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Mughal MS, Mirza HM, Bansal A, Kumar S, Ghani A, Yarkoni A, Waqar F, Wasty N, Rehman A. Outcomes in transcatheter aortic valve replacement (TAVR) patients requiring red blood cell transfusion: A nationwide perspective. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00557-8. [PMID: 38969562 DOI: 10.1016/j.carrev.2024.06.019] [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: 03/03/2024] [Revised: 06/06/2024] [Accepted: 06/26/2024] [Indexed: 07/07/2024]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) can be complicated by anemia due to periprocedural bleeding, hemolysis, vascular events, or significant bleeding associated with antiplatelet therapy. OBJECTIVE We used the National Inpatient Sample (NIS) database to study the outcomes of patients who underwent TAVR and developed significant anemia requiring red blood cell (RBC) transfusion. METHODS This is a retrospective cohort study utilizing the NIS database from 2016 to 2017. We identified patients who underwent TAVR and required RBC transfusion using ICD-10 and PCS-10 codes. The primary outcome was all-cause inpatient mortality, and the secondary outcomes were the cost of hospitalization and length of stay (LOS). Student t-test, Chi-square, and ANOVA were utilized for statistical analysis where applicable. Multivariate logistic regression was used to adjust for potential confounders. STATA 15.0 was utilized for data analysis. RESULTS A total of 18,325 patients underwent TAVR in 2016-2017. Among them, 6.7 % of patients required RBC transfusion. Patients were relatively older in the transfusion group (81 yrs vs 79 yrs; p < 0.001). The mean cost of hospitalization was higher in the transfusion group (283,153 USD vs 208,939 USD; p < 0.001). The mean length of stay (LOS) was higher in the transfusion group (9.0 days vs 4.3 days; p < 0.001). Patients in the transfusion group had higher inpatient all-cause mortality compared to patients without transfusion (6.1 % vs 1.3 %; odds ratio 4.94; p < 0.001, 95 % CI 3.7-6.4). Inpatient mortality and LOS didn't differ by race or sex in the transfusion group. All-cause mortality, LOS, and cost of hospitalization were independently increased by transfusion after adjusting for potential confounders i.e. sex, race, hospital teaching status, hospital region, heart block, pacemaker, arrhythmias, heart failure, diabetes, pulmonary hypertension, CKD, and others using multivariate logistic regression. CONCLUSION In patients undergoing TAVR, blood transfusion was associated with adverse outcomes including increased mortality, length of stay, and cost of hospitalization. The role of careful patient selection, judicious use of antiplatelets, anticoagulants, and pre-procedural optimization of anemia needs further investigation to optimize patient outcomes.
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Affiliation(s)
| | - Hasan M Mirza
- University of Massachusetts - Berkshire Medical Center, Pittsfield, MA, USA
| | | | | | | | - Alon Yarkoni
- United Health Services Heart and Vascular Institute, New York, USA
| | | | | | - Afzal Rehman
- United Health Services Heart and Vascular Institute, New York, USA
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GAROT P, Morice MC, Angiolillo DJ, Cabau JR, Park DW, Van Mieghem NM, Collet JP, Leon MB, Sengottuvelu G, Neylon A, ten Berg JM, Mylotte D, Tchétché D, Krucoff MW, Reardon MJ, Piazza N, Mack MJ, Généreux P, Makkar R, Hayashida K, Ohno Y, Mochizuki S, Shirai Y, Matsumara R, Jin Y, Webb JG, Cutlip DE, Chen M, Spitzer E, Mehran R, Capodanno D. Defining high bleeding risk in patients undergoing transcatheter aortic valve implantation: a VARC-HBR consensus document. EUROINTERVENTION 2024; 20:536-550. [PMID: 38726720 PMCID: PMC11067726 DOI: 10.4244/eij-d-23-01020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/12/2024] [Indexed: 05/14/2024]
Abstract
The identification and management of patients at high bleeding risk (HBR) undergoing transcatheter aortic valve implantation (TAVI) are of major importance, but the lack of standardised definitions is challenging for trial design, data interpretation, and clinical decision-making. The Valve Academic Research Consortium for High Bleeding Risk (VARC-HBR) is a collaboration among leading research organisations, regulatory authorities, and physician-scientists from Europe, the USA, and Asia, with a major focus on TAVI-related bleeding. VARC-HBR is an initiative of the CERC (Cardiovascular European Research Center), aiming to develop a consensus definition of TAVI patients at HBR, based on a systematic review of the available evidence, to provide consistency for future clinical trials, clinical decision-making, and regulatory review. This document represents the first pragmatic approach to a consistent definition of HBR evaluating the safety and effectiveness of procedures, devices and drug regimens for patients undergoing TAVI..
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Affiliation(s)
- Philippe GAROT
- Institut Cardiovasculaire Paris-Sud (ICPS), Hôpital privé Jacques Cartier, Ramsay-Santé, Massy, France
- Cardiovascular European Research Center (CERC), Massy, France
| | - Marie-Claude Morice
- Institut Cardiovasculaire Paris-Sud (ICPS), Hôpital privé Jacques Cartier, Ramsay-Santé, Massy, France
- Cardiovascular European Research Center (CERC), Massy, France
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Josep Rodés- Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
- Clínic Barcelona, Barcelona, Spain
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Nicolas M. Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, the Netherlands
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMR_S 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital, Paris, France
| | - Martin B. Leon
- Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA and Cardiovascular Research Foundation, New York, NY, USA
| | - Gunasekaran Sengottuvelu
- Department of Cardiology, Apollo Hospitals, Chennai, Tamil Nadu, India
- Department of Cardiology and Center for Platelet Function Research, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Antoinette Neylon
- Institut Cardiovasculaire Paris-Sud (ICPS), Hôpital privé Jacques Cartier, Ramsay-Santé, Massy, France
- Cardiovascular European Research Center (CERC), Massy, France
| | | | - Darren Mylotte
- Galway University Hospital and University of Galway, Galway, Ireland
| | - Didier Tchétché
- Groupe CardioVasculaire Interventionnel, Clinique Pasteur, Toulouse, France
| | - Mitchell W. Krucoff
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - Michael J. Reardon
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Nicolo Piazza
- McGill University Health Centre, Montreal, QC, Canada
| | | | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA
| | - Raj Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Ohno
- Department of Cardiology, Tokai University School of Medicine, Isehara, Japan
| | | | | | | | - Yu Jin
- Notified body 1639, SGS, Antwerp, Belgium
| | - John G. Webb
- Department of Cardiology, St. Paul’s Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Donald E. Cutlip
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA and Baim Clinical Research Institute, Boston, MA, USA
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ernest Spitzer
- Thoraxcenter, Erasmus University Medical Center, and Cardialysis, Clinical Trial Management and Core Laboratories, Rotterdam, the Netherlands
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Capodanno
- Cardiovascular European Research Center (CERC), Massy, France
- Cardio-Thoracic-Vascular Department, Centro Alte Specialità e Trapianti, Catania, Italy
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3
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Avvedimento M, Rodés-Cabau J. Reply: Extensive Impairment of the Hemostatic System Increases Bleeding Events: The Potential of CT-ADP. JACC Cardiovasc Interv 2023; 16:2934. [PMID: 38092502 DOI: 10.1016/j.jcin.2023.10.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 10/31/2023] [Accepted: 10/31/2023] [Indexed: 12/18/2023]
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Roth N, Heidel C, Xu C, Hubauer U, Wallner S, Meindl C, Holzamer A, Hilker M, Creutzenberg M, Sossalla S, Maier L, Jungbauer C, Debl K. Restoration of von Willebrand factor after transcatheter aortic valve replacement-A possible cause for posttranscatheter aortic valve replacement thrombocytopenia? Catheter Cardiovasc Interv 2023; 102:1376-1385. [PMID: 37727885 DOI: 10.1002/ccd.30841] [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: 05/04/2023] [Revised: 07/18/2023] [Accepted: 09/02/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVES The aim of the current study was to analyze the clinical and procedural predictors of thrombocytopenia and the relationship between the decrease in platelet count (DPC) and change in vWF function (ΔvWF) after transcatheter aortic valve replacement (TAVR). BACKGROUND TAVR often causes temporary thrombocytopenia. At the same time, TAVR leads to a restoration of von Willebrand factor (vWF) function. METHODS One hundred and forty-one patients with severe aortic stenosis undergoing TAVR were included in the study. Platelet count and vWF function (vWF:Ac/Ag ratio) were assessed at baseline and 6 h after TAVR. Thrombocytopenia was defined as platelet count <150/nL. RESULTS Median platelet count at baseline was 214/nL (interquartile range [IQR]: 176-261) and decreased significantly to 184/nL (IQR: 145-222) 6 h after TAVR. The number of patients with thrombocytopenia increased from 12.8% at baseline to 29.1% after 6 h. DPC 6 h after TAVR showed a significant correlation with ΔvWF (r = - 0.254, p = 0.002). Patients with DPC > 20% had significantly higher ΔvWF (10.9% vs. 6.5%, p = 0.021). Obese patients showed a significantly lower DPC (11.8% vs. 19.9%, p = 0.001). In multivariate analysis, ΔvWF 6 h after TAVR was the only significant predictor for DPC > 20% (p = 0.017). CONCLUSIONS The restoration of vWF after TAVR is a significant predictor for DPC after TAVR. An increased platelet consumption due to vWF restoration could play a key role in the development of thrombocytopenia after TAVR.
