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Chamoun N, Jdaidani J, Iskandarani DZ, Ghalayini S, Zgheib A, Khoury A, Alam S, Rebeiz AG, Ghazzal Z, Sawaya F. Short-Term Clinical Outcomes of Transcatheter Aortic Valve Replacement in a Developing Country. Cureus 2024; 16:e58334. [PMID: 38752027 PMCID: PMC11095913 DOI: 10.7759/cureus.58334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 05/18/2024] Open
Abstract
INTRODUCTION Transcatheter aortic valve replacement (TAVR) is an effective alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis in all surgical risk groups. Reports of clinical outcomes post-TAVR in developing countries are scarce. We aimed to address the clinical outcomes and safety profile of TAVR in a developing country. METHODS We conducted a single-center, retrospective study on patients undergoing TAVR at the American University of Beirut Medical Center (AUBMC) from January 2016 to April 2023. We included a total of 399 patients. Our primary endpoint was to assess the rate of TAVR in-hospital and 30-day mortality, neurologic events, and new permanent pacemaker implantation (PPI) in patients, stratified by the Society of Thoracic Surgeons (STS) risk of mortality score. RESULTS Survival rates were 98.7% (394) at discharge vs. 97.5% (389) at 30 days post-procedure. The technical success rate was 95% (379) at the end of the procedure. Device success and early safety rates were 93.5% (373) and 83% (331), respectively at 30 days post-procedure. The all-cause mortality rate increased from 1.3% (5) at discharge to 2.5% (10) at 30-day intervals. The rate of ischemic stroke was 1.3% (five) at discharge and increased to 2% (eight) at 30 days post-procedure. PPI was needed in 5.8% (23) of patients at discharge with an increase to 7% (28) at one-month interval. Overall, the rates of TAVR outcomes among the three risk groups were comparable including neurologic events, valve-related complications, bleeding problems, vascular and access-related complications, and myocardial infarction. CONCLUSION This study at AUBMC highlights the successful implementation of the TAVR program in a developing country, showcasing its efficacy and safety within 30 days post-operation, despite challenges such as financial constraints and limited access to specialized training. Larger cohorts and longer follow-up periods are needed to accurately represent clinical outcomes in developing countries.
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Affiliation(s)
- Nadia Chamoun
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Jennifer Jdaidani
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | | | - Sarah Ghalayini
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Ali Zgheib
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Alessandro Khoury
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Samir Alam
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Abdallah G Rebeiz
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Ziyad Ghazzal
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Fadi Sawaya
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
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Benenati S, Gallo F, Kim WK, Khokhar AA, Zeus T, Toggweiler S, Galea R, De Marco F, Mangieri A, Regazzoli D, Reimers B, Nombela-Franco L, Barbanti M, Regueiro A, Piva T, Rodes-Cabau J, Porto I, Colombo A, Giannini F, Sticchi A. Comparison of Mid-Term Prognosis in Intermediate-to-Low-Risk Contemporary Population with Guidelines-Oriented Age Cutoff. J Cardiovasc Dev Dis 2024; 11:33. [PMID: 38276659 PMCID: PMC10816002 DOI: 10.3390/jcdd11010033] [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: 11/30/2023] [Revised: 01/05/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Current European guidelines support transcatheter aortic valve implantation (TAVI) in intermediate-to-low-risk patients ≥75 years-old, but its prognostic relevance is unknown. METHODS Intermediate-to-low-risk (The Society of Thoracic Surgeons score <8%) patients enrolled in the HORSE registry were included. We compared the populations aged under 75 with those over 75. The primary endpoint was all-cause mortality. RESULTS A total of 2685 patients were included: 280 (8.6%) < 75 and 2405 ≥ 75 years. Through a mean follow-up of 437 ± 381 days, 198 (8.2%) and 23 (8.2%) patients died in the two arms without statistically significant differences (log-rank p = 0.925). At Cox regression analysis, age did not predict the occurrence of all-cause death, neither as a continuous variable (HR 1.01, 95% CI 0.99-1.04, p = 0.294) nor dichotomizing according to the prespecified cutoff of 75 years (HR 0.97, 95% CI 0.63-1.51, p = 0.924). Time-to-event ROC curves showed low accuracy of age to predict all-cause mortality (area under the curve of 0.54 for both 1-year and 2-year outcomes). CONCLUSIONS TAVI has comparable benefits across age strata for intermediate-to-low-risk patients. The age cutoff suggested by the current guidelines is not predictive of the risk of adverse events during hospital stays or of all-cause mortality through a mid-term follow-up.
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Affiliation(s)
- Stefano Benenati
- Dipartimento di Medicina Interna e Specialità Mediche (DIMI), University of Genoa, 16126 Genoa, Italy (I.P.)
| | - Francesco Gallo
- Interventional Cardiology, Department of Cardio-Thoracic and Vascular Sciences, Ospedale dell’Angelo, AULSS3 Serenissima, Mestre, 30174 Venezia, Italy
| | - Won-keun Kim
- Department of Cardiology, Kerckhoff Heart Center, 61231 Bad Nauheim, Germany;
| | - Arif A. Khokhar
- Cardiology Service, Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Tobias Zeus
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, 40225 Duesseldorf, Germany
| | - Stefan Toggweiler
- Department of Cardiology, Cantonal Hospital Lucern, 6000 Luzern, Switzerland
| | - Roberto Galea
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | | | - Antonio Mangieri
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy (D.R.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
| | - Damiano Regazzoli
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy (D.R.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
| | - Bernhard Reimers
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy (D.R.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
| | - Luis Nombela-Franco
- Interventional Cardiology Unit, Hospital Àlvaro Cunqueiro, 36312 Vigo, Spain
| | - Marco Barbanti
- Faculty of Medicine and Surgery, Università degli Studi di Enna “Kore”, 94100 Enna, Italy
| | - Ander Regueiro
- Cardiovascular Institute, Hospital Clinic, Institut D’investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Tommaso Piva
- Interventional Cardiology, Ospedali Riuniti Di Ancona, 60126 Ancona, Italy;
| | - Josep Rodes-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC G1V 4G5, Canada
| | - Italo Porto
- Dipartimento di Medicina Interna e Specialità Mediche (DIMI), University of Genoa, 16126 Genoa, Italy (I.P.)
| | - Antonio Colombo
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy (D.R.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
| | - Francesco Giannini
- Interventional Cardiology Unit, IRCCS Ospedale Galeazzi Sant’Ambrogio, 20157 Milan, Italy
| | - Alessandro Sticchi
- Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy (D.R.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Cardiac Catheterisation Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Pisana, 56124 Pisa, Italy
- Dipartimento di Patologia Chirurgica, University of Pisa, Medica, Molecolare e dell’Area Critica, 56126 Pisa, Italy
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Llerena-Velastegui J, Navarrete-Cadena C, Delgado-Quijano F, Trujillo-Delgado M, Aguayo-Zambrano J, Villacis-Lopez C, Marcalla-Rocha M, Benitez-Acosta K, Vega-Zapata J. Frequency of Stroke in Intermediate-Risk Patients in the Long-Term Undergoing TAVR vs SAVR: A Systematic Review and Meta-Analysis. Curr Probl Cardiol 2024; 49:102099. [PMID: 37741600 DOI: 10.1016/j.cpcardiol.2023.102099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 09/18/2023] [Indexed: 09/25/2023]
Abstract
The aim of this research is to compare the long-term incidence of stroke in intermediate-risk patients who have undergone either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) procedures. The objective is to identify which method exhibits a higher propensity for stroke occurrence, potentially contributing to disability or stroke-related mortality. We conducted a systematic review and meta-analysis to evaluate the frequency of stroke post-TAVR and SAVR procedures. Data were compiled from a diverse array of research articles, retrieved from the Embase, Cochrane Library, and PubMed databases. Conclusions were derived from the comprehensive analysis of forest plots. The analysis indicates no significant reduction in stroke incidence among patients undergoing TAVR compared to those receiving SAVR. This conclusion, underscored by a P-value of 0.76 and a 95% confidence interval (CI) ranging from 0.80 to 1.17, arises from a careful review of multiple pertinent studies. The meta-analysis of pooled data does not reveal a significant decrease in stroke frequency associated with TAVR. For intermediate-risk patients, both TAVR and SAVR present similar stroke risks, indicating no procedure is inherently safer. Healthcare providers must take this into account when counseling patients, considering each procedure's benefits and drawbacks. This study focuses specifically on intermediate-risk individuals, so results may not apply universally. Further research across different risk categories is needed. This study emphasizes the need for individualized patient care and informed decision-making in aortic stenosis management.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Julisa Vega-Zapata
- Regional Autonomous University of Los Andes, Medical School, Ambato, Ecuador
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4
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Fahrni G, Gullo G, Touray A, Fournier S, Jouannic AM, Lu H, Racine D, Muller O, Pozzessere C, Qanadli SD, Rotzinger DC. Investigating the Influence of High-Speed Gantry Rotation in Cardiac CT on Motion Artifacts in Aortic Stenosis Patients Not Premedicated with β-Blockers: The FAST-CCT Randomized Trial Protocol. J Cardiovasc Dev Dis 2023; 10:424. [PMID: 37887871 PMCID: PMC10607475 DOI: 10.3390/jcdd10100424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/20/2023] [Accepted: 10/10/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Coronary CT angiography (CCTA) is increasingly used as a non-invasive tool to assess coronary artery disease (CAD). However, CCTA is subject to motion artifacts, potentially limiting its clinical utility. Despite faster (0.35 and 0.28 s/rot) gantry rotation times, low (60-65 bpm) heartbeat is recommended, and the use of β-blockers is often needed. Technological advancements have resulted in the development of faster rotation speeds (0.23 s/rot). However, their added value in patients not premedicated with β-blockers remains unclear. This prospective single-center, two-arm, randomized, controlled trial aims to assess the influence of fast rotation on coronary motion artifacts, diagnostic accuracy of CCTA for CAD, and patient safety. METHODS We will randomize a total of 142 patients aged ≥ 50 scheduled for an aortic stenosis work-up to receive CCTA with either a fast (0.23) or standard (0.28 s/rot) gantry speed. PRIMARY OUTCOME rate of CCTAs with coronary motion artifacts hindering interpretation. SECONDARY OUTCOMES assessable coronary segments rate, diagnostic accuracy against invasive coronary angiography (ICA), motion artifact magnitude per segment, contrast-to-noise ratio (CNR), and patient ionizing radiation dose. The local ethics committee has approved the protocol. Potential significance: FAST-CCT may improve motion artifact reduction and diagnosis quality, thus eliminating the need for rate control and β-blocker administration. CLINICALTRIALS gov identifier: NCT05709652.
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Affiliation(s)
- Guillaume Fahrni
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland; (G.G.); (A.T.); (A.-M.J.); (C.P.)
| | - Giuseppe Gullo
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland; (G.G.); (A.T.); (A.-M.J.); (C.P.)
| | - Aisha Touray
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland; (G.G.); (A.T.); (A.-M.J.); (C.P.)
| | - Stéphane Fournier
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland; (S.F.); (H.L.); (O.M.)
| | - Anne-Marie Jouannic
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland; (G.G.); (A.T.); (A.-M.J.); (C.P.)
| | - Henri Lu
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland; (S.F.); (H.L.); (O.M.)
| | - Damien Racine
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, Rue du Grand-Pré 1, 46, 1007 Lausanne, Switzerland;
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland; (S.F.); (H.L.); (O.M.)
| | - Chiara Pozzessere
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland; (G.G.); (A.T.); (A.-M.J.); (C.P.)
| | - Salah D. Qanadli
- Riviera-Chablais Hospital, Rte du Vieux Séquoia 20, 1847 Rennaz, Switzerland;
- Faculty of Biology and Medicine (FBM), University of Lausanne, 1015 Lausanne, Switzerland
| | - David C. Rotzinger
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland; (G.G.); (A.T.); (A.-M.J.); (C.P.)
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Lerman TT, Levi A, Jørgensen TH, Søndergaard L, Talmor-Barkan Y, Kornowski R. Comparison of middle-term valve durability between transcatheter aortic valve implantation and surgical aortic valve replacement: an updated systematic review and meta-analysis of RCTs. Front Cardiovasc Med 2023; 10:1242608. [PMID: 37771663 PMCID: PMC10525352 DOI: 10.3389/fcvm.2023.1242608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/21/2023] [Indexed: 09/30/2023] Open
Abstract
Background This study aims to compare valve durability between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). Methods We conducted a systematic review and meta-analysis using data from randomized controlled trials (RCTs). The primary outcome was structural valve deterioration (SVD). Secondary outcomes were bioprosthetic valve failure, reintervention, effective orifice area (EOA), mean pressure gradient, and moderate-severe aortic regurgitation (AR, transvalvular and/or paravalvular). Results Twenty-five publications from seven RCTs consisting of 7,970 patients were included in the analysis with follow-up ranges of 2-8 years. No significant difference was found between the two groups with regard to SVD [odds ratio (OR) 0.72; 95% CI: 0.25-2.12]. The TAVI group was reported to exhibit a statistically significant higher risk of reintervention (OR 2.03; 95% CI: 1.34-3.05) and a moderate-severe AR (OR 6.54; 95% CI: 3.92-10.91) compared with the SAVR group. A trend toward lower mean pressure gradient in the TAVI group [(mean difference (MD) -1.61; 95% CI: -3.5 to 0.28)] and significant higher EOA (MD 0.20; 95% CI: 0.08-0.31) was noted. Conclusion The present data indicate that TAVI provides a comparable risk of SVD with favorable hemodynamic profile compared with SAVR. However, the higher risk of significant AR and reintervention was demonstrated. Systematic Review Registration PROSPERO (CRD42022363060).
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Affiliation(s)
- Tsahi T. Lerman
- Department of Internal Medicine F-Recanati, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amos Levi
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Troels Højsgaard Jørgensen
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Søndergaard
- Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Yeela Talmor-Barkan
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Savvoulidis P, Nadir MA, Moody WE, Steeds R, Ludman PF, Bradley JR, Singh A, Lawton E, Doshi SN. Intraprocedural versus next day transthoracic echocardiography following minimalist transfemoral TAVI. Echo Res Pract 2023; 10:14. [PMID: 37674237 PMCID: PMC10483768 DOI: 10.1186/s44156-023-00025-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/30/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Routine pre-discharge echocardiography (ECHO) is recommended post transcatheter aortic valve implantation (TAVI) as a baseline for future comparison. However, there is no clear guidance on the optimal timing of this study. AIM The purpose of this retrospective study was to investigate the safety and work-force efficiency of intraprocedural same-day ECHO versus next-day ECHO, following transfemoral TAVI. METHODS AND RESULTS In this retrospective study 100 consecutive patients who underwent intraprocedural ECHO only were compared with 100 consecutive patients undergoing both intraprocedural and routine next-day ECHO following elective transfemoral TAVI. All patients received the Sapien 3/Ultra transcatheter heart valve and were treated with a minimalist procedure with conscious sedation. The composite of in-hospital mortality, urgent ECHO and new tamponade after leaving the cath lab and before discharge was not different between the two groups (4 vs. 4%, P = 1). There was no paravalvular leak more than mild in any of the cases. Length of stay was similar (1 day). CONCLUSIONS Intraprocedural post-TAVI ECHO appears as safe as next day pre-discharge ECHO and obviates the need for a routine next day study, thereby reducing burden on echocardiography services and allows better utilisation of resources.
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Affiliation(s)
- Panagiotis Savvoulidis
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
| | - M Adnan Nadir
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - William E Moody
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Richard Steeds
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Peter F Ludman
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Joseph R Bradley
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
| | - Aldrin Singh
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
| | - Ewa Lawton
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
| | - Sagar N Doshi
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK.
