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Del Portillo JH, Farjat-Pasos J, Galhardo A, Avvedimento M, Mas-Peiro S, Mengi S, Nuche J, Mohammadi S, Rodés-Cabau J. Aortic Stenosis With Coronary Artery Disease: SAVR or TAVR-When and How? Can J Cardiol 2024; 40:218-234. [PMID: 37758014 DOI: 10.1016/j.cjca.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/10/2023] [Accepted: 09/19/2023] [Indexed: 10/03/2023] Open
Abstract
The growing number of candidates for transcatheter aortic valve replacement (TAVR) has increased the interest in the concomitant presence of coronary artery disease (CAD) and severe aortic stenosis (AS), prompting the need to define the appropriate revascularization strategy for each case. The reported prevalence of concurrent AS and CAD has varied over the years on the basis of the CAD definition and the population evaluated. Revascularization for treating CAD in patients with severe AS involves additional interventions that could impact outcomes. The addition of coronary artery bypass grafting (CABG) to surgical aortic valve replacement (SAVR) has demonstrated favourable effects on long-term prognosis, while the impact of adding percutaneous coronary intervention (PCI) to TAVR may depend on the CAD complexity and the feasibility of achieving complete or reasonably incomplete revascularization. Furthermore, the comparison between SAVR+CABG and TAVR+PCI in low-intermediate surgical risk and low-intermediate complex CAD patients did not reveal differences in all-cause mortality or stroke between the groups. However, there is some evidence showing a lower incidence of major cardiovascular events with the SAVR+CABG strategy for patients with complex CAD. Thus, SAVR+CABG seems to be the best option for patients with low-intermediate surgical risk and complex CAD, and TAVR+PCI for high surgical risk patients seeking complete and/or reasonable incomplete revascularization. After deciding between TAVR+PCI or SAVR+CABG, factors such as timing for PCI, low ejection fraction, coronary reaccess, and valve durability must be considered. Finally, alternative methods for assessing CAD severity are currently under evaluation to ascertain their real value for guiding revascularization in patients with severe AS with CAD.
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Affiliation(s)
| | - Julio Farjat-Pasos
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Attilio Galhardo
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Marisa Avvedimento
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Silvia Mas-Peiro
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Siddhartha Mengi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Jorge Nuche
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Siamak Mohammadi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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2
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Yassen M, Moustafa A, Venkataramany B, Schodowski E, Royfman R, Eltahawy E. Clinical Outcomes of Transcatheter Aortic Valve Replacement With and Without Percutaneous Coronary Intervention-An Updated Meta-Analysis and Systematic Review. Curr Probl Cardiol 2023; 48:101980. [PMID: 37473936 DOI: 10.1016/j.cpcardiol.2023.101980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/16/2023] [Indexed: 07/22/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is indicated for high-risk patients with severe degenerative aortic stenosis (AS). Given the shared risk factors and coexistence of obstructive coronary artery disease (CAD) and AS, there is inconsistent clinical data regarding potential survival benefits of paired percutaneous coronary intervention (PCI) with TAVR procedures. We performed a literature search using PubMed, Embase, and Cochrane Library from inception through June 2023 assessing the impact of concomitant PCI in patients with obstructive CAD undergoing TAVR. The primary outcomes were 30-day all-cause mortality, 30-day cardiovascular mortality, and 6 months-1 year all-cause mortality. Secondary outcomes included 30-day myocardial infarction, stroke, major bleeding complications, and acute kidney injury (AKI). A total of 11 studies involving 2804 patients were included in the final analysis. Compared to patients undergoing TAVR alone, the TAVR+PCI group showed no significant difference in 30-day all-cause mortality (RR 0.90, CI 0.66, 1.22, P = 0.49), 30-day cardiovascular mortality (RR 0.71 CI 0.44, 1.14, P = 0.16), or 6 months-1 year all-cause mortality (RR 0.94, CI 0.75, 1.18, P = 0.57). Regarding secondary outcomes, 30-day myocardial infarction was higher in the TAVR+PCI group (RR 3.09, CI 1.26, 7.57, P = 0.01), with no significant differences noted in rates of 30-day stroke (RR 1.14, CI 0.56, 2.33, P = 0.72), major bleeding/vascular complications (RR 1.11, CI 0.79, 1.56, P = 0.55), and AKI (RR 1.07, CI 0.75, 1.54, P = 0.71). Concomitant PCI does not confer any mortality benefit in patients with obstructive CAD and high-grade AS undergoing TAVR. Further trials are needed to confirm our findings.
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Affiliation(s)
- Mohammad Yassen
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio, United States.
| | - Abdelmoniem Moustafa
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Toledo Medical Center, Toledo, Ohio, United States
| | - Barat Venkataramany
- University of Toledo, College of Medicine and Life Sciences, Toledo, Ohio, United States
| | - Eve Schodowski
- University of Toledo, College of Medicine and Life Sciences, Toledo, Ohio, United States
| | - Rachel Royfman
- University of Toledo, College of Medicine and Life Sciences, Toledo, Ohio, United States
| | - Ehab Eltahawy
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Toledo Medical Center, Toledo, Ohio, United States
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Faerber G, Mukharyamov M, Doenst T. Is There a Future for Minimal Access and Robots in Cardiac Surgery? J Cardiovasc Dev Dis 2023; 10:380. [PMID: 37754809 PMCID: PMC10531980 DOI: 10.3390/jcdd10090380] [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: 07/31/2023] [Revised: 08/27/2023] [Accepted: 08/29/2023] [Indexed: 09/28/2023] Open
Abstract
Minimally invasive techniques in cardiac surgery have found increasing use in recent years. Both patients and physicians often associate smaller incisions with improved outcomes (i.e., less risk, shorter hospital stay, and a faster recovery). Videoscopic and robotic assistance has been introduced, but their routine use requires specialized training and is associated with potentially longer operating times and higher costs. Randomized evidence is scarce and transcatheter treatment alternatives are increasing rapidly. As a result, the concept of minimally invasive cardiac surgery may be viewed with skepticism. In this review, we examine the current status and potential future perspectives of minimally invasive and robotic cardiac surgery.
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Affiliation(s)
| | | | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena, Germany
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4
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Huang B, Yan H, Li Y, Zhou Q, Abudoureyimu A, Cao G, Jiang H. Transcatheter Aortic Valve Replacement in Elderly Patients: Opportunities and Challenges. J Cardiovasc Dev Dis 2023; 10:279. [PMID: 37504535 PMCID: PMC10380827 DOI: 10.3390/jcdd10070279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023] Open
Abstract
Over the past two decades, the rapid evolution of transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe aortic stenosis (AS) in the elderly. The prevalence of comorbidities in elderly AS patients presents a considerable challenge to the effectiveness and prognosis of patients after TAVR. In this article, we aim to summarize some of the clinical aspects of the current use of TAVR in elderly patients and attempt to highlight the challenges and issues that need further consideration.
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Affiliation(s)
- Bing Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Hui Yan
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Yunyao Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Qiping Zhou
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Ayipali Abudoureyimu
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Guiqiu Cao
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
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5
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Maeda M, Sakamoto SI, Murata T, Hiromoto A, Suzuki K, Ishii Y. Multiple cardiac surgical procedures in a case of an octogenarian with essential thrombocythemia. Surg Case Rep 2023; 9:96. [PMID: 37277566 DOI: 10.1186/s40792-023-01682-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 06/01/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Essential thrombocythemia (ET) is a chronic myeloproliferative disorder characterized by an elevation of platelet counts with a tendency for thrombosis and hemorrhage. The perioperative management of cardiovascular surgery of an ET patient is complicated. There is limited literature on the perioperative management of patients with ET undergoing cardiovascular surgery, particularly those requiring multiple procedures. CASE PRESENTATION An 85-year-old woman with a history of essential thrombocythemia (ET), which resulted in an abnormally high platelet count, was diagnosed with aortic valve stenosis, ischemic heart disease and paroxysmal atrial fibrillation. She underwent aortic valve replacement, coronary artery bypass grafting, and pulmonary vein isolation. The postoperative course was uneventful, nor hemorrhage and thrombosis. CONCLUSIONS We represent a case of perioperative management and successful treatment of three combined cardiac surgery for an octogenarian ET patient who is the oldest case ever reported.
