1
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Symes DG, McNamara LM, Conway C. Computational Investigation of Vessel Injury Due to Catheter Tracking During Transcatheter Aortic Valve Replacement. Ann Biomed Eng 2024; 52:1554-1567. [PMID: 38589731 PMCID: PMC11081929 DOI: 10.1007/s10439-024-03462-8] [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: 07/28/2023] [Accepted: 01/30/2024] [Indexed: 04/10/2024]
Abstract
Catheter reaction forces during transcatheter valve replacement (TAVR) may result in injury to the vessel or plaque rupture, triggering distal embolization or thrombosis. In vitro test methods represent the arterial wall using synthetic proxies to determine catheter reaction forces during tracking, but whether they can account for reaction forces within the compliant aortic wall tissue in vivo is unknown. Moreover, the role of plaque inclusions is not well understood. Computational approaches have predicted the impact of TAVR positioning, migration, and leaflet distortion, but have not yet been applied to investigate aortic wall reaction forces and stresses during catheter tracking. In this study, we investigate the role that catheter design and aorta and plaque mechanical properties have on the risk of plaque rupture during TAVR catheter delivery. We report that, for trackability testing, a rigid test model provides a reasonable estimation of the peak reaction forces experienced during catheter tracking within compliant vessels. We investigated the risk of rupture of both the aortic tissue and calcified plaques. We report that there was no risk of diseased aortic tissue rupture based on an accepted aortic tissue stress threshold (4.2 MPa). However, we report that both the aortic and plaque tissue exceed a rupture stress threshold (300 kPa) with and without the presence of stiff and soft plaque inclusions. We also highlight the potential risks associated with shorter catheter tips during catheter tracking and demonstrate that increasing the contact surface will reduce peak contact pressures experienced in the tissue.
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Affiliation(s)
- David G Symes
- Biomedical Engineering, School of Engineering, College of Science and Engineering, University of Galway, Galway, Ireland
| | - Laoise M McNamara
- Biomedical Engineering, School of Engineering, College of Science and Engineering, University of Galway, Galway, Ireland
| | - Claire Conway
- Department of Anatomy and Regenerative Medicine, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland.
- Trinity Centre for Bioengineering, Trinity College Dublin & RCSI, Dublin, Ireland.
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2
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Xiong T, Chen M. Transcatheter aortic valve replacement: A journey of two decades and beyond. Chin Med J (Engl) 2024; 137:1012-1015. [PMID: 38533588 PMCID: PMC11062698 DOI: 10.1097/cm9.0000000000003082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Indexed: 03/28/2024] Open
Affiliation(s)
- Tianyuan Xiong
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Laboratory of Cardiac Structure and Function, Institute of Cardiovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Laboratory of Cardiac Structure and Function, Institute of Cardiovascular Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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3
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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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4
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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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5
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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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6
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Mangner N, Brinkert M, Keller LS, Moriyama N, Hagemeyer D, Haussig S, Crusius L, Kobza R, Abdel-Wahab M, Laine M, Stortecky S, Pilgrim T, Nietlispach F, Ruschitzka F, Thiele H, Toggweiler S, Linke A. Continued non-vitamin K antagonist oral anticoagulants versus vitamin K antagonists during transcatheter aortic valve implantation. EUROINTERVENTION 2023; 18:e1066-e1076. [PMID: 36440479 PMCID: PMC9909456 DOI: 10.4244/eij-d-22-00521] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/27/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND One-third of patients undergoing transcatheter aortic valve implantation (TAVI) have an indication for long-term oral anticoagulation (OAC). AIMS We aimed to investigate whether continued non-vitamin K antagonist oral anticoagulant (NOAC) therapy compared with continued vitamin K antagonist (VKA) therapy during TAVI is equally safe and effective. Methods: Consecutive patients on OAC with either NOAC or VKA undergoing transfemoral TAVI at five European centres were enrolled. The primary outcome measure was a composite of major/life-threatening bleeding, stroke, and all-cause mortality at 30 days. RESULTS In total, 584 patients underwent TAVI under continued OAC with 294 (50.3%) patients receiving VKA and 290 (49.7%) patients receiving NOAC. At 30 days, the composite primary outcome had occurred in 51 (17.3%) versus 36 (12.4%) patients with continued VKA and with continued NOAC, respectively (odds ratio [OR] 0.68, 95% confidence interval [CI]: 0.43-1.07; p=0.092). Rates of major/life-threatening bleeding (OR 0.87, 95% CI: 0.52-1.47; p=0.606) and stroke (OR 1.02, 95% CI: 0.29-3.59; p=0.974) were not different between groups. In a multivariate Cox regression analysis, continued NOAC, compared with continued VKA, was associated with a lower risk for all-cause 1-year mortality (hazard ratio [HR] 0.61, 95% CI: 0.37-0.98; p=0.043). The analysis of the propensity score-matched cohort revealed similar results. CONCLUSIONS Continued NOAC compared with continued VKA during TAVI led to comparable outcomes with regard to the composite outcome measure indicating that continued OAC with both drugs is feasible. These hypothesis-generating results need to be confirmed by a dedicated randomised controlled trial.
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Affiliation(s)
- Norman Mangner
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Miriam Brinkert
- Division of Cardiology, Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Lukas S Keller
- Quebec Heart and Lung Institute, Laval University, Quebec, QC, Canada
| | - Noriaki Moriyama
- Division of Cardiology, Helsinki University Central Hospital, Helsinki, Finland
- Division of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Daniel Hagemeyer
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Stephan Haussig
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Lisa Crusius
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Richard Kobza
- Heart Center Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Mohamed Abdel-Wahab
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Mika Laine
- Division of Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Stefan Stortecky
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Fabian Nietlispach
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
- CardioVascular Center Zürich, Hirslanden Klinik im Park, Zürich, Switzerland
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | | | - Axel Linke
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
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7
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Xiong TY, Ali WB, Feng Y, Hayashida K, Jilaihawi H, Latib A, Lee MKY, Leon MB, Makkar RR, Modine T, Naber C, Peng Y, Piazza N, Reardon MJ, Redwood S, Seth A, Sondergaard L, Tay E, Tchetche D, Yin WH, Chen M, Prendergast B, Mylotte D. Transcatheter aortic valve implantation in patients with bicuspid valve morphology: a roadmap towards standardization. Nat Rev Cardiol 2023; 20:52-67. [PMID: 35726019 DOI: 10.1038/s41569-022-00734-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 02/08/2023]
Abstract
Indications for transcatheter aortic valve implantation (TAVI) have expanded in many countries to include patients with aortic stenosis who are at low surgical risk, and a similar expansion to this cohort is anticipated elsewhere in the world, together with an increase in the proportion of patients with bicuspid aortic valve (BAV) morphology as the age of the patients being treated decreases. To date, patients with BAV have been excluded from major randomized trials of TAVI owing to anatomical considerations. As a consequence, BAV has been a relative contraindication to the use of TAVI in international guidelines. Although clinical experience and observational data are accumulating, BAV presents numerous anatomical challenges for successful TAVI, despite advances in device design. Furthermore, in those with BAV, substantial geographical variation exists in patient characteristics, clinical approach and procedural strategy. Therefore, in this Roadmap article, we summarize the existing evidence and provide consensus recommendations from an international group of experts on the application of TAVI in patients with BAV in advance of the anticipated growth in the use of this procedure in this challenging cohort of patients.
