Late stroke after transcatheter aortic valve replacement: a nationwide study

Review of Bleeding and Thrombotic Risks Associated With Antithrombotic Therapy After Transcatheter Structural Heart Interventions

Transcatheter structural heart interventions have drastically evolved over the past 2 decades. However, most catheterization procedures require the deployment of devices in the body; therefore, the adhesion of thrombi to those devices is a major problem, resulting in the requirement of a period of postprocedural antithrombotic regimen. However, in recent years, bleeding associated with these antithrombotic therapies has also become a major concern, attracting the attention of investigators. This is complicated by the fact that patients at high thrombotic risk are also at high bleeding risk, making the issue of administrating antithrombotic therapy challenging. The objective of this review was to identify the important issues and summarize the current status of postoperative antithrombotic therapy and assessment of the bleeding risk following transcatheter structural heart interventions such as transcatheter aortic valve replacement, transcatheter edge-to-edge repair, and transcatheter left atrial appendage occlusion.

Cerebral embolic protection during transcatheter heart interventions

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.

Cerebral embolic protection during transcatheter aortic valve replacement: a systematic review and meta-analysis of propensity score matched and randomized controlled trials using the Sentinel cerebral embolic protection device

BACKGROUND

The Sentinel cerebral embolic protection device (CEP) aims to reduce the risk of stroke during transcatheter aortic valve replacement (TAVR). We performed a systematic review and meta-analysis of propensity score matched (PSM) and randomized controlled trials (RCT) investigating the effect of the Sentinel CEP to prevent strokes during TAVR.

METHODS

Eligible trials were searched through PubMed, ISI Web of science databases, Cochrane database, and proceedings of major congresses. Primary outcome was stroke. Secondary outcomes included all-cause mortality, major or life-threatening bleeding, major vascular complications and acute kidney injury at discharge. Fixed and random effect models were used to calculate the pooled risk ratio (RR) with 95% confidence intervals (CI) and absolute risk difference (ARD).

RESULTS

A total of 4066 patients from 4 RCTs (3'506 patients) and 1 PSM study (560 patients) were included. Use of Sentinel CEP was successful in 92% of patients and was associated with a significantly lower risk of stroke (RR: 0.67, 95% CI: 0.48-0.95, p = 0.02. ARD: -1.3%, 95% CI: -2.3 - -0.2, p = 0.02, number needed to treat (NNT) = 77), and a reduced risk of disabling stroke (RR: 0.33, 95% CI: 0.17-0.65. ARD: -0.9%, 95% CI: -1.5 - -0.3, p = 0.004, NNT = 111). Use of Sentinel CEP was associated with a lower risk of major or life-threatening bleeding (RR: 0.37, 95% CI: 0.16-0.87, p = 0.02). Risk for nondisabling stroke (RR: 0.93, 95% CI: 0.62-1.40, p = 0.73), all-cause mortality (RR: 0.70, 95% CI: 0.35-1.40, p = 0.31), major vascular complications (RR: 0.74, 95% CI: 0.33-1.67, p = 0.47) and acute kidney injury (RR: 0.74, 95% CI: 0.37-1.50, p = 0.40) were similar.

CONCLUSIONS

The use of CEP during TAVR was associated with lower risks of any stroke and disabling stroke with an NNT of 77 and 111, respectively.

Mild Paravalvular Leak May Pose an Increased Thrombogenic Risk in Transcatheter Aortic Valve Replacement (TAVR) Patients-Insights from Patient Specific In Vitro and In Silico Studies

In recent years, the treatment of aortic stenosis with TAVR has rapidly expanded to younger and lower-risk patients. However, persistent thrombotic events such as stroke and valve thrombosis expose recipients to severe clinical complications that hamper TAVR's rapid advance. We presented a novel methodology for establishing a link between commonly acceptable mild paravalvular leak (PVL) levels through the device and increased thrombogenic risk. It utilizes in vitro patient-specific TAVR 3D-printed replicas evaluated for hydrodynamic performance. High-resolution µCT scans are used to reconstruct in silico FSI models of these replicas, in which multiple platelet trajectories are studied through the PVL channels to quantify thrombogenicity, showing that those are highly dependent on patient-specific flow conditions within the PVL channels. It demonstrates that platelets have the potential to enter the PVL channels multiple times over successive cardiac cycles, increasing the thrombogenic risk. This cannot be reliably approximated by standard hemodynamic parameters. It highlights the shortcomings of subjectively ranked PVL commonly used in clinical practice by indicating an increased thrombogenic risk in patient cases otherwise classified as mild PVL. It reiterates the need for more rigorous clinical evaluation for properly diagnosing thrombogenic risk in TAVR patients.