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Affiliation(s)
- Nastasia Roth
- Department of Internal Medicine II, University Medical Center, Regensburg, Germany
| | - Carolin Heidel
- Department of Internal Medicine II, University Medical Center, Regensburg, Germany
| | - Congde Xu
- Department of Internal Medicine II, University Medical Center, Regensburg, Germany
| | - Ute Hubauer
- Department of Internal Medicine II, University Medical Center, Regensburg, Germany
| | - Stefan Wallner
- Department of Clinical Chemistry and Laboratory Medicine, University Medical Center, Regensburg, Germany
| | - Christine Meindl
- Department of Internal Medicine II, University Medical Center, Regensburg, Germany
| | - Andreas Holzamer
- Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany
| | - Michael Hilker
- Department of Cardiothoracic Surgery, University Medical Center, Regensburg, Germany
| | - Marcus Creutzenberg
- Department of Anesthesiology, University Medical Center, Regensburg, Germany
| | - Samuel Sossalla
- Department of Internal Medicine II, University Medical Center, Regensburg, Germany
| | - Lars Maier
- Department of Internal Medicine II, University Medical Center, Regensburg, Germany
| | - Carsten Jungbauer
- Department of Internal Medicine II, University Medical Center, Regensburg, Germany
| | - Kurt Debl
- Department of Internal Medicine II, University Medical Center, Regensburg, Germany
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Aikawa T, Kuno T, Malik AH, Briasoulis A, Kolte D, Kampaktsis PN, Latib A. Transcatheter Aortic Valve Replacement in Patients With or Without Active Cancer. J Am Heart Assoc 2023; 12:e030072. [PMID: 37889175 PMCID: PMC10727376 DOI: 10.1161/jaha.123.030072] [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: 03/04/2023] [Accepted: 09/18/2023] [Indexed: 10/28/2023]
Abstract
Background Data on clinical outcomes after transcatheter aortic valve replacement (TAVR) in specific cancer types or the presence of metastatic disease remain sparse. This study aimed to investigate the impact of active cancer on short-term mortality, complications, and readmission rates after TAVR across different cancer types. Methods and Results The authors assessed the Nationwide Readmissions Database for TAVR cases from 2012 to 2019. Patients were stratified by specific cancer types. Primary outcome was in-hospital mortality. Secondary outcomes included bleeding requiring blood transfusion and readmissions at 30, 90, and 180 days after TAVR. Overall, 122 573 patients undergoing TAVR were included in the analysis, of whom 8013 (6.5%) had active cancer. After adjusting for potential confounders, the presence of active cancer was not associated with increased in-hospital mortality (adjusted odds ratio [aOR], 1.06 [95% CI, 0.89-1.27]; P=0.523). However, active cancer was associated with an increased risk of readmission at 30, 90, and 180 days after TAVR and increased risk of bleeding requiring transfusion at 30 days. Active colon and any type of metastatic cancer were individually associated with readmissions at 30, 90, and 180 days after TAVR. At 30 days after TAVR, colon (aOR, 2.51 [95% CI, 1.68-3.76]; P<0.001), prostate (aOR, 1.40 [95% CI, 1.05-1.86]; P=0.021), and any type of metastatic cancer (aOR, 1.65 [95% CI, 1.23-2.22]; P=0.001) were individually associated with an increased risk of bleeding requiring transfusion. Conclusions Patients with active cancer had similar in-hospital mortality after TAVR but higher risk of readmission and bleeding requiring transfusion, the latter depending on certain types of cancer.
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Affiliation(s)
- Tadao Aikawa
- Department of CardiologyJuntendo University Urayasu HospitalUrayasuJapan
- Department of RadiologyJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical CenterAlbert Einstein College of MedicineNew YorkNYUSA
- Division of Cardiology, Jacobi Medical CenterAlbert Einstein College of MedicineNew YorkNYUSA
| | - Aaqib H. Malik
- Department of CardiologyWestchester Medical CenterValhallaNYUSA
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, Section of Heart Failure and TransplantationUniversity of IowaIowa CityIAUSA
| | - Dhaval Kolte
- Division of CardiologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | | | - Azeem Latib
- Division of Cardiology, Montefiore Medical CenterAlbert Einstein College of MedicineNew YorkNYUSA
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Trimaille A, Matsushita K, Marchandot B, Carmona A, Hess S, Reydel A, Faucher L, Granier A, Mai TA, Diop B, Ohlmann P, Jesel L, Morel O. Outcomes of patients with active cancer undergoing transcatheter aortic valve replacement. Arch Cardiovasc Dis 2023; 116:506-513. [PMID: 37758593 DOI: 10.1016/j.acvd.2023.08.001] [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: 05/16/2023] [Revised: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Cardiovascular disease and cancer are the two leading causes of mortality worldwide, and their association presents a therapeutic challenge. Current data regarding the prognosis of active cancer in patients undergoing transcatheter aortic valve replacement are conflicting. AIM To determine the impact and prognosis of active cancer in transcatheter aortic valve replacement. METHODS All consecutive patients with severe aortic stenosis treated by transcatheter aortic valve replacement between February 2010 and May 2019 were enrolled in a prospective study. The cohort was divided according to the presence or absence of active cancer at baseline. The primary endpoint was all-cause mortality 1 year after the procedure. RESULTS A total of 1,125 patients were enrolled: 1,037 (92.2%) without and 88 (7.8%) with active cancer. The most frequent cancers were haematological (36.4%), breast (14.8%) and prostate (14.8%), with 79.5% of patients receiving curative treatment and 17.0% receiving palliative treatment. The 1-year mortality rate was higher in patients with active cancer (27.3% vs. 13.9%; P<0.01), mainly driven by non-cardiovascular causes. An increased cardiovascular mortality rate at 2 years was seen in patients with active cancer (27.5% vs. 15.0%; P=0.03) compared with a similar rate at 1-year follow-up. Active cancer was a strong predictor of 1-year all-cause mortality (hazard ratio 2.46, 95% confidence interval 1.19-4.68; P=0.02). Major/life-threatening bleeding events at 1 year were more frequent in patients with active cancer (P=0.02). CONCLUSIONS Among patients who undergo transcatheter aortic valve replacement, 1-year all-cause mortality is higher in those with active cancer. We also observed a trend towards increased long-term bleeding events in case of active cancer.
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Affiliation(s)
- Antonin Trimaille
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Nouvel Hôpital Civil, 67091 Strasbourg, France; Inserm (French National Institute of Health and Medical Research), FMTS, Regenerative Nanomedicine, UMR 1260, 67000 Strasbourg, France
| | - Kensuke Matsushita
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Nouvel Hôpital Civil, 67091 Strasbourg, France; Inserm (French National Institute of Health and Medical Research), FMTS, Regenerative Nanomedicine, UMR 1260, 67000 Strasbourg, France
| | - Benjamin Marchandot
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Nouvel Hôpital Civil, 67091 Strasbourg, France
| | - Adrien Carmona
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Nouvel Hôpital Civil, 67091 Strasbourg, France
| | - Sebastien Hess
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Nouvel Hôpital Civil, 67091 Strasbourg, France
| | - Antje Reydel
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Nouvel Hôpital Civil, 67091 Strasbourg, France
| | - Loic Faucher
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Nouvel Hôpital Civil, 67091 Strasbourg, France
| | - Amandine Granier
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Nouvel Hôpital Civil, 67091 Strasbourg, France
| | - Trung Anh Mai
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Nouvel Hôpital Civil, 67091 Strasbourg, France
| | - Bamba Diop
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Nouvel Hôpital Civil, 67091 Strasbourg, France
| | - Patrick Ohlmann
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Nouvel Hôpital Civil, 67091 Strasbourg, France
| | - Laurence Jesel
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Nouvel Hôpital Civil, 67091 Strasbourg, France; Inserm (French National Institute of Health and Medical Research), FMTS, Regenerative Nanomedicine, UMR 1260, 67000 Strasbourg, France
| | - Olivier Morel
- Division of Cardiovascular Medicine, Strasbourg University Hospital, Nouvel Hôpital Civil, 67091 Strasbourg, France; Inserm (French National Institute of Health and Medical Research), FMTS, Regenerative Nanomedicine, UMR 1260, 67000 Strasbourg, France.
