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Kapadia S, Krishnaswamy A, Mack M. Acute Brain Infarctions and Periprocedural Stroke: Implications for Evaluating Cerebral Embolic Protection Devices. J Am Coll Cardiol 2024; 84:723-725. [PMID: 39142726 DOI: 10.1016/j.jacc.2024.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 06/12/2024] [Indexed: 08/16/2024]
Affiliation(s)
- Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Marcusohn E, Manoragavan R, Fremes S, Tarola C, Sathananthan J, Barabash IM, Orbach A, Sachedina AK, Radhakrishnan S, Wijeysundera HC. Impact of cerebral protection on observed versus predicted in-hospital stroke in a high stroke risk TAVR cohort. BMC Cardiovasc Disord 2024; 24:422. [PMID: 39135174 PMCID: PMC11321055 DOI: 10.1186/s12872-024-04097-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 08/06/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Despite impressive improvements in the safety profile of Transcatheter aortic valve replacement (TAVR), the risk for peri-procedural stroke after TAVR has not declined substantially. In an effort to reduce periprocedural stroke, cerebral embolic protection (CEP) devices have been utilized but have yet to demonstrate benefit in all-comers. There is a paucity of data supporting the utilization of CEP in TAVR patients with an anticipated high risk for peri-procedural stroke. METHODS The Transcatheter Aortic Valve Replacement In-Hospital Stroke (TASK) score is a clinical risk tool for predicting the in-hospital stroke risk of patients undergoing transfemoral TAVR. This score was used to identify high-risk patients and calculate the expected in-hospital stroke risk. This was a single-centre cohort study in all consecutive TAVR patients who had placement of CEP. The observed versus expected ratio for peri-procedural stroke was calculated. To obtain 95% credible intervals, we used 1000 bootstrapped samples of the original cohort sample size without replacement and recalculated the TASK predicted scores. RESULTS The study included 103 patients. The median age was 83 (IQR 78,89). 63 were male (61.1%) and 45 (43.69%) had a history of previous Stroke or TIA. Two patients had an in-hospital stroke after TAVR (1.94%). The expected risk of in-hospital stroke based on the TASK score was 3.39% (95% CI 3.07-3.73). The observed versus expected ratio was 0.57 (95% CI 0.52-0.64). CONCLUSION In this single-center study, we found that in patients undergoing TAVR with high stroke risk, CEP reduced the in-hospital stroke risk by 43% when compared with the risk-score predicted rate. CLINICAL TRIAL NUMBER N/A.
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Affiliation(s)
- Erez Marcusohn
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Ragavie Manoragavan
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Stephen Fremes
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Division of Cardiac Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Christopher Tarola
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Division of Cardiac Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Janarthanan Sathananthan
- Centre for Cardiovascular Innovation, St. Paul's and Vancouver General Hospital, Vancouver, Canada
- Cardiovascular Translational Laboratory, Providence Research and Centre for Heart Lung Innovation, Vancouver, Canada
- St. Paul's Hospital, Centre for Heart Valve Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Israel M Barabash
- Interventional Cardiology Unit, Leviev Heart and Vascular Center, Chaim Sheba Medical Center, Ramat Gan, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ady Orbach
- Cardiology Department, Edith Wolfson Medical Center, Holon, Israel
| | - Ayaaz K Sachedina
- Foothills Medical Centre, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Sam Radhakrishnan
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
- ICES, Toronto, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
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Basit J, Ahmed M, Kidess G, Zaheer Z, Fatima L, Naveed H, Hamza M, Fatima M, Goyal A, Loyalka P, Alam M, Alraies MC. Cerebral embolic protection for stroke prevention during transcatheter aortic valve replacement. Expert Rev Cardiovasc Ther 2024; 22:409-420. [PMID: 39056434 DOI: 10.1080/14779072.2024.2385989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 07/05/2024] [Accepted: 07/25/2024] [Indexed: 07/28/2024]
Abstract
INTRODUCTION Cerebral Embolic Protection Device (CEPD) captures emboli during Transcatheter Aortic Valve Replacement (TAVR). With recently published pivotal trials and multiple cohort studies reporting new data, there is a need to re-calibrate available statistical evidence. METHODS A systematic literature search was conducted across databases from inception till February 2023. Dichotomous outcomes were pooled using Odds Ratio (OR), while continuous outcomes were pooled using Standardized Mean Difference (SMD) along with 95% corresponding intervals (95% CIs). RESULTS Data was included from 17 studies (7 RCTs, 10 cohorts, n = 155,829). Use of CEPD was associated with significantly reduced odds of stroke (OR = 0.60, 95% CI = 0.43-0.85, p = 0.003). There was no significant difference in disabling stroke (p = 0.25), non-disabling stroke (p = 0.72), and 30-day mortality (p = 0.10) between the two groups. There were no significant differences between the two groups for Diffusion-Weighted Magnetic Resonance Imaging (DW-MRI) findings, acute kidney injury, risk of pacemaker implantation life-threatening bleed, major bleed, minor bleed, worsening National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and vascular complications (p > 0.05). CONCLUSIONS The use of CEPD during TAVR reduced the incidence of all-stroke (p = 0.003); however, there were no significant differences in any of the other pooled outcomes (p > 0.05). REGISTRATION The protocol of this meta-analysis was registered with the Open Science framework [https://doi.org/10.17605/OSF.IO/7W564] before data acquisition was started.
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Affiliation(s)
- Jawad Basit
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Mushood Ahmed
- Department of Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - George Kidess
- Department of Internal Medicine, Wayne State University, Michigan, USA
| | - Zaofashan Zaheer
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Laveeza Fatima
- Department of Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Hamza Naveed
- University of Houston/HCA kingwood Hospital, Houston, TX, USA
| | - Mohammad Hamza
- Department of Hospital Medicine, Guthrie Cortland Medical Center, Cortland, NY, USA
| | - Maurish Fatima
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Pranav Loyalka
- Department of cardiology, HCA medical Center, Houston, TX, USA
| | - Mahboob Alam
- Department of Interventional Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - M Chadi Alraies
- Cardiovascular Institute, Detroit Medical Center, Detroit, MI, USA
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Harmouch W, Karnkowska B, Thakker R, Rasmussen P, Shalaby M, Khalife W, Alwash H, Motiwala A, Kumfa P, Gilani S, Jneid H, Rangasetty U. Cerebral Embolic Protection in Transcatheter Aortic Valve Implantation Using the Sentinel Cerebral Protection System: A Systematic Review and Meta-Analysis. Cardiol Ther 2024; 13:299-314. [PMID: 38340292 PMCID: PMC11093944 DOI: 10.1007/s40119-024-00359-4] [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: 12/28/2023] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
INTRODUCTION Transcatheter aortic valve implantation (TAVI) plays a vital role in patients with symptomatic aortic stenosis. Despite the mortality benefit of TAVI, embolic stroke remains a feared complication. As a result, transcatheter cerebral embolic protection (TCEP) devices have been developed to reduce this risk. Given the ongoing debate of TCEP in TAVI, we performed a systematic review and meta-analysis of all randomized controlled trials to date to identify outcomes of periprocedural stroke using the Sentinel™ cerebral protection system (CPS). METHODS MEDLINE, Cochrane, and Scopus databases were utilized from inception until 12/2023. PRISMA criteria was utilized. Keywords included "cerebral embolic protection", "sentinel cerebral protection system", "transcatheter aortic valve implantation", and "transcatheter aortic valve replacement". Primary outcome was periprocedural stroke. Secondary outcomes included periprocedural disabling and non-disabling stroke, all-cause mortality, transient ischemic attack, delirium, acute kidney injury, vascular complications, bleeding, and pacemaker implantation. Risk ratios (RR) were measured via Mantel-Haenszel method with fixed analysis. Heterogeneity was assessed via chi-squared and Higgin's I2 test. RESULTS Four trials with 3528 patients were assessed. SAPIEN 3 was the most common bioprosthetic valve used. The average age was 79.4 years with 41.9% of the sample size being females. The most prevalent comorbidities were hypertension, diabetes mellitus, and coronary artery disease. There was no difference in periprocedural stroke in patients who underwent TAVI with the Sentinel™ CPS compared to no TCEP (RR 0.75, P = 0.12). Periprocedural disabling strokes were less likely in those who underwent TAVI with the Sentinel™ CPS compared to no TCEP (RR 0.41, P = 0.02) with a number needed to treat (NNT) of 123. All other outcomes did not reach statistical significance. CONCLUSIONS In our analysis, there was no difference between TAVI with the Sentinel™ CPS compared to TAVI without TCEP in regard to risk of periprocedural stroke; however, it was associated with a decreased risk of periprocedural disabling stroke.
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Affiliation(s)
- Wissam Harmouch
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA.
| | - Barbara Karnkowska
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Ravi Thakker
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Peter Rasmussen
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Mostafa Shalaby
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Wissam Khalife
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Haider Alwash
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Afaq Motiwala
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Paul Kumfa
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Syed Gilani
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Hani Jneid
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Umamahesh Rangasetty
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
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Heuts S, Gabrio A, Veenstra L, Maesen B, Kats S, Maessen JG, Walton AS, Nanayakkara S, Lansky AJ, van 't Hof AWJ, Vriesendorp PA. Stroke reduction by cerebral embolic protection devices in transcatheter aortic valve implantation: a systematic review and Bayesian meta-analysis. Heart 2024; 110:757-765. [PMID: 37996242 DOI: 10.1136/heartjnl-2023-323359] [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: 08/19/2023] [Accepted: 10/19/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVES The use of cerebral embolic protection (CEP) during transcatheter aortic valve implantation (TAVI) has been studied in several randomised trials. We aimed to perform a systematic review and Bayesian meta-analysis of randomised CEP trials, focusing on a clinically relevant reduction in disabling stroke. METHODS A systematic search was applied to three electronic databases, including trials that randomised TAVI patients to CEP versus standard treatment. The primary outcome was the risk of disabling stroke. Outcomes were presented as relative risk (RR), absolute risk differences (ARDs), numbers needed to treat (NNTs) and the 95% credible intervals (CrIs). The minimal clinically important difference was determined at 1.1% ARD, per expert consensus (NNT 91). The principal Bayesian meta-analysis was performed under a vague prior, and secondary analyses were performed under two informed literature-based priors. RESULTS Seven randomised studies were included for meta-analysis (n=3996: CEP n=2126, control n=1870). Under a vague prior, the estimated median RR of CEP use for disabling stroke was 0.56 (95% CrI 0.28 to 1.19, derived ARD 0.56% and NNT 179, I2=0%). Although the estimated posterior probability of any benefit was 94.4%, the probability of a clinically relevant effect was 0-0.1% under the vague and informed literature-based priors. Results were robust across multiple sensitivity analyses. CONCLUSION There is a high probability of a beneficial CEP treatment effect, but this is unlikely to be clinically relevant. These findings suggest that future trials should focus on identifying TAVI patients with an increased baseline risk of stroke, and on the development of new generation devices. PROSPERO REGISTRATION NUMBER CRD42023407006.
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Affiliation(s)
- Samuel Heuts
- Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Andrea Gabrio
- Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Leo Veenstra
- Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Bart Maesen
- Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Suzanne Kats
- Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Jos G Maessen
- Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Antony S Walton
- Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | - Shane Nanayakkara
- Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Alexandra J Lansky
- Yale Cardiovascular Research Group, Yale Medical School, New Haven, Connecticut, USA
| | - Arnoud W J van 't Hof
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Pieter A Vriesendorp
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
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Boccuto F, Carabetta N, Cacia MA, Kanagala SG, Panuccio G, Torella D, De Rosa S. Clinical impact of cerebral protection during transcatheter aortic valve implantation. Eur J Clin Invest 2024; 54:e14166. [PMID: 38269600 DOI: 10.1111/eci.14166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/12/2023] [Accepted: 12/23/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Embolization of debris can complicate transcatheter aortic valve implantation (TAVI) causing stroke. Cerebral embolism protection (CEP) devices can divert or trap debris. PURPOSE To evaluate the efficacy of CEP during TAVI vs the standard procedure. DATA SOURCES PubMed, SCOPUS and DOAJ 1/01/2014-04/12/2023. STUDY SELECTION Randomized and observational studies comparing CEP versus standard TAVI, according to PRISMA. PRIMARY OUTCOME stroke. SECONDARY OUTCOMES death, bleeding, vascular access complications, acute kidney injury and infarct area. DATA EXTRACTION Two investigators independently assessed study quality and extracted data. DATA SYNTHESIS Twenty-six articles were included (540.247 patients). The primary endpoint was significantly lower (RR = 0.800 95%CI:0.682-0.940; p = 0.007) with CEP. Similarly, death rates were significantly lower with CEP (RR = 0.610 95%CI:0.482-0.771; p < 0.001). No difference was found for bleeding (RR = 1.053 95%CI:0.793-1.398; p = 0.721), vascular complications (RR = 0.937 95%CI:0.820-1.070; p = 0.334) or AKI (RR = 0.982 95%CI:0.754-1.279; p = 0.891). CONCLUSIONS Use of CEP during TAVI is associated with improved outcomes. Future studies will identify patients who benefit most from CEP.
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Affiliation(s)
- Fabiola Boccuto
- Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Nicole Carabetta
- Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Michele Antonio Cacia
- Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Sai Gautham Kanagala
- Department of Internal Medicine, Metropolitan Hospital Center, New York, NY, USA
| | - Giuseppe Panuccio
- Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Daniele Torella
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Salvatore De Rosa
- Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
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Mehta VC, Chandrasekhar SA, Quimby DL, Bhandari A, Mazo V, Glaser AD, Rose DZ, Mohanty BD. Cerebral Protection in Trans-Catheter Aortic Valve Replacement: Review and Contemporary Assessment of Randomized Trial Data. Neurohospitalist 2024; 14:157-165. [PMID: 38666284 PMCID: PMC11040624 DOI: 10.1177/19418744231225680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
As the population has aged and as aortic valve therapies have evolved, the use of trans-catheter aortic valve replacement (TAVR) has grown dramatically over the past decade. A well-known complication of percutaneous cardiac intervention is embolic phenomena, and TAVR is among the highest risk procedures for clinical and subclinical stroke. As indications for TAVR expand to lower-risk and ultimately younger patients, the long-term consequences of stroke are amplified. Cerebral embolic protection (CEP) devices have taken a on unique preventative role following the Food and Drug Administration approval of the SentinelTM Cerebral Protection System (CPS). More recently, the PROTECTED TAVR study has spurred extensive debate in the neuro-cardiac community. In this review we describe the contemporary literature regarding stroke risk associated with TAVR, the history and role of CEP devices, a PROTECTED TAVR sub-group analysis, and implications for next steps in the field. Lastly, we explore the unique need for CEP in a younger TAVR population, as well as directions for future research.
