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Tscharre M, Mutschlechner D, Schlöglhofer T, Wiedemann D, Zimpfer D, Gremmel T. Omission of Antiplatelet Therapy in Patients With HeartMate 3 Left Ventricular Assist Devices: A Systematic Review and Meta-Analysis. ASAIO J 2024:00002480-990000000-00479. [PMID: 38728742 DOI: 10.1097/mat.0000000000002225] [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] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
The HeartMate 3 (HM3) left ventricular assist device has decreased thromboembolic events and minimized the risk of pump thrombosis. However, bleeding complications due to combined antithrombotic therapy with a vitamin K antagonist (VKA) and aspirin remain high. Only limited data on the safety of VKA monotherapy in HM3 patients are available. A systematic search on the main databases was performed. Observational data and randomized trials were eligible for this analysis. As primary endpoint, we analyzed hemocompatibility-related adverse events (HRAE). As secondary endpoints, we investigated the individual components of the primary endpoint. The analysis was carried out using the odds ratio (OR) as outcome measure. A random-effects model was fitted to the data. Five manuscripts fulfilled the inclusion criteria. These trials included 785 patients (381 on VKA monotherapy, 404 on VKA and aspirin). VKA monotherapy significantly reduced HRAE (OR: 0.11 [95% confidence interval {CI}: 0.02-0.59], p = 0.01, I2 = 87%). The reduction was driven by a decrease in bleeding complications (OR: 0.12 [95% CI: 0.02-0.62], p = 0.01, I2 = 86%) without increasing the rates of thromboembolic events (OR: 0.69 [95% CI: 0.26-1.81], p = 0.45, I = 0%). Vitamin K antagonist monotherapy is associated with a significant reduction of bleeding events without increasing the risk of thromboembolic complications in HM3 patients.
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Affiliation(s)
- Maximilian Tscharre
- From the Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
- Institute of Vascular Medicine and Cardiac Electrophysiology, Karl Landsteiner Society, St. Pölten, Austria
| | - David Mutschlechner
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
| | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Gremmel
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
- Institute of Cardiovascular Pharmacotherapy and Interventional Cardiology, Karl Landsteiner Society, St. Pölten, Austria
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Tscharre M, Steiner D, Mutschlechner D, Ay C, Gremmel T. Anticoagulation in atrial fibrillation and end-stage kidney disease on hemodialysis: a meta-analysis of randomized trials comparing direct oral anticoagulants with vitamin K antagonists. Res Pract Thromb Haemost 2024; 8:102332. [PMID: 38404942 PMCID: PMC10885786 DOI: 10.1016/j.rpth.2024.102332] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 01/04/2024] [Accepted: 01/07/2024] [Indexed: 02/27/2024] Open
Abstract
Background Only small randomized trials have investigated the efficacy and safety of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) in patients with non-valvular atrial fibrillation (NVAF) and end-stage kidney disease. Objectives To perform a systematic review and meta-analysis comparing anticoagulation with DOACs to VKAs in patients with NVAF undergoing chronic hemodialysis. Methods A systematic search using Medline, Web of Science, and Embase was performed. All randomized trials comparing DOACs with VKAs in patients with NVAF undergoing chronic hemodialysis were included. As primary endpoint, we analyzed all-cause mortality. As secondary endpoints, we investigated total bleeding events, life-threatening or major bleeding events, and thromboembolic events or stroke. We used the odds ratio as outcome measure and fitted a random-effects model due to the expected heterogeneity. Results Three studies fulfilled the inclusion criteria comprising 383 patients (218 on apixaban or rivaroxaban, 165 on VKA). No significant difference between DOACs and VKAs regarding death (OR, 0.94; 95% CI, 0.55-1.63; p = .84), total bleedings (OR, 0.99; 95% CI, 0.63-1.54; p = .96) and life-threatening or major bleeding (OR, 0.65; 95% CI, 0.32-1.33, p = .24) was detected. There was a trend toward a reduction of thromboembolic events or stroke in patients receiving DOACs (OR, 0.39; 95% CI, 0.14-1.05; p = .06). Conclusion Orally administered activated factor X inhibitors carried a similar risk of bleeding and death when compared with VKAs in patients with NVAF undergoing chronic hemodialysis. Moreover, there was a trend towards a reduction of thromboembolic events or stroke in patients receiving DOACs.
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Affiliation(s)
- Maximilian Tscharre
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Austria
- Institute of Vascular Medicine and Cardiac Electrophysiology, Karl Landsteiner Society, St. Pölten, Austria
| | - Daniel Steiner
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - David Mutschlechner
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Thomas Gremmel
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria
- Institute of Cardiovascular Pharmacotherapy and Interventional Cardiology, Karl Landsteiner Society, St. Pölten, Austria
- Karl Landsteiner University of Health Sciences, Krems, Austria
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
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Heger F, Schindler S, Pleininger S, Fueszl A, Blaschitz M, Lippert K, Hyden P, Hufnagl P, Mutschlechner D, Gremmel T, Hofer E, Markowicz M, Indra A. Three Cases of Tickborne Francisella tularensis Infection, Austria, 2022. Emerg Infect Dis 2023; 29:2349-2352. [PMID: 37877608 PMCID: PMC10617340 DOI: 10.3201/eid2911.230460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023] Open
Abstract
Tularemia is increasing in Austria. We report Francisella tularensis subspecies holarctica isolated from 3 patients who had been bitten by arthropods. Next-generation sequencing showed substantial isolate similarity. Clinicians should consider bloodstream F. tularensis infections for patients with signs/symptoms of ulceroglandular tularemia, and surveillance of potential vectors should be intensified.
