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Avvedimento M, Cepas-Guillén P, Garcia CB, Franzone A, Sorrentino S, Indolfi C, Esposito G, Mohammadi S, Pelletier-Beaumont E, Rodés-Cabau J. Incidence, Predictors, and Prognostic Impact of Neurologic Events After TAVR According to VARC-3 Criteria. JACC Cardiovasc Interv 2024; 17:1795-1807. [PMID: 39142756 DOI: 10.1016/j.jcin.2024.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/12/2024] [Accepted: 05/29/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND The Valve Academic Research Consortium (VARC)-3 definition for neurologic events after transcatheter aortic valve replacement (TAVR) lacks clinical validation. OBJECTIVES This study sought to determine the incidence, predictors, and clinical impact of neurologic events following TAVR as defined by VARC-3 criteria. METHODS This was a multicenter study including 2,924 patients with severe aortic stenosis undergoing TAVR. Based on Neurologic Academic Research Consortium (NeuroARC) classification, neurologic events were classified as NeuroARC type 1 (stroke), NeuroARC type 2 (covert central nervous system injury), and NeuroARC type 3 (transient ischemic attack and delirium). Baseline, procedural, and follow-up data were prospectively collected in a dedicated database. RESULTS After a median follow-up of 13 (7-37) months, neurologic events occurred in 471 patients (16.1%), NeuroARC type 1, 2, and 3 in 37.4%, 4.7%, and 58.0% of cases, respectively, and the majority (58.6%) were periprocedural. Advanced age, chronic kidney disease, atrial fibrillation, major vascular complications, and in-hospital bleeding determined an increased risk of periprocedural events (P < 0.03 for all). Neurologic events occurring during the periprocedural time frame were independently associated with a substantial increase in mortality at 1 year after the intervention (HR: 1.91; 95% CI: 1.23-2.97; P = 0.004). However, although NeuroARC type 1 was associated with an increased mortality risk (IRR: 3.38; 95% CI: 2.30-5.56; P < 0.001 and IRR: 21.7; 95% CI: 9.63-49.1; P < 0.001 for ischemic and hemorrhagic stroke, respectively), the occurrence of NeuroARC type 3 events had no impact on mortality. CONCLUSIONS Neurologic events after TAVR were associated with poorer short- and long-term survival. This correlation was related to the type of NeuroARC event defined by the VARC-3 criteria. Given the negative impact on clinical outcomes, every attempt should be made to reduce the risk of neurologic complications after TAVR.
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Affiliation(s)
| | | | | | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Siamak Mohammadi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | | | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada; Clinic Barcelona, Barcelona, Spain.
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2
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Del Portillo JH, Kalavrouziotis D, Dumont E, Paradis JM, Poulin A, Beaupré F, Avvedimento M, Mas-Peiro S, Cepas-Guillén P, Mengi S, Mohammadi S, Rodés-Cabau J. Five-year outcomes of transcarotid transcatheter aortic valve replacement. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00539-7. [PMID: 38936601 DOI: 10.1016/j.jtcvs.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/12/2024] [Accepted: 06/18/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Transcarotid transcatheter aortic valve replacement (TC-TAVR) has emerged as an alternative access route for transcatheter aortic valve replacement (TAVR). However, scarce data exist on long-term outcomes following TC-TAVR. This study aimed to evaluate clinical outcomes at 5 years after TC-TAVR. METHODS A total of 110 consecutive patients who underwent TC-TAVR were included. Baseline, procedural, and follow-up data were collected prospectively in a dedicated database. The primary endpoint was the incidence of a composite outcome of all-cause mortality, stroke, and repeat hospitalization at 5-year follow-up. Echocardiography results, New York Heart Association (NYHA) class, and quality of life (QoL) as assessed with the EuroQol visual analog scale (EQ-VAS) were examined over the 5-year follow-up. RESULTS The median patient age was 77 years (interquartile range [IQR], 72-82.2 years), 42.3% were women, and the median Society of Thoracic Surgeons (STS) risk score was 5.02% (IQR, 3.4%-7.5%). The incidence of the composite primary endpoint was 54.5%. Death from any cause occurred in 45.6% of patients (11.9 per 100 patient-years); stroke in 8.2% (1.9 per 100 patient-years); disabling stroke in 2.7% (0.7 per 100 patient-years); and rehospitalization in 27.2%. The improvements in valve hemodynamics, NYHA class, and EQ-VAS following the procedure persisted at 5-year follow-up (P < .001). The incidence of bioprosthetic valve failure was 0.9%. CONCLUSIONS About half of the moderate-to high-risk patients undergoing TC-TAVR survived with no major cardiovascular events at the 5-year follow-up. The yearly incidence of stroke events was low, and early improvements in valve hemodynamics, functional status, and QoL persisted at 5 years. These results suggest the long-term safety and efficacy of TC-TAVR and would support this approach as an alternative to surgery in non-transfemoral candidates.
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Affiliation(s)
- Juan Hernando Del Portillo
- Departments of Cardiology and Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Dimitri Kalavrouziotis
- Departments of Cardiology and Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Eric Dumont
- Departments of Cardiology and Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Jean-Michel Paradis
- Departments of Cardiology and Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Anthony Poulin
- Departments of Cardiology and Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Frederic Beaupré
- Departments of Cardiology and Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Marisa Avvedimento
- Departments of Cardiology and Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Silvia Mas-Peiro
- Departments of Cardiology and Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Pedro Cepas-Guillén
- Departments of Cardiology and Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Siddhartha Mengi
- Departments of Cardiology and Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Siamak Mohammadi
- Departments of Cardiology and Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Departments of Cardiology and Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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3
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Nuche J, Soliman F, Chavarría J, Okoh AK, Alvarado Mora H, Nault I, Natarajan MK, Russo M, Philippon F, Rodés-Cabau J. New-onset atrial fibrillation detected by ambulatory ECG monitoring after transcatheter aortic valve implantation. EUROINTERVENTION 2024; 20:591-601. [PMID: 38726722 PMCID: PMC11067725 DOI: 10.4244/eij-d-23-01014] [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: 11/24/2023] [Accepted: 03/01/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Little is known about the occurrence of subclinical new-onset atrial fibrillation (NOAF) after transcatheter aortic valve implantation (TAVI). AIMS We aimed to evaluate the incidence, predictors, and clinical impact of subclinical NOAF after TAVI. METHODS This was a multicentre study, including patients with aortic stenosis (AS) and no previous atrial fibrillation undergoing TAVI, with continuous ambulatory electrocardiogram (AECG) monitoring after TAVI. RESULTS A total of 700 patients (79±8 years, 49% female, Society of Thoracic Surgeons score 2.9% [1.9-4.0]) undergoing transarterial TAVI were included (85% balloon-expandable valves). AECG was started 1 (0-1) day after TAVI (monitoring time: 14121314 days). NOAF was detected in 49 patients (7%), with a median duration of 185 (43-421) minutes (atrial fibrillation burden of 0.7% [0.3-2.8]). Anticoagulation was started in 25 NOAF patients (51%). No differences were found in baseline or procedural characteristics, except for a higher AS severity in the NOAF group (peak gradient: no NOAF: 71.9±23.5 mmHg vs NOAF: 85.2±23.8 mmHg; p=0.024; mean gradient: no NOAF: 44.4±14.7 mmHg vs NOAF: 53.8±16.8 mmHg; p=0.004). In the multivariable analysis, the baseline mean transaortic gradient was associated with a higher risk of NOAF after TAVI (odds ratio 1.04, 95% confidence interval: 1.01-1.06 for each mmHg; p=0.006). There were no differences between groups in all-cause mortality (no NOAF: 4.7% vs NOAF: 0%; p=0.122), stroke (no NOAF: 1.4% vs NOAF: 2.0%; p=0.723), or bleeding (no NOAF: 1.9% vs NOAF: 4.1%; p=0.288) from the 30-day to 1-year follow-up. CONCLUSIONS NOAF detected with AECG occurred in 7% of TAVI recipients and was associated with a higher AS severity. NOAF detection determined the start of anticoagulation therapy in about half of the patients, and it was not associated with an increased risk of clinical events at 1-year follow-up.