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Affiliation(s)
- Vivek C. Mehta
- Division of Cardiology, Department of Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Sanjay A. Chandrasekhar
- Division of Cardiology, Department of Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Donald L. Quimby
- Division of Cardiology, Department of Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Ajay Bhandari
- Division of Cardiology, Department of Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Victoria Mazo
- Division of Vascular Neurology, Department of Neurology, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Alexander D. Glaser
- Section of Cardiology, Department of Internal Medicine, Louisiana State University, New Orleans, LA, USA
| | - David Z. Rose
- Division of Vascular Neurology, Department of Neurology, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Bibhu D. Mohanty
- Division of Cardiology, Department of Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
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Desai R, Mondal A, Katukuri N, Pingili A, Borra V, Nayak PR, Jain A, Patel H, Qaqish O, Vyas A, Kondur A. Examining the Role of Cerebral Embolic Protection Devices in Preventing Postoperative Stroke in Patients with a History of Stroke or Transient Ischemic: Insights from the National Inpatient Sample. Cardiol Rev 2024:00045415-990000000-00225. [PMID: 38436403 DOI: 10.1097/crd.0000000000000674] [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] [Indexed: 03/05/2024]
Abstract
Cerebral embolic protection devices (CEPD) during transcatheter aortic valve replacement (TAVR) have been shown to lower the risk of stroke during the procedure. However, their long-term and clinical effects on neuro-cognition are unknown. Therefore, we hypothesized the benefit of CEPD in TAVR patients with a prior history of stroke or transient ischemic attack (TIA). National Inpatient Sample (2019) and International Classification of Diseases, 10th Revision codes were used to identify patients undergoing TAVR with prior stroke or TIA. Propensity-matched analysis was performed to adjust for baseline characteristics and comorbidities. Primary outcome measures were postoperative stroke and all-cause mortality. Length of stay and hospital cost were secondary outcomes. Of 8450 unmatched TAVR patients with prior stroke or TIA in 2019, 1095 (13%) utilized CEPD. After propensity matching previous myocardial infarction (MI), coronary artery bypass grafting, and drug abuse were higher in the TAVR-only cohort. Postoperative stroke rate (1.4% vs 2.2%; P = 0.081) and odds [adjusted odds ratio (aOR), 0.48; 95% confidence interval (CI), 0.11-2.17; P = 0.341] were lower in the CEPD group. There was no difference in all-cause in-hospital mortality between the 2 groups (0.9% vs 1.0%). Length of stay (3 vs 2 days, P <0.001) and hospital expenditure ($172,711 vs $162,284; P = 0.002) were higher for the TAVR-only cohort. CEPD in TAVR patients with prior stroke or TIA did not show statistically significant postoperative stroke benefits. However, further larger-scale prospective studies are needed to evaluate the long-term neurocognitive benefits of CEPD in these patients. As the use of TAVR continues to expand, optimizing peri-procedural strategies such as the use of CEPD remains a critical area of research to improve patient outcomes.
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Affiliation(s)
| | - Avilash Mondal
- Department of Internal Medicine, Nazareth Hospital, Philadelphia, PA
| | | | - Adhvithi Pingili
- Department of Internal Medicine, MedStar Health Baltimore, Baltimore, MD
| | - Vamsikalyan Borra
- Department of Internal Medicine, The University of Texas Rio Grande Valley, Weslaco, TX
| | - Parth R Nayak
- Department of Physiology, Ananya College of Medicine and Research Kalol, India
| | - Akhil Jain
- Department of Internal Medicine, Mercy Catholic Medical Center, Darby, PA
| | - Harshil Patel
- Division of Cardiology, Ascension Providence Hospital, MI
| | - Omar Qaqish
- Division of Cardiology, Garden City Hospital, MI
| | - Ankit Vyas
- Department of Vascular Medicine, Ochsner Clinic Foundation, New Orleans, LA
| | - Ashok Kondur
- Division of Cardiology, Garden City Hospital, MI
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Wang C, Han J, Lu L, Qiu J, Fu Y, Zheng J. The efficacy of different types of cerebral embolic protection device during transcatheter aortic valve implantation: a meta-analysis. Front Cardiovasc Med 2024; 11:1205943. [PMID: 38464846 PMCID: PMC10924301 DOI: 10.3389/fcvm.2024.1205943] [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: 04/14/2023] [Accepted: 01/08/2024] [Indexed: 03/12/2024] Open
Abstract
Aims Perioperative stroke remains a devastating complication after transcatheter aortic valve implantation (TAVI), and using a cerebral embolic protection device (CEPD) during TAVI may reduce the occurrence of stroke according to some studies. Therefore, we conducted this meta-analysis to determine whether CEPD should be routinely used during TAVI. Methods and results The inclusion criteria for this study were randomized controlled trials (RCTs) that examined the outcome of stroke with or without CEPD during TAVI, with a minimum follow-up period of 30 days. The primary endpoint was the occurrence of stroke (including both cerebrovascular accidents and death due to cerebrovascular accidents). The risk of stroke was lower in the CEPD group: RR 0.68, 95% CI 0.49-0.96, p = 0.03, I2 = 0%. A subgroup analysis was conducted according to the type of CEPD. The risk of stroke was lower in the I&LCCA (filter cover the innominate and the left common carotid arteries) type CEPD group: RR 0.66, 95% CI 0.49-0.96, p = 0.03, I2 = 36%. However, there was no statistically significant difference in the risk of stroke in the TMCA [filter cover the three major cerebral arteries (innominate, left common carotid, and subclavian arteries)] type CEPD group: RR 0.81, 95% CI 0.36-1.80, p = 0.60, I2 = 0%. Conclusions In this meta-analysis, the I&LCCA-type CEPD can reduce the risk of stroke within 30 days following TAVI, but the TMCA type cannot.
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Affiliation(s)
- Chao Wang
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Thoracic and Cardiac Surgery, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Jingjun Han
- Department of Thoracic and Cardiac Surgery, The Eighth Affiliated Hospital, Sun Yat-Sen University, Shenzhen, China
| | - Liuyi Lu
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Junxiong Qiu
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yuan Fu
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Junmeng Zheng
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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Kaur A, Dhaliwal AS, Sohal S, Gwon Y, Gupta S, Bhatia K, Dominguez AC, Basman C, Tamis‐Holland J. Role of Cerebral Embolic Protection Devices in Patients Undergoing Transcatheter Aortic Valve Replacement: An Updated Meta-Analysis. J Am Heart Assoc 2024; 13:e030587. [PMID: 38240252 PMCID: PMC11056109 DOI: 10.1161/jaha.123.030587] [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: 04/20/2023] [Accepted: 12/05/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Cerebral embolic protection devices (CEPD) capture embolic material in an attempt to reduce ischemic brain injury during transcatheter aortic valve replacement. Prior reports have indicated mixed results regarding the benefits of these devices. With new data emerging, we performed an updated meta-analysis examining the effect of CEPD during transcatheter aortic valve replacement on various clinical, neurological, and safety parameters. METHODS AND RESULTS A comprehensive review of electronic databases was performed comparing CEPD and no-CEPD in transcatheter aortic valve replacement. Primary clinical outcome was all-cause stroke. Secondary clinical outcomes were disabling stroke and all-cause mortality. Neurological outcomes included worsening of the National Institutes of Health Stroke Scale score, Montreal Cognitive Assessment score from baseline at discharge, presence of new ischemic lesions, and total lesion volume on neuroimaging. Safety outcomes included major or minor vascular complications and stage 2 or 3 acute kidney injury. Seven randomized controlled trials with 4016 patients met the inclusion criteria. There was no statistically significant difference in the primary clinical outcome of all-cause stroke; secondary clinical outcomes of disabling stroke, all-cause mortality, neurological outcomes of National Institutes of Health Stroke Scale score worsening, Montreal Cognitive Assessment worsening, presence of new ischemic lesions, or total lesion volume on diffusion-weighted magnetic resonance imaging between CEPD versus control groups. There was no statistically significant difference in major or minor vascular complications or stage 2 or 3 acute kidney injury between the groups. CONCLUSIONS The use of CEPD in transcatheter aortic valve replacement was not associated with a statistically significant reduction in the risk of clinical, neurological, and safety outcomes.
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Affiliation(s)
- Arpanjeet Kaur
- Department of MedicineIcahn School of Medicine at Mount Sinai Morningside/West‐ New YorkNew YorkNY
| | - Arshdeep S. Dhaliwal
- Population Health Science and PolicyIcahn School of Medicine at Mount Sinai‐ New YorkNew YorkNY
| | - Sumit Sohal
- Division of Cardiovascular MedicineNewark Beth Israel Medical Center‐ NewarkNewarkNJ
| | - Yeongjin Gwon
- Department of BiostatisticsUniversity of Nebraska Medical CenterOmahaNE
| | - Soumya Gupta
- Department of MedicineIcahn School of Medicine at Mount Sinai Morningside/West‐ New YorkNew YorkNY
| | - Kirtipal Bhatia
- Division of CardiologyIcahn School of Medicine at Mount Sinai Morningside‐ New YorkNew YorkNY
| | - Abel Casso Dominguez
- Division of CardiologyIcahn School of Medicine at Mount Sinai Morningside‐ New YorkNew YorkNY
| | - Craig Basman
- Division of CardiologyLenox Hill Hospital‐ New YorkNew YorkNY
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11
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Tan N, Fei G, Rizwan Amanullah M, Lim ST, Abdul Aziz Z, Govindasamy S, Chao VTT, Ewe SH, Ho KW, Yap J. Safety and efficacy of cerebral embolic protection in transcatheter aortic valve implantation: an updated meta-analysis. ASIAINTERVENTION 2024; 10:51-59. [PMID: 38425806 PMCID: PMC10900717 DOI: 10.4244/aij-d-23-00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/23/2023] [Indexed: 03/02/2024]
Abstract
Background The use of cerebral embolic protection devices during transcatheter aortic valve implantation (TAVI) reveals conflicting data. Aims This updated meta-analysis aims to evaluate the efficacy and safety of the SENTINEL Cerebral Protection System. Methods A literature search for relevant studies up to September 2022 was performed. Study outcomes were divided based on time period - overall (up to 30 days) and short (≤7 days). The outcomes studied include stroke (disabling, non-disabling), mortality, neuroimaging findings, transient ischaemic attack, acute kidney injury and major vascular and bleeding complications. Results A total of 15 studies involving 294,134 patients were included. Regarding overall outcomes, significant reductions were noted for mortality (odds ratio [OR] 0.60, 95% confidence interval [CI]: 0.41-0.88; p=0.008), all stroke (OR 0.64, 95% CI: 0.46-0.88; p=0.006) and disabling stroke (OR 0.42, 95% CI: 0.23-0.74; p=0.003) using the SENTINEL device. No significant differences were noted for other outcomes. There was significant heterogeneity across the studies for mortality (p=0.013) and all stroke (p=0.003). Including only randomised data (n=4), there was only significant reduction in the incidence of disabling stroke (OR 0.39, 95% CI: 0.17-0.89; p=0.026) in the SENTINEL group. In studies reporting ≤7-day outcomes (n=8), use of the SENTINEL device demonstrated significantly lower rates of all stroke (p<0.001), disabling stroke (p<0.001) and major bleeding complications (p=0.02). No differences in neuroimaging outcomes were noted. Conclusions In this updated meta-analysis, use of the SENTINEL Cerebral Protection System was associated with lower rates of mortality, all stroke and disabling stroke, although significant heterogeneity was noted for mortality and all stroke. Including exclusively randomised data, there was only significant reduction in the incidence of disabling stroke. No significant adverse outcomes with device use were noted.
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Affiliation(s)
- Nicholas Tan
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Gao Fei
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | | | - Soo Teik Lim
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Zameer Abdul Aziz
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Sivaraj Govindasamy
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | | | - See Hooi Ewe
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Kay Woon Ho
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
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12
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Vinayak M, Leone PP, Tanner R, Dhulipala V, Camaj A, Makhija RRK, Hooda A, Kini AS, Sharma SK, Khera S. Transcatheter Aortic Valve Replacement: Current Status and Future Indications. J Clin Med 2024; 13:373. [PMID: 38256506 PMCID: PMC10817053 DOI: 10.3390/jcm13020373] [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: 12/12/2023] [Revised: 12/31/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
In the past two decades, transcatheter aortic valve replacement (TAVR) has transformed the management of aortic stenosis and has become the standard of care regardless of surgical risk levels. Advances in transcatheter valve design across newer generations, improved imaging, greater operator expertise, and technical enhancements have collectively contributed to increased safety and a decline in procedural complications over this timeframe. The application of TAVR has progressively expanded to include younger patients with lower risks, who have longer life expectancies. This article offers an up-to-date review of the latest innovations in transcatheter delivery systems, devices, and its possible future indications.
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Affiliation(s)
- Manish Vinayak
- Mount Sinai Heart, Mount Sinai Hospital, New York, NY 10029, USA; (P.P.L.); (R.T.); (V.D.); (A.C.); (R.R.K.M.); (A.H.); (A.S.K.); (S.K.S.)
| | | | | | | | | | | | | | | | | | - Sahil Khera
- Mount Sinai Heart, Mount Sinai Hospital, New York, NY 10029, USA; (P.P.L.); (R.T.); (V.D.); (A.C.); (R.R.K.M.); (A.H.); (A.S.K.); (S.K.S.)
