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Wang C, Han J, Lu L, Qiu J, Fu Y, Zheng J. The efficacy of different types of cerebral embolic protection device during transcatheter aortic valve implantation: a meta-analysis. Front Cardiovasc Med 2024; 11:1205943. [PMID: 38464846 PMCID: PMC10924301 DOI: 10.3389/fcvm.2024.1205943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 01/08/2024] [Indexed: 03/12/2024] Open
Abstract
Aims Perioperative stroke remains a devastating complication after transcatheter aortic valve implantation (TAVI), and using a cerebral embolic protection device (CEPD) during TAVI may reduce the occurrence of stroke according to some studies. Therefore, we conducted this meta-analysis to determine whether CEPD should be routinely used during TAVI. Methods and results The inclusion criteria for this study were randomized controlled trials (RCTs) that examined the outcome of stroke with or without CEPD during TAVI, with a minimum follow-up period of 30 days. The primary endpoint was the occurrence of stroke (including both cerebrovascular accidents and death due to cerebrovascular accidents). The risk of stroke was lower in the CEPD group: RR 0.68, 95% CI 0.49-0.96, p = 0.03, I2 = 0%. A subgroup analysis was conducted according to the type of CEPD. The risk of stroke was lower in the I&LCCA (filter cover the innominate and the left common carotid arteries) type CEPD group: RR 0.66, 95% CI 0.49-0.96, p = 0.03, I2 = 36%. However, there was no statistically significant difference in the risk of stroke in the TMCA [filter cover the three major cerebral arteries (innominate, left common carotid, and subclavian arteries)] type CEPD group: RR 0.81, 95% CI 0.36-1.80, p = 0.60, I2 = 0%. Conclusions In this meta-analysis, the I&LCCA-type CEPD can reduce the risk of stroke within 30 days following TAVI, but the TMCA type cannot.
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Affiliation(s)
- Chao Wang
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Thoracic and Cardiac Surgery, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Jingjun Han
- Department of Thoracic and Cardiac Surgery, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Liuyi Lu
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Junxiong Qiu
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yuan Fu
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Junmeng Zheng
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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Kaur A, Dhaliwal AS, Sohal S, Gwon Y, Gupta S, Bhatia K, Dominguez AC, Basman C, Tamis‐Holland J. Role of Cerebral Embolic Protection Devices in Patients Undergoing Transcatheter Aortic Valve Replacement: An Updated Meta-Analysis. J Am Heart Assoc 2024; 13:e030587. [PMID: 38240252 PMCID: PMC11056109 DOI: 10.1161/jaha.123.030587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 12/05/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Cerebral embolic protection devices (CEPD) capture embolic material in an attempt to reduce ischemic brain injury during transcatheter aortic valve replacement. Prior reports have indicated mixed results regarding the benefits of these devices. With new data emerging, we performed an updated meta-analysis examining the effect of CEPD during transcatheter aortic valve replacement on various clinical, neurological, and safety parameters. METHODS AND RESULTS A comprehensive review of electronic databases was performed comparing CEPD and no-CEPD in transcatheter aortic valve replacement. Primary clinical outcome was all-cause stroke. Secondary clinical outcomes were disabling stroke and all-cause mortality. Neurological outcomes included worsening of the National Institutes of Health Stroke Scale score, Montreal Cognitive Assessment score from baseline at discharge, presence of new ischemic lesions, and total lesion volume on neuroimaging. Safety outcomes included major or minor vascular complications and stage 2 or 3 acute kidney injury. Seven randomized controlled trials with 4016 patients met the inclusion criteria. There was no statistically significant difference in the primary clinical outcome of all-cause stroke; secondary clinical outcomes of disabling stroke, all-cause mortality, neurological outcomes of National Institutes of Health Stroke Scale score worsening, Montreal Cognitive Assessment worsening, presence of new ischemic lesions, or total lesion volume on diffusion-weighted magnetic resonance imaging between CEPD versus control groups. There was no statistically significant difference in major or minor vascular complications or stage 2 or 3 acute kidney injury between the groups. CONCLUSIONS The use of CEPD in transcatheter aortic valve replacement was not associated with a statistically significant reduction in the risk of clinical, neurological, and safety outcomes.
