Continuation versus Interruption of Oral Anticoagulation during TAVI

BACKGROUND

One third of patients undergoing transcatheter aortic-valve implantation (TAVI) have an indication for oral anticoagulation owing to concomitant diseases. Interruption of oral anticoagulation during TAVI may decrease the risk of bleeding, whereas continuation may decrease the risk of thromboembolism.

METHODS

We conducted an international, open-label, randomized, noninferiority trial involving patients who were receiving oral anticoagulants and were planning to undergo TAVI. Patients were randomly assigned in a 1:1 ratio to periprocedural continuation or interruption of oral anticoagulation. The primary outcome was a composite of death from cardiovascular causes, stroke from any cause, myocardial infarction, major vascular complications, or major bleeding within 30 days after TAVI.

RESULTS

A total of 858 patients were included in the modified intention-to-treat population: 431 were assigned to continuation and 427 to interruption of oral anticoagulation. A primary-outcome event occurred in 71 patients (16.5%) in the continuation group and in 63 (14.8%) in the interruption group (risk difference, 1.7 percentage points; 95% confidence interval [CI], -3.1 to 6.6; P = 0.18 for noninferiority). Thromboembolic events occurred in 38 patients (8.8%) in the continuation group and in 35 (8.2%) in the interruption group (risk difference, 0.6 percentage points; 95% CI, -3.1 to 4.4). Bleeding occurred in 134 patients (31.1%) in the continuation group and in 91 (21.3%) in the interruption group (risk difference, 9.8 percentage points; 95% CI, 3.9 to 15.6).

CONCLUSIONS

In patients undergoing TAVI with a concomitant indication for oral anticoagulation, periprocedural continuation was not noninferior to interruption of oral anticoagulation during TAVI with respect to the incidence of a composite of death from cardiovascular causes, stroke, myocardial infarction, major vascular complications, or major bleeding at 30 days. (Funded by the Netherlands Organization for Health Research and Development and the St. Antonius Research Fund; POPular PAUSE TAVI ClinicalTrials.gov number, NCT04437303.).

Stroke after transcatheter aortic valve replacement: A severe complication with low predictability

OBJECTIVES

We aimed to describe stroke and transient ischemic attacks (TIAs) after transcatheter aortic valve replacement (TAVR) and to identify associated risk factors.

BACKGROUND

Stroke/TIA after TAVR is a major complication.

METHODS

A total of 1919 concomitant patients underwent TAVR in a single center from 2007 to 2017. Pre-, intra-, and postprocedural data were collected prospectively in a database and analyzed retrospectively. Stroke and TIA were documented according to the Valve Academic Research Consortium-II criteria. Logistic regression was used to determine risk factors for stroke after TAVR.

RESULTS

Mean age was 79.5 ± 6.8 years, mean logistic EuroScore was 17.6% ± 12.8%, and 51.8% (n = 994) of the patients were female. Stroke/TIA occurred in 76 patients (3.9%), 1.9% were disabling, and 1.6% nondisabling. The predominant type of stroke were territorial ischemic lesions (82.4%), with primary bleeding in 4.4% and border zone infarctions in 4.4%. Left-sided lesions were more common (45.6% left sided vs. 25% right sided) and 13.2% of the lesions were bilateral (4.4% no finding and 11.8% missing data). In multivariate logistic regression, prior stroke (odds ratio [OR] = 1.83, p = 0.046) and initial experience (first 300 TAVR implanted at our center) were identified as independent risk factors for stroke/TIA during the first 30 days (OR = 1.95, p = 0.045). Overall, the occurrence of stroke had a highly significant impact on a 30-day mortality (13.2% vs. 4.9% in patients without stroke (p = 0.005).

CONCLUSION

Stroke within the first 30 days after TAVR severely impairs 30-day survival. We identified prior stroke and initial experience as significant independent risk factors for the occurrence of stroke after TAVR.

Predictors of Early Stroke or Death in Patients Undergoing Transcatheter Aortic Valve Implantation

BACKGROUND/OBJECTIVE

While postoperative stroke is a known complication of Transcatheter Aortic Valve Implantation (TAVI), predictors of early stroke occurrence have not been specifically reviewed. The objective of this study was to estimate the predictors and incidence of stroke during the first 30 days post-TAVI.

METHODS

A cohort of 506 consecutive patients having undergone TAVI between January 2017 and June 2019 was extracted from a prospective database. Preoperative, intraoperative and postoperative characteristics were analyzed by univariate analysis followed by logistic regression to find predictors of the occurrence of stroke or death within the first 30 days after the procedure.

