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Haum M, Steffen J, Sadoni S, Theiss H, Stark K, Estner H, Massberg S, Deseive S, Lackermair K. Pacing Using Cardiac Implantable Electric Device During TAVR: 10-Year Experience of a High-Volume Center. JACC Cardiovasc Interv 2024; 17:1020-1028. [PMID: 38658116 DOI: 10.1016/j.jcin.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is an effective and safe therapy for severe aortic stenosis. Rapid or fast pacing is required for implantation, which can be performed via a pre-existing cardiac implantable electric device (CIED). However, safety data on CIEDs for pacing in TAVR are missing. OBJECTIVES The aim of this study was to elucidate procedural safety and feasibility of internal pacing with a CIED in TAVR. METHODS Patients undergoing TAVR with a CIED were included in this analysis. Baseline characteristics, procedural details, and complications according to Valve Academic Research Consortium 3 (VARC-3) criteria after TAVR were compared between both groups. RESULTS A total of 486 patients were included. Pacing was performed using a CIED in 150 patients and a transient pacemaker in 336 patients. No differences in technical success according to VARC-3 criteria or procedure duration occurred between the groups. The usage of transient pacers for pacing was associated with a significantly higher bleeding rate (bleeding type ≥2 according to VARC-3-criteria; 2.0% vs 13.1%; P < 0.01). Furthermore, impairment of the CIED appeared in 2.3% of patients after TAVR only in the group in which pacing was performed by a transient pacer, leading to surgical revision of the CIED in 1.3% of all patients when transient pacemakers were used. CONCLUSIONS Internal pacing using a CIED is safe and feasible without differences of procedural time and technical success and might reduce bleeding rates. Furthermore, pacing using a CIED circumvents the risk of lead dislocation. Our data provide an urgent call for the use of a CIED for pacing during a TAVR procedure in general.
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Affiliation(s)
- Magda Haum
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany; German Centre for Cardiovascular Research (DZHK), Munich, Germany.
| | - Julius Steffen
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany; German Centre for Cardiovascular Research (DZHK), Munich, Germany
| | - Sebastian Sadoni
- Department of Cardiac Surgery, University Hospital Munich, Ludwig Maximilians University, Munich, Germany
| | - Hans Theiss
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany; German Centre for Cardiovascular Research (DZHK), Munich, Germany
| | - Konstantin Stark
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany; German Centre for Cardiovascular Research (DZHK), Munich, Germany
| | - Heidi Estner
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany; German Centre for Cardiovascular Research (DZHK), Munich, Germany
| | - Steffen Massberg
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany; German Centre for Cardiovascular Research (DZHK), Munich, Germany
| | - Simon Deseive
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany
| | - Korbinian Lackermair
- Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Munich, Germany
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Schenk J, Kho E, Rellum S, Kromhout J, Vlaar APJ, Baan J, van Mourik MS, Jorstad HT, van der Ster BJP, Westerhof BE, Bruns S, Immink RV, Vis MM, Veelo DP. Immediate reduction in left ventricular ejection time following TAVI is associated with improved quality of life. Front Cardiovasc Med 2022; 9:988840. [PMID: 36187009 PMCID: PMC9523106 DOI: 10.3389/fcvm.2022.988840] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTAVI has shown to result in immediate and sustained hemodynamic alterations and improvement in health-related quality of life (HRQoL), but previous studies have been suboptimal to predict who might benefit from TAVI. The relationship between immediate hemodynamic changes and outcome has not been studied before. This study sought to assess whether an immediate hemodynamic change, reflecting myocardial contractile reserve, following TAVI is associated with improved HRQoL. Furthermore, it assessed whether pre-procedural cardiac power index (CPI) and left ventricular ejection fraction (LVEF) could predict these changes.MethodsDuring the TAVI procedure, blood pressure and systemic hemodynamics were prospectively collected with a Nexfin® non-invasive monitor. HRQoL was evaluated pre-procedurally and 12 weeks after the procedure, using the EQ-5D-5L classification tool.ResultsOverall, 97/114 (85%) of the included patients were eligible for analyses. Systolic, diastolic and mean arterial pressure, heart rate, and stroke volume