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Franzone A, Esposito G. VARC-3 Criteria for Bleeding Events: Integrating Theory Into Practice. JACC Cardiovasc Interv 2023; 16:2275-2276. [PMID: 37676227 DOI: 10.1016/j.jcin.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/07/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Anna Franzone
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy.
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
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Avvedimento M, Real C, Nuche J, Farjat-Pasos J, Galhardo A, Trinh KH, Robichaud M, Delarochellière R, Paradis JM, Poulin A, Dumont E, Kalavrouziotis D, Mohammadi S, Côté M, Rodés-Cabau J. Incidence, Predictors, and Prognostic Impact of Bleeding Events After TAVR According to VARC-3 Criteria. JACC Cardiovasc Interv 2023; 16:2262-2274. [PMID: 37676226 DOI: 10.1016/j.jcin.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND The updated Valve Academic Research Consortium (VARC) definition for bleeding events after transcatheter aortic valve replacement (TAVR) lacks of clinical validation. OBJECTIVES The aim of this study was to determine the incidence, predictors, and clinical impact of bleeding events following TAVR as defined by recent VARC-3 criteria. METHODS A total of 2,384 consecutive patients with severe symptomatic aortic stenosis undergoing TAVR were included. Early (at index hospitalization) and late (after hospital discharge) bleeding complications were defined according to VARC-3 criteria as type 1, 2, 3, or 4. Baseline, procedural, and follow-up (24 [IQR: 12-43] months) data were prospectively collected. RESULTS Bleeding events occurred in 761 patients (31.9%): types 1, 2, 3, and 4 in 169 (22.2%), 399 (52.4%), 149 (19.6%), and 44 (5.8%) patients, respectively. The primary vascular access site and gastrointestinal locations were the most common bleeding sources among early and late bleeding events, respectively. Female sex, thoracotomy access, larger (14-F) sheath use, and dual antiplatelet therapy determined an increased risk of early bleeding events (P < 0.02 for all). The use of the radial artery for secondary access was associated with a significant risk reduction of early bleeding (P < 0.001). Type 2 and type 3 events were associated with an increased mortality risk at 30-day (HR: 2.94 [95% CI: 1.43-6.03; P = 0.003] and HR: 4.91 [95% CI: 2.19-11.03; P < 0.001], respectively) and 1-year (HR: 1.86 [95% CI: 1.28-2.69; P = 0.001] and HR: 2.28 [95% CI: 1.41-3.66; P = 0.001], respectively) follow-up. A similar prognostic pattern was observed when applying VARC-2 criteria but with a much lower global incidence of early bleeding events (19% vs 27%; P < 0.001). CONCLUSIONS Bleeding events after TAVR were associated with poorer short- and long-term survival. The magnitude of this correlation was proportional to bleeding severity defined according to VARC-3 criteria. Further studies on bleeding prevention following TAVR are warranted to improve procedural safety and patient prognosis.
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Affiliation(s)
- Marisa Avvedimento
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Carlos Real
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada; Department of Cardiology, Hospital Clinico San Carlos, Madrid, Spain
| | - Jorge Nuche
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Julio Farjat-Pasos
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Attilio Galhardo
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Kim-Hoang Trinh
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Mathieu Robichaud
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Jean-Michel Paradis
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Anthony Poulin
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Eric Dumont
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Siamak Mohammadi
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Mélanie Côté
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada; Clínic Barcelona, Barcelona, Spain.
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9
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Jiménez-Xarrié E, Asmarats L, Roqué-Figuls M, Millán X, Li CHP, Fernández-Peregrina E, Sánchez-Ceña J, Massó van Roessel A, Maestre Hittinger ML, Paniagua P, Arzamendi D. Impact of Baseline Anemia in Patients Undergoing Transcatheter Aortic Valve Replacement: A Prognostic Systematic Review and Meta-Analysis. J Clin Med 2023; 12:6025. [PMID: 37762965 PMCID: PMC10531747 DOI: 10.3390/jcm12186025] [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: 08/14/2023] [Revised: 09/01/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Transcatheter aortic valve replacement (TAVR) is currently the treatment of choice for patients aged ≥75 years with severe aortic stenosis. Preoperative anemia is present in a large proportion of patients and may increase the risk of post-procedural complications. The purpose of this prognostic systematic review was to analyze the impact of baseline anemia on short- and mid-term outcomes following TAVR. A computerized search was performed on PubMed and Web of Science databases for studies published between January 2013 and December 2022. Primary outcomes were 30-day need for transfusion, acute renal failure, 30-day and mid-term mortality, and readmission during the first year post-TAVR. Data were analyzed via random effects model using inverse variance method with 95% confidence intervals. Eleven observational studies met our eligibility criteria and included a total of 12,588 patients. The prevalence of baseline anemia ranged between 39% and 72%, with no relevant sex differences. Patients with preprocedural anemia received more blood transfusions [OR: 2.95 (2.13-4.09)]), and exhibited increased rates of acute kidney injury [OR:1.74 (1.45-2.10)], short-term mortality [OR: 1.47 (1.07-2.01], and mid-term [OR: 1.89 (1.58-2.25)] mortality following TAVR compared with those without anemia. Baseline anemia determined an increased risk for blood transfusion, acute kidney injury, and short/mid-term mortality among TAVR recipients.
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Affiliation(s)
- Elena Jiménez-Xarrié
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain
| | - Lluis Asmarats
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain
| | - Marta Roqué-Figuls
- Biomedical Research Institute Sant Pau (IIB Sant Pau), 08025 Barcelona, Spain
| | - Xavier Millán
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain
| | - Chi Hion Pedro Li
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain
| | - Estefanía Fernández-Peregrina
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain
| | - Juan Sánchez-Ceña
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain
| | - Albert Massó van Roessel
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain
| | - M. Luz Maestre Hittinger
- Anesthesiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain
| | - Pilar Paniagua
- Anesthesiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain
| | - Dabit Arzamendi
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute (IIB Sant Pau), 08025 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain
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10
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Karahan MZ, Aktan A, Güzel T, Kılıç R, Günlü S, Demir M, Ertaş F. Evaluation of Hematological Parameters After Transcatheter Aortic Valve Replacement. Angiology 2023:33197231177397. [PMID: 37236655 DOI: 10.1177/00033197231177397] [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: 05/28/2023]
Abstract
Although transcatheter aortic valve replacement (TAVR) is safe and effective, mortality and bleeding events post procedure are important. The present study investigated the changes in hematologic parameters to evaluate whether they predict mortality or major bleeding. We enrolled 248 consecutive patients (44.8% male; mean age 79.0 ± 6.4 years) undergoing TAVR. In addition to demographic and clinical examination, blood parameters were recorded before TAVR, at discharge, 1 month and 1 year. Hemoglobin levels before TAVR 12.1 ± 1.8 g/dL, 10.8 ± 1.7 g/dL at discharge, 11.7 ± 1.7 g/dL at first month, 11.8 ± 1.4 g/dL at first year (Hemoglobin values compared with pre-TAVR, P < .001, P = .019, P = .047, respectively). Mean platelet volume (MPV) before TAVR 8.72 ± 1.71 fL, 8.16 ± 1.46 fL at discharge, 8.09 ± 1.44 fL at first month, 7.94 ± 1.18 fL at first year (MPV values compared with pre-TAVR, P < .001, P < .001, P < .001, respectively). Other hematologic parameters were also evaluated. Hemoglobin, platelet count, MPV, and red cell distribution width before the procedure, at discharge, and at the first year did not predict mortality and major bleeding in receiver operating characteristic analysis. After multivariate Cox regression analysis, hematologic parameters were not independent predictors of in-hospital mortality, major bleeding, and death at 1 year after TAVR.
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Affiliation(s)
- Mehmet Zülküf Karahan
- Department of Cardiology, Mardin Artuklu University Faculty of Medicine, Mardin, Turkey
| | - Adem Aktan
- Department of Cardiology, Mardin Training and Research Hospital, Mardin, Turkey
| | - Tuncay Güzel
- Department of Cardiology, Health Science University, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey
| | - Raif Kılıç
- Department of Cardiology, Memorial Diyarbakır Hospital, Diyarbakır, Turkey
| | - Serhat Günlü
- Department of Cardiology, Mardin Artuklu University Faculty of Medicine, Mardin, Turkey
| | - Muhammed Demir
- Department of Cardiology, Dicle University Faculty of Medicine, Diyarbakır, Turkey
| | - Faruk Ertaş
- Department of Cardiology, Dicle University Faculty of Medicine, Diyarbakır, Turkey
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11
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Avvedimento M, Nuche J, Farjat-Pasos JI, Rodés-Cabau J. Bleeding Events After Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 81:684-702. [PMID: 36792284 DOI: 10.1016/j.jacc.2022.11.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/21/2022] [Indexed: 02/15/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) has gained over time a major reduction in procedural complications. Despite this, clinically relevant bleeding still occurs in a non-negligible proportion of patients and adversely affects prognosis. Patients with severe aortic stenosis are at heightened risk for spontaneous bleeding due to advanced age and a high comorbidity burden. Also, procedural factors and antithrombotic management contribute to define individual bleeding susceptibility. Bleeding prevention represents an emerging area for improving patient care. Because of the tight hemorrhagic/ischemic balance, a tailored approach based on individual bleeding-risk profile, such as a less invasive antithrombotic regimen or appropriate diagnostic preprocedural evaluation, should be pursued to avoid bleeding events. This review aims to provide an in-depth overview of bleeding events in the TAVR field, including definitions, timing and the extent of risk, and clinical impact, as well as updates on antithrombotic management and its potential influence on bleeding complications.