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Mutschlechner D, Tscharre M, Huber K, Gremmel T. Cardiovascular events in patients treated with bempedoic acid vs. placebo: systematic review and meta-analysis. Eur Heart J Cardiovasc Pharmacother 2023; 9:583-591. [PMID: 37463824 DOI: 10.1093/ehjcvp/pvad052] [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] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/17/2023] [Accepted: 07/17/2023] [Indexed: 07/20/2023]
Abstract
AIMS Reduction of low-density lipoprotein cholesterol (LDL-C) decreases cardiovascular mortality and morbidity. Bempedoic acid represents a promising novel lipid-modifying agent for patients who cannot reach guideline recommended LDL-C goals or statin-intolerant patients, but data on safety and cardiovascular outcomes are limited. We therefore aimed to systematically review randomized controlled trials investigating bempedoic acid vs. placebo in patients with hyperlipidaemia. METHODS A systematic search on the databases PubMed, Web of Science, and Embase until 20 March 2023 was performed. All randomized trials comparing bempedoic acid (180 mg daily) with placebo in patients with an indication for lipid-lowering therapy were included. As a primary endpoint, we analysed three-point major adverse cardiovascular events (MACEs) consisting of cardiovascular death, non-fatal myocardial infarction (MI), or non-fatal stroke. The analysis was carried out using the odds ratio (OR) as the outcome measure. Due to the expected heterogeneity across studies, a random-effects model was fitted to the data. RESULTS Out of 258 manuscripts, 10 manuscripts fulfilled the inclusion criteria. In total, these trials included 18 200 patients (9765 on bempedoic acid, 8435 on placebo). Bempedoic acid significantly reduced MACEs compared with placebo (OR 0.84 [95% confidence interval (CI) 0.76-0.96]; P < 0.001; I2 = 0%). The endpoint reduction was driven by a lower rate of non-fatal MI, whereas bempedoic acid had no significant effect on stroke (OR 0.86 [95% CI 0.69-1.08]; P = 0.20, I2 = 0%) and all-cause mortality (OR 1.19 [95% CI 0.73-1.93]; P = 0.49; I2 = 18%). CONCLUSION Bempedoic acid reduced non-fatal MI in patients with hyperlipidaemia, whereas it had no significant effect on stroke and all-cause mortality.
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Affiliation(s)
- David Mutschlechner
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstraße 67, 2130 Mistelbach, Austria
| | - Maximilian Tscharre
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Corvinusring 3-5, 2700 Wiener Neustadt, Austria
- Institute of Vascular Medicine and Cardiac Electrophysiology, Karl Landsteiner Society, Julius Raab-Promenade 49/1, 3100 St. Pölten, Austria
| | - Kurt Huber
- Medical Department, Cardiology and Intensive Care Medicine, Hospital Ottakring, Montleartstraße 37, 1160 Vienna, Austria
- Medical School, Sigmund-Freud University, Freudpl. 1+3, 1020 Vienna, Austria
| | - Thomas Gremmel
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Liechtensteinstraße 67, 2130 Mistelbach, Austria
- Institute of Cardiovascular Pharmacotherapy and Interventional Cardiology, Karl Landsteiner Society, Julius Raab-Promenade 49/1, 3100 St. Pölten, Austria
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Nitsche C, Koschutnik M, Dona C, Mutschlechner D, Spinka G, Dannenberg V, Mascherbauer K, Sinnhuber L, Kammerlander A, Winter MP, Bartko PE, Goliasch G, Hengstenberg C, Mascherbauer J. Life expectancy and early to mid-term dysfunction of transcatheter aortic prostheses: incidence, modes, correlates, and outcome. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2086] [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: 11/13/2022] Open
Abstract
Abstract
Backgrounds
Bioprosthetic valve dysfunction (BVD) is a major concern regarding transcatheter aortic valve implantation (TAVI) in low-risk patients.
Aims
To assess incidence, determinants, modes, and outcome of early to mid-term BVD after TAVI in relation with life expectancy.
Methods
Consecutive TAVI recipients (2007–2020) with a post-interventional follow-up ≥1-year were prospectively included. BVD components and bioprosthetic valve failure (BVF) were assessed according to updated Valve-Academic-Research-Consortium-3 criteria. Echocardiographic and laboratory follow-up was performed prior to discharge, at 3- and 12-months, and yearly thereafter. BVD/BVF and all-cause death served as endpoints. Average life expectancy was calculated from National Open Health Data and patients were stratified according to tertiles (1st: <6.85y, 2nd: 6.85–9.7y, 3rd: >9.7y).
