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Garagoli F, Chiabrando JG, Seropian IM, Lombardi M, Agatiello CR, Fernández Recalde ML, Vergallo R, Porto I, Bluro IM. Stroke risk after transcatheter aortic valve replacement in patients with carotid stenosis: A systematic review and meta-analysis. Int J Cardiol 2024; 408:132085. [PMID: 38702030 DOI: 10.1016/j.ijcard.2024.132085] [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: 01/07/2024] [Revised: 04/02/2024] [Accepted: 04/19/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Stroke is a feared complication of transcatheter aortic valve replacement (TAVR). Patients undergoing TAVR typically have multiple comorbidities, such as carotid artery stenosis (CAS). We conducted the present meta-analysis to determine the risk of stroke and mortality following TAVR in patients with CAS. METHODS We searched PubMed/Medline, Scopus, ScienceDirect, and Cochrane Clinical Trials databases for clinical studies that compared CAS ≥50% and CAS ≥70% versus non-CAS TAVR population. The endpoints included the 30-day incidence of stroke or transient ischemic attack (TIA) and 30-day all-cause of mortality. RESULTS We identified seven studies that included 12,418 patients in the CAS group and 102,316 in the control group. CAS ≥50% was not associated with an increased risk of 30-day stroke or TIA after TAVR [risk ratio (RR): 1.38; 95% confidence interval (95% CI): 0.95-2.02; p = 0.09]. However, patients with CAS ≥70% had an increased risk of stroke or TIA (RR: 1.43; 95% CI: 1.02-2.01; p = 0.04). No difference in 30-day all-cause mortality was observed between CAS ≥50% or CAS ≥70% and control groups (RR: 1.09; 95% CI: 0.79-1.52; p = 0.59 and RR: 1.11; 95% CI: 0.85-1.45; p = 0.43, respectively). CONCLUSIONS CAS ≥70% was associated with an increased risk of stroke or TIA following TAVR compared with patients without CAS.
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Affiliation(s)
- Fernando Garagoli
- Department of Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Juan Guido Chiabrando
- Department of Interventional Cardiology, Sanatorio Anchorena, Buenos Aires, Argentina
| | - Ignacio Miguel Seropian
- Department of Interventional Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marco Lombardi
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Largo R. Benzi, 10, 16132 Genova, Italy
| | - Carla Romina Agatiello
- Department of Interventional Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Rocco Vergallo
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Largo R. Benzi, 10, 16132 Genova, Italy; Cardiothoracic and Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132 Genova, Italy
| | - Italo Porto
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Largo R. Benzi, 10, 16132 Genova, Italy; Cardiothoracic and Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132 Genova, Italy
| | - Ignacio Martín Bluro
- Department of Cardiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Caetano L, Gibicoski TB, Rodriguez F, Scabello I, da Silva Neto EP, Iplinski B. Impact of carotid artery stenosis on outcomes of transcatheter aortic valve replacement: A systematic review and meta-analysis. Int J Cardiol 2024; 399:131670. [PMID: 38141726 DOI: 10.1016/j.ijcard.2023.131670] [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: 06/26/2023] [Revised: 12/03/2023] [Accepted: 12/18/2023] [Indexed: 12/25/2023]
Abstract
INTRODUCTION Carotid Artery Stenosis (CAS) is common in elderly patients undergoing Transcatheter Aortic Valve Replacement (TAVR). However, the impact of CAS on the outcomes of TAVR is unclear. PURPOSE This systematic review and meta-analysis aimed to compare the clinical and periprocedural outcomes in patients with and without CAS undergoing TAVR. METHODS PubMed, Embase, and Cochrane databases were searched until February 2023. We included studies that performed a direct comparison of outcomes of TAVR in CAS versus non-CAS patients. Data was extracted from published reports and the ROBINS-I tool was utilized for quality assessment. The R studio software (version 4.2.2) was adopted for statistical analysis. RESULTS Five observational studies and 111.915 patients were included. The mean age was 80.7 ± 8.2 years and 46.3% were female. The risk of stroke or transient ischemic attack was elevated in the group of patients with CAS (OR 1.44; 95% CI 1.07-1.95; p = 0.016). In contrast, myocardial infarction (OR 1.24; 95% CI 1.05-1.47; p = 0.074) and all-cause mortality (OR 0.99; 95% CI 0.73-1.35; p = 0.95) were not significantly different between CAS and non-CAS groups. Acute kidney injury and new pacemaker implantation did not differ between patients with and without CAS. CONCLUSIONS Our findings suggest that CAS is significantly associated with cerebrovascular events in patients undergoing TAVR, without significantly impacting all-cause mortality. Further prospective studies are needed for a more granular assessment of additional determinants of this association, such as unilateral vs. bilateral involvement and whether there is a threshold of CAS severity for increased risk.