RESULTS

Incidence of stroke within 30 days post-TAVI was 4.9%, [CI 95% 3.3-7.2], i.e., 25 strokes. Four out of the 25 patients (16%) with a stroke died within 30 days post-TAVI. After logistic regression analysis, the predictors of early stroke related to TAVI were: CHA2Ds2VASc score ≥ 5 (odds ratio [OR] 2.62; 95% CI: 1.06-6.49; p = .037), supra-aortic access vs. femoral access (OR: 9.00, 95%CI: 2.95-27.44; p = .001) and introduction post-TAVI of a single vs. two or three antithrombotic agents (OR: 5.13; CI 95%: 1.99 to 13.19; p = .001). Over the 30-day period, bleeding occurred in 28 patients (5.5%), in 25 of whom, it was associated with femoral or iliac artery access injury. Anti-thrombotic regimen was not associated with bleeding; two patients out of 48 (4.1%) bled with a single anti-thrombotic regimen vs. 26 patients out of 458 (5.6%) with a dual or triple anti-thrombotic regimen (p = 0.94). The overall 30-day mortality rate was 3.9%, [95% CI 2.5-6.0]. Patients with a single post-TAVI antithrombotic agent (OR: 44.07 [CI 95% 13.45-144.39]; p < .0001) and patients with previous coronary artery bypass surgery or coronary artery stenting (OR: 6.16, [CI 95% 1.99-21.29]; p = .002) were at significantly higher risk of death within the 30-day period.

CONCLUSION

In this large-scale single-center retrospective study, a single post-TAVI antithrombotic regimen independently predicted occurrence of early stroke or death. Dual or triple antithrombotic regimen was not associated with a higher risk of bleeding and should be considered as an option in patients undergoing TAVI.

Adjunctive Antithrombotic Therapy for Patients With Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

Importance

Transcatheter aortic valve replacement (TAVR) is an established alternative to surgery for patients with severe symptomatic aortic stenosis. Adjunctive antithrombotic therapy used to mitigate thrombotic risks in patients undergoing TAVR must be balanced against bleeding complications, since both are associated with increased mortality.

Observation

Stroke risk associated with TAVR is lower than that associated with surgical aortic valve replacement in recent trials including patients at intermediate or low risk, but it is constant beginning at the time of implant and accrues over time based on patient risk factors. Patients with aortic stenosis undergoing TAVR also have a sizable risk of life-threatening or major bleeding. Although dual antiplatelet therapy for 3 to 6 months after TAVR is the guideline-recommended regimen, this practice is not well supported by current evidence. In patients with no indication for oral anticoagulation, current registry-based evidence suggests that single antiplatelet therapy may be safer than dual antiplatelet therapy. Similarly, oral anticoagulation monotherapy appears superior to anticoagulation plus antiplatelet therapy in those where oral anticoagulant use is indicated. To date, no risk prediction models have been established to guide antithrombotic therapy.

Conclusions and Relevance

Despite the growing volume of TAVR procedures to treat patients with severe aortic stenosis, evidence for adjunctive antithrombotic therapy remains rather scarce. Ongoing clinical trials will provide better understanding to guide antithrombotic therapy.

Impact of Combined "CHADS-BLED" Score to Predict Short-Term Outcomes in Transfemoral and Transapical Aortic Valve Replacement

Background

High CHA₂DS₂-VASC and HAS-BLED scores are linked to increased mortality in structural and nonstructural cardiovascular interventions irrespective of the presence of atrial fibrillation (AF) or oral anticoagulation. We aimed to use the aforementioned scores to quantify the risk of 30-day mortality, major vascular and bleeding events (MVASC/BARC), and cerebrovascular insults (CVI) in patients undergoing different access routes in transcatheter aortic valve replacement (TAVR).

Methods

Out of 1329 patients, 980 transfemoral (TF) TAVR (73.7%) and 349 transapical (TA) TAVR (26.3%) were included. CHA₂DS₂-VASC, HAS-BLED, and combined “CHADS-BLED” scores were calculated and compared to the predictive value of the established EuroSCORE and STS score.

Results

In all-comers TF TAVR patients, the applied risk models showed only poor association with 30-day mortality while, in patients with concomitant AF, a strong association was observed using the combined CHADS-BLED score (c-index: 0.83; 95% CI: 0.76–0.91; p < 0.0001). Concerning 30-day mortality, only the STS score for TF TAVR (c-index: 0.68; 95% CI: 0.59–0.76; p = 0.001) and EuroSCORE for TA TAVR (c-index: 0.66; 95% CI: 0.56–0.76; p = 0.005) could show some predictive value. High CHADS-BLED was associated with enhanced CVI (3.0% vs. 7.2%;p=0.0039^∗) and more frequent MVASC/BARC (3.2% vs. 6.3%; p = 0.0362) in the all-comers TAVR cohort. All risk models failed in the prediction of CVI and MVASC/BARC for TA TAVR patients.