increased immediately after TAVI (all p < 0.005), and left ventricular ejection time (LVET) immediately decreased with 10 ms (95%CI = −4 to −16, p < 0.001). Overall HRQoLindex increased from 0.810 [0.662–0.914] before to 0.887 [0.718–0.953] after TAVI (p = 0.016). An immediate decrease in LVET was associated with an increase in HRQoLindex (0.02 index points per 10 ms LVET decrease, p = 0.041). Pre-procedural CPI and LVEF did not predict hemodynamic changes or change in HRQoL.ConclusionTAVI resulted in an immediate hemodynamic response and increase in HRQoL. Immediate reduction in LVET, suggesting unloading of the ventricle, was associated with an increase in HRQoL, but neither pre-procedural CPI nor LVEF predicted these changes.Clinical trial registrationhttps://clinicaltrials.gov/ct2/show/NCT03088787
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Affiliation(s)
- Jimmy Schenk
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- *Correspondence: Jimmy Schenk
| | - Eline Kho
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Santino Rellum
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Joris Kromhout
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Alexander P. J. Vlaar
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Jan Baan
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Martijn S. van Mourik
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Harald T. Jorstad
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Björn J. P. van der Ster
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Berend E. Westerhof
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
- Department of Perinatology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, Netherlands
| | - Steffen Bruns
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Rogier V. Immink
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Marije M. Vis
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | - Denise P. Veelo
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
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Alkhalil M, Jabri A, Puri R, Kalra A. Revascularization in the Transcatheter Aortic Valve Replacement Population. Interv Cardiol Clin 2021; 10:553-563. [PMID: 34593117 DOI: 10.1016/j.iccl.2021.06.003] [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: 11/26/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) is a standard treatment option for patients with severe aortic stenosis. Management of concomitant coronary artery disease (CAD) in these patients remains controversial with no randomized clinical trials to guide decision making in this cohort. The role of CAD in TAVR has been difficult to evaluate given the current heterogeneity in defining CAD, and the used methods to assess CAD. Subsequently, the role of coronary revascularization remains individualized and assessed on a case-by-case basis by the heart team. In this article, the authors discuss the rationale and prognostic role of CAD in patients undergoing TAVR.
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Affiliation(s)
- Mohammad Alkhalil
- Department of Cardiothoracic Services, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, UK; Vascular Biology, Newcastle University, Newcastle-upon-Tyne NE7 7DN, UK
| | - Ahmad Jabri
- Case Western Reserve University/MetroHealth Medical Center, Cleveland, OH 44109, USA
| | - Rishi Puri
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Ankur Kalra
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA; Section of Cardiovascular Research, Heart, Vascular, and Thoracic Department, Cleveland Clinic Akron General, Akron, OH, USA; Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 224 West Exchange Street, Suite 225, Akron, OH 44302, USA.
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4
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Beska B, Manoharan D, Mohammed A, Das R, Edwards R, Zaman A, Alkhalil M. Role of coronary angiogram before transcatheter aortic valve implantation. World J Cardiol 2021; 13:361-371. [PMID: 34589171 PMCID: PMC8436680 DOI: 10.4330/wjc.v13.i8.361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/26/2021] [Accepted: 07/16/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation (TAVI). Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes, challenging the clinical value of routine coronary angiogram (CA).
AIM To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.
METHODS This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI. A selective approach for performing CA tailored to patient clinical need was developed. Clinical outcomes were compared based on whether patients underwent CA. The primary endpoint was a composite of all-cause mortality, myocardial infraction, repeat CA, and re-admission with heart failure.