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Affiliation(s)
- Marisa Avvedimento
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Jorge Nuche
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada.
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12
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Abushouk A, Agrawal A, Hariri E, Dykun I, Kansara T, Saad A, Abdelfattah O, Badwan O, Jaggi C, Farwati M, Harb SC, Puri R, Reed GW, Krishnaswamy A, Yun J, Kapadia S. Association between haematological parameters and outcomes following transcatheter aortic valve implantation at mid-term follow-up. Open Heart 2022; 9:openhrt-2022-002108. [PMID: 36600647 PMCID: PMC9748985 DOI: 10.1136/openhrt-2022-002108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Patients undergoing transcatheter aortic valve implantation (TAVI) often have multiple comorbidities, such as anaemia and chronic inflammatory disorders. We sought to investigate the association between preoperative and postoperative haematological parameters and clinical outcomes in TAVI patients at mid-term follow-up. METHODS In the present study, consecutive patients (N=908) who underwent TAVI at the Cleveland Clinic between 2017 and 2019 with available complete blood counts were studied. Data were collected on preoperative and postoperative anaemia and elevations in neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). Survival analysis was used to study the association of haematologic parameters with all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE). RESULTS We found that preoperative anaemia and elevated NLR were significantly associated with a higher risk of all-cause mortality (aHR=1.6 (95% CI: 1.1 to 2.0) and 1.4 (95% CI: 1.1 to 1.6), respectively) and MACCE (aHR=1.9 (95% CI: 1.3 to 2.8) and 1.6 (95% CI: 1.1 to 2.4), respectively). While an elevated preoperative PLR was not associated with increased mortality risk, it had a significant association with MACCE risk (aHR: 1.6 (95% CI: 1.1 to 2.4)). Further, postoperative anaemia, elevated NLR and PLR were associated with increased risks of all-cause mortality and MACCE. CONCLUSION Pathological alterations in haematological parameters were associated with higher risks of post-TAVI mortality and MACCE at mid-term follow-up. Our findings advocate for further incorporating haematological parameters in the preoperative evaluation of TAVI candidates.
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Affiliation(s)
- Abdelrahman Abushouk
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ankit Agrawal
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Essa Hariri
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Iryna Dykun
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Tikal Kansara
- Department of Internal Medicine, Cleveland Clinic Union Hospital, Dover, Ohio, USA
| | - Anas Saad
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Omar Abdelfattah
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Connor Jaggi
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Medhat Farwati
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Serge C Harb
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Grant W Reed
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - James Yun
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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13
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Ten Berg J, Rocca B, Angiolillo DJ, Hayashida K. The search for optimal antithrombotic therapy in transcatheter aortic valve implantation: facts and uncertainties. Eur Heart J 2022; 43:4616-4634. [PMID: 36130256 DOI: 10.1093/eurheartj/ehac385] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 01/05/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure, which is used frequently in patients with symptomatic severe aortic valve stenosis. Most patients undergoing TAVI are over 80 years of age with a high bleeding as well as thrombotic risk. Despite the increasing safety of the procedure, thromboembolic events [stroke, (subclinical) valve thrombosis] remain prevalent. As a consequence, antithrombotic prophylaxis is routinely used and only recently new data on the efficacy and safety of antithrombotic drugs has become available. On the other hand, these antithrombotic drugs increase bleeding in a population with unique aortic stenosis-related bleeding characteristics (such as acquired von Willebrand factor defect and angiodysplasia). In this review, we discuss the impact of thromboembolic and bleeding events, the current optimal antithrombotic therapy based on registries and recent randomized controlled trials, as well as try to give a practical guide how to treat these high-risk patients. Finally, we discuss knowledge gaps and future research needed to fill these gaps.
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Affiliation(s)
- Jurrien Ten Berg
- Department of Cardiology and Center for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands.,The Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Bianca Rocca
- Department of Safety and Bioethics, Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Internal Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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14
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Jamil D, Tran HHV, Mansoor M, Bbutt SR, Satnarine T, Ratna P, Sarker A, Ramesh AS, Munoz Tello C, Mohammed L. Multimodal Treatment and Diagnostic Modalities in the Setting of Heyde’s Syndrome: A Systematic Review. Cureus 2022; 14:e28080. [PMID: 36127959 PMCID: PMC9477546 DOI: 10.7759/cureus.28080] [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: 06/26/2022] [Accepted: 08/15/2022] [Indexed: 12/02/2022] Open
Abstract
Heyde’s syndrome encompasses the triad of aortic stenosis (AS), angiodysplasia, and acquired Von Willebrand's disease (aVWD). The disease itself is a rare association that affects a small subset of patients who suffer from aortic stenosis. Nonetheless, it represents a vital area of clinical interest and is woefully underreported in the literature. Patients with Heyde’s syndrome develop gastrointestinal bleeding (GI) as a result of angiodysplasia and due to lack of adequate hemostasis, they tend to be positively predisposed toward developing gastrointestinal hemorrhage. Due to the glaring lack of comprehensive literature on Heyde's syndrome, this systematic review aims to bridge the gap by elucidating the various diagnostic and treatment options available to clinicians for Heyde’s syndrome patients as well as to give a detailed account of the pathophysiology of the disease. This systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Google Scholar, Gulf Medical University (GMU) e-library, and PubMed were thoroughly searched for studies done in the last 10 years, which corresponds with our outlined inclusion and exclusion criteria. Relevant studies were then selected on the basis of their abstracts and titles. These studies then underwent a comprehensive quality assessment in which any papers which did not meet this study’s eligibility criteria were omitted. Overall, 18 studies fulfilled the criteria of this systematic review.
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15
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Greco A, Spagnolo M, Capodanno D. Antithrombotic therapy after transcatheter aortic valve implantation. Expert Rev Med Devices 2022; 19:499-513. [PMID: 35881777 DOI: 10.1080/17434440.2022.2106853] [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: 11/04/2022]
Abstract
INTRODUCTION Transcatheter aortic valve implantation (TAVI) is a treatment option for patients with symptomatic severe aortic stenosis across the entire spectrum of surgical risk. TAVI conveys some risk for thrombotic complications, requiring antithrombotic drugs for their prevention. Bleeding events represent the major drawback of antithrombotic therapy, which should be carefully tailored over the individual patient's risk profile. AREAS COVERED This review aimed at exploring the rationale for the adoption of a tailored antithrombotic therapy after successful TAVI, with a description and analysis of common complications and their impact on therapy selection. In addition, we aimed at reviewing and discussing current knowledge in this area, with a main focus on the high-quality evidence supporting latest guideline recommendations. Finally, ongoing studies and future directions on antithrombotic therapy after TAVI were outlined. EXPERT OPINION Initial experience with antithrombotic therapy after TAVI was derived from percutaneous coronary intervention practice. Accruing evidence in the field led to the current monotherapy paradigm, which prioritizes oral anticoagulant and single antiplatelet therapy in patients with or without an established indication for long-term anticoagulation, respectively. Future studies will investigate the role of alternative antithrombotic strategies to improve clinical outcomes of TAVI patients by minimizing both thrombotic and bleeding complications.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
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16
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van Ginkel DJ, Bor WL, Veenstra L, van 't Hof AWJ, Fabris E. Evolving concepts in the management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation. Eur J Intern Med 2022; 101:14-20. [PMID: 35623935 DOI: 10.1016/j.ejim.2022.05.002] [Citation(s) in RCA: 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: 03/09/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/22/2022]
Abstract
Thromboembolic and bleeding complications negatively impact recovery and survival after transcatheter aortic valve implantation (TAVI). Particularly, there is a considerable risk of ischaemic stroke and vascular access related bleeding, as well as spontaneous gastro-intestinal bleeding. Therefore, benefit and harm of antithrombotic therapy should be carefully balanced. This review summarizes current evidence on peri- and post-procedural antithrombotic treatment. Indeed, in recent years, the management of antithrombotic therapy after TAVI has evolved from intensive, expert opinion-based strategies, towards a deescalated, evidence-based approach. Besides per procedural administration of unfractionated heparin, this encompasses single antiplatelet therapy in patients without a concomitant indication for oral anticoagulation (OAC); and OAC monotherapy in patients with such indication, mainly being atrial fibrillation. Combination therapy should generally be avoided to reduce bleeding risk, except after recent coronary stenting where a period of dual antiplatelet therapy (aspirin plus P2Y12-inhibitor) or P2Y12-inhibitor plus OAC (in patients with an independent indication for OAC) is recommended to prevent stent thrombosis. This new paradigm in which reduced antithrombotic intensity leads to improved patient safety, without a loss of efficacy, may be particularly suitable for elderly and fragile patients. Whether this holds in upcoming populations of younger and lower-risk patients and in specific populations as patients with subclinical valve thrombosis, is yet to be proven. Finally, whether less intensive or alternative approaches should be also applied for the periprocedural management of the antithrombotic therapy, has to be determined by ongoing and future studies.
