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Giuliani C, Zanuttini A, Salaun E, Côté N, Clavel MA, Pibarot P. Subclinical valve leaflet thrombosis following bioprosthetic aortic valve replacement. Curr Opin Cardiol 2024; 39:457-464. [PMID: 38899782 DOI: 10.1097/hco.0000000000001161] [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] [Indexed: 06/21/2024]
Abstract
PURPOSE OF REVIEW Subclinical leaflet thrombosis (SLT) is often an incidental finding characterized by a thin layer of thrombus involving one, two or three leaflets, with typical appearance on multi-detector computed tomography (MDCT) of hypo-attenuating defect at the aortic side of the leaflet, also called hypo-attenuating leaflet thickening (HALT). SLT may occur following both transcatheter aortic replacement (TAVR) or biological surgical aortic valve replacement (SAVR). The aim of this review is to present an overview of the current state of knowledge on the incidence, diagnosis, clinical impact, and management of SLT following TAVR or SAVR. RECENT FINDINGS SLT occurs in 10-20% of patients following TAVR and is somewhat more frequent than following SAVR (5-15%). SLT may regress spontaneously without treatment in about 50% of the cases but may also progress to clinically significant valve thrombosis in some cases. Oral anticoagulation with vitamin K antagonist is reasonable if SLT is detected by echocardiography and/or MDCT during follow-up and is generally efficient to reverse SLT. SLT is associated with mild increase in the risk of stroke but has no impact on survival. SLT has been linked with accelerated structural valve deterioration and may thus impact valve durability and long-term outcomes. SUMMARY SLT is often an incidental finding on echocardiography or MDCT that occurs in 10-20% of patients following TAVR or 5-15% following biological SAVR and is associated with a mild increase in the risk of thrombo-embolic event with no significant impact on mortality but may be associated with reduced valve durability.
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Affiliation(s)
- Carlos Giuliani
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada
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Chitturi KR, Aladin AI, Braun R, Al-Qaraghuli AK, Banerjee A, Reddy P, Merdler I, Chaturvedi A, Abusnina W, Haberman D, Lupu L, Rodriguez-Weisson FJ, Case BC, Wermers JP, Ben-Dor I, Satler LF, Waksman R, Rogers T. Bioprosthetic Aortic Valve Thrombosis: Definitions, Clinical Impact, and Management: A State-of-the-Art Review. Circ Cardiovasc Interv 2024; 17:e014143. [PMID: 38853766 DOI: 10.1161/circinterventions.123.014143] [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] [Indexed: 06/11/2024]
Abstract
Bioprosthetic aortic valve thrombosis is frequently detected after transcatheter and surgical aortic valve replacement due to advances in cardiac computed tomography angiography technology and standardized surveillance protocols in low-surgical-risk transcatheter aortic valve replacement trials. However, evidence is limited concerning whether subclinical leaflet thrombosis leads to clinical adverse events or premature structural valve deterioration. Furthermore, there may be net harm in the form of bleeding from aggressive antithrombotic treatment in patients with subclinical leaflet thrombosis. This review will discuss the incidence, mechanisms, diagnosis, and optimal management of bioprosthetic aortic valve thrombosis after transcatheter aortic valve replacement and bioprosthetic surgical aortic valve replacement.
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Affiliation(s)
- Kalyan R Chitturi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Amer I Aladin
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Ryan Braun
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD (R.B., T.R.)
| | - Abdullah K Al-Qaraghuli
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Avantika Banerjee
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Pavan Reddy
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Ilan Merdler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Abhishek Chaturvedi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Waiel Abusnina
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Dan Haberman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Lior Lupu
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Fernando J Rodriguez-Weisson
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Jason P Wermers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (K.R.C., A.I.A., A.K.A.-Q., A.B., P.R., I.M., A.C., W.A., D.H., L.L., F.J.R.-W., B.C.C., J.P.W., I.B.-D., L.F.S., R.W., T.R.)
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD (R.B., T.R.)
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Maznyczka A, Pilgrim T. Antithrombotic Treatment After Transcatheter Valve Interventions: Current Status and Future Directions. Clin Ther 2024; 46:122-133. [PMID: 37926630 DOI: 10.1016/j.clinthera.2023.09.028] [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: 06/26/2023] [Revised: 09/15/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE The optimal antithrombotic strategy after transcatheter valve interventions is a subject of ongoing debate. Although there is evidence from randomized trials in patients undergoing transcatheter aortic valve replacement (TAVR), current evidence on optimal antithrombotic management after transcatheter mitral or tricuspid valve interventions is sparse. This article appraises the current evidence on this topic. METHODS This narrative review presents key research findings and guideline recommendations, as well as highlights areas for future research. FINDINGS After TAVR, randomized trial evidence suggests that single antiplatelet therapy is reasonable for patients without pre-existing indications for oral anticoagulation (OAC). If there is a concurrent indication for OAC, the addition of antiplatelet therapy increases bleeding risk. Whether direct oral anticoagulants achieve better outcomes than vitamin K antagonists is uncertain in this setting. Although OAC has been shown to reduce subclinical leaflet thrombosis (which may progress to structural valve degeneration), bleeding events are unacceptably high. There is a lack of randomized trial data comparing antithrombotic strategies after transcatheter mitral or tricuspid valve replacement or after mitral or tricuspid transcatheter edge-to-edge repair. Single antiplatelet therapy after mitral or tricuspid transcatheter edge-to-edge repair may be appropriate, whereas at least 3 months of OAC is suggested after transcatheter mitral valve replacement or transcatheter tricuspid valve replacement. IMPLICATIONS Randomized studies are warranted to address the knowledge gaps in antithrombotic therapy after transcatheter valve interventions and to optimize outcomes.
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Affiliation(s)
- Annette Maznyczka
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, Bern, Switzerland.
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Nishiura N, Fuku Y, Sakata A, Maruo T, Kadota K. A Mobile Thrombus Adhering to an Intra-Annular Self-Expanding Transcatheter Aortic Valve. JACC Case Rep 2024; 29:102168. [PMID: 38264305 PMCID: PMC10801840 DOI: 10.1016/j.jaccas.2023.102168] [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: 11/16/2023] [Accepted: 11/22/2023] [Indexed: 01/25/2024]
Abstract
An 81-year-old woman who had undergone transcatheter aortic valve implantation 3 months earlier underwent routine follow-up transthoracic echocardiography, which revealed a mobile thrombus adhering to the bioprosthetic valve. This thrombus differed in morphology from transcatheter aortic valve implantation valve thrombi commonly seen in daily practice.
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Affiliation(s)
- Naoki Nishiura
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Okayama, Japan
| | - Yasushi Fuku
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Okayama, Japan
| | - Atsushi Sakata
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Okayama, Japan
| | - Takeshi Maruo
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Okayama, Japan
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Okayama, Japan
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Jung S, Ammon F, Smolka S, Moshage M, Marwan M, Achenbach S. Commissural misalignment independently predicts leaflet thrombosis after transcatheter aortic valve implantation. Clin Res Cardiol 2024; 113:29-37. [PMID: 37022472 PMCID: PMC10808532 DOI: 10.1007/s00392-023-02192-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 03/24/2023] [Indexed: 04/07/2023]
Abstract
AIMS Transcatheter aortic valve implantation (TAVI) has become a minimally invasive alternative to surgical aortic valve replacement. Hypo-attenuated leaflet thickening (HALT)-a marker of subclinical leaflet thrombosis commonly detected by cardiac computed tomography (CT) after TAVI-may influence valve durability and function. The purpose of this study was to compare commissural alignment of the native and prosthetic aortic valves in cardiac CT in subjects with and without HALT and thereby identify commissural misalignment as potential predictor for leaflet thrombosis after TAVI. METHODS AND RESULTS In 170 subjects, 85 with and 85 without HALT in post-TAVI CT, commissural orientation of the prosthesis was determined comparing native and prosthetic aortic valve orientation in cardiac CT by measuring the commissural angle relative to the right coronary ostium in the aortic valve plane. For the prosthetic valve, any deviation ≤ 15° compared to the native valve was classified as "aligned"; 16-30° as "mild", 31-45° as "moderate" and ≥ 45° as "severe" misalignment. Among subjects with HALT, median angular deviation was higher (36°, IQR 31°) than in the control group (29°, IQR 29°, p = 0.042). "Severe" misalignment was more frequent in subjects who developed HALT (n = 31, 37%) compared to the control group (n = 17, 20%, p = 0.013). In logistic regression analysis, more severe deviation (p = 0.015, OR = 1.02 per 1° deviation) and "severe" misalignment (p = 0.018, OR = 2.2) represented independent predictors for the occurrence of HALT after TAVI. CONCLUSION Subclinical leaflet thrombosis after TAVI is associated with commissural misalignment. Potential clinical advantages of obtaining commissural alignment remain to be systematically assessed.
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Affiliation(s)
- Susanne Jung
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany.
| | - Fabian Ammon
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Silvia Smolka
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Maximilian Moshage
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Mohamed Marwan
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
| | - Stephan Achenbach
- Medizinische Klinik 2, Kardiologie und Angiologie, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Ulmenweg 18, 91054, Erlangen, Germany
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Choi Y, Ahn JM, Kang DY, Kim HJ, Kim H, Lee J, Kim M, Park J, Kim KW, Koo HJ, Yang DH, Jung SC, Kim B, Anthony Wong YT, Simon Lam CC, Yin WH, Wei J, Lee YT, Kao HL, Lin MS, Ko TY, Kim WJ, Kang SH, Lee SA, Kim DH, Lee JH, Park SJ, Park DW. Frequency, Predictors, and Clinical Impact of Valvular and Perivalvular Thrombus After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2023; 16:2967-2981. [PMID: 38151311 DOI: 10.1016/j.jcin.2023.10.024] [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: 05/21/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Subclinical aortic valve complex (valvular and perivalvular) thrombus is not rare after transcatheter aortic valve replacement (TAVR). The risk factors and clinical implications of these findings remain uncertain. OBJECTIVES This study sought to evaluate the frequency, predictors, and clinical outcome of aortic valve complex thrombus after TAVR. METHODS In the ADAPT-TAVR (Anticoagulation Versus Dual Antiplatelet Therapy for Prevention of Leaflet Thrombosis and Cerebral Embolization After Transcatheter Aortic Valve Replacement) trial comparing edoxaban vs dual antiplatelet therapy in TAVR patients without an indication for chronic anticoagulation, the frequency of valvular (subclinical leaflet thrombus) and perivalvular (supravalvular, subvalvular, and sinus of Valsalva) thrombus was evaluated by 4-dimensional computed tomography at 6 months. The association of these phenomena with new cerebral thromboembolism on brain magnetic resonance imaging, neurologic and neurocognitive dysfunction, and clinical outcomes was assessed. RESULTS Among 211 patients with 6-month computed tomography evaluations, 91 patients (43.1%) had thrombus at any aortic valve complex, 30 (14.2%) patients had leaflet thrombus, and 78 (37.0%) patients had perivalvular thrombus. A small maximum diameter of the stent at the valve level and low body surface area were independent predictors of aortic valve complex and perivalvular thrombus, and decreased renal function was an independent predictor of leaflet thrombus. No significant differences were observed in new cerebral lesions, neurologic or neurocognitive functions, or clinical outcomes among patients with or without valvular or perivalvular thrombus. CONCLUSIONS Subclinical aortic valve complex (valvular and perivalvular) thrombus was common in patients who had undergone successful TAVR. However, these imaging phenomena were not associated with new cerebral thromboembolism, neurologic or neurocognitive dysfunction, or adverse clinical outcomes. (Anticoagulation Versus Dual Antiplatelet Therapy for Prevention of Leaflet Thrombosis and Cerebral Embolization After Transcatheter Aortic Valve Replacement [ADAPT-TAVR]; NCT03284827).