RESULTS Of 348 patients (average age 81 ± 7 and 57% male) were included with a median follow up of 19 (9-31) mo. One hundred and fifty-four (44%) patients, underwent CA before TAVI procedure. Patients who underwent CA were more likely to have previous myocardial infarction (MI) and previous percutaneous revascularisation. The primary endpoint was comparable between the two group (22.6% vs 22.2%; hazard ratio 1.05, 95%CI: 0.67-1.64, P = 0.82). Patients who had CA were less likely to be readmitted with heart failure (P = 0.022), but more likely to have repeat CA (P = 0.002) and MI (P = 0.007). In those who underwent CA, the presence of flow limiting lesions did not affect the incidence of primary endpoint, or its components, except for increased rate of repeat CA.
CONCLUSION Selective CA is a feasible and safe approach. The clinical value of routine CA should be challenged in future randomised trials
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Affiliation(s)
- Benjamin Beska
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
| | - Divya Manoharan
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
| | - Ashfaq Mohammed
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
| | - Rajiv Das
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
| | - Richard Edwards
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
| | - Azfar Zaman
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
| | - Mohammad Alkhalil
- Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne NE7 7DN, United Kingdom
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5
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Role of coronary angiogram before transcatheter aortic valve implantation. World J Cardiol 2021. [DOI: 10.4330/wjc.v13.i8.362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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6
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Veulemans V, Maier O, Piayda K, Berning KL, Binnebößel S, Polzin A, Afzal S, Dannenberg L, Horn P, Jung C, Westenfeld R, Kelm M, Zeus T. Factors associated with a high or low implantation of self-expanding devices in TAVR. Clin Res Cardiol 2021; 110:1930-1938. [PMID: 34165599 PMCID: PMC8639548 DOI: 10.1007/s00392-021-01901-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/21/2021] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Optimizing valve implantation depth (ID) plays a crucial role in minimizing conduction disturbances and achieving optimal functional integrity. Until now, the impact of intraprocedural fast (FP) or rapid ventricular pacing (RP) on the implantation depth has not been investigated. Therefore, we aimed to (1) evaluate the impact of different pacing maneuvers on ID, and (2) identify the independent predictors of deep ID. METHODS 473 TAVR patients with newer-generation self-expanding devices were retrospectively enrolled and one-to-one propensity-score-matching was performed, resulting in a matching of 189 FP and RP patients in each cohort. The final ID was analyzed, and the underlying functional, anatomical, and procedural conditions were evaluated by univariate and multivariate analysis. RESULTS The highest ID was reached under RP in severe aortic valve calcification and valve size 26 mm. Multivariate analysis identified left ventricular outflow (LVOT) calcification [OR 0.50 (0.31-0.81) p = 0.005*], a "flare" aortic root [OR 0.42 (0.25-0.71), p = 0.001*], and RP (OR 0.49 [0.30-0.79], p = 0.004*) as independent highly preventable predictors of a deep ID. In a model of protective factors, ID was significantly reduced with the number of protective criteria (0-2 criteria: - 5.7 mm ± 2.6 vs. 3-4 criteria - 4.3 mm ± 2.0; p < 0.0001*). CONCLUSION Data from this retrospective analysis indicate that RP is an independent predictor to reach a higher implantation depth using self-expanding devices. Randomized studies should prove for validation compared to fast and non-pacing maneuvers during valve delivery and their impact on implantation depth. TRAIL REGISTRATION Clinical Trial registration: NCT01805739. STUDY DESIGN Evaluation of the impact of different pacing maneuvers (fast ventricular pacing-FP vs. rapid ventricular pacing-RP) on implantation depth (ID). After one-to-one-propensity-score-matching, independent protective and risk factors for a very deep ID beneath 6 mm toward the LVOT (< - 6 mm) were identified. Stent frame pictures as a courtesy by Medtronic®. AVC aortic valve calcification.