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Affiliation(s)
- Jorge Nuche
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | - Fady Soliman
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Jorge Chavarría
- McMaster University, Hamilton, ON, Canada and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Alexis K Okoh
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Division of Cardiology, Emory University, Atlanta, GA, USA
| | - Hugo Alvarado Mora
- McMaster University, Hamilton, ON, Canada and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Isabelle Nault
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | - Madhu K Natarajan
- McMaster University, Hamilton, ON, Canada and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Mark Russo
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - François Philippon
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
- Clínic Barcelona, Barcelona, Spain
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Hlavicka J, Gettwart L, Landgraf J, Salem R, Hecker F, Salihi E, Van Linden A, Walther T, Holubec T. Minimally Invasive and Full Sternotomy Aortic Valve Replacements Lead to Comparable Long-Term Outcomes in Elderly Higher-Risk Patients: A Propensity-Matched Comparison. J Cardiovasc Dev Dis 2024; 11:112. [PMID: 38667730 PMCID: PMC11050264 DOI: 10.3390/jcdd11040112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/22/2024] [Accepted: 03/30/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Minimally invasive aortic valve replacement (AVR) via upper ministernotomy (MiniAVR) is a standard alternative to full sternotomy access. Minimally invasive cardiac surgery has been proven to provide a number of benefits to patients. The aim of this study was to compare the short- and long-term outcomes after MiniAVR versus conventional AVR via full sternotomy (FS) using a biological prosthesis in an elderly higher-risk population. METHODS Between January 2006 and July 2009, 918 consecutive patients received AVR ± additional procedures with different prostheses at our center. Amongst them, 441 received isolated AVR using a biological prosthesis (median age of 74.5; range: 52-93 years; 50% females) and formed the study population (EuroSCORE II: 3.62 ± 5.5, range: 0.7-42). In total, 137 (31.1%) of the operations were carried out through FS, and 304 (68.9%) were carried out via MiniAVR. Follow-up was complete in 96% of the cases (median of 7.6 years, 6610 patient-years). Propensity score matching (PSM) resulted in two groups of 68 patients with very similar baseline profiles. The primary endpoints were long-term survival, freedom from reoperation, and endocarditis, and the secondary endpoints were early major adverse cardiac and cerebrovascular events (MACCEs). RESULTS FS led to shorter cardio-pulmonary bypass and aortic cross-clamp durations: 90 (47-194) vs. 100 (46-246) min (p = 0.039) and 57 (33-156) vs. 69 (32-118) min (p = 0.006), respectively. Perioperative stroke occurred in three patients (4.4%; FS) vs. one patient (1.5%; MiniAVR) (p = 0.506). The 30-day mortality was similar in both groups (2.9%, p = 1.000). Survival at 1, 5, and 10 years was 94.1 ± 3% (FS and MiniAVR), 80.3 ± 5% vs. 75.7 ± 5%, and 45.3 ± 6% vs. 43.8 ± 6%, respectively (p = 0.767). There were two (2.9%) reoperations in each group and two thrombo-embolic events (2.9%) vs. one (1.5%) thrombo-embolic event in the MiniAVR and FS groups, respectively (p = 0.596). CONCLUSIONS In comparison to FS, MiniAVR provided similar short- and long-term outcomes in a higher-risk elderly population receiving biological prostheses. In particular, long-term survival, freedom from reoperation, and the incidence of endocarditis were comparable. These results clearly advocate for the routine use of MiniAVR as a standard procedure for AVR, even in a high-risk population.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Tomas Holubec
- Department of Cardiovascular Surgery, University Hospital Frankfurt and Goethe University Frankfurt, 60596 Frankfurt/Main, Germany; (J.H.); (L.G.); (J.L.); (R.S.); (F.H.); (E.S.); (A.V.L.); (T.W.)
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5
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Alaour B, Ferrari E, Heg D, Tueller D, Pilgrim T, Muller O, Noble S, Jeger R, Reuthebuch O, Toggweiler S, Templin C, Wenaweser P, Nietlispach F, Taramasso M, Huber C, Roffi M, Windecker S, Stortecky S. Non-Vitamin K Antagonist Versus Vitamin K Antagonist Oral Anticoagulant Agents After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2024; 17:405-418. [PMID: 38355269 DOI: 10.1016/j.jcin.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Studies comparing long-term outcomes between non-vitamin K antagonist (VKA) oral anticoagulant agents (direct oral anticoagulant agents [DOACs]) and VKA anticoagulant agents after transcatheter aortic valve replacement (TAVR) are scarce, with conflicting results. OBJECTIVES The aim of this study was to examine the periprocedural, short-term, and long-term safety and effectiveness of DOACs vs VKAs in patients undergoing TAVR via femoral access with concomitant indications for oral anticoagulation. METHODS Consecutive patients undergoing transfemoral TAVR in the prospective national SwissTAVI Registry between February 2011 and June 2021 were analyzed. Net clinical benefit (a composite of all-cause mortality, myocardial infarction, stroke, and life-threatening or major bleeding) and the primary safety endpoint (a composite of life-threatening and major bleeding) were compared between the VKA and DOAC groups at 30 days, 1 year, and 5 years after TAVR. RESULTS After 1:1 propensity score matching, 1,454 patients were available for analysis in each group. There was no significant difference in the rate of the net clinical benefit and the safety endpoints between the groups as assessed at 30 days and 1 and 5 years post-TAVR between VKAs and DOACs. VKAs were associated with significantly higher rates of 1- year (HR: 1.28; 95% CI: 1.01-1.62) and 5-year (HR: 1.25; 95% CI: 1.11-1.40) all-cause mortality. Long-term risk for disabling stroke was significantly lower in the VKA group after excluding periprocedural events (HR: 0.64; 95% CI: 0.46-0.90). CONCLUSIONS At 5 years after TAVR, VKAs are associated with a higher risk for all-cause mortality, a lower risk for disabling stroke, and a similar rate of life-threatening or major bleeding compared with DOACs. (SwissTAVI Registry; NCT01368250).
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Affiliation(s)
- Bashir Alaour
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Enrico Ferrari
- Department of Cardiovascular Surgery, Cardiocentro Ticino Institute-EOC, Lugano, Switzerland
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - David Tueller
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital-CHUV, Lausanne, Switzerland
| | - Stephane Noble
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Raban Jeger
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland; University of Basel, Basel, Switzerland
| | - Oliver Reuthebuch
- University of Basel, Basel, Switzerland; Department of Cardiovascular Surgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | | | - Christian Templin
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Peter Wenaweser
- Heart Clinic Hirslanden, Hirslanden Clinic Zurich, Zurich, Switzerland
| | | | | | - Christoph Huber
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Marco Roffi
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Demirel C, Sulzgruber P, Winter MP, Mascherbauer K, Halavina K, Heitzinger G, Dona C, Koschatko S, Jantsch C, Andreas M, Hengstenberg C, Bartko PE. Impact of stroke history on procedural cerebrovascular insult probability and long-term outcome after TAVI. Eur J Clin Invest 2024; 54:e14099. [PMID: 37771050 DOI: 10.1111/eci.14099] [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: 05/31/2023] [Revised: 08/21/2023] [Accepted: 09/11/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND In TAVI procedural stroke is one of the most feared complications and for this reason also extensively studied. But there is a lack of data concerning the impact of previous stroke on procedural stroke and on long-term survival. The aim of this registry-based cohort study is to evaluate the prevalence of previous stroke in TAVI patients and its impact on procedural stroke risk as well as long-term outcome. METHODS We included all patients treated with TAVI between January 2007 and December 2020 and investigated concerning previous stroke in their medical history. Among 958 patients, 55 patients had previous stroke and were included in the present analysis. RESULTS The salient finding of the present study is that previous stroke is significantly associated with higher all-cause mortality and has established itself as a predictor for poor outcome after TAVI. This is also observed after adjusting for confounders like EuroSCORE II (European system for cardiac operative risk evaluation) and AF (atrial fibrillation) as one of the main underlying diseases for cerebrovascular insult (CVI). However, previous stroke is not associated with higher rates of procedural CVI. CONCLUSION A history of stroke is significantly associated with higher all-cause mortality and has established itself as a predictor for poor outcome after TAVI without higher rates of procedural stroke.
