Paradoxical Increase of Stroke in Patients with Defect of High Molecular Weight Multimers of the von Willebrand Factors following Transcatheter Aortic Valve Replacement

2020 ◽  
Vol 120 (09) ◽  
pp. 1330-1338
Author(s):  
Kensuke Matsushita ◽  
Benjamin Marchandot ◽  
Antonin Trimaille ◽  
Marion Kibler ◽  
Joe Heger ◽  
...  
Keyword(s):  
Molecular Weight ◽  
Ischemic Stroke ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
High Molecular Weight ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Bleeding Events ◽  
Transcatheter Aortic Valve ◽  
Von Willebrand

Abstract Background Stroke is a major cause of disability after transcatheter aortic valve replacement (TAVR) and stroke prediction models and data are crucially needed. Following TAVR, high molecular weight (HMW) multimers defect of von Willebrand factor (VWF) as assessed by closure time of adenosine diphosphate (CT-ADP) value > 180 seconds is an independent predictor of bleeding events. This study sought to identify predictors of ischemic neurological events in patients who underwent TAVR and the specific impact of HMW multimers defect of VWF. Methods Patients were prospectively enrolled between November 2012 and May 2018 at our institution. The CT-ADP, a point-of-care measure of hemostasis, was assessed the day before and 24 hours after the procedures. The rate of ischemic stroke and transient ischemic attack (TIA) was recorded up to 30 days after the procedures. Results Of 565 TAVR patients, ischemic stroke/TIA was observed in 21 (3.7%) patients within 30 days. Ischemic stroke/TIA was associated with major/life-threatening bleeding complications (MLBCs) (9 [43%] vs. 88 [16%], p = 0.002) and postprocedure CT-ADP > 180 seconds (10 [48%] vs. 116 [21%], p = 0.01). By multivariate analysis, MLBCs (odds ratio [OR]: 3.58; 95% confidence interval [CI]: 1.45–8.84; p = 0.006) and postprocedure CT-ADP > 180 seconds (OR: 3.38; 95% CI: 1.38–8.25; p = 0.008) were evidenced as independent predictors of ischemic stroke/TIA. Conclusion MLBCs and CT-ADP > 180 seconds were identified as predictors for ischemic stroke or TIA. The present study suggests that the defects of HMW multimers of the VWFs may contribute not only to bleeding events but also to thrombotic events.

Abstract 15732: Transcatheter Aortic Valve Replacement as a Path to Transplant: Similar Short-term Outcomes in Liver and Renal Failure

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Hope Caughron ◽  
Devang Parikh ◽  
Zev Allison ◽  
Vaikom Mahadevan
Keyword(s):  
Renal Failure ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Liver Transplant ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Control Group ◽  
Bleeding Events ◽  
Transcatheter Aortic Valve ◽  
End Stage

Introduction: Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement in patients with predicted poor surgical outcomes due to end stage liver disease (ESLD) or end stage renal disease (ESRD), though there remains minimal data regarding outcomes and treatment strategy in this population. This study evaluates in-hospital, 30-day, and 1-year outcomes after TAVR in a cohort of patients with ESLD and/or ESRD compared to a cohort without these comorbidities. Methods: We retrospectively compared 317 consecutive patients (N=37 ESLD and ESRD, N=286 without ESLD or ESRD) age >18 who underwent transfemoral or transssubclavian TAVR at University of California San Francisco Medical Center from August 1 st , 2014 to April 1 st , 2020. Results: The ESLD and ESRD group had younger patients (69.8±11.5 vs 79.1±9.8, p<0.01), a higher incidence of diabetes mellitus (54.8% vs 28.3%, p<0.01), and higher STS-PROM scores (7.8±6.5 vs 4.7±3.9, p<0.01). Comparing the ESLD and ESRD to the control group, there were similar rates of in-hospital cerebrovascular events (3.2% vs 3.5%, p=0.94), vascular complications (6.5% vs 7.0%, p=0.91), and mortality (0.0%, vs 1.7%, p=0.46) with more bleeding events at discharge (9.7% vs 2.1%, p=0.01) and 1-year (29.2% vs 10.4%, p=0.01). Mortality rates were similar at 30-days (3.2% vs 2.1%, p=0.69) and 6-months (3.4% vs 2.8%, p=0.83), with a trend towards higher mortality in the ESLD and ESRD group at 1-year (16.7% vs 7.8%, p=0.15) from primarily noncardiac causes. Readmission rates were higher in the ESLD and ESRD cohort at 6-months (58.6% vs 27.2%, p<0.01) and 1-year (66.7% vs 40.6%, p=0.02). One patient received dual kidney-liver transplant, 1 patient received a liver transplant, and 8 patients remain on the transplant wait-list. Conclusion: Patients with ESLD and ESRD who underwent TAVR had higher rates of bleeding events and noncardiovascular readmissions with similar rates of mortality at discharge, 30-days, and 6-months when compared to patients without these comorbidities. This study suggests that TAVR may be a safe path to transplant in patients with liver or renal failure and aortic valve pathology, though additional studies are necessary to confirm these findings.

Antithrombotic selection in patients undergoing transcatheter aortic valve replacement

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.

Valvular Resistance and Bleeding Events Among Patients Undergoing Transcatheter Aortic Valve Replacement

2019 ◽  
Vol 3 (3) ◽  
pp. 220-228
Author(s):  
Masahiko Asami ◽  
Thomas Pilgrim ◽  
Stefan Stortecky ◽  
Fabien Praz ◽  
Jonas Lanz ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Bleeding Events ◽  
Transcatheter Aortic Valve
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