Acute Myocardial Infarction as the Initial Manifestation of Delayed Bioprosthesis Thrombosis After Transcatheter Aortic Valve Replacement

Background: Coronary artery obstruction is a rare, devastating complication of transcatheter aortic valve replacement. Transcatheter electrosurgical aortic leaflet laceration (Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction [BASILICA]) is a novel technique to prevent coronary artery obstruction. We report the 1-year outcomes of the BASILICA trial. Primary end points of 30-day success and safety have been reported previously. Methods: The BASILICA trial was a prospective, multicenter, single-arm safety and feasibility study. Subjects with severe native or bioprosthetic aortic valve disease at high or extreme risk for surgery, and high risk of coronary artery obstruction, were included. End points at 1 year included death, stroke, and myocardial infarction. Source data was independently verified and end points independently adjudicated. Results: Thirty subjects were enrolled between February 2018 and July 2018. At 30 days, BASILICA was successful in 28 subjects (93.3%), there were 3 strokes (10%), including 1 disabling stroke (3.3%), 1 death (3.3%), and 1 periprocedural myocardial infarction (3.3%). Between 30 days and 1 year, there were no additional strokes, no myocardial infarction, and 2 deaths (10% 1-year mortality). No subject needed repeat intervention for aortic valve or coronary disease. Two subjects had infective endocarditis (6.7%), but neither was isolated to the aortic valve. There were no hospital admissions for heart failure. Fourteen (46.7%) subjects required repeat hospital admission for other causes. Aortic valve gradients on echocardiography, New York Heart Association functional class, and Kansas City Cardiomyopathy Questionnaire scores improved from baseline to 30 days and were maintained at 1 year. Conclusions: In these subjects with multiple comorbidities and restrictive anatomy that underwent transcatheter aortic valve replacement, there was no late stroke, myocardial infarction, or death related to BASILICA. Mitigation of coronary obstruction remained intact at 1 year and was not related to recurrent readmission. These results are reassuring for patients and physicians who wish to avoid the long-term complications related to snorkel stenting. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03381989.

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Abstract 17539: Conventional vs. Transcatheter Aortic Valve Replacement - Propensity Score Adjusted Comparison of 3,751 Unselected Patients

Circulation ◽

10.1161/circ.132.suppl_3.17539 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Jochen Börgermann ◽

Eric Emmel ◽

Smita Scholtz ◽

Stephan Ensminger ◽

Werner Scholtz ◽

...

Keyword(s):

Myocardial Infarction ◽

Aortic Valve ◽

Propensity Score ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Vascular Complications ◽

Bleeding Complications ◽

Moderate Risk ◽

Transcatheter Aortic Valve

Background and Hypothesis: Transcatheter aortic valve replacement (TAVR) is an established method in high-risk patients. Two aspects of this procedure are currently under discussion: 1.) Do the data acquired from randomized studies and registers justify expansion of the procedure to include younger and healthier patients? 2.) Is the transfemoral approach superior to the transapical approach with regard to mortality and periprocedural complications? Against this background we examined the mortality and morbidity of all patients who received an isolated conventional, transapical or transfemoral aortic valve replacement in accordance with the criteria of the Valve Academic Research Consortium (VARC)-2. Methods: A prospective register was taken from a single center recording all conventional (CONV, n=2,881), transapical (TAVR-TA, n=363) and transfemoral (TAVR-TF, n=570) aortic valve implantations during the period from 07/2009 to 10/2014. Using propensity score (PS) matching, first CONV and TAVRall (TA+TF) and then TAVR-TA and TAVR-TF were paired on the basis of 21 risk variables, creating comparable groups. Results: 393 pairs CONV vs. TAVRall within a moderate risk could be created (EuroSCORE 18.7 vs. 18.5; STS 5.0 vs. 5.4). Comparison revealed no difference for 30d mortality (4.6% CONV vs. 5.1% TAVRall, p=0.74), stroke (2.8% vs. 2.0%, p=0.48) or myocardial infarction (0.0 vs. 0.3%, p=0.50). Bleeding complications were significantly more frequent in the CONV, SM implantations and vascular complications in the TAVRall group. In the PS-adjusted comparison TAVR-TA vs. TAVR-TF (289 pairs; EuroSCORE 25.1 vs. 22.1; STS 6.8 vs. 6.7) there was also no difference in the hard endpoints (30d mortality 4.9% TA vs. 4.2% TF, p=0.70; stroke 3.1% vs. 2.8%, p=0.81; myocardial infarction 0.4% vs. 0.4%, p=1.00). Here bleeding complications were significantly more frequent in the TA group, SM implantations and vascular complications in the TF group. Subgroup analyses show an advantage of the TAVR procedure in patients with high STS or low LVEF. Conclusions: These data show that 1.) conventional aortic valve replacement and TAVR are comparable in the moderate risk group, and 2.) the two approaches, transapical and transfemoral, produce comparable results.