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Affiliation(s)
- Arpanjeet Kaur
- Department of MedicineIcahn School of Medicine at Mount Sinai Morningside/West‐ New YorkNew YorkNY
| | - Arshdeep S. Dhaliwal
- Population Health Science and PolicyIcahn School of Medicine at Mount Sinai‐ New YorkNew YorkNY
| | - Sumit Sohal
- Division of Cardiovascular MedicineNewark Beth Israel Medical Center‐ NewarkNewarkNJ
| | - Yeongjin Gwon
- Department of BiostatisticsUniversity of Nebraska Medical CenterOmahaNE
| | - Soumya Gupta
- Department of MedicineIcahn School of Medicine at Mount Sinai Morningside/West‐ New YorkNew YorkNY
| | - Kirtipal Bhatia
- Division of CardiologyIcahn School of Medicine at Mount Sinai Morningside‐ New YorkNew YorkNY
| | - Abel Casso Dominguez
- Division of CardiologyIcahn School of Medicine at Mount Sinai Morningside‐ New YorkNew YorkNY
| | - Craig Basman
- Division of CardiologyLenox Hill Hospital‐ New YorkNew YorkNY
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Saia F, Orzalkiewicz M. How to reduce uncommon but severe transcatheter aortic valve implantation complications: stroke, thrombosis, endocarditis, cognitive decline? Eur Heart J Suppl 2021; 23:E142-E146. [PMID: 34650374 PMCID: PMC8503386 DOI: 10.1093/eurheartj/suab110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Transcatheter aortic valve implantation has become a valid alternative to surgical aortic valve replacement for patients with symptomatic severe aortic stenosis, regardless of baseline surgical risk. The incidence of periprocedural complications has steadily declined over the years, thanks to technical advancement of transcatheter heart valves, delivery systems, and increased operators' experience. Beyond the most common periprocedural complications, there are a few uncommon but potentially severe complications that more often occur during follow-up, although they may also arise in the periprocedural phase. Stroke, infective endocarditis, valve thrombosis, and cognitive decline are among them. In this brief review, we describe the incidence, predictive factors, and potential preventive measures for those events.
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Affiliation(s)
- Francesco Saia
- Cardiac Unit, Cardio-Thoracic-Vascular Department, IRCCS University Hospital of Bologna, Policlinico S. Orsola (Pav. 23), Via Massarenti, 9, 40138 Bologna, Italy
| | - Mateusz Orzalkiewicz
- Cardiac Unit, Cardio-Thoracic-Vascular Department, IRCCS University Hospital of Bologna, Policlinico S. Orsola (Pav. 23), Via Massarenti, 9, 40138 Bologna, Italy
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Gallo M, Sá MPBO, Doulamis IP, Hussein N, Laforgia PL, Kampaktsis PN, Tagliari AP, Ferrari E. Transcatheter valve-in-valve implantation for degenerated bioprosthetic aortic and mitral valves - an update on indications, techniques, and clinical results. Expert Rev Med Devices 2021; 18:597-608. [PMID: 34080501 DOI: 10.1080/17434440.2021.1939009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Aortic and mitral bioprosthesis are the gold standard treatment to replace a pathological native valve. However, bioprostheses are prone to structural valve degeneration, resulting in limited long-term durability. During the past decade, the implantation of transcatheter stent-valves within degenerated aortic and mitral bioprostheses, (the so-called 'valve-in-valve' procedure), represents a valid alternative to redo surgery in patients with high-risk surgical profiles.Areas covered: We reviewed the clinical outcomes and the procedural details of transcatheter aortic and mitral valve-in-valve series according to current published literature and include a practical guide for valve sizing and stent-valve positioning and strategies to prevent complications.Expert opinion: In both aortic and mitral positions meticulous planning is fundamental in these procedures to avoid serious complications including patient prosthesis mismatch, coronary obstruction and left ventricular outflow tract obstruction.
