 0.89]), but similar rate of in-hospital mortality (odds ratio [95% confidential interval]: 0.75 [0.54; 1.05]). No differences were observed in acute kidney injury, pacemaker implantation, major bleeding, vascular complication, length of stay. EPD during TAVR was associated with lower in-hospital stroke but did not affect procedural complications and length of stay.
Collapse
Affiliation(s)
- Junichi Shimamura
- Division of Cardiac Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein Medical College, Bronx, NY, USA
| | - Aaqib Malik
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | | | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, USA
| | - Hasan Ahmad
- Division of Cardiology, Westchester Medical Center, Valhalla, NY, USA
| | - Alexandros Briasoulis
- Section of Heart Failure and Transplant, Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA, 52242, USA.
| |
Collapse
|
40
|
Majmundar M, Kumar A, Kalra A. Impact of Embolic Protection Device Placed During Transcatheter Aortic Valve Implantation on Postdischarge Stroke Prevention. Am J Cardiol 2021; 158:150-152. [PMID: 34465461 DOI: 10.1016/j.amjcard.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 08/03/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Monil Majmundar
- Department of Cardiology, Maimonides Medical Center, Brooklyn, New York; Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, Ohio
| | - Ashish Kumar
- Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, Ohio; Department of Internal Medicine, Cleveland Clinic Akron General, Akron, Ohio
| | - Ankur Kalra
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, Ohio; Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| |
Collapse
|
41
|
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.
Collapse
|
42
|
Voss S, Campanella C, Burri M, Trenkwalder T, Sideris K, Erlebach M, Ruge H, Krane M, Vitanova K, Lange R. Anatomical reasons for failure of dual-filter cerebral embolic protection application in TAVR: A CT-based analysis. J Card Surg 2021; 36:4537-4545. [PMID: 34580919 DOI: 10.1111/jocs.16025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/06/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The dual-filter Sentinel™ Cerebral Protection System (Sentinel-CPS) is increasingly used during transcatheter aortic valve replacement (TAVR). However, complex vascular anatomy may challenge Sentinel-CPS deployment. AIM OF THE STUDY We sought to investigate the impact of anatomic features of the aortic arch and the supra-aortic arteries on technical device failure of Sentinel-CPS application. METHODS Analysis of the multislice computed tomography pre-TAVR aortograms of all patients undergoing TAVR with Sentinel-CPS between 2016 and 2020 (n = 92) was performed. We investigated the impact of aortic arch anatomy, configuration, and the angles of the supra-aortic arteries, including the determination of vascular tortuosity index on device failure of Sentinel-CPS application. RESULTS The Sentinel-CPS was applied successfully in 83 patients (90.2%). Device failure in nine patients (9.8%) was due to the infeasibility to perform correct deployment of both filters (n = 7) and to obtain peripheral radial access (n = 2). Patients with a failure of Sentinel-CPS application had a higher right subclavian tortuosity index (217 [92-324] vs. 150 [42-252], p = .046), a higher brachiocephalic tortuosity index (27 [5-51] vs. 10 [0-102], p = 0.033) and a larger angulation of the brachiocephalic artery (59° [22-80] vs. 39° [7-104], p = .014) compared with patients with successful application. A brachiocephalic angle more than 59° was predictive for device failure. No differences in aortic arch anatomy or common carotid artery tortuosity were detected between the groups. CONCLUSIONS Brachiocephalic tortuosity was found to be associated with failure of Sentinel-CPS application. Filter-based usage should be avoided in TAVR patients with a brachiocephalic angle more than 59°.