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13
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Sharma N, Heslin RF, Aleem SU, Medamana J, Gasimli-Gamache L, Yoo J, Bhasin V, Avvento PJ, Wiley J, Billfinger TV, Tannous HJ, Parikh PB, Kort S, Labropoulos N, Dangas GD, Reilly JP, Pyo RT. Prevalence of Neurovascular Microemboli After Transcatheter Aortic Valve Replacement. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101180. [PMID: 39131988 PMCID: PMC11308225 DOI: 10.1016/j.jscai.2023.101180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/16/2023] [Accepted: 09/12/2023] [Indexed: 08/13/2024]
Abstract
Background Neurolotic sequelae after transcatheter aortic valve replacement (TAVR) can cause significant morbidity and mortality. Transcranial Doppler (TCD) imaging can show real-time high intensity transient signals (HITS), which reflect active microembolization. Although it is well known that intraprocedural microembolism occurs, it is not known if this embolic phenomenon continues in the postprocedural period. We investigated whether microemboli occur post-TAVR and whether we could determine any clinical, procedural, or echocardiographic predictors. Methods We evaluated HITS in 51 consecutive patients undergoing unprotected TAVR with low-, intermediate-, or high-risk Society of Thoracic Surgeons score. Patients were excluded if they did not have temporal windows for insonation of the middle cerebral artery or if they were not willing to participate. Primary outcomes of HITS 24 hours post-TAVR were observed using a Philips iU22 TCD. TCD was performed at 3 time points (pre-, peri-, and post-TAVR) for each patient, before, during, and 24 hours postprocedure. Results While no HITS were detected in any of the patients preoperatively, all patients had HITS during the procedure. Interestingly, 56.8% had HITS 24 hours post-TAVR. One patient with HITS post-TAVR had a stroke 48 hours after TAVR. Conclusion We observed a high prevalence of microemboli 24 hours post-TAVR. None of the predictors for intraprocedural microembolism seemed to play an important role for post-TAVR microemboli.
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Affiliation(s)
- Navneet Sharma
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Ryan F. Heslin
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Saadat U. Aleem
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
| | - John Medamana
- Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Leyla Gasimli-Gamache
- Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Jeanwoo Yoo
- Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Varun Bhasin
- Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Peter J. Avvento
- Department of Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Jose Wiley
- Divison of Cardiology, Tulane University, New Orleans, Louisiana
| | - Thomas V. Billfinger
- Division of Cardiothoracic Surgery, Stony Brook University Medical Center, Stony Brook, New York
| | - Henry J. Tannous
- Division of Cardiothoracic Surgery, Stony Brook University Medical Center, Stony Brook, New York
| | - Puja B. Parikh
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Smadar Kort
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Nicos Labropoulos
- Divison of Cardiology, Tulane University, New Orleans, Louisiana
- Division of Vascular Surgery, Stony Brook University Medical Center, Stony Brook, New York
| | - George D. Dangas
- Division of Cardiology, The Mount Sinai Hospital, New York, New York
| | - John P. Reilly
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
| | - Robert T. Pyo
- Division of Cardiology, Stony Brook University Medical Center, Stony Brook, New York
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14
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Qian H, Piuhola J, Kiviniemi H, Niemelä M, Hautala N, Junttila J. Evaluation of cerebrovascular events via retinal angiography during transcatheter aortic valve implantation. SCAND CARDIOVASC J 2023; 57:2278279. [PMID: 37962426 DOI: 10.1080/14017431.2023.2278279] [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: 04/23/2023] [Accepted: 10/28/2023] [Indexed: 11/15/2023]
Abstract
OBJECTIVES Patients receiving transcatheter aortic valve implantation (TAVI) are elderly with multiple comorbidities and at increased risk of perioperative cerebrovascular events. Retinal vasculature represents a surrogate of central nervous system circulation and is noninvasively achievable by retinal imaging. The aim of this study was to evaluate the applicability of retinal angiography of microvascular complications and association to cerebral ischemic events during TAVI. DESIGN One hundred patients (male 54%, age: median 82 years, range 64-95 years) undergoing TAVI were recruited for this study. Imaging of retinal vasculature was evaluated with a handheld fundus camera before, during and 1 month after. Cerebrovascular events were determined as a part of contemporary clinical evaluation with cerebral CT and CTA imaging when symptoms occurred. RESULTS Altogether 66/100 patients (66%) were included in the analysis. In-hospital ischemic event (transient ischemic attack, cerebral infarction) was observed in 1/66 patient (1.5%). Retinal vascular abnormalities occurred in 8/66 patients (12.1%); 4/66 patients (6.1%) were detected with a cholesterol plaque in the retinal artery, 2/66 (3%) a capillary leakage, 1/66 (1.5%) and optic disk hemorrhage and 1/66 (1.5%) a macular bleeding. No significant association between retinal vasculature abnormalities and cerebrovascular events was detected mainly due to the low event rate. CONCLUSIONS Perioperative evaluation of cerebrovascular ischemia with noninvasive imaging of retinal vasculature is possible in most patients undergoing TAVI. More data is needed to evaluate the association of cerebrovascular events and retinal microvascular abnormalities during the procedure.
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Affiliation(s)
- Henna Qian
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Jarkko Piuhola
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Heidi Kiviniemi
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
- Turku University Hospital, Turku, Finland
| | - Matti Niemelä
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Nina Hautala
- Research Unit of Clinical Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Juhani Junttila
- Research Unit of Internal Medicine, Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
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15
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Streb W, Lasek-Bal A, Mitręga K, Kowalczyk J, Podolecki T, Kowalska W, Olma A, Sobczyk A, Kalarus Z. Rationale and design of a randomized clinical trial evaluating the efficacy of mechanical neuroprotection in reducing the risk of silent brain infarcts associated with percutaneous left atrial appendage closure: study protocol for a LAAC-SBI trial. Trials 2023; 24:749. [PMID: 37996955 PMCID: PMC10666419 DOI: 10.1186/s13063-023-07766-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/31/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Left atrial appendage closure (LAAC) procedures prevent cardioembolic stroke in patients with atrial fibrillation who have contraindications to oral anticoagulant medications. However, these procedures carry certain risks of peri-procedural complications. One such complication is silent brain infarcts (SBI), which can lead to cognitive impairment and mood disturbances. The implementation of mechanical neuroprotection systems during LAAC procedures may reduce the risk of SBI and associated cognitive and mood disorders. METHODS The LAAC-SBI trial is a prospective, multicenter, randomized, and double-blind interventional study. The study aims to enroll a total of 240 patients, with 120 patients allocated to each group. The study group will evaluate the use of the Sentinel CPS during LAAC, while the control group will undergo LAAC procedures without the Sentinel CPS. The primary endpoint of the study is the number of new SBIs or stroke foci detected by diffusion-weighted magnetic resonance imaging (DW MRI). Secondary endpoints include deterioration of cognitive function, development of dementia syndrome, and occurrence of depressive disorders. These endpoints will be assessed using questionnaire tools such as the Montreal Cognitive Assessment (MoCA), Trail Making Test (TMT), Controlled Oral Word Association Test (COWAT), and Hospital Anxiety and Depression Scale (HADS). The observational period for patients in the study is 2 years. DISCUSSION If the study demonstrates a favorable outcome with reduced incidence of SBI and improved cognitive and mood outcomes in patients receiving cerebral protection devices during LAAC, it will have significant implications for clinical management standards. This would support the use of neuroprotection devices not only for LAAC but also in procedures such as atrial fibrillation ablation or transcatheter mitral valve interventions, where the risk of embolic events and subsequent brain injury may also be present. TRIAL REGISTRATION ClinicalTrials.gov NCT05369195. Registration on 11.05.2022.
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Affiliation(s)
- Witold Streb
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland.
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland.
| | - Anetta Lasek-Bal
- Department of Neurology, Faculty of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Mitręga
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Jacek Kowalczyk
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Tomasz Podolecki
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Wiktoria Kowalska
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Anna Olma
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Agata Sobczyk
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
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16
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Grubman D, Ahmad Y, Leipsic JA, Blanke P, Pasupati S, Webster M, Nazif TM, Parise H, Lansky AJ. Predictors of Cerebral Embolic Debris During Transcatheter Aortic Valve Replacement: The SafePass 2 First-in-Human Study. Am J Cardiol 2023; 207:28-34. [PMID: 37722198 DOI: 10.1016/j.amjcard.2023.08.137] [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: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) generates significant debris, and strategies to mitigate cerebral embolization are needed. The novel Emboliner embolic protection catheter (Emboline, Inc., Santa Cruz, California) is designed to capture all particles generated during TAVR. This first-in-human study sought to assess the safety and feasibility of the device and to characterize the distribution and histopathology of the debris generated during TAVR. The SafePass 2 study was a prospective, nonrandomized, multicenter, single-arm investigation of the Emboliner device. Primary end points included 30-day major adverse cardiac and cerebrovascular events (MACCE) and technical performance. Computed tomography angiography was analyzed by an independent core laboratory, and filters were sent for histopathology of captured debris. Predictors of particle number were identified using >150 µm and >500 µm size thresholds. Of 31 subjects enrolled, technical success was 100%, and 30-day MACCE was 6.5% (2 cerebrovascular accidents, with 1 attributed to subtherapeutic dosing of rivaroxaban along with atrial fibrillation and the other to possible previous small ischemic strokes on magnetic resonance imaging; neither MACCE event had a causal relation to the Emboliner). All filters contained debris, with a median of 191.0 particles >150 µm and 14.0 particles >500 µm. Histopathology revealed mostly acute thrombus and valve or arterial tissue with lesser amounts of calcified tissue. A history of atrial fibrillation predicted a greater number of particles >500 µm (p = 0.0259) and its presence on admission was associated with 4.1 times more particles >150 µm (p = 0.0130) and 8.1 times more particles >500 µm (p = 0.0086). Self-expanding valves were associated with twice the number of particles >150 µm (p = 0.0281). TASK score was positively correlated with number of particles >500 µm (p = 0.0337). The Emboliner device was safe and feasible. Emboli after TAVR appear more numerous than previously documented. Atrial fibrillation, higher TASK score, and self-expanding valve use conferred higher embolic burden. Notably, none of the tested computed tomography angiography features were able to identify with higher embolic risk. Larger-scale studies are needed to identify high-risk patients for selective embolic protection device use.
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Affiliation(s)
- Daniel Grubman
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Yousif Ahmad
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jonathon A Leipsic
- Department of Radiology, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada
| | - Philipp Blanke
- Department of Radiology, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada
| | | | - Mark Webster
- Department of Cardiology, Auckland City Hospital, Auckland, New Zealand
| | - Tamin M Nazif
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Helen Parise
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut
| | - Alexandra J Lansky
- Division of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Connecticut.
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17
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Ubaid A, Kennedy KF, Chhatriwalla AK, Saxon JT, Hart A, Allen KB, Aberle C, Shatla I, Abumoawad A, Gunta SP, Skolnick D, Huded CP. Site Variability in Cerebral Embolic Protection for Transcatheter Aortic Valve Implantation and Association With Outcomes. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2023; 7:100202. [PMID: 38046858 PMCID: PMC10692348 DOI: 10.1016/j.shj.2023.100202] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/26/2023] [Accepted: 04/26/2023] [Indexed: 12/05/2023]
Abstract
Background The effectiveness of cerebral embolic protection devices (CEPD) in mitigating stroke after transcatheter aortic valve implantation (TAVI) remains uncertain, and therefore CEPD may be utilized differently across US hospitals. This study aims to characterize the hospital-level pattern of CEPD use during TAVI in the US and its association with outcomes. Methods Patients treated with nontransapical TAVI in the 2019 Nationwide Readmissions Database were included. Hospitals were categorized as CEPD non-users and CEPD users. The following outcomes were compared: the composite of in-hospital stroke or transient ischemic attack (TIA), in-hospital ischemic stroke, death, and cost of hospitalization. Logistic regression models were used for risk adjustment of clinical outcomes. Results Of 41,822 TAVI encounters, CEPD was used in 10.6% (n = 4422). Out of 392 hospitals, 65.8% were CEPD non-user hospitals and 34.2% were CEPD users. No difference was observed between CEPD non-users and CEPD users in the risk of in-hospital stroke or TIA (adjusted odds ratio (OR) = 0.99 [0.86-1.15]), ischemic stroke (adjusted OR = 1.00 [0.85-1.18]), or in-hospital death (adjusted OR = 0.86 [0.71-1.03]). The cost of hospitalization was lower in CEPD non-users. Conclusions Two-thirds of hospitals in the US do not use CEPD for TAVI, and no significant difference was observed in neurologic outcomes among patients treated at CEPD non-user and CEPD user hospitals.
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Affiliation(s)
- Aamer Ubaid
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Kevin F. Kennedy
- Department of Cardiovascular Medicine, St Lukes Mid America Heart Institute, Kansas City, Missouri, USA
| | - Adnan K. Chhatriwalla
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
- Department of Cardiovascular Medicine, St Lukes Mid America Heart Institute, Kansas City, Missouri, USA
| | - John T. Saxon
- Department of Cardiovascular Medicine, St Lukes Mid America Heart Institute, Kansas City, Missouri, USA
| | - Anthony Hart
- Department of Cardiovascular Medicine, St Lukes Mid America Heart Institute, Kansas City, Missouri, USA
| | - Keith B. Allen
- Department of Cardiothoracic Surgery, St Lukes Mid America Heart Institute, Kansas City, Missouri, USA
| | - Corinne Aberle
- Department of Cardiothoracic Surgery, St Lukes Mid America Heart Institute, Kansas City, Missouri, USA
| | - Islam Shatla
- Department of Internal Medicine, Kansas University Medical Center, Kansas City, Missouri, USA
| | - Abdelrhman Abumoawad
- Department of Vascular Medicine, Boston University Medical Center, Boston, Massachusetts, USA
| | - Satya Preetham Gunta
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - David Skolnick
- Department of Cardiovascular Medicine, St Lukes Mid America Heart Institute, Kansas City, Missouri, USA
| | - Chetan P. Huded
- Department of Cardiovascular Medicine, St Lukes Mid America Heart Institute, Kansas City, Missouri, USA
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18
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Jimenez Diaz VA, Kapadia SR, Linke A, Mylotte D, Lansky AJ, Grube E, Settergren M, Puri R. Cerebral embolic protection during transcatheter heart interventions. EUROINTERVENTION 2023; 19:549-570. [PMID: 37720969 PMCID: PMC10495748 DOI: 10.4244/eij-d-23-00166] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/17/2023] [Indexed: 09/19/2023]
Abstract
Stroke remains a devastating complication of transcatheter aortic valve replacement (TAVR), with the incidence of clinically apparent stroke seemingly fixed at around 3% despite TAVR's significant evolution during the past decade. Embolic showers of debris (calcium, atheroma, valve material, foreign material) are captured in the majority of patients who have TAVR using a filter-based cerebral embolic protection device (CEPD). Additionally, in systematic brain imaging studies, the majority of patients receiving TAVR exhibit new cerebral lesions. Mechanistic studies have shown reductions in the volume of new cerebral lesions using CEPDs, yet the first randomised trial powered for periprocedural stroke within 72 hours of a transfemoral TAVR failed to meet its primary endpoint of showing superiority of the SENTINEL CEPD. The present review summarises the clinicopathological rationale for the development of CEPDs, the evidence behind these devices to date and the emerging recognition of cerebral embolisation in many non-TAVR transcatheter procedures. Given the uniqueness of each of the various CEPDs under development, specific trials tailored to their designs will need to be undertaken to broaden the CEPD field, in addition to evaluating the role of CEPD in non-TAVR transcatheter heart interventions. Importantly, the cost-effectiveness of these devices will require assessment to broaden the adoption of CEPDs globally.