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Affiliation(s)
- Dirk Jan van Ginkel
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Willem L Bor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Leo Veenstra
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Arnoud W J van 't Hof
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Enrico Fabris
- Cardiothoracovascular Department, University of Trieste, Trieste, Italy.
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17
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Kvaslerud AB, Bardan S, Andresen K, Kløve SF, Fagerland MW, Edvardsen T, Gullestad L, Broch K. Intravenous iron supplement for iron deficiency in patients with severe aortic stenosis scheduled for TAVI Results of the IIISAS randomised trial. Eur J Heart Fail 2022; 24:1269-1279. [PMID: 35579454 PMCID: PMC9544901 DOI: 10.1002/ejhf.2557] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/11/2022] [Accepted: 05/14/2022] [Indexed: 11/12/2022] Open
Abstract
Aims The aim of this trial was to evaluate whether intravenous iron could provide benefit beyond transcatheter aortic valve implantation (TAVI) in iron‐deficient patients with severe aortic stenosis. Methods and results In this randomised, placebo‐controlled, double‐blind, single‐centre trial, we enrolled patients with severe aortic stenosis and iron deficiency (defined as ferritin <100 µg/L, or 100–299 µg/L with a transferrin saturation <20%) who were evaluated for TAVI. Patients were randomly assigned (1:1) to receive intravenous ferric derisomaltose or placebo ∼3 months before TAVI. The primary endpoint was the between‐group, baseline‐adjusted 6‐min walk distance measured 3 months after TAVI. Secondary outcomes included quality of life, iron stores, hand grip strength, New York Heart Association (NYHA) class, and safety. Between January 2020 and September 2021, we randomised 74 patients to ferric derisomaltose and 75 patients to placebo. The modified intention‐to‐treat population comprised the 104 patients who completed the 6‐min walk test at baseline and 3 months after successful TAVI. Iron stores were restored in 76% of the patients allocated to iron and 13% of the patients allocated to placebo (p < 0.001). There was no difference in the baseline‐adjusted 6‐min walk distance between the two treatment arms (p = 0.82). The number of serious adverse events, quality of life, hand grip strength, and NYHA class did not differ between the treatment arms. Conclusion Treatment with intravenous iron did not provide clinical benefit beyond TAVI in iron‐deficient patients with severe aortic stenosis. Clinical Trial Registration: ClinicalTrials.gov NCT04206228.
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Affiliation(s)
- Anette B Kvaslerud
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,KG Jebsen Center for Cardiac Research and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Sara Bardan
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kristoffer Andresen
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Sophie Foss Kløve
- Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Morten Wang Fagerland
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Thor Edvardsen
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Lars Gullestad
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,KG Jebsen Center for Cardiac Research and Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Kaspar Broch
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway.,KG Jebsen Center for Cardiac Research and Center for Heart Failure Research, University of Oslo, Oslo, Norway
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18
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Waldum H, Wahba A. Serotonin—A Driver of Progressive Heart Valve Disease. Front Cardiovasc Med 2022; 9:774573. [PMID: 35155625 PMCID: PMC8831548 DOI: 10.3389/fcvm.2022.774573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/06/2022] [Indexed: 01/12/2023] Open
Abstract
It is well known that some serotoninergic drugs and neuroendocrine tumors producing serotonin (5-HT) may induce valvular heart disease by stimulation of proliferation of valvular cells via interaction with a 5-HT receptor type 2B. Serotonin could play a role in the pathogenesis of progressive valvular disease for example as a complication of rheumatic fever, in patients with congenital bicuspid aortic valves or in degenerative aortic valve stenosis. The initial inflammation in acute rheumatic fever seems to affect both right and the left-side cardiac valves. Some patients develop chronic right-sided valve disease, particularly in connection with septum defects, though left-sided valves typically are predominantly affected, indicating that high flow velocity and systemic pressure close to the valves may be central in the pathogenesis. Serotonin is transported in granules in blood platelets. Changes in platelet number and concentrations of substances released from platelets in patients with valvular disease indicate that serotonin is released locally by shear stress when passing through an abnormal valve. Accordingly, any functional changes (like bicuspid aortic valves and changes secondary to degeneration) in the valves may progress due to locally released serotonin. Unfortunately, due to serotonin release by sampling and preparation of plasma, local serotonin assessment is not possible. Nevertheless, we suggest that serotonin may play a role in valvular disease in general and that patients may benefit from treatment reducing the effect of serotonin on the heart.
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Affiliation(s)
- Helge Waldum
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- *Correspondence: Helge Waldum
| | - Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav's University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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19
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Ng S, Zhu QF, Jiang JB, Liu CH, Fan JQ, Xu YM, Liu XB, Wang JA. Anemia and risk of periprocedural cerebral injury detected by diffusion-weighted magnetic resonance imaging in patients undergoing transcatheter aortic valve replacement. World J Emerg Med 2022; 13:32-39. [PMID: 35003413 PMCID: PMC8677916 DOI: 10.5847/wjem.j.1920-8642.2022.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 11/16/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Anemia is prevalent in patients undergoing transcatheter aortic valve replacement (TAVR) and has been linked to impaired outcomes after the procedure. Few studies have evaluated the impact of anemia and new ischemic lesions post TAVR. METHODS We prospectively enrolled 158 patients who received TAVR in our center. Anemia was defined according to the World Health Organization criteria as hemoglobin <12 g/dL in women and <13 g/dL in men. All patients underwent diffusion-weighted magnetic resonance imaging (DW-MRI) procedure before and within 4-7 days after TAVR. RESULTS Anemia was present in 85 (53.8%) patients who underwent TAVR, and 126 (79.7%) patients had 718 new DW-MRI positive lesions with a mean of 4.54±5.26 lesions per patient. The incidence of new ischemic lesions was 81.2% in patients with anemia versus 78.1% in patients without anemia (P=0.629). Moreover, anemic patients had bigger total volume/lesions in the anterior cerebral artery/middle cerebral artery (ACA/MCA) and MCA regions compared to the non-anemic patients (31.89±55.78 mm3 vs. 17.08±37.39 mm3, P=0.049; and 54.54±74.72 mm3 vs. 33.75±46.03 mm3, P=0.034). Anemia was independently associated with the volume/lesion in the ACA/MCA (β=16.796, 95% confidence interval [95% CI] 2.001 to 31.591, P=0.026) and in the MCA zone (β=0.020, 95% CI 0.001 to 0.040, P=0.041). CONCLUSIONS Patients with pre-procedural anemia may have bigger total volume/lesions in the ACA/MCA and MCA regions compared to the non-anemic patients. Whether the consequences of bigger total volume/lesions impact neurological and cognitive outcomes remains to be investigated.
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Affiliation(s)
- Stella Ng
- Department of Cardiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Qi-feng Zhu
- Department of Cardiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Ju-bo Jiang
- Department of Cardiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Chun-hui Liu
- Department of Cardiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Jia-qi Fan
- Department of Cardiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Ye-ming Xu
- Department of Cardiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Xian-bao Liu
- Department of Cardiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Jian-an Wang
- Department of Cardiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
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20
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Systemic bevacizumab for refractory bleeding and transfusion-dependent anemia in Heyde syndrome. Blood Adv 2021; 5:3850-3854. [PMID: 34500461 DOI: 10.1182/bloodadvances.2021004810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/01/2021] [Indexed: 11/20/2022] Open
Abstract
Heyde syndrome, the co-occurrence of aortic stenosis and bleeding gastrointestinal (GI) angiodysplasia, is managed with aortic valve replacement. However, severe bleeding and anemia can preclude safe use of the antiplatelet or anticoagulant therapy required for this intervention. We present a case of the novel and successful treatment of severe, refractory bleeding and transfusion dependence with antiangiogenic therapy in a patient with Heyde syndrome. After systemic bevacizumab was initiated, the patient achieved durable hemostasis with normalization of hemoglobin and liberation from red cell transfusion and dependence on iron infusion; aspirin therapy was successfully initiated where it had previously failed. This durable hemostasis facilitated her subsequent successful transcatheter aortic valve replacement. Plasma vascular endothelial growth factor levels, which were monitored during therapy, paradoxically rose after bevacizumab was initiated but normalized after it was discontinued. Given the angiogenic dysregulation of Heyde syndrome, systemic bevacizumab may be an effective and safe targeted therapy for managing refractory GI bleeding, which thereby facilitates antiplatelet therapy and aortic valve replacement in these challenging cases. Additional investigation into the therapeutic role of inhibiting angiogenesis as a hemostatic modality in Heyde syndrome is warranted.