Collapse
Affiliation(s)
- Stephanie Voss
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Caterina Campanella
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Teresa Trenkwalder
- Klinik für Herz- und Kreislauferkrankungen, German Heart Centre Munich, Technical University Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research) - Partner Site Munich Heart Alliance, Munich, Germany
| | - Konstantinos Sideris
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Magdalena Erlebach
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Hendrik Ruge
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Markus Krane
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Keti Vitanova
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technical University Munich, Munich, Germany.,Department of Cardiovascular Surgery, Insure (Institute of Translational Cardiac Surgery), German Heart Centre Munich, Technical University Munich, Munich, Germany.,DZHK (German Centre for Cardiovascular Research) - Partner Site Munich Heart Alliance, Munich, Germany
| |
Collapse
|
43
|
Kolte D, Khera S, Nazir S, Butala NM, Bhatt DL, Elmariah S. Trends in Cerebral Embolic Protection Device Use and Association With Stroke Following Transcatheter Aortic Valve Implantation. Am J Cardiol 2021; 152:106-112. [PMID: 34147212 DOI: 10.1016/j.amjcard.2021.04.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
Stroke remains a serious complication of transcatheter aortic valve implantation (TAVI). Prior studies examining the association between cerebral embolic protection device (CEPD) use and stroke following TAVI have produced conflicting results. We used the Nationwide Readmissions Databases to identify all percutaneous (non-transapical) TAVIs performed in the US from July, 2017 to December, 2018. Overlap propensity score weighted logistic regression models were used to determine the association between CEPD use and outcomes. The primary outcome was in-hospital stroke or transient ischemic attack (TIA). Among 50,000 percutaneous TAVIs (weighted national estimate: 88,886 [SE: 2,819]), CEPD was used in 2,433 (weighted national estimate: 3,497 [SE: 857]). Nationally, the utilization rate of CEPD was 3.9% (SE: 0.9%) of all TAVIs during the overall study period, which increased from 0.8% (SE: 0.4%) in 2017Q3 to 7.6% (SE: 1.6%) in 2018Q4 (p<0.001). The proportion of hospitals using CEPD increased from 2.3% in 2017Q3 to 14.7% in 2018Q4 (p<0.001). There were no significant differences in rates of in-hospital stroke/TIA in TAVIs with versus without CEPD (2.6% vs 2.2%; unadjusted OR [95% CI] 1.18 [0.98-1.52]; overlap propensity score weighted OR [95% CI] 1.19 [0.81-1.75]). CEPD use was not associated with statistically significant lower rates of in-hospital stroke, ischemic stroke, hemorrhagic stroke, TIA, all-cause mortality, or discharge to skilled nursing facility. In conclusion, the rates of CEPD utilization and proportion of TAVI hospitals using CEPD increased during the study period. The use of CEPD during TAVI was not associated with statistically significant lower rates of in-hospital stroke, TIA, or mortality.
Collapse
|
44
|
Stachon P, Kaier K, Heidt T, Wolf D, Duerschmied D, Staudacher D, Zehender M, Bode C, von Zur Mühlen C. The Use and Outcomes of Cerebral Protection Devices for Patients Undergoing Transfemoral Transcatheter Aortic Valve Replacement in Clinical Practice. JACC Cardiovasc Interv 2021; 14:161-168. [PMID: 33478631 DOI: 10.1016/j.jcin.2020.09.047] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/23/2020] [Accepted: 09/29/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES This study hypothesized that cerebral protection prevents strokes in patients undergoing transfemoral transcatheter aortic valve replacement (TAVR) in clinical practice. BACKGROUND Preventing strokes is an important aim in TAVR procedures. Embolic protection devices may protect against cardiac embolism during TAVR, but their use and outcomes in clinical practice remain controversial. METHODS Isolated transfemoral TAVR procedures performed in Germany with or without cerebral protection devices were extracted from a comprehensive nationwide billing dataset. RESULTS A total of 41,654 TAVR procedures performed between 2015 and 2017 were analyzed. The overall share of procedures incorporating cerebral protection devices was 3.8%. Patients receiving cerebral protection devices were at increased operative risk (European System for Cardiac Operative Risk Evaluation score 13.8 vs. 14.7; p < 0.001) but of lower age (81.1 vs. 80.6 years; p = 0.001). To compare outcomes that may be related to the use of cerebral protection devices, a propensity score comparison was performed. The use of a cerebral protection device did not reduce the risk for stroke (adjusted risk difference [aRD]: +0.88%; 95% confidence interval [CI]: -0.07% to 1.83%; p = 0.069) or the risk for developing delirium (aRD: +1.31%; 95% CI: -0.28% to 2.89%; p = 0.106) as a sign of acute brain failure. Although brain damage could not be prevented, in-hospital mortality was lower in the group receiving a cerebral protection device (aRD: -0.76%; 95% CI: -1.46% to -0.06%; p = 0.034). CONCLUSIONS In this large national database, cerebral embolic protection devices were infrequently used during TAVR procedures. Device use was associated with lower mortality but not a reduction in stroke or delirium. Future studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Peter Stachon
