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Pyrpyris N, Dimitriadis K, Theofilis P, Iliakis P, Beneki E, Pitsiori D, Tsioufis P, Shuvy M, Aznaouridis K, Tsioufis K. Transcatheter Structural Heart Interventions in the Acute Setting: An Emerging Indication. J Clin Med 2024; 13:3528. [PMID: 38930057 PMCID: PMC11204700 DOI: 10.3390/jcm13123528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 06/09/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
Structural heart disease is increasingly prevalent in the general population, especially in patients of increased age. Recent advances in transcatheter structural heart interventions have gained a significant following and are now considered a mainstay option for managing stable valvular disease. However, the concept of transcatheter interventions has also been tested in acute settings by several investigators, especially in cases where valvular disease comes as a result of acute ischemia or in the context of acute decompensated heart failure. Tested interventions include both the mitral and aortic valve, mostly evaluating mitral transcatheter edge-to-edge repair and transcatheter aortic valve implantation, respectively. This review is going to focus on the use of acute structural heart interventions in the emergent setting, and it will delineate the available data and provide a meaningful discussion on the optimal patient phenotype and future directions of the field.
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Affiliation(s)
- Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Kyriakos Dimitriadis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Panagiotis Theofilis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Panagiotis Iliakis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Eirini Beneki
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Daphne Pitsiori
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Panagiotis Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Mony Shuvy
- Jesselson Integrated Heart Centre, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, Jerusalem 9103102, Israel;
| | - Konstantinos Aznaouridis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
| | - Konstantinos Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27 Athens, Greece; (N.P.); (P.T.); (P.I.); (E.B.); (D.P.); (P.T.); (K.A.); (K.T.)
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Nair RM, Chawla S, Abdelghaffar B, Alkhalaieh F, Bansal A, Puri R, Yun J, Krishnaswamy A, Kapadia S, Menon V, Reed GW. Comparison of Contemporary Treatment Strategies in Patients With Cardiogenic Shock Due to Severe Aortic Stenosis. J Am Heart Assoc 2024; 13:e033601. [PMID: 38761069 PMCID: PMC11179830 DOI: 10.1161/jaha.123.033601] [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: 11/29/2023] [Accepted: 04/17/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND The aims of this study were to understand the incidence and outcomes of patients with cardiogenic shock (CS) due to severe aortic stenosis (AS), and the impact of conventional treatment strategies in this population. METHODS AND RESULTS All patients admitted to the Cleveland Clinic cardiac intensive care unit between January 1, 2010 and December 31, 2021 with CS were retrospectively identified and categorized into those with CS in the setting of severe AS versus CS without AS. The impact of various treatment strategies on mortality was further assessed. We identified 2754 patients with CS during the study period, of whom 216 patients (8%) had CS in the setting of severe AS. Medical management was associated with the highest 30-day mortality when compared with either balloon aortic valve replacement or aortic valve replacement (surgical or transcatheter aortic valve replacement) (hazard ratio, 3.69 [95% CI, 2.04-6.66]; P<0.0001). Among patients who received transcatheter therapy, 30-day mortality was significantly higher in patients who received balloon aortic valvuloplasty versus transcatheter aortic valve replacement (26% versus 4%, P=0.02). Both surgical and transcatheter aortic valve replacement had considerably lower mortality than medical management and balloon aortic valvuloplasty at 30 days and 1 year (P<0.05 for both comparisons). CONCLUSIONS CS due to severe AS is associated with high in-hospital and 30-day mortality, worse compared with those with CS without AS. In suitable patients, urgent surgical aortic valvuloplasty or transcatheter aortic valve replacement is associated with favorable short- and long-term outcomes. Although balloon aortic valvuloplasty may be used to temporize patients with CS in the setting of severe AS, mortality is ≈50% if not followed by definitive aortic valve replacement within 90 days.
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Affiliation(s)
- Raunak M Nair
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - Sanchit Chawla
- Cleveland Clinic Foundation Internal Medicine Department Cleveland OH USA
| | - Bahaa Abdelghaffar
- Cleveland Clinic Foundation Internal Medicine Department Cleveland OH USA
| | - Feras Alkhalaieh
- Cleveland Clinic Foundation Internal Medicine Department Cleveland OH USA
| | - Agam Bansal
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - Rishi Puri
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - James Yun
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - Amar Krishnaswamy
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - Samir Kapadia
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - Venu Menon
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
| | - Grant W Reed
- Cleveland Clinic Heart Vascular and Thoracic Institute Cleveland OH USA
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Avvedimento M, Angellotti D, Ilardi F, Leone A, Scalamogna M, Catiello DS, Manzo R, Mariani A, Molaro MI, Simonetti F, Spaccarotella CAM, Piccolo R, Esposito G, Franzone A. Acute advanced aortic stenosis. Heart Fail Rev 2023:10.1007/s10741-023-10312-7. [PMID: 37083966 PMCID: PMC10403405 DOI: 10.1007/s10741-023-10312-7] [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] [Accepted: 04/09/2023] [Indexed: 04/22/2023]
Abstract
Acute decompensation often represents the onset of symptoms associated with severe degenerative aortic stenosis (AS) and usually complicates the clinical course of the disease with a dismal impact on survival and quality of life. Several factors may derange the faint balance between left ventricular preload and afterload and precipitate the occurrence of symptoms and signs of acute heart failure (HF). A standardized approach for the management of this condition is currently lacking. Medical therapy finds very limited application in this setting, as drugs usually indicated for the control of acute HF might worsen hemodynamics in the presence of AS. Urgent aortic valve replacement is usually performed by transcatheter than surgical approach whereas, over the last decades, percutaneous balloon valvuloplasty gained renewed space as bridge to definitive therapy. This review focuses on the pathophysiological aspects of acute advanced AS and summarizes current evidence on its management.
