Transcatheter aortic valve implantation leads to a restoration of von Willebrand factor (VWF) abnormalities in patients with severe aortic stenosis – Incidence and relevance of clinical and subclinical VWF dysfunction in patients undergoing transfemoral TAVI

Translating proof-of-concept for platelet slip into improved antithrombotic therapeutic regimens

Platelets are central to thrombosis. Research at the intersection of biological and physical sciences provides proof-of-concept for shear rate-dependent platelet slip at vascular stenosis and near device surfaces. Platelet slip extends the observed biological "slip-bonds" to the boundary of functional gliding without contact. As a result, there is diminished engagement of the coagulation cascade by platelets at these surfaces. Comprehending platelet slip would more precisely direct antithrombotic regimens for different shear environments, including for percutaneous coronary intervention (PCI). In this brief report we promote translation of the proof-of-concept for platelet slip into improved antithrombotic regimens by: (1) reviewing new supporting basic biological science and clinical research for platelet slip; (2) hypothesizing the principal variables that affect platelet slip; (3) applying the consequent construct model in support of-and in some cases to challenge-relevant contemporary guidelines and their foundations (including for urgent, higher-risk PCI); and (4) suggesting future research pathways (both basic and clinical). Should future research demonstrate, explain and control platelet slip, then a paradigm shift for choosing and recommending antithrombotic regimens based on predicted shear rate should follow. Improved clinical outcomes with decreased complications accompanying this paradigm shift for higher-risk PCI would also result in substantive cost savings.

Defining high bleeding risk in patients undergoing transcatheter aortic valve implantation: a VARC-HBR consensus document

The identification and management of patients at high bleeding risk (HBR) undergoing transcatheter aortic valve implantation (TAVI) are of major importance, but the lack of standardised definitions is challenging for trial design, data interpretation, and clinical decision-making. The Valve Academic Research Consortium for High Bleeding Risk (VARC-HBR) is a collaboration among leading research organisations, regulatory authorities, and physician-scientists from Europe, the USA, and Asia, with a major focus on TAVI-related bleeding. VARC-HBR is an initiative of the CERC (Cardiovascular European Research Center), aiming to develop a consensus definition of TAVI patients at HBR, based on a systematic review of the available evidence, to provide consistency for future clinical trials, clinical decision-making, and regulatory review. This document represents the first pragmatic approach to a consistent definition of HBR evaluating the safety and effectiveness of procedures, devices and drug regimens for patients undergoing TAVI..

Heyde's syndrome: a challenging case of severe aortic stenosis and gastrointestinal bleeding

We present the case of an elderly man with a history of diastolic congestive heart failure, severe aortic stenosis and atrial fibrillation, who presented with fatigue, weakness, coffee ground emesis and black tarry stool. Haemoglobin was 68 g/L. Lactate dehydrogenase was elevated at 1038. Evaluation by cardiology and gastroenterology specialists revealed reflux oesophagitis and a mild hiatal hernia on oesophagogastroduodenoscopy, normal colonoscopy and small bowel series without obstruction. Capsule endoscopy identified angiodysplasia in the small intestine.The patient was diagnosed with Heyde's syndrome based on the triad of severe aortic stenosis, gastrointestinal bleeding from angiodysplasia and acquired von Willebrand syndrome. The patient underwent transcatheter aortic valve replacement, resulting in the resolution of symptoms.Heyde's syndrome represents a challenging clinical entity requiring a multidisciplinary approach for accurate diagnosis and management. Early recognition, prompt intervention and interdisciplinary collaboration are crucial in optimising patient outcomes.