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21
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Baştuğ S, Çöteli C, Çelik MC, Kasapkara HA, Bayram NA, Akcay M, Durmaz T. Baseline Anemia Is an Independent Predictor of Long-Term Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation. Angiology 2021; 73:26-32. [PMID: 34247538 DOI: 10.1177/00033197211029801] [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] [Indexed: 11/17/2022]
Abstract
This study aimed to investigate the relationship between baseline anemia and long-term mortality in a single-center retrospective study involving patients undergoing transcatheter aortic valve implantation (TAVI). The study population included 412 consecutive patients undergoing TAVI at a center for severe aortic valve stenosis between August 2011 and November 2018. The primary end point of the study was all-cause mortality. Baseline anemia was present in 50% of our study cohort. During the median follow-up of 29 months, all-cause mortality was observed in 40.3% of the whole study population and was more frequently observed in the anemic group compared with the nonanemic group (53.5% vs 27.1%, P < .001, respectively). Cox-regression analysis revealed that Society of Thoracic Surgeons Predicted Risk of Mortality score, previous stroke, pericardial tamponade, and neutrophil-lymphocyte ratio count are independent predictors of long-term mortality after TAVI. Additionally, the presence of anemia at baseline was an independent predictor of long-term mortality with a 2.3-fold difference in the anemic group compared with the nonanemic group (hazard ratio: 2.31, 95% CI: 1.59-3.37, P < .001). Baseline anemia was observed in half of our patient population undergoing TAVI, and baseline anemia was found to be an independent predictor of long-term mortality after TAVI.
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Affiliation(s)
- Serdal Baştuğ
- Cardiology Department, 226850Yildirim Beyazit University Medical School, Ankara, Turkey
| | - Cem Çöteli
- Cardiology Department, 226850Yildirim Beyazit University Medical School, Ankara, Turkey
| | - Muhammet Cihat Çelik
- Cardiology Department, Ankara Ataturk Education and Research Hospital, Ankara, Turkey
| | - Haci Ahmet Kasapkara
- Cardiology Department, 226850Yildirim Beyazit University Medical School, Ankara, Turkey
| | - Nihal Akar Bayram
- Cardiology Department, 226850Yildirim Beyazit University Medical School, Ankara, Turkey
| | - Murat Akcay
- Cardiology Department, 226850Yildirim Beyazit University Medical School, Ankara, Turkey
| | - Tahir Durmaz
- Cardiology Department, 226850Yildirim Beyazit University Medical School, Ankara, Turkey
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22
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Navarese EP, Zhang Z, Kubica J, Andreotti F, Farinaccio A, Bartorelli AL, Bedogni F, Rupji M, Tomai F, Giordano A, Reimers B, Spaccarotella C, Wilczek K, Stepinska J, Witkowski A, Grygier M, Kukulski T, Wanha W, Wojakowski W, Lesiak M, Dudek D, Zembala MO, Berti S. Development and Validation of a Practical Model to Identify Patients at Risk of Bleeding After TAVR. JACC Cardiovasc Interv 2021; 14:1196-1206. [PMID: 34112454 DOI: 10.1016/j.jcin.2021.03.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES No standardized algorithm exists to identify patients at risk of bleeding after transcatheter aortic valve replacement (TAVR). The aim of this study was to generate and validate a useful predictive model. BACKGROUND Bleeding events after TAVR influence prognosis and quality of life and may be preventable. METHODS Using machine learning and multivariate regression, more than 100 clinical variables from 5,185 consecutive patients undergoing TAVR in the prospective multicenter RISPEVA (Registro Italiano GISE sull'Impianto di Valvola Aortica Percutanea; NCT02713932) registry were analyzed in relation to Valve Academic Research Consortium-2 bleeding episodes at 1 month. The model's performance was externally validated in 5,043 TAVR patients from the prospective multicenter POL-TAVI (Polish Registry of Transcatheter Aortic Valve Implantation) database. RESULTS Derivation analyses generated a 6-item score (PREDICT-TAVR) comprising blood hemoglobin and serum iron concentrations, oral anticoagulation and dual antiplatelet therapy, common femoral artery diameter, and creatinine clearance. The 30-day area under the receiver-operating characteristic curve (AUC) was 0.80 (95% confidence interval [CI]: 0.75-0.83). Internal validation by optimism bootstrap-corrected AUC was 0.79 (95% CI: 0.75-0.83). Score quartiles were in graded relation to 30-day events (0.8%, 1.1%, 2.5%, and 8.5%; overall p <0.001). External validation produced a 30-day AUC of 0.78 (95% CI: 0.72-0.82). A simple nomogram and a web-based calculator were developed to predict individual patient probabilities. Landmark cumulative event analysis showed greatest bleeding risk differences for top versus lower score quartiles in the first 30 days, when most events occurred. Predictivity was maintained when omitting serum iron values. CONCLUSIONS PREDICT-TAVR is a practical, validated, 6-item tool to identify patients at risk of bleeding post-TAVR that can assist in decision making and event prevention.
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Affiliation(s)
- Eliano Pio Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland; Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada; SIRIO MEDICINE Research Network, Bydgoszcz, Poland.
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jacek Kubica
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland; SIRIO MEDICINE Research Network, Bydgoszcz, Poland
| | - Felicita Andreotti
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonella Farinaccio
- Department of Biotechnology and Biosciences, University of Milano-Bicocca, Italy
| | - Antonio L Bartorelli
- Centro Monzino, IRCCS and Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Milan, Italy
| | - Francesco Bedogni
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Manali Rupji
- Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | | | - Arturo Giordano
- Unità Operativa di Interventistica Cardiovascolare, Pineta Grande Hospital, Castel Volturno, Italy
| | - Bernard Reimers
- Division of Cardiology, CCU and Interventional, Cardiology, Cardio Center, Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy
| | | | - Krzysztof Wilczek
- Cardiac and Lung Transplantation Mechanical Circulatory Support, Silesian Center for Heart Diseases, Pomeranian Medical University, Szczecin, Poland
| | | | | | | | - Tomasz Kukulski
- Cardiac and Lung Transplantation Mechanical Circulatory Support, Silesian Center for Heart Diseases, Pomeranian Medical University, Szczecin, Poland
| | - Wojciech Wanha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Maciej Lesiak
- Department of Cardiology, Poznań University of Medical Sciences, Poznań, Poland
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Michal O Zembala
- Cardiac and Lung Transplantation Mechanical Circulatory Support, Silesian Center for Heart Diseases, Pomeranian Medical University, Szczecin, Poland
| | - Sergio Berti
- Department of Diagnostic and Interventional Cardiology, Gabriele Monasterio Tuscany Foundation, G. Pasquinucci Heart Hospital, Massa, Italy
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23
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Mas-Peiro S, Seppelt PC, De Rosa R, Murray MI, Yogarajah J, Berkowitsch A, Fichtlscherer S, Zeiher AM, Vasa-Nicotera M. Potential Role and Prognostic Value of Erythropoietin Levels in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement. Front Cardiovasc Med 2020; 7:605257. [PMID: 33330669 PMCID: PMC7733967 DOI: 10.3389/fcvm.2020.605257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Both EPO levels and anemia have shown prognostic value in several cardiac disorders. An observational study with a prospective follow-up was performed to investigate their independent prognostic roles in severe aortic stenosis. Methods: An up to 36-month follow-up of consecutive patients with severe aortic stenosis undergoing TAVR in a high-volume center was performed. Patients with eGRF <30 mL/min/1.73 m2 were excluded. EPO levels and/or anemia status and its association with mid-term mortality were assessed. Results: Out of 407, 360 met eligibility criteria. Median age was 83 years, with 71.4% having a NYHA class III/IV. Anemia was present in 51.9%, and iron deficiency in 52.8%. Median (IQR) EPO levels were 14.4 (9.30–24.30) mIU/mL. Median follow-up was 566 days. Anemia was associated with overall mortality (HR 2.40, 95% CI 1.51–3.80, p < 0.001). Higher logEPO levels were associated with mid-term mortality (HR 4.05, 95% CI 2.29–7.16, p < 0.001), even after adjusting for clinically and/or statistically relevant factors (multivariate HR 2.25, 95 CI 1.09–4.66, p = 0.029). Kaplan-Meier analyses showed early diverging curves for anemia vs. non-anemia, whereas curves for patients in various EPO level quartiles started to diverge at about 100 days, with differences consistently increasing during the subsequent entire follow-up period. Conclusions: Differently from anemia, which was a strong predictor for both early and late mortality in severe aortic stenosis after TAVR, independent prognostic value of EPO only emerged after post-TAVR recovery. EPO prognostic value was independent from anemia and mild-to-moderate renal dysfunction. High EPO levels could be useful to identify patients with severe aortic stenosis showing a compromised mid-term survival in spite of TAVR use and independently from early TAVR results.