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Klaus Kaier
- Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Timo Heidt
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dennis Wolf
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid Staudacher
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Mühlen
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
45
|
Alachkar MN, Schröder J, Autschbach R, Almalla M. A case report of transcatheter mitral valve repair in patient with severe acute mitral regurgitation, cardiogenic shock, and left atrial appendage thrombus as a rescue therapy: facing all enemies at once! EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab266. [PMID: 34296060 PMCID: PMC8290117 DOI: 10.1093/ehjcr/ytab266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/08/2021] [Accepted: 06/09/2021] [Indexed: 11/18/2022]
Abstract
Background Transcatheter mitral valve repair (TMVR) in patients with severe acute mitral regurgitation (MR) and high surgical risk has been described. Moreover, the use of cerebral protection device (CPD) during TMVR in patients without evidence of intracardiac thrombus has been investigated. To the best of our knowledge, TMVR as a rescue therapy in a patient with acute ischaemic MR, cardiogenic shock, and left atrial appendage (LAA) thrombus with concurrent use of CPD has not been reported. Case summary A 59-year-old female with subacute lateral myocardial infarction caused by subacute stent thrombosis after stent implantation in the left circumflex artery 3 weeks previously presented with acute heart failure due to acute severe MR at a peripheral hospital. The patient was transferred to our tertiary centre for operative mitral valve repair. Transoesophageal echocardiogram revealed the presence of LAA thrombus. During the admission, the patient developed an electrical storm and cardiogenic shock. Because of the extremely high surgical risk and the lack of other therapeutic options, the patient was treated with TMVR (MitraClip™, Abbott Structural Heart Devices, Santa Clara, CA, USA) with the use of CPD (Sentinel™; Boston scientific) as a rescue therapy. After the procedure, the clinical and haemodynamic conditions of the patient improved significantly, and she could be discharged home without any neurological sequelae. Conclusion TMVR with concurrent use of CPD as a rescue therapy may be considered in non-operable patients with cardiogenic shock caused by acute severe MR and evidence of LAA thrombus when no other therapy options are possible.
Collapse
Affiliation(s)
- Mhd Nawar Alachkar
- Department of Cardiology, Angiology and Intensive Care, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Jörg Schröder
- Department of Cardiology, Angiology and Intensive Care, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Rüdiger Autschbach
- Department of Heart Surgery, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Mohammad Almalla
- Department of Cardiology, Angiology and Intensive Care, University Hospital RWTH Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| |
Collapse
|
46
|
Risk of Stroke After Transcatheter Aortic Valve Implantation: Epidemiology, Mechanism, and Management. Am J Ther 2021; 28:e560-e572. [PMID: 34491954 DOI: 10.1097/mjt.0000000000001413] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) has become an established and increasingly used approach for management of severe symptomatic aortic stenosis, showing similar or even superior outcomes compared with standard surgical aortic valve replacement (SAVR). Stroke after TAVI is a relatively rare, but serious complication, associated with potential prolonged disability and increased mortality. AREAS OF UNCERTAINTY The overall incidence of 30-day stroke in TAVI patients is 3%-4%, but varies between different trials. Initial data suggested a higher risk of stroke after TAVI when compared with SAVR. The association between subclinical leaflet thrombosis and cerebral embolism, presented as stroke, transient ischemic accident, or silent cerebral ischemia is not entirely elucidated yet. Moreover, TAVI for severe bicuspid aortic stenosis is a relatively new issue, bicuspid anatomy being initially excluded from the pivotal clinical trials investigating TAVI procedure. Efficient stroke prevention strategies are under investigation. DATA SOURCES In the present manuscript, we used the available published data from the most relevant clinical trials, registries, and meta-analysis of patients from different risk categories who underwent TAVI or SAVR. THERAPEUTIC ADVANCES Predictors of acute stroke are mainly procedure related. Technological development, improvements in bioprosthesis valve delivery catheters, and implantation technique may explain the decrease of stroke over the years since the beginning of TAVI procedures. CONCLUSIONS The overall evidences confirm similar or lower rate of stroke in TAVI versus SAVR. Risk predictors for acute stroke after TAVI are generally related to procedural factors, whereas late stroke is mainly associated with patient characteristics, with a variable impact on cognitive function. The optimal choice for the antithrombotic treatment in TAVI for stroke prevention is yet to be determined. Current data do not support routine use of cerebral embolic protection devices during TAVI.