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Affiliation(s)
- Lucas Caetano
- Department of Medicine, Federal University of Paraiba, Joao Pessoa, Brazil.
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Bansal K, Soni A, Shah M, Kosinski AS, Gilani F, Khera S, Vemulapalli S, Elmariah S, Kolte D. Association Between Polyvascular Disease and Transcatheter Aortic Valve Replacement Outcomes: Insights From the STS/ACC TVT Registry. Circ Cardiovasc Interv 2023; 16:e013578. [PMID: 37870587 DOI: 10.1161/circinterventions.123.013578] [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: 09/01/2023] [Accepted: 10/13/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Atherosclerotic cardiovascular disease is highly prevalent in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Polyvascular disease (PVD), defined as involvement of ≥2 vascular beds (VBs), that is, coronary, cerebrovascular, or peripheral, portends a poor prognosis in patients with atherosclerotic cardiovascular disease; however, data on the association of PVD with outcomes of patients undergoing TAVR are limited. METHODS The Society of Thoracic Surgeons and the American College of Cardiology Transcatheter Valve Therapy Registry was analyzed to identify patients who underwent TAVR from November 2011 to March 2022. The exposure of interest was PVD. The primary outcome was all-cause mortality. Secondary outcomes included major vascular complications, major/life-threatening bleeding, myocardial infarction, transient ischemic attack/stroke, and valve- and non-valve-related readmissions. Outcomes were assessed at 30 days and 1 year. RESULTS Of 443 790 patients who underwent TAVR, PVD was present in 150 823 (34.0%; 111 425 [25.1%] with 2VB-PVD and 39 398 [8.9%] with 3VB-PVD). On multivariable analysis, PVD was associated with increased all-cause mortality at 1 year (hazard ratio, 1.17 [95% CI, 1.14-1.20]). There was an incremental increase in 1-year mortality with an increasing number of VBs involved (no PVD [reference]; 2VB-PVD: hazard ratio, 1.12 [95% CI, 1.09-1.15]: and 3VB-PVD: hazard ratio, 1.31 [95% CI, 1.26-1.36]). Patients with versus without PVD had higher rates of major vascular complications, major/life-threatening bleeding, transient ischemic attack/stroke, and non-valve-related readmissions at 30 days and 1 year. CONCLUSIONS PVD is associated with worse outcomes after TAVR, and the risk is highest in patients with 3VB-PVD.
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Affiliation(s)
- Kannu Bansal
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA (K.B., A.S.)
| | - Aakriti Soni
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA (K.B., A.S.)
| | - Miloni Shah
- Duke Clinical Research Institute, Durham, NC (M.S., A.S.K.)
| | | | - Fahad Gilani
- Division of Cardiovascular Medicine, Catholic Medical Center, Manchester, NH (F.G.)
| | - Sahil Khera
- Division of Interventional Cardiology, Mount Sinai Hospital, New York, NY (S.K.)
| | - Sreekanth Vemulapalli
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (S.V.)
- Division of Cardiology, Duke University Medical Center, Durham, NC (S.V.)
| | - Sammy Elmariah
- Division of Cardiology, University of California, San Francisco (S.E.)
| | - Dhaval Kolte
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston (D.K.)
