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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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Htun WW, Grines C, Schreiber T. Feasibility of coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement using a Medtronic™ self-expandable bioprosthetic valve. Catheter Cardiovasc Interv 2017; 91:1339-1344. [DOI: 10.1002/ccd.27346] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 08/21/2017] [Accepted: 08/29/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Wah Wah Htun
- Department of Cardiology; Detroit Medical Center/Wayne State University; Detroit Michigan
- Department of Cardiothoracic Surgery; Northwell Health, Lenox Hill Hospital; New York
| | - Cindy Grines
- Department of Cardiology; Northwell Health, North Shore University Hospital; Manhasset New York
| | - Theodore Schreiber
- Department of Cardiology; Detroit Medical Center/Wayne State University; Detroit Michigan
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Aortic stenosis: insights on pathogenesis and clinical implications. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:489-98. [PMID: 27582763 PMCID: PMC4987417 DOI: 10.11909/j.issn.1671-5411.2016.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Aortic stenosis (AS) is a common valvular heart disease in the Western populations, with an estimated overall prevalence of 3% in adults over 75 years. To understand its patho-biological processes represents a priority. In elderly patients, AS usually involves trileaflet valves and is referred to as degenerative calcific processes. Scientific evidence suggests the involvement of an active "atherosclerosis-like" pathogenesis in the initiation phase of degenerative AS. To the contrary, the progression could be driven by different forces (such as mechanical stress, genetic factors and interaction between inflammation and calcification). The improved understanding presents potentially new therapeutic targets for preventing and inhibiting the development and progression of the disease. Furthermore, in clinical practice the management of AS patients implies the evaluation of generalized atherosclerotic manifestations (i.e., in the coronary and carotid arteries) even for prognostic reasons. In counselling elderly patients, the risk stratification should address individual frailty beyond the generic risk scores. In these regard, the co-morbidities, and in particular those linked to the global atherosclerotic burden, should be carefully investigated in order to define the risk/benefit ratio for invasive treatment strategies. We present a detailed overview of insights in pathogenesis of AS with possible practical implications.
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Challenges of coronary angiography and intervention in patients previously treated by TAVI. Clin Res Cardiol 2015; 104:632-9. [PMID: 25720330 DOI: 10.1007/s00392-015-0824-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 02/09/2015] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Since the beginning of the transcatheter aortic valve implantation (TAVI) era, many prosthetic valves have entered clinical practice. TAVI prostheses differ regarding stent design and some may potentially interfere with diagnostic or interventional catheters. The aim of our analysis was to evaluate the feasibility of coronary angiography (CA) or percutaneous coronary intervention (PCI) in patients with prior TAVI. METHODS From 2011 to 2014, 1,000 patients were treated by TAVI at our center using eight different valve prostheses (Symetis ACURATE TA and ACURATE TF; Medtronic CoreValve and Engager; JenaValve, SJM Portico; Edwards Lifesciences SAPIEN and SAPIEN XT). In this analysis, all patients were included who underwent either CA or PCI after TAVI. CA or PCI were rated as fully feasible when coronary ostia could be fully intubated, partially feasible when coronary arteries could be displayed only unselectively or unfeasible when coronary arteries could not be displayed. RESULTS A total of 35 patients underwent CA/PCI after TAVI at our hospital. In all patients with valves implanted in a subcoronary position (SAPIEN n = 19; JenaValve n = 1), selective intubation was feasible using standard catheters. Out of 15 patients with valve types that are placed over the coronary ostia (CoreValve n = 10, ACURATE n = 4, Portico n = 1), selective intubation of coronary arteries was not possible in 9 cases, even with the use of different diagnostic catheters. Full accessibility was possible only in 3 cases. In 2 cases, display of the right CA was only feasible using unselective aortography. In 1 case, coronary arteries could not be displayed at all immediately after a valve-in-valve procedure. CONCLUSION CA or PCI after TAVI is usually feasible. Devices that are placed in a partially supracoronary position, however, can interfere with diagnostic or guiding catheters and impede straightforward intervention, especially when the prosthesis is not implanted in the correct position.