- Institute for Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
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Lerman TT, Levi A, Talmor-Barkan Y, Kornowski R. Early and Mid-Term Outcomes of Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement: Updated Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2023; 10:jcdd10040157. [PMID: 37103036 PMCID: PMC10146134 DOI: 10.3390/jcdd10040157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/31/2023] [Accepted: 04/02/2023] [Indexed: 04/08/2023] Open
Abstract
(1) Background: The use of transcatheter aortic valve implantation (TAVI) for the treatment of severe symptomatic aortic stenosis is expanding significantly. We aimed to perform a meta-analysis comparing the safety and efficacy of TAVI versus surgical aortic valve replacement (SAVR) during the early and mid-term follow-up period. (2) Methods: We conducted a meta-analysis of randomized controlled trials (RCTs) comparing 1- to 2-year outcomes between TAVI and SAVR. The study protocol was preregistered in PROSPERO and the results were reported according to PRISMA guidelines. (3) Results: The pooled analysis included data from eight RCTs totaling 8780 patients. TAVI was associated with a lower risk of all-cause mortality or disabling stroke (OR 0.87, 95%CI 0.77–0.99), significant bleeding (OR 0.38, 95%CI 0.25–0.59), acute kidney injury (AKI; OR 0.53, 95%CI 0.40–0.69) and atrial fibrillation (OR 0.28, 95%CI 0.19–0.43). SAVR was associated with a lower risk of major vascular complication (MVC; OR 1.99, 95%CI 1.29–3.07) as well as permanent pacemaker implantation (PPI; OR 2.28, 95%CI 1.45–3.57). (3) Conclusions: TAVI compared with SAVR during early and mid-term follow-up was associated with a lower risk of all-cause mortality or disabling stroke, significant bleeding, AKI and atrial fibrillation; however, it was associated with a higher risk of MVC and PPI.
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Affiliation(s)
- Tsahi T. Lerman
- Department of Internal Medicine F-Recanati, Beilinson Hospital, Rabin Medical Center, Petah Tikva 4941492, Israel
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Amos Levi
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Yeela Talmor-Barkan
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva 4941492, Israel
- The Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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8
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Fong KY, Yap JJL, Chan YH, Ewe SH, Chao VTT, Amanullah MR, Govindasamy SP, Aziz ZA, Tan VH, Ho KW. Network Meta-Analysis Comparing Transcatheter, Minimally Invasive, and Conventional Surgical Aortic Valve Replacement. Am J Cardiol 2023; 195:45-56. [PMID: 37011554 DOI: 10.1016/j.amjcard.2023.02.017] [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: 12/13/2022] [Revised: 02/11/2023] [Accepted: 02/14/2023] [Indexed: 04/05/2023]
Abstract
The landscape of aortic valve replacement (AVR) has evolved dramatically over the years, but time-varying outcomes have yet to be comprehensively explored. This study aimed to compare the all-cause mortality among 3 AVR techniques: transcatheter (TAVI), minimally invasive (MIAVR), and conventional AVR (CAVR). An electronic literature search was performed for randomized controlled trials (RCTs) comparing TAVI with CAVR and RCTs or propensity score-matched (PSM) studies comparing MIAVR with CAVR or MIAVR to TAVI. Individual patient data for all-cause mortality were derived from graphical reconstruction of Kaplan-Meier curves. Pairwise comparisons and network meta-analysis were conducted. Sensitivity analyses were performed in the TAVI arm for high risk and low/intermediate risk, as well as patients who underwent transfemoral (TF) TAVI. A total of 27 studies with 16,554 patients were included. In the pairwise comparisons, TAVI showed superior mortality to CAVR until 37.5 months, beyond which there was no significant difference. When restricted to TF TAVI versus CAVR, a consistent mortality benefit favoring TF TAVI was seen (shared frailty hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.76 to 0.98, p = 0.024). In the network meta-analysis involving majority PSM data, MIAVR demonstrated significantly lower mortality than TAVI (HR = 0.70, 95% CI = 0.59 to 0.82) and CAVR (HR = 0.69, 95% CI = 0.59 to 0.80); this association remained compared with TF TAVI but with a lower extent of benefit (HR = 0.80, 95% CI = 0.65 to 0.99). In conclusion, the initial short- to medium-term mortality benefit for TAVI over CAVR was attenuated over the longer term. In the subset of patients who underwent TF TAVI, a consistent benefit was found. Among majority PSM data, MIAVR showed improved mortality compared with TAVI and CAVR but less than the TF TAVI subset, which requires validation by robust RCTs.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Victor T T Chao
- Department of Cardiothoracic Surgery, National Heart Center Singapore, Singapore
| | | | | | - Zameer Abdul Aziz
- Department of Cardiothoracic Surgery, National Heart Center Singapore, Singapore
| | - Vern Hsen Tan
- Department of Cardiology, Changi General Hospital, Singapore
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Yokoyama H, Sugiyama Y, Miyashita H, Jalanko M, Ochiai T, Shishido K, Yamanaka F, Vähäsilta T, Saito S, Laine M, Moriyama N. Impact of Mild Paravalvular Regurgitation on Long-Term Clinical Outcomes After Transcatheter Aortic Valve Implantation. Am J Cardiol 2023; 191:14-22. [PMID: 36623409 DOI: 10.1016/j.amjcard.2022.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/26/2022] [Accepted: 12/04/2022] [Indexed: 01/09/2023]
Abstract
The impact of mild paravalvular regurgitation (PVR) after transcatheter aortic valve implantation (TAVI) remains controversial. We evaluated the impact of mild PVR after TAVI on long-term clinical outcomes. We included patients who underwent TAVI for severe symptomatic aortic stenosis between December 2008 and June 2019 at 2 international centers and compared all-cause death between the group with mild PVR (group 1) and the group with none or trace PVR (group 2). PVR was categorized using a 3-class grading scheme, and patients with PVR ≧ moderate and those who were lost to follow-up were excluded. This retrospective analysis included 1,404 patients (mean age 81.7 ± 6.5 years, 58.0% women). Three hundred fifty eight patients (25.5%) were classified into group 1 and 1,046 patients (74.5%) into group 2. At baseline, group 1 was older and had a lower body mass index, worse co-morbidities, and more severe aortic stenosis. To account for these differences, propensity score matching was performed, resulting in 332 matched pairs. Within these matched groups, during a mean follow-up of 3.2 years, group 1 had a significantly lower survival rate at 5 years (group 1: 62.0% vs group 2: 68.0%, log-rank p = 0.029, hazard ratio: 1.41 [95% confidence interval: 1.04 to 1.91]). In the matched cohort, patients with mild PVR had a significant 1.4-fold increased risk of mortality at 5 years after TAVI compared with those with none or trace PVR. Further studies with more patients are needed to evaluate the impact of longer-term outcomes.
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Affiliation(s)
- Hiroaki Yokoyama
- Department of Cardiology & Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan
| | - Yoichi Sugiyama
- Department of Cardiology & Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan; Heart and Lung Center, Helsinki University Central Hospital, Helsinki University, Helsinki, Finland
| | - Hirokazu Miyashita
- Department of Cardiology & Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan
| | - Mikko Jalanko
- Heart and Lung Center, Helsinki University Central Hospital, Helsinki University, Helsinki, Finland
| | - Tomoki Ochiai
- Department of Cardiology & Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan
| | - Koki Shishido
- Department of Cardiology & Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan
| | - Futoshi Yamanaka
- Department of Cardiology & Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan
| | - Tommi Vähäsilta
- Heart and Lung Center, Helsinki University Central Hospital, Helsinki University, Helsinki, Finland
| | - Shigeru Saito
- Department of Cardiology & Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan
| | - Mika Laine
- Heart and Lung Center, Helsinki University Central Hospital, Helsinki University, Helsinki, Finland
| | - Noriaki Moriyama
- Department of Cardiology & Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura City, Japan.
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10
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Ahmad Y, Howard JP, Arnold AD, Madhavan MV, Cook CM, Alu M, Mack MJ, Reardon MJ, Thourani VH, Kapadia S, Thyregod HGH, Sondergaard L, Jørgensen TH, Toff WD, Van Mieghem NM, Makkar RR, Forrest JK, Leon MB. Transcatheter versus surgical aortic valve replacement in lower-risk and higher-risk patients: a meta-analysis of randomized trials. Eur Heart J 2023; 44:836-852. [PMID: 36660821 DOI: 10.1093/eurheartj/ehac642] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 10/09/2022] [Accepted: 10/26/2022] [Indexed: 01/21/2023] Open
Abstract
AIMS Additional randomized clinical trial (RCT) data comparing transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (SAVR) is available, including longer term follow-up. A meta-analysis comparing TAVI to SAVR was performed. A pragmatic risk classification was applied, partitioning lower-risk and higher-risk patients. METHODS AND RESULTS The main endpoints were death, strokes, and the composite of death or disabling stroke, occurring at 1 year (early) or after 1 year (later). A random-effects meta-analysis was performed. Eight RCTs with 8698 patients were included. In lower-risk patients, at 1 year, the risk of death was lower after TAVI compared with SAVR [relative risk (RR) 0.67; 95% confidence interval (CI) 0.47 to 0.96, P = 0.031], as was death or disabling stroke (RR 0.68; 95% CI 0.50 to 0.92, P = 0.014). There were no differences in strokes. After 1 year, in lower-risk patients, there were no significant differences in all main outcomes. In higher-risk patients, there were no significant differences in main outcomes. New-onset atrial fibrillation, major bleeding, and acute kidney injury occurred less after TAVI; new pacemakers, vascular complications, and paravalvular leak occurred more after TAVI. CONCLUSION In lower-risk patients, there was an early mortality reduction with TAVI, but no differences after later follow-up. There was also an early reduction in the composite of death or disabling stroke, with no difference at later follow-up. There were no significant differences for higher-risk patients. Informed therapy decisions may be more dependent on the temporality of events or secondary endpoints than the long-term occurrence of main clinical outcomes.
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Affiliation(s)
- Yousif Ahmad
- Yale School of Medicine, Yale University, 135 College Street, Suite 101, New Haven, CT 06510, USA
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W120HS, UK
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W120HS, UK
| | - Mahesh V Madhavan
- Division of Cardiology, Department of Medicine, Columbia University Medical Center/New York-Presbyterian Hospital, W. 168th St. New York, NY 10032, USA.,Clinical Trials Center, The Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | | | - Maria Alu
- Clinical Trials Center, The Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | - Michael J Mack
- Department of Cardiovascular Disease, Baylor Scott and White Health, 4700 Alliance Blvd, Plano, TX 75093, USA
| | - Michael J Reardon
- Houston Methodist DeBakey Heart & Vascular Center, 6565 Fannin St Suite 1901, Houston, TX 77030, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart and Vascular Institute, 95 Collier Rd NW Suite 5015, Atlanta, GA 30309, USA
| | - Samir Kapadia
- Cleveland Clinic, 9500 Euclid Ave. Cleveland, OH 44195, USA
| | - Hans Gustav Hørsted Thyregod
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Section 2151, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Lars Sondergaard
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Section 2151, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Troels Højsgaard Jørgensen
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Section 2151, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - William D Toff
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University Rd, Leicester LE1 7RH, UK
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Raj R Makkar
- Cedars-Sinai Medical Center, Smidt Heart Institute, S San Vicente Blvd, Los Angeles, CA 90048, USA
| | - John K Forrest
- Yale School of Medicine, Yale University, 135 College Street, Suite 101, New Haven, CT 06510, USA
| | - Martin B Leon
- Division of Cardiology, Department of Medicine, Columbia University Medical Center/New York-Presbyterian Hospital, W. 168th St. New York, NY 10032, USA.,Clinical Trials Center, The Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
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11
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Lee G, Chikwe J, Milojevic M, Wijeysundera HC, Biondi-Zoccai G, Flather M, Gaudino MFL, Fremes SE, Tam DY. ESC/EACTS vs. ACC/AHA guidelines for the management of severe aortic stenosis. Eur Heart J 2023; 44:796-812. [PMID: 36632841 DOI: 10.1093/eurheartj/ehac803] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 11/08/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023] Open
Abstract
Aortic stenosis (AS) is a serious and complex condition, for which optimal management continues to evolve rapidly. An understanding of current clinical practice guidelines is critical to effective patient care and shared decision-making. This state of the art review of the 2021 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines and 2020 American College of Cardiology/American Heart Association Guidelines compares their recommendations for AS based on the evidence to date. The European and American guidelines were generally congruent with the exception of three key distinctions. First, the European guidelines recommend intervening at a left ventricular ejection fraction of 55%, compared with 60% over serial imaging by the American guidelines for asymptomatic patients. Second, the European guidelines recommend a threshold of ≥65 years for surgical bioprosthesis, whereas the American guidelines employ multiple age categories, providing latitude for patient factors and preferences. Third, the guidelines endorse different age cut-offs for transcatheter vs. surgical aortic valve replacement, despite limited evidence. This review also discusses trends indicating a decreasing proportion of mechanical valve replacements. Finally, the review identifies gaps in the literature for areas including transcatheter aortic valve implantation in asymptomatic patients, the appropriateness of Ross procedures, concomitant coronary revascularization with aortic valve replacement, and bicuspid AS. To summarize, this state of the art review compares the latest European and American guidelines on the management of AS to highlight three areas of divergence: timing of intervention, valve selection, and surgical vs. transcatheter aortic valve replacement criteria.
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Affiliation(s)
- Grace Lee
- Temerty Faculty of Medicine, 1 King's College Circle, Toronto, ON M5S1A8, Canada
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 San Vicente Blvd a3600, Los Angeles, CA 90048, USA
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Heroja Milana Tepića 1, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, M4N 3M5, University of Toronto, Toronto, ON, Canada
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185 Roma RM, Italy.,Mediterranea Cardiocentro, Via Orazio, 2, 80122 Napoli, NA, Italy
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 1300 York Ave, NY New York, USA
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto, 200 Elizabeth St., Toronto, ON M5G 2C4, Canada
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12
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Gupta R, Mahmoudi E, Behnoush AH, Khalaji A, Malik AH, Sood A, Bandyopadhyay D, Zaid S, Goel A, Sreenivasan J, Patel C, Vyas AV, Lavie CJ, Patel NC. Effect of BMI on patients undergoing transcatheter aortic valve implantation: A systematic review and meta-analysis. Prog Cardiovasc Dis 2023:S0033-0620(22)00158-X. [PMID: 36657654 DOI: 10.1016/j.pcad.2022.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 12/26/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND The relationship of body mass index (BMI) and an "obesity paradox" with cardiovascular risk prediction is controversial. This systematic review and meta-analysis aims to compare the associations of different BMI ranges on transcatheter aortic valve implantation (TAVI) outcomes. METHODS International databases, including PubMed, the Web of Science, and the Cochrane Library, were systematically searched for observational and randomized controlled trial studies investigating TAVI outcomes in any of the four BMI categories: underweight, normal weight, overweight, and obese with one of the predefined outcomes. Primary outcomes were in-hospital, 30-day, and long-term all-cause mortality. Random-effects meta-analysis was performed to calculate the odds ratio (OR) or standardized mean differences (SMD) with 95% confidence interval (CI) for each paired comparison between two of the BMI categories. RESULTS A total of 38 studies were included in our analysis, investigating 99,829 patients undergoing TAVI. There was a trend toward higher comorbidities such as hypertension, diabetes, and dyslipidemia in overweight patients and individuals with obesity. Compared with normal-weight, patients with obesity had a lower rate of 30-day mortality (OR 0.42, 95% CI 0.25-0.72, p < 0.01), paravalvular aortic regurgitation (OR 0.63, 95% CI 0.44-0.91, p = 0.01), 1-year mortality (OR 0.48, 95% CI 0.24-0.96, p = 0.04), and long-term mortality (OR 0.69, 95% CI 0.51-0.94, p = 0.02). However, acute kidney injury (OR 1.16, 95% CI 1.04-1.30, p = 0.01) and permanent pacemaker implantation (OR 1.25, 95% CI 1.05-1.50, p = 0.01) odds were higher in patients with obesity. Noteworthy, major vascular complications were significantly higher in underweight patients in comparison with normal weight cases (OR 1.62, 95% CI 1.07-2.46, p = 0.02). In terms of left ventricular ejection fraction (LVEF), patients with obesity had higher post-operative LVEF compared to normal-weight individuals (SMD 0.12, 95% CI 0.02-0.22, p = 0.02). CONCLUSION Our results suggest the presence of the "obesity paradox" in TAVI outcomes with higher BMI ranges being associated with lower short- and long-term mortality. BMI can be utilized for risk prediction of patients undergoing TAVI.