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Kulkarni A, Arafat M, Hou L, Liang S, Kassotis J. Racial Disparity Among Patients Undergoing Surgical Aortic Valve Replacement and Transcatheter Aortic Valve Replacement in the United States. Angiology 2023; 74:812-821. [PMID: 36426842 DOI: 10.1177/00033197221137025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative to surgical aortic valve replacement (SAVR). However, racial disparities in the utilization of TAVR persist. This meta-analysis attempts to determine whether the prevalence of adverse outcomes (procedure-related complications) represent barriers to the use of TAVR among African Americans (AA). The TAVR cohort consisted of 89.6% Caucasian (C) and 4.7% AA, while the SAVR cohort included 86.9% C and 6.4% AA. The utilization rate (UR) of TAVR was 1.48 and .35 among C and AA, respectively, while the UR of SAVR was 1.44 and .48 among C and AA, respectively. Following TAVR, for AA the odds ratio (OR) was greater for stroke (OR = 1.22, P = .02) and transient ischemic attack (TIA) (OR = 1.57, P < .001) and lower for undergoing the insertion of a permanent pacemaker (OR = .81, P < .001). While there was a significant difference between C and AA in TAVR and SAVR utilization, outcomes between groups following TAVR are comparable; therefore, adverse outcomes do not appear to be a barrier to the use of TAVR among eligible AA.
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Affiliation(s)
- Abha Kulkarni
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Mohammod Arafat
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Linle Hou
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Shiochee Liang
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - John Kassotis
- Department of Cardiology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Vella A, Roux O, Antiochos P, Monney P, Maurizi N, Skalidis I, Fournier S, Eeckhout E, Roguelov C, Oestreicher S, Kirsch M, Muller O, Lu H. Meta-Analysis of the Prognostic Significance of Carotid Artery Stenosis in Patients Who Underwent Transcatheter Aortic Valve Implantation. Am J Cardiol 2023; 200:225-231. [PMID: 37355356 DOI: 10.1016/j.amjcard.2023.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/10/2023] [Accepted: 04/18/2023] [Indexed: 06/26/2023]
Abstract
Stroke is a known complication of both transcatheter aortic valve implantation (TAVI) and carotid artery stenosis (CAS). Whether CAS is a predictor of worse prognosis after TAVI is unclear. We performed a meta-analysis to assess the impact of CAS on the incidence of neurovascular complications and mortality after TAVI. We searched PubMed/MEDLINE and EMBASE databases from inception to January 2023. CAS was defined by ≥50% stenosis of at least 1 carotid artery. Studies comparing CAS versus non-CAS TAVI populations were included. Patients' baseline characteristics and 30-day clinical outcomes were extracted. End points included the 30-day incidence of neurovascular complications (stroke or transient ischemic attack) and 30-day all-cause mortality. We identified six studies, totaling 6,763 patients in the CAS group and 23,861 patients in the non-CAS group. Patients with CAS had a higher prevalence of hypertension, diabetes mellitus, dyslipidemia, previous myocardial infarction, coronary artery bypass graft, peripheral artery disease, previous neurovascular disease, and chronic kidney disease. There was no significant difference in the rates of 30-day neurovascular complications between CAS and non-CAS groups (relative risk 1.23, 95% confidence interval 0.63 to 2.40, p = 0.54). CAS was associated with a higher risk of 30-day all-cause mortality (relative risk 1.28, 95% confidence interval 1.12 to 1.47, p <0.001), not found in a sensitivity analysis. In conclusion, patients with CAS presented with a significantly higher co-morbidity burden. CAS was not associated with an increased risk of 30-day neurovascular complications. 30-day mortality was higher in the CAS group but that may be a surrogate of the heavy co-morbidity burden of patients with CAS.
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Affiliation(s)
- Agnese Vella
- Service of Cardiology, Geneva University Hospital and University of Geneva, Geneva, Switzerland
| | - Olivier Roux
- HerzHirslanden Group, Herzzentrum im Park AG, Zurich, Switzerland
| | - Panagiotis Antiochos
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pierre Monney
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Niccolo Maurizi
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ioannis Skalidis
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Stephane Fournier
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eric Eeckhout
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christan Roguelov
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Simon Oestreicher
- Service of Internal Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Matthias Kirsch
- Service of Cardiovascular Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Olivier Muller
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Henri Lu
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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Ramanan B. No Benefit of Carotid Artery Screening before TAVI. Am J Cardiol 2023; 200:234-235. [PMID: 37328362 DOI: 10.1016/j.amjcard.2023.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Bala Ramanan
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Division of Vascular Surgery, Surgical Service, Dallas VA Medical Center, Dallas, Texas.