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Affiliation(s)
- Tian-Yuan Xiong
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | | | - Yuan Feng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | | | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, New York, NY, USA
| | | | - Martin B Leon
- Columbia University Medical Center, New York, NY, USA
| | - Raj R Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Thomas Modine
- Department of Heart Valve Therapy, CHU Bordeaux, Bordeaux, France.,IHU Lyric, Bordeaux-, Pessac, France.,Shanghai Jiaotong University, Shanghai, China
| | - Christoph Naber
- Department of Cardiology, Klinikum Wilhelmshaven, Wilhelmshaven, Germany
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Nicolo Piazza
- Division of Cardiology, Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Michael J Reardon
- Houston Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, TX, USA
| | - Simon Redwood
- Department of Cardiology, St Thomas' Hospital, London, UK
| | - Ashok Seth
- Fortis Escorts Heart Institute, New Delhi, India
| | - Lars Sondergaard
- The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Edgar Tay
- National University Heart Center, National University of Singapore, Singapore, Singapore
| | - Didier Tchetche
- Department of Cardiology, Clinique Pasteur, Toulouse, France
| | - Wei-Hsian Yin
- Heart Center, ChengHsin General Hospital, Taipei, China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China.
| | - Bernard Prendergast
- Department of Cardiology, St Thomas' Hospital, London, UK. .,Cleveland Clinic London, London, UK.
| | - Darren Mylotte
- Department of Cardiology, University Hospital Galway, National University of Ireland, Galway, Ireland.
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8
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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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9
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Jagielak D, Targonski R, Frerker C, Abdel-Wahab M, Wilde J, Werner N, Lauterbach M, Leick J, Grygier M, Misterski M, Erglis A, Narbute I, Witkowski AR, Adam M, Frank D, Gatto F, Schmidt T, Lansky AJ. Safety and performance of a novel cerebral embolic protection device for transcatheter aortic valve implantation: the PROTEMBO C Trial. EUROINTERVENTION 2022; 18:590-597. [PMID: 35608032 PMCID: PMC10241272 DOI: 10.4244/eij-d-22-00238] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/28/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Stroke remains a feared complication associated with transcatheter aortic valve implantation (TAVI). Embolic cerebral injury occurs in the majority of TAVI cases and can lead to cognitive dysfunction. AIMS The PROTEMBO C Trial evaluated the safety and performance of the ProtEmbo Cerebral Protection System in TAVI patients. METHODS Forty-one patients were enrolled in this single-arm study conducted at 8 European centres. The primary safety endpoint was the rate of VARC 2-defined major adverse cardiac and cerebrovascular events (MACCE) at 30 days; the primary performance endpoint was the composite rate of technical success versus performance goals (PG). Secondary endpoints included brain diffusion-weighted magnetic resonance imaging (DW-MRI), new lesion volume, and the rate of death or all strokes compared to historical data. RESULTS Thirty-seven of 41 enrolled patients underwent TAVI with the ProtEmbo device (intention-to-treat [ITT] population). Both primary endpoints were met. MACCE at 30 days was 8.1% (upper limit of the 95% confidence interval [CI]: 21.3% vs PG 25%; p=0.009), and technical success was 94.6% (lower limit of the 95% CI: 82.3% vs PG 75%; p=0.003). New DW-MRI lesion volumes with ProtEmbo were smaller than in historical data, and 87% of patients completing MRI follow-up had no single lesion >150 mm3. There was 1 stroke in a patient in whom the device was removed prematurely before TAVI completion. CONCLUSIONS The PROTEMBO C Trial met its primary safety and performance endpoints compared to prespecified historical PGs. Patients had smaller brain lesion volumes on DW-MRI compared to prior series and no larger single lesions. These results warrant further evaluation of the ProtEmbo in a larger randomised controlled trial (RCT).
