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Dawadi S, Oli PR, Shrestha DB, Shtembari J, Pant K, Shrestha B, Mattumpuram J, Katz DH. Transcarotid versus trans-axillary/subclavian transcatheter aortic valve replacement (TAVR): A systematic review and meta-analysis. Curr Probl Cardiol 2024; 49:102488. [PMID: 38417474 DOI: 10.1016/j.cpcardiol.2024.102488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/24/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Transcatheter Aortic Valve Replacement (TAVR) is the treatment of choice in patients with severe aortic stenosis. Transcarotid (TCa) or Trans-axillary/subclavian (TAx/Sc) are safer and less invasive non-femoral approaches, where transfemoral access is difficult or impossible to obtain. METHODS This meta-analysis was performed based on PRISMA guidelines after registering in PROSPERO (CRD42023482842). This meta-analysis was performed to compare the safety of the transcarotid and trans-axillary/subclavian approach for TAVR including studies from inception to October 2023. RESULTS Seven studies with a total of 6227 patients were included in the analysis (TCa: 2566; TAx/Sc: 3661). Transcarotid TAVR approach had a favorable trend for composite of stroke and all-cause mortality (OR 0.79, CI 0.60-1.04), all-cause mortality, stroke, major vascular complication, and new requirement of permanent pacemaker though those were statistically insignificant. On sub-analysis of the results of the studies based on the territory (USA vs French), composite outcome of all cause mortality, stroke and major bleeding (OR 0.54, CI 0.54-0.81), composite of stroke and all cause mortality (OR 0.64, CI 0.50-0.81), and stroke/TIA (OR 0.53, CI 0.39-0.73) showed lower odds of occurrence among patient managed with TCa approach in the American cohort. CONCLUSION Overall, transcarotid approach had favorable though statistically insignificant odds for composite (stroke and all-cause mortality) and individual outcomes (stroke, all-cause mortality, etc.). There are significant variations in observed outcomes based on study's geographic location. Large prospective randomized clinical trials comparing the two approaches with representative samples are necessary to guide the clinicians in choosing among these approaches.
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Affiliation(s)
- Sagun Dawadi
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, 44600, Nepal
| | - Prakash Raj Oli
- Department of Internal Medicine, Province Hospital, Birendranagar, Surkhet, Karnali Province 21700, Nepal
| | | | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL 60608, USA
| | - Kailash Pant
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Illinois College of Medicine, OSF Healthcare, Peoria, IL 61614, USA
| | - Bishesh Shrestha
- Division of Cardiology, Department of Internal Medicine, Bassett Medical Center, 1 Atwell Rd, Cooperstown, NY 13326, USA
| | - Jishanth Mattumpuram
- Division of Cardiology, Department of Internal Medicine, University of Louisville School of Medicine, 550 S Jackson St, Louisville, KY 40202, USA.
| | - Daniel H Katz
- Division of Cardiology, Department of Internal Medicine, Bassett Medical Center, 1 Atwell Rd, Cooperstown, NY 13326, USA
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Kaneko T, Hirji SA, Yazdchi F, Sun YP, Nyman C, Shook D, Cohen DJ, Stebbins A, Zeitouni M, Vemulapalli S, Thourani VH, Shah PB, O'Gara P. Association Between Peripheral Versus Central Access for Alternative Access Transcatheter Aortic Valve Replacement and Mortality and Stroke: A Report From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Circ Cardiovasc Interv 2022; 15:e011756. [PMID: 36126131 DOI: 10.1161/circinterventions.121.011756] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In some patients, the alternative access route for transcatheter aortic valve replacement (TAVR) is utilized because the conventional transfemoral approach is not felt to be either feasible or optimal. However, accurate prognostication of patient risks is not well established. This study examines the associations between peripheral (transsubclavian/transaxillary, and transcarotid) versus central access (transapical and transaortic) in alternative access TAVR and 30-day and 1-year end points of mortality and stroke for all valve platforms. METHODS Using data from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry with linkage to Medicare claims, patients who underwent alternative access TAVR from June 1, 2015 to June 30, 2018 were identified. Adjusted and unadjusted Cox proportional hazards modeling were performed to determine the association between alternate access TAVR site and 30-day and 1-year end points of mortality and stroke. RESULTS Of 7187 alternative access TAVR patients, 3725 (52%) had peripheral access and 3462 (48%) had central access. All-cause mortality was significantly lower in peripheral access versus central access group at in-hospital and 1 year (2.9% versus 6.3% and 20.3% versus 26.6%, respectively), but stroke rates were higher (5.0% versus 2.8% and 7.3% versus 5.5%, respectively; all P<0.001). These results persisted after 1-year adjustment (death adjusted hazard ratio, 0.72 [95% CI, 0.62-0.85] and stroke adjusted hazard ratio, 2.92 [95% CI, 2.21-3.85]). When broken down by individual subtypes, compared with transaxillary/subclavian access patients, transapical, and transaortic access patients had higher all-cause mortality but less stroke (P<0.05). CONCLUSIONS In this real-world, contemporary, nationally representative benchmarking study of alternate access TAVR sites, peripheral access was associated with favorable mortality and morbidity outcomes compared with central access, at the expense of higher stroke. These findings may allow for accurate prognostication of risk for patient counseling and decision-making for the heart team with regard to alternative access TAVR.