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Affiliation(s)
- Victor Alfonso Jimenez Diaz
- Cardiology Department, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IISGS), SERGAS-UVIGO, Vigo, Spain
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Axel Linke
- Department of Internal Medicine and Cardiology, Heart Center Dresden University Hospital, Dresden, Germany and Technische Universität Dresden, Dresden, Germany
| | - Darren Mylotte
- Department of Cardiology, University Hospital Galway, Galway, Ireland and University of Galway, Galway, Ireland
| | | | - Eberhard Grube
- Department of Medicine II, Heart Center, University Hospital Bonn, Bonn, Germany
| | - Magnus Settergren
- Heart and Vascular Unit, Karolinska University Hospital, Stockholm, Sweden and Karolinska Institutet, Stockholm, Sweden
| | - Rishi Puri
- Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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19
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Reddy RK, Ahmad Y, Arnold AD, Howard JP. Cerebral Embolic Protection Devices During Transcatheter Aortic Valve Replacement: A Meta-analysis of Randomized Controlled Trials. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:None. [PMID: 37780935 PMCID: PMC10533415 DOI: 10.1016/j.jscai.2023.101031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/16/2023] [Accepted: 04/23/2023] [Indexed: 10/03/2023]
Abstract
Background Stroke is a feared complication of transcatheter aortic valve replacement (TAVR), which embolic protection devices (EPDs) may mitigate. This systematic review and meta-analysis synthesized randomized controlled trials (RCTs) to evaluate the effect of EPDs in TAVR. Methods All RCTs comparing EPDs with control during TAVR were systematically identified. Prespecified primary end points were all stroke, disabling stroke, nondisabling stroke, and all-cause mortality. Safety and neuroimaging parameters were assessed. Sensitivity analyses were stratified by EPD type. Study registration was a priori (CRD42022377939). Results Eight trials randomizing 4043 patients were included. There was no significant difference between EPDs and control for all stroke (relative risk [RR], 0.88; 95% CI, 0.65-1.18; P = .39; I2 = 0%), disabling stroke (RR, 0.67; 95% CI, 0.31-1.46; P = .32; I2 = 8.6%), nondisabling stroke (RR, 0.99; 95% CI, 0.71-1.40; P = .97; I2 = 0%), or all-cause mortality (RR, 0.87; 95% CI, 0.43-1.78; P = .71; I2 = 2.3%). There were no differences in safety end points of bleeding, vascular complications, or acute kidney injury. EPDs did not result in differences in total lesion volume or the number of new lesions. The Sentinel EPD significantly reduced the risk of disabling stroke (RR, 0.42; 95% CI, 0.20-0.88; P = .022; I2 = 0%) but did not affect all stroke, nondisabling stroke, or all-cause mortality. Conclusions The totality of randomized data for EPDs during TAVR demonstrated no safety concerns or significant differences in clinical or neuroimaging end points. Analyses restricted to the Sentinel EPD demonstrated large, clinically meaningful reductions in disabling stroke. Ongoing RCTs may help validate these results.
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Affiliation(s)
- Rohin K. Reddy
- Cardiovascular Trials and Epidemiology Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale University, New Haven, Connecticut
| | - Ahran D. Arnold
- Cardiovascular Trials and Epidemiology Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James P. Howard
- Cardiovascular Trials and Epidemiology Section, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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20
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Preda A, Montalto C, Galasso M, Munafò A, Garofani I, Baroni M, Gigli L, Vargiu S, Varrenti M, Colombo G, Carbonaro M, Della Rocca DG, Oreglia J, Mazzone P, Guarracini F. Fighting Cardiac Thromboembolism during Transcatheter Procedures: An Update on the Use of Cerebral Protection Devices in Cath Labs and EP Labs. Life (Basel) 2023; 13:1819. [PMID: 37763223 PMCID: PMC10532856 DOI: 10.3390/life13091819] [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: 07/31/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023] Open
Abstract
Intraprocedural stroke is a well-documented and feared potential risk of cardiovascular transcatheter procedures (TPs). Moreover, subclinical neurological events or covert central nervous system infarctions are concerns related to the development of dementia, future stroke, cognitive decline, and increased risk of mortality. Cerebral protection devices (CPDs) were developed to mitigate the risk of cardioembolic embolism during TPs. They are mechanical barriers designed to cover the ostium of the supra-aortic branches in the aortic arch, but newer devices are able to protect the descending aorta. CPDs have been mainly designed and tested to provide cerebral protection during transcatheter aortic valve replacement (TAVR), but their use in both Catheterization and Electrophysiology laboratories is rapidly increasing. CPDs have allowed us to perform procedures that were previously contraindicated due to high thromboembolic risk, such as in cases of intracardiac thrombosis identified at preprocedural assessment. However, several concerns related to their employment have to be defined. The selection of patients at high risk of thromboembolism is still a subjective choice of each center. The aim of this review is to update the evidence on the use of CPDs in either Cath labs or EP labs, providing an overview of their structural characteristics. Future perspectives focusing on their possible future employment are also discussed.
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Affiliation(s)
- Alberto Preda
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Claudio Montalto
- Interventional Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy; (C.M.); (A.M.)
| | - Michele Galasso
- Interventional Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy; (C.M.); (A.M.)
| | - Andrea Munafò
- Interventional Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy; (C.M.); (A.M.)
| | - Ilaria Garofani
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Matteo Baroni
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Lorenzo Gigli
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Sara Vargiu
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Marisa Varrenti
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Giulia Colombo
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Marco Carbonaro
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Domenico Giovanni Della Rocca
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, European Reference Networks Guard-Heart, 1090 Brussels, Belgium
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX 78705, USA
| | - Jacopo Oreglia
- Interventional Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy; (C.M.); (A.M.)
| | - Patrizio Mazzone
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
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21
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Shrestha DB, Shtembari J, Lamichhane S, Baniya A, Shahi M, Dhungel S, Pant K, Sutton NR, Villablanca P, Mungee S. Safety and efficacy of cerebral embolic protection devices for patients undergoing transcatheter aortic valve replacement: An updated meta-analysis. Health Sci Rep 2023; 6:e1391. [PMID: 37404451 PMCID: PMC10314975 DOI: 10.1002/hsr2.1391] [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: 03/30/2023] [Revised: 06/18/2023] [Accepted: 06/20/2023] [Indexed: 07/06/2023] Open
Abstract
Background and Aims Cerebral embolic protection (CEP) devices are employed to capture embolic debris and reduce the risk of stroke during transcatheter aortic valve replacement (TAVR). Evidence is mixed regarding the safety and efficacy of CEP. We aimed to summarize the safety and effectiveness of CEP use during TAVR. Methods Electronic databases, including PubMed, PubMed Central, Scopus, Cochrane Library, and Embase, were searched using relevant search terms for articles relating to CEP. All relevant data from 20 studies were extracted into a standardized form. Statistical analyses were performed using Revman 5.4. Odds ratio (OR) or mean differences (MDs) were used to estimate the desired outcome with a 95% confidence interval (CI). Results Twenty studies (eight randomized controlled trials [RCTs]) involving 210,871 patients (19,261 in the CEP group and 191,610 in TAVR without the CEP group) were included. The use of CEP was associated with a lower odds of 30-day mortality by 39% (OR: 0.61, 95% CI: 0.53-0.70) and stroke by 31% (OR: 0.69, 95% CI: 0.52-0.92). Comparing devices, benefit in terms of mortality and stroke was observed with the use of the Sentinel device (Boston Scientific), but not among other devices. No differences were observed in the outcomes of acute kidney injury, major or life-threatening bleeding events, or major vascular complications between groups. When only RCTs were included, there were no observed differences in the primary or secondary outcomes for CEP versus no CEP use during TAVR. Conclusions The totality of evidence suggests a net benefit for the use of CEP, weighted by studies in which the Sentinal device was used. However, given the RCT subanalysis, additional evidence is needed to identify patients at the highest risk of stroke for optimal decision-making.
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Affiliation(s)
| | - Jurgen Shtembari
- Department of Internal MedicineMount Sinai HospitalChicagoIllinoisUSA
| | - Sandesh Lamichhane
- Department of Internal MedicineChitwan Medical College Teaching HospitalBharatpurNepal
| | - Abinash Baniya
- Department of Internal MedicineChitwan Medical College Teaching HospitalBharatpurNepal
| | - Manoj Shahi
- Department of Internal MedicineChitwan Medical College Teaching HospitalBharatpurNepal
| | - Swati Dhungel
- Division of Cardiovascular Medicine, Department of Internal Medicine, John H. StrogerJr. Hospital of Cook CountyChicagoIllinoisUSA
| | - Kailash Pant
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of Illinois College of Medicine, OSF HealthcarePeoriaIllinoisUSA
| | - Nadia R. Sutton
- Division of Cardiovascular Medicine, Department of Internal MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
- Department of Biomedical EngineeringVanderbilt UniversityNashvilleTennesseeUSA
| | - Pedro Villablanca
- Division of Interventional Cardiology and Structural Heart Disease, Department of Internal MedicineThe Center for Structural Heart Disease Henry Ford HospitalDetroitMichiganUSA
| | - Sudhir Mungee
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of Illinois College of Medicine, OSF HealthcarePeoriaIllinoisUSA
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22
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Iskander M, Jamil Y, Forrest JK, Madhavan MV, Makkar R, Leon MB, Lansky A, Ahmad Y. Cerebral Embolic Protection in Transcatheter Aortic Valve Replacement. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2023; 7:100169. [PMID: 37520138 PMCID: PMC10382985 DOI: 10.1016/j.shj.2023.100169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/12/2023] [Indexed: 08/01/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is a treatment option for patients with symptomatic severe aortic stenosis across the entire spectrum of surgical risk. Recent trial data have led to the expansion of TAVR into lower-risk patients. With iterative technological advances and successive increases in procedural experience, the occurrence of complications following TAVR has declined. One of the most feared complications remains stroke, and patients consider stroke a worse outcome than death. There has therefore been great interest in strategies to mitigate the risk of stroke in patients undergoing TAVR. In this paper, we will discuss mechanisms and predictors of stroke after TAVR and describe the currently available cerebral embolic protection devices, including their design and relevant clinical studies pertaining to their use. We will also review the current overall evidence base for cerebral embolic protection during TAVR and ongoing randomized controlled trials. Finally, we will discuss our pragmatic recommendations for the use of cerebral embolic protection devices in patients undergoing TAVR.
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Affiliation(s)
- Mina Iskander
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yasser Jamil
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - John K. Forrest
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Mahesh V. Madhavan
- Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York, USA
| | - Raj Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Martin B. Leon
- Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York, USA
| | - Alexandra Lansky
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
- Barts Heart Centre, London and Queen Mary University of London, London, UK
| | - Yousif Ahmad
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
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23
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Khan SU, Zahid S, Alkhouli MA, Akbar UA, Zaid S, Arshad HB, Little SH, Reardon MJ, Kleiman NS, Goel SS. An Updated Meta-Analysis on Cerebral Embolic Protection in Patients Undergoing Transcatheter Aortic Valve Intervention Stratified by Baseline Surgical Risk and Device Type. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2023; 7:100178. [PMID: 37520141 PMCID: PMC10382981 DOI: 10.1016/j.shj.2023.100178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 08/01/2023]
Abstract
Background Transcatheter aortic valve intervention (TAVI) can lead to the embolization of debris. Capturing the debris by cerebral embolic protection (CEP) devices may reduce the risk of stroke. New evidence has allowed us to examine the effects of CEP in patients undergoing TAVI. We aimed to assess the effects of CEP overall and stratified by the device used (SENTINEL or TriGuard) and the surgical risk of the patients. Methods We selected randomized controlled trials using electronic databases through September 17, 2022. We estimated random-effects risk ratios (RR) with (95% confidence interval) and calculated absolute risk differences at 30 days across baseline surgical risks derived from the TAVI trials for any stroke (disabling and nondisabling) and all-cause mortality. Results Among 6 trials (n = 3921), CEP vs. control did not reduce any stroke [RR: 0.95 (0.50-1.81)], disabling [RR: 0.75 (0.18-3.16)] or nondisabling [RR: 0.99 (0.65-1.49)] strokes, or all-cause mortality [RR: 1.23 (0.55-2.77)]. However, when analyzed by device, SENTINEL reduced disabling stroke [RR: 0.46 (0.22-0.95)], translating into 6 fewer per 1000 in high-risk, 3 fewer per 1000 in intermediate-risk, and 1 fewer per 1000 in low surgical-risk patients. CEP vs. control did not reduce the risk of any bleeding [RR: 1.03 (0.44-2.40)], major vascular complications [RR: 1.41 (0.57-3.48)], or acute kidney injury [RR: 1.36 (0.57-3.28)]. Conclusions This updated meta-analysis showed that SENTINEL CEP might reduce disabling stroke in patients undergoing TAVI. Patients with high and intermediate surgical risks were most likely to derive benefits.