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Affiliation(s)
- Rahul Gupta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA.
| | - Elham Mahmoudi
- Universal Scientific Education and Research Network, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Behnoush
- Universal Scientific Education and Research Network, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirmohammad Khalaji
- Universal Scientific Education and Research Network, Tehran University of Medical Sciences, Tehran, Iran
| | - Aaqib H Malik
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Aayushi Sood
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | - Dhrubajyoti Bandyopadhyay
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Syed Zaid
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Institute, Houston, TX, USA
| | - Akshay Goel
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Institute, Houston, TX, USA
| | - Jayakumar Sreenivasan
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Chirdeep Patel
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Apurva V Vyas
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Nainesh C Patel
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
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13
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Antony I, Mehari Abraha H, Hameed A, Conway C. A European update on transcatheter aortic valve implantation (TAVI) in the COVID era. J Anat 2022; 242:50-63. [PMID: 36152032 PMCID: PMC9773167 DOI: 10.1111/joa.13740] [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: 10/28/2021] [Revised: 07/26/2022] [Accepted: 07/26/2022] [Indexed: 12/31/2022] Open
Abstract
Minimally invasive approaches for aortic valve replacement are now at the forefront of pathological aortic valve treatment. New trials show comparability of these devices to existing therapies, not only in high-risk surgical cohorts but also in low-risk and intermediate-risk cohorts. This review provides vital clinical and anatomical background to aortic valvular disease treatment guidelines, while also providing an update on transcatheter aortic valve implantation (TAVI) devices in Europe, their interventional trials and associated complications.
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Affiliation(s)
- Ishan Antony
- School of MedicineRCSI University of Medicine and Health SciencesDublinIreland,Department of Anatomy and Regenerative Medicine, Tissue Engineering Research Group (TERG)RCSI University of Medicine and Health SciencesDublinIreland
| | - Hyab Mehari Abraha
- Department of Anatomy and Regenerative Medicine, Tissue Engineering Research Group (TERG)RCSI University of Medicine and Health SciencesDublinIreland,Trinity Centre for Biomedical Engineering (TCBE)Trinity College DublinDublinIreland
| | - Aamir Hameed
- Department of Anatomy and Regenerative Medicine, Tissue Engineering Research Group (TERG)RCSI University of Medicine and Health SciencesDublinIreland,Trinity Centre for Biomedical Engineering (TCBE)Trinity College DublinDublinIreland
| | - Claire Conway
- Department of Anatomy and Regenerative Medicine, Tissue Engineering Research Group (TERG)RCSI University of Medicine and Health SciencesDublinIreland,Trinity Centre for Biomedical Engineering (TCBE)Trinity College DublinDublinIreland
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14
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Ke Y, Wang J, Wang W, Guo S, Dai M, Wu L, Bao Y, Li B, Ju J, Xu H, Jin Y. Antithrombotic strategies after transcatheter aortic valve implantation: A systematic review and network meta-analysis of randomized controlled trials. Int J Cardiol 2022; 362:139-146. [PMID: 35654173 DOI: 10.1016/j.ijcard.2022.05.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022]
Abstract
AIMS Meta-analyses comparing different antithrombotic strategies were conducted to determine the optimal therapeutic regimen post transcatheter aortic valve implantation (TAVI). However, there were restricted high-quality direct comparisons across the different antithrombotic therapeutic regimens. We sought to explore the safety and efficacy of different antithrombotic therapy strategies after TAVI using network meta-analyses of randomized controlled trials (RCTs). METHODS We searched CENTRAL, PubMed, Embase and Medline through August 2021 for RCTs that directly compared different antithrombotic schemes in adults who had undergone TAVI. We conducted a pairwise and network meta-analysis measuring all-cause mortality, stroke, myocardial infarction, all bleeding and life-threatening or major bleeding events. The surface under the cumulative ranking (SUCRA) curve was estimated to rank the therapies. We evaluated the risk of bias and graded the quality of the evidence using established methods. RESULTS Six RCTs of 2824 patients who underwent TAVI were analysed. The risk of all bleeding [relative risk (RR) 1.88 (1.34-2.64)] and life-threatening or major bleeding [RR 2.03 (1.27-3.24)] was significantly higher for dual antiplatelet therapy (DAPT) than single antiplatelet therapy (SAPT), whereas there was no significant difference in the risk of all-cause mortality [RR 1.01 (0.61-1.68)] between DAPT and SAPT. Oral anticoagulant (OAC) + SAPT (OACSAPT) had significantly higher rates of all bleeding and life-threatening or major bleeding events compared with SAPT ([RR 3.46 (2.23-5.36)], [RR 2.86 (1.50-5.45)]). The risk of all-cause mortality [RR 1.72 (1.14-2.59)] and all bleeding [RR 1.84 (1.38-2.44)] were significantly higher for OACSAPT than DAPT, whereas there was no significant difference in the risk of life-threatening or major bleeding events [RR 1.41 (0.89-2.23)] between DAPT and OACSAPT. There was no significant difference in stroke or myocardial infarction among the different antithrombotic strategies (SAPT, DAPT and OACSAPT). Additionally, patients receiving OACSAPT had the highest risks for all-cause mortality (SUCRA 3.5%) and life-threatening or major bleeding (SUCRA 2.3%). SAPT seemed to be superior to DAPT in terms of all-cause mortality (SUCRA SAPT: 76.7%, DAPT: 69.8%) and stroke (SUCRA 69.6%, 59.7%). CONCLUSIONS Except for OACSAPT having a higher all-cause mortality than DAPT, patients who underwent TAVI had similar all-cause mortality, stroke and myocardial infarction rates among different antithrombotic regimens. Patients on SAPT had a significantly lower bleeding risk than those on DAPT and OACSAPT. Our study indicates that SAPT is the preferred therapeutic strategy when there is no indication for OAC or DAPT. Furthermore, the application of OACSAPT was ranked the worst among all antithrombotic regimens and should be averted due to an increased risk of all-cause mortality and all bleeding.
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Affiliation(s)
- Yijun Ke
- Discipline of Pharmacy Administration, Anqing Medical Center affiliated to Anhui Medical University(Anqing Municipal Hospital), Anqing, Anhui, China; School of Pharmacy, Anhui Medical University, Hefei, Anhui, China
| | - Juan Wang
- Department of Pharmacy, The Friendship Hospital of ILY Kazak Autonomous Prefecture, Xinjiang, Yili, China
| | - Wei Wang
- Department of Gastroenterology, Anqing Medical Center affiliated to Anhui Medical University(Anqing Municipal Hospital), Anqing, Anhui, China
| | - Sitong Guo
- Department of Pharmacy, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Mengfei Dai
- School of Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu 210000, China
| | - Lifang Wu
- School of Pharmacy, Anhui Medical University, Hefei, Anhui, China
| | - Yanni Bao
- School of Pharmacy, Anhui Medical University, Hefei, Anhui, China
| | - Baozhu Li
- School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Jing Ju
- Department of Equipment, Anqing Medical Center affiliated to Anhui Medical University(Anqing Municipal Hospital), Anqing, Anhui, China.
| | - Hang Xu
- Department of Pharmacy, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, Jiangsu, China.
| | - Yong Jin
- School of Pharmacy, Anhui Medical University, Hefei, Anhui, China.
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15
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Nguyen Q, Luc JGY, MacGillivray TE, Preventza OA. Transcatheter Versus Surgical Aortic Valve Replacement in Young, Low-risk Patients with Severe Aortic Stenosis. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2022.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Aortic stenosis is a common form of acquired degenerative valvular disease associated with poor survival after the onset of symptoms. Treatment options for patients with aortic stenosis in addition to medical therapy include surgical aortic valve replacement (SAVR) with either tissue or mechanical valves, or transcatheter aortic valve replacement (TAVR) with either balloon-expandable or self-expanding valves via either transfemoral or alternative access routes. In this review, the authors discuss the current evidence and special considerations regarding the use of TAVR versus SAVR in the management of severe aortic stenosis in young (<65 years of age), low-risk patients, highlighting the history of aortic stenosis treatment, the current guidelines and recommendations, and important issues that remain to be addressed. Ultimately, until ongoing clinical trials with long-term follow-up data shed light on whether interventions for aortic stenosis can be broadened to a low-risk population, TAVR in young, low-risk patients should be undertaken with caution and with guidance from a multidisciplinary heart team.
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Affiliation(s)
- Quynh Nguyen
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Jessica GY Luc
- Division of Cardiovascular Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Thomas E MacGillivray
- Division of Cardiac Surgery and Thoracic Transplantation Surgery, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX
| | - Ourania A Preventza
- Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX
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16
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Swift SL, Puehler T, Misso K, Lang SH, Forbes C, Kleijnen J, Danner M, Kuhn C, Haneya A, Seoudy H, Cremer J, Frey N, Lutter G, Wolff R, Scheibler F, Wehkamp K, Frank D. Transcatheter aortic valve implantation versus surgical aortic valve replacement in patients with severe aortic stenosis: a systematic review and meta-analysis. BMJ Open 2021; 11:e054222. [PMID: 34873012 PMCID: PMC8650468 DOI: 10.1136/bmjopen-2021-054222] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Patients undergoing surgery for severe aortic stenosis (SAS) can be treated with either transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR). The choice of procedure depends on several factors, including the clinical judgement of the heart team and patient preferences, which are captured by actively informing and involving patients in a process of shared decision making (SDM). We synthesised the most up-to-date and accessible evidence on the benefits and risks that may be associated with TAVI versus SAVR to support SDM in this highly personalised decision-making process. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE (Ovid), Embase (Ovid) and the Cochrane Central Register of Controlled Trials (CENTRAL; Wiley) were searched from January 2000 to August 2020 with no language restrictions. Reference lists of included studies were searched to identify additional studies. ELIGIBILITY CRITERIA Randomised controlled trials (RCTs) that compared TAVI versus SAVR in patients with SAS and reported on all-cause or cardiovascular mortality, length of stay in intensive care unit or hospital, valve durability, rehospitalisation/reintervention, stroke (any stroke or major/disabling stroke), myocardial infarction, major vascular complications, major bleeding, permanent pacemaker (PPM) implantation, new-onset or worsening atrial fibrillation (NOW-AF), endocarditis, acute kidney injury (AKI), recovery time or pain were included. DATA EXTRACTION AND SYNTHESIS Two independent reviewers were involved in data extraction and risk of bias (ROB) assessment using the Cochrane tool (one reviewer extracted/assessed the data, and the second reviewer checked it). Dichotomous data were pooled using the Mantel-Haenszel method with random-effects to generate a risk ratio (RR) with 95% CI. Continuous data were pooled using the inverse-variance method with random-effects and expressed as a mean difference (MD) with 95% CI. Heterogeneity was assessed using the I2 statistic. RESULTS 8969 records were retrieved and nine RCTs (61 records) were ultimately included (n=8818 participants). Two RCTs recruited high-risk patients, two RCTs recruited intermediate-risk patients, two RCTs recruited low-risk patients, one RCT recruited high-risk (≥70 years) or any-risk (≥80 years) patients; and two RCTs recruited all-risk or 'operable' patients. While there was no overall change in the risk of dying from any cause (30 day: RR 0.89, 95% CI 0.65 to 1.22; ≤1 year: RR 0.90, 95% CI 0.79 to 1.03; 5 years: RR 1.09, 95% CI 0.98 to 1.22), cardiovascular mortality (30 day: RR 1.03, 95% CI 0.77 to 1.39; ≤1 year: RR 0.90, 95% CI 0.76 to 1.06; 2 years: RR 0.96, 95% CI 0.83 to 1.12), or any type of stroke (30 day: RR 0.83, 95% CI 0.61 to 1.14;≤1 year: RR 0.94, 95% CI 0.72 to 1.23; 5 years: RR 1.07, 95% CI 0.88 to 1.30), the risk of several clinical outcomes was significantly decreased (major bleeding, AKI, NOW-AF) or significantly increased (major vascular complications, PPM implantation) for TAVI vs SAVR. TAVI was associated with a significantly shorter hospital stay vs SAVR (MD -3.08 days, 95% CI -4.86 to -1.29; 4 RCTs, n=2758 participants). Subgroup analysis generally favoured TAVI patients receiving implantation via the transfemoral (TF) route (vs non-TF); receiving a balloon-expandable (vs self-expanding) valve; and those at low-intermediate risk (vs high risk). All RCTs were rated at high ROB, predominantly due to lack of blinding and selective reporting. CONCLUSIONS No overall change in the risk of death from any cause or cardiovascular mortality was identified but 95% CIs were often wide, indicating uncertainty. TAVI may reduce the risk of certain side effects while SAVR may reduce the risk of others. Most long-term (5-year) results are limited to older patients at high surgical risk (ie, early trials), therefore more data are required for low risk populations. Ultimately, neither surgical technique was considered dominant, and these results suggest that every patient with SAS should be individually engaged in SDM to make evidence-based, personalised decisions around their care based on the various benefits and risks associated with each treatment. PROSPERO REGISTRATION NUMBER CRD42019138171.