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Affiliation(s)
- Marisa Avvedimento
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini, 5 - 8031, Naples, Italy
| | - Domenico Angellotti
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini, 5 - 8031, Naples, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini, 5 - 8031, Naples, Italy
| | - Attilio Leone
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini, 5 - 8031, Naples, Italy
| | - Maria Scalamogna
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini, 5 - 8031, Naples, Italy
| | - Domenico Simone Catiello
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini, 5 - 8031, Naples, Italy
| | - Rachele Manzo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini, 5 - 8031, Naples, Italy
| | - Andrea Mariani
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini, 5 - 8031, Naples, Italy
| | - Maddalena Immobile Molaro
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini, 5 - 8031, Naples, Italy
| | - Fiorenzo Simonetti
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini, 5 - 8031, Naples, Italy
| | | | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini, 5 - 8031, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini, 5 - 8031, Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini, 5 - 8031, Naples, Italy.
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Rescue aortic valvuloplasty for severe aortic stenosis is simple and effective in severely hemodynamically compromised patients presenting to centers without on-site heart surgery or TAVI facilities. Heart Vessels 2023; 38:957-963. [PMID: 36781429 DOI: 10.1007/s00380-023-02243-y] [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: 08/29/2021] [Accepted: 01/26/2023] [Indexed: 02/15/2023]
Abstract
Management of high-risk patients with severe aortic stenosis (AS) is a challenging issue. The prognosis of patients with AS presenting with therapy-refractory pulmonary edema (RPE) or cardiogenic shock (CS) remains poor. The purpose of this study was to assess the 30-day mortality of rescue percutaneous balloon aortic valvuloplasty (PBAV) in AS patients presenting with RPE or CS in a community-based hospital without on-site heart surgery. From January 2016 to February 2019, we identified consecutively admitted patients with CS or RPE related to severe AS who underwent emergent PBAV. The primary end point was 30-day mortality. Secondary end points included procedural adverse events according to the Valve Academic Research Consortium (VARC)-2 criteria and predictive factors of the primary end point. We identified 51 patients with either CS (n = 22) or RPE (n = 29). All PBAV procedures were successful with a significant reduction in peak-to-peak gradient (median, [IQR] from 40 [27] mmHg to 15 [20] mmHg, p < 0.001). No procedural deaths occurred, while adverse events included stroke (4%), minor vascular complications (6%), minor (4%) and major bleedings (4%), and no life-threatening bleeding. Overall, 15 deaths (29%) were noted at 30 days after PBAV, while 53% of the surviving patients were successfully bridged to transcatheter aortic valve implantation (TAVI). 30-day mortality was significantly higher in the CS group compared to the RPE (n = 10 (45%) vs n = 5 (7%), p = 0.029), and was significantly associated with the presence of acute kidney injury (OR 9.09, 95% CI 2.13-38.77, p = 0.003) and elevated pulmonary artery systolic pressure (OR 1.06, 95% CI 1.0-1.12, p = 0.047). Rescue PBAV in patients with severe AS presenting with RPE or CS is a feasible and effective therapeutic option, even in a community-based hospital without on-site heart surgery. Rescue PBAV resulted in 30-day survival of more than 70%, with more than half of the surviving patients having been successfully bridged to TAVI.
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Elkaryoni A, Cohen DJ, Lopez JJ, Huded CP, Kennedy KF, Arnold SV. Trends in invasive treatment of patients hospitalized with aortic stenosis complicated by cardiogenic shock. Catheter Cardiovasc Interv 2022; 100:1110-1116. [PMID: 36168864 DOI: 10.1002/ccd.30413] [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: 03/28/2022] [Revised: 08/29/2022] [Accepted: 09/07/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Before the development of transcatheter aortic valve replacement (TAVR), balloon aortic valvuloplasty (BAV) was the only potential nonsurgical intervention for patients with aortic stenosis complicated by cardiogenic shock. Emergent TAVR is now an option and has shown acceptable outcomes compared with elective TAVR. We explored how treatment patterns for aortic stenosis and cardiogenic shock among patients received invasive intervention have shifted since TAVR was introduced. METHODS We used the Nationwide In patients Sample to identify nonelective hospitalizations for patient with aortic stenosis complicated by cardiogenic shock who received invasive treatment (TAVR, BAV, or surgical aortic valve replacement [SAVR]). We explored the proportion treated with each treatment modality over time, the patient characteristics and in-hospital mortality associated with each treatment, and used multivariable logistic regression to examine whether changes in in-hospital mortality over time differed by treatment. RESULTS Between 2010 and 2019, we identified 9899 hospitalizations for decompensated aortic stenosis with cardiogenic shock during which patients received invasive treatment (TAVR 17.7%, BAV 20.2%, SAVR 62.1%). Use of both TAVR and BAV has increased over time compared with SAVR (TAVR 6.6% ≥ 33.8%, BAV 8.4% ≥ 23.2%, SAVR 91.6% ≥ 43.0%; p < 0.001 for trend). The overall in-hospital mortality rate was 21.0%, which decreased over time for all treatments (TAVR 20.0% ≥ 18.8%, BAV 66.0% ≥ 25.5%, SAVR 17.7% ≥ 11.8%; linear trend p < 0.001 for each), with lower mortality for TAVR versus BAV at all time points. Patients treated with TAVR (vs. BAV) were less likely to require mechanical ventilation (36.8% vs. 46.3%, p < 0.001) or mechanical circulatory support (22.5% vs. 29.9%, p < 0.001). In the multivariable analysis, the interaction between treatment and time was not significant (p = 0.245), indicating the reduction in in-hospital mortality over time did not differ among the treatments. CONCLUSIONS Since the introduction of TAVR, there has been a shift toward increased use of nonsurgical invasive treatments (both BAV and TAVR) for aortic stenosis and cardiogenic shock. Although in-hospital mortality has declined, it remains high in all groups, but particularly among patients treated with BAV, where the severity of cardiogenic shock appears to be higher than in those treated with other modalities.