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Affiliation(s)
- Motohiro Maeda
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-396 Kosugi-Cho, Nakahara-Ku, Kawasaki-Shi, Kanagawa, 211-8533, Japan
| | - Shun-Ichiro Sakamoto
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-396 Kosugi-Cho, Nakahara-Ku, Kawasaki-Shi, Kanagawa, 211-8533, Japan.
| | - Tomohiro Murata
- Department of Cardiovascular Surgery, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
| | - Atsushi Hiromoto
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-396 Kosugi-Cho, Nakahara-Ku, Kawasaki-Shi, Kanagawa, 211-8533, Japan
| | - Kenji Suzuki
- Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital, 1-396 Kosugi-Cho, Nakahara-Ku, Kawasaki-Shi, Kanagawa, 211-8533, Japan
| | - Yosuke Ishii
- Department of Cardiovascular Surgery, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-Ku, Tokyo, 113-8603, Japan
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Haseeb ul Rasool M, Saleem M, Nadeem M, Maqbool M, Aziz AA, Fox JM, Suleiman A. The Role of Transcatheter Aortic Valve Replacement in Asymptomatic Aortic Stenosis: A Feasibility Analysis. Cureus 2022; 14:e29522. [PMID: 36312695 PMCID: PMC9589522 DOI: 10.7759/cureus.29522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2022] [Indexed: 11/26/2022] Open
Abstract
Surgical aortic valve replacement (SAVR) is the current treatment of choice for good surgical candidates with moderate to severe symptomatic aortic stenosis (AS). As transcatheter aortic valvular replacement (TAVR) has shown an improved one and two-year all-cause mortality, it has been chosen for moderately symptomatic severe AS patients. The purpose of this review was to perform a clinical comparison of TAVR vs. SAVR and to analyze the Health Index Factor (HIF) that makes TAVR a treatment of choice in asymptomatic AS patients. An extensive literature search of PubMed, Cochrane, and Embase databases was performed using the keywords “Aortic stenosis”, “SAVR”, “TAVR”, and “Asymptomatic”. A total of 45 prospective randomized clinical trials in the English language that were published from the year 2000 onwards were included in the final analysis. It has been found that 59.3% of asymptomatic AS patients are likely to die in the next five years without proactive treatment. Multiple studies have proven that early intervention with aortic valve replacement is superior to conservative treatment in severe asymptomatic AS; however, the choice between SAVR and TAVR is not well established. The NOTION Trial, SURTAVI Trail, and PARTNER 3 study have shown the non-inferiority of TAVR over SAVR, during one-year follow-up for low surgical risk patients. Evolut Low-Risk study and Early TAVR are the only two prospective studies performed to date that have enrolled patients with asymptomatic severe AS. The Evolut Trial demonstrated no difference in all-cause mortality at 30 days (1.3% vs. 4.8%. p=0.23), and 12 days (1.3% vs. 6.5%, p=0.11). Additionally, TAVR also decreases the risk of post-procedural atrial fibrillation, acute kidney injury (AKI), and rehospitalization, and leads to significant improvement in the mean trans-aortic pressure gradient. TAVR also showed marked improvement in the 30-day Quality of Life (QOL) index, where SAVR did not report any significant change in the QOL index. However, the official recommendations of Early TAVR are still awaited. TAVR has consistently shown a statistically non-significant difference in case mortality, risk of stroke, and rehospitalization with moderate to high surgical risk patients whereby recent initial trials have shown significant improvement in the QOL index and hemodynamic index for patients with asymptomatic disease. More extensive studies are required to prove the risk stratifications, long-term outcomes, and clinical characteristics that would make TAVR a preferred intervention in asymptomatic patients.
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Koren O, Patel V, Naami R, Naami E, Nagasaka T, Shechter A, Natanzon SS, Kohan S, Allison Z, Lerner A, Cheng DE, Chakravarty T, Nakamura M, Cheng W, Jilaihawi H, Makkar RR. New adverse coronary events in valve-in-valve TAVR and native TAVR—A 2-year matched cohort. Front Cardiovasc Med 2022; 9:1004103. [PMID: 36211543 PMCID: PMC9532571 DOI: 10.3389/fcvm.2022.1004103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/29/2022] [Indexed: 12/05/2022] Open
Abstract
Objective To assess the incidence of new adverse coronary events (NACE) following transcatheter aortic valve replacement (TAVR) and valve-in-valve TAVR (ViV-TAVR). Background ViV-TAVR is an accepted treatment for degenerative prostheses among patients with high surgical-risk. TAVR studies have suggested an increased risk of coronary artery obstruction and flow stasis causing thrombus formation. Whether contemporary ViV-TAVR is associated with higher rate of coronary events compared to TAVR is unknown. Methods We used data from 1,224 TAVR patients between 2016 and 2021. We propensity-matched patients following ViV-TAVR and TAVR by significant predictors to overcome confounders in patients' baseline characteristics and procedural factors. Results The matched population included 129 patients in each group. In line with prior reports, there was a higher in-hospital coronary artery obstruction rate with ViV-TAVR (3.1 vs. 1.6%; p = 0.23). Despite this, 2-year cumulative NACE rates were similar between groups (4.7 vs. 6.2%, respectively, p = 0.79), with no difference between its components: myocardial infarction (MI) (p = 0.210), unplanned coronary catheterization (p = 0.477), or coronary artery bypass grafting (CABG) (p = 0.998). Moreover, hypoattenuated leaflets thickening (HALT) at 30-day CT was observed in nearly a quarter of the patients with no difference between groups (23.9 vs. 23.1%, HR 1.02, 95% CI 0.50–1.28, p = 0.872). The progression rate of the coronary artery calcium score (CACS), assessed in a third of patients, was similar between groups (p log-rank = 0.468, 95% CI 0.12–1.24). Low coronary artery height was an unfavorable predictor for in-hospital coronary obstruction and 2-year NACE rate (HR 1.20 and HR 1.25, p = 0.001 and p < 0.0001, respectively). Conclusion At 2-year follow-up, ViV-TAVR was not associated with a higher rate of myocardial infarction, unplanned catheterization, coronary artery bypass grafting, or hypoattenuated leaflet thickening.
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Affiliation(s)
- Ofir Koren
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
- Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Vivek Patel
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Robert Naami
- Internal Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Edmund Naami
- School of Medicine, University of Illinois, Chicago, IL, United States
| | - Takashi Nagasaka
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
- The Department of Cardiology, Gunma University Hospital, Gunma, Japan
| | - Alon Shechter
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Siamak Kohan
- Internal Medicine, Kaiser Permanente Medical Center, Los Angeles, CA, United States
| | - Zev Allison
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Addee Lerner
- David Geffen School of Medicine, University of California (UCLA), Los Angeles, Los Angeles, CA, United States
| | - Daniel Eugene Cheng
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Tarun Chakravarty
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Mamoo Nakamura
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Wen Cheng
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Hasan Jilaihawi
- Heart Valve Center, NYU Langone Health, New York, NY, United States
| | - Raj R. Makkar
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
- *Correspondence: Raj R. Makkar
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8
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Lunardi M, Venturi G, Del Sole PA, Ruzzarin A, Mainardi A, Pighi M, Pesarini G, Scarsini R, Tavella D, Gottin L, Ribichini FL. Optimal timing for percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation. Int J Cardiol 2022; 365:114-122. [PMID: 35870638 DOI: 10.1016/j.ijcard.2022.07.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The best timing to perform percutaneous coronary interventions (PCI) in patients undergoing TAVI is unknown. Most PCI are performed before TAVI, because of concerns about potential ischemic complications during valve implantation. In this study we aimed to compare short-and long-term outcomes of patients undergoing PCI before or after TAVI. METHODS Patients undergoing TAVI and PCI from 2010 to 2021 were analyzed. PCI was defined as high-risk when involving unprotected left main, proximal left anterior descending, proximal dominant right coronary artery or 3-vessel disease. The primary endpoint was the cumulative incidence of any TAVI procedural complication and in-hospital adverse events (VARC-3 criteria). RESULTS Out of 1162 patients, 144 underwent PCI, 68% after TAVI, 78.4% of which were at high-risk. The primary endpoint occurred in 28.4% of patients in PCI pre-TAVI group vs 21.4% in PCI post-TAVI group (p = 0.403) and in 34.4% vs 17.3% of patients respectively among high-risk patients (p = 0.075). A higher rate of stroke was observed in the PCI pre-TAVI group regardless of the PCI complexity (6.5% vs 0.0%, p = 0.031; 9.3% vs 0.0% p = 0.025 in the high-risk group). At 24 months, MACCE-free survival was lower in patients who underwent PCI before TAVI (84.4% vs 97.9%, adjusted HR 10.16, 95% CI 1.19-86.57, p = 0.019; and 84.4% vs 97.3%, adjusted HR 7.34 95% CI 0.78-62.28 p = 0.082 in the high-risk group). CONCLUSIONS PCI performed after TAVI does not expose patients to higher risks of peri-procedural hazards and provides a trend towards favourable clinical outcome at mid-to-long term.