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Affiliation(s)
| | - Thomas Puehler
- Department of Cardiac and Vascular Surgery, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
- German Centre for Cardiovascular Research, Kiel, Germany
| | - Kate Misso
- Kleijnen Systematic Reviews Ltd, York, UK
| | | | | | | | - Marion Danner
- National Competency Center for Shared Decision Making, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Christian Kuhn
- German Centre for Cardiovascular Research, Kiel, Germany
- Department of Cardiology and Angiology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Assad Haneya
- Department of Cardiac and Vascular Surgery, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Hatim Seoudy
- German Centre for Cardiovascular Research, Kiel, Germany
- Department of Cardiology and Angiology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Jochen Cremer
- Department of Cardiac and Vascular Surgery, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology, and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Georg Lutter
- Department of Cardiac and Vascular Surgery, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
- German Centre for Cardiovascular Research, Kiel, Germany
| | | | - Fueloep Scheibler
- National Competency Center for Shared Decision Making, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Kai Wehkamp
- Department of Internal Medicine I, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Derk Frank
- German Centre for Cardiovascular Research, Kiel, Germany
- Department of Cardiology and Angiology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
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Qureshi WT, Malhotra R, Schmidlin EJ, Ahmed M, Kundu A, Hafiz AM, Walker J, Kakouros N. Evaluation of ECG-gated and Fast Low-Angle Shot (FLASH) Dual Source Computed Tomography Scanning Protocols for Transcatheter Aortic Valve Replacement. Acad Radiol 2021; 28:1669-1674. [PMID: 32972842 DOI: 10.1016/j.acra.2020.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) procedural success relies heavily on volumetric reconstruction imaging, particularly ECG-gated multi-detector row computed tomography. We postulated that single examination using fast low-angle shot (FLASH) dual source CT scanning (DS-CTA) could provide lower dose than ECG-gated CTA while maintaining the image quality. METHODS In this single-centre cohort study, all patients who underwent ECG-gated and FLASH DS-CTA were evaluated. Volumetric reconstructions were performed for both ECG-gated and FLASH DS-CTA to obtain nonsagittal views of the structures. ECG-gated cardiac CT was obtained to evaluate the aortic annular size while FLASH DS-CTA was obtained to examine the aortic and iliac vasculature as part of TAVR imaging protocol. We evaluated measures of aortic annulus, coronaries and sinus of Valsalva using ECG-gated and FLASH DS-CTA scanning protocols. Image quality assessments were performed using aortic root region-of-interest signal-to-noise ratio. RESULTS A total of 130 patients (mean age 81.5 ± 9.2 years, 46.2% female, and 99.2% white) underwent both ECG-gated CT and FLASH DS-CTA. There were excellent correlations between aortic annular area (R2 = 0.934) and aortic annular perimeter (R2 = 0.923) measured by the two protocols. Only 2 (1.5%) patients had >10% difference between aortic annular measurements by ECG-gated and FLASH DS-CTA, while none of the patients had a >10% difference between aortic annular perimeter measured by ECG-gated and FLASH DS-CT scans. There was no significant difference in signal-to-noise ratio between the two methods (mean difference 13.4; 95% CI -2.1-28.8, p = 0.09). There was significantly lower radiation dose for FLASH DS-CTA than ECG-gated CT scan (mean dose-length product difference 404.38; 95% CI 328.9-479.87, p <0.001). The measurements by the two scans led to the same transcatheter valve size selection in majority of the 128 (98.5%) patients by balloon expandable valve sizing recommendations and 130 (100%) of patients by self-expanding valve sizing recommendations. CONCLUSION Overall, FLASH DS-CTA and ECG-gated CT scans provided comparable image quality and aortic annular dimensions for pre-TAVR evaluation. DS-CTA additionally provided the necessary angiographic imaging of the aorta and peripheral access vessels while still maintaining a lower radiation dose. We propose that a single non-ECG gated FLASH DS-CTA could be utilized to provide all the necessary pre-TAVR imaging information without a gated CT scan.
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Diagnostic Work-Up of the Aortic Patient: An Integrated Approach toward the Best Therapeutic Option. J Clin Med 2021; 10:jcm10215120. [PMID: 34768640 PMCID: PMC8584438 DOI: 10.3390/jcm10215120] [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: 09/29/2021] [Revised: 10/22/2021] [Accepted: 10/29/2021] [Indexed: 01/09/2023] Open
Abstract
Aortic stenosis (AS) is the most common valvular heart disease. In the last decade, transcatheter aortic valve implantation (TAVI) has become the standard of care for symptomatic patients at high surgical risk. Recently, indications to TAVI have also been extended to the low surgical risk and intermediate surgical risk populations. Consequently, in this setting, some aspects acquire greater relevance: surgical risk evaluation, clinical assessment, multimodality imaging of the valve, and management of coronary artery disease. Moreover, future issues such as coronary artery re-access and valve-in-valve interventions should be considered in the valve selection process. This review aims to summarize the principal aspects of a multidimensional (multidisciplinary) and comprehensive preprocedural work-up. The Heart Team is at the center of the decision-making process of the management of aortic valve disease and bears responsibility for offering each patient a tailored approach based on an individual evaluation of technical aspects together with the risks and benefits of each modality. Considering the progressive expansion in TAVI indication and technological progress, the role of a work-up and multidisciplinary Heart Team will be even more relevant.
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Albugami S, Al-Husayni F, Alfouti M, Algahtani M, Alansari W, Hanawi M, Albokhari A, Alkashkari W, Mufti HN, Krimly A, Alameen W, Albawardy R, Alsaiedi A. Self-Expandable Transcatheter Aortic Valve Implantation Outcomes: Findings From the Western Region of Saudi Arabia. Cureus 2021; 13:e18272. [PMID: 34722050 PMCID: PMC8544290 DOI: 10.7759/cureus.18272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2021] [Indexed: 11/21/2022] Open
Abstract
Background and objective The prevalence of aortic stenosis in Saudi Arabia is expected to increase owing to the rise in the life expectancy of the population. Such increase is expected to be met with higher demand for interventions including transcatheter aortic valve implantation (TAVI). In this study, we aimed to identify the outcomes of this procedure among the population of the Western region of Saudi Arabia. Methods This was a retrospective observational study involving patients who underwent TAVI at the King Faisal Cardiac Center (KFCC), Jeddah, Saudi Arabia from June 2018 to January 2020. All patients who had undergone TAVI were included, and patients who were lost to follow-up for more than 90 days were excluded. The collected data included sociodemographic characteristics, peri-procedural assessment, and outcomes within 90 days. Results The study included a total of 52 patients. There were 28 males (53.8%) and 24 females (46.2%). The mean age of the cohort was 78 years. Type two diabetes mellitus was present in 67.3%, and hypertension and dyslipidemia were seen in 80.8% of patients. Coronary diseases were seen in 55.8%. The majority had prior percutaneous coronary intervention (PCI) (53.8%) and 3.8% had coronary artery bypass grafting (CABG). Twenty patients (38.5%) had heart failure. Atrial fibrillation was encountered in 13 patients (25%). Chronic kidney disease was described in nine (17.3%) patients, and four (7.7%) were on regular hemodialysis. The median Society of Thoracic Surgery (STS) risk score was 2.4 (IQR: 1.97-5). High STS scores (>8) were only seen in 9% of the patients. The success rate was 98%, and the in-hospital mortality rate was 3.8%. Vascular complications were seen in eight patients (15.4%), and the majority of them were minor. One patient (1.9%) had a major vascular complication. There was a tendency toward high blood transfusions (19.2%). Clinically manifest stroke was seen in three patients (5.8%). Eight patients (15.4%) had post-procedure complete heart block (CHB). Endocarditis was seen in two patients (3.8%). Thirty-day cardiac readmission was observed in 17.3% of patients, and acute kidney injury was seen in eight patients (15.4%). Mild aortic regurgitation was seen in 51.9% of the patients, but moderate or severe aortic insufficiency (AI) was not encountered. Conclusion Transfemoral TAVI using a self-expandable valve is a safe and feasible procedure at KFCC, an intermediate-sized center. Our data is comparable to local and international centers of similar size. Program sustainability depends on the development of robust referral networks and implementing regulatory quality and patient safety standards.
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Affiliation(s)
- Saad Albugami
- Cardiology, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Cardiology, King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Faisal Al-Husayni
- Internal Medicine, King Abdullah International Medical Research Center, Jeddah, SAU
- Internal Medicine, National Guard Hospital, King Abdulaziz Medical City, Jeddah, SAU
| | - Mawaddah Alfouti
- Internal Medicine, National Guard Hospital, King Abdulaziz Medical City, Jeddah, SAU
| | | | - Wasna Alansari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Maha Hanawi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | | | - Wail Alkashkari
- Cardiology, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Cardiology, King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Hani N Mufti
- Medicine, King Abdullah International Medical Research Center, Jeddah, SAU
- Cardiac Surgery, King Faisal Cardiac Center, King Abdullah Medical City, Jeddah, SAU
- Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Ahmed Krimly
- Cardiology, King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Wail Alameen
- Cardiology, King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Rasha Albawardy
- Cardiology, King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Abdullah Alsaiedi
- Cardiology, King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
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Zhao PY, Wang YH, Liu RS, Zhu JH, Wu JY, Song B. The noninferiority of transcatheter aortic valve implantation compared to surgical aortic valve replacement for severe aortic disease: Evidence based on 16 randomized controlled trials. Medicine (Baltimore) 2021; 100:e26556. [PMID: 34260533 PMCID: PMC8284753 DOI: 10.1097/md.0000000000026556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 06/07/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Currently, transcatheter aortic valve implantation (TAVI) as an effective and convenient intervention has been adopted extensively for patients with severe aortic disease. However, the efficacy and safety of TAVI have not yet been well evaluated and its noninferiority compared with traditional surgical aortic valve replacement (sAVR) still lack sufficient evidence. This meta-analysis was designed to comprehensively compare the noninferiority of TAVI with sAVR for patients with severe aortic disease. METHODS A systematic search of PubMed, Embase, Cochrane Library, and Web of Science up to October 1, 2020 was conducted for relevant studies that comparing TAVI and sAVR in the treatment of severe aortic disease. The primary outcomes were early, midterm and long term mortality. The secondary outcomes included early complications and other late outcomes. Two reviewers assessed trial quality and extracted the data independently. All statistical analyzes were performed using the standard statistical procedures provided in Review Manager 5.2. RESULTS A total of 16 studies including 14394 patients were identified. There was no difference in 30-day, 1-year, 2-year, and 5-year all-cause or cardiovascular mortality as well as stroke between TAVI and sAVR. Regarding to the 30-day outcomes, compared with sAVR, TAVI experienced a significantly lower incidence of myocardial infarction (risk ratio [RR] 0.62; 95% confidence interval [CI] 0.40-0.97; 5441 pts), cardiogenic shock (RR 0.34; 95% CI 0.19-0.59; 1936 pts), acute kidney injury (AKI) > stage 2 (RR 0.37; 95% CI 0.25-0.54; 5371 pts), and new-onset atrial fibrillation (NOAF) (RR 0.29; 95% CI 0.24-0.35; 5371 pts) respectively, but higher incidence of permanent pacemaker implantation (RR 3.16; 95% CI 1.61-6.21; 5441 pts) and major vascular complications (RR 2.22; 95% CI 1.14-4.32; 5371 pts). Regarding to the 1- and 2-year outcomes, compared with sAVR, TAVI experienced a significantly lower incidence of NOAF, but higher incidence of neurological events, transient ischemic attacks (TIA), permanent pacemaker and major vascular complications respectively. Regarding to the 5-year outcomes, compared with sAVR, TAVI experienced a significantly lower incidence of NOAF, but higher incidence of TIA and reintervention respectively. CONCLUSIONS Our analysis shows that TAVI was equal to sAVR in early, midterm and long term mortality for patients with severe aortic disease. In addition, TAVI may be favorable in reducing the incidence of both early, midterm and long term NOAF. However, pooled results showed superiority of sAVR in reducing permanent pacemaker implantation, neurological events, TIA, major vascular complications and reintervention.
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Affiliation(s)
- Peng-Ying Zhao
- Department of Cardiovascular Surgery, Lanzhou University First Affiliated Hospital, Lanzhou, China
| | - Yong-Hong Wang
- Department of Cardiovascular Surgery, Qinghai University Affiliated Hospital, Xi’ning, China
- Medical College of Qinghai University, Qinghai University, Xi’ning, China
| | - Rui-Sheng Liu
- Department of Cardiovascular Surgery, Lanzhou University First Affiliated Hospital, Lanzhou, China
| | - Ji-Hai Zhu
- Department of Cardiovascular Surgery, Qinghai University Affiliated Hospital, Xi’ning, China
- Medical College of Qinghai University, Qinghai University, Xi’ning, China
| | - Jian-Ying Wu
- Department of Cardiovascular Surgery, Qinghai University Affiliated Hospital, Xi’ning, China
- Medical College of Qinghai University, Qinghai University, Xi’ning, China
| | - Bing Song
- Department of Cardiovascular Surgery, Lanzhou University First Affiliated Hospital, Lanzhou, China
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Ding Y, Wan M, Zhang H, Wang C, Dai Z. Comparison of postprocedural new-onset atrial fibrillation between transcatheter and surgical aortic valve replacement: A systematic review and meta-analysis based on 16 randomized controlled trials. Medicine (Baltimore) 2021; 100:e26613. [PMID: 34260547 PMCID: PMC8284731 DOI: 10.1097/md.0000000000026613] [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: 12/16/2020] [Accepted: 06/22/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Presently, transcatheter aortic valve replacement (TAVR) as an effective and convenient intervention has been adopted extensively for patients with severe aortic disease. However, after surgical aortic valve replacement (SAVR) and TAVR, the incidence of new-onset atrial fibrillation (NOAF) is prevalently found. This meta-analysis was designed to comprehensively compare the incidence of NOAF at different times after TAVR and SAVR for patients with severe aortic disease. METHODS A systematic search of PubMed, Embase, Cochrane Library, and Web of Science up to October 1, 2020 was conducted for relevant studies that comparing TAVR and SAVR in the treatment of severe aortic disease. The primary outcomes were the incidence of NOAF with early, midterm and long term follow-up. The secondary outcomes included permanent pacemaker (PM) implantation, myocardial infarction (MI), cardiogenic shock, as well as mortality and other complications. Two reviewers assessed trial quality and extracted the data independently. All statistical analyses were performed using the standard statistical procedures provided in Review Manager 5.2. RESULTS A total of 16 studies including 13,310 patients were identified. The pooled results indicated that, compared with SAVR, TAVR experienced a significantly lower incidence of 30-day/in-hospital, 1-year, 2-year, and 5-year NOAF, with pooled risk ratios (RRs) of 0.31 (95% confidence interval [CI] 0.23-0.41; 5725 pts), 0.30 (95% CI 0.24-0.39; 6321 pts), 0.48 (95% CI 0.38-0.61; 3441 pts), and 0.45 (95% CI 0.37-0.55; 2268 pts) respectively. In addition, TAVR showed lower incidence of MI (RR 0.62; 95% CI 0.40-0.97) and cardiogenic shock (RR 0.34; 95% CI 0.19-0.59), but higher incidence of permanent PM (RR 3.16; 95% CI 1.61-6.21) and major vascular complications (RR 2.22; 95% CI 1.14-4.32) at 30-day/in-hospital. At 1- and 2-year after procedure, compared with SAVR, TAVR experienced a significantly higher incidence of neurological events, transient ischemic attacks (TIA), permanent PM, and major vascular complications, respectively. At 5-year after procedure, compared with SAVR, TAVR experienced a significantly higher incidence of TIA and re-intervention respectively. There was no difference in 30-day, 1-year, 2-year, and 5-year all-cause or cardiovascular mortality as well as stroke between TAVR and SAVR. CONCLUSIONS Our analysis showed that TAVR was superior to SAVR in decreasing the both short and long term postprocedural NOAF. TAVR was equal to SAVR in early, midterm and long term mortality. In addition, TAVR showed lower incidence of 30-day/in-hospital MI and cardiogenic shock after procedure. However, pooled results showed that TAVR was inferior to SAVR in reducing permanent pacemaker implantation, neurological events, TIA, major vascular complications, and re-intervention.
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Affiliation(s)
| | - Minmin Wan
- Outpatient Department, Zhebei Mingzhou hospital, Huzhou, China
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Zhang G, Liu R, Pu M, Zhou X. Biomechanical Identification of High-Risk Patients Requiring Permanent Pacemaker After Transcatheter Aortic Valve Replacement. Front Bioeng Biotechnol 2021; 9:615090. [PMID: 34307314 PMCID: PMC8299755 DOI: 10.3389/fbioe.2021.615090] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 06/08/2021] [Indexed: 11/30/2022] Open
Abstract
Background Cardiac conduction disturbance requiring new permanent pacemaker implantation (PPI) is an important complication of TAVR that has been associated with increased mortality. It is extremely challenging to optimize the valve size alone to prevent a complete atrioventricular block (AVB). Methods In this study, we randomly took 48 patients who underwent TAVR and had been followed for at least 2 years to assess the risk of AVB. CT images of 48 patients with TAVR were analyzed using three-dimensional (3D) anatomical models of the aortic valve apparatus. The stresses were formulated according to loading force and tissue properties. Support vector regression (SVR) was used to model the relationship between AVB risk and biomechanical stresses. To avoid AVB, overlapping regions on the prosthetic valve where AV bundle passes will be removed as cylindrical sector with the angle θ. Thus, the optimization of the valve shape will be predicted with the joint optimization of the θ and valve size R. Results The average AVB risk prediction accuracy was 83.33% in the range from 0.8–0.85 with 95% CI for all cases; specifically, 85.71% for Group A (no AVB), and 80.0% for Group B (undergoing AVB after the TAVR). Conclusions This model can estimate the optimal valve size and shape to avoid the risk of AVB after TAVR. This optimization may eliminate the excessive stresses to keep the normal function of both AV bundle and valve leaflets, leading to a favorable clinical outcome. The combination of biomechanical properties and machine learning method substantially improved prediction of surgical results.