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Steinvil A, Leshem-Rubinow E, Abramowitz Y, Shacham Y, Arbel Y, Banai S, Bornstein NM, Finkelstein A, Halkin A. Prevalence and predictors of carotid artery stenosis in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2014; 84:1007-12. [PMID: 24975558 DOI: 10.1002/ccd.25585] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2014] [Revised: 06/02/2014] [Accepted: 06/22/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Our aim was to analyze the prevalence and predictors of Carotid artery stenosis (CAS) in patients undergoing transcatheter aortic valve implantation (TAVI). BACKGROUND CAS is associated with the risk of periprocedural stroke in patients undergoing cardiac surgery. However, little is known about the prevalence of and clinical significance of CAS in the setting of TAVI. METHODS Consecutive patients undergoing a carotid Doppler study the day before TAVI were followed prospectively. CAS was defined in accordance with current practice guidelines. Logistic regression models were used to identify independent correlates of CAS. RESULTS The study included 171 patients (age 82 ± 6, male gender 47%). Carotid atherosclerosis (CA, defined as any carotid plaque) was present in 164 (96%) of patients, and CAS (peak systolic velocity [PSV] ≥ 125 cm/sec; ≥50% diameter stenosis) in 57 (33%) patients. Severe CAS (PSV ≥ 230 cm/sec; ≥70% stenosis, or near occlusion) was found in 15 (9%) patients. By multivariate analysis, smoking and a higher Euroscore independently predicted the presence of CAS. Patients in the present TAVI cohort had a significantly higher prevalence of both unilateral and bilateral CAS ≥ 50% than those in a previously reported cohort (n = 494 patients, age ≥ 70) undergoing clinically driven coronary angiography (33% vs. 20%, OR = 1.9, P = 0.001; and, 13% vs. 6%, OR = 2.3, P = 0.003, respectively). CAS was not independently associated with 30-day mortality or stroke rates. CONCLUSIONS The prevalence of CAS in patients undergoing TAVI is high, exceeding that observed in patients undergoing catheterization for coronary indications. The impact of CAS on clinical outcomes following TAVI merits further research.
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Affiliation(s)
- Arie Steinvil
- Departments of Cardiology and Neurology, Tel-Aviv Medical Center, Tel-Aviv, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Abdel-Wahab M, Zahn R, Horack M, Gerckens U, Schuler G, Sievert H, Naber C, Voehringer M, Schäfer U, Senges J, Richardt G. Transcatheter aortic valve implantation in patients with and without concomitant coronary artery disease: comparison of characteristics and early outcome in the German multicenter TAVI registry. Clin Res Cardiol 2012; 101:973-81. [PMID: 22772776 DOI: 10.1007/s00392-012-0486-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Accepted: 06/08/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine the prevalence and impact of concomitant coronary artery disease (CAD) on short-term outcome after transcatheter aortic valve implantation (TAVI). BACKGROUND The prevalence of CAD in patients undergoing surgical aortic valve replacement is estimated at 30-50 % and its presence increases procedural risk. The prevalence and impact of CAD on outcome after TAVI are not well defined. METHODS We analyzed 1,382 patients enrolled in the German TAVI registry; the majority (81 %) received the Medtronic CoreValve. The presence of coronary lesions with ≥50 % stenosis on pre-TAVI angiography defined the existence of concomitant CAD. RESULTS 859 patients (62.2 %) had concomitant CAD, of which 534 (62.3 %) had multi-vessel and 83 (9.7 %) left main disease. Patients with CAD were younger (81.5 ± 6.1 vs. 82.1 ± 6.3 years, p < 0.05), more commonly males (49.4 vs. 30.0 %, p < 0.0001) and diabetics (36.9 vs. 31.2 %, p < 0.05), and had a worse Canadian Cardiovascular Society angina class at baseline compared to patients with no CAD. During TAVI patients with CAD more often required additional coronary intervention and had longer procedures, but procedural success rates were similar (97.1 vs. 97.7 %). Crude in-hospital mortality was higher in patients with CAD (10.0 vs. 5.5 %, OR 1.90, 95 % CI 1.23-2.93), but this was not significant after adjustment for confounders (adjusted OR 1.41, 95 % CI 0.85-2.33). Both groups had significant improvement in 30-day symptoms and quality of life. CONCLUSION The prevalence of CAD in contemporary TAVI patients is high. Its presence characterizes a high-risk population and is associated with increased crude short-term mortality, largely explained by co-morbidities, but does not limit functional improvement after TAVI.