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Affiliation(s)
- Mattia Lunardi
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | - Gabriele Venturi
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | | | | | - Andrea Mainardi
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | - Michele Pighi
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | - Gabriele Pesarini
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | - Roberto Scarsini
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | - Domenico Tavella
- Cardiology Division, Department of Medicine, University of Verona, Italy
| | - Leonardo Gottin
- Division of Cardio-Thoracic Anesthesiology and Intensive Care, Department of Surgery, University of Verona, Verona, Italy
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Staged versus concomitant transcatheter aortic valve replacement and percutaneous coronary intervention: A national analysis. JTCVS OPEN 2022; 10:148-161. [PMID: 36004248 PMCID: PMC9390561 DOI: 10.1016/j.xjon.2022.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/17/2022] [Indexed: 11/24/2022]
Abstract
Objective Methods Results Conclusions
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10
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de Azevedo Filho AF, Accorsi TA, Ribeiro HB. Coronary Artery Disease in Patients with Aortic Stenosis and Transcatheter Aortic Valve Implantation: Implications for Management. Eur Cardiol 2021; 16:e49. [PMID: 34950245 PMCID: PMC8674631 DOI: 10.15420/ecr.2021.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/16/2021] [Indexed: 01/09/2023] Open
Abstract
Aortic valve stenosis (AS) is the most common valvular heart disease among elderly patients. Since the pathophysiology of degenerative AS shares common pathways with atherosclerotic disease, the severity of AS in the elderly population is often concurrent to the presence of coronary artery disease (CAD). Although surgical aortic valve replacement has been the standard treatment for severe AS, the high operative morbidity and mortality in complex and fragile patients was the trigger to develop less invasive techniques. Transcatheter aortic valve implantation (TAVI) has been posed as the standard of care for elderly patients with severe AS with various risk profiles, which has meant that the concomitant management of CAD has become a crucial issue in such patients. Given the lack of randomised controlled trials evaluating the management of CAD in TAVI patients, most of the recommendations are based on retrospective cohort studies so that the Heart Team approach – together with an assessment of multiple parameters including symptoms and clinical characteristics, invasive and non-invasive ischaemic burden and anatomy – are crucial for the proper management of these patients. This article provides a review of current knowledge about assessment and therapeutic approaches for CAD and severe AS in patients undergoing TAVI.
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Affiliation(s)
| | - Tarso Ad Accorsi
- Department of Valvular Heart Disease, Heart Institute (InCor), University of São Paulo São Paulo, Brazil.,Samaritano Paulista Hospital São Paulo, Brazil
| | - Henrique B Ribeiro
- Samaritano Paulista Hospital São Paulo, Brazil.,Interventional Cardiology Department, Heart Institute (InCor), University of São Paulo São Paulo, Brazil
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11
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Shroff GR, Bangalore S, Bhave NM, Chang TI, Garcia S, Mathew RO, Rangaswami J, Ternacle J, Thourani VH, Pibarot P. Evaluation and Management of Aortic Stenosis in Chronic Kidney Disease: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e1088-e1114. [PMID: 33980041 DOI: 10.1161/cir.0000000000000979] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aortic stenosis with concomitant chronic kidney disease (CKD) represents a clinical challenge. Aortic stenosis is more prevalent and progresses more rapidly and unpredictably in CKD, and the presence of CKD is associated with worse short-term and long-term outcomes after aortic valve replacement. Because patients with advanced CKD and end-stage kidney disease have been excluded from randomized trials, clinicians need to make complex management decisions in this population that are based on retrospective and observational evidence. This statement summarizes the epidemiological and pathophysiological characteristics of aortic stenosis in the context of CKD, evaluates the nuances and prognostic information provided by noninvasive cardiovascular imaging with echocardiography and advanced imaging techniques, and outlines the special risks in this population. Furthermore, this statement provides a critical review of the existing literature pertaining to clinical outcomes of surgical versus transcatheter aortic valve replacement in this high-risk population to help guide clinical decision making in the choice of aortic valve replacement and specific prosthesis. Finally, this statement provides an approach to the perioperative management of these patients, with special attention to a multidisciplinary heart-kidney collaborative team-based approach.
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12
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Aortic Valve Disease and Associated Complex CAD: The Interventional Approach. J Clin Med 2021; 10:jcm10050946. [PMID: 33804391 PMCID: PMC7957505 DOI: 10.3390/jcm10050946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/19/2021] [Accepted: 02/20/2021] [Indexed: 01/09/2023] Open
Abstract
Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis (AS). The management of CAD is a central aspect of the work-up of patients undergoing transcatheter aortic valve implantation (TAVI), but few data are available on this field and the best percutaneous coronary intervention (PCI) practice is yet to be determined. A major challenge is the ability to elucidate the severity of bystander coronary stenosis independently of the severity of aortic valve stenosis and subsequent impact on blood flow. The prognostic role of CAD in patients undergoing TAVI is being still debated and the benefits and the best timing of PCI in this context are currently under evaluation. Additionally, PCI in the setting of advanced AS poses some technical challenges, due to the complex anatomy, risk of hemodynamic instability, and the increased risk of bleeding complications. This review aims to provide a comprehensive synthesis of the available literature on myocardial revascularization in patients with severe AS undergoing TAVI. This work can assist the Heart Team in individualizing decisions about myocardial revascularization, taking into account available diagnostic tools as well as the risks and benefits.
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13
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Short-and-Long-Term Outcomes after Coronary Rotational Atherectomy in Patients Treated with Trans-Catheter Aortic Valve Implantation. J Clin Med 2020; 10:jcm10010112. [PMID: 33396185 PMCID: PMC7796033 DOI: 10.3390/jcm10010112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 01/05/2023] Open
Abstract
Background. Coronary artery disease (CAD) is a common finding among patients undergoing trans-catheter aortic valve implantation (TAVI), who often present severely calcified coronary lesions. Evidence is scarce about the use of rotational atherectomy (RA) in this setting, in particular regarding long-term outcome. Methods. RA was performed on severely calcified coronary lesions concomitant with TAVI in a consecutive series of patients treated between 2010 and 2020. Immediate and long-term clinical outcomes are reported. Results. A concomitant CAD (coronary stenosis visually > 50%) was observed in 402/845 (47.6%) consecutive patients undergoing TAVI at the University Hospital of Verona. Angioplasty was performed in 104 patients (12.3%). Among these, 19 patients (18.3%, 20 coronary arteries), were treated with RA after TAVI: 10 after implantation of a balloon-expandable trans-catheter valve and 9 after a self-expandable valve. All procedures were successful. Hypotension occurred in 3 patients (15.8%), with rapid recovery after the procedure; CI-AKI (contrast-induced acute kidney injury) in 3 patients (15.8%), of which two recovered within discharge. At a median follow-up of 21.5 months (Q1–3: 6–36) event free survival was 83.3%. Only one patient suffered a target vessel failure >2 years after RA. Neither stroke nor peri-procedural infarctions were detected. Conclusions. RA concomitant with TAVI was feasible and safe in patients treated with implantation of either self-expandable, or balloon-expandable trans-catheter aortic valves. Long-term clinical events related to the coronary procedure were extremely infrequent and the survival rate at median follow-up of 21.5 months was 83.3%.
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14
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Gupta H, Kaur N, Sharma Y, Barwad P. ROTAVI: simultaneous left main rotablation and transcutaneous aortic valve implantation in calcified coronaries and severe aortic stenosis - a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-5. [PMID: 33204950 PMCID: PMC7649449 DOI: 10.1093/ehjcr/ytaa196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/16/2020] [Accepted: 06/09/2020] [Indexed: 11/30/2022]
Abstract
Background There is a high incidence of calcified coronary artery disease in patients with severe valvular aortic stenosis (AS). With transcutaneous aortic valve replacement (TAVR) as one of the promising options for severe AS in high and intermediate surgical risk patients; we will encounter more and more patients who will require both complex percutaneous coronary intervention (PCI) with rotablation (RA) and TAVR. The timing of PCI in patients undergoing TAVR; however remains indecisive. Due to the complexity of procedures and the risks involved, very few cases of concomitant TAVR and coronary RA have been reported so far. Case summary Seventy-five years old high surgical risk female had severe AS with calcified left main (LM) distal and ostial left anterior descending (LAD) artery lesion. Successful PCI with RA to LM-LAD lesion was done followed by uneventful transfemoral TAVR in the same setting. Discussion This is probably one of the very few cases reported where PCI to LM with RA and TAVR was done successfully in the same setting. Since the calcified lesion was focal and left ventricular ejection fraction of the patient was normal, we went ahead with PCI without prior balloon dilatation of aortic valve (BAV) which was a deviation from the prior reported cases, where BAV was performed prior to complex PCI to improve the cardiac output. We herein discuss our case and thoughts about concomitant complex PCI and TAVR.
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Affiliation(s)
- Himanshu Gupta
- Department of Cardiology, PGIMER, Chandigarh 160012, India
| | - Navjyot Kaur
- Department of Cardiology, PGIMER, Chandigarh 160012, India
| | | | - Parag Barwad
- Department of Cardiology, PGIMER, Chandigarh 160012, India
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15
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Ghobrial MSA, Khan K, Baguneid M, Levy RD. Transcatheter aortic valve implantation facilitated by right common carotid cut-down and innominate artery angioplasty with simultaneous right coronary artery vein graft percutaneous coronary intervention in a patient with mid aortic syndrome: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-5. [PMID: 32974444 PMCID: PMC7501900 DOI: 10.1093/ehjcr/ytaa134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/08/2017] [Accepted: 04/29/2020] [Indexed: 11/14/2022]
Abstract
Background Transcatheter aortic valve implantation (TAVI) is most commonly performed via the femoral approach. Small caliber ilio-femoral arteries, severe calcification and tortuosity are often prohibitive reasons for TAVI via the femoral approach. Mid-aortic syndrome is a rare condition describing congenital or acquired coarctation of the abdominal aorta. Case summary To the best of our knowledge, this case report describes the world's first TAVI in a patient with mid-aortic syndrome with challenging vascular access that would preclude conventional TAVI access routes. A 76-year-old woman with intermittent claudication, underwent work-up for axillo-bifemoral bypass, underwent a TAVI for incidental severe asymptomatic severe aortic stenosis via right common carotid TAVI facilitated by innominate artery angioplasty achieved vascular access for TAVI. Percutaneous coronary intervention to a right coronary artery vein graft was simultaneously performed via a left brachial artery cut down. Discussion We demonstrate that complex angioplasty to coronary artery bypass grafts and the innominate artery alongside TAVI via a variety of arterial access sites is both safe and feasible.