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Affiliation(s)
- Guangming Zhang
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Rong Liu
- Department of Internal Medicine/Cardiology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Min Pu
- Department of Internal Medicine/Cardiology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Xiaobo Zhou
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, United States
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Barili F, Freemantle N, Pilozzi Casado A, Rinaldi M, Folliguet T, Musumeci F, Gerosa G, Parolari A. Mortality in trials on transcatheter aortic valve implantation versus surgical aortic valve replacement: a pooled meta-analysis of Kaplan-Meier-derived individual patient data. Eur J Cardiothorac Surg 2021; 58:221-229. [PMID: 32236543 DOI: 10.1093/ejcts/ezaa087] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/12/2020] [Accepted: 02/16/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES This meta-analysis of Kaplan-Meier-estimated individual patient data was designed to evaluate the effects of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) on the long-term all-cause mortality rate, to examine the potential time-varying effect and to model their hazard ratios (HRs) over time. Moreover, we sought to compare traditional meta-analytic tools and estimated individual patient data meta-analyses. METHODS Trials comparing TAVI versus SAVR were identified through Medline, Embase, Cochrane databases and specialist websites. The primary outcome was death from any cause at follow-up. Enhanced secondary analyses of survival curves were performed estimating individual patient time-to-event data from published Kaplan-Meier curves. Treatments were compared with the random effect Cox model in a landmark framework and fully parametric models. RESULTS We identified 6 eligible trials that included 6367 participants, randomly assigned to undergo TAVI (3252) or SAVR (3115). According to the landmark analysis, the incidence of death in the first year after implantation was significantly lower in the TAVI group [risk-profile stratified HR 0.85, 95% confidence interval (CI) 0.73-0.99; P = 0.04], whereas there was a reversal of the HR after 40 months (risk-profile stratified HR 1.31, 95% CI 1.01-1.68; P = 0.04) favouring SAVR over TAVI. This time-varying trend of HRs was also confirmed by a fully parametric time-to-event model. Traditional meta-analytic tools were shown to be biased because they did not intercept heterogeneity and the time-varying effect. CONCLUSIONS The mortality rates in trials of TAVI versus SAVR are affected by treatments with a time-varying effect. TAVI is related to better survival in the first months after implantation whereas, after 40 months, it is a risk factor for all-cause mortality.
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Affiliation(s)
- Fabio Barili
- Department of Cardiac Surgery, S. Croce Hospital, Cuneo, Italy
| | - Nicholas Freemantle
- Department of Primary Care and Population Health, University College London, London, UK
| | | | - Mauro Rinaldi
- Department of Cardiac Surgery, AOU "Città della Salute e della Scienza di Torino", University of Turin, Turin, Italy
| | | | - Francesco Musumeci
- Department of Heart and Vessels, Cardiac Surgery Unit and Heart Transplantation Center, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Gino Gerosa
- Department of Cardiac Surgery, University of Padua, Padua, Italy
| | - Alessandro Parolari
- Unit of Cardiac Surgery and Translational Research, IRCCS Policlinico S. Donato, University of Milan, Milan, Italy
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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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Yerasi C, Rogers T, Forrestal BJ, Case BC, Khan JM, Ben-Dor I, Satler LF, Garcia-Garcia HM, Cohen JE, Kitahara H, Shults C, Waksman R. Transcatheter Versus Surgical Aortic Valve Replacement in Young, Low-Risk Patients With Severe Aortic Stenosis. JACC Cardiovasc Interv 2021; 14:1169-1180. [PMID: 34112453 DOI: 10.1016/j.jcin.2021.03.058] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 01/24/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is approved for all patient risk profiles and is an option for all patients irrespective of age. However, patients enrolled in the low- and intermediate-risk trials were in their 70s, and those in the high-risk trials were in their 80s. TAVR has never been systematically tested in young (<65 years), low-risk patients. Unanswered questions remain, including the safety and effectiveness of TAVR in patients with bicuspid aortic valves; future coronary access; durability of transcatheter heart valves; technical considerations for surgical transcatheter heart valve explantation; management of concomitant conditions such as aortopathy, mitral valve disease, and coronary artery disease; and the safety and feasibility of future TAVR-in-TAVR. The authors predict that balancing these questions with patients' clear preference for less invasive treatment will become common. In this paper, the authors consider each of these questions and discuss risks and benefits of theoretical treatment strategies in the lifetime management of young patients with severe aortic stenosis.
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Affiliation(s)
- Charan Yerasi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Brian J Forrestal
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jaffar M Khan
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Hector M Garcia-Garcia
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeffrey E Cohen
- Department of Cardiac Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Hiroto Kitahara
- Department of Cardiac Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Christian Shults
- Department of Cardiac Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA.
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Novel Combined Antioxidant Strategy against Hypertension, Acute Myocardial Infarction and Postoperative Atrial Fibrillation. Biomedicines 2021; 9:biomedicines9060620. [PMID: 34070760 PMCID: PMC8228412 DOI: 10.3390/biomedicines9060620] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/19/2021] [Accepted: 05/27/2021] [Indexed: 12/28/2022] Open
Abstract
Reactive oxygen species (ROS) play a physiological role in the modulation of several functions of the vascular wall; however, increased ROS have detrimental effects. Hence, oxidative stress has pathophysiological impacts on the control of the vascular tone and cardiac functions. Recent experimental studies reported the involvement of increased ROS in the mechanism of hypertension, as this disorder associates with increased production of pro-oxidants and decreased bioavailability of antioxidants. In addition, increased ROS exposure is found in ischemia-reperfusion, occurring in acute myocardial infarction and cardiac surgery with extracorporeal circulation, among other settings. Although these effects cause major heart damage, at present, there is no available treatment. Therefore, it should be expected that antioxidants counteract the oxidative processes, thereby being suitable against cardiovascular disease. Nevertheless, although numerous experimental studies agree with this notion, interventional trials have provided mixed results. A better knowledge of ROS modulation and their specific interaction with the molecular targets should contribute to the development of novel multitarget antioxidant effective therapeutic strategies. The complex multifactorial nature of hypertension, acute myocardial infarction, and postoperative atrial fibrillation needs a multitarget antioxidant strategy, which may give rise to additive or synergic protective effects to achieve optimal cardioprotection.
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D'Ascenzo F, Bruno F, Baldetti L, De Filippo O, Marengo G, Breviario S, Melillo F, Thyregod HGH, Thiele H, Sondergaard L, Popma JJ, Kodali S, Franchin L, Annaratone M, Marruncheddu L, Gallone G, Crimi G, La Torre M, Rinaldi M, Omedè P, Conrotto F, Salizzoni S, De Ferrari GM. Aortic valve replacement vs. balloon-expandable and self-expandable transcatheter implantation: A network meta-analysis. Int J Cardiol 2021; 337:90-98. [PMID: 33974961 DOI: 10.1016/j.ijcard.2021.04.068] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/21/2021] [Accepted: 04/30/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Recently, observational data have raised concerns about safety of selfexpandable (SE) compared to balloon-expandable (BE) valves in TAVI, although potentially limited by patient selection bias. METHODS All Randomized Controlled Trials (RCTs) comparing BE vs. SE TAVI or/and vs. aortic valve replacement (AVR) were included and compared through Network Meta Analysis (NMA). All-cause and cardiovascular (CV) mortality were the primary endpoints, stroke, rates of permanent pacemaker implantation (PPI), moderate/severe paravalvular leak (PVL) and reintervention were the secondary endpoints. Results We obtained data from 11 RCTs, encompassing 9752 patients. After one and two years, no significant differences for allcause and CV mortality were observed. Compared to surgical bioprostheses, both BE and SE TAVI reduced the risk of acute kidney injury (OR 0.42; CI 95% 0.30-0.60 and OR 0.44; CI 95% 0.32-0.60), new-onset atrial fibrillation (OR 0.24; CI 95% 0.14-0.42 and OR 0.21; CI 95% 0.13-0.34) and major bleedings (OR 0.32; CI 95% 0.16-0.65 and OR 0.47; CI 95% 0.25-0.89). The BE prostheses reduced the risk of moderate/severe PVL at 30-day (OR 0.31; CI 95% 0.17-0.55) and of PPI both at 30-day (OR 0.51; CI 95% 0.33-0.79) and 1 year (OR 0.40; CI 95% 0.30-0.55) as compared to SE TAVI. Conclusions A TAVI strategy, independently from BE or SE prostheses, offers a midterm survival comparable to AVR. The BE prostheses are associated with a reduction of PPI and PVL compared to SE prostheses without any differences in all-cause and CV mortality during two years of follow up. PROSPERO ID CRD42020182407.
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Affiliation(s)
- Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy.
| | - Francesco Bruno
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy
| | - Giorgio Marengo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy
| | - Susanna Breviario
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy
| | - Francesco Melillo
- Unit of echocardiography, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Holger Thiele
- Heart Center Leipzig, University of Leipzig, Germany
| | | | | | - Susheel Kodali
- Columbia University Medical Center (SKK), United States of America
| | - Luca Franchin
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy
| | | | - Laura Marruncheddu
- Department of Clinical Internal, Anesthesiological and Cardiovascular Science, Sapienza University of Rome, Rome, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy
| | | | - Michele La Torre
- Division of Cardiosurgery, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy
| | - Mauro Rinaldi
- Division of Cardiosurgery, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy
| | - Pierluigi Omedè
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy
| | - Federico Conrotto
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy
| | - Stefano Salizzoni
- Division of Cardiosurgery, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Italy
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Bäz L, Puscholt M, Lasch C, Diab M, Möbius-Winkler S, Schulze PC, Dannberg G, Franz M. Delayed Improvement of Depression and Anxiety after Transcatheter Aortic Valve Implantation (TAVI) in Stages of Extended Extra-Valvular Cardiac Damage. J Clin Med 2021; 10:jcm10081579. [PMID: 33918058 PMCID: PMC8070529 DOI: 10.3390/jcm10081579] [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: 02/11/2021] [Revised: 04/02/2021] [Accepted: 04/03/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Depression and anxiety are frequently occurring and likely to be linked to the severity of cardiac diseases like aortic stenosis (AS). This seems to be of interest since a staging classification of extra-valvular cardiac damage in AS has been introduced and shown to be of prognostic relevance. Objective: The current study aimed to investigate the frequency of depression and anxiety in association to staging and their dynamics after transcatheter aortic valve implantation (TAVI). Methods: A total number of 224 AS patients undergoing TAVI were classified according to the 2017 staging classification into stage 0 to 4 and further dichotomized into group A (stage 0 to 2) and B (stage 3 and 4). Using the Hospital Anxiety and Depression Scale (HADS-D), patients were assigned to depressive versus non-depressive or anxious versus non-anxious per staging group respectively, and analyzed at baseline, 6 weeks, 6 months and 12 months after TAVI. Results: After dichotomization, 158 patients (70.5%) were assigned to group A and 66 patients (29.5%) to group B. The part showing pathologic values for depression was 25.4% (57/224 patients) in the entire collective, 26.6% (42/158 patients) in group A and 22.7% (15/66 patients) in group B (p = n.s.). The proportion showing pathologic values for anxiety was 26.8% (60/224 patients) in the entire collective and did not differ between group A (24.7%, 39/158 patients) and B (31.8%, 21/66 patients) (p = n.s.). In patients revealing pathologic values for depression or anxiety prior to TAVI, there were significant and stable improvements over time observable already in short-term (6 weeks) follow-up in group A, and likewise, but later, in long-term (6/12 months) follow-up in group B. Conclusions: Although of proven prognostic relevance, higher stages of extra-valvular cardiac damage are not associated with higher rates of pre-existing depression or anxiety. The TAVI procedure resulted in a persisting reduction of depression and anxiety in patients showing pathologic values at baseline. Notably, these improvements are timely delayed in higher stages.
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Affiliation(s)
- Laura Bäz
- Department of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany; (L.B.); (M.P.); (C.L.); (S.M.-W.); (P.C.S.); (G.D.)
| | - Marisa Puscholt
- Department of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany; (L.B.); (M.P.); (C.L.); (S.M.-W.); (P.C.S.); (G.D.)
| | - Claudia Lasch
- Department of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany; (L.B.); (M.P.); (C.L.); (S.M.-W.); (P.C.S.); (G.D.)
| | - Mahmoud Diab
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany;
| | - Sven Möbius-Winkler
- Department of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany; (L.B.); (M.P.); (C.L.); (S.M.-W.); (P.C.S.); (G.D.)
| | - P. Christian Schulze
- Department of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany; (L.B.); (M.P.); (C.L.); (S.M.-W.); (P.C.S.); (G.D.)
| | - Gudrun Dannberg
- Department of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany; (L.B.); (M.P.); (C.L.); (S.M.-W.); (P.C.S.); (G.D.)
| | - Marcus Franz
- Department of Internal Medicine I, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany; (L.B.); (M.P.); (C.L.); (S.M.-W.); (P.C.S.); (G.D.)
- Correspondence: ; Tel.: +49-(3641)-9324127; Fax: +49-(3641)-0324102
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2020 update of the Austrian Society of Cardiology (ÖKG) and the Austrian Society of Cardiac Surgery (ÖGHTG) on the position statement of the ÖKG and ÖGHTG for transcatheter aortic valve implantation 2011. Wien Klin Wochenschr 2021; 133:750-761. [PMID: 33755758 DOI: 10.1007/s00508-021-01820-3] [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: 06/06/2020] [Accepted: 01/21/2021] [Indexed: 10/21/2022]
Abstract
This position statement is an update to the 2011 consensus statement of the Austrian Society of Cardiology (ÖKG) and the Austrian Society of Cardiac Surgery (ÖGTHG) for transfemoral transcatheter aortic valve implantation.Due to a number of recently published studies, broadening of indications and recommendations of medical societies and our own national developments, the ÖKG and the ÖGHTG wish to combine the 2017 ESC/EACTS guidelines for the management of valvular heart disease with a national position paper and to focus on certain details for the application in Austria. Thus, this position statement serves as a supplement and further interpretation of the international guidelines.