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Affiliation(s)
- Mohamed Abdel-Wahab
- Heart Center, Segeberger Kliniken GmbH, Academic Teaching Hospital of the Universities of Kiel and Hamburg, Am Kurpark 1, 23795, Bad Segeberg, Germany.
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Association between asymptomatic carotid atherosclerosis and degenerative aortic stenosis. Atherosclerosis 2012; 223:519-22. [PMID: 22749333 DOI: 10.1016/j.atherosclerosis.2012.06.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 06/01/2012] [Accepted: 06/06/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Degenerative aortic stenosis shows similarities with atherosclerosis. To confirm the hypothesis that aortic stenosis is an "atherosclerosis-like" disease, we investigated the association between degenerative aortic stenosis and atherosclerosis of carotid arteries. METHODS We studied 270 consecutive patients, 135 with degenerative aortic stenosis (trans-aortic peak velocity ≥ 2 m/sec) and other 135 subjects without aortic valve disease. All patients underwent echocardiography and ultrasound scan of the supra-aortic trunks to assess the presence of plaque and/or intima-media thickening (IMT). RESULTS Atherosclerosis of carotid arteries (IMT and plaque) was significantly more frequent in patients with aortic stenosis than in controls (95.5% vs. 66.6%, p < 0.0001). The same result was confirmed as concerns carotid plaques (69.6% vs. 42.2%, p < 0.0001). In addition, there was a significant association between aortic stenosis and degenerative carotid plaque (OR = 3.13; 95% C.I. = 1.90-5.17). Thus the presence of a linear correlation between the trans-aortic peak velocity of the cases and the thickness of the plaques and IMT was evaluated by calculating the coefficient of correlation (R = 0.15 for plaque and R = 0.53 for IMT). CONCLUSIONS The presence of carotid atherosclerosis is associated with degenerative aortic stenosis and the severity of aortic stenosis corresponds to an increase of the thickness of plaque and IMT. This relationship is quite new. Our result strengthens the pathogenetic hypothesis "atherosclerosis-like" of degenerative aortic stenosis and suggest the ultrasound scan as a non invasive method for risk stratification in patient with aortic stenosis, with therapeutic implications especially for higher risk subgroups.
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Gautier M, Pepin M, Himbert D, Ducrocq G, Iung B, Dilly MP, Attias D, Nataf P, Vahanian A. Impact of coronary artery disease on indications for transcatheter aortic valve implantation and on procedural outcomes. EUROINTERVENTION 2012; 7:549-55. [PMID: 21930458 DOI: 10.4244/eijv7i5a90] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AIMS To describe the characteristics of coronary artery disease (CAD) in high-risk patients with aortic stenosis (AS), and its impact on indications for transcatheter aortic valve implantation (TAVI), and on outcomes. METHODS AND RESULTS Of 240 patients referred for TAVI, 230 had documented CAD status. Mean age was 81.5±8 years. Hundred and forty-four (63%) had CAD. Compared to patients with no CAD, those with CAD had a higher risk of mortality (EuroSCORE: 31±18%, vs. 23±11%, p=0.004). Overall, 145 patients (63%) underwent TAVI, 31 (13%) surgery, and 54 (24%) medical treatment. No patient was denied intervention because of the CAD. CAD led to re-orientate one patient (0.4%) towards surgery. PCI was performed before TAVI in 11 (7%). Survival rates were respectively 90% and 85% in the CAD and non-CAD groups (p=0.37) at 30 days, and 76.4±5.4% and 70.6±6.8% (p=0.28) at 1-year. At follow-up, functional status was similar in both groups and no further revascularisation was needed. CONCLUSIONS In high-risk patients referred for TAVI, CAD is frequent and associated with worse baseline characteristics. It has a limited impact on indications for TAVI. It seldom requires revascularisation and does not preclude satisfactory outcomes after TAVI.