A Propensity-Matched National Analysis of Transcatheter Aortic Valve Implantation Outcome in Patients With Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding is often observed in severe aortic stenosis, which can be attributed to the presence of arteriovenous malformations and von Willebrand's factor deficiency. GI is one of the most common complications in patients who underwent transcatheter aortic valve implantation (TAVI). The outcome of the TAVI procedure with GI bleeding is unknown. We performed an International Classification of Diseases, Tenth Revision-based national cohort analysis using the national readmission database from 2016 to 2020. We compared cardiovascular outcomes, mortality, and readmission rates of patients with TAVI who developed GI bleeding compared with those who had no GI bleeding. A total of 320,353 hospitalizations with TAVI were identified from the year 2016 to 2020. Patients with TAVI with GI bleeding were 6,193.37 and without GI bleeding were 314,160. The median age of the patients with TAVI with GI or without GI bleeding was 80. GI bleed patients had statistically significantly higher readmission rates at 30, 90, and 180 days and they had higher odds of in-hospital mortality (adjusted odds ratio [aOR] = 6.35; 95% confidence interval [CI]: 5.37 to 7.52; p <0.0001), acute kidney injury (aOR = 5.22; 95% CI:4.75 to 5.74; p <0.0001), stroke (aOR = 2.83; 95% CI 2.05 to 3.91 p:0.0001, postprocedural bleeding (aOR: 1.76; 95% CI: 1.35 to 2.30; p:0.0001), cardiac tamponade (aOR = 2.54; 95% CI 1.86 to 3.49; p <0.0001), use of mechanical circulatory support (aOR: 5.33; 95% CI:4.13 to 6.86; p <0.0001), and heart failure (aOR:1.73; 95%CI: 1.54 to 1.94; p <0.0001). The total cost of hospitalization and length of stay was higher in the GI bleed group. Patients with TAVI with GI bleeding have worse clinical outcomes and higher in-hospital mortality and readmission rates compared with patients with no GI bleeding.

Influence of Aortic Valve Stenosis and Wall Shear Stress on Platelets Function

Aortic valve stenosis (AS) is a common heart valve disease in the elderly population, and its pathogenesis remains an interesting area of research. The degeneration of the aortic valve leaflets gradually progresses to valve sclerosis. The advanced phase is marked by the presence of extracellular fibrosis and calcification. Turbulent, accelerated blood flow generated by the stenotic valve causes excessive damage to the aortic wall. Elevated shear stress due to AS leads to the degradation of high-molecular weight multimers of von Willebrand factor, which may involve bleeding in the mucosal tissues. Conversely, elevated shear stress has been associated with the release of thrombin and the activation of platelets, even in individuals with acquired von Willebrand syndrome. Moreover, turbulent blood flow in the aorta may activate the endothelium and promote platelet adhesion and activation on the aortic valve surface. Platelets release a wide range of mediators, including lysophosphatidic acid, which have pro-osteogenic effects in AS. All of these interactions result in blood coagulation, fibrinolysis, and the hemostatic process. This review summarizes the current knowledge on high shear stress-induced hemostatic disorders, the influence of AS on platelets and antiplatelet therapy.

Impact of transcatheter aortic valve implantation on circulating von Willebrand factor in patients with severe aortic stenosis

INTRODUCTION

Severe aortic stenosis (AS) can lead to degradation of high molecular weight (HMW) von Willebrand factor (VWF) which can result in haemostatic abnormalities. While studies have explored changes in VWF profiles before and after surgical aortic valve replacement (SAVR), the longer-term changes in VWF profiles pre- and post-transcatheter aortic valve implantation (TAVI) are less understood.

AIM

Our primary objective was to identify differences in VWF multimer profiles and VWF function pre-TAVI and 1-month post-TAVI. Our secondary objective was to correlate VWF markers with measures of AS severity.

METHODS

Adult patients with severe AS referred for TAVI at our institution were prospectively enrolled in this cohort study. Blood samples were collected for plasma analysis at three time points for all patients: 1 day pre-TAVI, 3 days post-TAVI, and 1-month post-TAVI. VWF antigen, activity, propeptide, collagen binding, multimers, and factor VIII coagulant activity were determined at each time point. Correlations between VWF parameters and severity of AS were assessed.

RESULTS

Twenty participants (15 males, five females) with severe AS were recruited for the study. There was a significant increase in HMW VWF between pre-procedure and 1-month post-TAVI (p < .05). There was a transient increase in VWF antigen levels and activity at 3-days post TAVI that decreased to pre-TAVI levels at 1-month. There were no statistically significant correlations between VWF markers and AS severity.

CONCLUSIONS

This is the first study to elucidate longer-term (>1 week) improvements in HMW VWF after a TAVI procedure in severe AS patients.

Effectiveness of aortic valve replacement in Heyde syndrome: a meta-analysis

AIMS

Heyde syndrome is the co-occurrence of aortic stenosis, acquired von Willebrand syndrome, and gastrointestinal bleeding. Aortic valve replacement has been demonstrated to resolve all three associated disorders. A systematic review and meta-analysis were performed to obtain best estimates of the effect of aortic valve replacement on acquired von Willebrand syndrome and gastrointestinal bleeding.