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Humbert M, Büla CJ, Muller O, Krief H, Monney P. Delirium in older patients undergoing aortic valve replacement: incidence, predictors, and cognitive prognosis. BMC Geriatr 2021; 21:153. [PMID: 33653285 PMCID: PMC7927377 DOI: 10.1186/s12877-021-02100-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/22/2021] [Indexed: 12/14/2022] Open
Abstract
Background Transcatheter aortic valve replacement is increasingly performed in frail older patients who were previously ineligible for a standard surgical procedure. The objectives of this study are to determine delirium incidence, predictors, and relationship with cognitive performance at 3-month follow-up in older patients undergoing aortic valve replacement (AVR). Methods Patients (N = 93) aged 70 years and older, undergoing transcatheter (TAVR, N = 66) or surgical (SAVR, N = 27) aortic valve replacement in an academic medical center were enrolled in this prospective cohort study. Delirium was assessed using the Confusion Assessment Method (CAM) on postoperative days 1, 2, 3, and 7. Data on patients’ socio-demographics, functional status (including instrumental activities of daily living (IADL), and surgical risk scores (including Society of Thoracic Surgeons (STS) risk score), were collected at baseline. Cognitive status was assessed with the Mini-Mental Status Exam (MMSE) and the Clock Drawing Test (CDT) at baseline and 3 months after AVR. Results Delirium occurred in 21 (23%) patients, within the first three postoperative days in 95% (20/21) of the cases. Delirium incidence was lower in TAVR (13/66 = 20%) than SAVR (8/27 = 30%) patients, but this difference was not statistically significant (p = .298). Patients with delirium had lower baseline cognitive performance (median MMSE score 27.0 ± 3.0 vs 28.0 ± 3.0, p = .029), lower performance in IADL (7.0 vs 8.0, p = .038), and higher STS risk scores (4.7 ± 2.7 vs 2.9 ± 2.3, p = .020). In multivariate analyses, patients with intermediate (score > 3 to ≤8) and high (score > 8) STS risk scores had 4.3 (95%CI 1.2–15.1, p = .025) and 16.5 (95%CI 2.0–138.2, p = .010), respectively, higher odds of incident delirium compared to patients with low (score ≤ 3) STS risk scores. At 3-month follow-up (N = 77), patients with delirium still had lower MMSE score (27.0 ± 8.0 vs 28.0 ± 2.0, p = .007) but this difference did not remain significant once adjusting for baseline MMSE (β-coefficient 1.11, 95%CI [− 3.03–0.80], p = .248). Conclusions Delirium occurred in about one in five older patients undergoing AVR, almost essentially within the first three postoperative days. Beside cognitive performance, STS risk score could enhance the identification of high-risk older patients to better target preventative interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02100-5.
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Affiliation(s)
- Marc Humbert
- Service of Geriatric Medicine and Geriatric Rehabilitation, Department of Medicine, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland.
| | - Christophe J Büla
- Service of Geriatric Medicine and Geriatric Rehabilitation, Department of Medicine, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland
| | - Olivier Muller
- Service of Cardiology, Department of Cardio-Vascular Medicine and Surgery, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland
| | - Hélène Krief
- Service of Geriatric Medicine and Geriatric Rehabilitation, Department of Medicine, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland
| | - Pierre Monney
- Service of Cardiology, Department of Cardio-Vascular Medicine and Surgery, University of Lausanne Medical Center (CHUV), Lausanne, Switzerland
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Doyle MP, Woldendorp K, Ng M, Vallely MP, Wilson MK, Yan TD, Bannon PG. Minimally-invasive versus transcatheter aortic valve implantation: systematic review with meta-analysis of propensity-matched studies. J Thorac Dis 2021; 13:1671-1683. [PMID: 33841958 PMCID: PMC8024828 DOI: 10.21037/jtd-20-2233] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Minimally invasive aortic valve replacement (MiAVR) and transcatheter aortic valve implantation (TAVI) provide aortic valve replacement (AVR) by less invasive methods than conventional surgical AVR, by avoiding complete sternotomy. This study directly compares and analyses the available evidence for early outcomes between these two AVR methods. Methods Electronic databases were searched from inception until August 2019 for studies comparing MiAVR to TAVI, according to predefined search criteria. Propensity-matched studies with sufficient data were included in a meta-analysis. Results Eight studies with 9,744 patients were included in the quantitative analysis. Analysis of risk-matched patients showed no difference in early mortality (RR 0.76, 95% CI, 0.37–1.54, P=0.44). MiAVR had a signal towards lower rate of postoperative stroke, although this did not reach statistical significance (OR 0.42, 95% CI, 0.13–1.29, P=0.13). MiAVR had significantly lower rates of new pacemaker (PPM) requirement (OR 0.29, 95% CI, 0.16–0.52, P<0.0001) and postoperative aortic insufficiency (AI) or paravalvular leak (PVL) (OR 0.05, 95% CI, 0.01–0.20, P<0.0001) compared to TAVI, (OR 0.42, 95% CI, 0.13–1.29, P=0.13), while acute kidney injury (AKI) was higher in MiAVR compared to TAVI (11.1% vs. 5.2%, OR 2.28, 95% CI, 1.25–4.16, P=0.007). Conclusions In patients of equivalent surgical risk scores, MiAVR may be performed with lower rates of postoperative PPM requirement and AI/PVL, higher rates of AKI and no statistical difference in postoperative stroke or short-term mortality, compared to TAVI. Further prospective trials are needed to validate these results.
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Affiliation(s)
- Mathew P Doyle
- The Royal Prince Alfred Hospital, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,University of Wollongong School of Medicine, Keiraville, Australia
| | - Kei Woldendorp
- The Royal Prince Alfred Hospital, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,The University of Sydney Medical School, Camperdown, Australia
| | - Martin Ng
- The Royal Prince Alfred Hospital, Sydney, Australia.,The University of Sydney Medical School, Camperdown, Australia
| | | | - Michael K Wilson
- Macquarie University Hospital, Macquarie University, Sydney, Australia
| | - Tristan D Yan
- The Royal Prince Alfred Hospital, Sydney, Australia.,Macquarie University Hospital, Macquarie University, Sydney, Australia.,Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Paul G Bannon
- The Royal Prince Alfred Hospital, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia.,The University of Sydney Medical School, Camperdown, Australia
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Zhang XL, Zhang XW, Lan RF, Chen Z, Wang L, Xu W, Xu B. Long-term and Temporal Outcomes of Transcatheter Versus Surgical Aortic-valve Replacement in Severe Aortic Stenosis: A Meta-analysis. Ann Surg 2021; 273:459-466. [PMID: 32502078 DOI: 10.1097/sla.0000000000003906] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the 5-year and temporal performance of TAVR versus SAVR. BACKGROUND TAVR has become a valuable treatment for severe aortic stenosis but the long-term safety and efficacy remain unclear. METHODS Databases were searched until October 6, 2019 for randomized trials with ≥5 years' follow-up. Primary outcome was all-cause mortality. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled with random-effects models. RESULTS We included 4 trials with 3,758 patients. TAVR was associated with a significantly higher 5-year all-cause mortality than SAVR (OR, 1.19; 95% CI, 1.03-1.37; P = 0.02). Landmark analysis showed no significant difference within 2 years (OR, 0.92; 95% CI, 0.79-1.08; P = 0.33) but a statistically higher mortality in TAVR between 2 and 5 years (OR, 1.32; 95% CI, 1.14-1.52; P = 0.0002), with significant difference between these 2 temporal phases (P for interaction = 0.001). Similar interaction was found for cardiovascular mortality and several other outcomes. Rates of all-cause mortality or disabling stroke, permanent pacemaker implantation, aortic-valve rehospitalization, and reintervention were higher, but rates of major bleeding and new-onset fibrillation were lower in TAVR at 5 years. The incidences of myocardial infarction, stroke, and transient ischemic attack were not statistically different between TAVR and SAVR. CONCLUSIONS TAVR was associated with a significantly higher all-cause mortality at 5 years compared with SAVR. Of note, all-cause mortality presented a characteristic temporal pattern showing increased risk between 2 and 5 years but not within 2 years. Longer-term follow-up data are warranted.
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Affiliation(s)
- Xin-Lin Zhang
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xiao-Wen Zhang
- Department of Endocrinology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Rong-Fang Lan
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zheng Chen
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Lian Wang
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Wei Xu
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Biao Xu
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, Nanjing, China
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Meguro K, Kumamaru H, Kohsaka S, Hashimoto T, Kakizaki R, Kitamura T, Shimizu H, Ako J. Transcatheter Aortic Valve Replacement in Patients With a Small Annulus - From the Japanese Nationwide Registry (J-TVT). Circ J 2021; 85:967-976. [PMID: 33642425 DOI: 10.1253/circj.cj-20-1084] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The details and consequences of a small aortic annulus among transcatheter aortic valve replacement (TAVR) patients remain uncertain. This study investigated the short-term outcomes in patients with small annular size and compared the 30-day outcome between intra- and supra-annular devices, with similar outer casing diameter in this subgroup.Methods and Results:Cases registered in the Japanese national TAVR registry between August 2013 and December 2017 were analyzed. Among a total of 5,870 registered patients, 647 (11.0%) had small annulus (area ≤314 mm2) measured by multi-detector computed tomography. Patients with a small annulus had a significantly smaller indexed effective orifice area (iEOA, 1.10 cm2/m2[0.92-1.35] vs. 1.16 cm2/m2[0.96-1.39], P<0.001) and higher mean pressure gradient (mPG, 10.0 mmHg [6.9-14.2] vs. 8.5 mmHg [6.0-11.5], P<0.001) compared with a normal-sized annulus. Among patients with a small annulus, those receiving a 20 mm intra-annular device had a smaller iEOA (0.94 cm2/m2[0.78-1.06] vs. 1.07 cm2/m2[0.8-1.24], P=0.001) and higher mPG (14.0 mmHg [10.0-18.5] vs. 11.0 [7.0-14.0], P<0.001) compared with those receiving a 23-mm supra-annular device, although the incidence of paravalvular leakage (≥moderate) was similar (14.4% vs. 16.5%, P=0.69). CONCLUSIONS Patients with a small annulus were associated with less hemodynamic improvement. A supra-annular device is associated with better echocardiographic improvement in patients with a small annulus, without increasing paravalvular leakage.
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Affiliation(s)
- Kentaro Meguro
- Department of Cardiovascular Medicine, Kitasato University
| | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment, Graduate School of Medicine, the University of Tokyo
| | | | | | - Ryota Kakizaki
- Department of Cardiovascular Medicine, Kitasato University
| | | | | | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University
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Lin X, Wang S, Wang L, Guan Y, Huang J. Aspirin Alone Versus Dual Antiplatelet Therapy after Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis. Cardiovasc Drugs Ther 2021; 36:271-278. [PMID: 33570686 DOI: 10.1007/s10557-021-07145-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND The current American College of Cardiology and American Heart Association (ACC/AHA) guidelines recommend dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for 6 months followed by lifelong aspirin after transcatheter aortic valve replacement (TAVR). However, studies that have DAPT with aspirin following TAVR have questioned this recommendation as DAPT has been associated with more bleeding events compared to aspirin. We performed a systematic review and meta-analysis of all the RCTs comparing DAPT (aspirin plus clopidogrel) with aspirin alone as antithrombotic treatment following transcatheter aortic valve replacement. METHODS The databases of Embase, PubMed, and Cochrane library were searched from inception to Oct 1, 2020, and randomized controlled trials (RCTs) reporting aspirin plus clopidogrel with aspirin alone as antithrombotic treatment after TAVI were included. Revman 5.3 was used to conduct the analysis. RESULTS After screening 152 articles, four studies involving 1086 patients (541 patients in the aspirin group and 545 patients in the DAPT group) were included. The results demonstrated that, at 30 days follow-up, compared with DAPT, aspirin was not associated with a statistically significant difference in the rate of bleeding events (RR = 1.22, 95% CI 0.62 to 2.39, P = 0.57), all-cause mortality (RR = 1.21, 95% CI 0.52 to 2.84, P = 0.66), stroke (RR = 0.81, 95% CI 0.24 to 2.79, P = 0.74), and MI (RR = 4.00, 95% CI 0.45 to 35.22, P = 0.21). However, at the 6 to 12 months follow-up, DAPT appeared to increase the risk of bleeding events compared with aspirin alone (RR = 1.67, 95% CI 1.24 to 2.24, P < 0.001), and there was no significant difference in the rate of all-cause mortality (RR = 0.89, 95% CI 0.53 to 1.48, P = 0.65), stroke (RR = 1.04, 95% CI 0.57 to 1.92, P = 0.90), and MI (RR = 1.65, 95% CI 0.52 to 5.26, P = 0.40) among the two groups. CONCLUSIONS Our systematic review and meta-analysis suggested that aspirin alone could decrease the risk of bleeding and was not associated with higher risk of mortality, stroke or myocardial infarction compared with DAPT.
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Affiliation(s)
- Xiaoxiao Lin
- Zhejiang Chinese Medical University, Hangzhou, China
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Stress: No. 261, Huansha Road, Hangzhou, 310006, China
| | - Shuai Wang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Stress: No. 261, Huansha Road, Hangzhou, 310006, China
| | - Long Wang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Stress: No. 261, Huansha Road, Hangzhou, 310006, China
| | - Yihong Guan
- Zhejiang Chinese Medical University, Hangzhou, China
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Stress: No. 261, Huansha Road, Hangzhou, 310006, China
| | - Jinyu Huang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Stress: No. 261, Huansha Road, Hangzhou, 310006, China.
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Carnero-Alcázar M, Maroto-Castellanos LC, Hernández-Vaquero D, López-Menéndez J, Hornero-Sos F, Silva-Guisasola J, Cobiella-Carnicer J, Pérez-Camargo D, Álvarez-de Arcaya MA, Campelos-Fernández P, Elvira-Martínez C. Sustitución valvular aórtica convencional aislada en España: tendencias nacionales de riesgo, tipo de prótesis y mortalidad entre 1998 y 2017. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2020.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Stachon P, Steinfurt J, van de Loo T, Trolese L, Faber T, Kaier K, Heidt T, Bothe W, Krauss T, Wolf D, Duerschmied D, Zehender M, Bamberg F, Bode C, von Zur Mühlen C. Impact of Preprocedural Aortic Valve Calcification on Conduction Disturbances after Transfemoral Aortic Valve Replacement. Cardiology 2020; 146:228-237. [PMID: 32966978 DOI: 10.1159/000509389] [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: 01/17/2020] [Accepted: 06/10/2020] [Indexed: 11/19/2022]
Abstract
AIM The present study analyzes in depth the impact of different calcification patterns on disturbances of the conduction system in transcatheter aortic valve replacement (TAVR) patients. METHODS AND RESULTS A total of 169 preprocedural TAVR multislice computed tomography scans from consecutive transfemoral (TF) TAVRs performed between 2014 and 2017 using either Edwards SAPIEN or Medtronic Evolut R valves were retrospectively evaluated. The volume, distribution, and orientation of annular and valvular aortic valve calcification were measured and their impact on postoperative conduction disturbances was determined using linear and logistic regression analyses. The total volume of calcification and distribution at the aortic annulus or valve did not influence the conduction system. Oval calcification of the left aortic cusp was independently associated with an elevated risk for an increase in atrioventricular block degree (+0.6, p = 0.03). Moreover, orthogonal calcifications at the level of the aortic annulus were associated with an increased risk for QRS prolongation (+26 ms, p = 0.004) and an increased risk for permanent pacemaker implantation (OR 4.3, p = 0.03) after TF TAVR. This was more pronounced in patients undergoing TF TAVR using a balloon-expandable Edwards SAPIEN 3 valve (QRS +38.195 ms, p < 0.001; OR permanent pacemaker 15.48, p = 0.013). CONCLUSION Orthogonal annular calcification confers an increased risk for conduction disturbances after TAVR. This is even more pronounced after implantation of balloon-expandable valves.