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Affiliation(s)
- Yeonwoo Choi
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do-Yoon Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwa Jung Kim
- Division of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hoyun Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jinho Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mijin Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jinsun Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Won Kim
- Asan Image Metrics, Clinical Trial Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - Hyun Jung Koo
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Hyun Yang
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Chai Jung
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byungjun Kim
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yiu Tung Anthony Wong
- Division of Cardiology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Cheung Chi Simon Lam
- Division of Cardiology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Jeng Wei
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yung-Tsai Lee
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Mao-Shin Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung-Yu Ko
- Division of Cardiology, Department of Internal Medicine, Hsin-Chu Branch, National Taiwan University Hospital, Hsin-Chu, Taiwan
| | - Won-Jang Kim
- Department of Cardiology, CHA Medical Center, Korea
| | - Se Hun Kang
- Department of Cardiology, CHA Medical Center, Korea
| | - Seung-Ah Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Hee Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Hong Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jung Park
- 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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Jang MH, Ahn JM, Kang DY, Kim KW, Koo HJ, Yang DH, Jung SC, Kim B, Wong YTA, Lam CCS, Yin WH, Wei J, Lee YT, Kao HL, Lin MS, Ko TY, Kim WJ, Kang SH, Ko E, Lee SA, Kim DH, Kim H, Choi Y, Lee J, Park SJ, Park DW. Impact of leaflet thrombosis on valve haemodynamic status after transcatheter aortic valve replacement. Heart 2023; 110:140-147. [PMID: 37586823 DOI: 10.1136/heartjnl-2023-322946] [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: 05/09/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVES The effect of subclinical leaflet thrombosis, characterised by hypoattenuated leaflet thickening (HALT), on the valve haemodynamic function and durability of the bioprosthetic valve, is not yet determined. We determined the impact of HALT on valve haemodynamics after transcatheter aortic valve replacement (TAVR) and the predictors of haemodynamic structural valve deterioration (SVD). METHODS The Anticoagulation vs Dual Antiplatelet Therapy for Prevention of Leaflet Thrombosis and Cerebral Embolization after Transcatheter Aortic Valve Replacement(ADAPT-TAVR) trial is a multicenter, randomised trial that compared edoxaban and dual antiplatelet therapy in patients who had undergone successful TAVR. The presence of HALT was evaluated by four-dimensional CT at 6 months and serial echocardiography performed at baseline, immediately post-TAVR and after 6 months. SVD was defined as at least one of the following: (1) mean transprosthetic gradient ≥20 mm Hg, (2) change in the mean gradient ≥10 mm Hg from baseline, or (3) new or increase in intraprosthetic aortic regurgitation of at least ≥1 grade, resulting in moderate or greater regurgitation. RESULTS At 6 months, HALT was found in 30 of 211 (14.2%) patients. The presence of HALT did not significantly affect aortic valve mean gradients (with vs without HALT; 14.0±4.8 mm Hg vs 13.7±5.5 mm Hg; p=0.74) at 6 months. SVD was reported in 30 of 206 patients (14.6%) at 6-month follow-up echocardiography. Older age (OR: 1.138; 95% CI: 1.019 to 1.293; p=0.033), use of aortic valve size ≤23 mm (OR: 6.254; 95% CI: 2.230 to 20.569; p=0.001) and mean post-TAVR pressure gradient (OR: 1.233; 95% CI: 1.123 to 1.371; p<0.001) were independent predictors of haemodynamic SVD; however, the presence of HALT was not identified as a predictor of SVD. CONCLUSIONS In patients who had undergone successful TAVR, aortic valve haemodynamic status was not influenced by the presence of HALT. Although HALT was not a predictor of haemodynamic SVD at 6 months, it warrants further longer-term follow-up to evaluate the effect on long-term valve durability. TRIAL REGISTRATION NUMBER NCT03284827 (https://www. CLINICALTRIALS gov).
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Affiliation(s)
| | | | | | - Kyung Won Kim
- Asan Image Metrics, Clinical Trial Center, Asan Institue for Life Sciences, Asan Medical Center, Seoul, South Korea
| | | | | | | | - Byungjun Kim
- Radiology, Korea University Anam Hospital, Seoul, Korea
| | | | | | - Wei-Hsian Yin
- Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Jeng Wei
- Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yung-Tsai Lee
- Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Hsien-Li Kao
- Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Mao-Shin Lin
- Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung-Yu Ko
- Cardiology, Hsin-Chu Branch, National Taiwan University Hospital, Hsin-Chu, Taiwan
| | - Won-Jang Kim
- Cardiology, CHA Ilsan Medical Center, Goyang-si, Gyeonggi-do, Korea
| | - Se Hun Kang
- Cardiology, CHA Bundang Medical Center, Seongnam, Gyeonggi-do, Korea
| | - Euihong Ko
- Cardiology, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | | | - Dae-Hee Kim
- Cardiology, Asan Medical Center, Seoul, Korea
| | - Hoyun Kim
- Cardiology, Asan Medical Center, Seoul, Korea
| | | | - Jinho Lee
- Cardiology, Asan Medical Center, Seoul, Korea
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Roule V, Guedeney P, Silvain J, Beygui F, Zeitouni M, Sorrentino S, Kerneis M, Barthelemy O, Beaupré F, Portal JJ, Vicaut E, Montalescot G, Collet JP. Bioprosthetic leaflet thrombosis and reduced leaflet motion after transcatheter aortic valve replacement: A systematic review and meta-analysis. Arch Cardiovasc Dis 2023; 116:563-571. [PMID: 37968182 DOI: 10.1016/j.acvd.2023.10.003] [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: 05/17/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Leaflet thrombosis and reduced leaflet motion have become a concern with the expanding use of transcatheter aortic valve replacement in lower-risk patients. AIMS To assess the proportions, predictors and clinical impact of leaflet thrombosis and reduced leaflet motion after transcatheter aortic valve replacement. METHODS We performed a meta-analysis of studies assessing the proportions of and/or clinical outcomes according to the presence of leaflet thrombosis after transcatheter aortic valve replacement identified with computed tomography and/or echocardiography. RESULTS Fifty-three studies, representing 25,258 patients undergoing transcatheter aortic valve replacement, were considered. The proportion of leaflet thrombosis was 5.2% overall, and was higher in computed tomography versus echocardiography (16.4% vs. 1.1%, respectively); reduced leaflet motion was identified in 11% of patients with four-dimensional computed tomography. Intra-annular bioprostheses were associated with a higher proportion of leaflet thrombosis, whereas chronic oral anticoagulation was protective for leaflet thrombosis in both computed tomography and echocardiographic studies (9.7% vs. 17.5%; relative risk [RR]: 0.51, 95% confidence interval [95% CI]: 0.37-0.71 and 0.9% vs. 2.7%; RR: 0.22, 95% CI: 0.06-0.79, respectively) and for reduced leaflet motion (2.5% vs. 12.4%; RR: 0.32, 95% CI: 0.13-0.76). Leaflet thrombosis was not associated with an increased risk of death, but with a higher risk of stroke in computed tomography studies (2.8% vs. 2.4%; RR: 1.63, 95% CI: 1.05-2.55), a difference more pronounced when considering reduced leaflet motion (3.5% vs. 1.7%; RR: 2.39, 95% CI: 0.63-8.34). CONCLUSIONS The proportion of leaflet thrombosis is highly variable according to the screening approach, the type of valve and the use of oral anticoagulation. The occurrence of cerebral events is increased when leaflet thrombosis and/or reduced leaflet motion are diagnosed, but leaflet thrombosis has no impact on survival.
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Affiliation(s)
- Vincent Roule
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France; Service de Cardiologie, CHU de Caen Normandie, Normandie Université, 14000 Caen, France
| | - Paul Guedeney
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
| | - Johanne Silvain
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
| | - Farzin Beygui
- Service de Cardiologie, CHU de Caen Normandie, Normandie Université, 14000 Caen, France
| | - Michel Zeitouni
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
| | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Science, Magna Graecia University, 88100 Catanzaro, Italy
| | - Mathieu Kerneis
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
| | - Olivier Barthelemy
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
| | - Frédéric Beaupré
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
| | - Jean-Jacques Portal
- ACTION Study Group, Unité de Recherche Clinique, Lariboisière Hospital, AP-HP, 75010 Paris, France
| | - Eric Vicaut
- ACTION Study Group, Unité de Recherche Clinique, Lariboisière Hospital, AP-HP, 75010 Paris, France
| | - Gilles Montalescot
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France.
| | - Jean-Philippe Collet
- ACTION Study Group, Sorbonne Université, UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), 75013 Paris, France
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9
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Fukumoto Y. Thrombogenicity After Transcatheter Aortic Valve Replacement. Am J Cardiol 2023; 207:257-259. [PMID: 37769568 DOI: 10.1016/j.amjcard.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan.
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10
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Sajima T, Harada M, Onimaru T, Honjo T, Mizuguchi T, Yasuda A, Swamura S, Hioki H, Watanabe Y. Perioperative changes in coagulation and platelet contribution to clot strength after transcatheter aortic valve implantation: A study using thromboelastography and conventional markers. Perfusion 2023:2676591231216658. [PMID: 37963386 DOI: 10.1177/02676591231216658] [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: 11/16/2023]
Abstract
INTRODUCTION Thrombotic and haemorrhagic complications have been reported following transcatheter aortic valve implantation (TAVI). However, few reports have studied perioperative changes in coagulation and platelet function after TAVI. Furthermore, there are no clear guidelines for antithrombotic therapy. This study aimed to examine the perioperative changes in coagulation and platelet contribution to clot strength after TAVI using thromboelastography (TEG 6s; Hemonetics). METHODS This prospective observational study included 15 patients scheduled to undergo TAVI for severe aortic stenosis. TEG 6s global haemostasis was used to record three measurements: on the day of surgery (immediately before the operation) and postoperative days 1 and 3. The reaction time R to thrombosis; K and α, which represent the rate of thrombosis; and the maximum amplitude (MA) were measured from the kaolin thromboelastography (TEG) curves. The coagulation index (CI) was calculated from the measurement results to assess thrombotic tendency. In addition, MA was converted to elastic clot strength, and platelet function was assessed by the difference, Gp, in elastic strength depending on platelet activation. RESULTS R and K decreased, and α tended to increase in kaolin TEG on days 1 and 3 after TAVI, indicating elevated coagulation function compared with the preoperative period, but MA and CI did not show significant changes. Gp decreased significantly on days 1 and 3, suggesting a decrease in the platelet contribution to clot strength. CONCLUSIONS Compared with the preoperative period, coagulation tended to increase, and platelet contribution to clot strength decreased from days 1 to 3 after TAVI.
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Affiliation(s)
- Takeyuki Sajima
- Department of Anesthesiology, Teikyo University Hospital, Itabashi-ku, Japan
| | - Mae Harada
- Department of Anesthesiology, Teikyo University Hospital, Itabashi-ku, Japan
| | - Taichi Onimaru
- Department of Anesthesiology, Teikyo University Hospital, Itabashi-ku, Japan
| | - Takahiro Honjo
- Department of Anesthesiology, Teikyo University Hospital, Itabashi-ku, Japan
| | - Taisuke Mizuguchi
- Department of Anesthesiology, Teikyo University Hospital, Itabashi-ku, Japan
| | - Atsushi Yasuda
- Department of Anesthesiology, Teikyo University Hospital, Itabashi-ku, Japan
| | - Shigehito Swamura
- Department of Anesthesiology, Teikyo University Hospital, Itabashi-ku, Japan
| | - Hirofumi Hioki
- Department of Cardiology, Teikyo University Hospital, Itabashi-ku, Japan
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University Hospital, Itabashi-ku, Japan
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11
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Dobesh PP, Goldsweig AM. Antithrombotic therapy with Transcatheter aortic valve replacement. Pharmacotherapy 2023; 43:1064-1083. [PMID: 37464970 DOI: 10.1002/phar.2847] [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: 02/03/2023] [Revised: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 07/20/2023]
Abstract
Aortic valve replacement is a necessary management strategy for patients with severe aortic stenosis. The use of transaortic valve replacement (TAVR) has increased significantly over the last decade and now exceeds traditional surgical aortic valve replacement. Since the valve systems used in TAVR consist of bioprosthetic valve tissue encased in a metal stent frame, antithrombotic therapy recommendations cannot be extrapolated from prior data with differently constructed surgical bioprosthetic or mechanical valves. Data on the use of antithrombotic therapy with TAVR are a rapidly developing area of medicine. Choice of agents depends on several patient factors. Patients undergoing TAVR also have a relatively high incidence of subclinical valve thrombosis. The clinical impact of this phenomenon and the implications for antithrombotic therapy continue to evolve. It is critical for clinicians who treat patients undergoing TAVR to have a firm understanding of practice guidelines, the evolving evidence, and its implications for the use of antithrombotic therapy in these patients.
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Affiliation(s)
- Paul P Dobesh
- Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andrew M Goldsweig
- Cardiac Catheterization Laboratory, Cardiovascular Clinical Research, Baystate Medical Center, Springfield, Massachusetts, USA
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12
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Khodaei S, Abdelkhalek M, Maftoon N, Emadi A, Keshavarz-Motamed Z. Early Detection of Risk of Neo-Sinus Blood Stasis Post-Transcatheter Aortic Valve Replacement Using Personalized Hemodynamic Analysis. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2023; 7:100180. [PMID: 37745677 PMCID: PMC10512011 DOI: 10.1016/j.shj.2023.100180] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 09/26/2023]
Abstract
Background Despite the demonstrated benefits of transcatheter aortic valve replacement (TAVR), subclinical leaflet thrombosis and hypoattenuated leaflet thickening are commonly seen as initial indications of decreased valve durability and augmented risk of transient ischemic attack. Methods We developed a multiscale patient-specific computational framework to quantify metrics of global circulatory function, metrics of global cardiac function, and local cardiac fluid dynamics of the aortic root and coronary arteries. Results Based on our findings, TAVR might be associated with a high risk of blood stagnation in the neo-sinus region due to the lack of sufficient blood flow washout during the diastole phase (e.g., maximum blood stasis volume increased by 13, 8, and 2.7 fold in the left coronary cusp, right coronary cusp, and noncoronary cusp, respectively [N = 26]). Moreover, in some patients, TAVR might not be associated with left ventricle load relief (e.g., left ventricle load reduced only by 1.2 % [N = 26]) and diastolic coronary flow improvement (e.g., maximum coronary flow reduced by 4.94%, 15.05%, and 23.59% in the left anterior descending, left circumflex coronary artery, and right coronary artery, respectively, [N = 26]). Conclusions The transvalvular pressure gradient amelioration after TAVR might not translate into adequate sinus blood washout, optimal coronary flow, and reduced cardiac stress. Noninvasive personalized computational modeling can facilitate the determination of the most effective revascularization strategy pre-TAVR and monitor leaflet thrombosis and coronary plaque progression post-TAVR.
