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Faroux L, Villecourt A, Metz D. The Management of Coronary Artery Disease in TAVR Patients. J Clin Med 2023; 12:7126. [PMID: 38002738 PMCID: PMC10672348 DOI: 10.3390/jcm12227126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/01/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
About half of the transcatheter aortic valve replacement (TAVR) recipients exhibit some degree of coronary artery disease (CAD), and controversial results have been reported regarding the impact of the presence and severity of CAD on clinical outcomes post-TAVR. In addition to coronary angiography, promising data has been recently reported on the use of both cardiac computed tomography angiography and the functional invasive assessment of coronary lesions whether by FFR or iFR in the work-up pre-TAVR. Despite mitigated available data, percutaneous revascularization of significant coronary lesions has been the routine strategy in TAVR candidates with CAD. Additionally, scarce data exists on the incidence, characteristics and management of coronary events post-TAVR, and increasing interest exists on the potential coronary access challenges in patients requiring coronary angiography/intervention post-TAVR. This review provides an updated overview of the knowledge of CAD in TAVR recipients, focusing on its prevalence, clinical impact, pre- and post-procedural evaluation and management.
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Affiliation(s)
- Laurent Faroux
- Cardiology Department, Reims University Hospital, 51100 Reims, France
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Lérault A, Villecourt A, Decottignies-Dienne T, Tassan-Mangina S, Heroguelle V, Di Cesare A, Rubin S, Ruggieri VG, Metz D, Faroux L. Catheter versus surgical approach for the management of concomitant aortic stenosis and coronary artery disease: An inverse probability treatment weighting analysis. Arch Cardiovasc Dis 2023; 116:117-125. [PMID: 36702719 DOI: 10.1016/j.acvd.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Two therapeutic strategies are available when aortic stenosis and coronary artery disease coexist: a transcatheter approach, with percutaneous coronary intervention followed by transcatheter aortic valve replacement; and a surgical approach, consisting of surgical aortic valve replacement combined with coronary artery bypass graft. AIM We sought to compare the outcomes of these two strategies. METHODS The study population consisted of 241 patients who benefited from aortic valve replacement and coronary revascularization (transcatheter, n=150; surgery, n=91). RESULTS Patients in the transcatheter population were older (83.5 vs. 71.8years; P<0.001) and had a higher Logistic EuroSCORE (11.1% vs. 5.7%; P<0.001). At 30days postprocedure, patients who had surgery exhibited more life-threatening bleedings (12.1% vs 4.5%; P=0.034), acute kidney injury (12.1% vs. 1.3%; P<0.001) and atrial fibrillation (55.6% vs. 8.7%; P<0.001). After a median follow-up of 27months, the risk of major adverse cardiovascular or cerebrovascular events did not differ significantly between the two strategies (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.97-2.04; P=0.07), whereas estimated glomerular filtration rate<60mL/min (HR 2.22, 95% CI 1.58-3.12; P<0.001), peripheral artery disease (HR 2.00, 95% CI 1.37-2.91; P<0.001) and left ventricular ejection fraction<50% (HR 1.69, 95% CI 1.12-2.55; P=0.012) were associated with a negative prognosis. CONCLUSIONS In our study, patients with aortic stenosis and coronary artery disease treated by catheter were older and had a higher co-morbidity burden than those treated by surgery. The surgical strategy was associated with a higher rate of 30-day complications, but long-term outcomes were similar between the two strategies.
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Affiliation(s)
- Adèle Lérault
- Department of Cardiology, Reims University Hospital, 51092 Reims, France
| | | | | | | | | | | | - Sylvain Rubin
- Cardiac Surgery Department, Reims University Hospital, 51092 Reims, France
| | | | - Damien Metz
- Department of Cardiology, Reims University Hospital, 51092 Reims, France
| | - Laurent Faroux
- Department of Cardiology, Reims University Hospital, 51092 Reims, France; EA3801 HERVI, SFR CAP Santé, University of Reims Champagne Ardenne, 51100 Reims, France.