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Affiliation(s)
- Safi U. Khan
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Salman Zahid
- Sands-Constellation Heart Institute, Rochester General Hospital, Rochester, New York, USA
| | - Mohamad A. Alkhouli
- Division of Interventional Cardiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Usman Ali Akbar
- Department of Medicine, North Shore University Hospital, New York, New York, USA
| | - Syed Zaid
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Hassaan B. Arshad
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Stephen H. Little
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Michael J. Reardon
- Department of Cardiovascular Surgery, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Neal S. Kleiman
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Sachin S. Goel
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
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24
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Wolfrum M, Handerer IJ, Moccetti F, Schmeisser A, Braun-Dullaeus RC, Toggweiler S. Cerebral embolic protection during transcatheter aortic valve replacement: a systematic review and meta-analysis of propensity score matched and randomized controlled trials using the Sentinel cerebral embolic protection device. BMC Cardiovasc Disord 2023; 23:306. [PMID: 37330463 PMCID: PMC10276451 DOI: 10.1186/s12872-023-03338-0] [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] [Received: 12/05/2022] [Accepted: 06/08/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND The Sentinel cerebral embolic protection device (CEP) aims to reduce the risk of stroke during transcatheter aortic valve replacement (TAVR). We performed a systematic review and meta-analysis of propensity score matched (PSM) and randomized controlled trials (RCT) investigating the effect of the Sentinel CEP to prevent strokes during TAVR. METHODS Eligible trials were searched through PubMed, ISI Web of science databases, Cochrane database, and proceedings of major congresses. Primary outcome was stroke. Secondary outcomes included all-cause mortality, major or life-threatening bleeding, major vascular complications and acute kidney injury at discharge. Fixed and random effect models were used to calculate the pooled risk ratio (RR) with 95% confidence intervals (CI) and absolute risk difference (ARD). RESULTS A total of 4066 patients from 4 RCTs (3'506 patients) and 1 PSM study (560 patients) were included. Use of Sentinel CEP was successful in 92% of patients and was associated with a significantly lower risk of stroke (RR: 0.67, 95% CI: 0.48-0.95, p = 0.02. ARD: -1.3%, 95% CI: -2.3 - -0.2, p = 0.02, number needed to treat (NNT) = 77), and a reduced risk of disabling stroke (RR: 0.33, 95% CI: 0.17-0.65. ARD: -0.9%, 95% CI: -1.5 - -0.3, p = 0.004, NNT = 111). Use of Sentinel CEP was associated with a lower risk of major or life-threatening bleeding (RR: 0.37, 95% CI: 0.16-0.87, p = 0.02). Risk for nondisabling stroke (RR: 0.93, 95% CI: 0.62-1.40, p = 0.73), all-cause mortality (RR: 0.70, 95% CI: 0.35-1.40, p = 0.31), major vascular complications (RR: 0.74, 95% CI: 0.33-1.67, p = 0.47) and acute kidney injury (RR: 0.74, 95% CI: 0.37-1.50, p = 0.40) were similar. CONCLUSIONS The use of CEP during TAVR was associated with lower risks of any stroke and disabling stroke with an NNT of 77 and 111, respectively.
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Affiliation(s)
- Mathias Wolfrum
- Heart Center Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland.
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany.
| | - Immanuel Justus Handerer
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
| | | | - Alexander Schmeisser
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
| | - Ruediger C Braun-Dullaeus
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Magdeburg, Germany
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25
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Zhang J, Li X, Tian R, Zong M, Gu X, Xu F, Chen Y, Li C. Outcomes of Cerebral Embolic Protection for Bicuspid Aortic Valve Stenosis Undergoing Transcatheter Aortic Valve Replacement. J Am Heart Assoc 2023:e028890. [PMID: 37301750 DOI: 10.1161/jaha.122.028890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 04/18/2023] [Indexed: 06/12/2023]
Abstract
Background There was limited high-quality evidence that illuminated the efficiency of cerebral embolic protection (CEP) use during transcatheter aortic valve replacement (TAVR) for bicuspid aortic valve (BAV) stenosis. Methods and Results In this retrospective cohort study, patients with BAV stenosis undergoing TAVR with or without CEP were identified by querying the National Inpatient Sample database. The primary end point was any stroke during the hospitalization. The composite safety end point included any in-hospital death and stroke. We applied propensity score-matched analysis to minimize standardized mean differences of baseline variables and compare in-hospital outcomes. From July 2017 to December 2020, 4610 weighted hospitalizations with BAV stenosis undergoing TAVR were identified, of which 795 were treated with CEP. There was a significant increase in the CEP use rate for BAV stenosis (P-trend <0.001). A total of 795 discharges with CEP use were propensity score matched to 1590 comparable discharges but without CEP. CEP use was associated with a lower incidence of in-hospital stroke (1.3% versus 3.8%; P<0.001), which in multivariable regression was also independently associated with the primary outcome (adjusted odds ratio=0.38 [95% CI, 0.18-0.71]; P=0.005) and the safety end point (adjusted odds ratio=0.41 [95% CI, 0.22-0.68] P=0.001). Meanwhile, no significant difference was found in the cost of hospitalization ($46 629 versus $45 147; P=0.18) or the risk of vascular complications (1.9% versus 2.5%; P=0.41). Conclusions This observational study supported CEP use for BAV stenosis, which was independently associated with less in-hospital stroke without burdening the patients with a high hospitalization cost.
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Affiliation(s)
- Jiajun Zhang
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Cheeloo College of Medicine Shandong University Jinan Shandong China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province Qilu Hospital of Shandong University Jinan Shandong China
- Key Laboratory of Cardiovascular Remodeling and Function Research Qilu Hospital of Shandong University Jinan Shandong China
| | - Xiaoxing Li
- Department of Geriatrics Qilu Hospital of Shandong University Jinan Shandong China
| | - Rui Tian
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Cheeloo College of Medicine Shandong University Jinan Shandong China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province Qilu Hospital of Shandong University Jinan Shandong China
- Key Laboratory of Cardiovascular Remodeling and Function Research Qilu Hospital of Shandong University Jinan Shandong China
| | - Mengzhi Zong
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Cheeloo College of Medicine Shandong University Jinan Shandong China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province Qilu Hospital of Shandong University Jinan Shandong China
- Key Laboratory of Cardiovascular Remodeling and Function Research Qilu Hospital of Shandong University Jinan Shandong China
| | - Xinghua Gu
- Department of Cardiac Surgery Qilu Hospital of Shandong University Jinan Shandong China
| | - Feng Xu
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Cheeloo College of Medicine Shandong University Jinan Shandong China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province Qilu Hospital of Shandong University Jinan Shandong China
- Key Laboratory of Cardiovascular Remodeling and Function Research Qilu Hospital of Shandong University Jinan Shandong China
| | - Yuguo Chen
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Cheeloo College of Medicine Shandong University Jinan Shandong China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province Qilu Hospital of Shandong University Jinan Shandong China
- Key Laboratory of Cardiovascular Remodeling and Function Research Qilu Hospital of Shandong University Jinan Shandong China
| | - Chuanbao Li
- Department of Emergency Medicine and Chest Pain Center, Qilu Hospital of Shandong University, Cheeloo College of Medicine Shandong University Jinan Shandong China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province Qilu Hospital of Shandong University Jinan Shandong China
- Key Laboratory of Cardiovascular Remodeling and Function Research Qilu Hospital of Shandong University Jinan Shandong China
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Todd R, Rogers CA, Pufulete M, Culliford L, Pretorius P, Voets N, Akowuah E, Sayeed R, Lazaroo M, Kaur S, Angelini GD, Gibbison B. Efficacy and safety of carbon dioxide insufflation for brain protection for patients undergoing planned left-sided open heart valve surgery: protocol for a multicentre, placebo-controlled, blinded, randomised controlled trial (the CO2 Study). BMJ Open 2023; 13:e074221. [PMID: 37197819 DOI: 10.1136/bmjopen-2023-074221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
INTRODUCTION Brain injury is common following open heart valve surgery. Carbon dioxide insufflation (CDI) has been proposed to reduce the incidence of brain injury by reducing the number of air microemboli entering the bloodstream in surgery. The CO2 Study will evaluate the efficacy and safety of CDI in patients undergoing planned left-sided open heart valve surgery. METHODS AND ANALYSIS The CO2 Study is a multicentre, blinded, placebo-controlled, randomised controlled trial. Seven-hundred and four patients aged 50 years and over undergoing planned left-sided heart valve surgery will be recruited to the study, from at least eight UK National Health Service hospitals, and randomised in a 1:1 ratio to receive CDI or medical air insufflation (placebo) in addition to standard de-airing. Insufflation will be delivered at a flow rate of 5 L/min from before the initiation of cardiopulmonary bypass until 10 min after cardiopulmonary bypass weaning. Participants will be followed up until 3 months post-surgery. The primary outcome is acute ischaemic brain injury within 10 days post-surgery based on new brain lesions identified with diffusion-weighted MRI or clinical evidence of permanent brain injury according to the current definition of stroke. ETHICS AND DISSEMINATION The study was approved by the East Midlands-Nottingham 2 Research Ethics Committee in June 2020 and the Medicines and Healthcare products Regulatory Agency in May 2020. All participants will provide written informed consent prior to undertaking any study assessments. Consent will be obtained by the principal investigator or a delegated member of the research team who has been trained in the study and undergone Good Clinical Practice training. Results will be disseminated through peer-reviewed publications and presentations at national and international meetings. Study participants will be informed of results through study notifications and patient organisations. TRIAL REGISTRATION NUMBER ISRCTN30671536.
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Affiliation(s)
- Rachel Todd
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lucy Culliford
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Pieter Pretorius
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Natalie Voets
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Enoch Akowuah
- James Cook Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Rana Sayeed
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michelle Lazaroo
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Surinder Kaur
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Ben Gibbison
- Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Bristol Medical School, University of Bristol, Bristol, UK
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Tirziu D, Huang H, Parise H, Pietras C, Moses JW, Messé SR, Lansky AJ. Cerebral Embolic Risk in Coronary and Structural Heart Interventions: Clinical Evidence. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100631. [PMID: 39130705 PMCID: PMC11307836 DOI: 10.1016/j.jscai.2023.100631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 08/13/2024]
Abstract
Surgical and endovascular procedures for coronary and structural heart interventions carry a meaningful risk of acute stroke with greatly increased likelihood of disability and long-term neurocognitive sequelae. In the last decade, transcatheter aortic valve replacement procedures have focused our attention on a spectrum of procedure-related neurologic injuries that have led to various efforts to prevent ischemic injury with the use of embolic protection devices. As the number of patients undergoing surgical and transcatheter cardiac procedures in the United States continues to increase, the risk of iatrogenic brain injury is concerning, particularly in patient populations already at increased risk of thromboembolism and cognitive decline. In this study, we reviewed the current estimates of the incidence of iatrogenic cerebral embolization and ischemic infarction after surgical and percutaneous transcatheter interventions for coronary artery disease, stenotic aortic and mitral valves, atrial fibrillation, left atrial appendage and patent foramen ovale closure. Our findings show that every year in the United States, nearly 2 million patients undergo coronary and structural heart interventions, with approximately 8000 at risk of experiencing a symptomatic stroke and 330,225 (95% CI, 249,948-430,377) at the risk of ischemic brain injury after the procedure. Given the increased use of surgical and endovascular cardiac procedures in clinical practice, the risk of iatrogenic cerebral embolism is significant and demands careful consideration through neurologic and cognitive assessments and appropriate risk mitigation.
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Affiliation(s)
- Daniela Tirziu
- Yale Cardiovascular Research Group, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Haocheng Huang
- Yale Cardiovascular Research Group, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Helen Parise
- Yale Cardiovascular Research Group, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Cody Pietras
- Yale Cardiovascular Research Group, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey W. Moses
- Division of Cardiology, Department of Internal Medicine, Columbia University Medical Center, New York, New York
- St. Francis Hospital & Heart Center, Roslyn, New York
| | - Steven R. Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexandra J. Lansky
- Yale Cardiovascular Research Group, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Al-Abdouh A, Mhanna M, Jabri A, Ahmed T, Altibi AM, Ghanem F, Alhuneafat L, Albadawi A, Barbarawi M, Dewaswala N, Bhopalwala H, Kundu A, Elgendy IY. Meta-Analysis of Cerebral Embolic Protection During Transcatheter Aortic Valve Replacement. Am J Cardiol 2023; 192:255-257. [PMID: 36906352 DOI: 10.1016/j.amjcard.2023.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 03/02/2023]
Affiliation(s)
- Ahmad Al-Abdouh
- Department of Medicine, University of Kentucky, Lexington, Kentucky
| | - Mohammed Mhanna
- Department of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
| | - Ahmad Jabri
- Department of Cardiology, Case Western University (Metrohealth), Cleveland, Ohio
| | - Taha Ahmed
- Department of Medicine, University of Kentucky, Lexington, Kentucky
| | - Ahmed M Altibi
- Division of Cardiology, Oregon Health and Science University, Portland, Oregon
| | - Fares Ghanem
- Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee
| | - Laith Alhuneafat
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | - Mahmoud Barbarawi
- Department of Cardiology, University of Connecticut, Framingham, Connecticut
| | - Nakeya Dewaswala
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
| | | | - Amartya Kundu
- Department of Cardiology, University of Connecticut, Framingham, Connecticut
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
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Agrawal A, Isogai T, Shekhar S, Kapadia S. Cerebral Embolic Protection Devices: Current State of the Art. US CARDIOLOGY REVIEW 2023. [DOI: 10.15420/usc.2022.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has become a first-line treatment for severe aortic stenosis with intermediate to high-risk population with its use increasingly expanding into younger and low-risk cohorts as well. Cerebrovascular events are one of the most serious consequential complications of TAVR, which increase morbidity and mortality. The most probable origin of such neurological events is embolic in nature and the majority occur in the acute phase after TAVR when embolic events are most frequent. Cerebral embolic protection devices have been designed to capture or deflect these emboli, reducing the risk of peri-procedural ischaemic events. They also carry the potential to diminish the burden of new silent ischemic lesions during TAVR. Our review explores different types of these device systems, their rationale, and the established clinical data.