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Affiliation(s)
- Verena Veulemans
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Oliver Maier
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Kerstin Piayda
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Kira Lisanne Berning
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Stephan Binnebößel
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Amin Polzin
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Shazia Afzal
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Lisa Dannenberg
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Patrick Horn
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany.,CARID (Cardiovascular Research Institute Düsseldorf), Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Tobias Zeus
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Düsseldorf, Germany
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7
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Safety and feasibility of retrograde INOUE-BALLOON for balloon aortic valvuloplasty without rapid ventricular pacing during transcatheter aortic valve replacement. Cardiovasc Interv Ther 2021; 37:372-380. [PMID: 34110610 PMCID: PMC8927037 DOI: 10.1007/s12928-021-00789-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 06/03/2021] [Indexed: 11/21/2022]
Abstract
Rapid ventricular pacing (RVP) is commonly employed during transcatheter aortic valve replacement (TAVR); however, frequent TAVR is associated with worse prognoses. The retrograde INOUE-BALLOON® (IB) allows balloon aortic valvuloplasty (BAV) without RVP. The aim of this study was to evaluate the feasibility of retrograde IB for TAVR preparation. The study population included 178 consecutive patients (mean age, 84 ± 5 years; male, 47%) who underwent retrograde BAV before prosthetic valve replacement via the transfemoral approach. Patients were divided into a retrograde IB group without RVP (n = 74) and a conventional balloon (CB) group with RVP (n = 104). The primary endpoint was prolonged hypotension after BAV (reduced systolic pressure < 80 mmHg for over 1 min or vasopressor drug requirement). The incidence of prolonged hypotension after BAV was significantly lower in the IB group compared with the CB group (4% vs. 16%, p = 0.011). Balloons were able to penetrate and expand the aortic valve in both groups. RVP was used less for total TAVR in the IB group compared with the CB group. The aortic valve area-index after BAV was not significantly different between the two groups (0.72 ± 0.14 cm2/m2 vs. 0.71 ± 0.12 cm2/m2; p = 0.856). Multivariate analysis demonstrated that IB use was associated with avoidance of prolonged hypotension (OR, 0.27 [0.059–0.952]; p = 0.041). In conclusion, BAV using retrograde IB without RVP is both safe and feasible. More stable hemodynamics were achieved using retrograde IB by avoiding RVP during TAVR.
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8
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Delgado V, Kumbhani DJ. Cardiac and Vascular Changes After Transcatheter or Surgical Aortic Valve Replacement in Low-Risk Aortic Stenosis. Circulation 2020; 141:1538-1540. [PMID: 32392101 DOI: 10.1161/circulationaha.120.046693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, The Netherlands (V.D.)
| | - Dharam J Kumbhani
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.J.K.)
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9
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Michail M, Hughes AD, Comella A, Cameron JN, Gooley RP, McCormick LM, Mathur A, Parker KH, Brown AJ, Cameron JD. Acute Effects of Transcatheter Aortic Valve Replacement on Central Aortic Hemodynamics in Patients With Severe Aortic Stenosis. Hypertension 2020; 75:1557-1564. [PMID: 32306768 DOI: 10.1161/hypertensionaha.119.14385] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Severe aortic stenosis induces abnormalities in central aortic pressure, with consequent impaired organ and tissue perfusion. Relief of aortic stenosis by transcatheter aortic valve replacement (TAVR) is associated with both a short- and long-term hypertensive response. Counterintuitively, patients who are long-term normotensive post-TAVR have a worsened prognosis compared with patients with hypertension, yet the underlying mechanisms are not understood. We investigated immediate changes in invasively measured left ventricular and central aortic pressure post-TAVR in patients with severe aortic stenosis using aortic reservoir pressure, wave intensity analysis, and indices of aortic function. Fifty-four patients (mean age 83.6±6.2 years, 50.0% female) undergoing TAVR were included. We performed reservoir pressure and wave intensity analysis on invasively acquired pressure waveforms from the ascending aorta and left ventricle immediately pre- and post-TAVR. Following TAVR, there were increases in systolic, diastolic, mean, and pulse aortic pressures (all P<0.05). Post-TAVR reservoir pressure was unchanged (54.5±12.4 versus 56.6±14.0 mm Hg, P=0.30) whereas excess pressure increased 47% (29.0±10.9 versus 42.6±15.5 mm Hg, P<0.001). Wave intensity analysis (arbitrary units, au) demonstrated increased forward compression wave (64.9±35.5 versus 124.4±58.9, ×103 au, P<0.001), backward compression wave (11.6±5.5 versus 14.4±6.9, ×103 au, P=0.01) and forward expansion wave energies (43.2±27.3 versus 82.8±53.1, ×103 au, P<0.001). Subendocardial viability ratio improved with aortic function effectively unchanged post-TAVR. Increased central aortic pressure following TAVR relates to increased transmitted power and energy to the proximal aorta with increased excess pressure but unchanged reservoir pressure. These changes provide a potential mechanism for the improved prognosis associated with relative hypertension post-TAVR.