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 240] [Impact Index Per Article: 240.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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Shintoku R, Hayakawa M, Hoshi T, Okune S, Hiramine T, Takahashi T, Hosoo H, Ito Y, Marushima A, Ishikawa E, Matsumaru Y. Carotid artery stenosis concomitant with severe aortic stenosis treated by combination of staged angioplasty and transcatheter aortic valve implantation: A case report. Surg Neurol Int 2022; 13:469. [PMID: 36324943 PMCID: PMC9610214 DOI: 10.25259/sni_560_2022] [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: 06/19/2022] [Accepted: 09/16/2022] [Indexed: 11/24/2022] Open
Abstract
Background When severe aortic stenosis (AS) is concomitant with carotid stenosis, carotid artery stenting (CAS) will become a high-risk procedure because baroreceptor reflex-induced bradycardia and hypotension may cause irreversible circulatory collapse. When carotid stenosis-related misery perfusion is present, the risk of cerebral hyperperfusion syndrome increases after carotid revascularization. We report a case of severe carotid disease concomitant with severe AS successfully treated by a combination of staged angioplasty (SAP) and transcatheter aortic valve implantation (TAVI). Case Description An 86-year-old man presented with transient deterioration of mental status and sluggish responsiveness continuous from the previous day. Magnetic resonance imaging of the brain revealed a right putaminal infarction, occlusion of the right internal carotid artery (ICA), and severe stenosis of the left ICA. Severe AS was diagnosed and single-photon emission computed tomography showed misery perfusion at the bilateral ICA territories. We performed a staged treatment consisting of SAP for the left carotid stenosis and TAVI. A first-stage carotid angioplasty was performed, followed by TAVI 2 weeks later and second-stage CAS 1 week after that. There were no apparent periprocedural complications throughout the clinical course. Conclusion Combining SAP and TAVI may be an effective treatment option for severe carotid stenosis with misery perfusion concomitant with severe AS.
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Affiliation(s)
- Ryosuke Shintoku
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tomoya Hoshi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Sho Okune
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Japan
| | - Takato Hiramine
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Japan
| | - Toshihide Takahashi
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hisayuki Hosoo
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yoshiro Ito
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Aiki Marushima
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yuji Matsumaru
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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Update on Minimalist TAVR Care Pathways: Approaches to Care in 2022. Curr Cardiol Rep 2022; 24:1179-1187. [PMID: 35767177 PMCID: PMC9244066 DOI: 10.1007/s11886-022-01737-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2022] [Indexed: 11/20/2022]
Abstract
Purpose of Review This review summarizes current data supporting a minimalist TAVR approach and identifies the need for additional study to optimize TAVR care. The authors discuss future directions of the TAVR landscape and how this necessitates evolution of minimalist care pathways. Recent Findings Transcatheter aortic valve replacement (TAVR) has become a mainstay in the treatment of aortic stenosis since the initial procedure in 2002. Recently, attention has shifted to TAVR optimization and the minimalist approach with a focus on minimizing procedural sedation, protocolization of perioperative management, and prioritization on early discharge. This approach has been shown to be safe and reduce procedure time, length of stay, and overall cost for hospital systems. Summary The minimalist care pathway avoids general anesthesia, shortens procedure time and length of stay, and reduces cost without changing mortality or readmission rates at 30 days. A variety of protocols have been proposed without a clear consensus on specific components or patient eligibility. There is a continued need for data regarding patient risk stratification, valve selection, and discharge strategy as TAVR becomes increasingly common.