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Affiliation(s)
- Ankit Agrawal
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Shashank Shekhar
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
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30
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Baloch ZQ, Haider SJ, Siddiqui HF, Shaikh FN, Shah BUD, Ansari MM, Qintar M. Utility of Cerebral Embolic Protection Devices in Transcatheter Procedures: A Systematic Review and Meta-Analysis. Curr Probl Cardiol 2023; 48:101675. [PMID: 36870550 DOI: 10.1016/j.cpcardiol.2023.101675] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND With the emergence of the largest randomized control trial to date - the Stroke Protection With Sentinel During Transcatheter Aortic Valve Replacement (PROTECTED TAVR) study- we sought to conduct an updated meta-analyses to evaluate the utility of CEP devices on both clinical outcomes and neuroimaging parameters. METHODS Electronic databases were queried through November 2022 for clinical trials comparing the utility of Cerebral Embolic Protection (CEP) devices in Transcatheter Aortic Valve Replacement (TAVR) with non-CEP TAVR procedures. Meta-analyses were performed using the generic inverse variance technique, and a random-effects model, and results are presented as weighted mean differences (WMD) for continuous outcomes, and hazard ratios (HR) for dichotomous outcomes. Outcomes of interest included stroke, disabling stroke, non-disabling stroke, bleeding, mortality, vascular complications, new ischemic lesions, acute kidney injury (AKI) and total lesion volume. RESULTS 13 studies (8 RCTs, 5 observational studies) consisting of 128,471 patients were included in the analysis. Results from our meta-analyses showed a significant reduction in stroke (OR: 0.84 [0.74 - 0.95]; P < 0.01; I2 = 0%), disabling stroke (OR: 0.37 [0.21 - 0.67]; P < 0.01; I2 = 0%) and bleeding events (OR: 0.91 [0.83 - 0.99]; P = 0.04; I2 = 0%) through CEP device use in TAVR. The use of CEP devices had no significant impact on non-disabling stroke (OR: 0.94 [0.65 - 1.37]; P < 0.01; I2 = 0%), mortality (OR: 0.78 [0.53 - 1.14]; P < 0.01; I2 = 17%), vascular complications (OR: 0.99 [0.63 - 1.57]; P < 0.01; I2 = 28%), AKI (OR: 0.78 [0.46 - 1.32]; P < 0.01; I2 = 0%), new ischemic lesions (MD: -1.72 [-4.01, 0.57]; p < 0.001; I2 = 95%) and total lesion volume (MD: -46.11 [-97.38, 5.16]; p < 0.001; I2 = 81%). CONCLUSIONS The results suggest that CEP device use was associated with a lower risk of disabling stroke and bleeding events in patients undergoing TAVR.
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A Referral Center Experience with Cerebral Protection Devices: Challenging Cardiac Thrombus in the EP Lab. J Clin Med 2023; 12:jcm12041549. [PMID: 36836084 PMCID: PMC9967427 DOI: 10.3390/jcm12041549] [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: 12/29/2022] [Revised: 01/30/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Cerebral protection devices (CPD) are designed to prevent cardioembolic stroke and most evidence that exists relates to TAVR procedures. There are missing data on the benefits of CPD in patients that are considered high risk for stroke undergoing cardiac procedures like left atrial appendage (LAA) closure or catheter ablation of ventricular tachycardia (VT) when cardiac thrombus is present. PURPOSE This work aimed to examine the feasibility and safety of the routine use of CPD in patients with cardiac thrombus undergoing interventions in the electrophysiology (EP) lab of a large referral center. METHODS The CPD was placed under fluoroscopic guidance in all procedures in the beginning of the intervention. Two different CPDs were used according to the physician's discretion: (1) a capture device consisting of two filters for the brachiocephalic and left common carotid arteries placed over a 6F sheath from a radial artery; or (2) a deflection device covering all three supra-aortic vessels placed over an 8F femoral sheath. Retrospective periprocedural and safety data were obtained from procedural reports and discharge letters. Long-term safety data were obtained by clinical follow-up in our institution and telephone consultations. RESULTS We identified 30 consecutive patients in our EP lab who underwent interventions (21 LAA closure, 9 VT ablation) with placement of a CPD due to cardiac thrombus. Mean age was 70 ± 10 years and 73% were male, while mean LVEF was 40 ± 14%. The location of the cardiac thrombus was the LAA in all 21 patients (100%) undergoing LAA-closure, whereas, in the 9 patients undergoing VT ablation, thrombus was present in the LAA in 5 cases (56%), left ventricle (n = 3, 33%) and aortic arch (n = 1, 11%). The capture device was used in 19 out of 30 (63%) and the deflection device in 11 out of 30 cases (37%). There were no periprocedural strokes or transitory ischemic attacks (TIA). CPD-related complications comprised the vascular access and were as follows: two cases of pseudoaneurysm of the femoral artery not requiring surgery (7%), 1 hematoma at the arterial puncture site (3%) and 1 venous thrombosis (3%) resolved by warfarin. At long-term follow-up, 1 TIA and 2 non-cardiovascular deaths occurred, with a mean follow-up time of 660 days. CONCLUSIONS Placement of a cerebral protection device prior to LAA closure or VT ablation in patients with cardiac thrombus proved feasible, but possible vascular complications needed to be taken into account. A benefit in periprocedural stroke prevention for these interventions seemed plausible but has yet to be proven in larger and randomized trials.
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Ma X, Chu H, Han K, Shao Q, Yu Y, Jia S, Wang D, Wang Z, Zhou Y. Postoperative delirium after transcatheter aortic valve replacement: An updated systematic review and meta-analysis. J Am Geriatr Soc 2023; 71:646-660. [PMID: 36419366 DOI: 10.1111/jgs.18104] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/19/2022] [Accepted: 09/24/2022] [Indexed: 11/25/2022]
Abstract
AIMS To perform an updated systematic review and meta-analysis of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR). METHODS We conducted a systematic literature search of PubMed, Embase, and Cochrane Library databases from the time of the first human TAVR procedure in 2002 until December 24, 2021, which was supplemented by manual searches of bibliographies. Data were collected on incidence rates, risk factors, and/or associated mortality of POD after TAVR. Pooled analyses were conducted using random effects models to yield mean differences, odds ratios, hazard ratios, and risk ratios, with 95% confidence intervals. RESULTS A total of 70 articles (69 studies) comprising 413,389 patients were included. The study heterogeneity was substantial. The pooled mean incidence of POD after TAVR in all included studies was 9.8% (95% CI: 8.7%-11.0%), whereas that in studies using validated tools to assess for delirium at least once a day for at least 2 consecutive days after TAVR was 20.7% (95% CI: 17.8%-23.7%). According to the level of evidence and results of meta-analysis, independent preoperative risk factors with a high level of evidence included increased age, male sex, prior stroke or transient ischemic attack, atrial fibrillation/flutter, weight loss, electrolyte abnormality, and impaired Instrumental Activities of Daily Living; intraoperative risk factors included non-transfemoral access and general anesthesia; and acute kidney injury was a postoperative risk factor. POD after TAVR was associated with significantly increased mortality (pooled unadjusted RR: 2.20, 95% CI: 1.79-2.71; pooled adjusted RR: 1.62, 95% CI: 1.25-2.10), particularly long-term mortality (pooled unadjusted HR: 2.84, 95% CI: 1.91-4.23; pooled adjusted HR: 1.88, 95% CI: 1.30-2.73). CONCLUSIONS POD after TAVR is common and is associated with an increased risk of mortality. Accurate identification of risk factors for POD after TAVR and implementation of preventive measures are critical to improve prognosis.
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Affiliation(s)
- Xiaoteng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Huijun Chu
- Department of Anesthesia, Qingdao Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Kangning Han
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qiaoyu Shao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shuo Jia
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dunliang Wang
- Department of Anesthesia, Qingdao Women and Children's Hospital, Qingdao University, Qingdao, China
| | - Zhijian Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yujie Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Ten Berg J, Rocca B, Angiolillo DJ, Hayashida K. The search for optimal antithrombotic therapy in transcatheter aortic valve implantation: facts and uncertainties. Eur Heart J 2022; 43:4616-4634. [PMID: 36130256 DOI: 10.1093/eurheartj/ehac385] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 06/24/2022] [Accepted: 07/05/2022] [Indexed: 01/05/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure, which is used frequently in patients with symptomatic severe aortic valve stenosis. Most patients undergoing TAVI are over 80 years of age with a high bleeding as well as thrombotic risk. Despite the increasing safety of the procedure, thromboembolic events [stroke, (subclinical) valve thrombosis] remain prevalent. As a consequence, antithrombotic prophylaxis is routinely used and only recently new data on the efficacy and safety of antithrombotic drugs has become available. On the other hand, these antithrombotic drugs increase bleeding in a population with unique aortic stenosis-related bleeding characteristics (such as acquired von Willebrand factor defect and angiodysplasia). In this review, we discuss the impact of thromboembolic and bleeding events, the current optimal antithrombotic therapy based on registries and recent randomized controlled trials, as well as try to give a practical guide how to treat these high-risk patients. Finally, we discuss knowledge gaps and future research needed to fill these gaps.
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Affiliation(s)
- Jurrien Ten Berg
- Department of Cardiology and Center for Platelet Function Research, St Antonius Hospital, Nieuwegein, The Netherlands.,The Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Bianca Rocca
- Department of Safety and Bioethics, Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Internal Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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Isogai T, Vanguru HR, Krishnaswamy A, Agrawal A, Spilias N, Shekhar S, Saad AM, Verma BR, Puri R, Reed GW, Popović ZB, Unai S, Yun JJ, Uchino K, Kapadia SR. Cerebral embolic protection and severity of stroke following transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2022; 100:810-820. [PMID: 35916117 PMCID: PMC9805232 DOI: 10.1002/ccd.30340] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 07/04/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND The cerebral embolic protection (CEP) device captures embolic debris during transcatheter aortic valve replacement (TAVR). However, the impact of CEP on stroke severity following TAVR remains unclear. Therefore, we aimed to examine whether CEP was associated with reduced severity of stroke following TAVR. METHODS This was a retrospective cohort study of 2839 consecutive patients (mean age: 79.2 ± 9.5 years, females: 41.5%) who underwent transfemoral TAVR at our institution between 2013 and 2020. We categorized patients into Sentinel CEP users and nonusers. Neuroimaging data were reviewed and the final diagnosis of a cerebrovascular event was adjudicated by a neurologist blinded to the CEP use or nonuse. We compared the incidence and severity (assessed by the National Institutes of Health Stroke Scale [NIHSS]) of stroke through 72 h post-TAVR or discharge between the two groups using stabilized inverse probability of treatment weighting (IPTW) of propensity scores. RESULTS Of the eligible patients, 1802 (63.5%) received CEP during TAVR and 1037 (36.5%) did not. After adjustment for patient characteristics by stabilized IPTW, the rate of overall stroke was numerically lower in CEP users than in CEP nonusers, but the difference did not reach statistical significance (0.49% vs. 1.18%, p = 0.064). However, CEP users had significantly lower rates of moderate-or-severe stroke (NIHSS ≥ 6: 0.11% vs. 0.69%, p = 0.013) and severe stroke (NIHSS ≥ 15: 0% vs. 0.29%, p = 0.046). Stroke following CEP use (n = 8), compared with stroke following CEP nonuse (n = 15), tended to carry a lower NIHSS (median [IQR], 4.0 [2.0-7.0] vs. 7.0 [4.5-19.0], p = 0.087). Four (26.7%) out of 15 patients with stroke following CEP nonuse died within 30 days, with no death after stroke following CEP use. CONCLUSIONS CEP use may be associated with attenuated severity of stroke despite no significant difference in overall stroke incidence compared with CEP nonuse. This finding is considered hypothesis-generating and needs to be confirmed in large prospective studies.
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Affiliation(s)
- Toshiaki Isogai
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | | | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Ankit Agrawal
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Nikolaos Spilias
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Shashank Shekhar
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Anas M. Saad
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Beni Rai Verma
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Grant W. Reed
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Zoran B. Popović
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - James J. Yun
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
| | - Ken Uchino
- Cerebrovascular Center, Neurological InstituteCleveland ClinicClevelandOHUSA
| | - Samir R. Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic InstituteCleveland ClinicClevelandOhioUSA
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Jimenez Diaz VA, Estevez Loureiro R, Baz Alonso JA, Juan Salvadores P, Bastos Fernandez G, Caneiro Queija B, Veiga Garcia C, Iñiguez Romo A. Stroke prevention during and after transcatheter aortic valve implantation: From cerebral protection devices to antithrombotic management. Front Cardiovasc Med 2022; 9:958732. [PMID: 36324741 PMCID: PMC9618870 DOI: 10.3389/fcvm.2022.958732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/12/2022] [Indexed: 07/29/2023] Open
Abstract
Since its conception, transcatheter aortic valve implantation (TAVI) has undergone important improvements both in the implantation technique and in transcatheter devices, allowing an enthusiastic adoption of this therapeutic approach in a wide population of patients previously without a surgical option and managed conservatively. Nowadays, patients with severe symptomatic aortic stenosis are typically managed with TAVI, regardless of their risk to surgery, improving the prognosis of patients and thus achieving an exponential global expansion of its use. However, thromboembolic and hemorrhagic complications remain a latent concern in TAVI recipients. Both complications can appear simultaneously in the periprocedural period or during the follow-up, and when minor, they resolved without apparent sequelae, but in a relevant percentage of cases, they are devastating, overshadowing the benefit achieved with TAVI. Our review outlines the etiology and incidence of thromboembolic complications associated with TAVI, the main current strategies for their prevention, and the implications of its pharmacological management at the follow-up in a TAVI population, mostly frail and predisposed to bleeding complications.