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Affiliation(s)
- Mina S A Ghobrial
- Department of Cardiology, Freeman Hospital, Freeman Road, High Heaton, Newcastle NE7 7DN, UK
| | - Kamal Khan
- Department of Cardiology, University Hospital South Manchester, Manchester, UK
| | - Mohamed Baguneid
- Department of Vascular Surgery, University Hospital South Manchester, Manchester, UK
| | - Richard D Levy
- Department of Cardiology, University Hospital South Manchester, Manchester, UK
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16
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Coronary Artery Disease and Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 74:362-372. [PMID: 31319919 DOI: 10.1016/j.jacc.2019.06.012] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/10/2019] [Indexed: 01/09/2023]
Abstract
About one-half of transcatheter aortic valve replacement (TAVR) candidates have coronary artery disease (CAD), and controversial results have been reported regarding the effect of the presence and severity of CAD on clinical outcomes post-TAVR. In addition to coronary angiography, promising data has been recently reported on both the use of computed tomography angiography and the functional invasive assessment of coronary lesions in the work-up pre-TAVR. While waiting for the results of ongoing randomized trials, percutaneous revascularization of significant coronary lesions has been the routine strategy in TAVR candidates with CAD. Also, scarce data exists on the incidence, characteristics, and management of coronary events post-TAVR, and increasing interest exist on potential coronary access challenges in patients requiring coronary angiography/intervention post-TAVR. This review provides an updated overview of the current landscape of CAD in TAVR recipients, focusing on its prevalence, clinical impact, pre- and post-procedural evaluation and management, unresolved issues and future perspectives.
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17
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Harky A, Suen MMY, Wong CHM, Maaliki AR, Bashir M. Bioprosthetic Aortic Valve Replacement in <50 Years Old Patients - Where is the Evidence? Braz J Cardiovasc Surg 2019; 34:729-738. [PMID: 31112031 PMCID: PMC6894029 DOI: 10.21470/1678-9741-2018-0374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Aortic valve disease is one of the most common valvular heart diseases in the cardiovascular category. Surgical replacement of the diseased aortic valve remains the definitive intervention for most diseases. There is a clear consensus that in young patients who require aortic valve replacement, a mechanical prosthesis is the preferred choice due to its durable prosthesis without fear of wear and tear over time. However, this comes at the expense of increased risk of bleeding and thromboembolic events; in addition, there is a lack of strict evidence in using bioprosthesis in patients younger than 50 years. The objective of this review article is to assess the current evidence behind using bioprosthetic aortic valve in this young cohort.
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Affiliation(s)
- Amer Harky
- Liverpool Heart and Chest Hospital Department of Cardiothoracic Surgery Liverpool UK Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Michael Man Yuen Suen
- The Chinese University of Hong Kong Faculty of Medicine Hong Kong China Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Chris Ho Ming Wong
- The Chinese University of Hong Kong Faculty of Medicine Hong Kong China Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
| | - Abdul Rahman Maaliki
- Manchester Royal Infirmary Manchester UK Manchester Royal Infirmary, Oxford Road, Manchester, UK
| | - Mohamad Bashir
- Manchester Royal Infirmary Manchester UK Manchester Royal Infirmary, Oxford Road, Manchester, UK
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18
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Meta-Analysis Comparing Outcomes in Patients Undergoing Transcatheter Aortic Valve Implantation With Versus Without Percutaneous Coronary Intervention. Am J Cardiol 2019; 124:1757-1764. [PMID: 31575422 DOI: 10.1016/j.amjcard.2019.08.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 08/27/2019] [Accepted: 08/29/2019] [Indexed: 12/15/2022]
Abstract
Patients having transcatheter aortic valve implantation (TAVI) routinely undergo coronary angiography before the procedure to define the coronary anatomy and to evaluate the extend of coronary artery disease (CAD). Whether percutaneous coronary intervention (PCI) prior/concomitant with TAVI confers any additional clinical benefit in patients with CAD remains unclear. Literature search was performed using Medline, Embase, Google Scholar, and Scopus from inception of these databases till April 2019. Included outcomes were 30-day all-cause mortality, stroke, myocardial infarction (MI), acute kidney injury, and 1-year mortality. The main summary estimate was random effects odds ratio (OR) with 95% confidence intervals (CIs). Eleven cohort studies enrolling 5,580 patients (mean age 82.4 years and 52.6% females) were included. Our study found no difference in effect estimates for 30-day all-cause mortality (OR 1.30 [0.85 to 1.98], p = 0.22, I2 = 37.5%), stroke (OR 0.7 (0.36 to 1.45), p = 0.36, I2 = 32.8%), MI (OR 2.71 [0.55 to 12.23], p = 0.22, I2 = 41.3%), acute kidney injury (OR 0.7 [0.46 to 1.06], p = 0.08, I2 = 14.4%) and 1-year all-cause mortality (OR 1.19 [0.92 to 1.52], p = 0.18, I2 = 0.0%) in patients who underwent TAVI with and without PCI. In conclusion, our analysis indicates that PCI with TAVI in patients with severe aortic stenosis and concomitant CAD grants no additional clinical advantage in terms of patient important clinical outcomes. Further randomized studies are needed to better delineate the clinical practice for myocardial revascularization in patients receiving transcatheter therapy for aortic valve disease.
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19
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Fractional flow reserve in patients with coronary artery disease undergoing TAVI: a prospective analysis. Clin Res Cardiol 2019; 109:746-754. [PMID: 31679046 DOI: 10.1007/s00392-019-01563-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 10/17/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To determine the true prevalence of CAD in AS patients, to detect changes of the hemodynamic significance of coronary lesions following TAVI, to explore to what extent FFR-positive CAD might influence outcome and finally to develop a management algorithm for this patient subset. METHODS From May 2016 to March 2018, diagnostic coronary angiography was performed in 246 patients before TAVI. In the presence of coronary lesions with a diameter stenosis ≥ 50%, FFR was measured. In patients with positive FFR ≤ 0.80, a control angiography was performed 6-8 weeks after TAVI. RESULTS The study cohort was 81.0 ± 6.1 years old, 48.4% of the patients were male. 53.3% had concomitant CAD. 35.9% of these patients underwent PCI before TAVI due to functionally significant left main CAD and/or severe stenosis ≥ 90%. 31 patients underwent FFR measurements in cumulative 38 coronary lesions. Prior to TAVI, a negative FFR could be detected in 18 lesions, whereas a positive FFR was found in entirely 20 lesions. A control angiography and FFR measurement was performed in cumulative 13 lesions. Comparing the FFR values, there was no significant difference (0.77 ± 0.04 vs. 0.76 ± 0.08; p = 0.11). CONCLUSION Concomitant CAD was diagnosed in 53.3% of TAVI patients. FFR did not significantly change after TAVI, confirming the validity of FFR to evaluate coronary lesions in this specific clinical setting. Given the low rates of cardiac adverse events, it might therefore be considered to treat coronary stenoses not involving left main and those with a diameter stenosis < 90% after TAVI.
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20
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López Otero D, Ávila-Carrillo A, González Ferreiro R, Cid Menéndez A, Iglesias Álvarez D, Álvarez Rodríguez L, Antúnez Muiños P, Álvarez BC, Sanmartín Pena XC, Gómez Pérez F, Diéguez AR, Cruz-González I, Trillo Nouche R, González-Juanatey JR. Impact of Coronary Revascularization in Patients Who Underwent Transcatheter Aortic Valve Implantation. Am J Cardiol 2019; 123:948-955. [PMID: 30598242 DOI: 10.1016/j.amjcard.2018.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/06/2018] [Accepted: 12/13/2018] [Indexed: 11/27/2022]
Abstract
Coronary artery disease (CAD) is a common co-morbidity in transcatheter aortic valve implantation (TAVI) patients, but the prognostic value of coronary revascularization before TAVI is currently unknown. The aim of the present study was to assess the impact of coronary revascularization in patients who underwent TAVI. Patients underwent TAVI from 2008 to 2016 were included in the study. Baseline SYNTAX score and residual SYNTAX score (rSS) after percutaneous coronary intervention were calculated. Based on rSS, patients were classified as complete revascularization (rSS = 0), reasonably incomplete revascularization (rSS >0 and <8), and incomplete revascularization (rSS ≥8). The primary objective was to evaluate the impact of CAD and rSS on major cardiovascular adverse events (MACEs). The secondary objective was to assess the impact of rSS on hospitalization for heart failure. A total of 349 patients (mean age 82.4 ± 5.7 years, 53% women) were included in the study. A total of 187 patients (53.6%) had CAD (mean baseline SYNTAX score 9.2 ± 8.1). Percutaneous coronary intervention was performed in 29.9% of patients, achieving reasonably incomplete revascularization in 45.4%, and incomplete revascularization in 24.5%. The mean follow-up was 35.2 ± 25.3 months. No differences were observed in MACE rate between the CAD and non-CAD groups, or between the different degrees of revascularization. Differences were also not seen in the different levels of revascularization and hospitalization due to heart failure. In patients who underwent TAVI in this study, no association was found between the presence of CAD or the degree of revascularization in a long-term follow-up.