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Prevalence and Prognostic Impact of Carotid Artery Disease in Patients Undergoing TAVI. Ann Vasc Surg 2022; 84:61-68. [PMID: 35341937 DOI: 10.1016/j.avsg.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the prevalence of atherosclerotic carotid artery disease (ACAD) in patients undergoing transcatheter aortic valve implantation (TAVI) and postoperative cerebrovascular and evaluate its prognostic impact on post-operative cerebrovascular incidents (CVA). METHODS Retrospective review of all consecutive patients with severe symptomatic aortic valve stenosis (AVS) who underwent TAVI at a single tertiary university hospital (January 2008-December 2018). Patients with AVS scheduled for TAVI and concomitant carotid stenosis were evaluated for prophylactic carotid revascularization (carotid endarterectomy, CEA or carotid artery stenting, CAS). RESULTS 771 consecutive patients (mean age 80 years, 52% males), were treated by TAVI procedures. Carotid stenosis >70% was detected in 69 patients (9%); it was unilateral in 47 (68%) and bilateral in 22 (32%). Prophylactic carotid revascularization was performed before TAVI in 45 patients (31%): in 63.1% of patients (30/47) with unilateral carotid stenosis >70%, and in 68.1% (15/22) with bilateral carotid stenosis >70%. Postoperative CVA following TAVI procedures were recorded in 25 patients (3.2%): 22 cases of stroke (2.8%) and 3 cases of transient ischemic attack (0.4%). At multiple logistic regression, only bilateral carotid stenosis >70% (OR 1.16, CI 95% 1.03-1.31; p=.0009) was found as independent predictors of periprocedural CVA. CONCLUSIONS In patients with severe symptomatic AVS undergoing TAVI, carotid stenosis was frequently observed. Unilateral carotid stenosis >70% did not show a significant association with early CVA following TAVI. However, in the cohort of patients with bilateral carotid stenosis >70%, a significant association with postoperative CVA was observed.
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Alkhouli M, Moussa I, Deshmukh A, Ammash NM, Klaas JP, Holmes DR. The Heart Brain Team and Patient-Centered Management of Ischemic Stroke. JACC. ADVANCES 2022; 1:100014. [PMID: 38939078 PMCID: PMC11198076 DOI: 10.1016/j.jacadv.2022.100014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/28/2022] [Accepted: 02/28/2022] [Indexed: 06/29/2024]
Abstract
The multifaceted connections between the heart and the brain have been extensively studied at the anatomy, pathophysiology, and clinical levels. Studies have suggested a vital role for both cardiologists and neurologists in the management of various cardiovascular and neurological disorders. However, a true heart-brain team-based approach remained confined to large, specialized centers. In this paper, we review the various intersection areas of cardiology and neurology with regard to ischemic stroke. We focus our discussion on the challenges and opportunity for a heart-team approach to stroke in the context of atrial fibrillation, carotid disease, and patent foramen ovale, and in the setting of strokes complicating transcatheter endovascular interventions.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Issam Moussa
- Carle Illinois College of Medicine, University of Illinois, Carle Heart and Vascular Institute, Champaign, Illinois, USA
| | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nasser M. Ammash
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - James P. Klaas
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - David R. Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Carotid Duplex Poorly Predicts Stroke Risk During Transcatheter Aortic Valve Replacement. Ann Vasc Surg 2022; 84:107-113. [DOI: 10.1016/j.avsg.2021.12.075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 12/10/2021] [Accepted: 12/22/2021] [Indexed: 11/20/2022]
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Marie B, David CH, Guimbretière G, Foucher Y, Buschiazzo A, Letocart V, Manigold T, Plessis J, Jaafar P, Morin H, Rozec B, Roussel JC, Sénage T. Carotid versus femoral access for transcatheter aortic valve replacement: comparable results in the current era. Eur J Cardiothorac Surg 2021; 60:874-879. [PMID: 33724380 DOI: 10.1093/ejcts/ezab109] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 12/16/2020] [Accepted: 12/29/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The carotid approach for transcatheter aortic valve replacement (TAVR) has been shown to be feasible and safe. The goal of this study was to compare the 30-day outcomes of trans-carotid (TC) and transfemoral (TF) TAVR. METHODS This retrospective study enrolled 500 consecutive patients treated by TC-TAVR (n = 100) or TF-TAVR (n = 400) with percutaneous closure between January 2018 and January 2020 at the Nantes University Hospital. The primary end-point was the occurrence of cardiovascular death and cerebrovascular events at 30 days. RESULTS The mean age was 79.9 ± 8.1 in the TC group and 81.3 ± 6.9 (P = 0.069) in the TF group. The TC group had more men (69% vs 50.5%; P = 0.001) and more patients with peripheral vascular disease (86% vs 14.8%; P < 0.0001). Cardiac characteristics were similar between the groups, and the EuroSCORE II was 3.8 ± 2.6% vs 4.6 ± 6.0%, respectively (P = 0.443). The 30-day mortality was 2% in the TC group versus 1% in the TF group (P = 0.345). TC-TAVR was not associated with an increased risk of stroke (2% vs 2.5%; P = 0.999) or major vascular complications (2% vs 4%; P = 0.548). More permanent pacemakers were implanted in the TF group (14.9% vs 5.6%; P = 0.015), and no moderate or severe aortic regurgitation was observed in the TC group (0 vs 3.3%; P = 0.08). TC-TAVR was not associated with an increased risk of mortality or stroke at 30 days (odds ratio 1.32; 95% confidence interval 0.42-4.21; P = 0.63) in the multivariable analysis. CONCLUSIONS No statistically significant differences between TC-TAVR and TF-TAVR were observed; therefore, TC-TAVR should be the first alternative in patients with anatomical contraindications to the femoral route.