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Affiliation(s)
- Victor Alfonso Jimenez Diaz
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Rodrigo Estevez Loureiro
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Jose Antonio Baz Alonso
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Pablo Juan Salvadores
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Guillermo Bastos Fernandez
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Berenice Caneiro Queija
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Cesar Veiga Garcia
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Andres Iñiguez Romo
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
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Sondergaard L, Mylotte D, Capodanno D. What is the future role of cerebral embolic protection in transcatheter aortic valve implantation? EUROINTERVENTION 2022; 18:e617-e619. [PMID: 36205735 PMCID: PMC10241296 DOI: 10.4244/eij-e-22-00037] [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] [Indexed: 10/09/2023]
Affiliation(s)
- Lars Sondergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Darren Mylotte
- Department of Cardiology, Galway University Hospital, University of Galway, Galway, Ireland
| | - Davide Capodanno
- Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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Kapadia SR, Makkar R, Leon M, Abdel-Wahab M, Waggoner T, Massberg S, Rottbauer W, Horr S, Sondergaard L, Karha J, Gooley R, Satler L, Stoler RC, Messé SR, Baron SJ, Seeger J, Kodali S, Krishnaswamy A, Thourani VH, Harrington K, Pocock S, Modolo R, Allocco DJ, Meredith IT, Linke A. Cerebral Embolic Protection during Transcatheter Aortic-Valve Replacement. N Engl J Med 2022; 387:1253-1263. [PMID: 36121045 DOI: 10.1056/nejmoa2204961] [Citation(s) in RCA: 103] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transcatheter aortic-valve replacement (TAVR) for the treatment of aortic stenosis can lead to embolization of debris. Capture of debris by devices that provide cerebral embolic protection (CEP) may reduce the risk of stroke. METHODS We randomly assigned patients with aortic stenosis in a 1:1 ratio to undergo transfemoral TAVR with CEP (CEP group) or without CEP (control group). The primary end point was stroke within 72 hours after TAVR or before discharge (whichever came first) in the intention-to-treat population. Disabling stroke, death, transient ischemic attack, delirium, major or minor vascular complications at the CEP access site, and acute kidney injury were also assessed. A neurology professional examined all the patients at baseline and after TAVR. RESULTS A total of 3000 patients across North America, Europe, and Australia underwent randomization; 1501 were assigned to the CEP group and 1499 to the control group. A CEP device was successfully deployed in 1406 of the 1489 patients (94.4%) in whom an attempt was made. The incidence of stroke within 72 hours after TAVR or before discharge did not differ significantly between the CEP group and the control group (2.3% vs. 2.9%; difference, -0.6 percentage points; 95% confidence interval, -1.7 to 0.5; P = 0.30). Disabling stroke occurred in 0.5% of the patients in the CEP group and in 1.3% of those in the control group. There were no substantial differences between the CEP group and the control group in the percentage of patients who died (0.5% vs. 0.3%); had a stroke, a transient ischemic attack, or delirium (3.1% vs. 3.7%); or had acute kidney injury (0.5% vs. 0.5%). One patient (0.1%) had a vascular complication at the CEP access site. CONCLUSIONS Among patients with aortic stenosis undergoing transfemoral TAVR, the use of CEP did not have a significant effect on the incidence of periprocedural stroke, but on the basis of the 95% confidence interval around this outcome, the results may not rule out a benefit of CEP during TAVR. (Funded by Boston Scientific; PROTECTED TAVR ClinicalTrials.gov number, NCT04149535.).
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Affiliation(s)
- Samir R Kapadia
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Raj Makkar
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Martin Leon
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Mohamed Abdel-Wahab
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Thomas Waggoner
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Steffen Massberg
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Wolfgang Rottbauer
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Samuel Horr
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Lars Sondergaard
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Juhana Karha
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Robert Gooley
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Lowell Satler
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Robert C Stoler
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Steven R Messé
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Suzanne J Baron
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Julia Seeger
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Susheel Kodali
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Amar Krishnaswamy
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Vinod H Thourani
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Katherine Harrington
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Stuart Pocock
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Rodrigo Modolo
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Dominic J Allocco
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Ian T Meredith
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
| | - Axel Linke
- From the Department of Cardiovascular Medicine (S.R.K.), Cleveland Clinic Foundation (A.K.), Cleveland; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); Columbia Interventional Cardiovascular Care (M.L.), Columbia University Medical Center (S.K.), New York; Leipzig Heart Center, University of Leipzig, Leipzig (M.A.-W.), Medizinische Klinik und Poliklinik I, Klinikum der Universität München and German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Munich (S.M.), Universitaetsklinikum Ulm, Ulm (W.R.), Medical Campus Lake Constance, Friedrichshafen (J.S.), and the Clinic for Internal Medicine and Cardiology, Technische Universität Dresden, Herzzentrum, Dresden (A.L.) - all in Germany; Pima Heart and Vascular, Tucson Medical Center Healthcare, Tucson, AZ (T.W.); Centennial Medical Center, Nashville (S.H.); Rigshospitalet, Copenhagen University Hospital, Copenhagen (L. Sondergaard); Heart Hospital of Austin, Austin (J.K.), Baylor Heart and Vascular Hospital, Dallas (R.C.S.), and Baylor Scott and White the Heart Hospital-Plano, Plano (K.H.) - all in Texas; Monash Medical Centre, Clayton, VIC, Australia (R.G.); Washington Hospital Center, Washington, DC (L. Satler); the Department of Neurology, University of Pennsylvania, Philadelphia (S.R.M.); Lahey Hospital and Medical Center, Burlington (S.J.B.), and Boston Scientific, Marlborough (R. Modolo, D.J.A., I.T.M.) - both in Massachusetts; Piedmont Heart Institute, Atlanta (V.H.T.); and the London School of Hygiene and Tropical Medicine, London (S.P.)
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Worku B, Gulkarov I, Mack C. Embolization during cardiac surgery; to prevent or intercept. J Card Surg 2022; 37:2732-2733. [PMID: 35765996 DOI: 10.1111/jocs.16722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Berhane Worku
- Department of Cardiothoracic Surgery, New York Presbyterian Weill Cornell Medical Center, New York, New York, USA.,Department of Cardiothoracic Surgery, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
| | - Iosif Gulkarov
- Department of Cardiothoracic Surgery, New York Presbyterian Weill Cornell Medical Center, New York, New York, USA.,Department of Cardiothoracic Surgery, New York Presbyterian Queens Hospital, Queens, New York, USA
| | - Charles Mack
- Department of Cardiothoracic Surgery, New York Presbyterian Weill Cornell Medical Center, New York, New York, USA.,Department of Cardiothoracic Surgery, New York Presbyterian Queens Hospital, Queens, New York, USA
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Lowenstern A, Hung A, Manandhar P, Wegermann ZK, Kapadia SR, Lindman BR, Goel K, Levack M, Barker CM, Reed SD, Cohen DJ, Vemulapalli S. Association of Transcatheter Aortic Valve Replacement Reimbursement, New Technology Add-on Payment, and Procedure Volumes With Embolic Protection Device Use. JAMA Cardiol 2022; 7:945-952. [PMID: 35976635 PMCID: PMC9386613 DOI: 10.1001/jamacardio.2022.2608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/01/2022] [Indexed: 11/14/2022]
Abstract
Importance In the setting of uncertain efficacy and additional, unreimbursed cost, use of an embolic protection device (EPD) during transcatheter aortic valve replacement (TAVR) has had variable uptake. The Centers for Medicare & Medicaid Services (CMS) instituted a new technology add-on payment to cover EPD use in October 2018. Objective To evaluate the association between CMS TAVR reimbursement rates and EPD use. Design, Setting, and Participants This cohort study used the Society for Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry to identify patients who underwent TAVR between January 2018 and September 2019. Analysis took place between July 2020 and February 2022. Main Outcomes and Measures The association between EPD use and CMS reimbursement was assessed using multivariable logistic regression models adjusted for patient characteristics (model 1) and patient/hospital (annualized TAVR volume and teaching status) characteristics (model 2). Results Among 511 institutions, CMS reimbursement for TAVR ranged from $28 062 to $111 280 with a median (IQR) of $45 884 ($40 331-$53 627). Among 84 353 patients (median [IQR] age, 81.0 [75.0-86.0] years; 46 247 male individuals [54.8%]; 3958 [4.7%] of Hispanic or Latino ethnicity; 78 170 White individuals [92.7%]) treated at the sites, 6012 (7.1%) underwent TAVR with EPD. Patient characteristics associated with EPD use included prior stroke (adjusted odds ratio [aOR], 1.13 [95% CI, 1.00-1.27]; P = .048), female sex (aOR, 0.85 [95% CI, 0.78-0.93]; P < .001), hemodialysis (aOR, 0.52 [95% CI, 0.40-0.68]; P < .001), and shock (aOR, 0.62 [95% CI, 0.41-0.94]; P = .03). Higher CMS reimbursement up to $50 000 per TAVR was associated with greater likelihood of EPD use in model 1 (per $1000; aOR, 1.08 [95% CI, 1.01-1.16]; P = .02). However, this association was no longer apparent after adjusting for site characteristics (model 2; aOR, 1.03 [95% CI, 0.96-1.11]; P = .38). Higher TAVR volume was associated with increased EPD use (per 25 TAVRs; aOR, 1.15 [95% CI, 1.09-1.21]; P < .001). There was no significant change in the odds of EPD uptake before vs after institution of the CMS new technology add-on payment across tertiles of CMS TAVR reimbursement (Wald χ2 = 3.59; P = .17). Conclusions and Relevance EPD use during TAVR remains infrequent and is associated with multiple patient and site characteristics. While CMS reimbursement varies significantly across institutions, TAVR case volume, rather than CMS TAVR reimbursement or the CMS new technology add-on payment, appears to be the predominant factor associated with EPD use. Ongoing work is needed to understand the economic drivers that contribute to the association between procedural volume and EPD use.
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Affiliation(s)
- Angela Lowenstern
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna Hung
- Duke Clinical Research Institute, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | | | - Zachary K. Wegermann
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Samir R. Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian R. Lindman
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kashish Goel
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Colin M. Barker
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shelby D. Reed
- Duke Clinical Research Institute, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, New York
- St Francis Hospital and Heart Center, Roslyn, New York
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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Pérez-Camargo D, Travieso A, Carnero-Alcázar M, Taramasso M, Cobiella-Carnicer J, Maroto-Castellanos LC. Neurological outcomes of transcatheter aortic valve implantation with or without cerebral embolic protection devices: A meta-analysis. J Stroke Cerebrovasc Dis 2022; 31:106605. [PMID: 35843052 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106605] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/20/2022] [Accepted: 06/12/2022] [Indexed: 10/17/2022] Open
Abstract
INTRODUCTION Cerebral embolic protection devices (CEPDs) are designed to prevent embolization of debris during transcatheter aortic valve implantation (TAVI). Current evidence from randomized clinical trials (RCTs) and observational studies is controversial. AIMS The purpose of this meta-analysis was to study the influence of CEPDs on stroke, silent ischemic lesions and neurocognitive function. METHODS A systematic search was conducted including RCTs or adjusted observational studies comparing TAVI with or without CEPDs. Pooled odds ratios, risk ratios or standardized mean differences with 95% confidence intervals were calculated using the inverse of variance method. Risk of bias sensitivity analyses and meta regression for CEPD type were also conducted. RESULTS Five RCTs and five adjusted observational studies were included (n= 159,865). Mean age of the patients was 81.1 (SD 1.04) years in CEPDs and 81 (SD 1.86) in non-CEPD. The overall quality of evidence using the GRADE system for each endpoint was low to very low, mainly due to serious risk of bias, inconsistency and imprecision. Random effects meta-analysis detected no significant differences between CEPD and non-CEPD (OR= 0.74; 95% CI 0.51-1.07; P= 0.105; I2= 82.1%) for 30-day stroke. This finding was consistent in meta regression for CEPD type and subgroup analyses by study type and CEPD type. No significant differences between groups were observed in cerebral DW-MRI assessment and neurocognitive function evaluation. CONCLUSION In the present meta- analysis of five RCTs and five adjusted observational studies, the use of a CEPD during TAVI was not associated with a significant benefit on 30- day stroke, total lesion volume per patient, number of ischemic lesions per patient and neurocognitive function assessments.
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Affiliation(s)
- Daniel Pérez-Camargo
- Cardiac Surgery Department, Hospital Universitario Clínico San Carlos, Madrid, Spain.
| | - Alejandro Travieso
- Cardiology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
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Clinical Predictors for Procedural Stroke and Implications for Embolic Protection Devices during TAVR: Results from the Multicenter Transcatheter Aortic Valve Replacement In-Hospital Stroke (TASK) Study. J Pers Med 2022; 12:jpm12071056. [PMID: 35887554 PMCID: PMC9316224 DOI: 10.3390/jpm12071056] [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: 05/12/2022] [Revised: 06/08/2022] [Accepted: 06/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Data to support the routine use of embolic protection devices for stroke prevention during transcatheter aortic valve replacement (TAVR) are controversial. Identifying patients at high risk for peri-procedural cerebrovascular events may facilitate effective patient selection for embolic protection devices during TAVR. Aim: To generate a risk score model for stratifying TAVR patients according to peri-procedural cerebrovascular events risk. Methods and results: A total of 8779 TAVR patients from 12 centers worldwide were included. Peri-procedural cerebrovascular events were defined as an ischemic stroke or a transient ischemic attack occurring ≤24 h from TAVR. The peri-procedural cerebrovascular events rate was 1.4% (n = 127), which was independently associated with 1-year mortality (hazards ratio (HR) 1.78, 95% confidence interval (CI) 1.06−2.98, p < 0.028). The TASK risk score parameters were history of stroke, use of a non-balloon expandable valve, chronic kidney disease, and peripheral vascular disease, and each parameter was assigned one point. Each one-point increment was associated with a significant increase in peri-procedural cerebrovascular events risk (OR 1.96, 95% CI 1.56−2.45, p < 0.001). The TASK score was dichotomized into very-low, low, intermediate, and high (0, 1, 2, 3−4 points, respectively). The high-risk TASK score group (OR 5.4, 95% CI 2.06−14.16, p = 0.001) was associated with a significantly higher risk of peri-procedural cerebrovascular events compared with the low TASK score group. Conclusions: The proposed novel TASK risk score may assist in the pre-procedural risk stratification of TAVR patients for peri-procedural cerebrovascular events.
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Deveci OS, Okutucu S, Fatihoglu SG, Oto A. Cerebral embolic protection devices during transcatheter aortic valve implantation, the current state of the art. Acta Cardiol 2022; 77:196-203. [PMID: 33827380 DOI: 10.1080/00015385.2021.1909276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Stroke after transcatheter aortic valve (TAVI) is a devastating adverse event. The majority of these occur in the acute phase following TAVI where cerebral embolic events are frequent. Cerebral embolic protection devices (CEPD) have been developed to minimise the risk of peri-procedural ischaemic stroke during TAVI. CEPD have the potential to lower intraprocedural burden of new silent ischaemic brain injury. Several CEPD have been developed, but their clinical benefit remains unknown. Herein, we aimed to review the impact of the use of CEPD, in patients undergoing TAVI, on the reduction of strokes or the onset of new ischaemic lesions.