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Affiliation(s)
- Caglayan Demirel
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Patrick Sulzgruber
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Max Paul Winter
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Katharina Mascherbauer
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Kseniya Halavina
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Gregor Heitzinger
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Carolina Dona
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Sophia Koschatko
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Charlotte Jantsch
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Philipp E Bartko
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
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7
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Okuno T, Alaour B, Heg D, Tueller D, Pilgrim T, Muller O, Noble S, Jeger R, Reuthebuch O, Toggweiler S, Ferrari E, Templin C, Wenaweser P, Nietlispach F, Taramasso M, Huber C, Roffi M, Windecker S, Stortecky S. Long-Term Risk of Stroke After Transcatheter Aortic Valve Replacement: Insights From the SwissTAVI Registry. JACC Cardiovasc Interv 2023; 16:2986-2996. [PMID: 38151313 DOI: 10.1016/j.jcin.2023.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/26/2023] [Accepted: 10/10/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Stroke after transcatheter aortic valve replacement (TAVR) is associated with considerable morbidity and mortality. Predictors of stroke and the long-term risk after TAVR remain incompletely understood. OBJECTIVES The authors sought to investigate the short- and long-term incidence and predictors of stroke after TAVR in the SwissTAVI Registry. METHODS Between February 2011 and June 2021, consecutive patients undergoing TAVR were included. Standardized stroke ratios (SSRs) were calculated to compare trends in stroke of TAVR patients with an age- and sex-matched general population in Switzerland derived from the 2019 Global Burden of Disease study. RESULTS A total of 11,957 patients (81.8 ± 6.5 years of age, 48.0% female) were included. One-third of the patients (32.3%) had a history of atrial fibrillation, and 11.8% had a history of cerebrovascular accident. The cumulative 30-day incidence rate of stroke was 3.0%, with 69% of stroke events occurring within the first 48 hours after TAVR. The incidence of stroke was 4.3% at 1 year, and 7.8% at 5 years. Compared with an age- and sex-adjusted general population, the risk of stroke was significantly higher in the TAVR population during the first 2 years after TAVR: first year: SSR 7.26 (95% CI: 6.3-8.36) and 6.82 (95% CI: 5.97-7.79) for males and females, respectively; second year: SSR 1.98 (95% CI: 1.47-2.67) and 1.48 (95% CI: 1.09-2.02) for males and females, respectively; but returned to a comparable level to that observed in the matched population thereafter. CONCLUSIONS Compared with an age- and sex-matched population, TAVR patients experienced a higher risk of stroke for up to 2 years after the procedure, and a comparable risk thereafter. (SwissTAVI Registry; NCT01368250).
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Affiliation(s)
- Taishi Okuno
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Bashir Alaour
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - David Tueller
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital - CHUV, Lausanne, Switzerland
| | - Stephane Noble
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Raban Jeger
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland; University of Basel, Basel, Switzerland
| | - Oliver Reuthebuch
- University of Basel, Basel, Switzerland; Department of Cardiovascular Surgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | | | - Enrico Ferrari
- Department of Cardiovascular Surgery, Cardiocentro Ticino Institute, Lugano, Switzerland
| | - Christian Templin
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Peter Wenaweser
- Heart Clinic Hirslanden, Hirslanden Clinic Zurich, Zurich, Switzerland
| | - Fabian Nietlispach
- Cardiovascular Center Zurich, Hirslanden Klinik Im Park, Zurich, Switzerland
| | | | - Christoph Huber
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Marco Roffi
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Switzerland.
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8
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Sharma H, Afzal S, Leick J, Werner N, Doshi SN, Nadir MA. Antithrombotic therapy following transcatheter aortic valve intervention. Pharmacol Ther 2023; 250:108509. [PMID: 37572882 DOI: 10.1016/j.pharmthera.2023.108509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/27/2023] [Accepted: 08/08/2023] [Indexed: 08/14/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is increasingly being performed to treat symptomatic patients with aortic stenosis and annual procedure volume has overtaken surgical aortic valve replacement in the United States. However, current international guidelines were written prior to the publication of several important recent studies. Furthermore, European and American guidelines differ in their recommendations of antithrombotic therapy following TAVR. Consequently, there is a need to examine the literature to provide clinicians guidance on the optimum antithrombotic strategy, particularly as different patient populations exist. In this review, we examine the data for antiplatelet and anticoagulation therapy post-TAVR.
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Affiliation(s)
- Harish Sharma
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Shazia Afzal
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Jürgen Leick
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Nikos Werner
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Sagar N Doshi
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - M Adnan Nadir
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK.
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9
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Avvedimento M, Campelo-Parada F, Munoz-Garcia E, Nombela-Franco L, Fischer Q, Donaint P, Serra V, Veiga G, Gutiérrez E, Esposito G, Vilalta V, Alperi A, Regueiro A, Asmarats L, Ribeiro HB, Matta A, Munoz-Garcia A, Tirado-Conte G, Urena M, Metz D, Rodenas-Alesina E, de la Torre Hernandez JM, Fernandez-Nofrerias E, Pascual I, Vidal-Cales P, Arzamendi D, Campanha-Borges DC, Trinh KH, Côté M, Faroux L, Rodés-Cabau J. Late Bleeding Events in Patients Undergoing Percutaneous Coronary Intervention in the Workup Pre-TAVR. JACC Cardiovasc Interv 2023; 16:2153-2164. [PMID: 37704301 DOI: 10.1016/j.jcin.2023.06.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND In patients undergoing percutaneous coronary intervention (PCI) in the work-up pre-transcatheter aortic valve replacement (TAVR), the incidence and clinical impact of late bleeding events (LBEs) remain largely unknown. OBJECTIVES This study sought to determine the incidence, clinical characteristics, associated factors, and outcomes of LBEs in patients undergoing PCI in the work-up pre-TAVR. METHODS This was a multicenter study including 1,457 consecutive patients (mean age 81 ± 7 years; 41.5% women) who underwent TAVR and survived beyond 30 days. LBEs (>30 days post-TAVR) were defined according to the Valve Academic Research Consortium-2 criteria. RESULTS LBEs occurred in 116 (7.9%) patients after a median follow-up of 23 (IQR: 12-40) months. Late bleeding was minor, major, and life-threatening or disabling in 21 (18.1%), 63 (54.3%), and 32 (27.6%) patients, respectively. Periprocedural (<30 days post-TAVR) major bleeding and the combination of antiplatelet and anticoagulation therapy at discharge were independent factors associated with LBEs (P ≤ 0.02 for all). LBEs conveyed an increased mortality risk at 4-year follow-up compared with no bleeding (43.9% vs 36.0; P = 0.034). Also, LBE was identified as an independent predictor of all-cause mortality after TAVR (HR: 1.39; 95% CI: 1.05-1.83; P = 0.020). CONCLUSIONS In TAVR candidates with concomitant significant coronary artery disease requiring percutaneous treatment, LBEs after TAVR were frequent and associated with increased mortality. Combining antiplatelet and anticoagulation regimens and the occurrence of periprocedural bleeding determined an increased risk of LBEs. Preventive strategies should be pursued for preventing late bleeding after TAVR, and further studies are needed to provide more solid evidence on the most safe and effective antithrombotic regimen post-TAVR in this challenging group of patients.