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Affiliation(s)
- Basile Marie
- Department of Thoracic and Cardio-Vascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Charles Henri David
- Department of Thoracic and Cardio-Vascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Guillaume Guimbretière
- Department of Thoracic and Cardio-Vascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Yohann Foucher
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
| | - Antoine Buschiazzo
- Department of Thoracic and Cardio-Vascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Vincent Letocart
- Department of Cardiology, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Thibaut Manigold
- Department of Cardiology, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Julien Plessis
- Department of Cardiology, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Philippe Jaafar
- Department of Cardiology, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Hélène Morin
- Department of Anesthesiology, Nantes Hospital University, Nantes, France
| | - Bertrand Rozec
- Department of Anesthesiology, Nantes Hospital University, Nantes, France
| | - Jean Christian Roussel
- Department of Thoracic and Cardio-Vascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Thomas Sénage
- Department of Thoracic and Cardio-Vascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France.,INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France
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In-hospital clinical outcomes of transcatheter aortic valve replacement in patients with concomitant carotid artery stenosis: Insights from the national inpatient sample. IJC HEART & VASCULATURE 2020; 31:100621. [PMID: 32939395 PMCID: PMC7479274 DOI: 10.1016/j.ijcha.2020.100621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/12/2020] [Accepted: 08/16/2020] [Indexed: 11/23/2022]
Abstract
Background Carotid artery stenosis (CAS) is a common occurrence in elderly patients undergoing transcatheter aortic valve replacement (TAVR). We conducted a retrospective study to identify the impact of CAS on in-hospital outcomes following TAVR. Methods We queried the National Inpatient Sample (NIS) for 2016–2017 and identified patients who underwent TAVR with concomitant CAS using the ICD-10 codes. The primary endpoint of our study was in-hospital mortality and acute ischemic stroke. Results We identified 80,740 TAVR-related hospitalizations. Of these, 6.9% (N = 5555) patients had concomitant CAS. The mean age for CAS patients was 80 ± 7.4 years. Females were represented equally in both groups. Traditional comorbidities like dyslipidemia [78.3% (N = 4350) vs. 68.2% (N = 51261); P < 0.001] and peripheral arterial disease [27.4% (N = 1525) vs. 12.7% (N = 9526); P < 0.001] were more frequently observed among CAS patients. Patients with CAS had higher rates of previous stroke [17.5% (N = 970) vs. 11.8% (N = 8902); P < 0.001] and CABG 23.8% (N = 1320) vs. 18.6% (N = 14022); P < 0.001]. Other cardiovascular risk factors were similar between the two groups. Moreover, no differences in in-hospital outcomes including mortality [odds ratio (OR): 1.35, CI: 0.48–3.83; P = 0.57] were observed in the propensity matched cohort. Conclusions Our study did not find any major differences in outcomes in the CAS group following TAVR; however, a more detailed randomized controlled study with long-term follow-up of these patients is needed.