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Affiliation(s)
- Ahmed Elkaryoni
- Department of Internal Medicine, Division of Cardiovascular Disease, Loyola Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - David J Cohen
- Department of Internal Medicine, Division of Cardiovascular disease, St. Francis Hospital & Heart Center, Roslyn, New York, USA.,Department of Internal Medicine, Division of Cardiovascular disease, Cardiovascular Research Foundation, New York, New York, USA
| | - John J Lopez
- Department of Internal Medicine, Division of Cardiovascular Disease, Loyola Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Chetan P Huded
- Department of Internal Medicine, Division of Cardiovascular disease, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA.,Department of Internal Medicine, Division of Cardiovascular disease, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Kevin F Kennedy
- Department of Internal Medicine, Division of Cardiovascular disease, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Suzanne V Arnold
- Department of Internal Medicine, Division of Cardiovascular disease, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA.,Department of Internal Medicine, Division of Cardiovascular disease, University of Missouri-Kansas City, Kansas City, Missouri, USA
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Kumar A, Shah R, Young LD, Patel DR, Bansal A, Popovic ZB, Menon V, Kalra A, Tuzcu EM, White J, Puri R, Krishnaswamy A, Kapadia SR, Reed GW. Safety and Efficacy of Balloon Aortic Valvuloplasty Stratified by Acuity of Patient Illness. STRUCTURAL HEART 2021. [DOI: 10.1080/24748706.2021.1954274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Akodad M, Schurtz G, Adda J, Leclercq F, Roubille F. Management of valvulopathies with acute severe heart failure and cardiogenic shock. Arch Cardiovasc Dis 2019; 112:773-780. [PMID: 31492536 DOI: 10.1016/j.acvd.2019.06.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 11/26/2022]
Abstract
Cardiogenic shock is a critical clinical situation, requiring rapid diagnosis, aetiological assessment and immediate initiation of therapy. In industrialized countries, aortic stenosis is the most frequent left-sided valvulopathy, followed by mitral regurgitation, aortic regurgitation and mitral stenosis. Severe valvulopathies leading to cardiogenic shock are not rare conditions, but few data are available on their optimal management. Therapeutic options for such critical conditions include inotropic agents, mechanical support (when feasible) and rapid valvular intervention. Although surgery remains the gold-standard treatment for severe valvular disease, mortality is frequently prohibitive in the setting of cardiogenic shock, necessitating consideration of alternative therapies. Percutaneous management of valvulopathies has emerged as an alternative treatment for patients deemed at high surgical risk in a stable condition. Although few published data are available, catheter-based interventions may be feasible in the cardiogenic shock setting. This review offers an overview of different valvulopathies in the cardiogenic shock setting, and summarizes the different therapeutic options currently available in such critical situations.
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Affiliation(s)
- Mariama Akodad
- Cardiology Department, Montpellier University Hospital, 34295 Montpellier, France; Inserm U1046, CNRS UMR 9214, PhyMedExp, 34090 Montpellier, France.
| | - Guillaume Schurtz
- Cardiology Department, Lille University Hospital, 59000 Lille, France
| | - Jérôme Adda
- Cardiology Department, Montpellier University Hospital, 34295 Montpellier, France; Inserm U1046, CNRS UMR 9214, PhyMedExp, 34090 Montpellier, France
| | - Florence Leclercq
- Cardiology Department, Montpellier University Hospital, 34295 Montpellier, France; Inserm U1046, CNRS UMR 9214, PhyMedExp, 34090 Montpellier, France
| | - François Roubille
- Cardiology Department, Montpellier University Hospital, 34295 Montpellier, France; Inserm U1046, CNRS UMR 9214, PhyMedExp, 34090 Montpellier, France
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Varela ML, Teixeira P, Ponte M, Caeiro D, Dias A, Rodrigues A, Braga P. Balloon Aortic Valvuloplasty in Patients Admitted for Cardiogenic Shock with Severe Aortic Stenosis: A Retrospective Analysis of 14 Cases. Cureus 2019; 11:e5407. [PMID: 31632861 PMCID: PMC6795346 DOI: 10.7759/cureus.5407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Balloon aortic valvuloplasty (BAV), introduced in 1986, quickly lost its wide adoption due to the high incidence of restenosis after the procedure and due to improved skills in transcatheter aortic valve implantation (TAVI). It has seen a re-emergence in the last few years as bailout therapy in critical care patients presenting with cardiogenic shock (CS) and severe aortic stenosis (AS), who are temporarily unable to tolerate such a procedure as TAVI or surgery for valve replacement. Methods We did a retrospective analysis of every BAV performed between January 1, 2008, and November 11, 2018, in our hospital and identified those admitted to the cardiac intensive care unit (CICU) due to cardiogenic shock with severe aortic stenosis, as defined in the European Society of Cardiology Guidelines. Procedures were categorized as emergent (within 24h after the decision to intervene) and urgent (24h after the decision was made but before discharge). Results During this period, of 98 BAV performed, 14 were performed on patients with CS with severe AS, nine of them being emergent. The patients' mean age was 76.2±7.2 years, with 6 (43%) of them being female. On the day of BAV, the mean Euroscore II and sequential organ failure (SOFA) were, respectively, 19±7% and 8.0±2.4 in emergent cases and 11±5% and 4.8±2.9 in urgent cases. In patients deemed emergent, there was a tendency for a decrease in SOFA in the days following the procedure, although not statistically significant (p>0.05). Clinically significant aortic regurgitation did not occur in any patient, neither were there any major post-procedure complications. Thirty-day mortality was 33% in emergent cases and 0% in urgent cases. In emergent cases, four were later submitted to TAVI and one had surgery for aortic valve replacement surgery. Only one patient in the urgent group was regarded as a candidate for TAVI. Discussion and conclusion Emergent cases presented with higher scores of severity and procedure risk and had greater mortality. In this group, a greater proportion of survivors was later deemed fit for definite procedures. This highlights that presenting status does not seem to influence the prognosis of those extremely high-risk patients once the acute event is promptly treated. Nevertheless, the low sample size precludes generalization of the findings. BAV as bailout treatment may be safe in patients presenting with CS and severe AS, allowing patient survival for elective definitive treatment.