Collapse
|
47
|
Khan MZ, Zahid S, Khan MU, Kichloo A, Ullah W, Sattar Y, Munir MB, Singla A, Goldsweig AM, Balla S. Use and outcomes of cerebral embolic protection for transcatheter aortic valve replacement: A US nationwide study. Catheter Cardiovasc Interv 2021; 98:959-968. [PMID: 34145716 DOI: 10.1002/ccd.29842] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/10/2021] [Accepted: 06/11/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND Outcomes data on the use of cerebral embolic protection devices (CPDs) with transcatheter aortic valve replacement (TAVR) remain limited. Previous randomized trials were underpowered for primary outcomes of stroke prevention and mortality. METHODS The National Inpatient Sample and Nationwide Readmissions Database were queried from 2017 to 2018 to study utilization and inpatient mortality, neurological complications (ischemic stroke, hemorrhagic stroke, and transient ischemic attack), procedural complications, resource utilization, and 30-day readmissions with and without use of CPD. A 1:3 ratio propensity score matched model was created. RESULTS Among 108,315 weighted encounters, CPD was used in 4380 patients (4.0%). Adjusted mortality was lower in patients undergoing TAVR with CPD (1.3% vs. 0.5%, p < 0.01). Neurological complications (2.5% vs. 1.7%, p < 0.01), hemorrhagic stroke (0.2% vs. 0%, p < 0.01) and ischemic stroke (2.2% vs. 1.4%, p < 0.01) were also lower in TAVR with CPD. Multiple logistic regression showed CPD use was associated with lower adjusted mortality (odds ratio (OR], 0.34 [95% confidence interval [CI], 0.22-0.52), p < 0.01) and lower adjusted neurological complications (OR, 0.68 (95% CI, 0.54-0.85], p < 0.01). On adjusted analysis, 30-day all-cause readmissions (Hazard ratio, HR 0.839, [95% CI, 0.773-0.911], p < 0.01) and stroke (HR, 0.727 [95% CI, 0.554-0.955), p = 0.02) were less likely in TAVR with CPD. CONCLUSION We report real-world data on utilization and in-hospital outcomes of CPD use in TAVR. CPD use is associated with lower inpatient mortality, neurological, and clinical complications as compared to TAVR without CPD.
Collapse
Affiliation(s)
- Muhammad Zia Khan
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Salman Zahid
- Department of Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Muhammad U Khan
- Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA
| | - Asim Kichloo
- Division of medicine, St. Mary's of Saginaw Hospital, Saginaw, Michigan, USA
| | - Waqas Ullah
- Division of medicine, Abington Jefferson Health, Abington, Pennsylvania, USA
| | - Yasar Sattar
- Division of medicine, Icahn school of Medicine at Mount Sinai Elmhurst Hospital, New York, New York, USA
| | - Muhammad Bilal Munir
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California, USA
| | - Atul Singla
- Division of Cardiology/Department. of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sudarshan Balla
- Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA
| |
Collapse
|
48
|
Butala NM, Makkar R, Secemsky EA, Gallup D, Marquis-Gravel G, Kosinski AS, Vemulapalli S, Valle JA, Bradley SM, Chakravarty T, Yeh RW, Cohen DJ. Cerebral Embolic Protection and Outcomes of Transcatheter Aortic Valve Replacement: Results From the Transcatheter Valve Therapy Registry. Circulation 2021; 143:2229-2240. [PMID: 33619968 PMCID: PMC8184596 DOI: 10.1161/circulationaha.120.052874] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/27/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke remains a devastating complication of transcatheter aortic valve replacement (TAVR), which has persisted despite refinements in technique and increased operator experience. While cerebral embolic protection devices (EPDs) have been developed to mitigate this risk, data regarding their impact on stroke and other outcomes after TAVR are limited. METHODS We performed an observational study using data from the Society for Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Patients were included if they underwent elective or urgent transfemoral TAVR between January 2018 and December 2019. The primary outcome was in-hospital stroke. To adjust for confounding, the association between EPD use and clinical outcomes was evaluated using instrumental variable analysis, a technique designed to support causal inference from observational data, with site-level preference for EPD use within the same quarter of the procedure as the instrument. We also performed a propensity score-based secondary