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21
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Bao L, Gao Q, Chen S, Chen Y, Elhmidi Y, Shehada SE, Wang S, Ma C. Feasibility and safety of combined percutaneous coronary intervention among high-risk patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2018; 54:1052-1059. [PMID: 29982414 DOI: 10.1093/ejcts/ezy240] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/31/2018] [Indexed: 02/05/2023] Open
Affiliation(s)
- Liming Bao
- Department of Cardiac Surgery, Aerospace Center Hospital, Beijing, China
| | - Qing Gao
- Department of Cardiac Surgery, Peking University People’s Hospital, Beijing, China
| | - Shenglong Chen
- Department of Cardiac Surgery, Peking University People’s Hospital, Beijing, China
| | - Yu Chen
- Department of Cardiac Surgery, Peking University People’s Hospital, Beijing, China
| | - Yacine Elhmidi
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technische Universität München, Munich, Germany
| | - Sharaf-Eldin Shehada
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany
| | - Sheng Wang
- Department of Cardiovascular Surgery, Henan Provincial People’s Hospital, Zhengzhou, China
| | - Chenming Ma
- Department of Cardiovascular Surgery, German Heart Centre Munich, Technische Universität München, Munich, Germany
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22
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Coronary access following TAVI – Selective coronary engagement using balloon-assisted tracking of a guide catheter extension. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:384-389. [DOI: 10.1016/j.carrev.2017.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/21/2017] [Accepted: 07/24/2017] [Indexed: 01/27/2023]
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23
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Voudris KV, Petropulos P, Karyofillis P, Charitakis K. Timing and Outcomes of PCI in the TAVR Era. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:22. [PMID: 29508124 DOI: 10.1007/s11936-018-0619-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Transcatheter aortic valve replacement (TAVR) has become an established therapy for patients with symptomatic severe aortic stenosis (AS). As the number of patients referred for TAVR increases, so does the prevalence of untreated obstructive coronary artery disease (CAD) in the population under evaluation. Despite the high prevalence of CAD in patients treated with TAVR, the management strategy of concomitant CAD in these patients remains an area of considerable uncertainty. RECENT FINDINGS Percutaneous coronary intervention (PCI) in patients with CAD and severe AS has been shown to be feasible and safe. Whether revascularization before, during, or after TAVR is optimal remains a subject of debate. All three approaches represent valid strategies with advantages and disadvantages that need to be carefully weighed on an individual basis. Current expert opinions recommend that PCI should be performed before or at the time of TAVR as long as the risk of the procedure does not outweigh the potential benefits. The results of large clinical trials evaluating the optimal revascularization time are closely awaited.
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Affiliation(s)
- Konstantinos V Voudris
- Department of Medicine, University of Illinois at Chicago/Advocate Christ Medical Center, Chicago, IL, USA.
- Department of Medicine, Advocate Christ Medical Center, 4440 W 95th Street, Suite 131 NOB, Oak Lawn, IL, 60453, USA.
| | - Peter Petropulos
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | | | - Konstantinos Charitakis
- Department of Cardiology, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
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24
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Postma WR, Hermanides RS, Gosselink ATM, Kedhi E. Single-staged transfemoral transcatheter aortic valve implantation and percutaneous coronary intervention with rotablation in complex coronary artery disease: a case report. Eur Heart J Case Rep 2018; 2:yty016. [PMID: 31020096 PMCID: PMC6426104 DOI: 10.1093/ehjcr/yty016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/09/2018] [Accepted: 01/26/2018] [Indexed: 11/12/2022]
Affiliation(s)
- Warner R Postma
- Department of Cardiology, Isala Klinieken, Dr van Heesweg 2, 8025 AB Zwolle, The Netherlands
- Corresponding author. Tel: +31 38 4248590, Fax: +31 38 4243222,
| | - Renicus S Hermanides
- Department of Cardiology, Isala Klinieken, Dr van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - A T Marcel Gosselink
- Department of Cardiology, Isala Klinieken, Dr van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Elvin Kedhi
- Department of Cardiology, Isala Klinieken, Dr van Heesweg 2, 8025 AB Zwolle, The Netherlands
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25
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Witberg G, Zusman O, Codner P, Assali A, Kornowski R. Impact of Coronary Artery Revascularization Completeness on Outcomes of Patients With Coronary Artery Disease Undergoing Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2018; 11:e006000. [DOI: 10.1161/circinterventions.117.006000] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/30/2018] [Indexed: 11/16/2022]
Abstract
Background—
Coronary artery disease (CAD) is highly prevalent in patients undergoing transcatheter aortic valve replacement. In the overall CAD population, complete revascularization or reasonable incomplete revascularization (ICR) is associated with improved outcomes; whether the same applies for the transcatheter aortic valve replacement population is still a matter of debate.
Methods and Results—
We conducted a systematic review and meta-analysis of studies that examined the prognostic effect of revascularization completeness in patients undergoing transcatheter aortic valve replacement using the residual SYNTAX score (Synergy Between PCI With Taxus and Cardiac Surgery) to separate between reasonable ICR and ICR (using the individual threshold used by each study). Six studies with a total of 3107 patients were included. The duration of follow-up ranged from 0.7 to 3 years. Overall, ICR was associated with an increased risk for mortality. This was true when comparing ICR patients to those with no CAD (odds ratio, 1.85; 95% confidence interval, 1.42–2.40;
P
<0.01), to those with reasonable ICR (odds ratio, 1.69; 95% confidence interval, 1.26–2.28;
P
<0.001), or to both groups combined (odds ratio, 1.71; 95% confidence interval, 1.36–2.16;
P
<0.001). On the contrary, patients in the reasonable ICR category did not show an increased risk for mortality when compared with those with no CAD (odds ratio, 1.11; 95% confidence interval, 0.89–1.39;
P
=0.33).
Conclusions—
Our results suggest that for patients with CAD undergoing transcatheter aortic valve replacement, a residual SYNTAX score–guided revascularization strategy may carry significant benefits in terms of mortality. Adequate revascularization may offer a unique and valuable opportunity to improve the prognosis of these patients.
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Affiliation(s)
- Guy Witberg
- From the Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel (G.W., O.Z., P.C., A.A., R.K.); and Sackler Faculty of Medicine, Tel-Aviv University, Israel (G.W., O.Z., P.C., A.A., R.K.)
| | - Oren Zusman
- From the Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel (G.W., O.Z., P.C., A.A., R.K.); and Sackler Faculty of Medicine, Tel-Aviv University, Israel (G.W., O.Z., P.C., A.A., R.K.)
| | - Pablo Codner
- From the Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel (G.W., O.Z., P.C., A.A., R.K.); and Sackler Faculty of Medicine, Tel-Aviv University, Israel (G.W., O.Z., P.C., A.A., R.K.)
| | - Abid Assali
- From the Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel (G.W., O.Z., P.C., A.A., R.K.); and Sackler Faculty of Medicine, Tel-Aviv University, Israel (G.W., O.Z., P.C., A.A., R.K.)
| | - Ran Kornowski
- From the Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel (G.W., O.Z., P.C., A.A., R.K.); and Sackler Faculty of Medicine, Tel-Aviv University, Israel (G.W., O.Z., P.C., A.A., R.K.)
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26
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Cao D, Chiarito M, Pagnotta P, Reimers B, Stefanini GG. Coronary Revascularisation in Transcatheter Aortic Valve Implantation Candidates: Why, Who, When? Interv Cardiol 2018; 13:69-76. [PMID: 29928311 DOI: 10.15420/icr.2018:2:2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Coronary artery disease (CAD) and aortic stenosis (AS) frequently coexist. The presence of CAD has been consistently associated with an impaired prognosis in patients undergoing surgical aortic valve replacement during short- and long-term follow-up. Accordingly, current guidelines recommend coronary revascularisation of all significant stenoses in patients undergoing surgical aortic valve replacement. Conversely, the management of concomitant CAD in patients with severe AS undergoing transcatheter aortic valve implantation (TAVI) is still a matter of debate. The aim of this review article is to provide an overview on the role of coronary revascularisation in TAVI patients.