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Affiliation(s)
- Michael Michail
- From the Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia (M.M., A.C., R.G., L.M.M., A.J.B., J.D.C.).,Institute of Cardiovascular Science, University College London, United Kingdom (M.M., A.D.H., A.M.)
| | - Alun D Hughes
- Institute of Cardiovascular Science, University College London, United Kingdom (M.M., A.D.H., A.M.)
| | - Andrea Comella
- From the Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia (M.M., A.C., R.G., L.M.M., A.J.B., J.D.C.)
| | - James N Cameron
- St George's Hospital Medical School, London, United Kingdom (J.N.C.)
| | - Robert P Gooley
- From the Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia (M.M., A.C., R.G., L.M.M., A.J.B., J.D.C.)
| | - Liam M McCormick
- From the Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia (M.M., A.C., R.G., L.M.M., A.J.B., J.D.C.)
| | - Anthony Mathur
- Institute of Cardiovascular Science, University College London, United Kingdom (M.M., A.D.H., A.M.).,Centre for Cardiovascular Medicine and Device Innovation, Queen Mary University of London, United Kingdom (A.M.)
| | - Kim H Parker
- Department of Bioengineering, Imperial College, London, United Kingdom (K.M.P.)
| | - Adam J Brown
- From the Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia (M.M., A.C., R.G., L.M.M., A.J.B., J.D.C.)
| | - James D Cameron
- From the Monash Cardiovascular Research Centre and MonashHeart, Monash University and Monash Health, Melbourne, Australia (M.M., A.C., R.G., L.M.M., A.J.B., J.D.C.)
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10
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Sato T, Aizawa Y, Yuasa S, Taya Y, Fujita S, Ikeda Y, Kitazawa H, Takahashi M, Okabe M. The Determinants and Outcomes of Myocardial Injury After Transcatheter Aortic-Valve Implantation: SAPIEN 3 Study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:973-979. [PMID: 31924486 DOI: 10.1016/j.carrev.2019.12.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/29/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The effect of myocardial injury (MI) post-transcatheter aortic valve implantation (TAVI) on clinical outcomes is controversial. This study aimed to evaluate the effect of MI severity on clinical outcome and left ventricle function 30 days post-TAVI and determine MI post-TAVI predictors. METHODS Overall, 138 consecutive patients who underwent successful transfemoral TAVI using SAPIEN3 and diagnosed using echocardiography and computed tomography were analyzed. High-sensitivity cardiac troponin T (TnT) was evaluated at baseline, immediately, and at 24, 48, and 72 h post-TAVI. Echocardiography findings and N-terminal pro-B-type natriuretic peptide (Nt-pro BNP) levels were evaluated 30 days post-TAVI. RESULTS Mean age and STS score were 84.4 ± 3.5 years and 6.4 ± 3.2%, respectively. All cases showed severe aortic valve stenosis. Peri-procedural MI was observed in 48 of 100 patients (48.0%). Patients were grouped into MI (n = 48) and non-MI (n = 52), without significant difference in characteristics. Pre-balloon aortic valvuloplasty rate and total pacing time were significantly higher in MI vs non-MI. Total rapid pacing time (TRPT) was an independent predictor for MI (OR 1.06; 95% CI 1.01-1.16; p = 0.04). Echocardiography and Nt-pro BNP changes 30 days post-TAVI were similar between groups. CONCLUSION Peri-procedural MI, assessed by TnT changes, was observed in 48% of patients. The MI was not associated with overt cardiac dysfunction, and the recovery of left ventricular function and Nt-pro BNP level occurred similarly by 30 day post-TAVI between both groups. In multivariate analysis, TRPT was associated with MI after SAPIEN3 implantation. TRIAL REGISTRATION NUMBER UMIN000036669.