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Affiliation(s)
- Tsuyoshi Kaneko
- Division of Thoracic and Cardiac Surgery (T.K., S.H., F.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sameer A Hirji
- Division of Thoracic and Cardiac Surgery (T.K., S.H., F.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Farhang Yazdchi
- Division of Thoracic and Cardiac Surgery (T.K., S.H., F.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yee-Ping Sun
- Division of Cardiovascular Medicine (Y.P.S., P.S., P.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Charles Nyman
- Division of Cardiac Anesthesia (C.N., D.S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Douglas Shook
- Division of Cardiac Anesthesia (C.N., D.S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, NY (D.J.C.).,Duke Clinical Research Institute, Durham, NC (D.J.C.)
| | | | | | | | | | - Pinak B Shah
- Division of Cardiovascular Medicine (Y.P.S., P.S., P.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Patrick O'Gara
- Division of Cardiovascular Medicine (Y.P.S., P.S., P.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Wong CK, Chiu ACHO, Chan KYE, Sze SY, Tam FCC, Un KC, Lam SCC, Tse HF. Advances in technology and techniques for transcatheter aortic valve replacement with concomitant peripheral arterial disease. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:959249. [PMID: 36062263 PMCID: PMC9433652 DOI: 10.3389/fmedt.2022.959249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/19/2022] [Indexed: 11/30/2022] Open
Abstract
Aortic stenosis (AS) is a prevalent disease affecting 3.7% of the adult population aged 65 or above. In the past, surgical aortic valve replacement (SAVR) was the only definitive therapy available for the treatment of severe AS. Owing to the invasive nature of open-heart surgery, patients with advanced age and frailty could not benefit from SAVR. The advent of transcatheter aortic valve replacement (TAVR) in the past decade has offered an alternative treatment option for patients with severe AS, particularly those who are deemed to have high surgical risks. Nevertheless, a large proportion of patients also have concomitant peripheral arterial disease (PAD), which increases the risk of peri-procedural vascular complication, and precludes the possibility of transfemoral TAVR owing to inadequate luminal size for delivery system deployment. In this review, the prevalence and outcome of TAVR patients with PAD will be discussed. Furthermore, novel technologies and techniques that enable TAVR to be safely performed using transfemoral or alternative access in patients with severe PAD will be reviewed.
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Karout L, Salman R, Ershaid F, Sawaya F, Abi-Ghanem AS. Imaging Modalities Employed in the TAVR Procedure With a Focus on CTA: What the Radiologist Needs to Know. Acad Radiol 2022; 29 Suppl 4:S69-S81. [PMID: 34551883 DOI: 10.1016/j.acra.2021.08.012] [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: 05/30/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/01/2022]
Abstract
RATIONALE AND OBJECTIVES Aortic stenosis (AS) is one of the most common valvular heart disease. Symptomatic AS is associated with a high mortality rate which prompts fast intervention. The introduction of transcatheter aortic valve replacement (TAVR) has drastically improved the outcome of high surgical risk for mortality patients with severe AS. However, this procedure requires the employment of multimodality imaging in the pre-procedural planning, intra-procedural optimization, and post-procedural follow-up stages. This also requires an accurate understanding of the indications, measurements, strength, and limitations of each imaging modality during the different TAVR stages. CONCLUSION In this review, we aim to outline to radiologists the evidence-based approach and indications of different imaging modalities through the pre, peri, and post TAVR stages.
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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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Payabyab EC, Elbaum LS, Sharma N, George I, Mick SL. Shockwave and Non-transfemoral Transcatheter Aortic Valve Replacement. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2021.16] [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
Transcatheter aortic valve replacement (TAVR) has become a widely adopted treatment modality for severe aortic stenosis. Transfemoral access is the approach of choice; however, approximately 25% of patients undergoing TAVR also have concomitant peripheral arterial disease. The recent advent of intravascular lithotripsy has enabled preservation of transfemoral access in some patients; although, a proportion still require alternative, non-femoral access. Alternative access sites can be broadly categorized into transthoracic and peripheral, facilitated by surgical or percutaneous techniques. In this review, the technical details and clinical outcomes of various TAVR accesses are discussed. Initially, transthoracic approaches were most common, but recently, the trend has been toward alternative peripheral access due to superior outcomes. Although there are no randomized data to support all the alternative access sites, the experiences reported provide available options for a large portion of patients to be candidates for TAVR. The intervention site should be selected by a multidisciplinary heart team based on patient anatomical factors and institutional expertise.