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Affiliation(s)
- Seyedvahid Khodaei
- Department of Mechanical Engineering, McMaster University, Hamilton, Ontario, Canada
| | - Mohamed Abdelkhalek
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario, Canada
| | - Nima Maftoon
- Department of Systems Design Engineering, University of Waterloo, Waterloo, Ontario, Canada
- Centre for Bioengineering and Biotechnology, University of Waterloo, Waterloo, Ontario, Canada
| | - Ali Emadi
- Department of Mechanical Engineering, McMaster University, Hamilton, Ontario, Canada
- Department of Electrical and Computer Engineering, McMaster University, Hamilton, Ontario, Canada
| | - Zahra Keshavarz-Motamed
- Department of Mechanical Engineering, McMaster University, Hamilton, Ontario, Canada
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario, Canada
- School of Computational Science and Engineering, McMaster University, Hamilton, Ontario, Canada
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13
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Subclinical Leaflet Thrombosis After Balloon versus Self-Expandable Transcatheter Aortic Valve Implantation. Am J Cardiol 2023; 192:88-97. [PMID: 36758269 DOI: 10.1016/j.amjcard.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/23/2022] [Accepted: 01/07/2023] [Indexed: 02/10/2023]
Abstract
Hypoattenuated leaflet thickening (HALT) has been recognized as one of the complications after transcatheter aortic valve implantation and may promote structural valve degeneration and increase the risk of cerebrovascular events. The 2 main types of available transcatheter heart valves (THVs), the balloon-expandable (BE) and the self-expanding (SE), are interchangeably used in clinical practice despite substantial design differences. There is unclear evidence on whether these 2 different THV models are achieving similar or different rates of subclinical leaflet thrombosis/HALT. A systematic search of electronic databases was conducted to identify studies that reported the incidence of HALT between SE THVs and BE THVs. The Mantel-Haenszel method was used to calculate the 95% confidence interval and pooled risk ratio with a random-effects model. A total of 126 records were identified, of which 22 studies comprising 14,401 patients were included in our final analysis. Among 5,951 patients receiving SE THVs, 194 (3.2%) developed HALT, compared with 8,450 patients receiving BE THVs, of whom 484 (5.7%) developed HALT. There was a statistically significant decrease in the risk of developing HALT in patients receiving SE THVs compared with those receiving BE THVs (risk ratio 0.75, 95% confidence interval 0.59 to 0.95, I2 32%, p = 0.02). In conclusion, could potentially reduce the risk of HALT/subclinical leaflet thrombosis.
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14
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Aziminia N, Nitsche C, Mravljak R, Bennett J, Thornton GD, Treibel TA. Heart failure and excess mortality after aortic valve replacement in aortic stenosis. Expert Rev Cardiovasc Ther 2023; 21:193-210. [PMID: 36877090 PMCID: PMC10069375 DOI: 10.1080/14779072.2023.2186853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION In aortic stenosis (AS), the heart transitions from adaptive compensation to an AS cardiomyopathy and eventually leads to decompensation with heart failure. Better understanding of the underpinning pathophysiological mechanisms is required in order to inform strategies to prevent decompensation. AREAS COVERED In this review, we therefore aim to appraise the current pathophysiological understanding of adaptive and maladaptive processes in AS, appraise potential avenues of adjunctive therapy before or after AVR and highlight areas of further research in the management of heart failure post AVR. EXPERT OPINION Tailored strategies for the timing of intervention accounting for individual patient's response to the afterload insult are underway, and promise to guide better management in the future. Further clinical trials of adjunctive pharmacological and device therapy to either cardioprotect prior to intervention or promote reverse remodeling and recovery after intervention are needed to mitigate the risk of heart failure and excess mortality.
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Affiliation(s)
- Nikoo Aziminia
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | - Christian Nitsche
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | | | - Jonathan Bennett
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | - George D Thornton
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, England
- Barts Heart Centre, London, England
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15
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Imaeda S, Inohara T, Yoshijima N, Kobari Y, Myojin S, Ryuzaki T, Hattori O, Shinada K, Tsuruta H, Takahashi T, Yamazaki M, Kato J, Yamada Y, Jinzaki M, Shimizu H, Fukuda K, Hayashida K. Natural History of Leaflet Thrombosis After Transcatheter Aortic Valve Replacement: A 5-Year Follow-Up Study. J Am Heart Assoc 2022; 11:e026334. [PMID: 36444836 PMCID: PMC9851443 DOI: 10.1161/jaha.122.026334] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Subclinical leaflet thrombosis, characterized by hypoattenuated leaflet thickening (HALT) on multidetector computed tomography, is common after transcatheter aortic valve replacement (TAVR). Because little is known about the long-term natural history of subclinical HALT, we aimed to investigate this in patients who underwent TAVR without using additional anticoagulation. Methods and Results We retrospectively evaluated patients who underwent TAVR with the Edwards SAPIEN-XT at our institute between October 2013 and December 2015. Patients were grouped according to the presence or absence of HALT within 1 year after TAVR (HALT and No-HALT groups). The primary outcome, defined as the composite of all-cause mortality, heart failure readmission, and ischemic stroke, was compared. Valve performance was assessed over time by transthoracic echocardiography. Among 124 patients (men: 29.1%; median age, 85 years), 27 (21.8%) showed HALT on multidetector computed tomography within 1 year after TAVR. No patient required additional anticoagulation for treating HALT because of the absence of valve-related symptomatic deterioration. During the median follow-up period of 4.7 years (interquartile range, 4.0-5.6), the rate of primary outcome and valve performance was not statistically different between the 2 groups (37.0% versus 38.1%; log-rank test P=0.92; mean pressure gradient, 9 mm Hg [8-14 mm Hg] versus 10 mm Hg [7-15 mm Hg]; P=0.51, respectively). Conclusions Approximately 20% of patients after TAVR had HALT within 1 year; however, that did not change the risk of subsequent adverse cardiovascular events or the valve performance with statistical significance for up to 5 years despite no additional anticoagulation therapy.
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Affiliation(s)
- Shohei Imaeda
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Taku Inohara
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | | | - Yusuke Kobari
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Sosuke Myojin
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Toshinobu Ryuzaki
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Osamu Hattori
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Keitaro Shinada
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Hikaru Tsuruta
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Tatsuo Takahashi
- Department of Cardiovascular SurgeryKeio University School of MedicineTokyoJapan
| | - Masataka Yamazaki
- Department of Cardiovascular SurgeryKeio University School of MedicineTokyoJapan
| | - Jungo Kato
- Department of AnesthesiologyKeio University School of MedicineTokyoJapan
| | - Yoshitake Yamada
- Department of RadiologyKeio University School of MedicineTokyoJapan
| | - Masahiro Jinzaki
- Department of RadiologyKeio University School of MedicineTokyoJapan
| | - Hideyuki Shimizu
- Department of Cardiovascular SurgeryKeio University School of MedicineTokyoJapan
| | - Keiichi Fukuda
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Kentaro Hayashida
- Department of CardiologyKeio University School of MedicineTokyoJapan
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16
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Fukui M, Bapat VN, Garcia S, Dworak MW, Hashimoto G, Sato H, Gössl M, Enriquez-Sarano M, Lesser JR, Cavalcante JL, Sorajja P. Deformation of Transcatheter Aortic Valve Prostheses: Implications for Hypoattenuating Leaflet Thickening and Clinical Outcomes. Circulation 2022; 146:480-493. [PMID: 35862182 DOI: 10.1161/circulationaha.121.058339] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although transcatheter aortic valve replacement (TAVR) therapy continues to grow, there have been concerns about the occurrence of hypoattenuating leaflet thickening (HALT), which may affect prosthesis function or durability. This study aimed to examine prosthesis frame factors and correlate their extent to the frequency of HALT and clinical outcomes. METHODS We prospectively examined 565 patients with cardiac computed tomography screening for HALT at 30 days after balloon-expandable SAPIEN3 and self-expanding EVOLUT TAVR. Deformation of the TAVR prostheses, asymmetric prosthesis leaflet expansion, prosthesis sinus volumes, and commissural alignment were analyzed on the postprocedural computed tomography. For descriptive purposes, an index of prosthesis deformation was calculated, with values >1.00 representing relative midsegment underexpansion. A time-to-event model was performed to evaluate the association of HALT with the clinical outcome. RESULTS Overall, HALT was present in 21% of SAPIEN3 patients and in 16% of EVOLUT patients at 30 days after TAVR. The occurrence of HALT was directly associated with greater prosthesis frame deformation (P<0.001), worse asymmetry of the leaflets (P<0.001), and smaller TAVR neosinus volumes (P<0.001). These relations were present in both prosthetic types and in all of their size ranges (all P<0.05). In multivariable analyses that include clinical variables previously associated with HALT (eg, anticoagulant therapy), variables of TAVR prosthesis deformation remained predictive of HALT. Although HALT was not associated with changes in prosthetic hemodynamics, its presence was associated with the risk of mortality at 1 year, with respect to greater incidences of all-cause mortality (hazard ratio, 2.98 [95% CI, 1.57-5.63]; P=0.001), cardiac death (hazard ratio, 4.58 [95% CI, 1.81-11.6]; P=0.001), and a composite outcome of all-cause mortality and heart failure hospitalization (hazard ratio, 1.94 [95% CI, 1.14-3.30]; P=0.02) with adjustment for age, sex, and comorbidities. CONCLUSIONS Nonuniform expansion of TAVR prostheses resulting in frame deformation, asymmetric leaflet, and smaller neosinus volume is related to occurrence of HALT in patients who undergo TAVR. These data may have implications for both prosthesis valve design and deployment techniques to improve clinical outcomes for these patients.
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Affiliation(s)
- Miho Fukui
- Cardiovascular Imaging Research Center and Core Laboratory (M.F., G.H., J.L.C.), Minneapolis Heart Institute Foundation, MN.,Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (M.F., V.N.B., S.G., M.W.D., G.H., H.S., M.G., M.E.-S., J.R.L., J.L.C., P.S.)
| | - Vinayak N Bapat
- Valve Science Center (V.N.B., S.G., M.W.D., H.S., M.G., M.E.-S., J.R.L., P.S.), Minneapolis Heart Institute Foundation, MN.,Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (M.F., V.N.B., S.G., M.W.D., G.H., H.S., M.G., M.E.-S., J.R.L., J.L.C., P.S.)
| | - Santiago Garcia
- Valve Science Center (V.N.B., S.G., M.W.D., H.S., M.G., M.E.-S., J.R.L., P.S.), Minneapolis Heart Institute Foundation, MN.,Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (M.F., V.N.B., S.G., M.W.D., G.H., H.S., M.G., M.E.-S., J.R.L., J.L.C., P.S.)
| | - Marshall W Dworak
- Valve Science Center (V.N.B., S.G., M.W.D., H.S., M.G., M.E.-S., J.R.L., P.S.), Minneapolis Heart Institute Foundation, MN.,Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (M.F., V.N.B., S.G., M.W.D., G.H., H.S., M.G., M.E.-S., J.R.L., J.L.C., P.S.)
| | - Go Hashimoto
- Cardiovascular Imaging Research Center and Core Laboratory (M.F., G.H., J.L.C.), Minneapolis Heart Institute Foundation, MN.,Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (M.F., V.N.B., S.G., M.W.D., G.H., H.S., M.G., M.E.-S., J.R.L., J.L.C., P.S.)
| | - Hirotomo Sato
- Valve Science Center (V.N.B., S.G., M.W.D., H.S., M.G., M.E.-S., J.R.L., P.S.), Minneapolis Heart Institute Foundation, MN.,Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (M.F., V.N.B., S.G., M.W.D., G.H., H.S., M.G., M.E.-S., J.R.L., J.L.C., P.S.)
| | - Mario Gössl
- Valve Science Center (V.N.B., S.G., M.W.D., H.S., M.G., M.E.-S., J.R.L., P.S.), Minneapolis Heart Institute Foundation, MN.,Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (M.F., V.N.B., S.G., M.W.D., G.H., H.S., M.G., M.E.-S., J.R.L., J.L.C., P.S.)
| | - Maurice Enriquez-Sarano
- Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (M.F., V.N.B., S.G., M.W.D., G.H., H.S., M.G., M.E.-S., J.R.L., J.L.C., P.S.)
| | - John R Lesser
- Valve Science Center (V.N.B., S.G., M.W.D., H.S., M.G., M.E.-S., J.R.L., P.S.), Minneapolis Heart Institute Foundation, MN.,Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (M.F., V.N.B., S.G., M.W.D., G.H., H.S., M.G., M.E.-S., J.R.L., J.L.C., P.S.)
| | - João L Cavalcante
- Cardiovascular Imaging Research Center and Core Laboratory (M.F., G.H., J.L.C.), Minneapolis Heart Institute Foundation, MN.,Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (M.F., V.N.B., S.G., M.W.D., G.H., H.S., M.G., M.E.-S., J.R.L., J.L.C., P.S.)
| | - Paul Sorajja
- Valve Science Center (V.N.B., S.G., M.W.D., H.S., M.G., M.E.-S., J.R.L., P.S.), Minneapolis Heart Institute Foundation, MN.,Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (M.F., V.N.B., S.G., M.W.D., G.H., H.S., M.G., M.E.-S., J.R.L., J.L.C., P.S.)