METHODS AND RESULTS

A literature search was performed to identify articles on Heyde syndrome and aortic valve replacement up to 25 October 2022. Primary outcomes were the proportion of patients with recovery of acquired von Willebrand syndrome within 24 h (T1), 24-72 h (T2), 3-21 days (T3), and 4 weeks to 2 years (T4) after aortic valve replacement and the proportion of patients with cessation of gastrointestinal bleeding. Pooled proportions and risk ratios were calculated using random-effects models. Thirty-three studies (32 observational studies and one randomized controlled trial) on acquired von Willebrand syndrome (n = 1054), and 11 observational studies on gastrointestinal bleeding (n = 300) were identified. One study reported on both associated disorders (n = 6). The pooled proportion of Heyde patients with acquired von Willebrand syndrome recovery was 86% (95% CI, 79%-91%) at T1, 90% (74%-96%) at T2, 92% (84%-96%) at T3, and 87% (67%-96%) at T4. The pooled proportion of Heyde patients with gastrointestinal bleeding cessation was 73% (62%-81%). Residual aortic valve disease was associated with lower recovery rates of acquired von Willebrand syndrome (RR 0.20; 0.05-0.72; P = 0.014) and gastrointestinal bleeding (RR 0.57; 0.40-0.81; P = 0.002).

CONCLUSION

Aortic valve replacement is associated with rapid recovery of the bleeding diathesis in Heyde syndrome and gastrointestinal bleeding cessation. Residual valve disease compromises clinical benefits.

Gastrointestinal bleeding during the transcatheter aortic valve replacement perioperative period: A Review

With the aging of the population, the incidence of senile degenerative valvular heart disease is expected to increase. Transcatheter aortic valve replacement (TAVR) has been used for patients at lower surgical risk with symptomatic severe aortic valve stenosis. Because of the improvements in TAVR technology and increasing experience of the operators, TAVR is regarded as a safe and feasible procedure. Bleeding events during the TAVR perioperative period, especially gastrointestinal (GI) bleeding, have been proven to be related to the long-term prognosis and mortality. Elderly patients with valvular heart disease are susceptible to GI bleeding because of their use of antithrombotic drugs, physical damage of coagulation factors, and GI angiodysplasia. Frequent GI bleeding and low levels of preoperative hemoglobin increase the risk of TAVR, especially for elderly patients. Because of these risks, which are easily overlooked, we should focus more attention on the perioperative management of TAVR. Reasonable screening tools, including blood examinations, risk evaluation scales, and endoscopy, are beneficial to the prevention of complications that can occur during the perioperative period. Additionally, medical therapy can safely help patients at high-risk for bleeding patients throughout the perioperative period. This study aimed to characterize the pathology of TAVR patients and discuss treatment strategies for GI bleeding during the perioperative period.

The search for optimal antithrombotic therapy in transcatheter aortic valve implantation: facts and uncertainties

Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure, which is used frequently in patients with symptomatic severe aortic valve stenosis. Most patients undergoing TAVI are over 80 years of age with a high bleeding as well as thrombotic risk. Despite the increasing safety of the procedure, thromboembolic events [stroke, (subclinical) valve thrombosis] remain prevalent. As a consequence, antithrombotic prophylaxis is routinely used and only recently new data on the efficacy and safety of antithrombotic drugs has become available. On the other hand, these antithrombotic drugs increase bleeding in a population with unique aortic stenosis-related bleeding characteristics (such as acquired von Willebrand factor defect and angiodysplasia). In this review, we discuss the impact of thromboembolic and bleeding events, the current optimal antithrombotic therapy based on registries and recent randomized controlled trials, as well as try to give a practical guide how to treat these high-risk patients. Finally, we discuss knowledge gaps and future research needed to fill these gaps.

Multimodal Treatment and Diagnostic Modalities in the Setting of Heyde’s Syndrome: A Systematic Review

Heyde’s syndrome encompasses the triad of aortic stenosis (AS), angiodysplasia, and acquired Von Willebrand's disease (aVWD). The disease itself is a rare association that affects a small subset of patients who suffer from aortic stenosis. Nonetheless, it represents a vital area of clinical interest and is woefully underreported in the literature. Patients with Heyde’s syndrome develop gastrointestinal bleeding (GI) as a result of angiodysplasia and due to lack of adequate hemostasis, they tend to be positively predisposed toward developing gastrointestinal hemorrhage. Due to the glaring lack of comprehensive literature on Heyde's syndrome, this systematic review aims to bridge the gap by elucidating the various diagnostic and treatment options available to clinicians for Heyde’s syndrome patients as well as to give a detailed account of the pathophysiology of the disease.

This systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Google Scholar, Gulf Medical University (GMU) e-library, and PubMed were thoroughly searched for studies done in the last 10 years, which corresponds with our outlined inclusion and exclusion criteria. Relevant studies were then selected on the basis of their abstracts and titles. These studies then underwent a comprehensive quality assessment in which any papers which did not meet this study’s eligibility criteria were omitted. Overall, 18 studies fulfilled the criteria of this systematic review.

The impact of bicuspid aortic valve morphology on von Willebrand factor function in patients with severe aortic stenosis and its change after TAVI

BACKGROUND

Aortic stenosis (AS) can cause acquired von Willebrand syndrome (AVWS) and valve replacement has been shown to lead to von Willebrand factor (vWF) recovery. The aim of the current study was to investigate the prevalence of AVWS in different severe AS phenotypes and its course after transcatheter aortic valve implantation (TAVI).

METHODS

143 patients with severe AS undergoing TAVI were included in the study. vWF function was assessed at baseline, 6 and 24 h after TAVI. AVWS was defined as a reduced vWF:Ac/Ag ratio ≤ 0.7. Phenotypes were classified by tricuspid (TAV) and bicuspid (BAV) valve morphology, mean transvalvular gradient (P_mean), stroke volume index (SVI), ejection fraction (EF) and indexed effective orifice area (iEOA).

RESULTS

AVWS was present in 36 (25.2%) patients before TAVI. vWF:Ac/Ag ratio was significantly lower in high gradient compared to low-gradient severe AS [0.78 (IQR 0.67-0.86) vs. 0.83 (IQR 0.74-0.93), p < 0.05] and in patients with BAV compared to TAV [0.70 (IQR 0.63-0.78) vs. 0.81 (IQR 0.71-0.89), p < 0.05]. Normalization of vWF:Ac/Ag ratio was achieved in 61% patients 24 h after TAVI. As in the overall study cohort, vWF:Ac/Ag ratio increased significantly in all severe AS subgroups 6 h after TAVI (each p < 0.05). Regarding binary logistic regression analysis, BAV was the only significant predictor for AVWS.

CONCLUSIONS

BAV morphology is a strong predictor for AVWS in severe AS. TAVI restores vWF function in most patients with severe AS independently of AS phenotype and valve morphology.

Reduction of Gastrointestinal Bleeding in Patients With Heyde Syndrome Undergoing Transcatheter Aortic Valve Implantation

BACKGROUND

Heyde syndrome is the co-occurrence of aortic stenosis and gastrointestinal bleeding secondary to angiodysplasias. Surgical aortic valve replacement effectively reduces bleeding, but the effects of transcatheter aortic valve implantation (TAVI) are largely unknown. This study aimed to describe the reduction of gastrointestinal bleeding in patients with Heyde syndrome after TAVI and to identify the factors associated with rebleeding.

METHODS

We enrolled patients with Heyde syndrome from a prospective TAVI registry. Gastrointestinal bleeding episodes were assessed by the Bleeding Academic Research Consortium classification, and cumulative incidence functions were used to calculate cessation rates. Factors potentially associated with rebleeding were analyzed using logistic regression. Differences between Heyde and non-Heyde patients were assessed through a case-cohort study.

RESULTS

Between December 2008 and June 2020, 1111 patients underwent TAVI. There were 70 patients with Heyde syndrome (6.3%). In the first year following TAVI, gastrointestinal bleeding ceased in 46 of 70 patients (62% [95% CI, 50%-74%]). Bleeding episodes decreased from 3.2 (95% CI, 2.5-4.2) to 1.6 ([95% CI, 1.2-2.2] P=0.001) and hemoglobin levels increased from 10.3 (95% CI, 10.0-10.8) to 11.3 (95% CI, 10.8-11.6) g/dL (P=0.007). Between 1 and 5 years after TAVI (35 [interquartile range, 21-51] months), 53 of 62 patients (83% [95% CI, 72%-92%]) no longer experienced gastrointestinal bleeding. Paravalvular leakage (≥mild) was associated with rebleeding risk (odds ratio, 3.65 [95% CI, 1.36-9.80]; P=0.010). Periprocedural bleeding was more common in Heyde than in control patients (adjusted odds ratio, 2.55 [95% CI, 1.37-4.73]; P=0.003).