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Affiliation(s)
- Mathieu Gautier
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat-Claude Bernard Hospital, Paris, France
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Leon MB, Piazza N, Nikolsky E, Blackstone EH, Cutlip DE, Kappetein AP, Krucoff MW, Mack M, Mehran R, Miller C, Morel MA, Petersen J, Popma JJ, Takkenberg JJM, Vahanian A, van Es GA, Vranckx P, Webb JG, Windecker S, Serruys PW. Standardized endpoint definitions for transcatheter aortic valve implantation clinical trials: a consensus report from the Valve Academic Research Consortium. Eur Heart J 2011; 32:205-17. [PMID: 21216739 PMCID: PMC3021388 DOI: 10.1093/eurheartj/ehq406] [Citation(s) in RCA: 504] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To propose standardized consensus definitions for important clinical endpoints in transcatheter aortic valve implantation (TAVI), investigations in an effort to improve the quality of clinical research and to enable meaningful comparisons between clinical trials. To make these consensus definitions accessible to all stakeholders in TAVI clinical research through a peer reviewed publication, on behalf of the public health. BACKGROUND Transcatheter aortic valve implantation may provide a worthwhile less invasive treatment in many patients with severe aortic stenosis and since its introduction to the medical community in 2002, there has been an explosive growth in procedures. The integration of TAVI into daily clinical practice should be guided by academic activities, which requires a harmonized and structured process for data collection, interpretation, and reporting during well-conducted clinical trials. METHODS AND RESULTS The Valve Academic Research Consortium established an independent collaboration between Academic Research organizations and specialty societies (cardiology and cardiac surgery) in the USA and Europe. Two meetings, in San Francisco, California (September 2009) and in Amsterdam, the Netherlands (December 2009), including key physician experts, and representatives from the US Food and Drug Administration (FDA) and device manufacturers, were focused on creating consistent endpoint definitions and consensus recommendations for implementation in TAVI clinical research programs. Important considerations in developing endpoint definitions included (i) respect for the historical legacy of surgical valve guidelines; (ii) identification of pathophysiological mechanisms associated with clinical events; (iii) emphasis on clinical relevance. Consensus criteria were developed for the following endpoints: mortality, myocardial infarction, stroke, bleeding, acute kidney injury, vascular complications, and prosthetic valve performance. Composite endpoints for TAVI safety and effectiveness were also recommended. CONCLUSION Although consensus criteria will invariably include certain arbitrary features, an organized multidisciplinary process to develop specific definitions for TAVI clinical research should provide consistency across studies that can facilitate the evaluation of this new important catheter-based therapy. The broadly based consensus endpoint definitions described in this document may be useful for regulatory and clinical trial purposes.
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Affiliation(s)
- Martin B Leon
- Columbia University Medical Center, Center for Interventional Vascular Therapy, 173 Fort Washington Avenue, Heart Center, New York, NY 10032, USA.
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Standardized Endpoint Definitions for Transcatheter Aortic Valve Implantation Clinical Trials. J Am Coll Cardiol 2011; 57:253-69. [DOI: 10.1016/j.jacc.2010.12.005] [Citation(s) in RCA: 666] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Revised: 09/30/2010] [Accepted: 10/06/2010] [Indexed: 12/15/2022]
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