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Affiliation(s)
- Miguel L Varela
- Critical Care Medicine, Intensive Care Medicine 1, Hospital De Faro, Faro, PRT
| | - Pedro Teixeira
- Cardiology, Centro Hospitalar Vila Nova De Gaia, Gaia, PRT
| | - Marta Ponte
- Cardiology, Centro Hospitalar Vila Nova De Gaia, Gaia, PRT
| | - Daniel Caeiro
- Cardiology, Centro Hospitalar Vila Nova De Gaia, Gaia, PRT
| | - Adelaide Dias
- Cardiology, Centro Hospitalar Vila Nova De Gaia, Gaia, PRT
| | | | - Pedro Braga
- Cardiology, Centro Hospitalar Vila Nova De Gaia, Gaia, PRT
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Jones DR, Chew DP, Horsfall MJ, Chuang AM, Sinhal AR, Joseph MX, Baker RA, Bennetts JS, Selvanayagam JB, Lehman SJ. Effect of Balloon Aortic Valvuloplasty on Mortality in Patients With Severe Aortic Stenosis Prior to Conservative Treatment and Surgical or Transcatheter Aortic Valve Replacement. Heart Lung Circ 2019; 29:719-728. [PMID: 31285152 DOI: 10.1016/j.hlc.2019.06.717] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Outcomes following an initial strategy of balloon aortic valvuloplasty (BAV) prior to medical therapy or intervention with surgical or transcatheter aortic valve replacement (SAVR or TAVR) are unclear in the modern transcatheter intervention era. METHODS A retrospective, observational cohort study of the echocardiography, cardiothoracic surgery and TAVR databases between 1 January 2006 and 31 December 2016 was performed to compare outcomes between all patients with severe aortic stenosis (AS) treated with or without BAV prior to medical or invasive therapy. RESULTS 3,142 patients were available for analysis. 223 BAV treated patients had lower mortality relative to medically treated patients, particularly early (20.1% v. 7.6% at 6 months, 58.1% v. 52.5% at 5 years). Over 5 years, the adjusted hazard ratio (HR) was 0.62 (95% CI 0.48-0.80, p < 0.001). Compared with 630 patients proceeding directly to intervention, 75 patients receiving BAV experienced a higher mortality (HR = 2.76, 95% CI 2.07-3.66, p < 0.001). No subsequent excess perioperative mortality was observed with BAV compared with those receiving surgery directly (HR = 1.45, 95% CI 0.91-2.31, p = 0.117). CONCLUSIONS The risk associated with BAV is low, and improves mortality compared with medical therapy. Balloon aortic valvuloplasty treated patients have poorer outcomes, but treatment with BAV does not increase perioperative mortality and may lessen it.
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Affiliation(s)
- Dylan R Jones
- Flinders University, Adelaide, SA, Australia; Flinders Medical Centre, Adelaide, SA, Australia.
| | - Derek P Chew
- Flinders University, Adelaide, SA, Australia; Flinders Medical Centre, Adelaide, SA, Australia
| | | | - Anthony M Chuang
- Flinders University, Adelaide, SA, Australia; Flinders Medical Centre, Adelaide, SA, Australia
| | | | | | - Robert A Baker
- Flinders University, Adelaide, SA, Australia; Flinders Medical Centre, Adelaide, SA, Australia
| | - Jayme S Bennetts
- Flinders University, Adelaide, SA, Australia; Flinders Medical Centre, Adelaide, SA, Australia
| | - Joseph B Selvanayagam
- Flinders University, Adelaide, SA, Australia; Flinders Medical Centre, Adelaide, SA, Australia
| | - Sam J Lehman
- Flinders University, Adelaide, SA, Australia; Flinders Medical Centre, Adelaide, SA, Australia
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Impella support following emergency percutaneous balloon aortic valvuloplasty in patients with severe aortic valve stenosis and cardiogenic shock. Hellenic J Cardiol 2019; 60:178-181. [DOI: 10.1016/j.hjc.2018.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 02/18/2018] [Accepted: 02/21/2018] [Indexed: 12/18/2022] Open
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Schmidt T, Frerker C. Treatment Challenges in Patients with Acute Heart Failure and Severe Aortic Valve Stenosis. Curr Cardiol Rep 2019; 21:47. [PMID: 31011842 DOI: 10.1007/s11886-019-1135-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The goal of this paper is to describe the treatment challenges in patients with aortic stenosis in combination with a reduced left ventricular function. RECENT FINDINGS Since the risk of mortality is increased in this patient population, transcatheter aortic valve implantation emerged as an important treatment option. Concomitant factors such as mitral regurgitation or coronary artery disease are important co-factors that need to be evaluated and taken into account for treatment decision. Treatment of the severe aortic stenosis is key in this complex setting. Since several co-factors may exist in addition to aortic stenosis, treatment needs to be decided by a Heart Team.