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Affiliation(s)
- Dariusz Jagielak
- Department of Cardiac & Vascular Surgery, Uniwersyteckie Centrum Kliniczne, Gdansk, Poland
| | - Radoslaw Targonski
- Department of Cardiac & Vascular Surgery, Uniwersyteckie Centrum Kliniczne, Gdansk, Poland
| | | | | | - Johannes Wilde
- Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Nikos Werner
- Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
| | | | - Juergen Leick
- Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marcin Misterski
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Andrejs Erglis
- Pauls Stradiņš Clinical University Hospital, University of Latvia, Riga, Latvia
| | - Inga Narbute
- Pauls Stradiņš Clinical University Hospital, University of Latvia, Riga, Latvia
| | | | - Matti Adam
- University Hospital Cologne, Cologne, Germany
| | - Derk Frank
- UKSH University Medical Center Schleswig-Holstein, Kiel, Germany
- DZHK Partner Site Hamburg/Kiel/Lübeck, Germany
| | | | | | - Alexandra J Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
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10
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van Ginkel DJ, Bor WL, Veenstra L, van 't Hof AWJ, Fabris E. Evolving concepts in the management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation. Eur J Intern Med 2022; 101:14-20. [PMID: 35623935 DOI: 10.1016/j.ejim.2022.05.002] [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: 03/09/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/22/2022]
Abstract
Thromboembolic and bleeding complications negatively impact recovery and survival after transcatheter aortic valve implantation (TAVI). Particularly, there is a considerable risk of ischaemic stroke and vascular access related bleeding, as well as spontaneous gastro-intestinal bleeding. Therefore, benefit and harm of antithrombotic therapy should be carefully balanced. This review summarizes current evidence on peri- and post-procedural antithrombotic treatment. Indeed, in recent years, the management of antithrombotic therapy after TAVI has evolved from intensive, expert opinion-based strategies, towards a deescalated, evidence-based approach. Besides per procedural administration of unfractionated heparin, this encompasses single antiplatelet therapy in patients without a concomitant indication for oral anticoagulation (OAC); and OAC monotherapy in patients with such indication, mainly being atrial fibrillation. Combination therapy should generally be avoided to reduce bleeding risk, except after recent coronary stenting where a period of dual antiplatelet therapy (aspirin plus P2Y12-inhibitor) or P2Y12-inhibitor plus OAC (in patients with an independent indication for OAC) is recommended to prevent stent thrombosis. This new paradigm in which reduced antithrombotic intensity leads to improved patient safety, without a loss of efficacy, may be particularly suitable for elderly and fragile patients. Whether this holds in upcoming populations of younger and lower-risk patients and in specific populations as patients with subclinical valve thrombosis, is yet to be proven. Finally, whether less intensive or alternative approaches should be also applied for the periprocedural management of the antithrombotic therapy, has to be determined by ongoing and future studies.
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Affiliation(s)
- Dirk Jan van Ginkel
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Willem L Bor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Leo Veenstra
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Arnoud W J van 't Hof
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Enrico Fabris
- Cardiothoracovascular Department, University of Trieste, Trieste, Italy.
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11
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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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12
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Xiong TY, Luo CY, Tang HH, Søndergaard L, Prendergast B, Lui S, Chen M. Novel Neuroimaging Evidence of Brain Lesions Following Transcatheter Aortic Valve Replacement. J Am Heart Assoc 2021; 10:e023395. [PMID: 34845929 PMCID: PMC9075391 DOI: 10.1161/jaha.121.023395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Tian-Yuan Xiong
- Department of Cardiology West China HospitalSichuan University Chengdu China
| | - Chun-Yan Luo
- Functional and Molecular Imaging Key Laboratory of Sichuan Province Department of Radiology Huaxi MR Research Center (HMRRC) West China HospitalSichuan University Chengdu China.,Research Unit of Psychoradiology Chinese Academy of Medical Sciences Chengdu China
| | - He-Han Tang
- Department of Radiology West China HospitalSichuan University Chengdu China
| | - Lars Søndergaard
- The Heart Center Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Bernard Prendergast
- Department of Cardiology St Thomas' Hospital London United Kingdom.,Cleveland Clinic London London United Kingdom
| | - Su Lui
- Functional and Molecular Imaging Key Laboratory of Sichuan Province Department of Radiology Huaxi MR Research Center (HMRRC) West China HospitalSichuan University Chengdu China.,Research Unit of Psychoradiology Chinese Academy of Medical Sciences Chengdu China
| | - Mao Chen
- Department of Cardiology West China HospitalSichuan University Chengdu China
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13
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Stachon P, Kaier K, Heidt T, Wolf D, Duerschmied D, Staudacher D, Zehender M, Bode C, von Zur Mühlen C. The Use and Outcomes of Cerebral Protection Devices for Patients Undergoing Transfemoral Transcatheter Aortic Valve Replacement in Clinical Practice. JACC Cardiovasc Interv 2021; 14:161-168. [PMID: 33478631 DOI: 10.1016/j.jcin.2020.09.047] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/23/2020] [Accepted: 09/29/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES This study hypothesized that cerebral protection prevents strokes in patients undergoing transfemoral transcatheter aortic valve replacement (TAVR) in clinical practice. BACKGROUND Preventing strokes is an important aim in TAVR procedures. Embolic protection devices may protect against cardiac embolism during TAVR, but their use and outcomes in clinical practice remain controversial. METHODS Isolated transfemoral TAVR procedures performed in Germany with or without cerebral protection devices were extracted from a comprehensive nationwide billing dataset. RESULTS A total of 41,654 TAVR procedures performed between 2015 and 2017 were analyzed. The overall share of procedures incorporating cerebral protection devices was 3.8%. Patients receiving cerebral protection devices were at increased operative risk (European System for Cardiac Operative Risk Evaluation score 13.8 vs. 14.7; p < 0.001) but of lower age (81.1 vs. 80.6 years; p = 0.001). To compare outcomes that may be related to the use of cerebral protection devices, a propensity score comparison was performed. The use of a cerebral protection device did not reduce the risk for stroke (adjusted risk difference [aRD]: +0.88%; 95% confidence interval [CI]: -0.07% to 1.83%; p = 0.069) or the risk for developing delirium (aRD: +1.31%; 95% CI: -0.28% to 2.89%; p = 0.106) as a sign of acute brain failure. Although brain damage could not be prevented, in-hospital mortality was lower in the group receiving a cerebral protection device (aRD: -0.76%; 95% CI: -1.46% to -0.06%; p = 0.034). CONCLUSIONS In this large national database, cerebral embolic protection devices were infrequently used during TAVR procedures. Device use was associated with lower mortality but not a reduction in stroke or delirium. Future studies are needed to confirm these findings.
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Affiliation(s)
- Peter Stachon
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Klaus Kaier
- Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Timo Heidt
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dennis Wolf
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid Staudacher
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Mühlen
- University Heart Center Freiburg, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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14
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Sato Y, Kawakami R, Sakamoto A, Cornelissen A, Mori M, Kawai K, Ghosh S, Romero ME, Kolodgie FD, Virmani R, Finn AV. Efficacy and safety of cerebral embolic protection systems during transcatheter aortic valve replacement: a review of current clinical findings. Expert Rev Cardiovasc Ther 2021; 19:725-737. [PMID: 34263701 DOI: 10.1080/14779072.2021.1955346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Cerebrovascular events are one of the most serious consequences after transcatheter aortic valve replacement (TAVR). More than half of the cerebrovascular events following TAVR are due to procedure-related emboli. Embolic protection devices (EPDs) have the potential to decrease cerebrovascular events during TAVR procedure. However, randomized controlled trials (RCTs) have not conclusively determined if EPDs are effective, likely because of small number of patients enrolled. However, meta-analyses and propensity-matched analyses from large registries have shown efficacy and suggest the importance of EPDs in prevention of stroke during TAVR and perhaps other structural heart procedures. AREAS COVERED This review will focus on clinical and histopathologic studies examining the efficacy, safety, and histopathologic device capture findings in the presence and absence of EPDs during TAVR procedures. EXPERT OPINION Clinical studies have not conclusively determined the efficacy of EPDs. Current ongoing large-scale RCT (PROTECTED TAVR [NCT04149535]) has the potential to prove their efficacy. Histopathological evaluation of debris captured by EPDs contributes to our understanding of the mechanisms of TAVR procedure-related embolic events and suggests the importance of preventing cerebral embolization of debris released during this and other structural heart procedures.