CONCLUSIONS

Patients with Heyde syndrome are at increased risk for periprocedural bleeding. Post-TAVI, gastrointestinal bleeding disappears in the majority of patients. Paravalvular leakage may curtail these clinical benefits.

Mechanisms and Drug Therapies of Bioprosthetic Heart Valve Calcification

Valve replacement is the main therapy for valvular heart disease, in which a diseased valve is replaced by mechanical heart valve (MHV) or bioprosthetic heart valve (BHV). Since the 2000s, BHV surpassed MHV as the leading option of prosthetic valve substitute because of its excellent hemocompatible and hemodynamic properties. However, BHV is apt to structural valve degeneration (SVD), resulting in limited durability. Calcification is the most frequent presentation and the core pathophysiological process of SVD. Understanding the basic mechanisms of BHV calcification is an essential prerequisite to address the limited-durability issues. In this narrative review, we provide a comprehensive summary about the mechanisms of BHV calcification on 1) composition and site of calcifications; 2) material-associated mechanisms; 3) host-associated mechanisms, including immune response and foreign body reaction, oxidative stress, metabolic disorder, and thrombosis. Strategies that target these mechanisms may be explored for novel drug therapy to prevent or delay BHV calcification.

Platelets: Implications in Aortic Valve Stenosis and Bioprosthetic Valve Dysfunction From Pathophysiology to Clinical Care

Aortic stenosis (AS) is the most common heart valve disease requiring surgery in developed countries, with a rising global burden associated with aging populations. The predominant cause of AS is believed to be driven by calcific degeneration of the aortic valve and a growing body of evidence suggests that platelets play a major role in this disease pathophysiology. Furthermore, platelets are a player in bioprosthetic valve dysfunction caused by their role in leaflet thrombosis and thickening. This review presents the molecular function of platelets in the context of recent and rapidly evolving understanding the role of platelets in AS, both of the native aortic valve and bioprosthetic valves, where there remain concerns about the effects of subclinical leaflet thrombosis on long-term prosthesis durability. This review also presents the role of antiplatelet and anticoagulation therapies on modulating the impact of platelets on native and bioprosthetic aortic valves, highlighting the need for further studies to determine whether these therapies are protective and may increase the life span of surgical and transcatheter aortic valve implants. By linking molecular mechanisms through which platelets drive disease of native and bioprosthetic aortic valves with studies evaluating the clinical impact of antiplatelet and antithrombotic therapies, we aim to bridge the gaps between our basic science understanding of platelet biology and their role in patients with AS and ensuing preventive and therapeutic implications.

Heyde syndrome: prevalence and outcomes in patients undergoing transcatheter aortic valve implantation

Background

Heyde syndrome (HS) is known as the association of severe aortic stenosis (AS) and recurrent gastrointestinal bleeding (GIB) from angiodysplasia. Data on the prevalence of HS and results after TAVI remain scarce.

Methods

2548 consecutive patients who underwent TAVI for the treatment of AS from 2008 to 2017 were evaluated for a history of GIB and the presence of HS. The diagnosis of HS was defined as a clinical triad of severe AS, a history of recurrent GIB, and an endoscopic diagnosis of angiodysplasia. These patients (Heyde) were followed to investigate clinical outcomes, bleeding complications and the recurrence of GIB and were compared to patients with GIB unrelated to HS (Non-Heyde).

Results

A history of GIB prior to TAVI was detected in 190 patients (7.5%). Among them, 47 patients were diagnosed with HS (1.8%). Heyde patients required blood transfusions more frequently compared to Non-Heyde patients during index hospitalization (50.0% vs. 31.9%, p = 0.03). Recurrent GIB was detected in 39.8% of Heyde compared to 21.2% of Non-Heyde patients one year after TAVI (p = 0.03). In patients diagnosed with HS and recurrent GIB after TAVI, the rate of residual ≥ mild paravalvular leakage (PVL) was higher compared to those without recurrent bleeding (73.3% vs. 38.1%, p = 0.05).

Conclusion

A relevant number of patients undergoing TAVI were diagnosed with HS. Recurrent GIB was detected in a significant number of Heyde patients during follow-up. A possible association with residual PVL requires further investigation to improve treatment options and outcomes in patients with HS.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-021-01905-z.