analysis using overlap weights. RESULTS Our analytic sample included 123 186 patients from 599 sites. The use of EPD during TAVR increased over time, reaching 28% of sites and 13% of TAVR procedures by December 2019. There was wide variation in EPD use across hospitals, with 8% of sites performing >50% of TAVR procedures with an EPD and 72% performing no procedures with an EPD in the last quarter of 2019. In our primary analysis using the instrumental variable model, there was no association between EPD use and in-hospital stroke (adjusted relative risk, 0.90 [95% CI, 0.68-1.13]; absolute risk difference, -0.15% [95% CI, -0.49 to 0.20]). However, in our secondary analysis using the propensity score-based model, EPD use was associated with 18% lower odds of in-hospital stroke (adjusted odds ratio, 0.82 [95% CI, 0.69-0.97]; absolute risk difference, -0.28% [95% CI, -0.52 to -0.03]). Results were generally consistent across the secondary end points, as well as subgroup analyses. CONCLUSIONS In this nationally representative observational study, we did not find an association between EPD use for TAVR and in-hospital stroke in our primary instrumental variable analysis, and found only a modestly lower risk of in-hospital stroke in our secondary propensity-weighted analysis. These findings provide a strong basis for large-scale randomized, controlled trials to test whether EPDs provide meaningful clinical benefit for patients undergoing TAVR.
Collapse
Affiliation(s)
- Neel M. Butala
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston MA
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Raj Makkar
- Cedars–Sinai Medical Center, Los Angeles, CA
| | - Eric A. Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | | | | | | | | | - Javier A. Valle
- University of Colorado School of Medicine, Aurora, CO and Michigan Heart and Vascular Institute, Ann Arbor, MI
| | | | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston MA
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, NY
- St. Francis Hospital, Roslyn, NY
| |
Collapse
|
49
|
Chiang J, Mathevosian S, Aboulhosn J, Moriarty JM. Prevention of Paradoxical Cerebral Embolus with Protection System during Combination Right Atrial Clot Aspiration Thrombectomy and Closure of Patent Foramen Ovale. THE ARAB JOURNAL OF INTERVENTIONAL RADIOLOGY 2021. [DOI: 10.1055/s-0041-1730117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AbstractIn this technical case report, we describe a 41-year-old female with a history of breast cancer who was found to have a right atrial clot attached to the tip of her Port-A-Cath. During transthoracic echocardiography to evaluate her clot, she was also noted to also have a patent foramen ovale. The decision was made to perform a simultaneous right atrial endovascular aspiration thrombectomy and patent foramen ovale closure. To minimize the risk for paradoxical embolus during clot manipulation, an intravascular embolic neuroprotection device was deployed. After the procedure, it was noted on visual inspection that the device filter contained several embolic fragments. The presence of macroscopic embolic fragments in the filter baskets highlights the role of prophylactic embolic protection when performing cardiac interventions in the setting of a patent foramen ovale, particularly in the presence of a right atrial thrombus or mass.
Collapse
Affiliation(s)
- Jason Chiang
- Department of Radiology, Ronald Reagan UCLA Medical Center, Los Angeles, California, United States
| | - Sipan Mathevosian
- Department of Radiology, Ronald Reagan UCLA Medical Center, Los Angeles, California, United States
| | - Jamil Aboulhosn
- Division of Cardiology, Ronald Reagan UCLA Medical Center, Los Angeles, California, United States
| | - John M Moriarty
- Department of Radiology, Ronald Reagan UCLA Medical Center, Los Angeles, California, United States
| |
Collapse
|
50
|
Binder RK, Dweck M, Prendergast B. The year in cardiology: valvular heart disease. Eur Heart J 2021; 41:912-920. [PMID: 31901941 DOI: 10.1093/eurheartj/ehz948] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 11/23/2019] [Accepted: 12/24/2019] [Indexed: 01/01/2023] Open
Abstract
Abstract
Collapse
Affiliation(s)
- Ronald K Binder
- Department of Cardiology and Intensive Care, Klinikum Wels, Wels, Austria
| | - Marc Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Bernard Prendergast
- Department of Cardiology, St Thomas' Hospital and Cleveland Clinic, London, UK
| |
Collapse
|