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Affiliation(s)
- Marisa Avvedimento
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Erika Munoz-Garcia
- Cardiology Department, Hospital Universitario Virgen de la Victoria, Málaga, CIBERCV, Spain
| | - Luis Nombela-Franco
- Cardiology Department, Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico de San Carlos, Madrid, Spain
| | - Quentin Fischer
- Cardiology Department, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pierre Donaint
- Cardiology Department, Reims University Hospital, Reims, France
| | - Vicenç Serra
- Cardiology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Gabriela Veiga
- Cardiology Department, Hospital Universitario Marques de Valdecilla, IDIVAL, Santander, Spain
| | | | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Victoria Vilalta
- Cardiology Department, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Alberto Alperi
- Cardiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Ander Regueiro
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | - Lluis Asmarats
- Cardiology Department, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Henrique B Ribeiro
- Cardiology Department, Heart Institute, University of São Paulo, São Paulo, Brazil
| | - Anthony Matta
- Cardiology Department, Hôpital Rangueil, CHU Toulouse, Toulouse, France
| | - Antonio Munoz-Garcia
- Cardiology Department, Hospital Universitario Virgen de la Victoria, Málaga, CIBERCV, Spain
| | - Gabriela Tirado-Conte
- Cardiology Department, Instituto Cardiovascular, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico de San Carlos, Madrid, Spain
| | - Marina Urena
- Cardiology Department, Bichat-Claude Bernard Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Damien Metz
- Cardiology Department, Reims University Hospital, Reims, France
| | | | | | | | - Isaac Pascual
- Cardiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Pablo Vidal-Cales
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | - Dabit Arzamendi
- Cardiology Department, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Kim Hoang Trinh
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Mélanie Côté
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Laurent Faroux
- Cardiology Department, Reims University Hospital, Reims, France
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain.
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10
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Suhai FI, Varga A, Szilveszter B, Nagy-Vecsey M, Apor A, Nagy AI, Kolossváry M, Karády J, Bartykowszki A, Molnár L, Jermendy ÁL, Panajotu A, Maurovich-Horvat P, Merkely B. Predictors and neurological consequences of periprocedural cerebrovascular events following transcatheter aortic valve implantation with self-expanding valves. Front Cardiovasc Med 2022; 9:951943. [PMID: 36277778 PMCID: PMC9581280 DOI: 10.3389/fcvm.2022.951943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/09/2022] [Indexed: 11/13/2022] Open
Abstract
Aims To evaluate the patient- and procedure-related predictors of transcatheter aortic-valve implantation (TAVI)-associated ischemic brain lesions and to assess the effect of silent cerebral ischemic lesions (SCIL) on neurocognitive function. Methods and results We investigated 113 consecutive patients with severe aortic stenosis who underwent brain magnetic resonance imaging (MRI) within a week following TAVI. To assess periprocedural cerebral ischemic lesions, diffusion-weighted MRI was utilized. We used multivariate linear regression to identify the independent predictors of TAVI-related ischemic lesion volume (ILV) and periprocedural stroke. Neurocognitive evaluation was performed before and following TAVI at 6-month and one-year follow-up. Following TAVI, a total of 944 new cerebral ischemic lesions were detected in 104 patients (92%). The median ILV was 257 μl (interquartile range [IQR]:97.1–718.8μl) with a median lesion number of 6/patient [IQR:2–10]. The majority of ischemic lesions were clinically silent (95%), while 5% of the lesions induced a stroke, which was confirmed by MRI. Predilatation (β = 1.13[95%CI:0.32–1.93], p = 0.01) and the number of valve positioning attempts during implantation (β = 0.28[95%CI:0.06–0.50], p = 0.02) increased the log-transformed total ILV. Predilatation (OR = 12.04[95%CI:1.46–99.07], p = 0.02) and alternative access routes (OR = 7.84[95%CI:1.01–61.07], p = 0.02) were associated with stroke after adjustments for comorbidities and periprocedural factors. The presence of SCILs were not associated with a change in neurocognitive function that remained stable during the one-year follow-up. Conclusion While periprocedural ischemic lesions are frequent, most of them are clinically silent and might not impact the patients' neurocognitive function. The number of valve positioning attempts, predilatation, and alternative access routes should be taken into consideration during TAVI to reduce the ILV and risk for stroke.
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Affiliation(s)
- Ferenc Imre Suhai
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Andrea Varga
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bálint Szilveszter
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary,*Correspondence: Bálint Szilveszter
| | - Milán Nagy-Vecsey
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Astrid Apor
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Anikó Ilona Nagy
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary,Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Márton Kolossváry
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary,Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Júlia Karády
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary,Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Andrea Bartykowszki
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Levente Molnár
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ádám L. Jermendy
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Alexisz Panajotu
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Béla Merkely
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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11
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Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement. J Clin Med 2022; 11:jcm11082190. [PMID: 35456283 PMCID: PMC9031701 DOI: 10.3390/jcm11082190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022] Open
Abstract
Due to a large technical improvement in the past decade, transcatheter aortic valve replacement (TAVR) has expanded to lower-surgical-risk patients with symptomatic and severe aortic stenosis. While mortality rates related to TAVR are decreasing, the prognosis of patients is still impacted by ischemic and bleeding complications, and defining the optimal antithrombotic regimen remains a priority. Recent randomized control trials reported lower bleeding rates with an equivalent risk in ischemic outcomes with single antiplatelet therapy (SAPT) when compared to dual antiplatelet therapy (DAPT) in patients without an underlying indication for anticoagulation. In patients requiring lifelong oral anticoagulation (OAC), the association of OAC plus antiplatelet therapy leads to a higher risk of bleeding events with no advantages on mortality or ischemic outcomes. Considering these data, guidelines have recently been updated and now recommend SAPT and OAC alone for TAVR patients without and with a long-term indication for anticoagulation. Whether a direct oral anticoagulant or vitamin K antagonist provides better outcomes in patients in need of anticoagulation remains uncertain, as recent trials showed a similar impact on ischemic and bleeding outcomes with apixaban but higher gastrointestinal bleeding with edoxaban. This review aims to summarize the most recently published data in the field, as well as describe unresolved issues.
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12
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Aladin AI, Case BC, Wermers JP, Rogers T, Waksman R. Overview of FDA Circulatory System Devices Panel virtual meeting on TriGUARD 3 cerebral embolic protection. Catheter Cardiovasc Interv 2022; 99:1789-1795. [PMID: 35084082 DOI: 10.1002/ccd.30098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/04/2022] [Accepted: 01/10/2022] [Indexed: 11/06/2022]
Abstract
Despite advances in transcatheter aortic valve replacement (TAVR) technology, periprocedural stroke remains a complication of TAVR procedures. The TriGUARD 3 device is designed to be positioned in the aortic arch to deflect debris away from the brachiocephalic, left common carotid, and left subclavian arteries during TAVR. The United States Food and Drug Administration (FDA) assembled the Circulatory System Devices Panel to review safety and effectiveness data for the TriGUARD 3 device. Because of the coronavirus disease 2019 pandemic, this meeting was held virtually. In this manuscript, we summarize the data presented by both the sponsor and FDA, as well as the panel discussion.
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Affiliation(s)
- Amer I Aladin
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Jason P Wermers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA.,Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia, USA
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13
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Tanawuttiwat T, Stebbins A, Marquis-Gravel G, Vemulapalli S, Kosinski AS, Cheng A. Use of Direct Oral Anticoagulant and Outcomes in Patients With Atrial Fibrillation after Transcatheter Aortic Valve Replacement: Insights From the STS/ACC TVT Registry. J Am Heart Assoc 2021; 11:e023561. [PMID: 34970918 PMCID: PMC9075194 DOI: 10.1161/jaha.121.023561] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Clinical evidence on the safety and effectiveness of using direct oral anticoagulants (DOACs) in patients with atrial fibrillation after transcatheter aortic valve replacement (TAVR) remains limited. The aim of this study was to investigate the trends and outcomes of using DOACs in patients with TAVR and atrial fibrillation. Methods and Results Data from the STS/ACC TVT (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy) Registry was used to identify patients who underwent successful TAVR with preexisting or incident atrial fibrillation who were discharged on oral anticoagulation between January 2013 and May 2018. Patients with a mechanical valve, valve‐in‐valve procedure, or prior stroke within a year were excluded. The adjusted primary outcome was 1‐year stroke events. The adjusted secondary outcomes included bleeding, intracranial hemorrhage, and death. A total of 21 131 patients were included in the study (13 004 TAVR patients were discharged on a vitamin K antagonist and 8127 were discharged on DOACs.) The use of DOACs increased 5.5‐fold from 2013 to 2018. The 1‐year incidence of stroke was comparable between DOAC‐treated patients and vitamin K antagonist‐treated patients (2.51% versus 2.37%; hazard ratio [HR], 1.00; 95% CI, 0.81–1.23) whereas DOAC‐treated patients had lower 1‐year incidence of any bleeding (11.9% versus 15.0%; HR, 0.81; 95% CI, 0.75–0.89), intracranial hemorrhage (0.33% versus 0.59%; HR, 0.54; 95% CI, 0.33–0.87), and death (15.8% versus 18.2%; HR, 0.92; 95% CI, 0.85–1.00). Conclusions In patients with TAVR and atrial fibrillation, DOAC use, when compared with vitamin K antagonists, was associated with comparable stroke risk and significantly lower risks of bleeding, intracranial hemorrhage, and death at 1 year.