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Affiliation(s)
- Davide Cao
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan Italy.,Cardio Center, Humanitas Research Hospital, Rozzano-Milan Italy
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan Italy.,Cardio Center, Humanitas Research Hospital, Rozzano-Milan Italy
| | - Paolo Pagnotta
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan Italy.,Cardio Center, Humanitas Research Hospital, Rozzano-Milan Italy
| | - Bernhard Reimers
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan Italy.,Cardio Center, Humanitas Research Hospital, Rozzano-Milan Italy
| | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan Italy.,Cardio Center, Humanitas Research Hospital, Rozzano-Milan Italy
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27
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Yang Y, Huang FY, Huang BT, Xiong TY, Pu XB, Chen SJ, Chen M, Feng Y. The safety of concomitant transcatheter aortic valve replacement and percutaneous coronary intervention: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e8919. [PMID: 29310382 PMCID: PMC5728783 DOI: 10.1097/md.0000000000008919] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 10/31/2017] [Accepted: 11/07/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND TAVR is a rapidly spreading treatment option for severe aortic valve stenosis. Significant coronary artery disease (CAD) is present in 40% to 75% of patients undergoing TAVR. However, when to treat the concomitant coronary artery lesions is controversial. METHODS This is a systematic review comparing concomitant PCI and TAVR versus staged PCI and TAVR. The OVID database was systematically searched for studies reporting PCI in patients undergoing TAVR. A random effects model was used to calculate the pooled odds ratio (OR) with 95% confidence intervals. RESULTS Four observational studies and a total of 209 patients were included in this analysis. Overall 30-day mortality was similar between concomitant PCI and TAVR versus staged PCI and TAVR [OR: 1.47 (0.47-4.62); P = .51], renal failure was not significantly different between both groups [OR: 3.22 (0.61-17.12); P = .17], periprocedural myocardial infarction was not different between the 2 groups [OR: 1.44 (0.12-16.94); P = .77], life-threatening bleeding did not differ between both groups [OR: 0.45 (0.11-1.87); P = .27], and major stroke also was not significantly different [OR: 3.41 (0.16-74.2); P = .44]. CONCLUSION These data did not show a significant difference in short-term outcomes between concomitant PCI and TAVR versus staged PCI and TAVR.
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28
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Chakos A, Wilson-Smith A, Arora S, Nguyen TC, Dhoble A, Tarantini G, Thielmann M, Vavalle JP, Wendt D, Yan TD, Tian DH. Long term outcomes of transcatheter aortic valve implantation (TAVI): a systematic review of 5-year survival and beyond. Ann Cardiothorac Surg 2017; 6:432-443. [PMID: 29062738 DOI: 10.21037/acs.2017.09.10] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation/replacement (TAVI/TAVR) is becoming more frequently used to treat aortic stenosis (AS), with increasing push for the procedure in lower risk patients. Numerous randomized controlled trials have demonstrated that TAVI offers a suitable alternative to the current gold standard of surgical aortic valve replacement (SAVR) in terms of short-term outcomes. The present review evaluates long-term outcomes following TAVI procedures. METHODS Literature search using three electronic databases was performed up to June 2017. Studies which included 20 or more patients undergoing TAVI procedures, either as a stand-alone or concomitant procedure and with a follow-up of at least 5 years, were included in the present review. Literature search and data extraction were performed by two independent researchers. Digitized survival data were extracted from Kaplan-Meier curves in order to re-create the original patient data using an iterative algorithm and subsequently aggregated for analysis. RESULTS Thirty-one studies were included in the present analysis, with a total of 13,857 patients. Two studies were national registries, eight were multi-institutional collaborations and the remainder were institutional series. Overall, 45.7% of patients were male, with mean age of 81.5±7.0 years. Where reported, the mean Logistic EuroSCORE (LES) was 22.1±13.7 and the mean Society of Thoracic Surgeons (STS) score was 9.2±6.6. The pooled analysis found 30-day mortality, cerebrovascular accidents, acute kidney injury (AKI) and requirement for permanent pacemaker (PPM) implantation to be 8.4%, 2.8%, 14.4%, and 13.4%, respectively. Aggregated survival at 1-, 2-, 3-, 5- and 7-year were 83%, 75%, 65%, 48% and 28%, respectively. CONCLUSIONS The present systematic review identified acceptable long-term survival results for TAVI procedures in an elderly population. Extended follow-up is required to assess long-term outcomes following TAVI, particularly before its application is extended into wider population groups.
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Affiliation(s)
- Adam Chakos
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Ashley Wilson-Smith
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Sameer Arora
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, USA
| | - Tom C Nguyen
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Memorial Hermann Hospital - Heart and Vascular Institute, Houston, TX, USA
| | - Abhijeet Dhoble
- Division of Cardiology, University of Texas Health Science Center, Houston, Houston, TX, USA
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University Padua, Padua, Italy
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Duisburg, Germany
| | - John P Vavalle
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, USA
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University Duisburg-Essen, Duisburg, Germany
| | - Tristan D Yan
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - David H Tian
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
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29
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Huczek Z, Zbroński K, Grodecki K, Scisło P, Rymuza B, Kochman J, Dąbrowski M, Witkowski A, Wojakowski W, Parma R, Ochała A, Grygier M, Olasińska-Wiśniewska A, Araszkiewicz A, Jagielak D, Ciećwierz D, Puchta D, Paczwa K, Filipiak KJ, Wilimski R, Zembala M, Opolski G. Concomitant coronary artery disease and its management in patients referred to transcatheter aortic valve implantation: Insights from the POL-TAVI Registry. Catheter Cardiovasc Interv 2017; 91:115-123. [PMID: 28843025 DOI: 10.1002/ccd.27251] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 06/25/2017] [Accepted: 07/22/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) and degenerative aortic stenosis often coexist. However, the impact of CAD and its management on the prognosis after transcatheter aortic valve implantation (TAVI) remains uncertain. We sought to evaluate the impact of obstructive CAD, SYNTAX score (Ss), and percutaneous coronary intervention (PCI) prior to TAVI on short-term outcome. METHODS Overall, 896 patients who underwent TAVI after heart team decision was included. Pre-procedural angiograms were analysed to calculate baseline Ss (bSs) and residual Ss (rSs). Baseline, procedural and follow-up data up to 30 days was acquired from the national POL-TAVI registry. RESULTS Patients with obstructive CAD at baseline (n = 462, 52%) had higher mortality as compared with the remaining (8.7 vs. 5.1%, log-rank P = 0.039). Also, after correction for confounding factors obstructive CAD was identified as independent predictor of mortality (hazard ratio [HR] 1.74, 95% confidence intervals [CIs] 1.03-2.94, P = 0.037). In obstructive CAD, neither bSs (AUC 0.47, CI 0.38-0.56, P = 0.47) nor rSs (AUC 0.47, CI 0.30-0.64, P = 0.72 for those undergoing PCI and AUC 0.48, CI 0.37-0.59, P = 0.75 for the remaining) was predictive of mortality. When revascularization status was considered, patients with PCI prior to TAVI had similar outcome as those without obstructive CAD at baseline (7.7 vs. 5.1%, log-rank P = 0.23) with no negative impact on mortality (HR 1.13, CI 0.62-2.09, P = 0.69). CONCLUSIONS In conclusion, obstructive CAD at baseline evaluation for TAVI has independent negative impact on short-term prognosis. However, neither baseline nor residual Ss values have prognostic ability in patients undergoing TAVI. Revascularization prior to TAVI seems to improve survival to levels comparable with patients without obstructive CAD at baseline.
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Affiliation(s)
- Zenon Huczek
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Karol Zbroński
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Kajetan Grodecki
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Scisło
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Bartosz Rymuza
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Janusz Kochman
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Wojciech Wojakowski
- Third Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Radosław Parma
- Third Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Andrzej Ochała
- Third Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Marek Grygier
- First Department of Cardiology, Medical University of Poznan, Poznan, Poland
| | | | | | - Dariusz Jagielak
- Department of Cardiac and Vascular Surgery, Medical University of Gdańsk, Gdańsk, Poland
| | - Dariusz Ciećwierz
- Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Dominika Puchta
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Paczwa
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Marian Zembala
- Department of Cardiac Surgery, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Grzegorz Opolski
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
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30
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Rodés-Cabau J. Combining Transcatheter Aortic Valve Replacement and Coronary Angiography/Percutaneous Coronary Intervention Procedures: Ready for Prime Time? Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.117.005664. [PMID: 28768761 DOI: 10.1161/circinterventions.117.005664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Josep Rodés-Cabau
- From the Quebec Heart and Lung Institute, Laval University, Quebec City, Canada.