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Affiliation(s)
- Michele Gallo
- Cardiovascular Surgery, Cardiocentro Ticino Institute, Lugano, Switzerland
| | - Michel Pompeu B O Sá
- Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco PROCAPE, University of Pernambuco-UPE, Recife, Brazil
| | - Ilias P Doulamis
- Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nabil Hussein
- Department of Congenital Cardiac Surgery, Yorkshire Heart Centre, Leeds General Infirmary, England, UK
| | - Pietro L Laforgia
- Department of Cardiology, Institut Cardiovasculaire Paris Sud, Massy, France
| | | | - Ana Paula Tagliari
- Postgraduate Program in Health Sciences: Cardiology and Cardiovascular Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Enrico Ferrari
- Cardiovascular Surgery, Cardiocentro Ticino Institute, Lugano, Switzerland
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5
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Woldendorp K, Indja B, Bannon PG, Fanning JP, Plunkett BT, Grieve SM. Silent brain infarcts and early cognitive outcomes after transcatheter aortic valve implantation: a systematic review and meta-analysis. Eur Heart J 2021; 42:1004-1015. [PMID: 33517376 DOI: 10.1093/eurheartj/ehab002] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/16/2020] [Accepted: 01/08/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Silent brain infarcts (SBIs) are frequently identified after transcatheter aortic valve implantation (TAVI), when patients are screened with diffusion-weighted magnetic resonance imaging (DW-MRI). Outside the cardiac literature, SBIs have been correlated with progressive cognitive dysfunction; however, their prognostic utility after TAVI remains uncertain. This study's main goals were to explore (i) the incidence of and potential risk factors for SBI after TAVI; and (ii) the effect of SBI on early post-procedural cognitive dysfunction (PCD). METHODS AND RESULTS A systematic literature review was performed to identify all publications reporting SBI incidence, as detected by DW-MRI after TAVI. Silent brain infarct incidence, baseline characteristics, and the incidence of early PCD were evaluated via meta-analysis and meta-regression models. We identified 39 relevant studies encapsulating 2408 patients. Out of 2171 patients who underwent post-procedural DW-MRI, 1601 were found to have at least one new SBI (pooled effect size 0.76, 95% CI: 0.72-0.81). The incidence of reported stroke with focal neurological deficits was 3%. Meta-regression noted that diabetes, chronic renal disease, 3-Tesla MRI, and pre-dilation were associated with increased SBI risk. The prevalence of early PCD increased during follow-up, from 16% at 10.0 ± 6.3 days to 26% at 6.1 ± 1.7 months and meta-regression suggested an association between the mean number of new SBI and incidence of PCD. The use of cerebral embolic protection devices (CEPDs) appeared to decrease the volume of SBI, but not their overall incidence. CONCLUSIONS Silent brain infarcts are common after TAVI; and diabetes, kidney disease, and pre-dilation increase overall SBI risk. While higher numbers of new SBIs appear to adversely affect early neurocognitive outcomes, long-term follow-up studies remain necessary as TAVI expands to low-risk patient populations. The use of CEPD did not result in a significant decrease in the occurrence of SBI.
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Affiliation(s)
- Kei Woldendorp
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia.,Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia.,Baird Institute of Applied Heart and Lung Research, 100 Carillon Avenue, Sydney, NSW 2042, Australia
| | - Ben Indja
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia
| | - Paul G Bannon
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia.,Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia.,Baird Institute of Applied Heart and Lung Research, 100 Carillon Avenue, Sydney, NSW 2042, Australia
| | - Jonathon P Fanning
- The Prince Charles Hospital, Critical Care Research Group, Brisbane, QLC 4032, Australia.,Faculty of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
| | - Brian T Plunkett
- Cardiothoracic Surgical Department, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia.,Baird Institute of Applied Heart and Lung Research, 100 Carillon Avenue, Sydney, NSW 2042, Australia
| | - Stuart M Grieve
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia.,Sydney Translational Imaging Laboratory, Charles Perkins Centre, University of Sydney, NSW 2006, Australia.,Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Sydney, NSW 2050, Australia
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Manual Carotid Compression is a Viable Alternative for Reduction of Cerebral Microemboli. Cardiovasc Eng Technol 2021; 12:353-360. [PMID: 33686541 DOI: 10.1007/s13239-021-00528-9] [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: 10/21/2020] [Accepted: 02/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Stroke is a devastating complication of cardiovascular surgeries, and the risk is particularly high for those requiring cardiopulmonary bypass (CPB). Embolic particles generated during the unclamping of the aortic cross-clamp may enter the cerebral circulation, lodging in small vessels. External manual compression of the carotid arteries is a non-invasive technique that has been proposed for cerebral protection during CPB procedures but is not widely deployed. METHODS The aim of this study is to assess the potential for cerebral emboli reduction with carotid compression using an in vitro model. Experiments were performed with a glass aortic arch model in a mock cardiovascular circuit. Small fluorescent particles were released into the circulation with and without carotid compression, and the particles visualized in the aortic midplane. The number of particles in the aorta and arch branch vessels were counted from the images before, during and following the release of carotid compression for durations of 10, 15 and 20 s. A gamma variate function was fit to the data to describe the bolus dynamics. RESULTS Carotid compression for 10 s reduces the number of embolic articles entering the carotid arteries by over 75%. A compression duration of 15-20 s does not result in greater particle reduction than one of 10 s. CONCLUSION Brief compression of the common carotid arteries during cardiovascular interventions has the potential to dramatically reduce the number of cerebral emboli and should be investigated further.