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Affiliation(s)
| | | | | | | | | | - Alan Cheng
- Department of Medicine Johns Hopkins University School of Medicine Baltimore MD
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14
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Muntané-Carol G, Okoh AK, Chen C, Nault I, Kassotis J, Mohammadi S, Coromilas J, Lee LY, Alperi A, Philippon F, Russo MJ, Rodés-Cabau J. Ambulatory Electrocardiographic Monitoring Following Minimalist Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2021; 14:2711-2722. [PMID: 34949396 DOI: 10.1016/j.jcin.2021.08.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/27/2021] [Accepted: 08/17/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVES The aim of this study was to determine the impact of delayed high-degree atrioventricular block (HAVB) or complete heart block (CHB) after transcatheter aortic valve replacement (TAVR) using a minimalist approach followed by ambulatory electrocardiographic (AECG) monitoring. BACKGROUND Little is known regarding the clinical impact of HAVB or CHB in the early period after discharge following TAVR. METHODS A prospective, multicenter study was conducted, including 459 consecutive TAVR patients without permanent pacemaker who underwent continuous AECG monitoring for 14 days (median length of hospital stay 2 days; IQR: 1-3 days), using 2 devices (CardioSTAT and Zio AT). The primary endpoint was the occurrence of HAVB or CHB. Patients were divided into 3 groups: 1) no right bundle branch block (RBBB) and no electrocardiographic (ECG) changes; 2) baseline RBBB with no further changes; and 3) new-onset ECG conduction disturbances. RESULTS Delayed HAVB or CHB episodes occurred in 21 patients (4.6%) (median 5 days postprocedure; IQR: 4-6 days), leading to PPM in 17 (81.0%). HAVB or CHB events were rare in group 1 (7 of 315 [2.2%]), and the incidence increased in group 2 (5 of 38 [13.2%]; P < 0.001 vs group 1) and group 3 (9 of 106 [8.5%]; P = 0.007 vs group 1; P = 0.523 vs group 2). No episodes of sudden or all-cause death occurred at 30-day follow-up. CONCLUSIONS Systematic 2-week AECG monitoring following minimalist TAVR detected HAVB and CHB episodes in about 5% of cases, with no mortality at 1 month. Whereas HAVB or CHB was rare in patients without ECG changes post-TAVR, baseline RBBB and new-onset conduction disturbances determined an increased risk. These results would support tailored management using AECG monitoring and the possibility of longer hospitalization periods in patients at higher risk for delayed HAVB or CHB.
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Affiliation(s)
- Guillem Muntané-Carol
- Cardiology Department, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Alexis K Okoh
- Department of Surgery, Division of Cardiac Surgery, Robert Wood Johnson University Medical School, New Brunswick, New Jersey, USA
| | - Chunguang Chen
- Department of Surgery, Division of Cardiac Surgery, Robert Wood Johnson University Medical School, New Brunswick, New Jersey, USA
| | - Isabelle Nault
- Cardiology Department, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - John Kassotis
- Department of Medicine, Division of Cardiology, Robert Wood Johnson University Medical School, New Brunswick, New Jersey, USA
| | - Siamak Mohammadi
- Cardiology Department, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - James Coromilas
- Department of Medicine, Division of Cardiology, Robert Wood Johnson University Medical School, New Brunswick, New Jersey, USA
| | - Leonard Y Lee
- Department of Surgery, Division of Cardiac Surgery, Robert Wood Johnson University Medical School, New Brunswick, New Jersey, USA
| | - Alberto Alperi
- Cardiology Department, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - François Philippon
- Cardiology Department, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Mark J Russo
- Department of Surgery, Division of Cardiac Surgery, Robert Wood Johnson University Medical School, New Brunswick, New Jersey, USA
| | - Josep Rodés-Cabau
- Cardiology Department, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Hospital Clínic of Barcelona, Barcelona, Spain.
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15
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Vilalta V, Alperi A, Cediel G, Mohammadi S, Fernández-Nofrerias E, Kalvrouziotis D, Delarochellière R, Paradis JM, González-Lopera M, Fadeuilhe E, Carrillo X, Abdul-Jawad Altisent O, Rodríguez-Leor O, Voisine P, Bayés-Genís A, Rodés-Cabau J. Midterm Outcomes Following Sutureless and Transcatheter Aortic Valve Replacement in Low-Risk Patients With Aortic Stenosis. Circ Cardiovasc Interv 2021; 14:e011120. [PMID: 34607449 DOI: 10.1161/circinterventions.121.011120] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Sutureless-surgical aortic valve replacement (SU-SAVR) has been proposed as a surgical alternative for treating aortic stenosis, which facilitates a minimally invasive approach. While some studies have compared the early outcomes of SU-SAVR versus transcatheter aortic valve replacement (TAVR), most data were obtained in high-risk patients and/or limited to in-hospital outcomes. This study aimed to compare in-hospital and midterm clinical outcomes following SU-SAVR and TAVR in low-risk patients with aortic stenosis. METHODS A total of 806 consecutive low-risk (EuroSCORE II <4%) patients underwent TAVR or SU-SAVR between 2011 and 2020 in 2 centers. A 1:1 propensity score matching was performed and identified 171 pairs with similar characteristics that were included in the analysis. Baseline characteristics, in-hospital and follow-up events (defined according to Valve Academic Research Consortium-2) were collected. RESULTS Baseline characteristics were well balanced between groups, with a median EuroSCORE II of 1.9% (1.3%-2.5%) in both SU-SAVR and TAVR groups (P=0.85). There were no statistically significant differences regarding in-hospital mortality (SU-SAVR: 4.1%, TAVR: 1.8%, P=0.199) and stroke (SU-SAVR: 2.3%, TAVR: 2.9%, P=0.736), but SU-SAVR recipients exhibited higher rates of bleeding and new-onset atrial fibrillation, higher residual transvalvular gradients (P<0.001), and a lower rate of pacemaker implantation (P=0.011). After a median follow-up of 2 (1-3) years, there were no differences between groups in all-cause mortality (hazard ratio, 0.97 [95% CI, 0.52-1.82], P=0.936) and stroke (hazard ratio, 0.83 [95% CI, 0.32-2.15], P=0.708), but SU-SAVR was associated with a higher risk of heart failure hospitalization (hazard ratio, 5.38 [95% CI, 1.88-15.38], P=0.002). CONCLUSIONS In low-risk patients with aortic stenosis, TAVR was associated with improved in-hospital outcomes (except for conduction disturbances) and valve hemodynamics, compared with SU-SAVR. Although similar mortality and stroke rates were observed at 2-year follow-up, the risk of heart failure hospitalization was higher among SU-SAVR patients. These results may contribute to reinforce TAVR over SU-SAVR for the majority of such patients. Graphic Abstract: A graphic abstract is available for this article.