Conclusion

The combined CHADS-BLED score was a strong predictor for 30-day mortality in TF TAVR patients with AF. A high CHADS-BLED score showed a good predictive value for major vascular and bleeding events as well as CVI in TF TAVR patients. This study is registered at clinical trials (NCT01805739).

The Link Between CHA2DS2-VASc Score and Thromboembolic Risk in Patients Without Known Atrial Fibrillation: Are We Missing a Silent Culprit?

Stroke is a leading cause of morbidity and mortality. The majority of strokes are ischemic and a subset of these are due to atrial fibrillation (AF). Other etiologies include a variety of cardiovascular disorders. The CHA₂DS₂-VASc score is a validated stroke prediction tool for patients with non-valvular AF. However, it has also been shown to predict increased risk for stroke or thromboembolism in the absence of AF. Given how common subclinical AF (SCAF) is when looked for in patients with elevated CHA₂DS₂-VaSc scores who are not known to have AF, (especially when implanted monitors are used), the stroke/thromboembolism risk that has been associated with CHA₂DS₂-VASc scores absent known AF may be an overestimate of the true risk due to the likely presence of SCAF in some of the subjects included. This has not yet been adequately addressed in the literature. Finally, the risk of a left atrial thromboembolic event is a consequence of the altered atrial anatomy and physiology (atrial cardiomyopathy) that may result from comorbid disorders and AF itself, or, additively from both - whether or not the AF has been already recognized clinically.

Modified CHA2DS2-VASc score predicts in-hospital mortality and procedural complications in acute coronary syndrome treated with percutaneous coronary intervention

Background

Current risk prediction models in acute coronary syndrome (ACS) patients undergoing PCI are mathematically complex. This study was undertaken to assess the accuracy of a modified CHA₂DS₂-VASc score, comprised of easily accessible clinical factors in predicting adverse events.

Methods

The National Inpatient Sample (NIS) was queried for ACS patients who underwent PCI between 2010 and 2014. We developed a modified CHA₂DS₂-VASc score for risk prediction in ACS patients. Multivariate mixed effect logistic regression was utilized to study the adjusted risk for adverse outcomes based on the score. The primary outcome evaluated was in-hospital mortality. Secondary outcomes assessed were stroke, respiratory failure, acute kidney injury, all-cause bleeding, pacemaker insertion, vascular complications, length of stay and cost.

Results

There were 252,443 patients admitted with ACS included. Mean age was 62 ± 12 years. The mean CH₃A₂DS-VASc score was 1.6 ± 1.6. The in-hospital mortality rate was 2.5%. CH₃A₂DS-VASc score was highly correlated with increased rate of mortality and all secondary outcomes. ROC curve analysis for association of CH₃A₂DS-VASc score with mortality demonstrates that area under the curve (AUC) = 0.83 (95%C: 0.82–0.84). Stepwise increases in CH₃A₂DS-VASc score correlated with incremental risk, and total score was an independent predictor of mortality (adjusted OR: 1.99 (95%CI: 1.96–2.03) p < 0.001) and all secondary outcomes.

Conclusion

This study supports the applicability of the CH₃A₂DS-VASc score as an accurate risk prediction model for ACS patients undergoing PCI and could supplant more complicated models for quality assurance.

CHA2DS2-VASc score for prediction of ischemic stroke in patients with systemic lupus erythematosus without atrial fibrillation

Objective We conducted this study to assess the role of CHA2DS2-VASc score in predicting ischemic stroke among systemic lupus erythematosus (SLE) patients without atrial fibrillation (AF). Methods We selected the SLE patients from the Registry of Catastrophic Illnesses Patient Database in Taiwan. We excluded the SLE patients with AF or atrial flutter. The patients were followed up until the occurrence of ischemic stroke, censored for death or withdrawal from the dataset, or the end of follow-up. Cox models were performed to obtain the hazard ratios (HRs) and the 95% confidence intervals (CIs) of ischemic stroke associated with the CHA2DS2-VASc score. A receiver operating characteristic (ROC) curve was generated to evaluate the predictive ability of CHA2DS2-VASc score for ischemic stroke in SLE patients without AF. Results A total of 11,962 study participants were included in this study. The incidence of ischemic stroke increased from 4.00 per 1000 person-years (PYs) for patients with a CHA2DS2-VASc score of 0 to 87.4 per 1000 PYs for those with a CHA2DS2-VASc score of ≧6. Moreover, patients with a CHA2DS2-VASc score of ≧2 were 3.98-fold (95% CI 3.15-5.04) more likely to develop ischemic stroke than those with a CHA2DS2-VASc score of <2 (14.0 vs. 2.99 per 1000 PYs). ROC curve analysis of the CHA2DS2-VASc score demonstrated a moderate discrimination power for ischemic stroke development with a c-statistic of 0.65(95% CI 0.62-0.69). Conclusions We found that a CHA2DS2-VASc score greater than or equal to 2 in SLE patients without AF is associated with a significantly higher rate of ischemic stroke.