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17
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Radovanovic M, Nordstrom CW, Hanna RD. Bioprosthetic Aortic Valve Thrombosis and Literature Review. J Cardiovasc Dev Dis 2022; 9:jcdd9080252. [PMID: 36005416 PMCID: PMC9409674 DOI: 10.3390/jcdd9080252] [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: 07/18/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022] Open
Abstract
An 83-year-old gentleman with a history of 23-mm Hancock-II-bioprosthetic aortic valve (BAV) replacement ten-years prior presented with symptoms of dyspnea and lower extremity edema. During the preceding seven-years, he had been noted to have asymptomatic increased mean transvalvular gradients (MG; 36–50 mmHg) felt to be due to either early bioprosthetic degeneration, pannus formation, or patient–prosthesis mismatch. An echocardiogram at the time of symptom development demonstrated significant flow acceleration through the aortic valve, mild regurgitation, and severely increased MG (48 mmHg) with prolonged acceleration time (AT, 140 msec). A trial of warfarin anticoagulation resulted in dramatic improvement after only 6 weeks with laminar flow through the AV, near-total resolution of regurgitation, and a decrease in MG to 14 mmHg and AT to 114 msec. These findings strongly suggest that BAV thrombosis was the predominant mechanism responsible for the longstanding high MG. Our case highlights that BAV thrombosis should be considered in the differential of elevated gradients regardless of the age of prosthesis, and that a trial of warfarin anticoagulation may be beneficial even if elevated gradients have been present for a prolonged period. Valvular gradients are often abnormal long before a formal diagnosis; however, these may reverse quickly with anticoagulation therapy.
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Affiliation(s)
- Milan Radovanovic
- Mayo Clinic Alix School of Medicine, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
- Correspondence:
| | - Charles W. Nordstrom
- Mayo Clinic Alix School of Medicine, Rochester, MN 55905, USA
- Department of Hospital Medicine, Mayo Clinic Health System, Eau Claire, WI 54703, USA
| | - Richard D. Hanna
- Mayo Clinic Alix School of Medicine, Rochester, MN 55905, USA
- Department of Cardiology, Mayo Clinic Health System, Eau Claire, WI 54703, USA
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18
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Nappi F, Avtaar Singh SS, Nappi P, Fiore A. Biomechanics of Transcatheter Aortic Valve Implant. Bioengineering (Basel) 2022; 9:bioengineering9070299. [PMID: 35877350 PMCID: PMC9312295 DOI: 10.3390/bioengineering9070299] [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: 04/28/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 11/16/2022] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has grown exponentially within the cardiology and cardiac surgical spheres. It has now become a routine approach for treating aortic stenosis. Several concerns have been raised about TAVI in comparison to conventional surgical aortic valve replacement (SAVR). The primary concerns regard the longevity of the valves. Several factors have been identified which may predict poor outcomes following TAVI. To this end, the lesser-used finite element analysis (FEA) was used to quantify the properties of calcifications which affect TAVI valves. This method can also be used in conjunction with other integrated software to ascertain the functionality of these valves. Other imaging modalities such as multi-detector row computed tomography (MDCT) are now widely available, which can accurately size aortic valve annuli. This may help reduce the incidence of paravalvular leaks and regurgitation which may necessitate further intervention. Structural valve degeneration (SVD) remains a key factor, with varying results from current studies. The true incidence of SVD in TAVI compared to SAVR remains unclear due to the lack of long-term data. It is now widely accepted that both are part of the armamentarium and are not mutually exclusive. Decision making in terms of appropriate interventions should be undertaken via shared decision making involving heart teams.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
- Correspondence: ; Tel.: +33-149334104; Fax: +33-149334119
| | | | - Pierluigi Nappi
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy;
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France;
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19
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van Ginkel DJ, Bor WL, Veenstra L, van 't Hof AWJ, Fabris E. Evolving concepts in the management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation. Eur J Intern Med 2022; 101:14-20. [PMID: 35623935 DOI: 10.1016/j.ejim.2022.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/22/2022]
Abstract
Thromboembolic and bleeding complications negatively impact recovery and survival after transcatheter aortic valve implantation (TAVI). Particularly, there is a considerable risk of ischaemic stroke and vascular access related bleeding, as well as spontaneous gastro-intestinal bleeding. Therefore, benefit and harm of antithrombotic therapy should be carefully balanced. This review summarizes current evidence on peri- and post-procedural antithrombotic treatment. Indeed, in recent years, the management of antithrombotic therapy after TAVI has evolved from intensive, expert opinion-based strategies, towards a deescalated, evidence-based approach. Besides per procedural administration of unfractionated heparin, this encompasses single antiplatelet therapy in patients without a concomitant indication for oral anticoagulation (OAC); and OAC monotherapy in patients with such indication, mainly being atrial fibrillation. Combination therapy should generally be avoided to reduce bleeding risk, except after recent coronary stenting where a period of dual antiplatelet therapy (aspirin plus P2Y12-inhibitor) or P2Y12-inhibitor plus OAC (in patients with an independent indication for OAC) is recommended to prevent stent thrombosis. This new paradigm in which reduced antithrombotic intensity leads to improved patient safety, without a loss of efficacy, may be particularly suitable for elderly and fragile patients. Whether this holds in upcoming populations of younger and lower-risk patients and in specific populations as patients with subclinical valve thrombosis, is yet to be proven. Finally, whether less intensive or alternative approaches should be also applied for the periprocedural management of the antithrombotic therapy, has to be determined by ongoing and future studies.
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Affiliation(s)
- Dirk Jan van Ginkel
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Willem L Bor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Leo Veenstra
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Arnoud W J van 't Hof
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Enrico Fabris
- Cardiothoracovascular Department, University of Trieste, Trieste, Italy.
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20
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Hein M, Schoechlin S, Schulz U, Minners J, Breitbart P, Lehane C, Neumann FJ, Ruile P. Long-Term Follow-Up of Hypoattenuated Leaflet Thickening After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2022; 15:1113-1122. [PMID: 35680190 DOI: 10.1016/j.jcin.2022.04.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/01/2022] [Accepted: 04/05/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Early hypoattenuated leaflet thickening (HALT) occurs in at least 10% of all transcatheter aortic valve replacement (TAVR) patients. The long-term prognostic impact of HALT is uncertain. OBJECTIVES The aim of this study was to assess the long-term risk of early HALT post-TAVR. METHODS We report outcome data from our prospective observational registry with post-TAVR computed tomography angiography performed between May 2012 and December 2017. The outcomes were survival, cardiovascular mortality, ischemic cerebrovascular events, and symptomatic hemodynamic valve deterioration. RESULTS Early HALT was diagnosed in 115 (16.0%) of 804 patients. During a median follow-up of 3.25 years, survival rates did not differ significantly between patients with and without HALT (Kaplan-Meier 3-year estimates for survival 70.1% vs 74.0%, P = 0.597). The 3-year cardiovascular mortality rate was 13.2% versus 11.3% (with vs without HALT, P = 0.733). The 3-year event rate for cerebrovascular events was 2.0% versus 4.4% (with vs without HALT, P = 0.246), and the 3-year event rate of symptomatic hemodynamic valve deterioration was 9.4% versus 1.5% (with vs without HALT, P < 0.001). Multivariable analysis revealed the following predictors of symptomatic hemodynamic valve deterioration: HALT (HR: 6.10; 95% CI: 2.59-14.29; P < 0.001), the mixed valve-type group (HR: 6.51; 95% CI: 2.38-17.81; P < 0.001), and prosthesis diameter (HR valve size per 3 mm [HR: 0.37; 95% CI: 0.17-0.79]; P = 0.011). CONCLUSIONS During a median follow-up of more than 3 years, HALT was not associated with mortality or cerebrovascular events. However, we observed an association of HALT with symptomatic hemodynamic valve deterioration.
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Affiliation(s)
- Manuel Hein
- Department of Cardiology and Angiology, University Heart Center, Freiburg-Bad Krozingen, Germany.
| | - Simon Schoechlin
- Department of Cardiology and Angiology, University Heart Center, Freiburg-Bad Krozingen, Germany
| | - Undine Schulz
- Department of Cardiology and Angiology, University Heart Center, Freiburg-Bad Krozingen, Germany
| | - Jan Minners
- Department of Cardiology and Angiology, University Heart Center, Freiburg-Bad Krozingen, Germany
| | - Philipp Breitbart
- Department of Cardiology and Angiology, University Heart Center, Freiburg-Bad Krozingen, Germany
| | - Cornelius Lehane
- Department of Anesthesiology, University Heart Center Freiburg, Bad Krozingen, Freiburg, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology, University Heart Center, Freiburg-Bad Krozingen, Germany
| | - Philipp Ruile
- Department of Cardiology and Angiology, University Heart Center, Freiburg-Bad Krozingen, Germany
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21
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van Wiechen MP, el Azzouzi I, Knol WG, Adrichem R, Hokken TW, Ooms JF, de Ronde-Tillmans MJ, Daemen J, de Jaegere PP, Hirsch A, Budde RP, Van Mieghem NM. Leaflet thickening and motion after transcatheter aortic valve replacement: Design and rationale of the Rotterdam edoxaban trial. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:67-70. [DOI: 10.1016/j.carrev.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 06/06/2022] [Accepted: 06/10/2022] [Indexed: 11/03/2022]
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22
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Hussein AA, Alvarez P, Reed G, Heresi GA. Off-Label Use and Inappropriate Dosing of Direct Oral Anticoagulants in Cardiopulmonary Disease. Chest 2022; 161:1360-1369. [PMID: 35101404 DOI: 10.1016/j.chest.2022.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 12/28/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are increasingly used in clinical practice and have become essential in the management of atrial fibrillation and VTE. The enthusiasm for DOACs has fueled the off-label application of these agents in cardiopulmonary disease, and their use has often outpaced the evidence supporting their application. This article reviews the evidence and current off-label use of DOACs in various cardiopulmonary disease states.
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Affiliation(s)
- Ayman A Hussein
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland, OH.
| | - Paulino Alvarez
- Section of Heart Failure, Department of Cardiovascular Medicine, Cleveland, OH
| | - Grant Reed
- Section of Interventional Cardiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, OH
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23
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Kim WK, Charitos E. Prosthesis Type-Associated Risk of Subclinical Leaflet Thrombosis. JACC Cardiovasc Interv 2022; 15:676. [PMID: 35331461 DOI: 10.1016/j.jcin.2022.01.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 01/25/2022] [Indexed: 11/27/2022]
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24
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Performance of Computed Tomography Angiography (CTA) for the Diagnosis of Hypo-Attenuated Leaflet Thickening (HALT). J Clin Med 2022; 11:jcm11071817. [PMID: 35407425 PMCID: PMC8999481 DOI: 10.3390/jcm11071817] [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: 02/08/2022] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 11/28/2022] Open
Abstract
(1) Background: Early hypo-attenuated leaflet thickening (HALT) is diagnosed by computed tomography angiography (CTA) in approximately 15% of patients undergoing transcatheter aortic valve replacement (TAVR). We sought to investigate the diagnostic performance of CTA for the diagnosis of HALT, focusing on timing data assessment within the cardiac cycle. (2) Methods: The study enrolled 50 patients with and 50 without HALT with available post-TAVR-CTA. The primary objective was to compare the diagnostic performance of CTA readings at specific intervals and time points during the cardiac cycle (entire systole, entire diastole, end-systole, and mid-diastole) versus gold standard (consensus reading by two observers based on multiphase full cardiac cycle data sets). (3) Results: 100 CTAs were independently analysed by two observers blinded to clinical characteristics of the study population and the results from the gold standard reading. Sensitivity and specificity for the diagnosis of HALT were 84%/94% in systole, 87%/92% in diastole, 78%/95% at end-systole, and 80%/94% at mid-diastole. End-systole had the highest positive predictive value (0.88) and positive likelihood ratio (36). Cohen’s kappa for interobserver reliability was 0.715 in systole, 0.578 in diastole, 0.650 at end-systole, and 0.517 at mid-diastole. (4) Conclusion: Limiting CTA reading to distinct intervals or time points during the cardiac cycle has good specificity but lowers sensitivity. For a reliable diagnosis of HALT, data sets from a multiphase CTA covering the entire cardiac cycle should be analysed. A double reader approach would be desirable in further studies investigating HALT.