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Affiliation(s)
- Silvia Mas-Peiro
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Germany.,Cardiopulmonary Institute (CPI), Frankfurt, Germany
| | - Philipp C Seppelt
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Roberta De Rosa
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany
| | - Marie-Isabel Murray
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Jörg Yogarajah
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany
| | | | - Stephan Fichtlscherer
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Germany.,Cardiopulmonary Institute (CPI), Frankfurt, Germany
| | - Andreas M Zeiher
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Germany.,Cardiopulmonary Institute (CPI), Frankfurt, Germany
| | - Mariuca Vasa-Nicotera
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany.,German Center for Cardiovascular Research (DZHK), Berlin, Germany.,Cardiopulmonary Institute (CPI), Frankfurt, Germany
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24
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Bendayan M, Messas N, Perrault LP, Asgar AW, Lauck S, Kim DH, Arora RC, Langlois Y, Piazza N, Martucci G, Lefèvre T, Noiseux N, Lamy A, Peterson MD, Labinaz M, Popma JJ, Webb JG, Afilalo J. Frailty and Bleeding in Older Adults Undergoing TAVR or SAVR: Insights From the FRAILTY-AVR Study. JACC Cardiovasc Interv 2020; 13:1058-1068. [PMID: 32381184 DOI: 10.1016/j.jcin.2020.01.238] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The aim of this study was to examine the value of frailty to predict in-hospital major bleeding and determine its impact on mid-term mortality following transcatheter (TAVR) or surgical (SAVR) aortic valve replacement. BACKGROUND Bleeding complications are harbingers of mortality and major morbidity in patients undergoing TAVR or SAVR. Despite the high prevalence of frailty in this population, little is known about its effects on bleeding risk. METHODS A post hoc analysis was performed of the multinational FRAILTY-AVR (Frailty Aortic Valve Replacement) cohort study, which prospectively enrolled older adults ≥70 years of age undergoing TAVR or SAVR. Trained researchers assessed frailty using a questionnaire and physical performance battery pre-procedure and ascertained clinical data from the electronic health record. The primary endpoint was major or life-threatening bleeding during the index hospitalization, and the secondary endpoint was units of packed red blood cells transfused. RESULTS The cohort consisted of 1,195 patients with a mean age of 81.3 ± 6.0 years. The incidence of life-threatening bleeding, major bleeding with a clinically apparent source, and major bleeding without a clinically apparent source was, respectively, 3%, 6%, and 9% in the TAVR group and 8%, 10%, and 31% in the SAVR group. Frailty measured using the Essential Frailty Toolset was an independent predictor of major bleeding and packed red blood cell transfusions in both groups. Major bleeding was associated with a 3-fold increase in 1-year mortality following TAVR (odds ratio: 3.40; 95% confidence interval: 2.22 to 5.21) and SAVR (odds ratio: 2.79; 95% confidence interval: 1.25 to 6.21). CONCLUSIONS Frailty is associated with post-procedural major bleeding in older adults undergoing TAVR and SAVR, which is in turn associated with a higher risk for mid-term mortality.
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Affiliation(s)
- Melissa Bendayan
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada; Centre for Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Nathan Messas
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Louis P Perrault
- Division of Cardiac Surgery, Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Anita W Asgar
- Division of Cardiology, Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Sandra Lauck
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dae H Kim
- Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard University, Boston, Massachusetts
| | - Rakesh C Arora
- Divisions of Cardiac Surgery and Critical Care, St. Boniface Hospital, University of Manitoba, Winnipeg, Manitoba
| | - Yves Langlois
- Division of Cardiac Surgery, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Nicolo Piazza
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Giuseppe Martucci
- Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Thierry Lefèvre
- Division of Cardiology, Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Massy, France
| | - Nicolas Noiseux
- Division of Cardiac Surgery, Center Hospitalier de l'Université de Montréal, Centre de Recherche du CHUM, Montreal, Quebec
| | - Andre Lamy
- Division of Cardiac Surgery, Hamilton Health Sciences, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Mark D Peterson
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marino Labinaz
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jeffrey J Popma
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard University, Boston, Massachusetts
| | - John G Webb
- Centre for Heart Valve Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathan Afilalo
- Division of Experimental Medicine, McGill University, Montreal, Quebec, Canada; Centre for Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada; Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
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25
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Kisacik H, Tok D, Balci KG, Demirkan B, Karakurt M, Açar B, Karabulut Ö, Erbay I, Balci MM. Evaluation of Acquired Thrombocytopenia According to the Balloon-Expandable Versus Self-Expandable Valves in Patients Undergoing Transcatheter Aortic Valve Replacement. Angiology 2020; 72:290-294. [PMID: 32873055 DOI: 10.1177/0003319720953048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In patients with severe aortic stenosis, the data about the incidence of acquired thrombocytopenia according to the use of balloon-expandable or self-expandable valves are limited. We investigated the relationship between the post-transcatheter aortic valve replacement (TAVR) thrombocytopenia and the balloon-expandable or self-expandable valves. A total of 127 consecutive patients who underwent TAVR were retrospectively analyzed. Among the study population, 61 (48%) patients underwent TAVR with the balloon-expandable valve and the 66 (52%) patients with the self-expandable valve. Procedural success did not differ between the groups (P = .575). The access site complications and in-hospital mortality were the same across the groups (P = .225 and P = .466). However, paravalvular (PV) leaks were significantly higher in the self-expandable valve group (P = .007). Among all, 65 patients experienced thrombocytopenia, which was more frequent in the self-expandable valve group (63.6 vs 37.7%, P = .005). In multivariate analyses, admission platelet count, PV leak, and self-expandable valve deployment were the predictors of thrombocytopenia (P = .001, P = .002, and P = .021, respectively). The present study showed a higher incidence of acquired thrombocytopenia in the self-expandable valve group. Although the procedural success was similar between the groups, postprocedural PV leaks were more common in the self-expandable valve group.
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Affiliation(s)
| | - Derya Tok
- 536164Ankara City Hospital, Ankara, Turkey
| | | | | | | | - Burak Açar
- 52980Kocaeli University Medical Faculty, Kocaeli, Turkey
| | | | - Ilke Erbay
- 536164Ankara City Hospital, Ankara, Turkey
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26
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Oliveira FA, Lemos PA. TAVR patients count on their thrombocytes: Platelets count is accountable for the outcomes! Catheter Cardiovasc Interv 2020; 96:422-423. [PMID: 32797747 DOI: 10.1002/ccd.29171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 11/10/2022]
Abstract
Chronic thrombocytopenia is frequent in patients undergoing TAVR in the real world. Chronic thrombocytopenia is associated with worse in-hospital outcomes after TAVR. Future research is necessary to establish a better way of conducting and monitoring these patients.
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Affiliation(s)
| | - Pedro A Lemos
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil.,Heart Institute (InCor), University of São Paulo Medical School, Sao Paulo, Brazil
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27
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Takahashi S, Yokoyama N, Watanabe Y, Katayama T, Hioki H, Yamamoto H, Kawasugi K, Kozuma K. Predictor and Mid-Term Outcome of Clinically Significant Thrombocytopenia After Transcatheter Aortic Valve Selection. Circ J 2020; 84:1020-1027. [PMID: 32336739 DOI: 10.1253/circj.cj-19-0875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The frequency and predictors of thrombocytopenia after transcatheter aortic valve implantation (TAVI) are unclear.Methods and Results:This study enrolled 342 patients undergoing TAVI (245 with a percutaneous transfemoral approach, 65 with transfemoral surgical cutdown, and 32 with a non-transfemoral approach). Balloon-expandable and self-expanding valves were implanted in 235 and 107 patients, respectively. Platelet counts started to drop immediately, reaching a nadir 2-4 days after TAVI. Clinically significant thrombocytopenia (CSTP) was defined as a platelet count ≤50×109/L at the time of the nadir or both a platelet count between 80 and 51×109/L and a decrease in platelet count ≥50%. CSTP occurred in 16.7% patients. Approach site and TAVI valve selection significantly predicted CSTP. In multivariate analysis, independent predictors of CSTP were liver cirrhosis (odds ratio [OR] 7.22; 95% confidence interval [CI] 1.05-49.82), baseline platelet count ≤120×109/L (OR 2.98; 95% CI 1.20-7.38), multiple blood transfusions (OR 4.03; 95% CI 1.72-9.41), and the use of balloon-expandable valves (OR 2.38; 95% CI 1.04-5.46). Kaplan-Meier survival analysis with a generalized Wilcoxon test revealed that mid-term (2 years) mortality was greater for patients with than without CSTP (31.4% vs. 15.5%; P=0.008). CONCLUSIONS TAVI-related CSTP was not rare and was associated with poor mid-term outcomes. CSTP was not only caused by patients' comorbidities and TAVI complications, but also related to TAVI procedural factors.