Stroke prediction with CHA2DS2-VASc score in patients with mesenteric ischemia without atrial fibrillation-insights from a nationwide cohort

BACKGROUND

The current study sought to evaluate the accuracy of CHA₂DS₂-VASc score for ischemic stroke prediction in patients with mesenteric ischemia without atrial fibrillation (AF).

METHODS

The study participants included patients aged ≥18years with a new diagnosis of mesenteric ischemia during hospitalization between January 1, 2000 and December 31, 2011. Individuals with atrial fibrillation (AF) or atrial flutter during the study period were excluded. The study participants were followed up until the ischemic stroke appeared or they were censored due to withdrawal from this program, mortality, or the end of the study period, whichever came first. Cox proportional hazards regression models were applied for ischemic stroke risk stratification in the study participants by CHA₂DS₂-VASc score. The c-statistic based on the receiver operating characteristic (ROC) analysis was applied to investigate the accuracy of CHA₂DS₂-VASc score for ischemic stroke risk discrimination.

RESULTS

A total of 24039 study participants were enrolled. Ischemic stroke incidence increased from 1.54% in CHA₂DS₂-VASc score of 0 to 9.23% in CHA₂DS₂-VASc score of 6 or more. Moreover, the Kaplan-Meier curve with a log rank test demonstrated that patients with a higher CHA₂DS₂-VASc score were associated with an increased cumulative incidence rate of ischemic stroke during the follow-up period (p<0.001). The discriminatory performance of the CHA2DS2-VASc score resulted in C-statistics of 0.65(95% CI=0.63-0.66) for predicting ischemic stroke risk among patients with mesenteric ischemia without AF.

CONCLUSIONS

A higher CHA₂DS₂-VASc score is demonstrated to be associated with an increased risk of ischemic stroke among patients with mesenteric ischemia without comorbid AF.

CHA2DS2-VASc score in the prediction of ischemic bowel disease among patients with atrial fibrillation: Insights from a nationwide cohort

PURPOSE

This study aimed to evaluate the predictive role of CHA₂DS₂-VASc score specifically for the development of ischemic bowel disease (IBD) among atrial fibrillation (AF) patients.

METHODS

Using a nationwide dataset, an AF cohort was established. The study participants were followed up from the index date until they withdrew from the health insurance system, the occurrence of IBD or until the end of 2011. The hazard ratios (HRs) and 95% confidence intervals (CIs) were examined by Cox models to present the subsequent risk of IBD among AF patients by CHA₂DS₂-VASc score. The area under the receiver operating characteristic (ROC) curve was used to assess the predictive power of CHA₂DS₂-VASc score for IBD development among AF patients.

RESULTS

The cumulative incidence of IBD was higher for AF patients with a CHA₂DS₂-VASc score≥2 than those with a CHA₂DS₂-VASc score<2 by 2.30% (p<0.001) at the end of follow-up. After adjustment for hyperlipidemia, chronic obstructive pulmonary disease, and chronic kidney disease, the AF patients with a CHA₂DS₂-VASc score≥2 had a 3.35 times higher risk for IBD development compared to those with a CHA₂DS₂-VASc score<2 [adjusted HR (aHR)=3.35, 95% CI=2.71-4.13]. Among AF patients, the C-statistic of the CHA₂DS₂-VASc score as a predictor of IBD was 0.56 (95% CI=0.55-0.57).

CONCLUSIONS

In conclusion, the study is​ the first to investigate the predictive role of CHA₂DS₂-VASc score specifically for IBD development among AF patients. However, the predictive power was relatively low; further studies are necessary to confirm our findings.

Managing Stroke During Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has become the default treatment option for high-risk patients with aortic stenosis and an alternative to surgical aortic valve replacement in intermediate-risk patients. There are, however, concerns regarding strokes during TAVR. Reported stroke rates vary strongly depending on the type of study, stroke definition, cohort and study period. Furthermore, stroke after TAVR occurs in three distinct phases: 1) early high-risk, directly procedure related; 2) elevated risk interval between day 2 and day 30; 3) late hazard interval. Each of these phases is caused by the different aetiologies of stroke. This review summarises the different aetiologies and potential strategies for managing stroke during TAVR.