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Affiliation(s)
- Peter Stachon
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany,
| | - Johannes Steinfurt
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tim van de Loo
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Luca Trolese
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Faber
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Timo Heidt
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolfgang Bothe
- University Heart Center Freiburg, Department of Cardiovascular Surgery, Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Tobias Krauss
- University Hospital Freiburg, Department of Radiology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dennis Wolf
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Fabian Bamberg
- University Hospital Freiburg, Department of Radiology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Mühlen
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Zhang D, Mao X, Liu D, Zhang J, Luo G, Luo L. Transcatheter vs surgical aortic valve replacement in low to intermediate surgical risk aortic stenosis patients: A systematic review and meta-analysis of randomized controlled trials. Clin Cardiol 2020; 43:1414-1422. [PMID: 32926456 PMCID: PMC7724228 DOI: 10.1002/clc.23454] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 01/21/2023] Open
Abstract
Background Transcatheter aortic valve replacement (TAVR) is regarded as the most superior alternative treatment approach for patients with aortic stenosis (AS) who are associated with high surgical risk, whereas the effectiveness of TAVR vs surgical aortic valve replacement (SAVR) in low to intermediate surgical risk patients remained inconclusive. This study aimed to determine the best treatment strategies for AS with low to intermediate surgical risk based on published randomized controlled trials (RCTs). Hypothesis and Methods RCTs that compared TAVR vs SAVR in AS patients with low to intermediate surgical risk were identified by PubMed, EmBase, and the Cochrane library from inception till April 2019. The pooled relative risks (RRs) with 95% confidence intervals (CIs) were calculated for the data collected using random‐effects models. Results Seven RCTs with a total of 6929 AS patients were enrolled. We noted that TAVR significantly increased the risk of transient ischemic attack (TIA) (RR: 1.43; 95%CI: 1.04‐1.96; P = .029), and permanent pacemaker implantation (RR: 3.00; 95%CI: 1.70‐5.30; P < .001). However, TAVR was associated with lower risk of post‐procedural bleeding (RR: 0.57; 95%CI: 0.33‐0.98; P = .042), new‐onset or worsening of atrial fibrillation (RR: 0.32; 95%CI: 0.23‐0.45; P < .001), acute kidney injury (RR: 0.40; 95%CI: 0.25‐0.63; P < .001), and cardiogenic shock (RR: 0.34; 95%CI: 0.19‐0.59; P < .001). The risk of aortic‐valve reintervention at 1‐ (RR: 2.63; 95%CI: 1.34‐5.15; P = .005), and 2 years (RR: 3.19; 95%CI: 1.63‐6.24; P = .001) in low to intermediate surgical risk patients who received TAVR was significantly increased than those who received SAVR. Conclusions These findings indicated that low to intermediate surgical risk patients who received TAVR had low risk of complications, whereas the risk of TIA, permanent pacemaker implantation, and aortic‐valve reintervention was increased.
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Affiliation(s)
- Dengshen Zhang
- Department of Cardiovascular Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Xin Mao
- Department of Cardiovascular Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Daxing Liu
- Department of Cardiovascular Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Jian Zhang
- Department of Cardiovascular Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Gang Luo
- Department of Cardiovascular Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Liangliang Luo
- Department of Cardiovascular Surgery, The Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
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Brown RA, Reid AB, Turaga M, Huang AL, Maggiore PL, Sellers SL, Kiritchkov L, Tarazi SC, Blanke P, Leipsic JA. Subclinical Leaflet Thrombosis Post Transcatheter Aortic Valve Replacement – An Update for 2020. STRUCTURAL HEART 2020. [DOI: 10.1080/24748706.2020.1805534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Isolated aortic valve replacement in Spain: national trends in risks, valve types, and mortality from 1998 to 2017. ACTA ACUST UNITED AC 2020; 74:700-707. [PMID: 32800747 DOI: 10.1016/j.rec.2020.06.008] [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] [Received: 04/20/2020] [Accepted: 06/02/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND OBJECTIVES To help to illustrate the trends in isolated surgical aortic valve replacement (SAVR) in Spain, we performed a national-level analysis to investigate the changes from 1998 to 2017 in a) SAVR volume, b) patients' risk profiles, c) in-hospital mortality, and d) types of aortic valve prostheses. METHODS We included all episodes of patients undergoing isolated SAVR from January 1998 to December 2017 recorded in the Minimum Basic Data Set (Ministry of Health, Consumer Affairs, and Social Welfare, Spain). The study duration was divided into four 5-year periods. We analyzed the trends in SAVR volume, comorbidity prevalence, and in-hospital mortality. Through multivariate logistic regression, we identified factors associated with mortality and type of prosthesis. The risk-adjusted mortality rate was compared over the study period. RESULTS In total, 73 668 patients underwent an isolated SAVR from 1998 to 2017. The annual volume of procedures increased from 16 363 between 1998 and 2002 to 22 685 between 2013 and 2017. The prevalence of all investigated comorbidities increased, except for history of previous myocardial infarction and unplanned admission. The Charlson comorbidity index worsened from 1998-2002 (2.3; SD, 1.4) to 2013-2017 (3.6; SD, 1.7) (P <.001). In-hospital mortality decreased from 7.2% to 3.3% (P <.001) while the risk-adjusted mortality index improved from 1.3 to 0.7. The proportion of bioprostheses increased from 20.7% (1998-2002) to 59.6% (2013-2017) (P <.001). CONCLUSIONS We detected an increase in the annual SAVR volume in Spain, with more patients receiving bioprostheses. Despite an increased risk profile of the patients, in-hospital mortality substantially reduced.
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Transcatheter Versus Surgical Aortic Valve Replacement: An Updated Systematic Review and Meta-Analysis With a Focus on Outcomes by Sex. Heart Lung Circ 2020; 30:86-99. [PMID: 32732125 DOI: 10.1016/j.hlc.2020.05.112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 05/11/2020] [Accepted: 05/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Women at increased surgical risk have been shown to have better outcomes with transcatheter aortic valve implantation (TAVI) as compared to surgical valve replacement (SAVR). With the scope of TAVI moving into low-surgical risk patients, we aimed to update the current literature to include the new low-risk randomised controlled trial (RCT) data in investigating outcomes by sex. METHODS We systematically searched MEDLINE (Ovid), PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov and reference lists for relevant RCTs comparing TAVI to SAVR published prior to 4 May 2020. Data extraction was performed by two independent authors and included trial design details, baseline characteristics and outcome data stratified by sex. Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. Quantitative synthesis of pooled data was performed using Mantel-Haenszel fixed or random effects model. Q-statistic and the I2 test were used for assessment of heterogeneity. RESULTS Our search yielded eight RCTs included in the final quantitative synthesis. The overall pooled cohort was 8,040, of whom 41.4% were female. Women had significantly lower rates of one-year all-cause mortality (12.2% vs 17.7%, pooled OR 0.59, 95% CI 0.40-0.86) and one-year composite endpoint (9.7% vs 12.4%, pooled OR 0.73, 95% CI 0.58-0.92) with TAVI as compared to SAVR. The selective mortality benefit with TAVI over SAVR in women did not persist to 5 years (pooled HR 1.01, 95% CI 0.87-1.17). At 30 days, women demonstrated lower rates of major bleeding and acute kidney injury following TAVI compared to SAVR. For men, these outcomes were similar regardless of type of intervention. Both sexes were at increased risk of major vascular complications with TAVI as compared to SAVR, however women demonstrated nearly double the odds of major vascular complication with TAVI compared to men. CONCLUSION Our updated meta-analysis demonstrates that at one-year women undergoing TAVI have significantly lower mortality and better safety outcomes compared to those undergoing SAVR. These benefits are not seen in men. In the new low-risk era, these results are ever more important for guiding appropriate patient selection.
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Stachon P, Kaier K, Zirlik A, Bothe W, Heidt T, Zehender M, Bode C, von Zur Mühlen C. Risk-Adjusted Comparison of In-Hospital Outcomes of Transcatheter and Surgical Aortic Valve Replacement. J Am Heart Assoc 2020; 8:e011504. [PMID: 30897991 PMCID: PMC6509703 DOI: 10.1161/jaha.118.011504] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Transfemoral transcatheter aortic valve replacement (TF‐TAVR) is recommended for patients suffering from aortic valve stenosis at increased operative risk. Beyond that, patients with different comorbidities could benefit from TF‐TAVR. The present study compares real‐world in‐hospital outcomes of surgical aortic valve replacement and TF‐TAVR. Methods and Results For all 33 789 isolated TF‐TAVR and surgical aortic valve replacement procedures performed in Germany in 2014 and 2015, comorbidities and in‐hospital outcomes were identified by International Classification of Diseases (ICD)‐ and OPS (Operation and procedure key)‐codes. Patients undergoing TF‐TAVR were older and at increased estimated risk. Outcomes were risk‐adjusted to allow comparison. TF‐TAVR was associated with a lower risk for acute kidney injuries (odds ratio [OR] 0.62, P<0.001), for bleeding (OR 0.17, P<0.001), and for prolonged mechanical ventilation (>48 hours, OR 0.21, P<0.001). Risk for stroke was similar (OR 1.07, P=0.558). As expected, the risk for pacemaker implantations was higher after TF‐TAVR (OR 4.61, P<0.001). In all patients, none of the treatment strategies had a clear advantage on the risk for in‐hospital mortality (OR 0.83, P=0.068). However, in patients aged >80 years and at high operative risk undergoing TF‐TAVR in‐hospital mortality was lower (TF‐TAVR versus surgical aortic valve replacement 80–84, OR 0.55; P=0.002; ≥85 years, OR 0.42, P=0.006; EuroSCORE (European System for Cardiac Operative Risk Evaluation) >9: OR 0.62, P=0.001). TF‐TAVR was superior in patients with renal failure and in NYHA (New York Heart Association)‐Class III/IV. Other risk groups were not found to be factors favoring a treatment strategy. Conclusions The present study indicates a superiority of TF‐TAVR in clinical practice for patients at increased operative risk, aged >80 years, in NYHA‐Class III/IV, and with renal failure.
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Affiliation(s)
- Peter Stachon
- 1 University Heart Center Freiburg Department of Cardiology and Angiology I Faculty of Medicine University of Freiburg Freiburg Germany
| | - Klaus Kaier
- 1 University Heart Center Freiburg Department of Cardiology and Angiology I Faculty of Medicine University of Freiburg Freiburg Germany.,2 Institute of Medical Biometry and Medical Informatics University Medical Center Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Andreas Zirlik
- 1 University Heart Center Freiburg Department of Cardiology and Angiology I Faculty of Medicine University of Freiburg Freiburg Germany.,3 Department of Cardiology University Hospital Graz Austria
| | - Wolfgang Bothe
- 4 Department of Cardiac and Vascular Surgery Heart Center Freiburg Faculty of Medicine University of Freiburg Freiburg Germany
| | - Timo Heidt
- 1 University Heart Center Freiburg Department of Cardiology and Angiology I Faculty of Medicine University of Freiburg Freiburg Germany
| | - Manfred Zehender
- 1 University Heart Center Freiburg Department of Cardiology and Angiology I Faculty of Medicine University of Freiburg Freiburg Germany
| | - Christoph Bode
- 1 University Heart Center Freiburg Department of Cardiology and Angiology I Faculty of Medicine University of Freiburg Freiburg Germany
| | - Constantin von Zur Mühlen
- 1 University Heart Center Freiburg Department of Cardiology and Angiology I Faculty of Medicine University of Freiburg Freiburg Germany
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Conduction disturbances in low-surgical-risk patients undergoing transcatheter aortic valve replacement with self-expandable or balloon-expandable valves. Cardiovasc Interv Ther 2020; 36:355-362. [PMID: 32627145 DOI: 10.1007/s12928-020-00687-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 06/27/2020] [Indexed: 10/23/2022]
Abstract
Despite a considerable improvement in TAVR devices and procedures, together with a reduction in procedural complications, the rate of conduction disturbances (CD) remained stable over the years. Indeed, the CD rate is still significantly higher than in surgical aortic valve replacement, and represents one of the main limitations to the expansion of TAVR to younger low-risk patients. The aim of the present study was to assess the incidence and predictors of CD in low-risk patients undergoing TAVR. Among 637 patients without preexisting CD who underwent TAVR, 116 (18.2%) were considered at low surgical risk. Up to 25% of low-risk patients presented with persistent CD at discharge. The pacemaker implantation rate was similar in the low-risk group compared to the intermediate-/high-risk group (8.7% vs 10.6%, p = 0.55). Moreover, the rate of new persistent left bundle branch block (LBBB) following TAVR was also similar between both groups (18.1% vs 22.1%, p = 0.34). At 1-year follow-up, LBBB was persistent in 62.5% of patients and 3 of them required a pacemaker implantation. Depth of valve implantation, baseline QRS duration and mean aortic transvalvular gradient were identified as independent predictors of CD in low-risk patients. Patients at low surgical risk showed an equivalent CD rate than intermediate-/high-risk patients. The depth of valve implantation was the main predictor of CD in low-risk patients undergoing TAVR. Baseline QRS duration and mean aortic transvalvular gradient were also associated with increased CD.
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Tham JLM, Adams H, Paleri S, Wright C, Dimitriou J, Newcomb A, MacIsaac AI, Whitbourn RJ, Palmer SC. Clinical outcomes of self-expandable vs. balloon-expandable TAVI for severe aortic stenosis. Acta Cardiol 2020; 75:218-225. [PMID: 30931804 DOI: 10.1080/00015385.2019.1572959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Transcatheter aortic valve implantation (TAVI) is an established therapy for patients with severe aortic stenosis (AS). There is limited data exploring differences in outcomes post-TAVI SEV vs. BEV. This study compared procedural success and 30-d clinical outcomes self-expandable valves (SEV), vs. balloon-expandable valves (BEV) for patients with severe AS.Methods: Retrospective analysis was undertaken of patients receiving TAVI at St Vincent's Hospital, Melbourne between August 2009 and May 2018. The primary endpoints included procedural success, clinical outcomes and complication rates at 30-d.Results: Out of 151 patients undergoing TAVI, 70 received (46.3%) SEV (Medtronic CoreValve & Evolut-R) and 81 (53.6%) BEV (Edwards SAPIEN-XT & S3). The mean Society of Thoracic Surgery (STS) risk score did not differ between the groups, SEV (83.6 ± 4.9 years, STS 4.4 ± 3.8) compared to BEV (82.3 ± 5.8 years, STS 4.9 ± 4.9). Procedural success was similar SEV 67 (95.7%) vs. BEV 78 (96.3%). Rates of ≥ moderate paravalvular aortic regurgitation (PAR) at 30-d were significantly higher in SEV compared to BEV (6.7 vs. 0.0%; p = .02). SEV patients had higher rates of pacemaker insertion (36.4 vs. 9.5%; p = .001) and stroke rates (12.4 vs. 1.4%; p = .04) compared to BEV patients. The difference in 30-d mortality between the two groups was similar (SEV 4.6% vs. BEV 1.3%; p = .23).Conclusions: This real-world retrospective analysis demonstrates higher rates of ≥ moderate PAR, stroke and pacemaker insertion with SEV compared to BEV at 30 d post-TAVI for severe symptomatic AS.