Transcatheter Aortic Valve Replacement vs. Surgical Aortic Valve Replacement for Long-Term Mortality Due to Stroke and Myocardial Infarction: A Meta-Analysis during the COVID-19 Pandemic

Background and objectives: One of the leading causes of mortality and morbidity in people over the age of 50 is stroke. The acceptance of transcatheter aortic valve replacement (TAVR) as a treatment option for severe symptomatic aortic stenosis (AS) has increased as a result of numerous randomized clinical trials comparing surgical aortic valve replacement (SAVR) and TAVR in high- and intermediate-risk patients, showing comparable clinical outcomes and valve hemodynamics. Materials and Methods: An electronic search of Medline, Google Scholar and Cochrane Central was carried out from their inception to 28 September 2022 without any language restrictions. Results: Our meta-analysis demonstrated that, as compared with SAVR, TAVR was not linked with a lower stroke ratio or stroke mortality. It is clear from this that the SAVR intervention techniques applied in the six studies were successful in reducing cardiogenic consequences over time. Conclusions: A significantly decreased rate of mortality from cardiogenic causes was associated with SAVR. Additionally, when TAVR and SAVR were compared for stroke mortality, the results were nonsignificant with a p value of 0.57, indicating that none of these procedures could decrease stroke-related mortality.

Predictors and neurological consequences of periprocedural cerebrovascular events following transcatheter aortic valve implantation with self-expanding valves

Aims

To evaluate the patient- and procedure-related predictors of transcatheter aortic-valve implantation (TAVI)-associated ischemic brain lesions and to assess the effect of silent cerebral ischemic lesions (SCIL) on neurocognitive function.

Methods and results

We investigated 113 consecutive patients with severe aortic stenosis who underwent brain magnetic resonance imaging (MRI) within a week following TAVI. To assess periprocedural cerebral ischemic lesions, diffusion-weighted MRI was utilized. We used multivariate linear regression to identify the independent predictors of TAVI-related ischemic lesion volume (ILV) and periprocedural stroke. Neurocognitive evaluation was performed before and following TAVI at 6-month and one-year follow-up. Following TAVI, a total of 944 new cerebral ischemic lesions were detected in 104 patients (92%). The median ILV was 257 μl (interquartile range [IQR]:97.1–718.8μl) with a median lesion number of 6/patient [IQR:2–10]. The majority of ischemic lesions were clinically silent (95%), while 5% of the lesions induced a stroke, which was confirmed by MRI. Predilatation (β = 1.13[95%CI:0.32–1.93], p = 0.01) and the number of valve positioning attempts during implantation (β = 0.28[95%CI:0.06–0.50], p = 0.02) increased the log-transformed total ILV. Predilatation (OR = 12.04[95%CI:1.46–99.07], p = 0.02) and alternative access routes (OR = 7.84[95%CI:1.01–61.07], p = 0.02) were associated with stroke after adjustments for comorbidities and periprocedural factors. The presence of SCILs were not associated with a change in neurocognitive function that remained stable during the one-year follow-up.

Conclusion

While periprocedural ischemic lesions are frequent, most of them are clinically silent and might not impact the patients' neurocognitive function. The number of valve positioning attempts, predilatation, and alternative access routes should be taken into consideration during TAVI to reduce the ILV and risk for stroke.