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Affiliation(s)
- Tobias Schmidt
- Department of Cardiology, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Germany.
| | - Christian Frerker
- Department of Cardiology, Asklepios Klinik St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Germany
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Frerker C. Urgent balloon aortic valvuloplasty in cardiogenic shock patients: still state of the art in the TAVI era? EUROINTERVENTION 2018; 14:e494-e495. [PMID: 30082265 DOI: 10.4244/eijv14i5a87] [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)
- Christian Frerker
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
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Debry N, Kone P, Vincent F, Lemesle G, Delhaye C, Schurtz G, Spillemaeker H, Porouchani S, Coisne A, Auffray JL, Sudre A, Lamblin N, Bonello L, Van Belle E. Urgent balloon aortic valvuloplasty in patients with cardiogenic shock related to severe aortic stenosis: time matters. EUROINTERVENTION 2018; 14:e519-e525. [PMID: 29741481 DOI: 10.4244/eij-d-18-00029] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of the study was to assess the outcomes of balloon aortic valvuloplasty (BAV) as a rescue therapy in patients with cardiogenic shock (CS) related to severe aortic stenosis (AS). METHODS AND RESULTS Forty-four consecutive patients, n=31 with hypotensive CS (HCS) and n=13 with non-hypotensive CS (NHCS) due to acutely decompensated severe AS, from two centres were treated with urgent BAV. The composite primary endpoint was mortality or recurrent CS at one-year follow-up. These patients (77.3±8.1 years old; 75% male) had a mean EuroSCORE II of 41.6±13.7%. One-month mortality was 47%. Twelve patients (27%) had either a staged TAVR (n=10) or surgical aortic valve replacement (SAVR) (n=2) with a median delay of 79 days after BAV: n=6 (19%) in the HCS subgroup and n=6 (46%) in the NHCS population (p=0.06). At one year, the rate of composite all-cause death or recurrent CS was 75% and significantly higher in the HCS subgroup (83% vs. 53%; p=0.03). Overall one-year mortality was 70% (n=31) with a trend for a better prognosis in NHCS patients (54% vs. 77%; p=0.09). Univariate predictive factors of the primary endpoint included preoperative dose of dobutamine >5 microg/kg/min (100% vs. 57%; p=0.001) and delayed BAV >48 hrs (90% vs. 59%; p=0.01). CONCLUSIONS Despite the initial success of urgent BAV, morbidity and mortality of CS related to severe AS remain high and directly related to the time of the valvuloplasty. Performing BAV before or within 48 hours of starting inotropic agents appears to be key to survival.
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Affiliation(s)
- Nicolas Debry
- Department of Cardiology, CHRU Lille, Institut Coeur-Poumon, Lille, France
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Eugène M, Urena M, Abtan J, Carrasco JL, Ghodbane W, Nataf P, Vahanian A, Himbert D. Effectiveness of Rescue Percutaneous Balloon Aortic Valvuloplasty in Patients With Severe Aortic Stenosis and Acute Heart Failure. Am J Cardiol 2018; 121:746-750. [PMID: 29397882 DOI: 10.1016/j.amjcard.2017.11.048] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 11/25/2017] [Accepted: 11/28/2017] [Indexed: 11/16/2022]
Abstract
The prognosis of patients with cardiogenic shock (CS) or refractory pulmonary edema because of severe aortic stenosis remains poor. The purpose of this study was to assess the outcomes of rescue percutaneous balloon aortic valvuloplasty (PBAV) in the transcatheter aortic valve implantation (TAVI) era. Patients were consecutively included between 2008 and 2016. CS was defined as ≥1 sign of systemic hypoperfusion and need of catecholamines. Refractory pulmonary edema was defined as not controlled by optimal medical treatment. A total of 40 patients, 22 men (55%), aged 79 ± 9 years, were included: 17 with CS (42.5%), 23 with refractory pulmonary edema (57.5%). After PBAV, mean transaortic gradient decreased from 47 ± 16 mm Hg to 32 ± 10 mm Hg (p < 0.001), aortic valve area increased from 0.60 ± 0.18 cm2 to 0.88 ± 0.22 cm2 (p < 0.0001), left ventricular ejection fraction increased from 35 ± 15 to 37 ± 14% (p = 0.02), and systolic pulmonary artery pressure decreased from 61 ± 15 to 48 ± 12 mm Hg (p = 0.002). There was no procedural death. Early death occurred in 12 patients (30%). After PBAV, 16 of the 28 survivors (57%) were bridged to surgical aortic valve replacement (SAVR; n = 7) or TAVI (n = 9), and 12 (43%) were denied definitive therapy. The 2-year estimated survival rate was 71 ± 17% after SAVR, 36 ± 19% after TAVI, and 8 ± 8% after PBAV alone. In conclusion, rescue PBAV is safe in patients with CS and high-risk aortic stenosis or refractory pulmonary edema and may improve their dismal prognosis when followed by TAVI or SAVR.
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Affiliation(s)
- Marc Eugène
- Department of Cardiology, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Marina Urena
- Department of Cardiology, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Jérémie Abtan
- Department of Cardiology, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - José-Luis Carrasco
- Department of Anesthesiology, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Walid Ghodbane
- Department of Cardiovascular Surgery, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Patrick Nataf
- Department of Cardiovascular Surgery, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Alec Vahanian
- Department of Cardiology, Bichat-Claude Bernard Hospital, AP-HP, Paris, France
| | - Dominique Himbert
- Department of Cardiology, Bichat-Claude Bernard Hospital, AP-HP, Paris, France.
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Abstract
Patients with inoperable, high-risk, and intermediate-risk aortic stenosis can now be treated with transcatheter aortic valve replacement. Centers for Medicare and Medicaid Services and the Food and Drug Administration selectively choose centers based on experience and require a collaborative, multidisciplinary team approach in the treatment and decision making for these patients. The work-up has been streamlined. Gated multislice computed tomography angiogram has emerged as the gold standard for assessment of valve anatomy and sizing of the transcatheter heart valve. Assessment of risk has evolved to include a more comprehensive functional and frailty evaluation. Long term-results are needed before the expansion of transcatheter aortic valve replacement into the low-risk category.
