Very little is known about long-term valve durability after transcatheter aortic valve replacement (TAVR).
This study sought to evaluate the incidence of structural valve degeneration (SVD) 5 to 10 ...years post-procedure.
Demographic, procedural, and in-hospital outcome data on patients who underwent TAVR from 2007 to 2011 were obtained from the U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) registry. Patients in whom echocardiographic data were available both at baseline and ≥5 years post-TAVR were included. Hemodynamic SVD was determined according to European task force committee guidelines.
A total of 241 patients (79.3 ± 7.5 years of age; 46% female) with paired post-procedure and late echocardiographic follow-up (median 5.8 years, range 5 to 10 years) were included. A total of 149 patients (64%) were treated with a self-expandable valve and 80 (34.7%) with a balloon-expandable valve. Peak aortic valve gradient at follow-up was lower than post-procedure (17.1 vs. 19.1 mm Hg; p = 0.002). More patients had none/trivial aortic regurgitation (AR) (47.5% vs. 33%), and fewer had mild AR (42.5% vs. 57%) at follow-up (p = 0.02). There was 1 case (0.4%) of severe SVD 5.3 years after implantation (new severe AR). There were 21 cases (8.7%) of moderate SVD (mean 6.1 years post-implantation; range 4.9 to 8.6 years). Twelve of these (57%) were due to new AR and 9 (43%) to restenosis.
Long-term transcatheter aortic valve function is excellent. In the authors’ study, 91% of patients remained free of SVD between 5 and 10 years post-implantation. The incidence of severe SVD was <1%. Moderate SVD occurred in 1 in 12 patients.
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Objectives Our objective was to assess endogenous thrombolytic activity in acute coronary syndrome (ACS) patients and relate this to their likelihood of future adverse cardiovascular events. ...Background Spontaneous lysis of platelet-rich thrombi is an important defense mechanism against lasting occlusion. Despite convincing evidence for the role of endogenous fibrinolysis in ACS, the prognostic value of plasma fibrinolytic markers in assessing risk is limited. We employed a novel global test which, in addition to platelet reactivity, allows assessment of endogenous thrombolytic activity to identify ACS patients who remain at risk of cardiovascular events. Methods We used the global thrombosis test (GTT) to assess thrombotic and thrombolytic status in 300 ACS patients receiving dual-antiplatelet therapy. The test assesses the time required to form an occlusive thrombus, the occlusion time (OT), and the time to lyse this, the lysis time (LT). The end point of the study at 12 months' follow-up was the composite of death, nonfatal myocardial infarction, or stroke. Results The OT and LT were both prolonged in ACS patients compared with normal volunteers (p < 0.001). LT ≥3,000 s occurred in 23% of ACS patients versus none of the normal subjects and was a significant and independent predictor of cardiovascular death and nonfatal myocardial infarction in a multivariate model adjusted for cardiovascular risk factors. LT ≥3,000 s was the optimal cutoff value for predicting 12-month major adverse cardiovascular events (hazard ratio HR: 2.52, 95% confidence interval: 1.34 to 4.71, p = 0.004) and cardiovascular death (HR: 4.2, 95% confidence interval: 1.13 to 15.62, p = 0.033). HR increased further as LT increased. No association was found between OT and the risk of major adverse cardiovascular events. Conclusions Assessment of endogenous thrombolytic status based on the lysis of platelet-rich thrombi from native blood using the point-of-care GTT can identify ACS patients at risk of future cardiac events.
Transcatheter aortic valve implantation (TAVI) has become the standard treatment for aortic stenosis in high-risk patients. TAVI for native valve aortic regurgitation is technically more demanding ...because of a lack of anchoring calcification, a lower index incidence, heterogeneous causes, and larger anatomy. We present 3 cases in which the Lotus TAV was used to treat severe native aortic regurgitation (AR) successfully.
Abstract Objective To determine and compare thrombotic and endogenous thrombolytic status in Japanese and Western populations. Background Incidence of coronary heart disease (CHD) and AMI in Japan ...remains lower than in Western countries. Primary genetic effects are unlikely, given the increased CHD in Japanese migrants. For men, cholesterol and blood pressure have been similar in Japan and the U.S. Dietary factors are implicated, but how these effect CHD is unclear. We postulated that differences in thrombotic and/or thrombolytic status may contribute. Methods We measured thrombotic and thrombolytic status in 100 healthy Japanese (J) from Japan and 100 healthy Westerners (W) from the U.K. using the Global Thrombosis Test (GTT). The GTT employs non-anticoagulated blood to create platelet-rich thrombi under high shear (occlusion time OT; seconds), and then measures the restart of blood flow, due to spontaneous thrombolysis (lysis time LT; seconds). Results OT was longer in (J) compared to (W) (545 vs. 364, p < 0.0001). LT was longer in (J) than in (W) (1753 vs. 1052, p < 0.0001). Distribution of LT in (J) did not conform to a normal population, with markedly impaired thrombolytic status (LT > 3000 s) in 18%, compared to none of the Westerners (p < 0.0001). Conclusions There are marked differences in thrombotic and thrombolytic status, with (J) having less prothrombotic (longer OT) but less favourable endogenous thrombolytic profile (longer LT). This may be important in the aetiology of thrombotic events. Since platelets and thrombolysis were both inhibited in (J) and yet incidence of AMI is lower, OT would seem more important than LT as a determinant of overall thrombotic risk in this population.