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Feasibility and Safety of Cerebral Embolic Protection Device Insertion in Bovine Aortic Arch Anatomy. J Clin Med 2020; 9:jcm9124118. [PMID: 33419286 PMCID: PMC7766100 DOI: 10.3390/jcm9124118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/11/2020] [Accepted: 12/16/2020] [Indexed: 11/17/2022] Open
Abstract
Background: Cerebral embolic protection devices (CEPDs) have emerged as a mechanical barrier to prevent debris from reaching the cerebral vasculature, potentially reducing stroke incidence. Bovine aortic arch (BAA) is the most common arch variant and represents challenge anatomy for CEPD insertion during transcatheter aortic valve replacement (TAVR). Methods: Cohort study reporting the SentinelTM Cerebral Protection System insertion’s feasibility and safety in 165 adult patients submitted to a transfemoral TAVR procedure from April 2019 to April 2020. Patients were divided into 2 groups: (1) BAA; (2) non-BAA. Results: Median age, EuroScore II, and STS score were 79 years (74–84), 2.9% (1.7–6.2), and 2.2% (1.6–3.2), respectively. BAA was present in 12% of cases. Successful two-filter insertion was 86.6% (89% non-BAA vs. 65% BAA; p = 0.002), and debris was captured in 95% (94% non-BAA vs. 95% BAA; p = 0.594). No procedural or vascular complications associated with Sentinel insertion and no intraprocedural strokes were reported. There were two postprocedural non-disabling strokes, both in non-BAA. Conclusion: This study demonstrated Sentinel insertion feasibility and safety in BAA. No procedural and access complications related to Sentinel deployment were reported. Being aware of the bovine arch prevalence and having the techniques to navigate through it allows operators to successfully use CEPDs in this anatomy.
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Short and long-term clinical impact of transcatheter aortic valve implantation in Portugal according to different access routes: Data from the Portuguese National Registry of TAVI. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2020.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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9
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Guerreiro C, Ferreira PC, Teles RC, Braga P, Canas da Silva P, Patrício L, Silva JC, Baptista J, de Sousa Almeida M, Gama Ribeiro V, Silva B, Brito J, Infante Oliveira E, Cacela D, Madeira S, Silveira J. Short and long-term clinical impact of transcatheter aortic valve implantation in Portugal according to different access routes: Data from the Portuguese National Registry of TAVI. Rev Port Cardiol 2020; 39:705-717. [PMID: 33261991 DOI: 10.1016/j.repc.2020.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/22/2020] [Accepted: 02/01/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The Portuguese National Registry of Transcatheter Aortic Valve Implantation records prospectively the characteristics and outcomes of transcatheter aortic valve implantation (TAVI) procedures in Portugal. OBJECTIVES To assess the 30-day and one-year outcomes of TAVI procedures in Portugal. METHODS We compared TAVI results according to the principal access used (transfemoral (TF) vs. non-transfemoral (non-TF)). Cumulative survival curves according to access route, other procedural and clinical variables were obtained. The Valve Academic Research Consortium-2 (VARC-2) composite endpoint of early (30-days) safety was assessed. VARC-2 predictors of 30-days and 1-year all-cause mortality were identified. RESULTS Between January 2007 and December 2018, 2346 consecutive patients underwent TAVI (2242 native, 104 valve-in-valve; mean age 81±7 years, 53.2% female, EuroSCORE-II - EuroS-II, 4.3%). Device success was 90.1% and numerically lower for non-TF (87.0%). Thirty-day all-cause mortality was 4.8%, with the TF route rendering a lower mortality rate (4.3% vs. 10.1%, p=0.001) and higher safety endpoint (86.4% vs. 72.6%, p<0.001). The one-year all-cause mortality rate was 11.4%, and was significantly lower for TF patients (10.5% vs. 19.4%, p<0.002). After multivariate analysis, peripheral artery disease, previous percutaneous coronary intervention, left ventricular dysfunction and NYHA class III-IV were independent predictors of 30-day all-cause mortality. At one-year follow-up, NYHA class III-IV, non-TF route and occurrence of life-threatening bleeding predicted mortality. Kaplan-Meier survival analysis of the first year of follow-up shows decreased survival for patients with an EuroS-II>5% (p<0.001) and who underwent non-TF TAVI (p<0.001). CONCLUSION Data from our national real-world registry showed that TAVI was safe and effective. The use of a non-transfemoral approach demonstrated safety in the short term. Long-term prognosis was, however, adversely associated with this route, with comorbidities and the baseline clinical status.