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Affiliation(s)
- Yu Sato
- CVPath Institute, Gaithersburg, MD, USA
| | | | | | | | | | | | | | | | | | | | - Aloke V Finn
- CVPath Institute, Gaithersburg, MD, USA.,University of Maryland, School of Medicine, Baltimore, MD, USA
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15
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Katayama T, Yokoyama N, Watanabe Y, Takahashi S, Hioki H, Kawasugi K, Kozuma K. Blood Coagulation Changes With or Without Direct Oral Anticoagulant Therapy Following Transcatheter Aortic Valve Implantation. Am J Cardiol 2021; 147:88-93. [PMID: 33617810 DOI: 10.1016/j.amjcard.2021.01.042] [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] [Received: 12/07/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
Thromboembolic events remain clinically unresolved after transcatheter aortic valve implantation (TAVI). The use of direct oral anticoagulant (DOAC) to reduce thrombosis associated with TAVI remains controversial. This study aimed at investigating the periprocedural change in blood coagulation and thrombolysis parameters in 199 patients undergoing transfemoral TAVI. Prothrombin activation fragment 1 + 2 (F1 + 2), thrombin-antithrombin complex (TAT), soluble fibrin monomer complex (SFMC), and fibrin/fibrinogen degradation product (FDP) levels were measured before and 1 hour after TAVI and 1, 2, and 7 days postoperatively. Of the 199 patients, 49 were treated with DOAC (apixaban in 32, edoxaban in 10, and rivaroxaban in 7). The F1 + 2 and TAT levels immediately increased 1 hour after TAVI and then gradually decreased in both groups. The SFMC level also significantly increased with a peak on day 1. The FDP level gradually increased, peaking on day 2. The values of F1 + 2, TAT, SFMC, and FDP in patients who used DOAC were significantly lower than those who did not use DOAC at 1 hour after TAVI in F1 + 2 (600 [452 to 765] vs 1055 [812 to 1340] pmol/L; p < 0.001), TAT (21.4 [16.2 to 37.0] vs 38.7 [26.4 to 58.7] μg/mL; p < 0.001) and on day 1 in SFMC (18.2 [9.4 to 57.9] vs 113.4 [70.9 to 157.3] μg/mL; p < 0.001) and day 2 in FDP (6.0 [4.7 to 10.0] vs 12.6 [8.2 to 17.4] μg/mL; p < 0.001). Ischemic stroke within 30 days after TAVI occurred in 3 patients (1.5%), who were not treated with DOAC. Coagulation cascade activation was observed after TAVI. DOAC could reduce transient hypercoagulation following TAVI.
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16
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Macherey S, Meertens M, Mauri V, Frerker C, Adam M, Baldus S, Schmidt T. Meta-Analysis of Stroke and Mortality Rates in Patients Undergoing Valve-in-Valve Transcatheter Aortic Valve Replacement. J Am Heart Assoc 2021; 10:e019512. [PMID: 33682426 PMCID: PMC8174195 DOI: 10.1161/jaha.120.019512] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background During the past decade, the use of transcatheter aortic valve replacement (TAVR) was extended beyond treatment‐naïve patients and implemented for treatment of degenerated surgical bioprosthetic valves. Selection criteria for either valve‐in‐valve (viv) TAVR or redo surgical aortic valve replacement are not well established, and decision making on the operative approach still remains challenging for the interdisciplinary heart team. Methods and Results This review was intended to analyze all studies on viv‐TAVR focusing on short‐ and mid‐term stroke and mortality rates compared with redo surgical aortic valve replacement or native TAVR procedures. A structured literature search and review process led to 1667 potentially relevant studies on July 1, 2020. Finally, 23 studies fulfilled the inclusion criteria for qualitative analysis. All references were case series either with or without propensity score matching and registry analyses. Quantitative synthesis of data from 8509 patients revealed that viv‐TAVR is associated with mean 30‐day stroke and mortality rates of 2.2% and 4.2%, respectively. Pooled data analysis showed no significant differences in 30‐day stroke rate, 30‐day mortality, and 1‐year mortality between viv‐TAVR and comparator treatment (native TAVR [n=11 804 patients] or redo surgical aortic valve replacement [n=498 patients]). Conclusions This review is the first one comparing the risk for stroke and mortality rates in viv‐TAVR procedures with native TAVR approach and contributes substantial data for the clinical routine. Moreover, this systematic review is the most comprehensive analysis on ischemic cerebrovascular events and early mortality in patients undergoing viv‐TAVR. In this era with increasing numbers of bioprosthetic valves used in younger patients, viv‐TAVR is a suitable option for the treatment of degenerated bioprostheses.