Trans-catheter aortic valve implantation (TAVI) has become an established treatment for inoperable and high-surgical risk patients with severe, symptomatic aortic stenosis (AS). Post-procedural acute ...kidney injury (AKI) is a frequent complication following TAVI and is associated with increased mortality. Patients with pre-existing chronic renal impairment are at particularly high risk. The etiology of post-TAVI AKI is multi-factorial, but the principal procedural issues are contrast-induced nephropathy, and renal hypoperfusion secondary to intra-procedural hypotension. We report a case of a TAVI in an 80-year-old patient with severe AS and significant chronic kidney disease (CKD), which was carried out without the use of contrast and with minimal procedural hypotension.
Pre-procedural imaging was carried out using 3D trans-esophageal echocardiography (TEE) rather than computed tomography (CT) to avoid contrast administration. The Lotus valve (Boston Scientific, Marlborough, MA, USA) was chosen due to a number of design features which minimize both the need for contrast injection and procedural hypotension during valve positioning and deployment. The procedure was carried out successfully and produced an excellent result with no decline in renal function. We believe that the approach of using TEE and the mechanically-expanded Lotus valve illustrates an important therapeutic approach in patients with severe CKD.
<Learning objective: Post-procedural acute kidney injury (AKI) is a frequent complication following trans-catheter aortic valve implantation (TAVI), and is associated with increased mortality. The principal procedural issues are contrast-induced nephropathy and intra-procedural hypotension. Our case report demonstrates how TAVI can be performed with zero contrast and minimization of procedural hypotension, facilitated by the use of trans-esophageal echocardiography and the mechanically-expanded Lotus valve. This approach should only be used in exceptional circumstances, but can be particularly relevant for patients with pre-existing chronic renal impairment, who are at increased risk of post-TAVI AKI.>
Transcatheter aortic valve replacement (TAVR) is being increasingly performed in patients with bicuspid aortic valve stenosis (AS).
This study sought to compare the procedural and clinical outcomes ...in patients with bicuspid versus tricuspid AS from the Bicuspid AS TAVR multicenter registry.
Outcomes of 561 patients with bicuspid AS and 4,546 patients with tricuspid AS were compared after propensity score matching, assembling 546 pairs of patients with similar baseline characteristics. Procedural and clinical outcomes were recorded according to Valve Academic Research Consortium-2 criteria.
Compared with patients with tricuspid AS, patients with bicuspid AS had more frequent conversion to surgery (2.0% vs. 0.2%; p = 0.006) and a significantly lower device success rate (85.3% vs. 91.4%; p = 0.002). Early-generation devices were implanted in 320 patients with bicuspid and 321 patients with tricuspid AS, whereas new-generation devices were implanted in 226 and 225 patients with bicuspid and tricuspid AS, respectively. Within the group receiving early-generation devices, bicuspid AS had more frequent aortic root injury (4.5% vs. 0.0%; p = 0.015) when receiving the balloon-expanding device, and moderate-to-severe paravalvular leak (19.4% vs. 10.5%; p = 0.02) when receiving the self-expanding device. Among patients with new-generation devices, however, procedural results were comparable across different prostheses. The cumulative all-cause mortality rates at 2 years were comparable between bicuspid and tricuspid AS (17.2% vs. 19.4%; p = 0.28).
Compared with tricuspid AS, TAVR in bicuspid AS was associated with a similar prognosis, but lower device success rate. Procedural differences were observed in patients treated with the early-generation devices, whereas no differences were observed with the new-generation devices.
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Common femoral arterial (CFA) access is the most commonly used access route for transcatheter aortic valve implantation (TAVI). In majority of cases, it is easily accessible percutaneously without ...requiring surgical cut down. However, in patients with high body mass index (BMI) or central obesity, it can be more than 8–10 cm below the skin making the procedure more technically demanding and satisfactory hemostasis more difficult to achieve. The superficial femoral artery (SFA) lies only a few centimeters distal to the CFA with little compromise on vessel caliber, yet can allow more suitable access in certain patients with a high BMI. We describe three cases in which SFA access was successfully used as the primary delivery route for TAVI.
Management of dyslipidaemia is crucial for the reduction in the risk of atherosclerotic cardiovascular disease in the population. Optimum control of this risk factor in both primary and secondary ...care will not only help reduce cardiovascular disease, but also help reduce long-term healthcare costs for hospital stays, clinic visits and morbidity due to a chronic disease. The purpose of this review is to compare the recent American College of Cardiology/American Heart Association 2013 guidelines with those in Europe, Britain, Canada and the International Atherosclerosis Society position paper.
The American College of Cardiology/American Heart Association Task Force have published new guidelines on the management of LDL cholesterol for the reduction in atherosclerotic cardiovascular disease risk, which are in variance with the European Society of Cardiology/European Atherosclerosis Society and other country guidelines and have significant repercussions in different populations.
Significant variance between the guidelines can make it difficult for healthcare providers to provide standardized care in different countries, and their long-term implications are uncertain.
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