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Affiliation(s)
- John H Braxton
- Structural Heart Services, Marshfield Clinic, Saint Joseph Hospital, 1000 North Oak Avenue, Section 2C2, Marshfield, WI 54449, USA.
| | - Kelly S Rasmussen
- Structural Heart Services, Department of Cardiology, Marshfield Clinic, Saint Joseph Hospital, 1000 North Oak Avenue, Section 2C2, Marshfield, WI 54449, USA
| | - Milind S Shah
- Structural Heart Services, Section of Cardiology, Marshfield Clinic, Saint Joseph Hospital, 1000 North Oak Avenue, Section 2C2, Marshfield, WI 54449, USA
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Tron C, Bizios A, Durand E, Bouhzam N, Bettinger N, Eltchaninoff H. La valvuloplastie percutanée en urgence : quels patients, quels résultats ? Presse Med 2016; 45:898-902. [PMID: 27374262 DOI: 10.1016/j.lpm.2016.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 05/30/2016] [Indexed: 11/30/2022] Open
Affiliation(s)
- Christophe Tron
- CHU de Rouen, hôpital Charles-Nicolle, service de cardiologie, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France.
| | - Anna Bizios
- CHU de Rouen, hôpital Charles-Nicolle, service de cardiologie, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France
| | - Eric Durand
- CHU de Rouen, hôpital Charles-Nicolle, service de cardiologie, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France
| | - Najime Bouhzam
- CHU de Rouen, hôpital Charles-Nicolle, service de cardiologie, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France
| | - Nicolas Bettinger
- CHU de Rouen, hôpital Charles-Nicolle, service de cardiologie, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France
| | - Hélène Eltchaninoff
- CHU de Rouen, hôpital Charles-Nicolle, service de cardiologie, CHU de Rouen, 1, rue de Germont, 76000 Rouen, France
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Frerker C, Schewel J, Schlüter M, Schewel D, Ramadan H, Schmidt T, Thielsen T, Kreidel F, Schlingloff F, Bader R, Wohlmuth P, Schäfer U, Kuck KH. Emergency transcatheter aortic valve replacement in patients with cardiogenic shock due to acutely decompensated aortic stenosis. EUROINTERVENTION 2016; 11:1530-6. [PMID: 25751886 DOI: 10.4244/eijy15m03_03] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AIMS To assess outcomes of TAVR as a rescue therapy in patients with cardiogenic shock due to acutely decompensated aortic stenosis. METHODS AND RESULTS Of 771 high-risk patients who underwent TAVR, 27 (3.5%; 78±9 years; 12 men) were treated emergently due to acutely decompensated aortic stenosis with cardiogenic shock. SAPIEN and CoreValve prostheses were implanted in 11 and 16 patients, respectively: the transfemoral access route was used in 25. Three patients died within 72 hours of successful valve deployment, and a further six died within a month, giving a 30-day mortality of 33.3%, which was significantly higher than in electively treated patients (7.7%, p<0.0001). Univariate predictors of 30-day mortality in cardiogenic-shock patients were baseline cardiac output <3.0 l/min, reduced cardiac power index, impaired renal function, and mechanical ventilation, as well as severe acute kidney injury after TAVR. Estimated one-year survival was 59.3% in emergently and 82.7% in electively treated patients (p=0.0009). However, 30-day landmark analysis showed no difference in cumulative survival between TAVR modalities. In cardiogenic-shock patients without concomitant reduced cardiac output and impaired renal function at baseline (n=22), estimated one-year survival was 72.7%. CONCLUSIONS TAVR should be considered a reasonable rescue therapy in patients with cardiogenic shock secondary to decompensated aortic stenosis.
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Affiliation(s)
- Christian Frerker
- Department of Cardiology, Asklepios Klinik, St. Georg Hospital, Hamburg, Germany
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18
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Pizzighini S, Finet G, Obadia JF, Revel D, Bresson D, Rioufol G. [Emergent transcatheter aortic valve implantation in a patient with bicuspid aortic valve stenosis in cardiogenic shock]. Ann Cardiol Angeiol (Paris) 2015; 64:39-42. [PMID: 24874251 DOI: 10.1016/j.ancard.2014.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 04/08/2014] [Indexed: 06/03/2023]
Abstract
Transcatheter aortic valve implantation is a therapeutic option for high-risk patients with severe aortic valve stenosis and with cardiac symptoms. This procedure requires the preliminary evaluation by a "heart team" and presents some contraindications. We report the case of a 58-year-old man with severe bicuspid aortic valve stenosis and cardiogenic shock. In spite of contraindications and because of the failure of balloon aortic valvuloplasty, transcatheter aortic valve implantation was performed in emergency.
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Affiliation(s)
- S Pizzighini
- Service de cardiologie, filière coronaires/valves, hôpital Louis-Pradel, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron, France.
| | - G Finet
- Service de cardiologie, filière coronaires/valves, hôpital Louis-Pradel, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron, France; Service d'hémodynamique et de cardiologie interventionnelle, hôpital Louis-Pradel, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron, France
| | - J-F Obadia
- Service de chirurgie cardiaque, hôpital Louis-Pradel, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron, France
| | - D Revel
- Service de radiologie, hôpital Louis-Pradel, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron, France
| | - D Bresson
- Service de soins intensifs cardiologiques, hôpital Louis-Pradel, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron, France
| | - G Rioufol
- Service d'hémodynamique et de cardiologie interventionnelle, hôpital Louis-Pradel, hospices civils de Lyon, 59, boulevard Pinel, 69677 Bron, France
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19
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Bacterial Translocation and Plasma Cytokines During Transcatheter and Open-Heart Aortic Valve Implantation. Shock 2015; 43:62-7. [DOI: 10.1097/shk.0000000000000262] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Balloon aortic valvuloplasty in the era of transcatheter aortic valve replacement: acute and long-term outcomes. Am Heart J 2014; 167:235-40. [PMID: 24439985 DOI: 10.1016/j.ahj.2013.10.019] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 10/20/2013] [Indexed: 01/18/2023]
Abstract
BACKGROUND The use of balloon aortic valvuloplasty (BAV) has resurged since the development of transcatheter aortic valve replacement (TAVR). The aim of our study was to determine the procedural and long-term outcomes of patients treated by BAV in the early TAVR era. METHODS From 2005 to 2008, 323 consecutive patients presenting with severe aortic stenosis were treated by BAV in our institution. RESULTS Mean age and logistic EuroSCORE were 80.5 ± 9.9 years and 28.7% ± 12.5%, respectively. The effective orifice area increased from 0.68 ± 0.25 to 1.12 ± 0.39 cm(2) (P < .001) after BAV. Inhospital major complications occurred in 22 patients (6.8%), with a mortality rate of 2.5%. Eighty-five patients (26.3%) were bridged to surgical aortic valve replacement (SAVR, 9.6%) or TAVR (16.7%). Twenty-eight patients (8.7%) had at least 1 repeat BAV. Two hundred ten patients (65%) received only medical therapy post-BAV. Mean duration of follow-up was 20.7 ± 20.0 months. Kaplan-Meier analysis demonstrated that survival after single BAV was poor. Patients treated by BAV followed by SAVR or TAVR had the highest long-term survival rate (P < .001). Multivariable analysis revealed that logistic EuroSCORE, severe aortic regurgitation and stroke complications post-BAV, and medical therapy post-BAV were independent predictors of mortality. CONCLUSIONS The results of our study suggest that BAV is an acceptable bridge to SAVR or TAVR in a very high-risk population not immediately suitable for definitive therapy. Balloon aortic valvuloplasty remains only a brief temporizing procedure with a poor long-term outcome without subsequent definitive therapy.
