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de Sá Marchi MF, Calomeni P, Gauza MDM, Kanhouche G, Ravani LV, Rodrigues CVF, Tarasoutchi F, de Brito FS, Rodés-Cabau J, Van Mieghem NM, Abizaid A, Ribeiro HB. Impact of periprocedural myocardial injury after transcatheter aortic valve implantation on long-term mortality: a meta-analysis of Kaplan-Meier derived individual patient data. Front Cardiovasc Med 2023; 10:1228305. [PMID: 38028447 PMCID: PMC10667910 DOI: 10.3389/fcvm.2023.1228305] [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: 05/24/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023] Open
Abstract
Background Periprocedural myocardial injury (PPMI) frequently occurs after transcatheter aortic valve implantation (TAVI), although its impact on long-term mortality is uncertain. Methods We performed a pooled analysis of Kaplan-Meier-derived individual patient data to compare survival in patients with and without PPMI after TAVI. Flexible parametric models with B-splines and landmark analyses were used to determine PPMI prognostic value. Subgroup analyses for VARC-2, troponin, and creatine kinase-MB (CK-MB)-defined PPMI were also performed. Results Eighteen observational studies comprising 10,094 subjects were included. PPMI was associated with lower overall survival (OS) after two years (HR = 1.46, 95% CI 1.30-1.65, p < 0.01). This was also observed when restricting the analysis to overall VARC-2-defined PPMI (HR = 1.23, 95% CI 1.07-1.40, p < 0.01). For VARC-2 PPMI criteria and VARC-2 troponin-only, higher mortality was restricted to the first 2 months after TAVI (HR = 1.64, 95% CI 1.31-2.07, p < 0.01; and HR = 1.32, 95% CI 1.05-1.67, p = 0.02, respectively), while for VARC-2 defined CK-MB-only the increase in mortality was confined to the first 30 days (HR = 7.44, 95% CI 4.76-11.66, p < 0.01). Conclusion PPMI following TAVI was associated with lower overall survival compared with patients without PPMI. PPMI prognostic impact is restricted to the initial months after the procedure. The analyses were consistent for VARC-2 criteria and for both biomarkers, yet CK-MB was a stronger prognostic marker of mortality than troponin.
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Affiliation(s)
- Mauricio Felippi de Sá Marchi
- Departamento de Cardiologia Intervencionista e Hemodinamica, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
- Department of Interventional Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Pedro Calomeni
- Departamento de Cardiologia Intervencionista e Hemodinamica, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | | | - Gabriel Kanhouche
- Departamento de Cardiologia Intervencionista e Hemodinamica, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Lis Victória Ravani
- Departamento de Cardiologia Intervencionista e Hemodinamica, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Caio Vinicius Fernandes Rodrigues
- Departamento de Cardiologia Intervencionista e Hemodinamica, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Flávio Tarasoutchi
- Unidade Clinica de Valvopatias, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Fábio Sandoli de Brito
- Departamento de Cardiologia Intervencionista e Hemodinamica, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Josep Rodés-Cabau
- Department of Cardiovascular Medicine, Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
- Department of Cardiovascular Medicine, Institut Clinic Cardiovascular, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Alexandre Abizaid
- Departamento de Cardiologia Intervencionista e Hemodinamica, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
| | - Henrique Barbosa Ribeiro
- Departamento de Cardiologia Intervencionista e Hemodinamica, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brasil
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Real C, Avvedimento M, Nuche J, Franzone A, Farjat-Pasos J, Trinh KH, Delarochellière R, Paradis JM, Poulin A, Dumont E, Kalavrouziotis D, Mohammadi S, Mengi S, Esposito G, Rodés-Cabau J. Myocardial Injury After Transcatheter Aortic Valve Replacement According to VARC-3 Criteria. JACC Cardiovasc Interv 2023; 16:1221-1232. [PMID: 37225294 DOI: 10.1016/j.jcin.2023.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND The Valve Academic Research Consortium (VARC)-3 definition for myocardial injury after transcatheter aortic valve replacement (TAVR) lacks of clinical validation. OBJECTIVES This study sought to determine the incidence, predictors, and clinical impact of periprocedural myocardial injury (PPMI) following TAVR as defined by recent VARC-3 criteria. METHODS We included 1,394 consecutive patients who underwent TAVR with a new-generation transcatheter heart valve. High-sensitivity troponin levels were assessed at baseline and within 24 hours after the procedure. PPMI was defined according to VARC-3 criteria as an increase ≥70 times in troponin levels (vs ≥15 times according to the VARC-2 definition). Baseline, procedural, and follow-up data were prospectively collected. RESULTS PPMI was diagnosed in 193 (14.0%) patients. Female sex and peripheral artery disease were independent predictors of PPMI (P < 0.01 for both). PPMI was associated with a higher risk of mortality at 30-day (HR: 2.69, 95% CI: 1.50-4.82; P = 0.001) and 1-year (for all-cause mortality, HR: 1.54; 95% CI: 1.04-2.27; P = 0.032; for cardiovascular mortality, HR: 3.04; 95% CI: 1.68-5.50; P < 0.001) follow-up. PPMI according to VARC-2 criteria had no impact on mortality. CONCLUSIONS About 1 out of 10 patients undergoing TAVR in the contemporary era had PPMI as defined by recent VARC-3 criteria, and baseline factors like female sex and peripheral artery disease determined an increased risk. PPMI had a negative impact on early and late survival. Further studies on the prevention of PPMI post-TAVR and implementing measures to improve outcomes in PPMI patients are warranted.
