Antithrombotic Therapy in Patients Undergoing Transcatheter Interventions for Structural Heart Disease

Circulation ◽  
2021 ◽  
Vol 144 (16) ◽  
pp. 1323-1343
Author(s):  
Paolo Calabrò ◽  
Felice Gragnano ◽  
Giampaolo Niccoli ◽  
Rossella Marcucci ◽  
Marco Zimarino ◽  
...  

Contemporary evidence supports device-based transcatheter interventions for the management of patients with structural heart disease. These procedures, which include aortic valve implantation, mitral or tricuspid valve repair/implantation, left atrial appendage occlusion, and patent foramen ovale closure, profoundly differ with respect to clinical indications and procedural aspects. Yet, patients undergoing transcatheter cardiac interventions require antithrombotic therapy before, during, or after the procedure to prevent thromboembolic events. However, these therapies are associated with an increased risk of bleeding complications. To date, challenges and controversies exist regarding balancing the risk of thrombotic and bleeding complications in these patients such that the optimal antithrombotic regimens to adopt in each specific procedure is still unclear. In this review, we summarize current evidence on antithrombotic therapies for device-based transcatheter interventions targeting structural heart disease and emphasize the importance of a tailored approach in these patients.

ESC CardioMed ◽  
2018 ◽  
pp. 1176-1178
Author(s):  
Daniel J. Lenihan

The treatment of multiple myeloma has dramatically changed in the last decade. Novel therapies have had an important impact on the overall outcome for patients but are associated with important cardiovascular events. There is certainly concern about the development of heart failure but also treatment-induced hypertension and a known increased risk of thrombotic events, including ischaemic heart disease. The management of these cardiac events includes prevention, early detection, and optimal treatment with antithrombotic therapy as well as medical therapy for heart failure.


ESC CardioMed ◽  
2018 ◽  
pp. 560-565
Author(s):  
Victoria Delgado

Computed tomography (CT) has become an important imaging tool to evaluate cardiac anatomy. This three-dimensional, isotropic imaging technique provides volumetric datasets with submillimetre tissue resolution that can be post-processed to define the cardiac structures. CT has become the mainstay imaging technique for selection of patients for, and planning of, transcatheter interventions for structural heart disease. Electrocardiographic-gated CT permits acquisition of cardiac datasets along the cardiac cycle enabling assessment of left and right ventricular function and valvular heart disease. In addition, the advent of three-dimensional printing technologies, which use three-dimensional patient-specific models frequently obtained from CT datasets, has opened a myriad of possibilities in terms of development of anatomical teaching tools, functional models to assess vessel and valve function, planning surgical or transcatheter interventions, and designing of transcatheter cardiac devices. This chapter reviews the role of CT in assessing cardiac morphology and function and valvular heart disease.


Author(s):  
Francesco Costa ◽  
Marco Valgimigli ◽  
Philippe Gabriel Steg ◽  
Deepak L Bhatt ◽  
Stefan H Hohnloser ◽  
...  

Abstract Aims Patients with atrial fibrillation undergoing coronary intervention are at higher bleeding risk due to the concomitant need for oral anticoagulation and antiplatelet therapy. The RE-DUAL PCI trial demonstrated better safety with dual antithrombotic therapy (DAT: dabigatran 110 or 150 mg b.i.d., clopidogrel or ticagrelor) compared to triple antithrombotic therapy (TAT: warfarin, clopidogrel or ticagrelor, and aspirin). We explored the impact of baseline bleeding risk based on the PRECISE-DAPT score for decision-making regarding DAT vs. TAT. Methods and results A score ≥25 points qualified high bleeding risk (HBR). Comparisons were made for the primary safety endpoint International Society of Thrombosis and Haemostasis major or clinically relevant non-major bleeding, and the composite efficacy endpoint of death, thrombo-embolic events, or unplanned revascularization, analysed by time-to-event analysis. PRECISE-DAPT was available in 2336/2725 patients, and 37.9% were HBR. Compared to TAT, DAT with dabigatran 110 mg reduced bleeding risk both in non-HBR [hazard ratio (HR) 0.42, 95% confidence interval (CI) 0.31–0.57] and HBR (HR 0.70, 95% CI 0.52–0.94), with a greater magnitude of benefit among non-HBR (Pint = 0.02). Dual antithrombotic therapy with dabigatran 150 mg vs. TAT reduced bleeding in non-HBR (HR 0.60, 95% CI 0.45–0.80), with a trend toward less benefit in HBR patients (HR 0.92, 95% CI 0.63–1.34; Pint = 0.08). The risk of ischaemic events was similar on DAT with dabigatran (both 110 and 150 mg) vs. TAT in non-HBR and HBR patients (Pint = 0.45 and Pint = 0.56, respectively). Conclusions PRECISE-DAPT score appeared useful to identify AF patients undergoing PCI at further increased risk of bleeding complications and may help clinicians identifying the antithrombotic regimen intensity with the best benefit–risk ratio in an individual patient.


Heart ◽  
2020 ◽  
Vol 107 (1) ◽  
pp. 61-66
Author(s):  
Jasmine Grewal ◽  
Anne Marie Valente ◽  
Alexander C Egbe ◽  
Fred M Wu ◽  
Eric V Krieger ◽  
...  