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Affiliation(s)
| | - Heath Adams
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, Australia
- School of Medicine, University of Tasmania, Hobart, Australia
| | - Sarang Paleri
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, Australia
| | - Christine Wright
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, Australia
| | - Jim Dimitriou
- Department of Cardiac Surgery, St Vincent’s Hospital Melbourne, Fitzroy, Australia
| | - Andrew Newcomb
- Department of Cardiac Surgery, St Vincent’s Hospital Melbourne, Fitzroy, Australia
| | - Andrew I. MacIsaac
- Department of Medicine, University of Melbourne, Fitzroy, Australia
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, Australia
| | - Robert J. Whitbourn
- Department of Medicine, University of Melbourne, Fitzroy, Australia
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, Australia
| | - Sonny C. Palmer
- Department of Medicine, University of Melbourne, Fitzroy, Australia
- Department of Cardiology, St Vincent’s Hospital Melbourne, Fitzroy, Australia
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Asgar AW, Ouzounian M, Adams C, Afilalo J, Fremes S, Lauck S, Leipsic J, Piazza N, Rodes-Cabau J, Welsh R, Wijeysundera HC, Webb JG. 2019 Canadian Cardiovascular Society Position Statement for Transcatheter Aortic Valve Implantation. Can J Cardiol 2020; 35:1437-1448. [PMID: 31679616 DOI: 10.1016/j.cjca.2019.08.011] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/29/2019] [Accepted: 08/02/2019] [Indexed: 01/12/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) or replacement has rapidly changed the treatment of patients with severe symptomatic aortic stenosis. It is now the standard of care for patients believed to be inoperable or at high surgical risk, and a reasonable alternative to surgical aortic valve replacement for those at intermediate surgical risk. Recent clinical trial data have shown the benefits of this technology in patients at low surgical risk as well. This update of the 2012 Canadian Cardiovascular Society TAVI position statement incorporates clinical evidence to provide a practical framework for patient selection that does not rely on surgical risk scores but rather on individual patient evaluation of risk and benefit from either TAVI or surgical aortic valve replacement. In addition, this statement features new wait time categories and treatment time goals for patients accepted for TAVI. Institutional requirements and recommendations for operator training and maintenance of competency have also been revised to reflect current standards. Procedural considerations such as decision-making for concomitant coronary intervention, antiplatelet therapy after intervention, and follow-up guidelines are also discussed. Finally, we suggest that all patients with aortic stenosis might benefit from evaluation by the heart team to determine the optimal individualized treatment decision.
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Affiliation(s)
- Anita W Asgar
- Institut de Cardiologie de Montreal, Universite de Montreal, Montreal, Quebec, Canada.
| | - Maral Ouzounian
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Corey Adams
- Health Sciences Centre, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Jonathan Afilalo
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Stephen Fremes
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sandra Lauck
- St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathan Leipsic
- St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Josep Rodes-Cabau
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Universite de Laval, Quebec, Quebec, Canada
| | - Robert Welsh
- Mazankowski Alberta Heart Institute and University of Alberta, Edmonton, Alberta, Canada
| | | | - John G Webb
- St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Sellers SL, Sathananthan J, Bouchareb R, Mostaço-Guidolin LB, Lau KPL, Bugis J, Hensey M, Blanke P, Payne GW, Lebeche D, Pibarot P, Hackett TL, Webb JG, Leipsic JA. Impact of Over-Expansion on SAPIEN 3 Transcatheter Heart Valve Pericardial Leaflets. STRUCTURAL HEART 2020. [DOI: 10.1080/24748706.2020.1742950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Takeji Y, Taniguchi T, Morimoto T, Saito N, Ando K, Shirai S, Sakaguchi G, Arai Y, Fuku Y, Kawase Y, Komiya T, Ehara N, Kitai T, Koyama T, Watanabe S, Watanabe H, Shiomi H, Minamino-Muta E, Matsuda S, Yaku H, Yoshikawa Y, Yamazaki K, Kawatou M, Sakamoto K, Tamura T, Miyake M, Sakaguchi H, Murata K, Nakai M, Kanamori N, Izumi C, Mitsuoka H, Kato M, Hirano Y, Inada T, Nagao K, Mabuchi H, Takeuchi Y, Yamane K, Tamura T, Toyofuku M, Ishii M, Inoko M, Ikeda T, Ishii K, Hotta K, Jinnai T, Higashitani N, Kato Y, Inuzuka Y, Morikami Y, Minatoya K, Kimura T. Transcatheter Aortic Valve Implantation vs. Surgical Aortic Valve Replacement for Severe Aortic Stenosis in Real-World Clinical Practice. Circ J 2020; 84:806-814. [DOI: 10.1253/circj.cj-19-0951] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yasuaki Takeji
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | | | - Naritatsu Saito
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Kenji Ando
- Division of Cardiology, Kokura Memorial Hospital
| | | | | | - Yoshio Arai
- Division of Cardiovascular Surgery, Kokura Memorial Hospital
| | - Yasushi Fuku
- Department of Cardiology, Kurashiki Central Hospital
| | - Yuichi Kawase
- Department of Cardiology, Kurashiki Central Hospital
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Natsuhiko Ehara
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Tadaaki Koyama
- Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital
| | - Shin Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Eri Minamino-Muta
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Shintaro Matsuda
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hidenori Yaku
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Kazuhiro Yamazaki
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | - Masahide Kawatou
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | - Kazuhisa Sakamoto
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | | | | | | | - Masanao Nakai
- Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital
| | | | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hirokazu Mitsuoka
- Division of Cardiology, Nara Hospital, Kindai University Faculty of Medicine
| | - Masashi Kato
- Department of Cardiology, Mitsubishi Kyoto Hospital
| | - Yutaka Hirano
- Department of Cardiology, Kindai University Hospital
| | - Tsukasa Inada
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | - Kazuya Nagao
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | | | | | | | - Takashi Tamura
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital
| | | | | | - Kozo Hotta
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | | | | | | | | | | | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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Ueyama H, Kuno T, Ando T, Hayashida K, Takagi H. Network Meta-analysis of Surgical Aortic Valve Replacement and Different Transcatheter Heart Valve Systems for Symptomatic Severe Aortic Stenosis. Can J Cardiol 2020; 37:27-36. [PMID: 32569594 DOI: 10.1016/j.cjca.2020.02.088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/14/2020] [Accepted: 02/23/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Although different transcatheter heart valve (THV) systems have been introduced to overcome transcatheter aortic valve replacement (TAVR)-specific complications, head-to-head comparisons of these THV systems are scarce. The aim of this study was to compare different THV systems and surgical aortic valve replacement (SAVR) by conducting a network meta-analysis. METHODS PubMed and EMBASE were searched through November 2019 for studies comparing safety and efficacy of balloon-expandable valve (BEV), self-expanding valve (SEV), mechanically expandable valve (MEV), and SAVR for symptomatic severe aortic stenosis. End points in the short term at 30 days or discharge and the long term up to 2 years were assessed. RESULTS We identified 11 randomized controlled trials with a total of 10,300 patients eligible for inclusion in our study. There were no significant differences in all-cause death among different THV systems and SAVR in both short and long terms. Disabling stroke was significantly lower with MEV vs BEV and SAVR (hazard ratios [HRs] 0.31 [95% confidence interval [CI] 0.12-0.77] and 0.33 [95% CI 0.14-0.76], respectively) in the long term. MEV was associated with an increased risk of new permanent pacemaker implantation compared with BEV, SEV, and SAVR (HRs 3.82 [95% CI 1.83-7.97], 1.85 [95% CI 1.02-3.36], and 5.23 [95% CI 2.61-10.47], respectively) in the long term. CONCLUSIONS In patients with symptomatic severe aortic stenosis undergoing intervention, there were no significant differences in all-cause death among different THV systems and SAVR. MEV had low frequency of disabling stroke compared with BEV and SAVR, but an increased frequency of permanent pacemaker implantation compared with other interventions.
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Affiliation(s)
- Hiroki Ueyama
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA.
| | - Tomo Ando
- Center for Interventional Vascular Therapy, Division of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
| | - Kentaro Hayashida
- Division of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hisato Takagi
- Division of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
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Hirji SA, McCarthy E, Kim D, McGurk S, Ejiofor J, Ramirez-Del Val F, Kolkailah AA, Rosner B, Shook D, Nyman C, Berry N, Sobieszczyk P, Pelletier M, Shah P, O'Gara P, Kaneko T. Relationship Between Hospital Surgical Aortic Valve Replacement Volume and Transcatheter Aortic Valve Replacement Outcomes. JACC Cardiovasc Interv 2020; 13:335-343. [PMID: 32029250 DOI: 10.1016/j.jcin.2019.09.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 09/03/2019] [Accepted: 09/17/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to examine whether hospital surgical aortic valve replacement (SAVR) volume was associated with corresponding transcatheter aortic valve replacement (TAVR) outcomes. BACKGROUND Recent studies have demonstrated a volume-outcome relationship for TAVR. METHODS In total, 208,400 fee-for-service Medicare beneficiaries were analyzed for all aortic valve replacement procedures from 2012 to 2015. Claims for patients <65 years of age, concomitant coronary artery bypass grafting surgery, other heart valve procedures, or other major open heart procedures were excluded, as were secondary admissions for aortic valve replacement. Hospital SAVR volumes were stratified on the basis of mean annual SAVR procedures during the study period. The primary outcomes were 30-day and 1-year post-operative TAVR survival. Adjusted survival following TAVR was assessed using multivariate Cox regression. RESULTS A total of 65,757 SAVR and 42,967 TAVR admissions were evaluated. Among TAVR procedures, 21.7% (n = 9,324) were performed at hospitals with <100 (group 1), 35.6% (n = 15,298) at centers with 100 to 199 (group 2), 22.9% (n = 9,828) at centers with 200 to 299 (group 3), and 19.8% (n = 8,517) at hospitals with ≥300 SAVR cases/year (group 4). Compared with group 4, 30-day TAVR mortality risk-adjusted odds ratios were 1.32 (95% confidence interval: 1.18 to 1.47) for group 1, 1.25 (95% confidence interval: 1.12 to 1.39) for group 2, and 1.08 (95% confidence interval: 0.82 to 1.25) for group 3. These adjusted survival differences in TAVR outcomes persisted at 1 year post-procedure. CONCLUSIONS Total hospital SAVR volume appears to be correlated with TAVR outcomes, with higher 30-day and 1-year mortality observed at low-volume centers. These data support the importance of a viable surgical program within the heart team, and the use of minimum SAVR hospital thresholds may be considered as an additional metric for TAVR performance.
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Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ellen McCarthy
- Institute for Aging Research, Hebrew Senior Life, Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Dae Kim
- Institute for Aging Research, Hebrew Senior Life, Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julius Ejiofor
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Fernando Ramirez-Del Val
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ahmed A Kolkailah
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bernard Rosner
- Division of Pharmacoepidemiology & Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Douglas Shook
- Department of Anesthesia, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Charles Nyman
- Department of Anesthesia, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Natalia Berry
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Piotr Sobieszczyk
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc Pelletier
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pinak Shah
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Patrick O'Gara
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Zhang X, Wang T, Lan R, Dai Q, Kang L, Wang L, Wang Y, Xu W, Xu B. Meta-Analysis Comparing Results of Transcatheter Versus Surgical Aortic-Valve Replacement in Patients With Severe Aortic Stenosis. Am J Cardiol 2020; 125:449-458. [PMID: 31780077 DOI: 10.1016/j.amjcard.2019.10.057] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 10/24/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022]
Abstract
Transcatheter aortic-valve replacement (TAVR) has emerged as a promising strategy for treating patients with severe aortic stenosis. We aimed to compare TAVR with surgical aortic-valve replacement (SAVR) and determine the performance of TAVR over time and within several subgroups. We included 8 randomized trials comparing TAVR versus SAVR. Compared with SAVR, TAVR was associated with a lower rate of all-cause mortality or disabling stroke at 30-day (odds ratio [OR], 0.72; p = 0.004), 1-year (OR, 0.83; p = 0.01), and 2-year (OR, 0.86; p = 0.02), but not at long-term follow-up (rate ratio [RR], 1.02 [confidence interval 0.92 to 1.13]; p = 0.67). Notably, 5-year data showed numerically higher incidence in TAVR (RR, 1.11 [confidence interval 0.97 to 1.27]; p = 0.12). The risks associated with TAVR versus SAVR increased over time, showing a significant interaction (p for interaction = 0.01), as were for new-onset atrial fibrillation and rehospitalization. Incidences of major bleeding, new-onset fibrillation, and acute kidney injury were lower in TAVR, whereas transient ischemic attack, major vascular complications, permanent pacemaker implantation, reintervention, and paravalvular leak were lower in SAVR. Incidences for all-cause and cardiovascular mortality, myocardial infarction, and stroke were not statistically different. TAVR with transfemoral approach and new-generation valve was associated with reduction in all-cause mortality or disabling stroke compared with corresponding comparators. In conclusion, TAVR was associated with a lower risk for all-cause mortality or disabling stroke within 2 years, but not at long-term follow-up compared with SAVR; the risks seems to increase over time. More data are needed to determine longer-term performance of TAVR.
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Kefer J, Maes F, Renkin J, Kautbally S, De Meester C, Delacour M, Pouleur AC. Resheathing of self-expanding bioprosthesis: Impact on procedural results, clinical outcome and prosthetic valve durability after transcatheter aortic valve implantation. IJC HEART & VASCULATURE 2020; 26:100462. [PMID: 31921975 PMCID: PMC6948261 DOI: 10.1016/j.ijcha.2019.100462] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/20/2019] [Accepted: 12/20/2019] [Indexed: 01/08/2023]
Abstract
To resheath a SEV doesn’t increase the procedural risk of TAVI. To resheath a SEV doesn’t impair the clinical outcome of patients. The resheath has no negative impact on the acute prosthetic valve function. Resheathing manœuvre has no deleterious effect on the prosthetic valve durability at short term follow-up.
Background New transcatheter aortic valves were recently developed, enabling to resheath and reposition the prosthesis. The aim of the present study was to investigate whether the resheath manoeuvre did not impair the outcome of patients and the bioprosthesis durability after transcatheter aortic valve implantation (TAVI). Methods and results On the 346 consecutive patients (84 ± 7 yrs-old, mean STS 6.7 ± 5%) undergoing a transfemoral TAVI in our institution since January 2008, 170 patients were implanted using a self-expanding valve (SEV). Among those, 39 (Group 1) required resheathing to achieve a successful implantation, while 131 did not require it (Group 2, N = 131). A balloon-expanding valve (BEV) was used in 176 patients (Group 3). Baseline characteristics were similar between groups. Device success was 98%, the rate of in-hospital death was 2%, and the number of procedural complications was similarly low, with no significant difference between groups. The follow-up was complete in 337 of 338 patients undergoing a successful TAVI (781 patients-year). Kaplan-Meier analysis showed that overall survival was 80 ± 2% and 42 ± 3% at 1 and 5 years respectively, with no difference between groups. On multivariate analysis, acute kidney injury, post-dilatation, pulmonary hypertension, porcelain aorta and STS score, but not resheath, were independant predictors of death after TAVI. The annual event rate of structural valve deterioration was 0.6% patients-year, and similar between groups. Conclusions Our study shows that SEV resheath did not impair the procedural results, the outcome of patients nor the valve durability at short term after TAVI.
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Affiliation(s)
- Joelle Kefer
- Cliniques Universitaires Saint-Luc, Division of Cardiology and Intitut de Recherche Experimentale en Cardiologie (IREC), Brussels, Belgium
| | - Frederic Maes
- Cliniques Universitaires Saint-Luc, Division of Cardiology and Intitut de Recherche Experimentale en Cardiologie (IREC), Brussels, Belgium
| | - Jean Renkin
- Cliniques Universitaires Saint-Luc, Division of Cardiology and Intitut de Recherche Experimentale en Cardiologie (IREC), Brussels, Belgium
| | - Shakeel Kautbally
- Cliniques Universitaires Saint-Luc, Division of Cardiology and Intitut de Recherche Experimentale en Cardiologie (IREC), Brussels, Belgium
| | | | - Marine Delacour
- Cliniques Universitaires Saint-Luc, Division of Cardiology and Intitut de Recherche Experimentale en Cardiologie (IREC), Brussels, Belgium
| | - Anne-Catherine Pouleur
- Cliniques Universitaires Saint-Luc, Division of Cardiology and Intitut de Recherche Experimentale en Cardiologie (IREC), Brussels, Belgium
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