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Single antiplatelet therapy versus dual antiplatelet therapy after transcatheter aortic valve replacement: a meta-analysis of randomized controlled trials

European Heart Journal ◽

10.1093/eurheartj/ehab724.2171 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

G Sayat ◽

L G Porciuncula ◽

A Gerodias

Keyword(s):

Myocardial Infarction ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Antiplatelet Therapy ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Dual Antiplatelet Therapy ◽

Meta Analysis ◽

Randomized Controlled ◽

Transcatheter Aortic Valve

Abstract Background The performance of transcatheter aortic valve replacement (TAVR) has expanded considerably during the past decade. Technological advances and refinement in implantation techniques have resulted in improved procedural outcomes, whereas indications are progressively extending toward lower-risk patients. Ischemic/embolic complications and major bleeding remain important and strongly correlate to mortality. In this regard, the optimal antithrombotic regimen after successful transcatheter aortic valve replacement remains unclear. Purpose To compare the efficacy and safety of single antiplatelet therapy (SAPT) versus dual antiplatelet therapy (DAPT) for post Transcatheter Aortic Valve Replacement. Search strategy Key Terms: transcatheter aortic valve replacement, transcatheter aortic valve implantation, antiplatelet, single antiplatelet therapy, dual antiplatelet therapy. Selection criteria Four randomized, controlled clinical trials comparing single antiplatelet therapy versus dual antiplatelet therapy for post TAVR patients were included in this study. Method Extensive search of PubMed, Medline, Cochrane and Ovid was done for articles published until November 20, 2020. Studies were limited to RCTs comparing SAPT and DAPT among patients who underwent TAVR. Outcome measures include: stroke, myocardial infarction, all-cause mortality and major bleeding. Two reviewers independently reviewed the studies. Results were gathered from published articles, journals and clinical trials. Studies were critically appraised with regards to methods of minimizing bias. All four studies included received a quality scale for meta-analysis overall score of not less than B. Statistical analysis was done using Review manager V5.4. Main results Four RCTs with 1086 patients were included in this meta-analysis. Overall, the risk of stroke (OR 0.94 [0.54 −1.64]), myocardial infarction (OR 0.50 [0.18–1.40]), and overall mortality (OR 1.01 [0.65–1.57]) did not differ significantly between DAPT and SAPT. There was noted increased risk of bleeding noted with DAPT, thus favoring SAPT (OR 0.44 [0.30–0.65]). Author's conclusions Among patients who underwent TAVR, DAPT compared to SAPT had similar rates of stroke, myocardial infarction and death. Due to lower rates of bleeding, we recommend using single antiplatelet therapy after TAVR. FUNDunding Acknowledgement Type of funding sources: None.

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Impact of Incomplete Coronary Revascularization on Late Ischemic and Bleeding Events after Transcatheter Aortic Valve Replacement

Journal of Clinical Medicine ◽

10.3390/jcm9072267 ◽

2020 ◽

Vol 9 (7) ◽

pp. 2267

Author(s):

Adrien Carmona ◽

Benjamin Marchandot ◽

François Severac ◽

Marion Kibler ◽

Antonin Trimaille ◽

...

Keyword(s):

Myocardial Infarction ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Coronary Revascularization ◽

Bleeding Complications ◽

Syntax Score ◽

Bleeding Events ◽

Transcatheter Aortic Valve

Background: The impact of coronary artery disease (CAD) and revascularization by percutaneous coronary intervention (PCI) on prognosis in patients undergoing transcatheter aortic valve replacement (TAVR) remain debated. A dismal prognosis in patients undergoing PCI has been associated with elevated baseline SYNTAX score (bSS) and residual SYNTAX score (rSS). The objective was to investigate whether the degree of bSS and rSS impacted ischemic and bleeding events after TAVR. Methods: bSS and rSS were calculated in 311 patients admitted for TAVR. The primary outcome was the occurrence of major adverse cardiac events (MACE), a composite endpoint of myocardial infarction, stroke, cardiovascular death, or rehospitalization for heart failure. The occurrence of late major/life-threatening bleeding complications (MLBCs) and each primary endpoint individually were the secondary endpoints. Results: bSS > 22 was associated with higher occurrence of MACE (p = 0.013). rSS > 8 and bSS > 22 had no impact on overall cardiovascular mortality. rSS > 8 and bSS > 22 were associated with higher rates of myocardial infarction (p = 0.001 and p = 0.004) and late occurrence of MLBCs. Multivariate analysis showed that bSS > 22 (sHR 2.48) and rSS > 8 (sHR 2.35) remained predictors of MLBCs but not of myocardial infarction. Conclusions: Incomplete coronary revascularization and CAD burden did not impact overall and cardiac mortality but constitute predictors of late MLBCs in TAVR patients.

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