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25
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Lüscher TF, Davies A, Beer JH, Valgimigli M, Nienaber CA, Camm JA, Baumgartner I, Diener HC, Konstantinides SV. Towards personalized antithrombotic management with drugs and devices across the cardiovascular spectrum. Eur Heart J 2022; 43:940-958. [PMID: 34624084 DOI: 10.1093/eurheartj/ehab642] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 05/06/2021] [Accepted: 09/01/2021] [Indexed: 01/10/2023] Open
Abstract
Intravascular thrombus formation and embolization are among the most frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. The underlying causes are stasis of the circulating blood, genetic and acquired coagulation disorders, and reduced antithrombotic or prothrombotic properties of the vascular wall (Virchow's triad). In the venous system, intravascular thrombi can cause venous thrombosis and pulmonary and even peripheral embolism including ischaemic stroke [through a patent foramen ovale (PFO)]. Thrombi in the left atrium and its appendage or ventricle form in the context of atrial fibrillation and infarction, respectively. Furthermore, thrombi can form on native or prosthetic aortic valves, within the aorta (in particular at sites of ulcers, aortic dissection, and abdominal aneurysms), and in cerebral and peripheral arteries causing stroke and critical limb ischaemia, respectively. Finally, thrombotic occlusion may occur in arteries supplying vital organs such the heart, brain, kidney, and extremities. Thrombus formation and embolization can be managed with anticoagulants and devices depending on where they form and embolize and on patient characteristics. Vitamin K antagonists are preferred in patients with mechanical valves, while novel oral anticoagulants are first choice in most other cardiovascular conditions, in particular venous thromboembolism and atrial fibrillation. As anticoagulants are associated with a risk of bleeding, devices such as occluders of a PFO or the left atrial appendage are preferred in patients with an increased bleeding risk. Platelet inhibitors such as aspirin and/or P2Y12 antagonists are preferred in the secondary prevention of coronary artery disease, stroke, and peripheral artery disease either alone or in combination depending on the clinical condition. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article.
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Affiliation(s)
- Thomas F Lüscher
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Allan Davies
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - Juerg H Beer
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Valgimigli
- CardioCentro, Lugano, Switzerland.,University of Bern, Bern, Switzerland
| | - Christoph A Nienaber
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - John A Camm
- St. Georges University and Imperial College, London, UK
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Duisburg-Essen, Germany
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26
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Kuneman JH, Singh GK, Hansson NC, Fusini L, Poulsen SH, Fortuni F, Vollema EM, Pedersen ALD, Annoni AD, Nørgaard BL, Pontone G, Ajmone Marsan N, Delgado V, Bax JJ, Knuuti J. Subclinical leaflet thrombosis after transcatheter aortic valve implantation: no association with left ventricular reverse remodeling at 1-year follow-up. Int J Cardiovasc Imaging 2022; 38:695-705. [PMID: 34655348 PMCID: PMC8926967 DOI: 10.1007/s10554-021-02438-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022]
Abstract
Hypo-attenuated leaflet thickening (HALT) of transcatheter aortic valves is detected on multidetector computed tomography (MDCT) and reflects leaflet thrombosis. Whether HALT affects left ventricular (LV) reverse remodeling, a favorable effect of LV afterload reduction after transcatheter aortic valve implantation (TAVI) is unknown. The aim of this study was to examine the association of HALT after TAVI with LV reverse remodeling. In this multicenter case-control study, patients with HALT on MDCT were identified, and patients without HALT were propensity matched for valve type and size, LV ejection fraction (LVEF), sex, age and time of scan. LV dimensions and function were assessed by transthoracic echocardiography before and 12 months after TAVI. Clinical outcomes (stroke or transient ischemic attack, heart failure hospitalization, new-onset atrial fibrillation, all-cause mortality) were recorded. 106 patients (age 81 ± 7 years, 55% male) with MDCT performed 37 days [IQR 32-52] after TAVI were analyzed (53 patients with HALT and 53 matched controls). Before TAVI, all echocardiographic parameters were similar between the groups. At 12 months follow-up, patients with and without HALT showed a significant reduction in LV end-diastolic volume, LV end-systolic volume and LV mass index (from 125 ± 37 to 105 ± 46 g/m2, p = 0.001 and from 127 ± 35 to 101 ± 27 g/m2, p < 0.001, respectively, p for interaction = 0.48). Moreover, LVEF improved significantly in both groups. In addition, clinical outcomes were not statistically different. Improvement in LVEF and LV reverse remodeling at 12 months after TAVI were not limited by HALT.
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Affiliation(s)
- Jurrien H Kuneman
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Gurpreet K Singh
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Nicolaj C Hansson
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Laura Fusini
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Steen H Poulsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Federico Fortuni
- Department of Cardiology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - E Mara Vollema
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | | | - Andrea D Annoni
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Gianluca Pontone
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Nina Ajmone Marsan
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
| | - Juhani Knuuti
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
- Turku PET Centre, University of Turku and Turku University Hospital, Turku, Finland
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27
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Garcia S, Fukui M, Dworak MW, Okeson BK, Garberich R, Hashimoto G, Sato H, Cavalcante JL, Bapat VN, Lesser J, Cheng V, Newell MC, Goessl M, Elmariah S, Bradley SM, Sorajja P. Clinical Impact of Hypoattenuating Leaflet Thickening After Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2022; 15:e011480. [PMID: 35236097 DOI: 10.1161/circinterventions.121.011480] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hypoattenuated leaflet thickening (HALT), identified on functional cardiac computed tomography (CTA), can affect valve function and clinical outcomes. The objective of this study was to assess the impact of HALT on clinical outcomes in patients treated with transcatheter aortic valve replacement (TAVR). METHODS In July 2015, Minneapolis Heart Institute implemented prospective screening of HALT at 30-day post-TAVR with CTA. Patients with evidence of HALT were recommended to initiate anticoagulation for 3 to 6 months with warfarin. Echocardiographic, ischemic, and bleeding outcomes were compared between HALT+ and HALT- patients. Survival rates were compared between HALT+ and HALT- patients using log-rank test, with Cox regression analysis used to identify variables independently associated with long-term death landmarked at time of CTA. This analysis included patients treated from July 1, 2015 to October 31, 2019. RESULTS Of 856 patients undergoing TAVR during the study period, 638 (75%) underwent CTA post-TAVR (median time 31 [30-37] days). HALT+ was evident in 79 (12.3%). HALT+ patients were more likely prescribed warfarin at 1, 3, and 12 months (all P<0.001) and had similar gradients compared with HALT- patients. After a median follow-up of 2.2 years (1.5-3.2), HALT+ patients had increased mortality (30% versus 20%; P=0.001). In Cox regression analysis, presence of HALT (hazard ratio, 1.83 [95% CI, 1.13-2.97]; P=0.014) remained independently associated with long-term mortality. CONCLUSIONS In a large, real-world cohort of patients receiving TAVR followed by systematic screening with CTA 30-days post-procedure, HALT was found in 12% of patients and independently associated with long-term mortality. Findings of this nonrandomized, observational cohort study require independent validation.
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Affiliation(s)
- Santiago Garcia
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - Miho Fukui
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - Marshall W Dworak
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - Brynn K Okeson
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - Ross Garberich
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - Go Hashimoto
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - Hirotomo Sato
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - João L Cavalcante
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - Vinayak N Bapat
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - John Lesser
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - Victor Cheng
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - Marc C Newell
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - Mario Goessl
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - Sammy Elmariah
- Massachusetts General Hospital and Harvard Medical School, Boston (S.E.)
| | - Steven M Bradley
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
| | - Paul Sorajja
- Minneapolis Heart Institute, Abbott Northwestern Hospital, MN (S.G., M.F., M.W.D., B.K.O., R.G., G.H., H.S., J.L.C., V.N.B., J.L., V.C., M.C.N., M.G., S.M.B., P.S.)
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Salah HM, Almaddah N, Xu J, Al-Hawwas M, Agarwal SK, Uretsky BF, Dhar G, Al Aref SJ. Gender Differences and Outcomes of Hypoattenuated Leaflet Thickening (HALT) Following Transcatheter Aortic Valve Replacement: A Meta-analysis of Randomized and Cohort Studies. Curr Probl Cardiol 2022; 48:101155. [DOI: 10.1016/j.cpcardiol.2022.101155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022]
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Bogyi M, Schernthaner RE, Loewe C, Gager GM, Dizdarevic AM, Kronberger C, Postula M, Legutko J, Velagapudi P, Hengstenberg C, Siller-Matula JM. Subclinical Leaflet Thrombosis After Transcatheter Aortic Valve Replacement: A Meta-Analysis. JACC Cardiovasc Interv 2021; 14:2643-2656. [PMID: 34949391 DOI: 10.1016/j.jcin.2021.09.019] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022]
Abstract
This meta-analysis and systematic review was performed to evaluate the clinical relevance of subclinical leaflet thrombosis (SLT) following transcatheter aortic valve replacement. PubMed, Web of Science, and CENTRAL were searched for eligible randomized and nonrandomized studies until November 2020. Risk ratios (RRs) or odds ratios and 95% CIs were calculated, using a random-effects model. Overall, 25 studies were eligible for the analysis and comprised a total of 11,098 patients. The median incidence of SLT was 6% at a median follow-up of 30 days. Use of intra-annular valves was associated with 2-fold greater risk for the development of SLT compared with use of supra-annular valves. There was no difference in the risk for SLT (RR: 0.97; 95% CI: 0.72-1.29; P = 0.83) between single-antiplatelet therapy (SAPT) and dual-antiplatelet therapy (DAPT), whereas oral anticoagulation (OAC) was associated with a 58% relative risk reduction for SLT (RR: 0.42; 95% CI: 0.29-0.61; P < 0.00001) compared with SAPT and DAPT. In patients with diagnosed leaflet thrombosis at follow-up, the risk for stroke or transient ischemic attack was increased by 2.6-fold (RR: 2.56; 95% CI: 1.60-4.09; P < 0.00001) compared with patients without leaflet thrombosis. In patients diagnosed with SLT, the odds of SLT resolution increased by 99% after switch from antiplatelet agents to OAC (odds ratio: 0.01; 95% CI: 0.00-0.06; P < 0.00001). To summarize, indication-based use of OAC after transcatheter aortic valve replacement is associated with a lower risk for SLT compared with SAPT and DAPT. Switching to OAC seems to be effective for SLT resolution. As SLT increased the odds of stroke or transient ischemic attack in the included population, further studies are needed to investigate whether screening tests for SLT and appropriate antithrombotic therapy improve long-term valve functionality and clinical prognosis.
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Affiliation(s)
- Matthias Bogyi
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Rüdiger E Schernthaner
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Gloria M Gager
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria; Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Al Medina Dizdarevic
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Christina Kronberger
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Marek Postula
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Center for Preclinical Research and Technology CEPT, Warsaw, Poland
| | - Jacek Legutko
- Jagiellonian University Medical College, Faculty of Medicine, Institute of Cardiology, Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
| | - Poonam Velagapudi
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Christian Hengstenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Jolanta M Siller-Matula
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria; Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Center for Preclinical Research and Technology CEPT, Warsaw, Poland.
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30
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Sellers SL, Gulsin GS, Zaminski D, Bing R, Latib A, Sathananthan J, Pibarot P, Bouchareb R. Platelets: Implications in Aortic Valve Stenosis and Bioprosthetic Valve Dysfunction From Pathophysiology to Clinical Care. JACC Basic Transl Sci 2021; 6:1007-1020. [PMID: 35024507 PMCID: PMC8733745 DOI: 10.1016/j.jacbts.2021.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 10/31/2022]
Abstract
Aortic stenosis (AS) is the most common heart valve disease requiring surgery in developed countries, with a rising global burden associated with aging populations. The predominant cause of AS is believed to be driven by calcific degeneration of the aortic valve and a growing body of evidence suggests that platelets play a major role in this disease pathophysiology. Furthermore, platelets are a player in bioprosthetic valve dysfunction caused by their role in leaflet thrombosis and thickening. This review presents the molecular function of platelets in the context of recent and rapidly evolving understanding the role of platelets in AS, both of the native aortic valve and bioprosthetic valves, where there remain concerns about the effects of subclinical leaflet thrombosis on long-term prosthesis durability. This review also presents the role of antiplatelet and anticoagulation therapies on modulating the impact of platelets on native and bioprosthetic aortic valves, highlighting the need for further studies to determine whether these therapies are protective and may increase the life span of surgical and transcatheter aortic valve implants. By linking molecular mechanisms through which platelets drive disease of native and bioprosthetic aortic valves with studies evaluating the clinical impact of antiplatelet and antithrombotic therapies, we aim to bridge the gaps between our basic science understanding of platelet biology and their role in patients with AS and ensuing preventive and therapeutic implications.