Recurrent Gastrointestinal Bleeding in a Patient With Severe Aortic Valve Stenosis: A Diagnosis of Heyde's Syndrome

Heyde's syndrome is defined as the coexistence of aortic valve stenosis (AS) and recurrent gastrointestinal (GI) bleeding from intestinal angiodysplasia (IA). Despite the fact that Heyde's syndrome was first described decades ago, the association between AS and IA remains frequently unidentified, and thus, a high clinical suspicion is needed for its diagnosis. Here we present a case of a 60-year-old man with a history of severe AS, who presented with recurrent GI bleeding and was found to have multiple intestinal angioectasias on endoscopy.

Heyde Syndrome-Pathophysiology and Perioperative Implications

Gastrointestinal (GI) bleeding in patients with calcific aortic valve stenosis (AVS), termed Heyde syndrome, was first described by Edward C. Heyde. The strong association between valvular replacement and the eradication of clinically significant GI bleeding confirmed an underlying pathophysiologic relationship. The rheologic stress created by AVS increases proteolysis of von Willebrand factor (VWF), resulting in loss of predominantly high-molecular-weight VWF (Hmw VWF). Angiodysplastic vessels present in patients with AVS, coupled with the lack of functioning Hmw VWF, increase the risk for GI bleeds. Aortic valve replacement, both surgical and transcatheter-based, is often a definitive treatment for GI bleeding, leading to recovery of Hmw VWF multimers. Perioperative management of patients involves monitoring their coagulation profiles with relevant laboratory tests and instituting appropriate management. Management can be directed in the following two ways: by improving internal release of VWF or by administration of external therapeutics containing VWF. It is important for perioperative physicians to obtain an understanding of the pathophysiology of this disease process and closely monitor the bleeding pattern so that targeted therapies can be initiated.

Pathologic Shear and Elongation Rates Do Not Cause Cleavage of Von Willebrand Factor by ADAMTS13 in a Purified System

INTRODUCTION

Pathological flows in patients with severe aortic stenosis are associated with acquired von Willebrand syndrome. This syndrome is characterized by excessive cleavage of von Willebrand factor by its main protease, A Disintegrin and Metalloproteinase with a Thrombospondin Type 1 Motif, Member 13 (ADAMTS13) leading to decreased VWF function and mucocutaneous bleeding. Aortic valve replacement and correction of the flow behavior to physiological levels reverses the syndrome, supporting the association between pathological flow and acquired von Willebrand syndrome. We investigated the effects of shear and elongational rates on von Willebrand factor cleavage in the presence of ADAMTS13.

METHODS

We identified acquired von Willebrand syndrome in five patients with severe aortic stenosis. Doppler echography values from these patients were used to develop three computational fluid dynamic (CFD) aortic valve models (normal, mild and severe stenosis). Shear, elongational rates and exposure times identified in the CFD simulations were used as parameters for the design of microfluidic devices to test the effects of pathologic shear and elongational rates on the structure and function of von Willebrand factor.

RESULTS

The shear rates (0-10,000s-1), elongational rates (0-1000 s-1) and exposure times (1-180 ms) tested in our microfluidic designs mimicked the flow features identified in patients with aortic stenosis. The shear and elongational rates tested in vitro did not lead to excessive cleavage or decreased function of von Willebrand factor in the presence of the protease.

CONCLUSIONS

High shear and elongational rates in the presence of ADAMTS13 are not sufficient for excessive cleavage of von Willebrand Factor.

Blood Disorders in Patients Undergoing Transcatheter Aortic Valve Replacement: A Review

Transcatheter aortic valve replacement (TAVR) is well established for treating patients with severe aortic stenosis considered at intermediate to high surgical risk. Blood disorders such as anemia, thrombocytopenia, and acquired type 2A von Willebrand disease are relatively frequent in TAVR candidates, and multiple studies to date have highlighted their potential clinical association with mortality and/or bleeding complications post-TAVR. The present review provides an overview of various blood disorders observed pre- and post-TAVR, with special focus on their incidence, etiology, clinical association, and management.

Administration of plasma-derived coagulation factor VIII during the perioperative period of mastectomy for breast cancer with acquired von Willebrand syndrome

Background

Acquired von Willebrand syndrome (aVWS) is a rare bleeding disorder with laboratory findings similar to those of congenital von Willebrand disease (VWD). Patients with aVWS may require prophylactic treatment to prevent excessive bleeding following surgery. To our knowledge, to date, there have been no reports on perioperative management for breast cancer patients with aVWS.