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Affiliation(s)
- Onur Sinan Deveci
- Department of Cardiology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Sercan Okutucu
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
| | | | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
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Linder M, Higgen FL, Voigtländer L, Weimann J, Ludwig S, Waldschmidt L, Focke C, Bhadra OD, Grundmann D, Demal TJ, von Zastrow A, Schäfer A, Schirmer J, Reichenspurner H, Blankenberg S, Westermann D, Schofer N, Conradi L, Thomalla G, Seiffert M. Stroke events after transcatheter aortic valve implantation: Temporal relationships and affected brain regions. Am Heart J 2022; 247:112-122. [PMID: 35149038 DOI: 10.1016/j.ahj.2022.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/17/2022] [Accepted: 02/03/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND Despite continuous improvements in transcatheter aortic valve implantation (TAVI), periprocedural strokes remain a devastating complication. Randomized controlled trials failed to demonstrate a reduction in clinically apparent strokes or mortality after TAVI due to cerebral embolic protection (CEP). To identify potential targets of CEP strategies during TAVI, we evaluated affected brain regions, and temporal patterns of stroke onset in a routine clinical sample. METHODS AND RESULTS A total of 3,164 consecutive patients treated with TAVI from 2008 to 2019 at a single center were screened for cerebrovascular events. Affected cerebral regions were determined according to clinical symptoms and brain imaging. Rates of disabling stroke and non-disabling stroke at 30 days were 2.2% and 1.4%, respectively. The frequency of all strokes decreased from 5.0% to 3.0% over time (P = .012). Patients with impaired left-ventricular function (OR 2.19), increased CHA2DS2-VASc (OR 1.39) and moderate/severe spontaneous echo contrast (OR 3.60) had a higher stroke risk. Acute symptom onset occurred during TAVI (19.4%), within 24 hours (40.3%) or later (25.0%); 98.3% of strokes were of ischemic origin. In intraprocedural strokes, 53.2% of lesions were found in locations considered protected by current CEP devices, and 37.5% of patients with intraprocedural strokes were exclusively affected in these areas. Baseline or procedural parameters were not associated with embolic distribution patterns. CONCLUSIONS Most strokes occurred early after TAVI - but not necessarily during the procedure - and affected multiple brain regions only partially protected by current CEP devices. Efficient prevention of cerebrovascular events may require strategies beyond the TAVI procedure to minimize stroke risk and additional randomized controlled trials will be required to clarify the role of CEP in efficient stroke prevention during TAVI.
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Affiliation(s)
- Matthias Linder
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Focko Lorenz Higgen
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lisa Voigtländer
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
| | - Jessica Weimann
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian Ludwig
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lara Waldschmidt
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Charlotte Focke
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver Daniel Bhadra
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - David Grundmann
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Till Joscha Demal
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas von Zastrow
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Schäfer
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Schirmer
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
| | - Niklas Schofer
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Seiffert
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany.
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Linder M, Seiffert M. Periprocedural Strategies for Stroke Prevention in Patients Undergoing Transcatheter Aortic Valve Implantation. Front Cardiovasc Med 2022; 9:892956. [PMID: 35557539 PMCID: PMC9086549 DOI: 10.3389/fcvm.2022.892956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/15/2022] [Indexed: 11/22/2022] Open
Abstract
Cerebrovascular events remain a serious complication in patients undergoing transcatheter aortic valve implantation with an incidence of 2-3% at 30 days. While expanding TAVI to younger low-risk patients, prevention of periprocedural strokes becomes even more important. Different cerebral embolic protection devices have been tested but a clear clinical benefit has not been demonstrated in randomized trials. Due to the multifactorial aetiology with different predisposing factors, stroke prevention should include procedural and periprocedural strategies. This article aims to summarize different approaches and discuss open questions.
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Affiliation(s)
- Matthias Linder
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Seiffert
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Hamburg, Germany
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Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement. J Clin Med 2022; 11:jcm11082190. [PMID: 35456283 PMCID: PMC9031701 DOI: 10.3390/jcm11082190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022] Open
Abstract
Due to a large technical improvement in the past decade, transcatheter aortic valve replacement (TAVR) has expanded to lower-surgical-risk patients with symptomatic and severe aortic stenosis. While mortality rates related to TAVR are decreasing, the prognosis of patients is still impacted by ischemic and bleeding complications, and defining the optimal antithrombotic regimen remains a priority. Recent randomized control trials reported lower bleeding rates with an equivalent risk in ischemic outcomes with single antiplatelet therapy (SAPT) when compared to dual antiplatelet therapy (DAPT) in patients without an underlying indication for anticoagulation. In patients requiring lifelong oral anticoagulation (OAC), the association of OAC plus antiplatelet therapy leads to a higher risk of bleeding events with no advantages on mortality or ischemic outcomes. Considering these data, guidelines have recently been updated and now recommend SAPT and OAC alone for TAVR patients without and with a long-term indication for anticoagulation. Whether a direct oral anticoagulant or vitamin K antagonist provides better outcomes in patients in need of anticoagulation remains uncertain, as recent trials showed a similar impact on ischemic and bleeding outcomes with apixaban but higher gastrointestinal bleeding with edoxaban. This review aims to summarize the most recently published data in the field, as well as describe unresolved issues.
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Embolic Protection with the TriGuard 3 System in Nonagenarian Patients Undergoing Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis. J Clin Med 2022; 11:jcm11072003. [PMID: 35407611 PMCID: PMC8999484 DOI: 10.3390/jcm11072003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/21/2022] [Accepted: 03/28/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Transcatheter aortic valve replacement (TAVR) improves the survival and life quality of nonagenarian patients with aortic stenosis. Stroke remains one of the most worrisome complications following TAVR. Cerebral embolic protection devices (CEPDs) may reduce neurological complications after TAVR. This study evaluated the safety and efficacy of CEPDs during TAVR in nonagenarian patients. Methods: Between January 2018 and October 2021, 869 patients underwent transfemoral TAVR (TF-TAVR) at our center. Of these, 51 (5.9%) patients were older than ninety years. In 33 consecutive nonagenarian patients, TF-TAVR was implanted without CEPDs using balloon-expandable valves (BEVs) and self-expandable valves (SEVs). Eighteen consecutive nonagenarians underwent TF-TAVR using a CEPD (CP group). Follow up period was in-hospital or 30 days after the procedure, respectively. Results: Minor access site complications occurred in two patients (3.9%) and were not CEPD-associated. Postinterventional delirium occurred in nine patients (17.6%). Periprocedural minor non-disabling stroke and delirium occurred in ten patients (19.6%). Periprocedural major fatal stroke occurred in two patients in the BEV group (3.9%). Two patients in the BEV group died due to postinterventional pneumonia with sepsis. The mortality rate was 7.8%. The results did not differ between the groups. Conclusions: Age alone is no longer a contraindication for TAVR. CEPD using the Triguard 3 system in nonagenarian TAVR patients was feasible and safe and did not increase access site complications.
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Meertens MM, Macherey S, Asselberghs S, Lee S, Schipper JH, Mees B, Eitel I, Baldus S, Frerker C, Schmidt T. A systematic review and meta-analysis of the cerebrovascular event incidence after transcatheter aortic valve implantation. Clin Res Cardiol 2022; 111:843-858. [PMID: 35298700 DOI: 10.1007/s00392-022-01997-1] [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: 10/19/2021] [Accepted: 02/21/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Periinterventional stroke is one of the most feared potential complication, among patients treated with transcatheter aortic valve implantation (TAVI). The purpose of this review was to investigate the incidence of cerebrovascular events and the influence of postinterventional neurologic check-up in patients undergoing TAVI. METHODS A systematic review and meta-analysis were conducted according to the PRISMA guideline. Three separate electronic searches of the public domains Medline and Clinicaltrials.gov were performed to identify the 30-day incidence of stroke within randomized controlled trials (RCTs) and registries for patients undergoing a TAVI procedure. A meta-analysis was conducted to evaluate the 30-day incidence of stroke within RCTs. Furthermore, we pooled the RCTs in which a scheduled neurological check-up was conducted or not to investigate the effect of this intervention. RESULTS Twenty-three studies including 399,532,491 TAVI patients were included, 6370 from RCTs, 857,833 from cerebral-embolic protection device RCTs and 392,288 were adopted from registries. The mean 30-day incidence of stroke among all reviewed studies was 2.33%. In RCTs evaluating TAVI the pooled stroke incidence was 3.86%, among RCTs focused CEP the incidence was 6.4436% and in registries the incidence was 2.29%. Ten RCTs conducted scheduled neurological check-ups, the incidence in these was 4.03% and among the remaining RCTs it was 2.47%. In the meta-analysis, the pooled 30-day stroke incidence was 3.61% (95% CI 2.57-4.79%). CONCLUSION This systematic review demonstrates that the stroke incidences following TAVI differ strongly according to the study design and neurological follow-up. Intense neurological testing increases the incidence of a stroke after TAVI.
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Affiliation(s)
- Max M Meertens
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sascha Macherey
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Sebastiaan Asselberghs
- Department of Pathology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Samuel Lee
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jan Hendrik Schipper
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Barend Mees
- Department of Pathology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Vascular Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ingo Eitel
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Stephan Baldus
- Department III of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Christian Frerker
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Tobias Schmidt
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538, Lübeck, Germany.
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany.
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Changes in demographics, treatment and outcomes in a consecutive cohort who underwent transcatheter aortic valve implantation between 2005 and 2020. Neth Heart J 2022; 30:411-422. [PMID: 35212972 PMCID: PMC9402869 DOI: 10.1007/s12471-022-01662-2] [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] [Accepted: 12/13/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Transcatheter aortic valve implantation (TAVI) has matured to the treatment of choice for most patients with aortic stenosis (AS). We sought to identify trends in patient and procedural characteristics, and clinical outcomes in all patients who underwent TAVI between 2005 and 2020. Methods A single-centre analysis was performed on 1500 consecutive patients who underwent TAVI, divided into three tertiles (T) of 500 patients treated between November 2005 and December 2014 (T1), January 2015 and May 2018 (T2) and June 2018 and April 2020 (T3). Results Over time, mean age and gender did not change (T1 to T3: 80, 80 and 79 years and 53%, 55% and 52% men, respectively), while the Society of Thoracic Surgeons risk score declined (T1: 4.5% to T3: 2.7%, p < 0.001). Use of general anaesthesia also declined over time (100%, 24% and 1% from T1 to T3) and transfemoral TAVI remained the default approach (87%, 94% and 92%). Median procedure time and contrast volume decreased significantly (186, 114 and 56 min and 120, 100 and 80 ml, respectively). Thirty-day mortality (7%, 4% and 2%), stroke (7%, 3% and 3%), need for a pacemaker (19%, 22% and 8%) and delirium (17%, 12% and 8%) improved significantly, while major bleeding/vascular complications did not change (both approximately 9%, 6% and 6%). One-year survival was 80%, 88% and 92%, respectively. Conclusion Over our 15 years’ experience, patient age remained unchanged but the patient risk profile became more favourable. Simplification of the TAVI procedure occurred in parallel with major improvement in outcomes and survival. Bleeding/vascular complications and the need for pacemaker implantation remain the Achilles’ heel of TAVI. Supplementary Information The online version of this article (10.1007/s12471-022-01662-2) contains supplementary material, which is available to authorized users.
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Donà C, Koschutnik M, Nitsche C, Winter MP, Seidl V, Siller-Matula J, Mach M, Andreas M, Bartko P, Kammerlander AA, Goliasch G, Lang I, Hengstenberg C, Mascherbauer J. Cerebral Protection in TAVR-Can We Do Without? A Real-World All-Comer Intention-to-Treat Study-Impact on Stroke Rate, Length of Hospital Stay, and Twelve-Month Mortality. J Pers Med 2022; 12:jpm12020320. [PMID: 35207808 PMCID: PMC8878932 DOI: 10.3390/jpm12020320] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Stroke associated with transcatheter aortic valve replacement (TAVR) is a potentially devastating complication. Until recently, the Sentinel™ Cerebral Protection System (CPS; Boston Scientific, Marlborough, MA, USA) has been the only commercially available device for mechanical prevention of TAVR-related stroke. However, its effectiveness is still undetermined. Objectives: To explore the impact of Sentinel™ on stroke rate, length of hospital stay (LOS), and twelve-month mortality in a single-center, real-world, all-comers TAVR cohort. Material and Methods: Between January 2019 and August 2020 consecutive patients were assigned to TAVR with or without Sentinel™ in a 1:1 fashion according to the treating operator. We defined as primary endpoint clinically detectable cerebrovascular events within 72 h after TAVR and as secondary endpoints LOS and 12-month mortality. Logistic and linear regression analyses were used to assess associations of Sentinel™ use with endpoints. Results: Of 411 patients (80 ± 7 y/o, 47.4% female, EuroSCORE II 6.3 ± 5.9%), Sentinel™ was used in 213 (51.8%), with both filters correctly deployed in 189 (46.0%). Twenty (4.9%) cerebrovascular events were recorded, ten (2.4%) of which were disabling strokes. Patients with Sentinel™ suffered 71% less (univariate analysis; OR 0.29, 95%CI 0.11–0.82; p = 0.02) and, respectively, 76% less (multivariate analysis; OR 0.24, 95%CI 0.08–0.76; p = 0.02) cerebrovascular events compared to patients without Sentinel™. Sentinel™ use was also significantly associated with shorter LOS (Regression coefficient −2.47, 95%CI −4.08, −0.87; p < 0.01) and lower 12-month all-cause mortality (OR 0.45; 95%CI 0.22–0.93; p = 0.03). Conclusion: In the present prospective all-comers TAVR cohort, patients with Sentinel™ use showed (1) lower rates of cerebrovascular events, (2) shortened LOS, and (3) improved 12-month survival. These data promote the use of a CPS when implanting TAVR valves.
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Affiliation(s)
- Carolina Donà
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Matthias Koschutnik
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Christian Nitsche
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Max-Paul Winter
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Veronika Seidl
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Jolanta Siller-Matula
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Markus Mach
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.M.); (M.A.)
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.M.); (M.A.)
| | - Philipp Bartko
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Andreas Anselm Kammerlander
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
- Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Georg Goliasch
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Irene Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Christian Hengstenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
| | - Julia Mascherbauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (C.D.); (M.K.); (C.N.); (M.-P.W.); (V.S.); (J.S.-M.); (P.B.); (A.A.K.); (G.G.); (I.L.); (C.H.)
- Department of Internal Medicine 3, University Hospital St. Poelten, Karl Landsteiner University of Health Sciences, 3500 Krems, Austria
- Correspondence: ; Tel.: +43-1-40400-46140; Fax: +43-1-40400-42160
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Augoustides JG. Protecting the Central Nervous System During Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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