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Key Words
- AS, aortic stenosis
- AV, aortic valve
- AVR, aortic valve replacements
- COX, cyclooxygenase
- ECM, extracellular matrix protein
- HALT, hypoattenuating leaflet thickening
- HMW, high molecular weight
- MK, megakaryocyte
- SAVR, surgical aortic valve replacement
- TAVR
- TAVR, transcatheter aortic valve replacements
- TGF, transforming growth factor
- VEC, vascular endothelial cell
- VHD, valvular heart disease
- VIC, valve interstitial cell
- WSS, wall shear stress
- aortic stenosis
- calcified aortic valves
- platelets
- thrombosis
- vWF, Von Willebrand factor
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Affiliation(s)
- Stephanie L. Sellers
- Department of Radiology, St Paul’s Hospital and University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation and Cardiovascular Translational Laboratory, St Paul’s Hospital and University of British Columbia, Vancouver, British Columbia, Canada
- Division of Cardiology and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gaurav S. Gulsin
- Department of Radiology, St Paul’s Hospital and University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Heart Lung Innovation and Cardiovascular Translational Laboratory, St Paul’s Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Devyn Zaminski
- Cardiovascular Research Institute, Department of Medicine, and Graduate School of Biological Sciences, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rong Bing
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Azeem Latib
- Department of Cardiology, Montefiore Medical Center, Bronx, New York, USA
| | - Janarthanan Sathananthan
- Centre for Heart Lung Innovation and Cardiovascular Translational Laboratory, St Paul’s Hospital and University of British Columbia, Vancouver, British Columbia, Canada
- Division of Cardiology and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Philippe Pibarot
- Institut de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Rihab Bouchareb
- Cardiovascular Research Institute, Department of Medicine, and Graduate School of Biological Sciences, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Raghav V, Midha P, Sharma R, Babaliaros V, Yoganathan A. Transcatheter aortic valve thrombosis: a review of potential mechanisms. J R Soc Interface 2021; 18:20210599. [PMID: 34814733 DOI: 10.1098/rsif.2021.0599] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Transcatheter aortic valve (TAV) thrombosis has been recognized as a significant problem that sometimes occurs as early as within 30 days after valve implantation, leading to increased concerns of stroke and long-term valve durability. In this article, a critical summary of the relevant literature on identifying potential mechanisms of TAV thrombosis from the perspective of the well-known Virchow's triad, which comprises blood flow, foreign materials and blood biochemistry, is presented. Blood flow mechanisms have been the primary focus thus far, with a general consensus on the flow mechanisms with respect to haemodynamic conditions, the influence of TAV placement and expansion and the influence of coronary flow. Less attention has been paid to the influence of blood biochemistry and foreign materials (and related endothelial damage), with little consensus among studies with regards to platelet and/or microparticle levels post-TAV implantation. Finally, we discuss the future outlook for research with unanswered scientific questions.
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Affiliation(s)
- Vrishank Raghav
- Department of Aerospace Engineering, Auburn University, Auburn, AL, USA
| | - Prem Midha
- Abbott Laboratories, Abbott Park, IL, USA
| | - Rahul Sharma
- Interventional Cardiology, Cardiovascular Medicine Faculty, Stanford University, Stanford, CA, USA
| | - Vasilis Babaliaros
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University, Atlanta, GA, USA
| | - Ajit Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology & Emory University, Atlanta, GA, USA
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Transcatheter Aortic Valve Leaflet Thrombosis: Prevalence, Management, and Future Directions. Curr Cardiol Rep 2021; 23:186. [PMID: 34762219 DOI: 10.1007/s11886-021-01614-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW We review the pathology, prevalence, diagnosis, hemodynamics, risk factors, prognosis, and treatment of leaflet thrombosis (LT), and suggest future directions in this field. RECENT FINDINGS The latest meta-analysis showed the prevalence of overall LT is 5.4% (clinical LT of 1.2% and subclinical LT of 15.1%). Either subclinical or clinical LT is not associated with risk of mortality; however, clinical LT is associated with increased risk of stroke. Although LT can be reduced by oral anticoagulation therapy (OAT), routine use of OAT as primary prevention for high-risk patients is not recommended due to increased risk of mortality. Four-dimensional computed tomography plays an important role in the diagnosis of LT and the accumulation of qualitative or qualitative assessments of hypoattenuated leaflet thickening would provide more clues to clarify effective OAT strategies. In addition, further studies are warranted to evaluate the efficacy of other anticoagulants in low-intermediate risk patients.
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Thrombose et TAVI : beaucoup de questions restent sans réponses. Ann Cardiol Angeiol (Paris) 2021; 70:395-400. [PMID: 34740396 DOI: 10.1016/j.ancard.2021.10.004] [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: 09/13/2021] [Accepted: 10/02/2021] [Indexed: 11/20/2022]
Abstract
Over the past decade, TAVI has become the standard technique for treatment of severe symptomatic aortic stenosis in patients at high or intermediate surgical risk and more recently in low-surgical-risk patients. Like any technique, TAVI is associated with certain complications such as post-TAVI thrombosis. This complication can have clinical manifestations with recurrence of symptoms and/or increase in trans-prosthetic gradients. It can also be infraclinical, i.e asymptomatic without trans-prosthetic gradient elevation as revealed by cardiac CT scan showing a thickening of the valvular leaflets or cusp thrombosis, with potential impairment of the valve opening. This greatly underestimated complication has a 10% to 15% incidence. Biomechanical factors, intrinsic patient-related predisposition as well as post-TAVI anti-thrombotic treatment have all been incriminated in the occurrence of TAVI thrombosis. The use of anticoagulation treatment by AVK or DOAC in the presence of post TAVI prosthetic thrombosis seems obvious. However, their benefit in the treatment of infraclinical thrombosis has not been clearly established.
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Woldendorp K, Doyle MP, Black D, Ng M, Keech A, Grieve SM, Bannon PG. Subclinical valve thrombosis in transcatheter aortic valve implantation: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2021; 162:1491-1499.e2. [DOI: 10.1016/j.jtcvs.2020.01.084] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 12/21/2019] [Accepted: 01/16/2020] [Indexed: 11/27/2022]
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Mouyen T, Manigold T, Collet JP, Durand E, Barbey C, Lhermusier T, Tchetche D, Chollet T, Mulliez A, Motreff P, Combaret N, Souteyrand G. Transcatheter aortic valve thrombosis: Data from a French multicenter cohort analysis. Catheter Cardiovasc Interv 2021; 98:352-362. [PMID: 33615701 DOI: 10.1002/ccd.29555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 02/02/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To evaluate the effectiveness of anticoagulant therapies in patients with clinical transcatheter heart valve (THV) thrombosis, to describe complications, and to assess their risk profile was the objectives. BACKGROUND Little research has been conducted on clinical THV thrombosis. METHODS Patients with clinical THV thrombosis were identified based on greater than 50% increased transvalvular gradient on transthoracic echocardiogram confirmed by 4-dimensional computed tomography, transesophageal echocardiogram, or regression with anticoagulant therapy. A cohort free from thrombosis for more than 1,100 days postprocedure was used for comparison. RESULTS Fifty-four patients with clinical THV thrombosis were identified. Most subjects (98.1%) received anticoagulant therapy which was effective (≥50% reduction in transvalvular gradient or return to postprocedure value) in 96%. The rate of serious hemodynamic or embolic complications in the thrombosis population was 31.5%. A multivariate analysis of subjects with and without thrombosis indicated a significantly increased risk of thrombosis from preexisting thrombocytopenia (odds ratio [OR] 9.96), absence of predilatation (OR = 5.67), renal insufficiency (OR = 4.84), and >10 mmHg mean transvalvular gradient postprocedure (OR = 3.36). No recurrence of thrombosis was identified during on average 685 days follow-up. CONCLUSIONS These data, from one of the largest cohorts with clinical THV thrombosis confirm anticoagulants appear effective. The rate of serious associated complications was high. The findings underline the importance of recognizing risk factors for thrombosis.
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Affiliation(s)
- Thomas Mouyen
- Department of Cardiology, CHU Clermont-Ferrand, CNRS UMR 6602, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Thibaut Manigold
- CHU Guillaume et René Laennec, Institut du Thorax, Service de Cardiologie, Nantes, France
| | | | - Eric Durand
- CHU Rouen-Charles-Nicolle, Service de Cardiologie, Rouen, France
| | | | - Thibault Lhermusier
- CHU de Toulouse, Département de Cardiologie, Inserm U1048, Université de Toulouse 3, Toulouse, France
| | - Didier Tchetche
- Clinique Pasteur, Groupe Cardiovasculaire Interventionnel, Toulouse, France
| | - Thomas Chollet
- Clinique Pasteur, Groupe Cardiovasculaire Interventionnel, Toulouse, France
| | - Aurélien Mulliez
- Direction de la Recherche Clinique et de l'Innovation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Pascal Motreff
- Department of Cardiology, CHU Clermont-Ferrand, CNRS UMR 6602, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Nicolas Combaret
- Department of Cardiology, CHU Clermont-Ferrand, CNRS UMR 6602, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Géraud Souteyrand
- Department of Cardiology, CHU Clermont-Ferrand, CNRS UMR 6602, Université Clermont Auvergne, Clermont-Ferrand, France
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36
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Wunderlich NC, Honold J, Swaans MJ, Siegel RJ. How to Image and Manage Prosthesis-Related Complications After Transcatheter Aortic Valve Replacement. Curr Cardiol Rep 2021; 23:94. [PMID: 34196775 DOI: 10.1007/s11886-021-01522-2] [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] [Accepted: 05/14/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW In this review, we provide an overview of potential prosthesis - related complications after transcatheter aortic valve replacement, their incidences, the imaging modalities best suited for detection, and possible strategies to manage these complications. RECENT FINDINGS Therapy for severe aortic valve stenosis requiring intervention has increasingly evolved toward transcatheter aortic valve replacement over the past decade, and the number of procedures performed has increased steadily in recent years. As more and more centers favor a minimalistic approach and largely dispense with general anesthesia and intra-procedural imaging by transesophageal echocardiography, post-procedural imaging is becoming increasingly important to promptly detect dysfunction of the transcatheter valve and potential complications. Complications after transcatheter aortic valve replacement must be detected immediately in order to initiate adequate therapeutic measures, which require a profound knowledge of possible complications that may occur after transcatheter aortic valve replacement, the imaging modalities best suited for detection, and available treatment options.
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Affiliation(s)
| | - Jörg Honold
- Cardiovascular Center Darmstadt, Darmstadt, Germany
| | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Robert J Siegel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Patterson T, Hurrell H, Lee J, Esposito G, Dutta U, Grapsa J, Aroney N, Ahmed-Jushuf F, Allen C, Rajani R, Preston R, Young C, Lucchese G, Parmar K, Hunt B, Prendergast BD, Redwood SR. Coagulation derangement and risk factors for valve thrombosis following transcatheter aortic valve implantation. Open Heart 2021; 8:openhrt-2020-001496. [PMID: 34127530 PMCID: PMC8204180 DOI: 10.1136/openhrt-2020-001496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/01/2021] [Accepted: 04/12/2021] [Indexed: 11/03/2022] Open
Abstract
Aims Durability of transcatheter aortic valve implantation (TAVI) is key to its expansion. We sought to identify incidence of valve thrombosis and predictors of valve thrombosis in our single centre with associated coagulation testing pre-TAVI and post-TAVI. Methods and results This single-centre observational study comprised patients undergoing transfemoral TAVI discussed in the Heart Team meeting. Patients were followed up with echocardiography at 120 days to identify incidence of elevated transvalvular gradient and multivariable analysis was performed to identify factors associated with an increased odds of developing valve thrombosis. In addition, 11 patients underwent baseline, day 1 and day 120 post-TAVI coagulation testing. Between August 2017 and August 2019, 437 consecutive patients underwent transfemoral TAVI. Of these patients, 207/437 (47.4%) had 3-month follow-up echo data available and were analysed. Of these patients, 26/207 (12.6%) had elevated transvalvular gradients. These patients tended to be younger (80±14 vs 83±6 years; p=0.047) with a lower ejection fraction (49±13 vs 54%±11%; p=0.021), with a greater proportion of the population experiencing atrial fibrillation (14/21, 54% vs 68/181, 38%; p=0.067). Following multivariable analysis, there remained a trend towards higher eccentricity index associated with elevated gradients. Baseline (pre-TAVI) elevation of thrombin antithrombin levels (56±63; reference range 1.0–4.1 ng/L) and PF 1+2 (791±632; reference range 69–229 ng/mL) normalised at 120 days post-TAVI Conclusion This study demonstrated that in the cohort of patients undergoing transfemoral TAVI in our centre: younger age, poor ejection fraction, atrial fibrillation and increased baseline eccentricity of the aortic valve annulus were present to a greater extent in patients exhibiting elevated transvalvular gradients at 3-month follow-up. Further work is required to delineate the extent of coagulation derangement and confirm predictors of thrombosis.