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Affiliation(s)
- Victoria Vilalta
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.).,CIBER Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.).,Department of Medicine, Universitat Autònoma de Barcelona, Spain (V.V., A.B.-G.)
| | - Alberto Alperi
- Quebec Heart & Lung Institute, Quebec City, Canada (A.A., S.M., D.K., R.D., J.-M.P., P.V., J.R.-C.)
| | - Germán Cediel
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.).,CIBER Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.)
| | - Siamak Mohammadi
- Quebec Heart & Lung Institute, Quebec City, Canada (A.A., S.M., D.K., R.D., J.-M.P., P.V., J.R.-C.)
| | - Eduard Fernández-Nofrerias
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.).,CIBER Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.)
| | - Dimitri Kalvrouziotis
- Quebec Heart & Lung Institute, Quebec City, Canada (A.A., S.M., D.K., R.D., J.-M.P., P.V., J.R.-C.)
| | - Robert Delarochellière
- Quebec Heart & Lung Institute, Quebec City, Canada (A.A., S.M., D.K., R.D., J.-M.P., P.V., J.R.-C.)
| | - Jean-Michel Paradis
- Quebec Heart & Lung Institute, Quebec City, Canada (A.A., S.M., D.K., R.D., J.-M.P., P.V., J.R.-C.)
| | - Marta González-Lopera
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.)
| | - Edgar Fadeuilhe
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.).,CIBER Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.)
| | - Xavier Carrillo
- CIBER Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.)
| | - Omar Abdul-Jawad Altisent
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.).,CIBER Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.)
| | - Oriol Rodríguez-Leor
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.).,CIBER Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.)
| | - Pierre Voisine
- Quebec Heart & Lung Institute, Quebec City, Canada (A.A., S.M., D.K., R.D., J.-M.P., P.V., J.R.-C.)
| | - Antoni Bayés-Genís
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.).,CIBER Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (V.V., G.C., E.F.-N., M.G.-L., E.F., X.C., O.A.-J.A., O.R.-L., A.B.-G.).,Department of Medicine, Universitat Autònoma de Barcelona, Spain (V.V., A.B.-G.)
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Quebec City, Canada (A.A., S.M., D.K., R.D., J.-M.P., P.V., J.R.-C.).,Hospital Clínic de Barcelona, Spain (J.R.-C.)
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Neurologic Complications in Transcatheter Aortic Valve Replacement. Interv Cardiol Clin 2021; 10:519-529. [PMID: 34593114 DOI: 10.1016/j.iccl.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) has become the mainstay of treatment for severe symptomatic aortic stenosis. Although many TAVR complication rates including mortality and aortic regurgitation have decreased, stroke rates have remained stable for years. TAVR-related strokes are devastating to patients and their families, and very costly for health care systems. The predictors of stroke in TAVR are not yet well defined, although older age, female gender, carotid and peripheral arterial disease, bicuspid aortic valve anatomy, and atrial fibrillation are emerging as risk factors across studies.
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17
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Balloon-Expandable versus Self-Expandable Valves in Transcatheter Aortic Valve Implantation: Complications and Outcomes from a Large International Patient Cohort. J Clin Med 2021; 10:jcm10174005. [PMID: 34501454 PMCID: PMC8432462 DOI: 10.3390/jcm10174005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/12/2021] [Accepted: 08/31/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Both balloon-expandable (BE) and self-expandable (SE) valves for transcatheter aortic valve implantation (TAVI) are broadly used in clinical practice. However, adequately powered randomized controlled trials comparing these two valve designs are lacking. Methods: The CENTER-study included 12,381 patients undergoing transfemoral TAVI. Patients undergoing TAVI with a BE-valve (n = 4096) were compared to patients undergoing TAVI with an SE-valve (n = 4096) after propensity score matching. Clinical outcomes including one-year mortality and stroke rates were assessed. Results: In the matched population of n = 5410 patients, the mean age was 81 ± 3 years, 60% was female, and the STS-PROM predicted 30-day mortality was 6.2% (IQR 4.0–12.4). One-year mortality was not different between patients treated with BE- or SE-valves (BE: 16.4% vs. SE: 17.0%, Relative Risk 1.04, 95%CI 0.02–1.21, p = 0.57). One-year stroke rates were also comparable (BE: 4.9% vs. SE: 5.3%, RR 1.09, 95%CI 0.86–1.37, p = 0.48). Conclusion: This study suggests that one-year mortality and stroke rates were comparable in patients with severe aortic valve stenosis undergoing TAVI with either BE or SE-valves.
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18
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Muntané-Carol G, Urena M, Nombela-Franco L, Amat-Santos I, Kleiman N, Munoz-Garcia A, Atienza F, Serra V, Deyell MW, Veiga-Fernandez G, Masson JB, Canadas-Godoy V, Himbert D, Castrodeza J, Elizaga J, Francisco Pascual J, Webb JG, de la Torre Hernandez JM, Asmarats L, Pelletier-Beaumont E, Philippon F, Rodés-Cabau J. Arrhythmic burden in patients with new-onset persistent left bundle branch block after transcatheter aortic valve replacement: 2-year results of the MARE study. Europace 2021; 23:254-263. [PMID: 33083813 DOI: 10.1093/europace/euaa213] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 07/10/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS We determined the incidence and type of arrhythmias at 2-year follow-up in patients with new-onset persistent left bundle branch block (LBBB) following transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS Multicentre prospective study including 103 consecutive patients with new-onset persistent LBBB post-TAVR (SAPIEN XT/3: 53; CoreValve/Evolut R: 50). An implantable cardiac monitor (Reveal XT, Reveal Linq) was implanted before hospital discharge and patients had continuous monitoring for up to 2 years. Arrhythmic events were adjudicated in a central core lab. 1836 new arrhythmic events (tachyarrhythmias: 1655 and bradyarrhythmias: 181) occurred at 2 years. Of these, 283 (15%) occurred beyond 1 year (tachyarrhythmias 212, bradyarrhythmias 71) in 33 (36%) patients, without differences between valve type. Most late (>1 year) arrhythmic events were asymptomatic (94%) and led to a treatment change in 17 (19%) patients. A total of 71 late bradyarrhythmias [high-degree atrioventricular block (HAVB): 3, severe bradycardia: 68] were detected in 17 (21%) patients. At 2 years, 18 (17%) patients had received a permanent pacemaker (PPM) or implantable cardiac-defibrillator. PPM implantation due to HAVB predominated in the early phase post-TAVR, with only 1 HAVB event requiring PPM implantation after 1 year. CONCLUSION Patients with new-onset LBBB post-TAVR exhibited a very high burden of arrhythmic events within the 2 years post-procedure. While new tachyarrhythmic events were homogeneously distributed over time, the vast majority of new HAVB episodes leading to PPM implantation occurred early after the procedure. These results should help to guide the management of this challenging group of patients. (clinicaltrials.gov: NCT02153307).