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Affiliation(s)
- Sascha Macherey
- Department III of Internal Medicine University Hospital of Cologne Cologne Germany
| | - Max Meertens
- Department III of Internal Medicine University Hospital of Cologne Cologne Germany
| | - Victor Mauri
- Department III of Internal Medicine University Hospital of Cologne Cologne Germany
| | - Christian Frerker
- Department III of Internal Medicine University Hospital of Cologne Cologne Germany
| | - Matti Adam
- Department III of Internal Medicine University Hospital of Cologne Cologne Germany
| | - Stephan Baldus
- Department III of Internal Medicine University Hospital of Cologne Cologne Germany
| | - Tobias Schmidt
- Department III of Internal Medicine University Hospital of Cologne Cologne Germany
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17
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Brain Injury After Transcatheter Replacement of Bicuspid Versus Tricuspid Aortic Valves. J Am Coll Cardiol 2021; 76:2579-2590. [PMID: 33243378 DOI: 10.1016/j.jacc.2020.09.605] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND An increasing number of bicuspid aortic valve (BAV) patients are undergoing transcatheter aortic valve replacement (TAVR), but the risk of brain injury in diffusion-weighted magnetic resonance imaging (DW-MRI) is currently unknown. OBJECTIVES This study sought to evaluate the risk of brain injury in BAV patients following TAVR. METHODS A total of 204 consecutive severe aortic stenosis patients who underwent TAVR were enrolled. A total of 83 (40.7%) patients were BAV patients, and the other 121 patients were tricuspid aortic valve (TAV) patients. All patients received DW-MRI at baseline, and after TAVR. RESULTS Median ages (76 years [interquartile range (IQR): 71 to 81 years] vs. 79 years [IQR: 74 to 83 years]; p = 0.004) and Society of Thoracic Surgeons scores (4.87 [IQR: 3.72 to 8.54] vs. 6.38 [IQR: 3.96 to 9.50]; p = 0.044) of the BAV and TAV patients were significantly different, while the overt stroke rates (2.4% vs. 1.7%; p = 0.704) were comparable between the 2 groups. BAV patients were associated with higher number of new lesions (4.0 [IQR: 1.0 to 8.0] vs. 2.0 [IQR: 1.0 to 5.0]; p = 0.008), total lesion volume (290 mm3 [IQR: 70 to 930 mm3] vs. 140 mm3 [IQR: 35 to 480 mm3]; p = 0.008), and the volume per lesion (70.0 mm3 [IQR: 45.0 to 115.0 mm3] vs. 57.5 mm3 [IQR: 24.5 to 93.0 mm3]; p = 0.037) in DW-MRI. Moreover, the proportion of patients with lesions larger than 1 cm3 (28.6% vs. 10.9%; p = 0.005) was higher in BAV patients than in TAV patients. CONCLUSIONS BAV patients may encounter more severe brain injuries not only due to greater number of lesions, but also due to larger lesion size in the early phase after TAVR. (Transcatheter Aortic Valve Replacement Single Center Registry in Chinese Population [TORCH]; NCT02803294).
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18
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Bagur R, Sposato L. Cerebral embolic protection during TAVI: the game is not over. EUROINTERVENTION 2021; 16:1123-1125. [PMID: 33605879 PMCID: PMC9707453 DOI: 10.4244/eijv16i14a201] [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: 11/23/2022]
Affiliation(s)
- Rodrigo Bagur
- Division of Cardiology, University Hospital, London Health Sciences Centre, 339 Windermere Road, University Hospital, London, ON N6A 5A5, Canada
| | - Luciano Sposato
- Department of Clinical Neurological Sciences, Stroke, Dementia & Heart Disease Laboratory, London Health Sciences Centre, Western University, London, ON, Canada
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19
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Kroon H, von der Thusen J, Ziviello F, van Wiechen M, Ooms JF, Kardys I, Schipper M, van Gils L, Daemen J, de Jaegere PP, Van Mieghem NM. Heterogeneity of debris captured by cerebral embolic protection filters during TAVI. EUROINTERVENTION 2021; 16:1141-1147. [PMID: 32894232 PMCID: PMC9724925 DOI: 10.4244/eij-d-20-00744] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to investigate the total amount, size and heterogeneity of debris captured among different transcatheter valve types and while repositioning. METHODS AND RESULTS A total of 328 patients who underwent transcatheter aortic valve implantation (TAVI) with the SENTINEL cerebral embolic protection (CEP) at our centre were eligible. Histopathological and semiquantitative analysis of captured debris was performed and data were entered into our prospective database. TAVI was performed with either the Evolut R/PRO (N=123), SAPIEN 3 (N=113) or Lotus valve (N=92). Capture of debris occurred in 98% of patients. Lotus TAVI resulted in more frequent foreign body material (62% vs 40% vs 47%, p=0.006), endothelium (49% vs 30% vs 16%, p<0.0005), calcified material (33% vs 12% vs 24%, p=0.001) and myocardial tissue (19% vs 11% vs 2%, p<0.0005) compared to SAPIEN 3 or Evolut R/PRO. Native (functional) bicuspid valves (OR 2.91, 95% CI: 1.20-7.03, p=0.02) and Lotus (OR 2.44, 95% CI: 1.14-5.24, p=0.02) were associated with the highest risk for dislodging particles ≥1,000 um. Valve repositioning was independently associated with larger amounts of debris (OR 2.96, 95% CI: 1.42-6.16, p=0.004). CONCLUSIONS All THV platforms had similar amounts of captured debris. THV repositioning seemed to be associated with a higher risk for dislodging greater amounts of debris to the brain.
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Affiliation(s)
- Herbert Kroon
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jan von der Thusen
- Department of Pathology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Francesca Ziviello
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Maarten van Wiechen
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Joris F. Ooms
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Isabella Kardys
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Lennart van Gils
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Peter P. de Jaegere
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Nicolas M. Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Room NT-645, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
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Brinkert M, Mangner N, Moriyama N, Keller LS, Hagemeyer D, Crusius L, Lehnick D, Kobza R, Abdel-Wahab M, Laine M, Stortecky S, Pilgrim T, Nietlispach F, Ruschitzka F, Thiele H, Linke A, Toggweiler S. Safety and Efficacy of Transcatheter Aortic Valve Replacement With Continuation of Vitamin K Antagonists or Direct Oral Anticoagulants. JACC Cardiovasc Interv 2020; 14:135-144. [PMID: 33358653 DOI: 10.1016/j.jcin.2020.09.062] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study investigated whether transcatheter aortic valve replacement (TAVR) with peri-procedural continuation of oral anticoagulation is equally safe and efficacious as TAVR with peri-procedural interruption of anticoagulation. BACKGROUND A significant proportion of patients undergoing TAVR have an indication for long-term oral anticoagulation. The optimal peri-procedural management of such patients is unknown. METHODS Consecutive patients on oral anticoagulation who underwent transfemoral TAVR at 5 European centers were enrolled. Oral anticoagulation was either stopped 2 to 4 days before TAVR or continued throughout the procedure. Primary safety outcome was major bleeding. Secondary efficacy endpoints included vascular complications, stroke, and mortality. RESULTS Of 4,459 patients, 584 patients were treated with continuation of anticoagulation and 733 with interruption of anticoagulation. At 30 days, major or life-threatening bleedings occurred in 66 (11.3%) versus 105 (14.3%; odds ratio [OR]: 0.86; 95% confidence interval [CI]: 0.61 to 1.21; p = 0.39) and major vascular complications in 64 (11.0%) versus 90 (12.3%; OR: 0.89; CI: 0.62 to 1.27; p = 0.52) of patients with continuation and with interruption of anticoagulation, respectively. Transfusion of packed red blood cells was less often required in patients with continuation of anticoagulation (80 [13.7%] vs. 130 [17.7%]; OR: 0.59; 95% CI: 0.42 to 0.81; p = 0.001). Kaplan-Meier estimates of survival at 12 months were 85.3% in patients with continuation of anticoagulation and 84.0% in patients with interruption of anticoagulation (hazard ratio: 0.90; 95% CI: 0.73 to 1.12; p = 0.36). CONCLUSIONS Continuation of oral anticoagulation throughout TAVR did not increase bleeding or vascular complication rates. Moreover, packed red blood cell transfusions were less often required in patients with continuation of oral anticoagulation.