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Affiliation(s)
| | | | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine
| | - Taiga Katayama
- Department of Cardiology, Teikyo University School of Medicine
| | - Hirofumi Hioki
- Department of Cardiology, Teikyo University School of Medicine
| | | | | | - Ken Kozuma
- Department of Cardiology, Teikyo University School of Medicine
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28
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Greco A, Capodanno D. Anticoagulation after Transcatheter Aortic Valve Implantation: Current Status. Interv Cardiol 2020; 15:e02. [PMID: 32382318 PMCID: PMC7203879 DOI: 10.15420/icr.2019.24] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 01/27/2020] [Indexed: 02/07/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is the standard of care for symptomatic severe aortic stenosis. Antithrombotic therapy is required after TAVI to prevent thrombotic complications but it increases the risk of bleeding events. Current clinical guidelines are mostly driven by expert opinion and therefore yield low-grade recommendations. The optimal antithrombotic regimen following TAVI has yet to be determined and several randomised controlled trials assessing this issue are ongoing. The purpose of this article is to critically explore the impact of antithrombotic drugs, especially anticoagulants, on long-term clinical outcomes following successful TAVI.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, CAST, PO G Rodolico, Policlinico-Vittorio Emanuele University Hospital, University of Catania Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, CAST, PO G Rodolico, Policlinico-Vittorio Emanuele University Hospital, University of Catania Catania, Italy
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29
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Grossman K, Williams MR, Ibrahim H. Between a Rock and a Hard Place: How to Use Antithrombotics in Patients Undergoing Transcatheter Aortic Valve Replacement. US CARDIOLOGY REVIEW 2020. [DOI: 10.15420/usc.2019.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has become the preferred method for management of severe aortic stenosis in patients who are at high and intermediate surgical risk, and has recently gained approval from the Food and Drug Administration in the US for use in patients at low risk for surgery. Thrombocytopenia and thromboembolic events in patients undergoing TAVR is associated with increased morbidity and mortality, and yet there is insufficient evidence supporting the current guideline-mediated therapy for antithrombotics post-TAVR. In this article, the authors review current guidelines for antithrombotic therapy in patients undergoing TAVR, studies evaluating antiplatelet regimens, and studies evaluating the use of platelet function testing after TAVR. They also offer a potential link between thrombocytopenia and antiplatelet treatments in patients undergoing TAVR.
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Affiliation(s)
| | - Mathew R Williams
- Departments of Surgery and Medicine, NYU Langone Health, New York, NY
| | - Homam Ibrahim
- Departments of Surgery and Medicine, NYU Langone Health, New York, NY
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30
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Cammalleri V, Muscoli S, Versaci F, Romeo F. Periprocedural anemia management in severe aortic stenosis patients undergoing transcatheter aortic valve implantation. J Cardiol 2020; 75:117-123. [DOI: 10.1016/j.jjcc.2019.08.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/29/2019] [Accepted: 08/13/2019] [Indexed: 12/17/2022]
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31
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Fugar S, Behnamfar O, Okoh AK, Alabre AF, Salia S, Kosinski M, Mahmood A, Jolly N, Doukky R, Kavinsky CJ. Impact of chronic thrombocytopenia on in-hospital outcomes and healthcare resource utilization after transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2019; 96:413-421. [PMID: 31714681 DOI: 10.1002/ccd.28519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 09/18/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND There is little data on the impact of chronic thrombocytopenia (CTP) on outcomes after transcatheter aortic valve repair (TAVR). Most studies are from single centers and mostly focused on postprocedure thrombocytopenia. OBJECTIVES This study sought to report on the impact of CTP (>1 year) on in-hospital outcomes and healthcare resource utilization after TAVR. METHODS From the National Inpatient Sample (NIS) between 2012 and 2015, we identified patients with CTP who underwent TAVR. A 1:1 propensity-matched cohort was created to examine in-hospital outcomes in patients with and without CTP. The primary outcome was in-hospital mortality. Secondary outcomes included postprocedure complications, length of stay, total cost, and discharge disposition. RESULTS A matched pair of 4,300 patients with and without CTP were identified. Patients with CTP had higher in-hospital mortality as compared to no CTP patients (6.0 vs. 3.3%, p-value .007), increased postprocedure hemorrhage, platelet and blood transfusion, vascular complications, postop sepsis, and acute kidney injury. With regards to resource utilization, CTP patients had a longer length of stay, higher total cost and were more likely to be discharged to a facility (34.1 vs. 27.6%) other than home (All, p-value <.001). Subanalysis, however, revealed this difference in resource utilization was seen when patients developed postprocedure complications. CONCLUSION This study demonstrated higher risk of in-hospital mortality, perioperative complications, and healthcare resource utilization in patients with baseline CTP undergoing TAVR. Further studies are required to investigate ways to improve the management of these patients.
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Affiliation(s)
- Setri Fugar
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois
| | - Omid Behnamfar
- Department of Medicine, Cook County Health, Chicago, Illinois
| | - Alexis K Okoh
- Cardiovascular Research Unit, RWJ Barnabas Heart Health Center, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Alisha F Alabre
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Soziema Salia
- Department of Medicine, Cape Coast Teaching Hospital, Cape Coast, Ghana
| | - Mark Kosinski
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois
| | - Ali Mahmood
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois
| | - Neeraj Jolly
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois
| | - Rami Doukky
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois.,Division of Cardiology, Cook County Health, Chicago, Illinois
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Thrombotic Versus Bleeding Risk After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2019; 74:2088-2101. [DOI: 10.1016/j.jacc.2019.08.1032] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/26/2019] [Accepted: 08/27/2019] [Indexed: 01/09/2023]
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Dauerman HL, DeStephan CM, Sommer HT, Kurchena KC, DeSarno M, Mendoza EG, Henderson A, Schneider DJ. Prolonged Clotting Time Among Patients Undergoing Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2019; 74:820-821. [PMID: 31395135 DOI: 10.1016/j.jacc.2019.06.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/10/2019] [Accepted: 06/10/2019] [Indexed: 11/16/2022]
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Greco A, Capranzano P, Barbanti M, Tamburino C, Capodanno D. Antithrombotic pharmacotherapy after transcatheter aortic valve implantation: an update. Expert Rev Cardiovasc Ther 2019; 17:479-496. [PMID: 31198065 DOI: 10.1080/14779072.2019.1632189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Transcatheter aortic valve implantation (TAVI) is the treatment of choice for a large proportion of patients with severe aortic stenosis. Despite numerous technological and clinical advances, TAVI remains associated with thrombotic complications requiring antithrombotic pharmacotherapy, which exposes to the risk of bleeding, especially in elderly individuals. The optimal antithrombotic regimen following TAVI is uncertain and several investigations are ongoing. Areas covered: Clinical guidelines are mostly driven by observational trials and experts' opinions, thus resulting into low-grade level of evidence. The aim of the current review is to critically explore the epidemiology, pathophysiology and prognostic value of thrombotic and bleeding events after TAVI, and to review the current literature on antithrombotic strategies following the procedure. Expert opinion: Thrombotic and bleeding events remain major complications occurring in the frail population that is currently offered TAVI. Waiting for upcoming evidence from ongoing randomized clinical trials, tailoring antithrombotic therapies based on patients' characteristics, values and circumstances is a preferable approach.
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Affiliation(s)
- Antonio Greco
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Piera Capranzano
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Marco Barbanti
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Corrado Tamburino
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
| | - Davide Capodanno
- a Division of Cardiology , A.O.U. "Policlinico-Vittorio Emanuele", University of Catania , Catania , Italy
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Block PC, Lisko JC. Thrombocytopenia after transcatheter aortic valve replacement: What is really going on? Catheter Cardiovasc Interv 2019; 93:1352-1353. [PMID: 31172677 DOI: 10.1002/ccd.28353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 11/10/2022]
Abstract
In a multivariate model, the drop-in platelet count (DPC) was significantly higher in patients treated with a balloon expandable valve (BEV) than a self-expandable valve (SEV) (36.3% ± 15.1% vs. 27.7% ± 14.4%, p < .001). In a univariate model, a higher DPC post-transcatheter aortic valve replacement was observed in patients requiring alternate access and lower contrast volume. The platelet count nadir was nearly a day later in patients implanted with a BEV compared with an SEV. At 30 days, there was a higher rate of adverse events and mortality in patients with a high DPC. At 1 year, there was no significant difference in mortality rates between the high DPC group and the low DPC group.
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