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Affiliation(s)
- Takao Sato
- Tachikawa General Hospital, Cardiology, Nagaoka, Japan.
| | | | - Sho Yuasa
- Tachikawa General Hospital, Cardiology, Nagaoka, Japan
| | - Yuji Taya
- Tachikawa General Hospital, Cardiology, Nagaoka, Japan
| | | | - Yoshio Ikeda
- Tachikawa General Hospital, Cardiology, Nagaoka, Japan
| | | | | | - Masaaki Okabe
- Tachikawa General Hospital, Cardiology, Nagaoka, Japan
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11
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Abstract
Regulation of coronary blood flow is maintained through a delicate balance of ventriculoarterial and neurohumoral mechanisms. The aortic valve is integral to the functions of these systems, and disease states that compromise aortic valve integrity have the potential to seriously disrupt coronary blood flow. Aortic stenosis (AS) is the most common cause of valvular heart disease requiring medical intervention, and the prevalence and associated socio-economic burden of AS are set to increase with population ageing. Valvular stenosis precipitates a cascade of structural, microcirculatory, and neurohumoral changes, which all lead to impairment of coronary flow reserve and myocardial ischaemia even in the absence of notable coronary stenosis. Coronary physiology can potentially be normalized through interventions that relieve severe AS, but normality is often not immediately achievable and probably requires continued adaptation. Finally, the physiological assessment of coronary artery disease in patients with AS represents an ongoing challenge, as the invasive physiological measures used in current cardiology practice are yet to be validated in this population. This Review discusses the key concepts of coronary pathophysiology in patients with AS through presentation of contemporary basic science and data from animal and human studies.
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Broyd CJ, Rigo F, Nijjer S, Sen S, Petraco R, Al-Lamee R, Foin N, Chukwuemeka A, Anderson J, Parker J, Malik IS, Mikhail GW, Francis DP, Parker K, Hughes AD, Mayet J, Davies JE. Regression of left ventricular hypertrophy provides an additive physiological benefit following treatment of aortic stenosis: Insights from serial coronary wave intensity analysis. Acta Physiol (Oxf) 2018; 224:e13109. [PMID: 29935058 DOI: 10.1111/apha.13109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 01/10/2023]
Abstract
AIM Severe aortic stenosis frequently involves the development of left ventricular hypertrophy (LVH) creating a dichotomous haemodynamic state within the coronary circulation. Whilst the increased force of ventricular contraction enhances its resultant relaxation and thus increases the distal diastolic coronary "suction" force, the presence of LVH has a potentially opposing effect on ventricular-coronary interplay. The aim of this study was to use non-invasive coronary wave intensity analysis (WIA) to separate and measure the sequential effects of outflow tract obstruction relief and then LVH regression following intervention for aortic stenosis. METHODS Fifteen patients with unobstructed coronary arteries undergoing aortic valve intervention (11 surgical aortic valve replacement [SAVR], 4 TAVI) were successfully assessed before and after intervention, and at 6 and 12 months post-procedure. Coronary WIA was constructed from simultaneously acquired coronary flow from transthoracic echo and pressure from an oscillometric brachial cuff system. RESULTS Immediately following intervention, a decline in the backward decompression wave (BDW) was noted (9.7 ± 5.7 vs 5.1 ± 3.6 × 103 W/m2 /s, P < 0.01). Over 12 months, LV mass index fell from 114 ± 19 to 82 ± 17 kg/m2 . Accompanying this, the BDW fraction increased to 32.8 ± 7.2% at 6 months (P = 0.01 vs post-procedure) and 34.7 ± 6.7% at 12 months (P < 0.001 vs post-procedure). CONCLUSION In aortic stenosis, both the outflow tract gradient and the presence of LVH impact significantly on coronary haemodynamics that cannot be appreciated by examining resting coronary flow rates alone. An immediate change in coronary wave intensity occurs following intervention with further effects appreciable with hypertrophy regression. The improvement in prognosis with treatment is likely to be attributable to both features.