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Affiliation(s)
- Tiffany Patterson
- Cardiovascular Division, School of Life Science and Medicine, King's College London, London, UK
| | - Harriet Hurrell
- Cardiovascular Division, School of Life Science and Medicine, King's College London, London, UK
| | - Jack Lee
- Division of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Giulia Esposito
- Cardiovascular Division, School of Life Science and Medicine, King's College London, London, UK
| | - Utkarsh Dutta
- Cardiovascular Division, School of Life Science and Medicine, King's College London, London, UK
| | - Julia Grapsa
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas Aroney
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fiyyaz Ahmed-Jushuf
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher Allen
- Cardiovascular Division, School of Life Science and Medicine, King's College London, London, UK
| | - Ronak Rajani
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rebecca Preston
- Department of Radiology and Cardiac CT, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher Young
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gianluca Lucchese
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kiran Parmar
- Department of Haematology and Thrombosis, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Beverley Hunt
- Department of Haematology and Thrombosis, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Simon R Redwood
- Cardiovascular Division, School of Life Science and Medicine, King's College London, London, UK
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Aortic valve function post-replacement of severe aortic stenosis by transcatheter procedure versus surgery: a systematic review and metanalysis. Sci Rep 2021; 11:11975. [PMID: 34099815 PMCID: PMC8184892 DOI: 10.1038/s41598-021-91548-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 05/20/2021] [Indexed: 11/08/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has shown to reduce mortality compared to surgical aortic valve replacement (sAVR). However, it is unknown which procedure is associated with better post-procedural valvular function. We conducted a meta-analysis of randomized clinical trials that compared TAVR to sAVR for at least 2 years. The primary outcome was post-procedural patient-prosthesis-mismatch (PPM). Secondary outcomes were post-procedural and 2-year: effective orifice area (EOA), paravalvular gradient (PVG) and moderate/severe paravalvular leak (PVL). We identified 6 trials with a total of 7022 participants with severe aortic stenosis. TAVR was associated with 37% (95% CI [0.51–0.78) mean RR reduction of post-procedural PPM, a decrease that was not affected by the surgical risk at inclusion, neither by the transcatheter heart valve system. Postprocedural changes in gradient and EOA were also in favor of TAVR as there was a pooled mean difference decrease of 0.56 (95% CI [0.73–0.38]) in gradient and an increase of 0.47 (95% CI [0.38–0.56]) in EOA. Additionally, self-expandable valves were associated with a higher decrease in gradient than balloon ones (beta = 0.38; 95% CI [0.12–0.64]). However, TAVR was associated with a higher risk of moderate/severe PVL (pooled RR: 9.54, 95% CI [5.53–16.46]). All results were sustainable at 2 years.
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39
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Ascione G, Denti P. Transcatheter Mitral Valve Replacement and Thrombosis: A Review. Front Cardiovasc Med 2021; 8:621258. [PMID: 34150861 PMCID: PMC8212998 DOI: 10.3389/fcvm.2021.621258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 04/12/2021] [Indexed: 11/25/2022] Open
Abstract
Mitral regurgitation is the most prevalent form of moderate or severe valve disease in developed countries. Surgery represents the standard of care for symptomatic patients with severe mitral regurgitation, but up to 50% of patients are denied surgery because of high surgical risk. In this context, different transcatheter options have been developed to address this unmet need. Transcatheter mitral valve replacement (TMVR) is an emergent field representing an alternative option in high complex contexts when transcatheter mitral valve repair is not feasible or suboptimal due to anatomical issues. However, TMVR is burdened by some device-specific issues (device malposition, migration or embolization, left ventricular outflow tract obstruction, hemolysis, thrombosis, stroke). Here we discuss the thrombotic risk of TMVR and current evidence about anticoagulation therapy after TMVR.
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Affiliation(s)
- Guido Ascione
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Paolo Denti
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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40
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Shahim B, Malaisrie SC, George I, Thourani VH, Biviano AB, Russo MJ, Brown DL, Babaliaros V, Guyton RA, Kodali SK, Nazif TM, McCabe JM, Williams MR, Généreux P, Lu M, Yu X, Alu MC, Webb JG, Mack MJ, Leon MB, Kosmidou I. Atrial Fibrillation and Outcomes After Transcatheter or Surgical Aortic Valve Replacement (from the PARTNER 3 Trial). Am J Cardiol 2021; 148:116-123. [PMID: 33691183 DOI: 10.1016/j.amjcard.2021.02.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/10/2021] [Accepted: 02/19/2021] [Indexed: 11/30/2022]
Abstract
The prognostic impact of preexisting atrial fibrillation or flutter (AF) in low-risk patients with severe aortic stenosis treated with transcatheter (TAVR) or surgical aortic valve replacement (SAVR) remains unknown. In this sub-analysis of the PARTNER 3 trial of patients with severe aortic stenosis at low surgical risk randomized 1:1 to TAVR versus SAVR, clinical outcomes were analyzed at 2 years according to AF status. Among 948 patients included in the analysis (452 [47.7%] in the SAVR vs 496 [52.3%] in the TAVR arm), 168 (17.6%) patients had AF [88/452 (19.5%) and 80/496 (16.1%) treated with SAVR and TAVR, respectively]. At 2 years, patients with AF had higher unadjusted rates of the composite outcome of death, stroke or rehospitalization (21.2% vs 12.9%, p = 0.007) and rehospitalization alone (15.3% vs 9.4%, p = 0.03) but not all cause death (3.8% vs 2.6%, p = 0.45) or stroke (4.8% vs 2.6%, p = 0.12). In adjusted analyses, patients with AF had a higher risk for the composite outcome of death, stroke or rehospitalization (hazard ratio [HR] 1.80, 95% confidence interval [CI] 1.20-2.71, p = 0.0046) and rehospitalization alone (HR 1.8, 95% CI 0.12-2.9, p = 0.015), but not death or stroke. There was no interaction between treatment modality and AF on the composite outcome (Pinter = 0.83). In conclusion, preexisting AF in patients with severe AS at low surgical risk was associated with increased risk of the composite outcome of death, stroke or rehospitalization at 2 years, irrespective of treatment modality.
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Affiliation(s)
- Bahira Shahim
- Cardiovascular Research Foundation, New York, New York
| | - S Chris Malaisrie
- Division of Cardiac Surgery, Northwestern University, Chicago, Illinois
| | - Isaac George
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Vinod H Thourani
- Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, Georgia
| | - Angelo B Biviano
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Mark J Russo
- Division of Cardiac Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | | | | | - Susheel K Kodali
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Tamim M Nazif
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | | | | | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
| | - Michael Lu
- Edwards Lifesciences, Irvine, California
| | - Xiao Yu
- Edwards Lifesciences, Irvine, California
| | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York; NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - John G Webb
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | | | - Martin B Leon
- Cardiovascular Research Foundation, New York, New York; NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Ioanna Kosmidou
- Cardiovascular Research Foundation, New York, New York; NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York.
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41
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Percutaneous versus Surgical Intervention for Severe Aortic Valve Stenosis: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3973924. [PMID: 34136565 PMCID: PMC8175165 DOI: 10.1155/2021/3973924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/04/2021] [Accepted: 05/14/2021] [Indexed: 11/18/2022]
Abstract
Aortic stenosis is a disease that is increasing in prevalence and manifests as decreased cardiac output, which if left untreated can result in heart failure and ultimately death. It is primarily a disease of the elderly who often have multiple comorbidities. The advent of transcatheter aortic valve therapies has changed the way we treat these conditions. However, long-term results of these therapies remain uncertain. Recently, there has been an increasing number of studies examining the role of both surgical aortic valve replacement and transcatheter aortic valve replacement. We therefore performed a systematic review using Ovid MEDLINE, Ovid Embase, and the Cochrane Library. Two investigators searched papers published between January 1, 2007, and to date using the following terms: "aortic valve stenosis," "aortic valve operation," and "transcatheter aortic valve therapy." Both strategies in aortic stenosis treatment highlighted specific indications alongside the pitfalls such as structural valve degeneration and valve thrombosis which have a bearing on clinical outcomes. We propose some recommendations to help clinicians in the decision-making process as technological improvements make both surgical and transcatheter therapies viable options for patients with aortic stenosis. Finally, we assess the role of finite element analysis in patient selection for aortic valve replacement. THVT and AVR-S are both useful tools in the armamentarium against aortic stenosis. The decision between the two treatment strategies should be best guided by a strong robust evidence base, ideally with a long-term follow-up. This is best performed by the heart team with the patient as the center of the discussion.
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42
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Ng ACT, Holmes DR, Mack MJ, Delgado V, Makkar R, Blanke P, Leipsic JA, Leon MB, Bax JJ. Leaflet immobility and thrombosis in transcatheter aortic valve replacement. Eur Heart J 2021; 41:3184-3197. [PMID: 32930773 PMCID: PMC9186299 DOI: 10.1093/eurheartj/ehaa542] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/17/2020] [Accepted: 07/01/2020] [Indexed: 12/13/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has grown exponentially worldwide in the last decade. Due to the higher bleeding risks associated with oral anticoagulation and in patients undergoing TAVR, antiplatelet therapy is currently considered first-line antithrombotic treatment after TAVR. Recent studies suggest that some patients can develop subclinical transcatheter heart valve (THV) thrombosis after the procedure, whereby thrombus forms on the leaflets that can be a precursor to leaflet dysfunction. Compared with echocardiography, multidetector computed tomography is more sensitive at detecting THV thrombosis. Transcatheter heart valve thrombosis can occur while on dual antiplatelet therapy with aspirin and thienopyridine but significantly less with anticoagulation. This review summarizes the incidence and diagnostic criteria for THV thrombosis and discusses the pathophysiological mechanisms that may lead to thrombus formation, its natural history, potential clinical implications and treatment for these patients. ![]()
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Affiliation(s)
- Arnold C T Ng
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Australia
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Raj Makkar
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Philipp Blanke
- Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathon A Leipsic
- Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Martin B Leon
- Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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43
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Kikoïne J, Urena M, Chong Nguyen C, Fischer Q, Carrasco J, Brochet E, Ducrocq G, Vahanian A, Iung B, Himbert D. Predictors and clinical impact of thrombosis after transcatheter mitral valve implantation using balloon-expandable bioprostheses. EUROINTERVENTION 2021; 16:1455-1462. [PMID: 33226001 PMCID: PMC9724835 DOI: 10.4244/eij-d-20-00991] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to report the predictors and clinical impact of transcatheter heart valve (THV) thrombosis in patients undergoing transcatheter mitral valve implantation (TMVI). METHODS AND RESULTS We included 130 patients who consecutively underwent TMVI. Transoesophageal echocardiography (TOE) and/or computed tomography (CT) were performed in 91.7% of patients at discharge, in 73.3% at three months and in 72% beyond three months. THV thrombosis was defined as the presence of at least one thickened leaflet with restricted motion confirmed by TOE or contrast CT and classified as immediate, early, or late according to the timing of diagnosis. THV thrombosis was observed in 16 (12.3%) patients: immediate in 43.7%, early in 37.5% and late in 18.8%. Most of these thromboses were subclinical (93.7%) and non-obstructive (87.5%). No thromboembolic event occurred. After optimisation of antithrombotic treatment, THV thromboses resolved in all but one patient. Predictors were shock for immediate (p<0.001), male sex for early (p=0.045) and absence of anticoagulation for both early (p=0.018) and late (p=0.023) THV thromboses. CONCLUSIONS THV thrombosis is frequent after TMVI, occurs mainly within the first three months, is mostly subclinical and resolves after optimisation of antithrombotic treatment. An anticoagulation therapy for at least three months after the procedure is mandatory.
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Affiliation(s)
- John Kikoïne
- Department of Cardiology, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Marina Urena
- Department of Cardiology, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France,University of Paris, Paris, France,INSERM U1148, Paris, France
| | - Caroline Chong Nguyen
- Department of Cardiology, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Quentin Fischer
- Department of Cardiology, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jose Carrasco
- Department of Anesthesiology, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Eric Brochet
- Department of Cardiology, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Gregory Ducrocq
- Department of Cardiology, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France,University of Paris, Paris, France,INSERM U1148, Paris, France
| | | | - Bernard Iung
- Department of Cardiology, Bichat Claude Bernard Hospital, Assistance Publique Hôpitaux de Paris, Paris, France,University of Paris, Paris, France,INSERM U1148, Paris, France
| | - Dominique Himbert
- Department of Cardiology, CHU Bichat Claude Bernard, APHP, 46 rue Henri Huchard, 75018 Paris, France
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44
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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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45
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Rheude T, Pellegrini C, Stortecky S, Marwan M, Xhepa E, Ammon F, Pilgrim T, Mayr NP, Husser O, Achenbach S, Windecker S, Cassese S, Joner M. Meta-Analysis of Bioprosthetic Valve Thrombosis After Transcatheter Aortic Valve Implantation. Am J Cardiol 2021; 138:92-99. [PMID: 33065085 DOI: 10.1016/j.amjcard.2020.10.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 09/26/2020] [Accepted: 10/05/2020] [Indexed: 12/22/2022]
Abstract
Bioprosthetic valve thrombosis may complicate transcatheter aortic valve implantation (TAVI). This meta-analysis sought to evaluate the prevalence and clinical impact of subclinical leaflet thrombosis (SLT) and clinical valve thrombosis (CVT) after TAVI. We summarized diagnostic strategies, prevalence of SLT and/or CVT and estimated their impact on the risk of all-cause death and stroke. Twenty studies with 12,128 patients were included. The prevalence of SLT and CVT was 15.1% and 1.2%, respectively. The risk of all-cause death was not significantly different between patients with SLT (relative risk [RR] 0.77; p = 0.22) and CVT (RR 1.29; p = 0.68) compared with patients without. The risk of stroke was higher in patients with CVT (RR 7.51; p <0.001) as compared with patients without, while patients with SLT showed no significant increase in the risk of stroke (RR 1.81; p = 0.17). Reduced left ventricular function was associated with increased prevalence, while oral anticoagulation was associated with reduced prevalence of bioprosthetic valve thrombosis. Bioprosthetic valve thrombosis is frequent after TAVI, but does not increase the risk of death. Clinical valve thrombosis is associated with a significantly increased risk of stroke. Future studies should focus on prevention and treatment of bioprosthetic valve thrombosis.