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21
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Martinez CA, Singh V, Londoño JC, Cohen MG, Alfonso CE, O'Neill WW, Heldman AW. Percutaneous retrograde left ventricular assist support for interventions in patients with aortic stenosis and left ventricular dysfunction. Catheter Cardiovasc Interv 2012; 80:1201-9. [DOI: 10.1002/ccd.24303] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 12/03/2011] [Accepted: 12/18/2011] [Indexed: 11/08/2022]
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22
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Tissot CM, Attias D, Himbert D, Ducrocq G, Iung B, Dilly MP, Juliard JM, Lepage L, Détaint D, Messika-Zeitoun D, Nataf P, Vahanian A. Reappraisal of percutaneous aortic balloon valvuloplasty as a preliminary treatment strategy in the transcatheter aortic valve implantation era. EUROINTERVENTION 2011; 7:49-56. [DOI: 10.4244/eijv7i1a11] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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23
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Cubeddu RJ, Jneid H, Don CW, Witzke CF, Cruz-Gonzalez I, Gupta R, Rengifo-Moreno P, Maree AO, Inglessis I, Palacios IF. Retrograde versus antegrade percutaneous aortic balloon valvuloplasty: immediate, short- and long-term outcome at 2 years. Catheter Cardiovasc Interv 2009; 74:225-31. [PMID: 19434744 DOI: 10.1002/ccd.22085] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The short- and long-term vascular risks and hemodynamic benefits of antegrade versus retrograde percutaneous aortic balloon valvuloplasty (PAV) have not been clearly established. With the advent of percutaneous aortic valve replacement strategies, more valvuloplasties are being performed. The antegrade approach may reduce vascular complications, particularly in patients with peripheral vascular disease (PVD). Comparing the clinical efficacy and complications of each technique is warranted. METHODS A cohort of 157 consecutive patients undergoing PAV between 2000 and 2006 were included in the study. Of these, 46 (29%) patients underwent antegrade PAV and 111 (71%) retrograde PAV. Choice of vascular approach (antegrade or retrograde) were determined by operator preference. The rate of death, nonfatal vascular complications, and 2-year survival was explored. RESULTS The mean age of the study population was 79 years. Patients undergoing antegrade PAV were more likely hypertensive (56% vs. 39%, P = 0.001) with PVD (41% vs. 18%, P = 0.004). Nevertheless, logistic Euroscores were no different between the groups (antegrade 18% vs. retrograde 14%; P = 0.30). Baseline and postprocedural valve areas were also similar. However, patients undergoing antegrade PAV had significantly fewer vascular complications (2% vs. 19%; P = 0.005). Two-year follow-up revealed no significant difference in death (antegrade 81% vs. retrograde 69%; P = 0.16), stroke, congestive heart failure, and surgical aortic valve replacement. CONCLUSIONS The hemodynamic benefit of PAV occurs regardless of the selected vascular approach. The antegrade technique results in significantly fewer vascular complications and similar long-term outcomes. Antegrade PAV is feasible and safe, particularly in patients with PVD.
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Affiliation(s)
- Roberto J Cubeddu
- Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Buchwald AB, Meyer T, Scholz K, Schorn B, Unterberg C. Efficacy of balloon valvuloplasty in patients with critical aortic stenosis and cardiogenic shock--the role of shock duration. Clin Cardiol 2009; 24:214-8. [PMID: 11288967 PMCID: PMC6655224 DOI: 10.1002/clc.4960240308] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Because of limited long-term success, aortic balloon valvuloplasty is considered to be a palliative procedure, including patients at excessive risk for standard therapy-aortic valve replacement-that is, those in cardiogenic shock. HYPOTHESIS The study was undertaken to evaluate the outcome of balloon valvuloplasty for critical aortic stenosis complicated by cardiogenic shock. METHODS Over a 10-year-period, we followed 14 patients (age 74+/-11 years, range 50-91) presenting in cardiogenic shock and critical aortic stenosis, who underwent valvuloplasty, together with 19 patients with critical aortic stenosis requiring urgent major noncardiac surgery. RESULTS In patients in shock, calculated aortic valve area could be increased successfully by at least 0.3 cm2, from 0.38+/-0.09 to 0.81+/-0.12 cm2, with an insignificant increase in cardiac index from 1.89+/-0.33 to 2.01+/-0.41 l/min * m2. In-hospital mortality was 71% (10 patients). Two patients underwent valve replacement within 16 days and survived after 1 year, as did two patients refusing surgery. By multivariate logistic regression analysis, only an interval between onset of shock symptoms and valvuloplasty of > 48 h was significantly associated with fatal outcome (p < 0.01). In those patients requiring noncardiac surgery, this was possible after valvuloplasty in 95% who survived 1 year after hospital discharge. One patient in this group died of pulmonary embolism the day after the procedure. CONCLUSION These data support the concept of causal treatment in patients with cardiogenic shock, as well as in the setting of cardiogenic shock and critical aortic stenosis, at the earliest possible convenience.