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Affiliation(s)
- Miriam Brinkert
- Heart Center Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Norman Mangner
- Heart Center Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
| | - Noriaki Moriyama
- Division of Cardiology of the Helsinki University Central Hospital, Helsinki, Finland
| | - Lukas S Keller
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Hagemeyer
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Lisa Crusius
- Heart Center Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
| | - Dirk Lehnick
- Clinical Trial Unit, Biostatistics and Methodology, University Lucerne, Lucerne, Switzerland
| | - Richard Kobza
- Heart Center Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Mohamed Abdel-Wahab
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Department of Internal Medicine/Cardiology, Leipzig, Germany
| | - Mika Laine
- Division of Cardiology of the Helsinki University Central Hospital, Helsinki, Finland
| | - Stefan Stortecky
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Fabian Nietlispach
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland; CardioVascularCenter Zurich, Hirslanden Clinic im Park, Zurich, Switzerland
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Department of Internal Medicine/Cardiology, Leipzig, Germany
| | - Axel Linke
- Heart Center Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
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Meta-analysis Comparing Outcomes of Self-Expanding Versus Balloon-Expandable Valves for Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 128:202-209. [PMID: 32534734 DOI: 10.1016/j.amjcard.2020.05.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/03/2020] [Accepted: 05/05/2020] [Indexed: 01/08/2023]
Abstract
There are two commercially available transcatheter heart valve systems: balloon expandable valves (BEV) and self-expanding valves (SEV). However, there is a paucity of randomized trials comparing both systems. Electronic databases (Medline, the Cochrane Library, Web of Science, and clinicaltrials.gov) and major conference proceedings were searched for randomized trials of patients with symptomatic severe aortic stenosis and received transcatheter aortic valve implantation (TAVI) with a SEV or BEV or surgical aortic valve replacement. The main efficacy outcomes were all-cause mortality and stroke at the longest available follow-up. The main analysis was performed using a random-effects network meta-analysis complemented by several subgroup and sensitivity analyses. Ten trials with 9,439 patients (mostly undergoing transfemoral TAVI) were included. At a median of 27 months, there was no difference between BEV and SEV valves in terms of all-cause mortality (odds ratio [OR] 1.05, 95% confidence interval [CI] 0.79 to 1.42). The incidence of any stroke was higher with BEV (OR 1.51, 95% CI 1.01 to 2.26), but there was no difference in the incidence of disabling stroke. At 30-days, BEV valves were associated with lower incidence of new permanent pacemaker placement (OR 0.50, 95% CI 0.32 to 0.79) and moderate/severe paravalvular regurgitation (OR 0.39, 95% CI 0.22 to 0.68). In conclusion, in patients with severe symptomatic aortic stenosis undergoing transfemoral TAVI, SEV and BEV were associated with similar all-cause mortality. BEV were associated with a higher incidence of any stroke driven by nondisabling strokes, but lower incidence of new permanent pacemaker placement and moderate/severe paravalvular regurgitation compared with SEV.
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Insights on Embolic Protection, Repositioning, and Stroke: A Subanalysis of the RESPOND Study. J Interv Cardiol 2020; 2020:3070427. [PMID: 32518532 PMCID: PMC7251468 DOI: 10.1155/2020/3070427] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 03/12/2020] [Indexed: 11/21/2022] Open
Abstract
RESPOND is a prospective, single-arm study enrolling 1014 transcatheter aortic valve replacement (TAVR) patients. The objective of this analysis is to assess the impact of cerebral embolic protection (CEP) devices and prosthetic valve repositioning on the risk of neurologic complications in patients treated with the fully repositionable Lotus Valve in the RESPOND postmarket study. Valve repositioning and CEP use were at the operators' discretion. Stroke events were adjudicated by an independent medical reviewer. This analysis assessed the baseline differences among patients according to CEP use and valve repositioning and evaluated the neurological complications at 72 hours after TAVR, hospital discharge, and 30-day follow-up. A multivariate analysis was performed to identify the potential predictors of stroke. Of the 996 patients implanted with the Lotus Valve (mean age: 80.8 years, 50.8% female, STS score 6.0 ± 6.9), 92 cases (9.2%) used CEP. The overall rate of acute stroke/transient ischemic attack (TIA) was 3.0% at 72 hours after TAVR. The 72-hour stroke/TIA rate was 1.1% in patients who had CEP and 3.2% in those who did not. Use of CEP was associated with a 2.1% absolute reduction in the risk of acute neurological events (relative risk reduction: 65.6%), although the difference was not statistically significant (p=0.51). Repositioning of the Lotus Valve occurred in 313/996 procedures (31.4%). The 72-hour rate of stroke/TIA was similar in patients who had valve repositioning (2.9%) compared with those who did not (3.1%; p=0.86). The selective use of a CEP device in the RESPOND study was associated with a nonsignificantly lower risk for stroke within 72 hours. The use of the repositioning feature of the Lotus Valve did not increase the stroke risk.