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Affiliation(s)
- Cláudio Guerreiro
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia, Portugal
| | - Pedro Carrilho Ferreira
- Department of Cardiology, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Portugal
| | - Rui Campante Teles
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal; CEDOC, Nova Medical School, Lisbon, Portugal.
| | - Pedro Braga
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia, Portugal
| | - Pedro Canas da Silva
- Department of Cardiology, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Portugal
| | - Lino Patrício
- Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Portugal
| | - João Carlos Silva
- Department of Cardiology, Centro Hospitalar Universitário de São João, Portugal
| | - José Baptista
- Department of Cardiology, Hospital dos Lusíadas, Portugal
| | - Manuel de Sousa Almeida
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal; CEDOC, Nova Medical School, Lisbon, Portugal
| | - Vasco Gama Ribeiro
- Department of Cardiology, Hospital da Cruz Vermelha Portuguesa, Portugal
| | - Bruno Silva
- Department of Cardiology, Hospital de Nélio Mendonça, Funchal, Portugal
| | - João Brito
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal; CEDOC, Nova Medical School, Lisbon, Portugal
| | - Eduardo Infante Oliveira
- Department of Cardiology, Hospital de Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Portugal
| | - Duarte Cacela
- Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Portugal
| | - Sérgio Madeira
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal; CEDOC, Nova Medical School, Lisbon, Portugal
| | - João Silveira
- Department of Cardiology, Hospital de Santo António, Centro Hospitalar do Porto, Portugal
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Krishnan S, Sharma A, Subramani S, Arora L, Mohananey D, Villablanca P, Ramakrishna H. Analysis of Neurologic Complications After Surgical Versus Transcatheter Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2019; 33:3182-3195. [DOI: 10.1053/j.jvca.2018.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Indexed: 11/11/2022]
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Power DA, Guedeney P, Dangas GD. Adjunct Pharmacotherapy After Transcatheter Aortic Valve Replacement: Current Status and Future Directions. Interv Cardiol Clin 2019; 8:357-371. [PMID: 31445720 DOI: 10.1016/j.iccl.2019.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is a validated treatment option for severe aortic stenosis. Ischemic and thrombotic complications remain important and strongly correlate with mortality. The optimal postprocedural antithrombotic strategy for prevention of thrombotic events remains unclear. The international guidelines for medical management following TAVR are discordant, allowing for significant variance in prescribing habits. The optimal treatment strategy has yet to be delineated. Clinical trials are ongoing to assess the risks and benefits of various strategies. We discuss the pathobiology and rationale for antithrombotic therapy after TAVR, review current evidence and guidelines, and offer a concise evidence-based approach to this subject.
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Affiliation(s)
- David A Power
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York City, NY 10029, USA
| | - Paul Guedeney
- ACTION Coeur, Sorbonne Université, UMR_S 1166, Institut de Cardiologie (APHP), Hôpital Pitié Salpêtrière, 47-83 Boulevard de l'Hôpital, Paris 75013, France
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York City, NY 10029, USA.