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Affiliation(s)
- Guillem Muntané-Carol
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, 2725 Ch Ste-Foy, Quebec City, G1V 4G5, Quebec, Canada
| | - Marina Urena
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Höpital Bichat-Claude Bernard, Paris, France
| | - Luis Nombela-Franco
- Department of Cardiology, Instituto Cardiovascular, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Ignacio Amat-Santos
- Department of Cardiology, Hospital Universitario de Valladolid, Valladolid, Spain
| | - Neal Kleiman
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA
| | | | - Felipe Atienza
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Vicenç Serra
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Marc W Deyell
- Division of Cardiology and Centre for Cardiovascular Innovation, University of British Columbia, St Paul's hospital, Vancouver, British Columbia, Canada
| | | | - Jean-Bernard Masson
- Department of Cardiology, Centre Hospitalier Universitaire de Montreal, Montreal, Quebec, Canada
| | - Victoria Canadas-Godoy
- Department of Cardiology, Instituto Cardiovascular, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Dominique Himbert
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Höpital Bichat-Claude Bernard, Paris, France
| | - Javier Castrodeza
- Department of Cardiology, Hospital Universitario de Valladolid, Valladolid, Spain
| | - Jaime Elizaga
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - John G Webb
- Division of Cardiology and Centre for Cardiovascular Innovation, University of British Columbia, St Paul's hospital, Vancouver, British Columbia, Canada
| | | | - Lluis Asmarats
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, 2725 Ch Ste-Foy, Quebec City, G1V 4G5, Quebec, Canada
| | - Emilie Pelletier-Beaumont
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, 2725 Ch Ste-Foy, Quebec City, G1V 4G5, Quebec, Canada
| | - Francois Philippon
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, 2725 Ch Ste-Foy, Quebec City, G1V 4G5, Quebec, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, 2725 Ch Ste-Foy, Quebec City, G1V 4G5, Quebec, Canada
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Muntané-Carol G, Nombela-Franco L, Serra V, Urena M, Amat-Santos I, Vilalta V, Chamandi C, Lhermusier T, Veiga-Fernandez G, Kleiman N, Canadas-Godoy V, Francisco-Pascual J, Himbert D, Castrodeza J, Fernandez-Nofrerias E, Baudinaud P, Mondoly P, Campelo-Parada F, De la Torre Hernandez JM, Pelletier-Beaumont E, Philippon F, Rodés-Cabau J. Late arrhythmias in patients with new-onset persistent left bundle branch block after transcatheter aortic valve replacement using a balloon-expandable valve. Heart Rhythm 2021; 18:1733-1740. [PMID: 34082083 DOI: 10.1016/j.hrthm.2021.05.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/10/2021] [Accepted: 05/26/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The arrhythmic burden after discharge in patients with new-onset left bundle branch block (LBBB) undergoing transcatheter aortic valve replacement (TAVR) with the balloon-expandable SAPIEN 3 (S3) valve remains largely unknown. OBJECTIVE The purpose of this study was to determine the incidence of late arrhythmias in patients with new-onset LBBB undergoing TAVR with the balloon-expandable S3 valve. METHODS This was a multicenter, prospective study that included 104 consecutive TAVR patients with new-onset persistent LBBB following TAVR with the S3 valve. An implantable cardiac monitor (Reveal XT, Reveal LINQ) was implanted before discharge. The primary endpoint was the incidence of high-degree atrioventricular block or complete heart block (HAVB/CHB). RESULTS A total of 40 patients (38.5%) had at least 1 significant arrhythmic event, leading to a treatment change in 17 (42.5%). Significant bradyarrhythmias occurred in 20 of 104 patients (19.2%) (34 HAVB/CHB episodes, 252 severe bradycardia episodes), with 10 of 20 patients (50%) exhibiting at least 1 episode of HAVB/CHB. Most HAVB/CHB episodes (60%) occurred within 4 weeks after discharge. Nine patients (8.7%) underwent permanent pacemaker implantation at 12 months based on the Reveal findings (6 HAVB/CHB, 3 severe bradycardia). CONCLUSION S3 valve recipients with new-onset LBBB have a high arrhythmic burden, with more than one-third of patients exhibiting at least 1 significant arrhythmic episode within 12 months (HAVB/CHB in 10% of patients). About one-half of bradyarrhythmic events occurred within 4 weeks after discharge. These results should inform future strategies on the use of continuous electrocardiographic monitoring in TAVR S3 patients with new conduction disturbances following the procedure.
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Affiliation(s)
- Guillem Muntané-Carol
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Luis Nombela-Franco
- Instituto Cardiovascular, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Vicenç Serra
- Department of Cardiology, Hospital Universitari Vall d'Hebron, CIBER-CV, Barcelona, Spain
| | - Marina Urena
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Höpital Bichat-Claude Bernard, Paris, France
| | - Ignacio Amat-Santos
- Department of Cardiology, Hospital Universitario de Valladolid, Valladolid, Spain
| | - Victoria Vilalta
- Department of Cardiology, Hospital Germans Trias i Pujol, Badalona, Spain
| | | | - Thibault Lhermusier
- Department of Cardiology, Hôpital Universitaire de Toulouse, Toulouse, France
| | | | - Neal Kleiman
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | | | | | - Dominique Himbert
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Höpital Bichat-Claude Bernard, Paris, France
| | - Javier Castrodeza
- Department of Cardiology, Hospital Universitario de Valladolid, Valladolid, Spain
| | | | - Pierre Baudinaud
- Department of Cardiology, Hôpital Européen George Pompidou, Paris, France
| | - Pierre Mondoly
- Department of Cardiology, Hôpital Universitaire de Toulouse, Toulouse, France
| | | | | | - Emilie Pelletier-Beaumont
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - François Philippon
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada; Hospital Clínic de Barcelona, Barcelona, Spain.
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20
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Bjursten H, Norrving B, Ragnarsson S. Late stroke after transcatheter aortic valve replacement: a nationwide study. Sci Rep 2021; 11:9593. [PMID: 33953339 PMCID: PMC8100158 DOI: 10.1038/s41598-021-89217-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/22/2021] [Indexed: 12/12/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) is a rapidly growing field. Short-term safety and efficacy of these procedures have been studied extensively. However, little is known about the safety of these devices over time. Stroke is one feared long-term complication, and an increased stroke rate could affect guidelines for treating both the aortic stenosis and choosing antithrombotic therapy after TAVR. The primary objective was to study the incidence of stroke up to 8 years after TAVR implantation, comparing it with the risk of stroke in the general population. Secondary objectives were to study risk factors for late stroke and to study outcomes after stroke. A nationwide, all-comers study of patients who underwent TAVR in Sweden 2008–2018 was performed. The study was based on data from three national registries: a TAVR registry, a stroke registry, and a diagnosis registry. The main outcome was stroke incidence 30-days or more after TAVR implantation and was compared to a standardized incidence. The annual risk for stroke varied between 2.0% and 3.1% as compared to 1.5% and 1.9% in an age- and sex-matched cohort. Risk factors for developing stroke were reduced renal function, diabetes, history of stroke, age, and male sex. The 1-year mortality after stroke was 44%. This study demonstrated an increased rate of stroke after TAVR, but the findings suggest that this can in part be attributed to the group’s higher frequency of pre-disposing risk factors.
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Affiliation(s)
- Henrik Bjursten
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, 221 85, Lund, Sweden.
| | - Bo Norrving
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Sigurdur Ragnarsson
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, 221 85, Lund, Sweden
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21
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Abstract
PURPOSE OF REVIEW Transcatheter aortic valve replacement (TAVR) has expanded as a treatment option for severe aortic stenosis throughout the surgical risk spectrum. Decreasing procedural risk and inclusion of lower risk population has shifted the focus to optimization of postprocedural management and balancing the thrombotic and bleeding complications. In this review, we outline various patient and procedure related factors affecting choice of antithrombotic therapy post TAVR and provide an update of recent development in this area. RECENT FINDINGS Multiple studies have confirmed the high incidence of both ischemic and bleeding complications in the early to midterm post-TAVR. In addition, new data has emerged for the role of high resolution computed tomography to detect decreased leaflet mobility and leaflet micro thrombi associated with implications for bioprosthetic valve dysfunction and cerebrovascular events post TAVR. Randomized clinical trials have reported increased bleeding with dual antiplatelet therapy (DAPT) and oral anticoagulation (OAC) plus antiplatelet therapy. These findings suggest that aspirin monotherapy or OAC monotherapy likely provides the appropriate balance for antithrombotic protection and risk of bleeding. SUMMARY Majority of patients undergoing TAVR have multiple comorbidities and are at increased risk of ischemic and bleeding complications. In the absence of robust clinical evidence, there is significant variability among guideline recommendations and antithrombotic therapy post TAVR across institutions. The available evidence confirms a high rate of bleeding with more potent and prolonged antithrombotic regimens without a documented benefit for clinical endpoints. The authors favor a conservative anti thrombotic approach and suggest monotherapy with aspirin or systemic anticoagulation based upon an individual's risk of thromboembolic complications. DAPT is reserved for patients with recent stenting and OAC plus aspirin is prescribed for patients with established CAD in the post TAVR setting.