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Clinical Outcomes of Sentinel Cerebral Protection System Use During Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:717-722. [DOI: 10.1016/j.carrev.2019.04.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 04/11/2019] [Accepted: 04/19/2019] [Indexed: 11/21/2022]
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Stachel G, Woitek FJ, Crusius L, Haussig S, Kiefer P, Leontyev S, Schlotter F, Spindler A, Höllriegel R, Hommel J, Borger MA, Thiele H, Holzhey D, Linke A, Mangner N. Left-Atrial Appendage Thrombosis in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation. Can J Cardiol 2020; 37:450-457. [PMID: 32450289 DOI: 10.1016/j.cjca.2020.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/25/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Data about the impact of left-atrial appendage thrombosis (LAAT) on early safety and mortality in patients undergoing transfemoral transcatheter aortic valve implantation (TF-TAVI) are scarce. We aimed to investigate the prevalence and predictors of LAAT and the outcome associated with this condition in patients treated by TF-TAVI. METHODS Retrospective data analysis was derived from a prospective single-centre registry comparing patients with and without LAAT regarding early safety at 30 days, according to Valve Academic Research Consortium-2 (VARC-2) and 2-year mortality. RESULTS LAAT was found in 7.6% of the whole cohort (n = 2527) and in 16.6% in those patients with known pre-existing atrial fibrillation (AF cohort, n = 1099). Compared with controls, patients with LAAT were sicker, indicated by a higher Society of Thoracic Surgeons (STS) score and burden of comorbidities. Neither VARC-2-defined early safety at 30 days nor the rate of stroke was different between LAAT and controls in both the whole (early safety: 29.2% vs 24.2%, P = 0.123; stroke: 5.9% vs 4.7%, P = 0.495) and AF cohort (early safety: 29.1% vs 22.9%, P = 0.072; stroke: 5.6% vs 3.3%, P = 0.142). Evaluating the whole cohort in a univariate analysis, the 2-year mortality was significantly higher in LAAT compared with controls (hazard ratio, 1.41; 95% confidence interval, 1.07-1.86; P = 0.014). However, multivariate analysis of the whole cohort and the AF cohort revealed no association between LAAT and 2-year mortality. CONCLUSIONS LAAT was frequent in patients undergoing TF-TAVI- in particular, in patients with histories of AF-but it was not associated with an increase in periprocedural complications and did not predict 2-year mortality.
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Affiliation(s)
- Georg Stachel
- Heart Center Leipzig at the University of Leipzig, Department of Cardiology, Leipzig, Germany
| | - Felix J Woitek
- Herzzentrum Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
| | - Lisa Crusius
- Heart Center Leipzig at the University of Leipzig, Department of Cardiology, Leipzig, Germany
| | - Stephan Haussig
- Herzzentrum Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
| | - Philipp Kiefer
- Heart Center Leipzig-University Hospital, Department of Cardiac Surgery, Leipzig, Germany
| | - Sergey Leontyev
- Heart Center Leipzig-University Hospital, Department of Cardiac Surgery, Leipzig, Germany
| | - Florian Schlotter
- Heart Center Leipzig at the University of Leipzig, Department of Cardiology, Leipzig, Germany
| | - Aileen Spindler
- Heart Center Leipzig at the University of Leipzig, Department of Cardiology, Leipzig, Germany
| | - Robert Höllriegel
- Herzzentrum Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
| | - Jennifer Hommel
- Herzzentrum Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
| | - Michael A Borger
- Heart Center Leipzig-University Hospital, Department of Cardiac Surgery, Leipzig, Germany
| | - Holger Thiele
- Heart Center Leipzig at the University of Leipzig, Department of Cardiology, Leipzig, Germany
| | - David Holzhey
- Heart Center Leipzig-University Hospital, Department of Cardiac Surgery, Leipzig, Germany
| | - Axel Linke
- Herzzentrum Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
| | - Norman Mangner
- Herzzentrum Dresden, Technische Universität Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany.
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Braghiroli J, Kapoor K, Thielhelm TP, Ferreira T, Cohen MG. Transcatheter aortic valve replacement in low risk patients: a review of PARTNER 3 and Evolut low risk trials. Cardiovasc Diagn Ther 2020; 10:59-71. [PMID: 32175228 DOI: 10.21037/cdt.2019.09.12] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) has become a mainstay in treatment for patients with severe aortic stenosis who are considered high-risk surgical candidates. The use of TAVR in low-risk patients with severe aortic stenosis is being explored as an alternative to surgical aortic valve replacement (SAVR). Recent results from the Medtronic Evolut Low Risk trial and the Placement of Aortic Transcatheter Valves (PARTNER) 3 trial shed light on the use of TAVR in low-risk surgical candidates. The Evolut Low Risk trial compared TAVR with a self-expanding supra-annular bioprosthesis to SAVR in 1468 patients with severe aortic stenosis who were low surgical risk. Patients with a mean age of 74 and a mean Society of Thoracic Surgeons (STS) risk score of 1.9% were randomized to either TAVR or SAVR groups. Using the composite end point of death or disabling stroke at 24 months, the study found an incidence of 5.3% in the TAVR arm and 6.7% in the surgical arm. The Evolut Low Risk trial thus concluded that TAVR was statistically noninferior but not superior to SAVR (difference, -1.4 percentage points; 95% Bayesian credible interval for the difference, -4.9 to 2.1; posterior probability of noninferiority, >0.999). The PARTNER 3 trial assigned 1,000 patients with severe aortic stenosis and low surgical risk to either TAVR with transfemoral placement of balloon expandable valve or SAVR. Patients with a mean age of 73 and a mean STS score of 1.9% were randomized to either TAVR or SAVR groups. With respect to the primary endpoint of composite death from any cause, stroke, or rehospitalization, the study found an occurrence of 8.5% in TAVR and 15.1% in SAVR, confirming both noninferiority and superiority in the TAVR group [absolute difference, -6.6 percentage points; 95% confidence interval (CI), -10.8 to -2.5; P<0.001 for noninferiority; hazard ratio, 0.54; 95% CI, 0.37 to 0.79; P=0.001 for superiority]. Both the Evolut low risk trial and the PARTNER 3 trial provide evidence that the use of TAVR extends beyond the scope of high and intermediate risk surgical patients and is at the very least equivalent to SAVR in the treatment low-risk surgical candidates when using a transfemoral approach in patients without bicuspid aortic valves. In this article we provide an extensive review on the Evolute low risk and PARTNER 3 trials, including a discussion on clinically relevant outcomes.