Visions of TAVR Future: Development and Optimization of a Second Generation Novel Polymeric TAVR

Tissue-based transcatheter aortic valve (AV) replacement (TAVR) devices have been a breakthrough approach for treating aortic valve stenosis. However, with the expansion of TAVR to younger and lower risk patients, issues of long-term durability and thrombosis persist. Recent advances in polymeric valve technology facilitate designing more durable valves with minimal in vivo adverse reactions. We introduce our second-generation polymeric transcatheter aortic valve (TAV) device, designed and optimized to address these issues. We present the optimization process of the device, wherein each aspect of device deployment and functionality was optimized for performance, including unique considerations of polymeric technologies for reducing the volume of the polymer material for lower crimped delivery profiles. The stent frame was optimized to generate larger radial forces with lower material volumes, securing robust deployment and anchoring. The leaflet shape, combined with varying leaflets thickness, was optimized for reducing the flexural cyclic stresses and the valve's hydrodynamics. Our first-generation polymeric device already demonstrated that its hydrodynamic performance meets and exceeds tissue devices for both ISO standard and patient-specific in vitro scenarios. The valve already reached 900 × 106 cycles of accelerated durability testing, equivalent to over 20 years in a patient. The optimization framework and technology led to the second generation of polymeric TAV design- currently undergoing in vitro hydrodynamic testing and following in vivo animal trials. As TAVR use is rapidly expanding, our rigorous bio-engineering optimization methodology and advanced polymer technology serve to establish polymeric TAV technology as a viable alternative to the challenges facing existing tissue-based TAV technology.

Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement

Due to a large technical improvement in the past decade, transcatheter aortic valve replacement (TAVR) has expanded to lower-surgical-risk patients with symptomatic and severe aortic stenosis. While mortality rates related to TAVR are decreasing, the prognosis of patients is still impacted by ischemic and bleeding complications, and defining the optimal antithrombotic regimen remains a priority. Recent randomized control trials reported lower bleeding rates with an equivalent risk in ischemic outcomes with single antiplatelet therapy (SAPT) when compared to dual antiplatelet therapy (DAPT) in patients without an underlying indication for anticoagulation. In patients requiring lifelong oral anticoagulation (OAC), the association of OAC plus antiplatelet therapy leads to a higher risk of bleeding events with no advantages on mortality or ischemic outcomes. Considering these data, guidelines have recently been updated and now recommend SAPT and OAC alone for TAVR patients without and with a long-term indication for anticoagulation. Whether a direct oral anticoagulant or vitamin K antagonist provides better outcomes in patients in need of anticoagulation remains uncertain, as recent trials showed a similar impact on ischemic and bleeding outcomes with apixaban but higher gastrointestinal bleeding with edoxaban. This review aims to summarize the most recently published data in the field, as well as describe unresolved issues.

Trends and Outcomes of Aortic Valve Replacement in Patients With Diabetes in the US

Aims

We aimed to assess the trend and outcome of aortic valve replacement in patients with diabetes.

Background

Diabetes is associated with higher cardiovascular events.

Methods

Data from the National Inpatient Sample was analyzed between 2012 and 2017. We compared hospitalizations and in-hospital cardiovascular outcomes in patients with diabetes to those without diabetes, hospitalized for aortic valve replacement.

Results

In diabetes patients undergoing TAVR, the mean age of participants decreased from 79.6 ± 8 to 67.8 ± 8, hospitalizations increased from 0.97 to 7.68/100,000 US adults (p < 0.002 for both). There was a significant temporal decrease in mortality, acute renal failure (ARF), and stroke. Compared to non-diabetic patients, those with diabetes had a higher risk of stroke, ARF, and pacemaker requirement [adjusted OR = 1.174 (1.03–1.34), 1.294 (1.24–1.35), 1.153 (1.11–1.20), respectively], but a similar adjusted mortality risk. In diabetes patients undergoing sAVR, the mean age of participants decreased from 70.4 ± 10 to 68 ± 9 (p < 0.001), hospitalizations dropped from 7.72 to 6.63/100,000 US adults (p = 0.025), so did mortality, bleeding, and ARF. When compared to non-diabetes patients, those with diabetes were older and had a higher adjusted risk of mortality, stroke, and ARF [adjusted OR= 1.115 (1.06–1.17), 1.140 (1.05–1.23), 1.217 (1.18–1.26); respectively].

Conclusion

The recent temporal trend of aortic valve replacement in patients with diabetes shows a significant increase in TAVR coupled with a decrease in sAVR. Mortality and other cardiovascular outcomes decreased in both techniques. sAVR, but not TAVR, was associated with higher in-hospital mortality risk.