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Affiliation(s)
| | - Fausto Rigo
- Division of Cardiology; dell'Angelo Hospital; Mestre-Venice Italy
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13
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Fefer P, Bogdan A, Grossman Y, Berkovitch A, Brodov Y, Kuperstein R, Segev A, Guetta V, Barbash IM. Impact of Rapid Ventricular Pacing on Outcome After Transcatheter Aortic Valve Replacement. J Am Heart Assoc 2018; 7:JAHA.118.009038. [PMID: 29987119 PMCID: PMC6064853 DOI: 10.1161/jaha.118.009038] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Rapid ventricular pacing (RVP) is used commonly during transcatheter aortic valve replacement (TAVR). Little is known about the safety and clinical consequences of this step. The aim of this study was to assess the impact of RVP on immediate and long‐term clinical outcomes in a large cohort of non‐selected TAVR patients. Method and Results The study included 412 consecutive patients undergoing TAVR with a mean age of 82±7 years, of which 47% were male. Patients were divided according to the number of RVPs during the TAVR procedure comparing patients undergoing no pacing (0), 1 to 2, and ≥3 pacing episodes (3+). Patients undergoing 3+ pacing episodes were significantly more likely to develop new atrial fibrillation (5.6% versus 7.3% versus 15%, respectively, for 0, 1–2, and 3+ groups, P=0.047), acute kidney injury (AKI) (18% versus 18% versus 28%, respectively, P<0.001), prolonged procedural hypotension (0%, 16%, and 25%, respectively; P<0.001), and suffered greater in‐hospital mortality (1.7%, 1.7%, and 6.5%, respectively, P=0.045), and 1‐year mortality (11.1%, 7.7%, and 18%, respectively, P=0.015). Multivariate Cox regression analysis indicated that acute kidney injury (OR 3.27 [1.763–6.09], P<0.001), euroSCORE II (OR 1.06 per unit [1.01–1.12], P=0.03), and 3+ pacing episodes (OR 2.35 [1.18–4.7], P=0.02) were the only independent predictors for 1‐year mortality. Conclusions In patients undergoing TAVR, multiple RVP episodes and prolonged RVP duration are associated with adverse outcomes including short‐ and long‐term mortality. Thus, operators should attempt to minimize the use of RVP, especially in patients who are at risk for post‐procedural acute kidney injury.
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Affiliation(s)
- Paul Fefer
- Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andrada Bogdan
- Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoni Grossman
- Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Berkovitch
- Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yafim Brodov
- Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rafael Kuperstein
- Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Segev
- Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Victor Guetta
- Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Israel M Barbash
- Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Right ventricular systolic function in patients undergoing transcatheter aortic valve implantation: A systematic review and meta-analysis. Int J Cardiol 2018; 257:40-45. [DOI: 10.1016/j.ijcard.2018.01.117] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/15/2018] [Accepted: 01/26/2018] [Indexed: 11/15/2022]
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