Case presentation

A 60-year-old woman with breast cancer was diagnosed with aVWS due to polycythemia vera. Pre-operative laboratory testing showed a high platelet count and low von Willebrand factor (VWF) activity. The VWF activity did not improve despite an attempt to suppress platelet count with hydroxyurea. Therefore, we decided to perioperatively supplement with plasma-derived factor VIII (FVIII) containing von Willebrand factor (FVIII/VWF concentrates) to perform curative surgery for breast cancer safely. Consequently, the patient did not develop hemorrhage during/after surgery and was discharged on postoperative day 7, as planned, without problems.

Conclusions

For a patient with aVWS, which carries a high risk of hemorrhage during the perioperative period, initiation of appropriate management like supplementation of FVIII/VWF concentrates might enable safe curative surgery for breast cancer, and collaboration with the hematology department is critical.

Aortic stenosis and anemia with an update on approaches to managing angiodysplasia in 2018

Angiodyplasia and aortic stenosis are both conditions that are highly prevalent in elderly people and can often co-exist. Recent studies suggest that this association is related to subtle alterations in plasma coagulation factors. The von Willebrand factor is the strongest link between aortic stenosis and bleeding associated with gastrointestinal angiodysplasia. With an ageing population, the disease burden of aortic stenosis and its association with angiodysplasia of the bowel makes this an incredibly underdiagnosed yet important condition. Clinicians should be aware of this association when dealing with elderly patients presenting either with unexplained anemia, gastrointestinal bleeding or with aortic stenosis. A high index of suspicion and appropriate diagnostic techniques followed by appropriate and prompt treatment could be life-saving. No clear guidelines exist on management but surgical aortic valve replacement is thought to offer the best hope for long-term resolution of bleeding. With a growing number of technological armamentarium in the management of such patients, especially with the advent of transcatheter aortic valve implantation, new options can be offered even to elderly patients with comorbidities for whom conventional surgery would have been impossible.

A case of recurrent obscure gastrointestinal bleeding: Heyde's syndrome - case report and review

Gastrointestinal bleeding from angiodysplasias in patients with aortic stenosis is termed as 'Heyde's syndrome'. We report a case of Heyde's syndrome successfully treated with trans-catheter aortic valve replacement.

Overview of small bowel angioectasias: clinical presentation and treatment options

Elderly patients with multiple co-morbidities are at an increased risk of developing small bowel angioectasias. Treating these lesions can be both challenging and costly with patients requiring extensive investigations and recurrent admissions for iron infusions and blood transfusions as well as invasive procedures. This review presents treatment options and describes in detail drugs that should be considered whilst taking into account their effectiveness and their safety profile. Areas covered: A PubMed search was carried out using the following keywords: small bowel angiodysplasias, small bowel angioectasias, small bowel bleeding and obscure gastrointestinal bleeding to assess existing evidence. The pathophysiology and risk factors are covered in this review together with appropriate methods of investigation and management. Treatment options discussed are endoscopic measures, surgical options and pharmacotherapy. The role of serum biomarkers is also discussed. Expert commentary: Future work should be directed at alternative drugs with a good safety profile that target biomarkers. Novel pharmacotherapy directed at biomarkers could potentially provide a non-invasive treatment option for angioectasias particularly in the elderly where management can be challenging.

Von Willebrand Factor as a Novel Player in Valvular Heart Disease: From Bench to Valve Replacement

von Willebrand Factor (vWF) is a well-known mediator of hemostasis and vascular inflammation. Its dynamic modulation in the bloodstream, according to hemodynamic conditions, makes it an appealing biomarker in patients with valvular heart disease (VHD). Recent studies highlight the close connection between vWF and VHD, with possible implications in the pathogenesis of VHD, promoting valve aging and calcification or favoring the development of infective endocarditis. Moreover, vWF has been recently proposed as a new diagnostic and prognostic tool in patients with valve stenosis or regurgitation, showing a strict correlation with severity of valve disease, outcome, and bleeding (Heyde syndrome). A novel role for vWF is also emerging in patients undergoing percutaneous or surgical valve repair/replacement to select and stratify patients, evaluate periprocedural bleeding risk, and detect procedural complications. We also report our single-center experience, suggesting, for the first time, possible clinical implications for vWF in percutaneous mitral valve repair (MitraClip). This review summarizes recent advances in the role of vWF in VHD with an updated overview going from bench to operating room.