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31
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Thourani VH, Borger MA, Holmes D, Maniar H, Pinto F, Miller C, Rodés-Cabau J, Mohr FW, Schröfel H, Moat NE, Beyersdorf F, Patterson GA, Weisel R. Transatlantic Editorial on Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2017. [DOI: 10.1016/j.athoracsur.2017.04.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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32
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Thourani VH, Borger MA, Holmes D, Maniar H, Pinto F, Miller C, Rodés-Cabau J, Mohr FW, Schröfel H, Moat NE, Beyersdorf F, Patterson AG, Weisel R. Transatlantic Editorial on transcatheter aortic valve replacement. Eur J Cardiothorac Surg 2017; 52:1-13. [PMID: 28874024 DOI: 10.1093/ejcts/ezx196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 03/11/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Vinod H Thourani
- Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, GA, USA
| | - Michael A Borger
- Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, NY, USA
| | - David Holmes
- Department of Cardiology, Mayo Clinic, Rochester, MN, USA
| | - Hersh Maniar
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, MO, USA
| | - Fausto Pinto
- Department of Cardiology, University Hospital Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Craig Miller
- Department of Cardiac Surgery, Stanford University, Palo Alto, CA, USA
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | | | | | - Neil E Moat
- Cardiovascular Biomedical Research Unit, National Institute Health Research, Royal Brompton Hospital and Harefield National Health Service Foundation Trust, London, UK
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Centre Freiburg University, Freiburg, Germany
| | - Alec G Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Richard Weisel
- Division of Cardiovascular Surgery, Peter Munk Cardiovascular Center, Toronto General Research Institute, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
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33
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Thourani VH, Borger MA, Holmes D, Maniar H, Pinto F, Miller C, Rodés-Cabau J, Mohr FW, Schröfel H, Moat NE, Beyersdorf F, Patterson GA, Weisel R. Transatlantic editorial on transcatheter aortic valve replacement. J Thorac Cardiovasc Surg 2017. [DOI: 10.1016/j.jtcvs.2017.03.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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34
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Witberg G, Regev E, Chen S, Assali A, Barbash IM, Planer D, Vaknin-Assa H, Guetta V, Vukasinovic V, Orvin K, Danenberg HD, Segev A, Kornowski R. The Prognostic Effects of Coronary Disease Severity and Completeness of Revascularization on Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2017; 10:1428-1435. [DOI: 10.1016/j.jcin.2017.04.035] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/17/2017] [Accepted: 04/19/2017] [Indexed: 11/27/2022]
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35
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Kotronias RA, Kwok CS, George S, Capodanno D, Ludman PF, Townend JN, Doshi SN, Khogali SS, Généreux P, Herrmann HC, Mamas MA, Bagur R. Transcatheter Aortic Valve Implantation With or Without Percutaneous Coronary Artery Revascularization Strategy: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2017; 6:e005960. [PMID: 28655733 PMCID: PMC5669191 DOI: 10.1161/jaha.117.005960] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/03/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Recent recommendations suggest that in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation and coexistent significant coronary artery disease, the latter should be treated before the index procedure; however, the evidence basis for such an approach remains limited. We performed a systematic review and meta-analysis to study the clinical outcomes of patients with coronary artery disease who did or did not undergo revascularization prior to transcatheter aortic valve implantation. METHODS AND RESULTS We conducted a search of Medline and Embase to identify studies evaluating patients who underwent transcatheter aortic valve implantation with or without percutaneous coronary intervention. Random-effects meta-analyses with the inverse variance method were used to estimate the rate and risk of adverse outcomes. Nine studies involving 3858 participants were included in the meta-analysis. Patients who underwent revascularization with percutaneous coronary intervention had a higher rate of major vascular complications (odd ratio [OR]: 1.86; 95% confidence interval [CI], 1.33-2.60; P=0.0003) and higher 30-day mortality (OR: 1.42; 95% CI, 1.08-1.87; P=0.01). There were no differences in effect estimates for 30-day cardiovascular mortality (OR: 1.03; 95% CI, 0.35-2.99), myocardial infarction (OR: 0.86; 95% CI, 0.14-5.28), acute kidney injury (OR: 0.89; 95% CI, 0.42-1.88), stroke (OR: 1.07; 95% CI, 0.38-2.97), or 1-year mortality (OR: 1.05; 95% CI, 0.71-1.56). The timing of percutaneous coronary intervention (same setting versus a priori) did not negatively influence outcomes. CONCLUSIONS Our analysis suggests that revascularization before transcatheter aortic valve implantation confers no clinical advantage with respect to several patient-important clinical outcomes and may be associated with an increased risk of major vascular complications and 30-day mortality. In the absence of definitive evidence, careful evaluation of patients on an individual basis is of paramount importance to identify patients who might benefit from elective revascularization.
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Affiliation(s)
- Rafail A Kotronias
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom
- Oxford University Clinical Academic Graduate School, Oxford University, Oxford, United Kingdom
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom
- The Heart Centre, Royal Stoke Hospital, University Hospital of North Midlands Trust, Stoke-on-Trent, United Kingdom
| | - Sudhakar George
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom
- The Heart Centre, Royal Stoke Hospital, University Hospital of North Midlands Trust, Stoke-on-Trent, United Kingdom
| | - Davide Capodanno
- Cardio-Thoracic-Vascular Department, Ferrarotto Hospital University of Catania, Italy
| | - Peter F Ludman
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Jonathan N Townend
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Sagar N Doshi
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Saib S Khogali
- The Heart and Lung Centre, New Cross Hospital, Wolverhampton, United Kingdom
| | - Philippe Généreux
- Cardiovascular Research Foundation, New York, NY
- Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
- Morristown Medical Center, Morristown, NJ
| | - Howard C Herrmann
- Cardiology Division, Department of Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom
- The Heart Centre, Royal Stoke Hospital, University Hospital of North Midlands Trust, Stoke-on-Trent, United Kingdom
| | - Rodrigo Bagur
- Keele Cardiovascular Research Group, Institute for Applied Clinical Science and Centre for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom
- Division of Cardiology, Department of Medicine, London Health Sciences Centre, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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36
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Alkhouli M, Al Mustafa A, Chaker Z, Alqahtani F, Aljohani S, Holmes DR. Mechanical circulatory support in patients with severe aortic stenosis and left ventricular dysfunction undergoing percutaneous coronary intervention. J Card Surg 2017; 32:245-249. [PMID: 28271553 DOI: 10.1111/jocs.13116] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Management of obstructive coronary artery disease in patients with aortic stenosis and severe left ventricular dysfunction is challenging. Mechanical circulatory support at the time of percutaneous coronary interventions may be necessary in these extreme-risk patients. We present a case in which the TandemHeart was used to support a patient with severe aortic stenosis, severe protected left main and circumflex disease, and severe cardiomyopathy and review the literature on this subject.
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Affiliation(s)
- Mohamad Alkhouli
- WVU Heart and Vascular Institute, West Virginia University School of Medicine, Morgantown, West Virginia.,Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | | | | | - Fahad Alqahtani
- WVU Heart and Vascular Institute, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Sami Aljohani
- WVU Heart and Vascular Institute, West Virginia University School of Medicine, Morgantown, West Virginia
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
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37
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Pesarini G, Scarsini R, Zivelonghi C, Piccoli A, Gambaro A, Gottin L, Rossi A, Ferrero V, Vassanelli C, Ribichini F. Functional Assessment of Coronary Artery Disease in Patients Undergoing Transcatheter Aortic Valve Implantation. Circ Cardiovasc Interv 2016; 9:CIRCINTERVENTIONS.116.004088. [DOI: 10.1161/circinterventions.116.004088] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 09/26/2016] [Indexed: 01/09/2023]
Abstract
Background—
Aortic valve stenosis may influence fractional flow reserve (FFR) of concomitant coronary artery disease by causing hypertrophy and reducing the vasodilatory reserve of the coronary circulation. We sought to investigate whether FFR values might change after valve replacement.
Methods and Results—
The functional relevance of 133 coronary lesions was assessed by FFR in 54 patients with severe aortic valve stenosis before and after transcatheter aortic valve implantation (TAVI) during the same procedure. A linear mixed model was used to verify the interaction of TAVI effect with the FFR values. No significant overall change in FFR values was found before and after the aortic valve stenosis removal (0.89±0.10 versus 0.89±0.13;
P
=0.73). A different trend in FFR groups (positive if ≤0.8; negative if >0.8) was found after TAVI (
P
for interaction <0.001). Positive FFR values worsened after TAVI (0.71±0.11 versus 0.66±0.14). Conversely, negative FFR values improved after TAVI (0.92±0.06 versus 0.93±0.07). Similarly, FFR values in coronary arteries with lesions presenting percent diameter stenosis >50 worsened after TAVI (0.84±0.12 versus 0.82±0.16;
P
=0.02), whereas FFR values in arteries with mild lesions (percent diameter stenosis <50) tended toward improvement after TAVI (0.90±0.07 versus 0.91±0.09;
P
=0.69). Functional FFR variations after TAVI changed the indication to treat the coronary stenosis in 8 of 133 (6%) lesions.
Conclusions—
Coronary hemodynamics are influenced by aortic valve stenosis removal. Nevertheless, FFR variations after TAVI are minor and crossed the diagnostic cutoff of 0.8 in a small number of patients after valve replacement. Borderline coronary lesions might become functionally significant after valve replacement, although FFR-guided interventions were infrequent even in patients with angiographically significant lesions.