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15
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Matsushita K, Marchandot B, Trimaille A, Kibler M, Heger J, Peillex M, Hess S, Grunebaum L, Reydel A, Kindo M, Hoang MT, Sato C, De Poli F, Leddet P, Ohana M, Jesel L, Ohlmann P, Susen S, Morel O. Paradoxical Increase of Stroke in Patients with Defect of High Molecular Weight Multimers of the von Willebrand Factors following Transcatheter Aortic Valve Replacement. Thromb Haemost 2020; 120:1330-1338. [PMID: 32726854 DOI: 10.1055/s-0040-1713424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Stroke is a major cause of disability after transcatheter aortic valve replacement (TAVR) and stroke prediction models and data are crucially needed. Following TAVR, high molecular weight (HMW) multimers defect of von Willebrand factor (VWF) as assessed by closure time of adenosine diphosphate (CT-ADP) value > 180 seconds is an independent predictor of bleeding events. This study sought to identify predictors of ischemic neurological events in patients who underwent TAVR and the specific impact of HMW multimers defect of VWF. METHODS Patients were prospectively enrolled between November 2012 and May 2018 at our institution. The CT-ADP, a point-of-care measure of hemostasis, was assessed the day before and 24 hours after the procedures. The rate of ischemic stroke and transient ischemic attack (TIA) was recorded up to 30 days after the procedures. RESULTS Of 565 TAVR patients, ischemic stroke/TIA was observed in 21 (3.7%) patients within 30 days. Ischemic stroke/TIA was associated with major/life-threatening bleeding complications (MLBCs) (9 [43%] vs. 88 [16%], p = 0.002) and postprocedure CT-ADP > 180 seconds (10 [48%] vs. 116 [21%], p = 0.01). By multivariate analysis, MLBCs (odds ratio [OR]: 3.58; 95% confidence interval [CI]: 1.45-8.84; p = 0.006) and postprocedure CT-ADP > 180 seconds (OR: 3.38; 95% CI: 1.38-8.25; p = 0.008) were evidenced as independent predictors of ischemic stroke/TIA. CONCLUSION MLBCs and CT-ADP > 180 seconds were identified as predictors for ischemic stroke or TIA. The present study suggests that the defects of HMW multimers of the VWFs may contribute not only to bleeding events but also to thrombotic events.
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Affiliation(s)
- Kensuke Matsushita
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France.,UMR1260 INSERM, Nanomédecine Régénérative, Faculté de Pharmacie, Université de Strasbourg, Illkirch, France
| | - Benjamin Marchandot
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France
| | - Antonin Trimaille
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France
| | - Marion Kibler
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France
| | - Joe Heger
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France
| | - Marilou Peillex
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France
| | - Sebastien Hess
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France
| | - Lelia Grunebaum
- Department of Haemostasis, Centre Hospitalier Universitaire, Strasbourg, France
| | - Antje Reydel
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France
| | - Michel Kindo
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France
| | - Minh Tam Hoang
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France
| | - Chisato Sato
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France
| | - Fabien De Poli
- Department of Cardiology, Centre Hospitalier de Haguenau, Haguenau, France
| | - Pierre Leddet
- Department of Cardiology, Centre Hospitalier de Haguenau, Haguenau, France
| | - Mickael Ohana
- Department of Radiology, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Strasbourg, France
| | - Laurence Jesel
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France.,UMR1260 INSERM, Nanomédecine Régénérative, Faculté de Pharmacie, Université de Strasbourg, Illkirch, France
| | - Patrick Ohlmann
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France
| | - Sophie Susen
- INSERM U1011 - EGID, Institut Pasteur de Lille, University of Lille, Lille, France.,Hematology Transfusion, CHU Lille, Lille, France
| | - Olivier Morel
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, Strasbourg, France.,UMR1260 INSERM, Nanomédecine Régénérative, Faculté de Pharmacie, Université de Strasbourg, Illkirch, France
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Lansky A, Ghare MI, Tchétché D, Baumbach A. TAVI and the brain: update on definitions, evidence of neuroprotection and adjunctive pharmacotherapy. EUROINTERVENTION 2018; 14:AB53-AB63. [DOI: 10.4244/eij-d-18-00454] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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17
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Lansky AJ, Ghare MI, Pietras C. Carotid Disease and Stroke After Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2018; 11:e006826. [DOI: 10.1161/circinterventions.118.006826] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alexandra J. Lansky
- From the Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (A.J.L., M.I.G., C.P.)
- Barts Heart Center, William Harvey Research Institute, St Bartholomew’s Hospital, Queen Mary University of London, United Kingdom (A.J.L.)
| | - M. Imran Ghare
- From the Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (A.J.L., M.I.G., C.P.)
| | - Cody Pietras
- From the Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (A.J.L., M.I.G., C.P.)
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