Results
Of 1047 patients (81.6±6.8 y/o, 52.7% female, EuroSCORE II 4.5±2.5), ≥2 follow-ups were available from 622 (serial echo cohort). After a median echo follow-up of 12.2 months, incidence rates of BVD and BVF were 8.4% [95% confidence interval 6.7–10.3], and 3.5% [2.5–4.9] per valve-year, respectively, without differences between life expectancy tertiles (Figure 1). BVD incidence was double within the first year of implant (9.9% [7.7–12.6] per valve-year; mostly non-structural VD) vs. beyond (4.8% [3.1–7.2] per valve-year; structural and non-structural VD). Valve-in-valve procedure, and stenosis severity (both p<0.05), but not age/life expectancy (p>0.5) predisposed for BVD.
After 4.4±3.0 years, mortality was 36.7%. Time-dependent BVD/BVF were independently associated with outcome for patients in the first (adjusted hazard ratio [AHR] 1.72 [1.06–2.88]/ 2.97 [1.72–6.22]) and second (AHR 1.96 [1.02–3.73]/ 2.31 [1.00–5.30]), but not the third tertile of life expectancy (AHR 1.42 [0.66–3.12]/ 1.84 [0.71–4.79]; Figure 1).
Conclusions
In this large prospective observational cohort, early to mid-term BVD after TAVI occurred at the same rate across the spectrum of life expectancy and was not prognostic among those with the longest life expectancy.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- C Nitsche
- Medical University of Vienna AKH , Vienna , Austria
| | - M Koschutnik
- Medical University of Vienna AKH , Vienna , Austria
| | - C Dona
- Medical University of Vienna AKH , Vienna , Austria
| | | | - G Spinka
- Medical University of Vienna AKH , Vienna , Austria
| | - V Dannenberg
- Medical University of Vienna AKH , Vienna , Austria
| | | | - L Sinnhuber
- Medical University of Vienna AKH , Vienna , Austria
| | | | - M P Winter
- Medical University of Vienna AKH , Vienna , Austria
| | - P E Bartko
- Medical University of Vienna AKH , Vienna , Austria
| | - G Goliasch
- Medical University of Vienna AKH , Vienna , Austria
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Nitsche C, Koschutnik M, Donà C, Mutschlechner D, Halavina K, Spinka G, Dannenberg V, Mascherbauer K, Sinnhuber L, Kammerlander A, Winter MP, Bartko P, Goliasch G, Pibarot P, Hengstenberg C, Mascherbauer J. Incidence, causes, correlates, and outcome of bioprosthetic valve dysfunction and failure following transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging 2022; 24:796-806. [PMID: 36099163 DOI: 10.1093/ehjci/jeac188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/14/2022] [Accepted: 08/18/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Bioprosthetic valve dysfunction (BVD) is a major concern regarding transcatheter aortic valve implantation (TAVI) durability. We aimed to assess incidence, correlates, causes, and outcome of early to mid-term BVD after TAVI in relation to patient's life expectancy. METHODS AND RESULTS Consecutive TAVI recipients (2007-20) with a follow-up ≥1 year were prospectively included. BVD and bioprosthetic valve failure (BVF) were assessed according to Valve-Academic-Research-Consortium-3. BVD/BVF and all-cause death served as endpoints. Average life expectancy was calculated from National Open Health Data and patients were stratified according to tertiles (1st: <6.85 years, 2nd: 6.85-9.7 years, 3rd: >9.7 years). Of 1047 patients (81.6 ± 6.8 years old, EuroSCORE II 4.5 ± 2.5), ≥2 follow ups were available from 622 (serial echo cohort). After a median echo follow up of 12.2 months, incidence rates of BVD/BVF were 8.4% (95% confidence interval 6.7-10.3), and 3.5% (2.5-4.9) per valve-year, respectively, without differences between life expectancy tertiles. The incidence of BVD was two-fold higher within the first year of implant (9.9% per valve-year) vs. beyond (4.8% per valve-year). Valve-in-valve procedure and residual stenosis, but not age/life expectancy predisposed for BVD. BVD/BVF were independently associated with outcome for patients in the first [adjusted hazard ratio (AHR) 1.72 (1.06-2.88)/2.97 (1.72-6.22)] and second [AHR 1.96 (1.02-3.73)/2.31 (1.00-5.30)], but not the third tertile of life expectancy (P = n.s.). CONCLUSIONS In this large prospective observational cohort, early to mid-term BVD after TAVI occurred at the same rate across the spectrum of life expectancy and was associated with increased mortality in patients with short but not in those with the longest life expectancy.
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Affiliation(s)
- Christian Nitsche
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Matthias Koschutnik
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Carolina Donà
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - David Mutschlechner
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Kseniya Halavina
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Georg Spinka
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Varius Dannenberg
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | | | - Leah Sinnhuber
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Andreas Kammerlander
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Max Paul Winter
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Philipp Bartko
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,Herzzentrum Währing, Vienna, Austria
| | - Philippe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Department of Medicine, Laval University, Québec, Canada
| | | | - Julia Mascherbauer
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine, Karl Landsteiner University of Health Sciences, 3, University Hospital St. Pölten, Krems, Austria
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