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12
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Shimamura K, Kuratani T, Kin K, Shijo T, Masada K, Sawa Y. Effectiveness of embolic protection filter devices in stroke prevention during endovascular aortic arch repair in significant aortic atheroma patients. Interact Cardiovasc Thorac Surg 2019; 28:974-980. [DOI: 10.1093/icvts/ivz004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/14/2018] [Accepted: 01/03/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kazuo Shimamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Toru Kuratani
- Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keiwa Kin
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takayuki Shijo
- Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenta Masada
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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13
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Masada K, Kuratani T, Shimamura K, Kin K, Shijo T, Goto T, Sawa Y. Silent cerebral infarction after thoracic endovascular aortic repair: a magnetic resonance imaging study. Eur J Cardiothorac Surg 2019; 55:1071-1078. [DOI: 10.1093/ejcts/ezy449] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 11/20/2018] [Accepted: 11/27/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kenta Masada
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Toru Kuratani
- Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keiwa Kin
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takayuki Shijo
- Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takasumi Goto
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Conti M, Vandenberghe S, Marconi S, Ferrari E, Romarowski RM, Morganti S, Auricchio F, Demertzis S. Reversed Auxiliary Flow to Reduce Embolism Risk During TAVI: A Computational Simulation and Experimental Study. Cardiovasc Eng Technol 2018; 10:124-135. [PMID: 30341729 DOI: 10.1007/s13239-018-00386-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 10/11/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Endovascular treatments, such as transcatheter aortic valve implantation (TAVI), carry a risk of embolization due to debris dislodgement during various procedural steps. Although embolic filters are already available and marketed, mechanisms underlying cerebral embolism still need to be elucidated in order to further reduce cerebrovascular events. METHODS We propose an experimental framework with an in silico duplicate allowing release of particles at the level of the aortic valve and their subsequent capture in the supra-aortic branches, simulating embolization under constant inflow and controlled hemodynamic conditions. The effect of a simple flow modulation, consisting of an auxiliary constant flow via the right subclavian artery (RSA), on the amount of particle entering the brachiocephalic trunk was investigated. Preliminary computational fluid dynamics (CFD) simulations were performed in order to assess the minimum retrograde flow-rate from RSA required to deviate particles. RESULTS Our results show that a constant reversed auxiliary flow of 0.5 L/min from the RSA under a constant inflow of 4 L/min from the ascending aorta is able to protect the brachiocephalic trunk from particle embolisms. Both computational and experimental results also demonstrate that the distribution of the bulk flow dictates the distribution of the particles along the aortic branches. This effect has also shown to be independent of release location and flow rate. CONCLUSIONS The present study confirms that the integration of in vitro experiments and in silico analyses allows designing and benchmarking novel solutions for cerebral embolic protection during TAVI such as the proposed embo-deviation technique based on an auxiliary retrograde flow from the right subclavian artery.
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Affiliation(s)
- Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Via Ferrata 3, 27100, Pavia, Italy.
| | | | - Stefania Marconi
- Department of Civil Engineering and Architecture, University of Pavia, Via Ferrata 3, 27100, Pavia, Italy
| | - Enrico Ferrari
- Department of Cardiac Surgery, Cardiocentro Ticino, Lugano, Switzerland
| | - Rodrigo M Romarowski
- 3D and Computer Simulation Laboratory, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Simone Morganti
- Department of Electrical, Computer, and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Ferdinando Auricchio
- Department of Civil Engineering and Architecture, University of Pavia, Via Ferrata 3, 27100, Pavia, Italy
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Literaturübersicht 2017 zur Herzklappenchirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-018-0248-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shiyovich A, Kornowski R. Neuroprotective measures throughout the TAVI pathway. Minerva Cardioangiol 2018; 67:39-56. [PMID: 30014679 DOI: 10.23736/s0026-4725.18.04763-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Aortic stenosis (AS) is the most common clinical valvular heart disorder that warrants active treatment. Symptomatic and severe AS is associated with increased morbidity and mortality if left untouched. Transcatheter aortic valve implantation (TAVI) is an innovative therapeutic modality approved initially for patients with prohibitive surgical risk and subsequently became a mainstream practice and the preferred treatment modality for many patients with severe AS at high and moderate surgical risk. Consistently global TAVI volumes have increased and indications continue to widen toward younger and lower-risk patients. However, periprocedural stroke is one of the most feared complications of TAVI, and when clinically evident, it is often associated with significant increase in mortality, physical disability, social isolation and financial costs. Furthermore, even when clinically overt stroke is not evident following TAVI, highly sensitive imaging modalities have demonstrated new post-procedural ischemic lesions in most patients. Although little is known about the long-term clinical significance of these lesions, there are strong signals showing they might be related with reduced subsequent neurocognitive function. This review provides a comprehensive contemporary insight of the definitions, incidence and temporal trends of stroke in TAVI patients, as well as the mechanisms, etiologies and risk factors for such neurological events. Furthermore, an integrated approach of neuroprotective measures targeted to reduce the incidence of stroke during each phase of the periprocedural TAVI pathway is suggested with a special focus on the role of embolic protective devices.
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Affiliation(s)
- Arthur Shiyovich
- Department of Cardiology, Institute of Interventional Cardiology, Rabin Medical Center, Petach-Tikva, Israel.,"Sackler" Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ran Kornowski
- Department of Cardiology, Institute of Interventional Cardiology, Rabin Medical Center, Petach-Tikva, Israel - .,"Sackler" Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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