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Affiliation(s)
- Joao Braghiroli
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospitals and Clinics, Miami, Florida, USA
| | - Kunal Kapoor
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospitals and Clinics, Miami, Florida, USA
| | - Torin P Thielhelm
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospitals and Clinics, Miami, Florida, USA
| | - Tanira Ferreira
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospitals and Clinics, Miami, Florida, USA
| | - Mauricio G Cohen
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine and the Elaine and Sydney Sussman Cardiac Catheterization Laboratory, University of Miami Hospitals and Clinics, Miami, Florida, USA
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van Gils L, Van Mieghem NM. Transcatheter Aortic Valve Replacement with the Lotus Valve: Concept and Current State of the Data. Interv Cardiol Clin 2019; 8:393-402. [PMID: 31445723 DOI: 10.1016/j.iccl.2019.06.002] [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: 11/30/2022]
Abstract
Multiple transcatheter heart valve iterations have created an interesting range of options with which to perform transcatheter aortic valve replacement. The Lotus valve has several attractive features. The ability to eradicate even mild paravalvular leak mirrors the outcomes of surgical aortic valve replacement. New design iterations of the Lotus valve and refined sizing algorithms may help mitigate the need for permanent pacemaker implantation and consolidate its best-in-class results in terms of paravalvular leak. Ongoing trials should help define the safety and efficacy of the Lotus transcatheter heart valve in contemporary practice.
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Affiliation(s)
- Lennart van Gils
- Department of Interventional Cardiology, Thoraxcenter, ErasmusMC, Room Rg-628, 's Gravendijkwal 230, Rotterdam 3015 CE, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, ErasmusMC, Room Rg-628, 's Gravendijkwal 230, Rotterdam 3015 CE, The Netherlands.
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27
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Mehta RI, Rai AT, Vos JA, Solis OE, Mehta RI. Intrathrombus polymer coating deposition: a pilot study of 91 patients undergoing endovascular therapy for acute large vessel stroke. Part I: Histologic frequency. J Neurointerv Surg 2019; 11:1191-1196. [PMID: 31103995 PMCID: PMC6902067 DOI: 10.1136/neurintsurg-2018-014684] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/07/2019] [Accepted: 04/09/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Polymer coating embolism due to vascular medical device use is an increasingly recognized iatrogenic complication. This phenomenon has been linked with various adverse effects including neuroinflammation, acute ischemic stroke, cerebral hemorrhage, and death. Notably, procedure- and device-specific risks of this complication are poorly investigated. In this study, we evaluate the detectable frequency of intra-arterial polymer coating delamination among patients who underwent endovascular thrombectomy for treatment of acute ischemic stroke due to large vessel occlusion. METHODS Ninety-two cerebral thrombectomy specimens were retrospectively analyzed for the presence of polymer coating particulates. Histologic findings were correlated with demographic and procedural details and patient outcomes. RESULTS Evidence of polymer coating deposition was found in 30 of 92 extracted thrombi (33%). No correlation between intrathrombus polymer deposition and use of a specific thrombectomy device such as a stent retriever, aspiration catheter, or guide catheter was found. However, heterogeneous patterns of device use suggest a number of culprit devices. A trend toward longer procedure times and multiple thrombectomy passes was noted in positive cases. Intrathrombus polymer deposition was not associated with adverse clinical outcomes as measured by the 90-day modified Rankin Scale (mRS); however, small sample size and follow-up intervals limit interpretation. Ninety-day outcomes based on mRS may not fully capture the clinical effects of acute and/or delayed intracerebral polymer complications. CONCLUSION In light of documented adverse neurologic effects, the frequency of intrathrombus polymer particulates indicates the need for consensus testing methods and large-scale long-term prospective clinical device trials, with inclusion of relevant endpoints to better assess biomaterial and device risks to patients.
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Affiliation(s)
- Rashi I Mehta
- Department of Radiology, West Virginia University, Morgantown, West Virginia, USA
| | - Ansaar T Rai
- Department of Neurointerventional Radiology, West Virginia University, Morgantown, West Virginia, USA
| | - Jeffrey A Vos
- Department of Pathology, West Virginia University, Morgantown, West Virginia, USA
| | - Orestes E Solis
- Department of Pathology and Laboratory Medicine, University of Rochester, Rochester, New York, USA
| | - Rupal I Mehta
- Department of Pathology and Laboratory Medicine, University of Rochester, Rochester, New York, USA.,Department of Neuroscience, University of Rochester, Rochester, NY, USA
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Gasior T, Mangner N, Bijoch J, Wojakowski W. Cerebral embolic protection systems for transcatheter aortic valve replacement. J Interv Cardiol 2018; 31:891-898. [PMID: 30467892 DOI: 10.1111/joic.12573] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/08/2018] [Accepted: 10/12/2018] [Indexed: 11/29/2022] Open
Abstract
In the recent years, ischemic brain injury related to embolization after transcatheter aortic valve replacement (TAVR) has received increased attention as new embolic protection strategies emerged to protect the brain. Diverse cerebral protection devices have been developed to reduce cerebral embolization during TAVR. These devices work through various mechanisms and are in different stages of clinical translation. This review provides the evidence-based review of peri-procedural stroke prevention during TAVR and summarizes currently available cerebral embolic protection devices.
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Affiliation(s)
- Tomasz Gasior
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Norman Mangner
- Technical University of Dresden, Heart Center Dresden, Department of Internal Medicine and Cardiology, Dresden, Germany
| | - Julia Bijoch
- SMDZ in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
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30
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Tchetche D, de Biase C. Embolic Events Post-Transcatheter Aortic Valve Replacement: Time to Protect the Brain. JACC Cardiovasc Interv 2018; 11:1694-1695. [PMID: 30154061 DOI: 10.1016/j.jcin.2018.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 07/16/2018] [Indexed: 11/19/2022]
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Moliterno DJ. Year 1: A Short Look Back and a Long Look Forward. JACC Cardiovasc Interv 2018; 11:1793-1795. [PMID: 30190073 DOI: 10.1016/j.jcin.2018.08.001] [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: 10/28/2022]
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