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22
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Ko E, Park DW. Optimal Antithrombotic Strategy After Transcatheter Aortic Valve Replacement: Is the "Less Is More" Concept Always Better? J Am Heart Assoc 2021; 10:e021241. [PMID: 33870701 PMCID: PMC8200736 DOI: 10.1161/jaha.121.021241] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Euihong Ko
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Duk-Woo Park
- Division of Cardiology Asan Medical Center University of Ulsan College of Medicine Seoul Korea
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23
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Gomes WJ, Almeida RMS, Petrucci O, Antunes MJ, Albuquerque LC. The 2020 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Management of Patients with Valvular Heart Disease. Should the World Jump In? Braz J Cardiovasc Surg 2021; 36:278-288. [PMID: 34048208 PMCID: PMC8163277 DOI: 10.21470/1678-9741-2021-0953] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Walter J Gomes
- Cardiovascular Surgery Discipline and São Paulo Hospital. Escola Paulista de Medicina. Federal University of São Paulo, São Paulo, Brazil
| | - Rui M S Almeida
- Faculty of Medicine of the University Center Assis Gurgacz, Cascavel, PR, Brazil
| | - Orlando Petrucci
- Faculty of Medical Sciences. State University of Campinas - UNICAMP, Campinas, SP, Brazil
| | | | - Luciano C Albuquerque
- São Lucas Hospital of the Pontifical Catholic University of Porto Alegre, Porto Alegre, RS, Brazil
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24
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Ghoreishi M, Thourani VH, Badhwar V, Massad M, Svensson L, Taylor BS, Pasrija C, Gammie JS, Jacobs JP, Cox M, Grau-Sepulveda M, Brennan M, Griffith BP, Milliken JC, Abdelhady K, Kon Z. Less-Invasive Aortic Valve Replacement: Trends and Outcomes From The Society of Thoracic Surgeons Database. Ann Thorac Surg 2021; 111:1216-1223. [DOI: 10.1016/j.athoracsur.2020.06.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/01/2020] [Accepted: 06/08/2020] [Indexed: 10/23/2022]
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25
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Bencivenga L, Sepe I, Palaia ME, Komici K, Corbi G, Puzone B, Arcopinto M, Cittadini A, Ferrara N, Femminella GD, Rengo G. Antithrombotic therapy in patients undergoing transcatheter aortic valve replacement: the complexity of the elderly. Eur J Prev Cardiol 2021; 28:87-97. [PMID: 33624104 PMCID: PMC7665487 DOI: 10.1093/eurjpc/zwaa053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/03/2020] [Accepted: 08/12/2020] [Indexed: 12/13/2022]
Abstract
Along with epidemiologic transitions of the global population, the burden of aortic stenosis (AS) is rapidly increasing and transcatheter aortic valve replacement (TAVR) has quickly spread; indeed, it is nowadays also employed in treating patients with AS at intermediate operative risk. Nonetheless, the less invasive interventional strategy still carries relevant issues concerning post-procedural optimal antithrombotic strategy, given the current indications provided by guidelines are not completely supported by evidence-based data. Geriatric patients suffer from high bleeding and thromboembolic risks, whose balance is particularly subtle due to the presence of concomitant conditions, such as atrial fibrillation and chronic kidney disease, that make the post-TAVR antithrombotic management particularly insidious. This scenario is further complicated by the lack of specific evidence regarding the 'real-life' complex conditions typical of the geriatric syndromes, thus, the management of such a heterogeneous population, ranging from healthy ageing to frailty, is far from being defined. The aim of the present review is to summarize the critical points and the most updated evidence regarding the post-TAVR antithrombotic approach in the geriatric population, with a specific focus on the most frequent clinical settings.
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Affiliation(s)
| | - Immacolata Sepe
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Maria Emiliana Palaia
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Klara Komici
- Department of Medicine and Health Sciences, University of Molise, Via Francesco De Sanctis 1, Campobasso 86100, Italy
| | - Graziamaria Corbi
- Department of Medicine and Health Sciences, University of Molise, Via Francesco De Sanctis 1, Campobasso 86100, Italy
| | - Brunella Puzone
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Michele Arcopinto
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Antonio Cittadini
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
| | - Nicola Ferrara
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
- Istituti Clinici Scientifici Maugeri SPA, Società Benefit, IRCCS, Istituto Scientifico di Telese, Via Bagni Vecchi 1, Telese Terme 82037 (BN), Italy
| | - Grazia Daniela Femminella
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
- Department of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Giuseppe Rengo
- Department of Translational Medical Sciences, University of Naples “Federico II”, Via Sergio Pansini 5, Naples 80131, Italy
- Istituti Clinici Scientifici Maugeri SPA, Società Benefit, IRCCS, Istituto Scientifico di Telese, Via Bagni Vecchi 1, Telese Terme 82037 (BN), Italy
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26
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Muntané-Carol G, Philippon F, Nault I, Faroux L, Alperi A, Mittal S, Rodés-Cabau J. Ambulatory Electrocardiogram Monitoring in Patients Undergoing Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 77:1344-1356. [PMID: 33706878 DOI: 10.1016/j.jacc.2020.12.062] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 12/29/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) has changed the treatment of patients with severe aortic stenosis. However, the occurrence of conduction disturbances has not decreased significantly over time and remains the main drawback of the procedure. In addition, new-onset atrial fibrillation is the most frequent tachyarrhythmia during the hospitalization period and is associated with worse clinical outcomes. However, little is known regarding the incidence and clinical impact of arrhythmic events beyond the periprocedural TAVR period. Ambulatory electrocardiogram (AECG) monitoring has recently emerged as a tool to unravel the complex issue of arrhythmic disorders (bradyarrhythmias and tachyarrhythmias) before and after TAVR. To date, the preliminary results from the initial experience using AECG monitoring systems showed the safety, usefulness, and potential clinical implications of this diagnostic tool in TAVR recipients. This review provides an overview of the current status, clinical implications, and future perspectives of AECG monitoring in the TAVR setting.
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Affiliation(s)
- Guillem Muntané-Carol
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada. https://twitter.com/MuntaneCarol
| | - François Philippon
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Isabelle Nault
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Laurent Faroux
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Alberto Alperi
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Suneet Mittal
- Snyder Center for Comprehensive Atrial Fibrillation and Department of Cardiology at Valley Health System, Ridgewood, New Jersey, USA
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada; Hospital Clínic de Barcelona, Barcelona, Spain.
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27
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Carrel T, Heinisch PP. History, development and clinical perspectives of sutureless and rapid deployment surgical aortic valve replacement. Ann Cardiothorac Surg 2020; 9:375-385. [PMID: 33102176 DOI: 10.21037/acs-2020-surd-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Degenerative aortic stenosis is the most frequent valvular heart disease in industrialized countries. Conservative treatment may beneficially influence symptoms but is never successful. Surgical aortic valve replacement (SAVR) was the only recognized treatment option to provide substantially prolonged survival until 2008. Operative mortality of isolated SAVR has been reported as low as 0.5% to 1% in experienced institutions, while long-term survival is close to that observed in a control healthy population of similar age. A multitude of studies have demonstrated the beneficial effects of SAVR with regard to improvement in quality of life and physical performance in the majority of symptomatic patients. In the last decade, transcatheter aortic valve implantation (TAVI) has emerged as an equal treatment modality, first in patients with high surgical risk and more recently in patients with intermediate and low surgical risk. Paravalvular regurgitation and the higher rate of pacemaker implantation remain points of consideration. Additionally, the long-term durability of TAVI devices and occurrence of stroke late after TAVI require additional analyses. Sutureless (SU-SAVR) and rapid deployment valve (R-SAVR) were designed to simplify and accelerate a conventional or less invasive surgical procedure while allowing complete excision of the calcified native valve. From 3 different implants tested more than 10 to 15 years ago, only two are available on the market today: the Perceval® valve from Liva Nova and the Intuity® sutureless prosthesis from Edwards Lifesciences. There has been extensive experience with these two devices in previous years and the results obtained are comparable to those observed following the use of conventional implants. The sutureless devices may be of particular interest for more complex and combined surgical procedures. This review summarizes the sutureless (SU-SAVR) and rapid deployment valve technologies and presents a clinical outlook for the patient population managed with these devices.
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Affiliation(s)
- Thierry Carrel
- Department for Cardiovascular Surgery, University Hospital and University of Bern, Bern, Switzerland
| | - Paul Philipp Heinisch
- Department for Cardiovascular Surgery, University Hospital and University of Bern, Bern, Switzerland
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Sorajja P, Garcia S. Keeping Survivors From Falling Ill. JACC Cardiovasc Interv 2020; 13:882-883. [PMID: 32171719 DOI: 10.1016/j.jcin.2019.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 12/31/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Paul Sorajja
- Center for Valve and Structural Heart Disease, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota.
| | - Santiago Garcia
- Center for Valve and Structural Heart Disease, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
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