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Villecourt A, Faroux L, Muneaux A, Tassan-Mangina S, Heroguelle V, Poncet A, Nazeyrollas P, Ruggieri V, Metz D. Comparison of clinical outcomes after transcarotid and transsubclavian versus transfemoral TAVI: a propensity-matched analysis. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Transcarotid (TC) and transsubclavian (TSc) accesses are increasingly used as alternative approaches for TAVI when the transfemoral (TF) access is not suitable. However, concerns remain about the risk of peri-procedural stroke and long-term outcomes following TC or TSc TAVI.
The present study sought to compare early- and long-term outcomes of TC/TSc vs. TF TAVI after propensity-score matching.
260 patients who underwent TAVI through a TF (n=220), TC (n=32) or TSc (n=8) approach at our institution during a 4 years period were identified. A 1:1 matching based on the propensity-score was performed, leading to a population of 40 TF and 40 TC/TSc. Primary endpoints were early complications whereas secondary endpoints were long-term outcomes.
There was no difference in the baseline characteristics. At 30-day post-TAVI, there was no difference in mortality and stroke rates between TF and TC/TSc TAVI (5% vs. 5% mortality, p=1.0 and 2 vs. 1 stroke, p=1.0). After a median follow-up of 21 months, the risk of death (p=0.950), stroke (p=0.817) and myocardial infarction (p=0.155) did not differ between the 2 groups.
After propensity-score matching, no significant difference in early and long-term outcomes was observed between TF and TSc/TSc TAVI. These findings should encourage Heart-Teams to consider a TC or TSc approach when TF access is not available.
Table 1. 30-day and 1-year outcomes according to the arterial access (TF vs. TC/TSc) Variables TF-TAVI (n=40) TC/TSc-TAVI (n=40) p-value 30-day outcomes All-cause mortality 2 (5.0) 2 (5.0) 1.000 All-stroke 2 (5.0) 1 (2.5) 1.000 Life-threatening bleeding 4 (10.0) 1 (2.5) 0.375 Acute kidney injury stage 2 or 3 2 (5.0) 1 (2.5) 1.000 Major vascular complication 6 (15.0) 6 (15.0) 1.000 Coronary obstruction 0 0 – Early safety composite endpoint (VARC-2) 10 (25.0) 8 (20.0) 0.804 1-year outcomes All-cause mortality 6 (15.0) 7 (17.5) 1.000 Cardiovascular mortality 5 (12.5) 3 (7.5) 0.727 Stroke 3 (7.5) 2 (5.0) 1.000 Myocardial infarction 0 (0) 2 (5) 0.500 MACCE 8 (20.0) 9 (22.5) 1.000 Readmission for heart failure 6 (15.0) 2 (5) 0.219
Figure 1
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
| | - L Faroux
- University Hospital of Reims, Reims, France
| | - A Muneaux
- University Hospital of Reims, Reims, France
| | | | | | - A Poncet
- University Hospital of Reims, Reims, France
| | | | | | - D Metz
- University Hospital of Reims, Reims, France
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Faroux L, Villecourt A, Guimaraes L, Wintzer-Wehekind J, Junquera L, Arsenault J, Blanpain T, Tassan-Mangina S, Heroguelle V, Ruggieri VG, Metz D, Kalavrouziotis D, Dumont E, Paradis JM, Delarochellière R, Del Val D, Muntané-Carol G, Mohammadi S, Rodés-Cabau J. Radiation Exposure During Transcatheter Aortic Valve Replacement: Impact of Arterial Approach and Prosthesis Type. Ann Thorac Surg 2020; 111:1601-1606. [PMID: 32950489 DOI: 10.1016/j.athoracsur.2020.06.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/03/2020] [Accepted: 06/29/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND The impact of novel alternative access and valve type on radiation exposure during transcatheter aortic valve replacement (TAVR) has not yet been evaluated. This study sought to determine the impact of a transarterial approach and prosthesis type on physician and patient exposure to radiation during TAVR. METHODS This was a prospective study including 140 consecutive patients undergoing TAVR by transfemoral (n = 102) or transcarotid (TC) (n = 38) access at 2 centers. Implanted valves were the self-expanding Evolut R/PRO system (Medtronic, Minneapolis, MN; n = 38) and the balloon-expandable SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA; n = 102). The primary endpoint was first operator radiation exposure. The secondary endpoint was patient radiation exposure. RESULTS First operator radiation exposure was 4-fold greater during TC TAVR (P < .001). The use of a self-expanding valve was associated with a longer x-ray time (P = .015) and a 2-fold greater first operator radiation dose (P = .018). Patient radiation dose was not significantly affected by arterial approach (P = .055) or valve type (P = .095). After adjustment for potential confounders, the TC approach remained associated with a 174.8% (95% confidence interval, 80.6-318.3, P < .001) increase in first operator radiation dose, whereas the use of a self-expanding valve no longer influenced the first operator dose (P = .630). CONCLUSIONS TC access and the use of a self-expanding valve were associated with a 4- and 2-fold greater first operator radiation exposure during TAVR procedures, respectively. Unlike the arterial approach, the effect of bioprosthesis type on radiation exposure was mainly related to x-ray time and was no longer significant after adjustment.