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Affiliation(s)
- Carlos Real
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Department of Cardiology, Hospital Clínico San Carlos, Madrid, Spain
| | - Marisa Avvedimento
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Jorge Nuche
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Julio Farjat-Pasos
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Kim-Hoang Trinh
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Jean-Michel Paradis
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Anthony Poulin
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Eric Dumont
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Siamak Mohammadi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Siddartha Mengi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Clínic Barcelona, Barcelona, Spain.
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De Marzo V, Viglino U, Zecchino S, Matos JG, Piredda E, Pigati M, Vercellino M, Crimi G, Balbi M, Seitun S, Porto I. Supra-renal aortic atheroma extent and composition predict acute kidney injury after transcatheter aortic valve replacement: A three-dimensional computed tomography study. Int J Cardiol 2023; 381:8-15. [PMID: 37001646 DOI: 10.1016/j.ijcard.2023.03.053] [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: 10/14/2022] [Revised: 03/21/2023] [Accepted: 03/24/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE Acute kidney injury (AKI) may complicate transcatheter aortic valve replacement (TAVR) and could be linked to atheroembolization associated with catheter manipulation in the supra-renal (SR) aorta. We sought to determine the impact of SR aortic atheroma burden (SR-AAB) and composition, as well as of the aortic valve calcium score (AV-CS), measured at pre-operative multislice computed tomography (PO-MSCT), on AKI-TAVR. METHODS All TAVR-patients 3 January-2018 to December-2020 were included. A three-dimensional analysis of PO-MSCT was performed, calculating percentage SR-AAB (%SR-AAB) as [(absolute SR-AAB volume)*100/vessel volume]. Types of plaque were defined according to Hounsfield unit (HU) intensity ranges. Calcified plaque was subcategorized into 3 strata: low- (351-700 HU), mid- (701-1000 HU), and high‑calcium (>1000 HU, termed 1 K-plaque). RESULTS The study population included 222 patients [mean age 83.3 ± 5.7 years, 95 (42.8%) males], AKI-TAVR occurred in 67/222 (30.2%). Absolute SR-AAB (41.3 ± 16.4 cm3 vs. 32.5 ± 10.7 cm3,p < 0.001) and %SR-AAB (17.6 ± 5.1% vs. 13.9 ± 4.3%,p < 0.001) were significantly higher in patients developing AKI-TAVR. Patients who developed AKI-TAVR had higher mid‑calcium (6.9 ± 3.8% vs. 4.2 ± 3.5%,p < 0.001) and 1 K-plaque (5.4 ± 3.7% vs. 2.4 ± 2.4%,p < 0.001) with no difference in AV-CS (p = 0.691). Adjusted multivariable logistic regression analysis showed that %SR-AAB [OR (x%increase): 1.12, 95%CI: 1.04-1.22,p = 0.006] and %SR-calcified plaque [OR (x%increase): 5.60, 95%CI: 2.50-13.36,p < 0.001] were associated with AKI-TAVR. Finally, 3-knots spline analyses identified %SR-AAB >15.0% and %SR-calcified plaque >7.0% as optimal thresholds to predict an increased risk of AKI-TAVR. CONCLUSIONS Suprarenal aortic atheroma, when highly calcified, is associated with AKI-TAVR. Perioperative-MSCT assessment of aortic atherosclerosis may help in identification of patients at high-risk for AKI-TAVR, who could benefit from higher peri-operative surveillance.
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Affiliation(s)
- Vincenzo De Marzo
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy
| | - Umberto Viglino
- Radiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Simone Zecchino
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy
| | - Joao Gavina Matos
- Radiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Elisa Piredda
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy
| | - Maria Pigati
- Radiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Vercellino
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy
| | - Gabriele Crimi
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy
| | - Manrico Balbi
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy; Cardiology Unit, Cardiothoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Sara Seitun
- Radiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Italo Porto
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Italy; Cardiology Unit, Cardiothoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
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Chen W, Han Y, Wang C, Chen W. Association between periprocedural myocardial injury and long-term all-cause mortality in patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis. SCAND CARDIOVASC J 2022; 56:387-393. [PMID: 36317197 DOI: 10.1080/14017431.2022.2139412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/23/2022] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
Objective. The purpose of this meta-analysis was to investigate the effect of periprocedural myocardial injury (PPMI) on long-term all-cause mortality in patients undergoing transcatheter aortic valve replacement (TAVR) and to explore potential factors associated with mortality risk. Design. The PubMed, Embase, and Cochrane Library databases were searched up to April 2022. Studies reporting the effect of PPMI on the risk of long-term all-cause mortality were included. The summary odds ratio (OR) was calculated using a random effects model. Additionally, meta-regression and subgroup analyses were conducted according to specific research characteristics to explore sources of heterogeneity. Results. Fourteen studies involving 6,415 patients who underwent TAVR showed that the occurrence of PPMI was associated with a higher risk of long-term mortality. Subgroup analysis showed that in the group of aged ≥82 years, men accounted for less than 50%, coronary artery disease patients accounted for more than 50%, and the proportion of patients with chronic kidney disease accounted for more than 60%, the proportion of patients with atria fibrillation accounted for less than 30%, and the Society of Thoracic Surgeons predicted risk of mortality score was >8 points, patients with PPMI had higher long-term all-cause mortality than those without PPMI. Conclusions. Among the patients who underwent TAVR, those who developed PPMI had higher long-term all-cause mortality.
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Affiliation(s)
- Wentao Chen
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Yilong Han
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Chunlin Wang
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Wenqiang Chen
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
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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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