Selection of Transcatheter Heart Valves: The Plethora of Device-Specific, Anatomic-Specific and Patient-Specific Aspects for Optimal Results in Transcatheter Aortic Valve Replacement

Due to the high individual differences in the anatomy and pathophysiology of patients, planning individualized treatment requires patient-specific diagnosis. Indeed, hemodynamic quantification can be immensely valuable for accurate diagnosis, however, we still lack precise diagnostic methods for numerous cardiovascular diseases including complex (and mixed) valvular, vascular, and ventricular interactions (C3VI) which is a complicated situation made even more challenging in the face of other cardiovascular pathologies. Transcatheter aortic valve replacement (TAVR) is a new less invasive intervention and is a growing alternative for patients with aortic stenosis. In a recent paper, we developed a non-invasive and Doppler-based diagnostic and monitoring computational mechanics framework for C3VI, called C3VI-DE that uses input parameters measured reliably using Doppler echocardiography. In the present work, we have developed another computational-mechanics framework for C3VI (called C3VI-CT). C3VI-CT uses the same lumped-parameter model core as C3VI-DE but its input parameters are measured using computed tomography and a sphygmomanometer. Both frameworks can quantify: (1) global hemodynamics (metrics of cardiac function); (2) local hemodynamics (metrics of circulatory function). We compared accuracy of the results obtained using C3VI-DE and C3VI-CT against catheterization data (gold standard) using a C3VI dataset (N = 49) for patients with C3VI who undergo TAVR in both pre and post-TAVR with a high variability. Because of the dataset variability and the broad range of diseases that it covers, it enables determining which framework can yield the most accurate results. In contrast with C3VI-CT, C3VI-DE tracks both the cardiac and vascular status and is in great agreement with cardiac catheter data.

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Antithrombotic selection in patients undergoing transcatheter aortic valve replacement

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxaa329 ◽

2020 ◽

Vol 78 (1) ◽

pp. 22-35

Author(s):

Jennifer K Lai ◽

Katie L Willenborg ◽

Theodore Berei ◽

Anne E Rose

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Antiplatelet Therapy ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Current Evidence ◽

Patient Specific ◽

Bleeding Events ◽

Transcatheter Aortic Valve ◽

Specific Factors

Abstract Purpose Clinical controversy regarding the most appropriate antithrombotic regimen after transcatheter aortic valve replacement remains. Current evidence, guidelines, and recommendations are discussed. Summary Antithrombotic selection following transcatheter aortic valve replacement depends on a variety of patient-specific factors. For patients without a preexisting indication for anticoagulation, initial trials employed dual antiplatelet therapy as the postprocedural therapy of choice. Newer studies in this patient population, however, suggest single antiplatelet therapy reduces bleeding events without sacrificing ischemic protection. In patients with a preexisting indication for anticoagulation, warfarin plus single antiplatelet therapy, as opposed to triple antithrombotic therapy, offered similar ischemic protection while reducing clinically significant bleeding. Warfarin monotherapy was associated with a further reduction in bleeding events. One trial demonstrated the safety and efficacy of using apixaban in patients with concomitant atrial fibrillation; however, routine use of rivaroxaban increased adverse cardiac and bleeding events, leaving the utility of direct-acting oral anticoagulants in question. Conclusion Available evidence and current guidelines point to a lack of consensus regarding antithrombotic selection after transcatheter aortic valve replacement. Patient-specific factors and comorbidities must be considered when tailoring therapy, with an emphasis on balancing thrombotic and bleeding risks.

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Abstract 20549: Patient-Specific CT Image-Based Engineering Analysis of Transcatheter Aortic Valve Replacement - Implications for Aortic Root Rupture

Circulation ◽

10.1161/circ.130.suppl_2.20549 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Qian Wang ◽

Caitlin Martin ◽

Susheel Kodali ◽

Jonathon Leipsic ◽

Philipp Blanke ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Clinical Outcomes ◽

Valve Replacement ◽

Aortic Root ◽

Transcatheter Aortic Valve Replacement ◽

Aortic Rupture ◽

Blind Study ◽

Patient Specific ◽

Transcatheter Aortic Valve

Introduction: Despite the increased global experience with transcatheter aortic valve replacement (TAVR), there remain major adverse clinical events. One of the most severe complications of TAVR is aortic rupture. Although several clinical risk factors of TAVR-induced rupture have been identified, the mechanisms remain largely unknown. The objective of this study was to use computational models to predict potential aortic rupture in TAVR patients. Methods: Pre-procedural CT scans of TAVR patients were used to reconstruct patient-specific finite element (FE) models, which included the aortic root, aortic leaflets, calcification, mitral-aortic intervalvular fibrosa, anterior mitral leaflet, fibrous trigones, and left ventricle. Stent deployment was simulated in a total of 25 patients to evaluate the potential for aortic rupture. Our research design consisted of two phases: Phase One, which was to develop and calibrate FE modeling techniques by retrospectively analyzing 7 Edwards SAPIEN cases with known results; and Phase Two, which was to implement the modeling methodology developed in Phase One to conduct a blind study of 18 cases from a database of 60 patients consisting of 50% rupture cases. For the blind study, FE simulations were completed by researchers blind to the clinical outcomes, and data analysis was conducted by an independent researcher. Results: Simulations correctly predicted 83% of the rupture cases. The balloon pressure at time of rupture was approximately 3.52 atm and 2.53 atm for SAPIEN 23 and 26 valves, respectively. The average contact force between the stent and native tissue was about 81N. Conclusion: Our analysis of over 18 patients suggested that the TAVR outcome could depend on the patient-specific aortic sinus shape, calcification volume, shape, location, and orientation. These results demonstrate the potential for simulation-based pre-TAVR planning tools to evaluate device performance and improve clinical outcomes.

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