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Affiliation(s)
- Tobias Rheude
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Costanza Pellegrini
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Stefan Stortecky
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mohamed Marwan
- Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Erion Xhepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Fabian Ammon
- Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - N Patrick Mayr
- Institut für Anästhesiologie, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Oliver Husser
- Klinik für Innere Medizin I, Kardiologie, St. Johannes-Hospital Dortmund, Dortmund, Germany
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Salvatore Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michael Joner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Munich, Germany.
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46
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Faroux L, Alperi A, Muntané-Carol G, Rodes-Cabau J. Safety and efficacy of repeat transcatheter aortic valve replacement for the treatment of transcatheter prosthesis dysfunction. Expert Rev Med Devices 2020; 17:1303-1310. [PMID: 33196328 DOI: 10.1080/17434440.2020.1848540] [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: 12/14/2022]
Abstract
Introduction: Transcatheter aortic valve replacement (TAVR) has recently expanded toward the treatment of younger patients with lower surgical risk and longer life expectancy. Thus, transcatheter heart valve (THV) durability has become a central issue, and an important increase in the number of TAVR-in-TAVR is expected in the coming years. Areas covered: Overview of the current status of TAVR-in-TAVR for the treatment of THV dysfunction, focusing on safety and efficacy of repeat TAVR procedures. Expert opinion: An accurate analysis of the pre-procedure cardiac computed tomography, incorporating new parameters such as the position of the top of the first THV in relation to the sinotubular-junction, will be necessary to assess the risk of coronary occlusion. Subsequent coronary angiography will be necessary in a proportion of TAVR-in-TAVR patients, but coronary access may be very difficult or even impossible in some of them. Therefore, the choice between TAVR and SAVR in young low-risk patients should incorporate the potential need for treating coronary events at mid- to long-term follow-up. Likewise, the choice of the valve type and the implantation position at the time of the first TAVR procedure should take into account the possibility of TAVR-in-TAVR in the future.Abbreviations ACS: acute coronary syndrome; CO: coronary obstruction; EOA: effective orifice area; SAVR: surgical aortic valve replacement; SVD: structural valve degenerationTAVR: transcatheter aortic valve replacement; THV: transcatheter heart valve.
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Affiliation(s)
- Laurent Faroux
- Cardiology Department, Quebec Heart and Lung Institute, Laval University , Quebec City, Quebec, Canada
| | - Alberto Alperi
- Cardiology Department, Quebec Heart and Lung Institute, Laval University , Quebec City, Quebec, Canada
| | - Guillem Muntané-Carol
- Cardiology Department, Quebec Heart and Lung Institute, Laval University , Quebec City, Quebec, Canada
| | - Josep Rodes-Cabau
- Cardiology Department, Quebec Heart and Lung Institute, Laval University , Quebec City, Quebec, Canada
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47
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Karády J, Apor A, Nagy AI, Kolossváry M, Bartykowszki A, Szilveszter B, Simon J, Molnár L, Jermendy ÁL, Panajotu A, Suhai FI, Varga A, Rajani R, Maurovich-Horvat P, Merkely B. Quantification of hypo-attenuated leaflet thickening after transcatheter aortic valve implantation: clinical relevance of hypo-attenuated leaflet thickening volume. Eur Heart J Cardiovasc Imaging 2020; 21:1395-1404. [PMID: 32756984 DOI: 10.1093/ehjci/jeaa184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/13/2020] [Accepted: 06/03/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Our aim was to establish an objective, quantitative methodology for volumetric hypo-attenuated leaflet thickening (HALT) diagnosis and evaluate its clinical significance. METHODS AND RESULTS We prospectively enrolled 144 patients who underwent transcatheter aortic valve implantation (TAVI) between 2011 and 2016. At inclusion, cardiac computed tomography angiography (CTA), transthoracic echocardiography, and brain magnetic resonance imaging (MRI) were performed. We quantified HALT on CTA datasets by segmenting the inner volume of TAVI frame at the level of leaflets and extracted voxels between a threshold of -200 to 200 HU based on prior recommendation. The median HALT volume was 72 [inter-quartile range (IQR): 1-154] mm3 (intra- and inter-reader agreement: intra-class correlation coefficient = 0.92 and 0.94, respectively) and 79% (n = 87/111) of the patients had HALT >0 mm3. In multivariate linear regression, oral anti-coagulation (β: -0.32; 95% CI: -0.62 to -0.01; P = 0.004) and history of myocardial infarction (β: 0.32; 95% CI: 0.01-0.63; P = 0.043) were associated with HALT quantity. Log-transformed HALT volume was associated with elevated (>13 mmHg) aortic mean gradient (AMG, OR: 12.85; 95% CI: 1.96-152.93; P = 0.021) and moderate-to-severe valvular degeneration (AMG ≥ 20 mmHg or ΔAMG ≥ 10 mmHg; OR: 10.56; 95% CI: 1.44-148.71; P = 0.046) but did not predict ischaemic brain lesions on MRI or all-cause death after a median follow-up of 29 (IQR: 11-29) months (all P > 0.05). CONCLUSION Through systematic analysis of asymptomatic patients with TAVI, an objective and reproducible methodology was feasible for volumetric measurement of HALT. Anti-coagulation might have a protective effect against HALT. Ischaemic brain lesions and all-cause death were not associated with HALT; nevertheless, it might deteriorate prosthesis function due to its association with elevated AMG. CLINICAL TRIAL REGISTRATION http//:www.ClinicalTrials.gov; NCT02826200.
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Affiliation(s)
- Júlia Karády
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary.,Cardiovascular Imaging Research Center, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
| | - Astrid Apor
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Anikó I Nagy
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary.,Department of Medicine, Karolinska Institutet, 1 Solnavägen, Solna 171 77, Stockholm, Sweden
| | - Márton Kolossváry
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Andrea Bartykowszki
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Bálint Szilveszter
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Judit Simon
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Levente Molnár
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Ádám L Jermendy
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Alexisz Panajotu
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Ferenc I Suhai
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Andrea Varga
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
| | - Ronak Rajani
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary.,Department of Radiology, Medical Imaging Centre, Semmelweis University, 78 Ulloi St, Budapest 1082, Hungary
| | - Béla Merkely
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, 68 Varosmajor St, Budapest 1122, Hungary
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48
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Predictors and Biomarkers of Subclinical Leaflet Thrombosis after Transcatheter Aortic Valve Implantation. J Clin Med 2020; 9:jcm9113742. [PMID: 33233321 PMCID: PMC7700436 DOI: 10.3390/jcm9113742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/12/2020] [Accepted: 11/18/2020] [Indexed: 01/03/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is a recent revolutionary treatment for high-risk patients with severe aortic stenosis who are not suitable for surgery, expanding to intermediate and low-risk patients. Valve leaflet thrombosis (LT) is a potentially fatal complication after TAVI. The incidence of subclinical LT is as high as 25% among patients in the first year after TAVI. Subclinical LT may evolve into symptomatic thrombosis or lead to premature bioprosthesis degeneration, increasing the risk of neurological complications. Because imaging-based methods have limited sensitivity to detect subclinical LT, there is an urgent need for predictors and biomarkers that would make it possible to predict LT after TAVI. Here, we summarize recent data regarding (i) patient-related, (ii) procedure-related, (iii) blood-based and (iv) imaging predictors and biomarkers which might be useful for the early diagnosis of subclinical LT after TAVI. Prevention of LT might offer an opportunity to improve risk stratification and tailor therapy after TAVI.
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49
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In-Vitro Assessment of the Effects of Transcatheter Aortic Valve Leaflet Design on Neo-Sinus Geometry and Flow. Ann Biomed Eng 2020; 49:1046-1057. [PMID: 33098058 DOI: 10.1007/s10439-020-02664-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/16/2020] [Indexed: 10/23/2022]
Abstract
Transcatheter aortic valve (TAV) leaflet thrombosis is a clinical risk with potentially fatal consequences. Studies have identified neo-sinus flow stasis as a cause of leaflet thrombosis. Flow stasis is influenced by the TAV leaflets, which affect the local fluid dynamics in the aortic sinus and neo-sinus. This study evaluated the effects of TAV leaflet features on the neo-sinus flow as a measure of leaflet thrombosis risk. Five TAVs of varied leaflet length and insertion height were tested in a simulator. Hydrodynamics and leaflet kinematics through en-phase imaging were quantified. Velocity fields were assessed using high-speed particle image velocimetry. Regions of flow stasis and particle residence times (PRTs) were quantified. TAVs with shorter leaflet length exhibited larger orifice areas and lower transvalvular pressure gradients. Shorter leaflet length and increased leaflet insertion TAVs additionally exhibited lower neo-sinus PRTs (0.44 ± 0.21 vs 2.83 ± 0.48 cycles, p < 0.05) and higher neo-sinus peak velocities (0.15 ± 0.009 vs 0.07 ± 0.005 m/s, p < 0.05) than TAVs with longer leaflet length and lower leaflet insertion. The average neo-sinus volume positively correlated with PRT(r = 0.810, p < 0.001), and extent of flow stasis (r = 0.682, p < 0.05). These results suggest that a small neo-sinus volume may reduce flow stagnation and particle residence, potentially reducing the risk of leaflet thrombosis. We propose that leaflet design features might be proactively controlled in the design of future transcatheter aortic valves.
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Szilveszter B, Oren D, Molnár L, Apor A, Nagy AI, Molnár A, Vattay B, Kolossváry M, Karády J, Bartykowszki A, Jermendy ÁL, Suhai FI, Panajotu A, Maurovich-Horvat P, Merkely B. Subclinical leaflet thrombosis is associated with impaired reverse remodelling after transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging 2020; 21:1144-1151. [PMID: 31665257 DOI: 10.1093/ehjci/jez256] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 07/12/2019] [Accepted: 10/24/2019] [Indexed: 01/19/2023] Open
Abstract
AIMS Cardiac CT is increasingly applied for planning and follow-up of transcatheter aortic valve implantation (TAVI). However, there are no data available on reverse remodelling after TAVI assessed by CT. Therefore, we aimed to evaluate the predictors and the prognostic value of left ventricular (LV) reverse remodelling following TAVI using CT angiography. METHODS AND RESULTS We investigated 117 patients with severe, symptomatic aortic stenosis (AS) who underwent CT scanning before and after TAVI procedure with a mean follow-up time of 2.6 years after TAVI. We found a significant reduction in LV mass (LVM) and LVM indexed to body surface area comparing pre- vs. post-TAVI images: 180.5 ± 53.0 vs. 137.1 ± 44.8 g and 99.7 ± 25.4 vs. 75.4 ± 19.9 g/m2, respectively, both P < 0.001. Subclinical leaflet thrombosis (SLT) was detected in 25.6% (30/117) patients. More than 20% reduction in LVM was defined as reverse remodelling and was detected in 62.4% (73/117) of the patients. SLT, change in mean pressure gradient on echocardiography and prior myocardial infarction was independently associated with LV reverse remodelling after adjusting for age, gender, and traditional risk factors (hypertension, body mass index, diabetes mellitus, and hyperlipidaemia): OR = 0.27, P = 0.022 for SLT and OR = 0.22, P = 0.006 for prior myocardial infarction, OR = 1.51, P = 0.004 for 10 mmHg change in mean pressure gradient. Reverse remodelling was independently associated with favourable outcomes (HR = 0.23; P = 0.019). CONCLUSION TAVI resulted in a significant LVM regression on CT. The presence of SLT showed an inverse association with LV reverse remodelling and thus it may hinder the beneficial LV structural changes. Reverse remodelling was associated with improved long-term prognosis.
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Affiliation(s)
- Bálint Szilveszter
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Daniel Oren
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Levente Molnár
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Astrid Apor
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Anikó I Nagy
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Andrea Molnár
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Borbála Vattay
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Márton Kolossváry
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Júlia Karády
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Andrea Bartykowszki
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Ádám L Jermendy
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Ferenc I Suhai
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Alexisz Panajotu
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary.,Medical Imaging Center, Semmelweis University, Üllői Street, 1082 Budapest, Hungary
| | - Béla Merkely
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Városmajor Street, 1122 Budapest, Hungary
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