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Affiliation(s)
- A B Buchwald
- Departments of Cardiology Surgery, University Clinic Göttingen, Germany
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25
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Ferrari M, Figulla HR, Schlosser M, Tenner I, Frerichs I, Damm C, Guyenot V, Werner GS, Hellige G. Transarterial aortic valve replacement with a self expanding stent in pigs. Heart 2004; 90:1326-31. [PMID: 15486135 PMCID: PMC1768554 DOI: 10.1136/hrt.2003.028951] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To evaluate the feasibility of percutaneous aortic valve replacement without cardiac arrest in animal experiments. METHODS A self expanding nitinol stent, containing pulmonary valves from pigs in its proximal part, was implanted in six pigs (94-118 kg) by means of a 25 French catheter through the left subclavian artery under guidance of fluoroscopy and transoesophageal echocardiography. During stent deployment the original aortic valve was pushed against the aortic wall by the self expanding force of the stent while the new valve was expanded. RESULTS It was possible to replace the aortic valve in the beating heart in four pigs (67%) with no complication or relevant drop in blood pressure. The procedure failed in two pigs (33%) due to dysfunction of the catheter device in one case and to problems with correct positioning in the left ventricular outflow tract in the other. After successful stent valve implantation, dopamine was infused in doses of 5 microg/kg/min, 10 microg/kg/min, and 15 microg/kg/min. Cardiac output increased from 4.4 to 8.8 l/min and the mean arterial pressure rose from 79 to 105 mm Hg. The maximum peak to peak pressure gradient across the valve carrying stent reached a maximum of 8 mm Hg under dopamine infusion. All pigs were killed six hours after transvascular aortic valve replacement. The chest was opened, and the left ventricle and the ascending aorta were carefully inspected. There were no signs of malfunction of the implant, of damage of the aortic vessel wall, or of obstruction of the coronary ostia. CONCLUSIONS Percutaneous aortic valve replacement with a self expanding nitinol stent in the beating heart is possible. The device was safe under pharmacological stress test. After successful chronic animal experiments, this concept may become a feasible option for treating patients with relevant aortic valve disease but where open heart surgery would be risky.
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Affiliation(s)
- M Ferrari
- Clinic of Internal Medicine I, Friedrich-Schiller University, Erlanger Allee 101, D-07740 Jena, Germany.
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Melzer C, Gliech V, Baumann G, Theres H. Severe aortic stenosis and reduced ejection fraction: intensive care treatment. Intensive Care Med 2001; 27:617. [PMID: 11355138 DOI: 10.1007/s001340100864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sprigings DC, Forfar JC. How should we manage symptomatic aortic stenosis in the patient who is 80 or older? BRITISH HEART JOURNAL 1995; 74:481-4. [PMID: 8562230 PMCID: PMC484065 DOI: 10.1136/hrt.74.5.481] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- D C Sprigings
- Department of Medicine, Northampton General Hospital
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28
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Moreno PR, Jang IK, Newell JB, Block PC, Palacios IF. The role of percutaneous aortic balloon valvuloplasty in patients with cardiogenic shock and critical aortic stenosis. J Am Coll Cardiol 1994; 23:1071-5. [PMID: 8144770 DOI: 10.1016/0735-1097(94)90592-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES The goal of this study was to evaluate the role of percutaneous aortic valvuloplasty in patients with cardiogenic shock due to severe aortic stenosis and associated major comorbid conditions and to establish predictors of survival. BACKGROUND The prognosis for patients in cardiogenic shock with severe aortic stenosis is poor. Aortic valve replacement can be lifesaving, but the presence of multiorgan failure precludes these patients from operation. Percutaneous aortic balloon valvuloplasty has been used in these patients with short-term improvement and could be an alternative therapeutic option. METHODS Of 310 patients undergoing percutaneous aortic balloon valvuloplasty, 21 were in cardiogenic shock and were included in this study. All 21 patients had associated major comorbid conditions at the time of presentation. RESULTS After percutaneous aortic balloon valvuloplasty, systolic aortic pressure increased from 77 +/- 3 (mean +/- SEM) to 116 +/- 8 mm Hg (p = 0.0001); aortic valve area increased from 0.48 +/- 0.04 to 0.84 +/- 0.06 cm2 (p = 0.0001); and cardiac index increased from 1.84 +/- 0.13 to 2.24 +/- 0.15 liters/min per m2 (p = 0.06). Nine patients died in the hospital, two during the procedure and seven after successful percutaneous aortic balloon valvuloplasty (five from multiorgan failure). Five patients had vascular complications. Stroke, cholesterol emboli and aortic regurgitation requiring aortic valve replacement occurred in one patient each. Twelve patients (57%) survived and were followed up for 15 +/- 6 months; five patients subsequently died. The Kaplan-Meier survival curve showed a 38 +/- 11% survival rate at 27 months. The only predictor for longer survival rate was the postprocedure cardiac index. CONCLUSIONS 1) Emergency percutaneous aortic balloon valvuloplasty can be performed successfully as a lifesaving procedure. 2) Morbidity and mortality remain high despite successful percutaneous aortic balloon valvuloplasty. 3) For nonsurgical candidates, percutaneous aortic balloon valvuloplasty may be the only therapeutic alternative.
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Affiliation(s)
- P R Moreno
- Cardiac Unit, Massachusetts General Hospital, Boston 02114
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30
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Affiliation(s)
- I F Goldenberg
- Research Division, Minneapolis Heart Institute Foundation 55407
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