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Affiliation(s)
- Laurent Faroux
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Department of Cardiology, Reims University Hospital, Reims, France; EA3797 VieFra, University of Reims Champagne-Ardenne, Reims, France
| | | | - Leonardo Guimaraes
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Lucia Junquera
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Jean Arsenault
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Thierry Blanpain
- Department of Cardiology, Reims University Hospital, Reims, France
| | | | | | | | - Damien Metz
- Department of Cardiology, Reims University Hospital, Reims, France
| | | | - Eric Dumont
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Jean-Michel Paradis
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - David Del Val
- 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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Kinnel M, Faroux L, Villecourt A, Tassan-Mangina S, Heroguelle V, Nazeyrollas P, Poncet A, Ruggieri VG, Metz D. Abdominal aorta tortuosity on computed tomography identifies patients at risk of complications during transfemoral transcatheter aortic valve replacement. Arch Cardiovasc Dis 2020; 113:159-167. [DOI: 10.1016/j.acvd.2019.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 10/02/2019] [Accepted: 10/15/2019] [Indexed: 12/20/2022]
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Villecourt A, Faroux L, Blanpain T, Kinnel M, Mora C, Tassan-Mangina S, Heroguelle V, Nazeyrollas P, Metz D. Exposure to Ionizing Radiation in Patients Undergoing Transfemoral Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 125:114-119. [PMID: 31699362 DOI: 10.1016/j.amjcard.2019.09.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 09/16/2019] [Accepted: 09/17/2019] [Indexed: 11/17/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is currently becoming an alternative to surgical valve replacement for patients at low risk, a population that is likely to experience an increase in the radiation-induced cancer risk following TAVI. We aimed to evaluate the overall exposure to ionizing radiation in patients who underwent transfemoral TAVI, including the procedure itself as well as the procedures performed in the preintervention work-up and the post-TAVI interventions. All patients who underwent transfemoral TAVI for symptomatic aortic stenosis in our center over a 26 months period were included. Dosimetric indicators from preprocedural coronary angiography and computed tomography (CT), the TAVI procedure, and any postprocedural interventions (electrophysiology study and/or pacemaker implantation) were collected and converted into an effective dose. A total of 119 transfemoral TAVI procedures were included. The mean cumulative effective dose (ED) was 37.3 mSv. Three irradiating procedures were necessary for 84 patients (71% of the population, i.e., coronary angiography, CT scan and the TAVI procedure itself), whereas 30 patients (25%) required a fourth procedure, and 5 required a fifth (4%). The majority of the dose was from the CT, while only 11% of the dose derived from the TAVI procedure itself. In conclusion, overall exposure to ionizing radiation for patients who underwent transfemoral TAVI seems acceptable, and the majority of the overall ED comes from the CT scan.
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Affiliation(s)
| | - Laurent Faroux
- Department of Cardiology, Reims University Hospital, Reims, France.
| | - Thierry Blanpain
- Department of Cardiology, Reims University Hospital, Reims, France; Department of Radiation Protection, Reims University Hospital, Reims, France
| | - Marine Kinnel
- Department of Cardiology, Reims University Hospital, Reims, France
| | - Caroline Mora
- Department of Radiology, Reims University Hospital, Reims, France
| | | | | | | | - Damien Metz
- Department of Cardiology, Reims University Hospital, Reims, France
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