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Affiliation(s)
- Eden C Payabyab
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY
| | - Lindsay S Elbaum
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York City, NY
| | - Navneet Sharma
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York City, NY
| | - Isaac George
- NewYork-Presbyterian Hospital, Columbia University Medical Center, New York City, NY
| | - Stephanie L Mick
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY
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Prasad NK, Boyajian G, Gupta A, Hall M, Toursavadkouhi S, Ghoreishi M, Taylor BS. Transcarotid Approach for Ascending Aortic Endovascular Repair. Ann Thorac Surg 2021; 112:e17-e19. [DOI: 10.1016/j.athoracsur.2020.10.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/21/2020] [Indexed: 10/22/2022]
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Abstract
Due to its potential benefits and increased patient satisfaction minimal invasive cardiac surgery (MICS) is rapidly gaining in popularity. These procedures are not without challenges and require careful planning, pre-operative patient assessment and excellent intraoperative communication. Assessment of patient suitability for MICS by a multi-disciplinary team during pre-operative workup is desirable. MICS requires additional skills that many might not consider to be part of the standard cardiac anesthetic toolkit. Anesthetists involved in MICS need not only be highly skilled in performing transesophageal echocardiography (TEE) but need to be proficient in multimodal analgesia, including locoregional or neuroaxial techniques. MICS procedures tend to cause more postoperative pain than standard median sternotomies do, and patients need analgesic management more in keeping with thoracic operations. Ultrasound guided peripheral regional anesthesia techniques like serratus anterior block can offer an advantage over neuroaxial techniques in patients on anti-platelet therapy or anticoagulation with low molecular weight or unfractionated heparin The article reviews the salient points pertaining to pre-operative assessment and suitability, intraoperative process and postoperative management of minimally invasive cardiac procedures in the operating theatre as well as the catheterization lab. Special emphasis is given to anesthetic management and analgesia techniques.
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Affiliation(s)
- Alexander White
- Senior Fellow in Anaesthetics and Intensive Care, The Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Chinmay Patvardhan
- Consultant in Anaesthetics and Intensive Care, The Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Florian Falter
- Consultant in Anaesthetics and Intensive Care, The Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Abstract
Transcatheter aortic valve replacement (TAVR) is a minimally invasive approach to treat symptomatic severe aortic stenosis. The patient populations that have been shown to benefit from this procedure continue to grow with time. Techniques and technology in TAVR persistently advance with a continued trend toward improved outcomes for patients. In this review, we highlight the advances in vascular access, TAVR valve design, progress in reducing procedural complications, and emerging evidence in the field.
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Affiliation(s)
- Morgan H Randall
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Anthony A Bavry
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA.
- North Florida/South Georgia, Veterans Health System, Gainesville, FL, USA.
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Anderson RD, Gargus N, Randall MH. Editorial: The use of Fascia iliaca Block with Minimal Conscious Sedation in Transcatheter Aortic Valve Replacement: Advances in TAVR Anesthesia. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:602-603. [PMID: 32201210 DOI: 10.1016/j.carrev.2020.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 03/10/2020] [Indexed: 11/19/2022]
Affiliation(s)
- R David Anderson
- University of Florida, Division of Cardiovascular Medicine, 1329 SW 16th St., PO Box 100288, Gainesville, FL 32608, United States of America.
| | - Nathan Gargus
- University of Florida, Division of Cardiovascular Medicine, 1329 SW 16th St., PO Box 100288, Gainesville, FL 32608, United States of America
| | - Morgan H Randall
- University of Florida, Division of Cardiovascular Medicine, 1329 SW 16th St., PO Box 100288, Gainesville, FL 32608, United States of America
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Therapeutic strategies for thrombosis: new targets and approaches. Nat Rev Drug Discov 2020; 19:333-352. [PMID: 32132678 DOI: 10.1038/s41573-020-0061-0] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2020] [Indexed: 12/19/2022]
Abstract
Antiplatelet agents and anticoagulants are a mainstay for the prevention and treatment of thrombosis. However, despite advances in antithrombotic therapy, a fundamental challenge is the side effect of bleeding. Improved understanding of the mechanisms of haemostasis and thrombosis has revealed new targets for attenuating thrombosis with the potential for less bleeding, including glycoprotein VI on platelets and factor XIa of the coagulation system. The efficacy and safety of new agents are currently being evaluated in phase III trials. This Review provides an overview of haemostasis and thrombosis, details the current landscape of antithrombotic agents, addresses challenges with preventing thromboembolic events in patients at high risk and describes the emerging therapeutic strategies that may break the inexorable link between antithrombotic therapy and bleeding risk.
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