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Affiliation(s)
- Gabriele Pesarini
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Roberto Scarsini
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Carlo Zivelonghi
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Anna Piccoli
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Alessia Gambaro
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Leonardo Gottin
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Andrea Rossi
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Valeria Ferrero
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Corrado Vassanelli
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
| | - Flavio Ribichini
- From the Division of Cardiology, Department of Medicine, School of Medicine (G.P., R.S., C.Z., A.P., A.G., A.R., V.F., C.V., F.R.) and Department of Anesthesia and Intensive Care (L.G.), University of Verona, Italy
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Penkalla A, Kempfert J, Unbehaun A, Buz S, Drews T, Pasic M, Falk V. Transcatheter Aortic Valve Implantation in Nonagenarians. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Semih Buz
- Deutsches Herzzentrum Berlin, Berlin, Germany
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Transcatheter Aortic Valve Implantation in Nonagenarians. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:390-395. [DOI: 10.1097/imi.0000000000000315] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objective In this report, we assess the outcome of transcatheter aortic valve implantation (TAVI) in nonagenarians at our institution during a 6-year period. Methods Between April 2008 and July 2014, 40 patients with a mean ± SD age of 91.8 ± 2.3 years (range, 90–98 years) underwent TAVI. Thirty-three patients (82.5%) received transapical TAVI, and seven patients (17.5%) received transfemoral TAVI. Baseline characteristics were as follows: mean ± SD EuroSCORE II, 23.9 ± 14.21; mean ± SD Society of Thoracic Surgeons mortality score, 24.2 ± 11.4; mean ± SD SYNTAX score, 7.6 ± 9.3; mean ± SD NYHA class, 3.5 ± 0.5; mean ± SD transvalvular gradient, 46.8 ± 17.8 mm Hg; mean ± SD aortic valve area, 0.7 ± 0.2 cm2. Results Intraoperative mortality was 2.5% and 30-day all-cause mortality was 10%. The actuarial survival rates at 1 and 5 years were 58.6% and 30.4%, respectively. Seven patients (17.5%) underwent simultaneous elective TAVI and percutaneous coronary intervention. Three patients (7.5%) were operated on with the use of cardiopulmonary bypass. No conversion to open surgery occurred. In transesophageal echocardiography assessment, no moderate or severe prosthetic aortic valve regurgitation was observed. Four patients (10%) had postoperative acute renal failure stage 3 and needed new dialysis (P = 0.125). Three patients (7.5%) had a disabling stroke. Periprocedural myocardial infarction occurred in one patient (2.5%). Seven patients (17.5%) needed postoperative pacemaker implantation. Male sex and renal insufficiency were found to be predictors of mortality in univariable analysis. Conclusions Transcatheter aortic valve implantation can be performed in nonagenarians despite very high preoperative risk scores and substantial multimorbidity, with acceptable outcomes.
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Transaortic Transcatheter Aortic Valve Implantation and Concomitant Off Pump Revascularization. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:363-366. [PMID: 27635474 DOI: 10.1097/imi.0000000000000293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
An increasing number of patients with severe aortic stenosis and concomitant critical coronary artery disease were referred to our hospital. Some of those patients were classified as high-risk patients qualifying for a transcatheter therapy with the additional need for coronary revascularization. As a consequence of their comorbidities, the established transapical as well as transfemoral approach were either not possible or not favored owing to the indispensable need for coronary revascularization. We present 4 successfully combined off-pump procedures consisting of a transcatheter aortic valve implantation (Edwards SAPIEN XT) via the transaortic approach and an off-pump coronary artery bypass grafting. All patients were discharged free from stroke, myocardial infarction, or access site complications either to rehabilitation facility or to the referring hospital with none or trace aortic regurgitation and patent grafts. These cases confirm the feasibility of those combined operations and should be considered as realistic alternative for surgical treatment in high-risk patients who are clearly identified to benefit from transcatheter approach to treat aortic stenosis and who have severe concomitant coronary artery disease.
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Baumbach H, Ahad S, Hill S, Schäufele T, Adili S, Wachter K, Franke UFW. Transaortic Transcatheter Aortic Valve Implantation and Concomitant off Pump Revascularization. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Hardy Baumbach
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Samir Ahad
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Stephan Hill
- Department of Cardiology, Robert Bosch Hospital, Stuttgart, Germany
| | - Tim Schäufele
- Department of Cardiology, Robert Bosch Hospital, Stuttgart, Germany
| | - Sara Adili
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Kristina Wachter
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Ulrich F. W. Franke
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
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Johansson M, Nozohoor S, Bjursten H, Ragnarsson S, Götberg M, Kimblad PO, Zindovic I, Sjögren J. Late survival and heart failure after transcatheter aortic valve implantation. Asian Cardiovasc Thorac Ann 2016; 24:318-25. [PMID: 26966020 DOI: 10.1177/0218492316637712] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Short-term survival in patients undergoing transcatheter aortic valve implantation is favorable. Our aim was to evaluate late survival and composite clinical endpoints specified by the Valve Academic Research Consortium-2, including rehospitalization for congestive heart failure. METHODS Between January 2008 and April 2014, 166 consecutive patients with severe symptomatic aortic stenosis underwent 168 transcatheter aortic valve implantation procedures at our facility. This cohort was compared with propensity score-matched aortic valve replacement patients. Event rates were estimated by the Kaplan-Meier method and compared using the log-rank test. Cox regression analysis was performed to determine predictors of outcome. RESULTS Although 30-day mortality rates following both procedures were similar (4.2% and 4.8%; p = 0.81), significant differences were seen in corresponding rates of survival (51.7% ± 5.8% vs. 72.3% ± 4.3%; p < 0.001) and cumulative rehospitalization for congestive heart failure (41.3% ± 7.2% vs. 23% ± 4.3%; p = 0.006). New York Heart Association functional class IV preoperative status was an independent risk factor for rehospitalization due to congestive heart failure (p = 0.015). CONCLUSIONS This study confirms the merit of transcatheter aortic valve implantation in high-risk patients with aortic stenosis, although late survival proved inferior to that of aortic valve replacement in propensity score-matched subjects. Early safety was excellent for both treatment groups, however, patients undergoing transcatheter aortic valve implantation had a higher incidence of rehospitalization for congestive heart failure and myocardial infarction during follow-up. Patients with severe congestive heart failure should be carefully monitored and aggressively treated to improve outcomes.
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Affiliation(s)
- Malin Johansson
- Department of Cardiothoracic Surgery, Cardiothoracic Anesthesia and Intensive Care, Skane University Hospital, Lund, Sweden Department of Clinical Sciences, Lund Cardiothoracic Surgery, Lund, Sweden
| | - Shahab Nozohoor
- Department of Cardiothoracic Surgery, Cardiothoracic Anesthesia and Intensive Care, Skane University Hospital, Lund, Sweden Department of Clinical Sciences, Lund Cardiothoracic Surgery, Lund, Sweden
| | - Henrik Bjursten
- Department of Cardiothoracic Surgery, Cardiothoracic Anesthesia and Intensive Care, Skane University Hospital, Lund, Sweden Department of Clinical Sciences, Lund Cardiothoracic Surgery, Lund, Sweden
| | - Sigurdur Ragnarsson
- Department of Cardiothoracic Surgery, Cardiothoracic Anesthesia and Intensive Care, Skane University Hospital, Lund, Sweden Department of Clinical Sciences, Lund Cardiothoracic Surgery, Lund, Sweden
| | - Matthias Götberg
- Department of Coronary Heart Disease, Skane University Hospital, Lund, Sweden Department of Clinical Sciences, Lund Cardiology, Lund, Sweden
| | - Per Ola Kimblad
- Department of Cardiothoracic Surgery, Cardiothoracic Anesthesia and Intensive Care, Skane University Hospital, Lund, Sweden Department of Clinical Sciences, Lund Cardiothoracic Surgery, Lund, Sweden
| | - Igor Zindovic
- Department of Cardiothoracic Surgery, Cardiothoracic Anesthesia and Intensive Care, Skane University Hospital, Lund, Sweden Department of Clinical Sciences, Lund Cardiothoracic Surgery, Lund, Sweden
| | - Johan Sjögren
- Department of Cardiothoracic Surgery, Cardiothoracic Anesthesia and Intensive Care, Skane University Hospital, Lund, Sweden Department of Clinical Sciences, Lund Cardiothoracic Surgery, Lund, Sweden
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Reducing Patient Radiation Dose With Image Noise Reduction Technology in Transcatheter Aortic Valve Procedures. Am J Cardiol 2016; 117:834-8. [PMID: 26742472 DOI: 10.1016/j.amjcard.2015.12.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 12/03/2015] [Accepted: 12/03/2015] [Indexed: 12/30/2022]
Abstract
X-ray radiation exposure is of great concern for patients undergoing structural heart interventions. In addition, a larger group of medical staff is required and exposed to radiation compared with percutaneous coronary interventions. This study aimed at quantifying radiation dose reduction with implementation of specific image noise reduction technology (NRT) in transcatheter aortic valve implantation (TAVI) procedures. We retrospectively analyzed 104 consecutive patients with TAVI procedures, 52 patients before and 52 after optimization of x-ray radiation chain, and implementation of NRT. Patients with 1-step TAVI and complex coronary intervention, or complex TAVI procedures, were excluded. Before the procedure, all patients received a multislice computed tomography scan, which was used to size aortic annulus, select the optimal implantation plane, valve type and size, and guide valve implantation using a software tool. Air kerma and kerma-area product were compared in both groups to determine patient radiation dose reduction. Baseline parameters, co-morbidity, or procedural data were comparable between groups. Mean kerma-area product was significantly lower (p <0.001) in the NRT group compared with the standard group (60 ± 39 vs 203 ± 106 Gy × cm(2), p <0.001), which corresponds to a reduction of 70%. Mean air kerma was reduced by 64% (494 ± 360 vs 1,355 ± 657 mGy, p <0.001). In conclusion, using optimized x-ray chain combined with specific image noise reduction technology has the potential to significantly reduce by 2/3 radiation dose in standard TAVI procedures without worsening image quality or prolonging procedure time.
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Piccoli A, Lunardi M, Ariotti S, Ferrero V, Vassanelli C, Ribichini F. Expanding TAVI options: elective rotational atherectomy during trans-catheter aortic valve implantation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2015; 16:58-61. [DOI: 10.1016/j.carrev.2014.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 11/10/2014] [Accepted: 11/13/2014] [Indexed: 11/28/2022]
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