ObjectivesWomen with Turner syndrome (TS) are frequently counselled against pregnancy due to lack of data and unclear aortic dissection risk. However, with advances in fertility therapy, more women with TS are contemplating pregnancy. This study compared rates of adverse cardiovascular (CV) outcomes among: (1) pregnant and non-pregnant women with TS and (2) pregnant women with TS with/without structural heart disease.MethodsRetrospective analysis of pregnant and age-matched non-pregnant controls with TS (2005–2017) across 10 CV centres was done. Data were collected at initial evaluation in pregnancy and outcomes were assessed to 6 months postpartum. Adverse CV events were defined as CV death, aortic dissection/rupture and/or aortic intervention. Non-pregnant age-matched controls were followed over the same time period.ResultsSixty-eight pregnancies were included (60 women, mean age 33 years, 48% primigravid, 49% fertility therapy, 80% structurally normal heart, 25% XO karyotype). Based on American Society of Reproductive Medicine criteria, 10 pregnancies occurred in women stratified to high-risk category. There were no CV events in the pregnant women or in the non-pregnant women with TS. Obstetric events complicated 12 (18%) pregnancies with 9 (13%) attributed to hypertensive disorder of pregnancy. Fetal events included small for gestational age neonates (18%), preterm delivery (15%) and fetal death (3%).ConclusionsThis study helps to refine the approach to pregnancy in women with TS. Among women with TS without structural heart disease, pregnancy does not impose an increased risk of CV outcomes. Among women with TS with structural heart disease, the risk of pregnancy is not as prohibitive as previously described but does require ongoing evaluation.


2020 ◽  
Author(s):  
Herbert Chen ◽  
Irene Lou

The management of perioperative anticoagulation, antiplatelet therapy, and perioperative venous thromboembolism (VTE) prophylaxis is essentially a balancing act between patient risk factors for thrombosis and surgical risk factors for bleeding. The purpose of this review is to assist surgeons with the identification of patients at increased risk for thromboembolism when antithrombotic therapy is interrupted, patients for whom bridging anticoagulation should be considered, patients who require perioperative VTE prophylaxis, and patients at increased risk for bleeding complications and to briefly review the literature and major guidelines regarding perioperative antithrombotic therapy management and perioperative VTE prophylaxis. Figures show approaches to the management of perioperative anticoagulation, antiplatelet therapy, and VTE prophylaxis.  This review contains 2 figures, 7 tables, and 61 references. Keywords: Venous thromboembolism, pulmonary embolism, anticoagulation, surgery, perioperative period, prophylaxis  


2020 ◽  
Author(s):  
Naomi Hirota ◽  
Shinya Suzuki ◽  
Takuto Arita ◽  
Naoharu Yagi ◽  
Takayuki Otsuka ◽  
...  

Abstract Background: The 12-lead electrocardiogram (ECG) is affected by not only the cardiovascular but also the non-cardiovascular status. Whether ECG can be the determinant of biological age (BA) and the gap between chronological age (CA) and ECG-predicted BA reflect differences in prognosis are unclear. Methods: In the Shinken Database 2010 – 2017 (n = 19170), 12-lead ECG was analyzed in 13005 patients excluding those with structural heart disease or having pacing beats, atrial or ventricular tachyarrhythmia, and indeterminate axis (R axis > 180˚) on index ECG. The prediction model of BA was developed by principal component analysis with 438 ECG parameters. The gap between ECG-predicted BA and CA was calculated (AgeDiff = ECG-predicted BA − CA). Results: The ECG-predicted BA was significantly correlated with CA (r = 0.967). Patients with a positively wide AgeDiff had a higher incidence of all-cause mortality compared to those with a narrow AgeDiff or those with negative AgeDiff. The risk of AgeDiff > 0 for all-cause mortality compared with AgeDiff ≤ 0 was 1.78 (95%CI: 1.00 − 3.16), which increased according to the aging and became the highest in patients with CA of 71 − 80 years. Conclusion: Our data suggested that 12-lead ECG can be a tool to estimate BA. The gap between ECG-predicted BA and CA allowed estimation of increased risk of all-cause mortality in patients without structural heart disease.


2021 ◽  
Vol 10 (16) ◽  
pp. 3696
Author(s):  
Carlo Lavalle ◽  
Sara Trivigno ◽  
Giampaolo Vetta ◽  
Michele Magnocavallo ◽  
Marco Valerio Mariani ◽  
...  

Flecainide is an IC antiarrhythmic drug (AAD) that received in 1984 Food and Drug Administration approval for the treatment of sustained ventricular tachycardia (VT) and subsequently for rhythm control of atrial fibrillation (AF). Currently, flecainide is mainly employed for sinus rhythm maintenance in AF and the treatment of idiopathic ventricular arrhythmias (IVA) in absence of ischaemic and structural heart disease on the basis of CAST data. Recent studies enrolling patients with different structural heart diseases demonstrated good effectiveness and safety profile of flecainide. The purpose of this review is to assess current evidence for appropriate and safe use of flecainide, 30 years after CAST data, in the light of new diagnostic and therapeutic tools in the field of ischaemic and non-ischaemic heart disease.


EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
J Francisco Pascual ◽  
N Rivas Gandara ◽  
A Santos Ortega ◽  
J Perez Rodon ◽  
B Benito ◽  
...  

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Hospital Universitari Vall d"Hebron - Vall d"Hebron Institut de Recerca. CIBERCV BACKGROUND Patients with structural heart disease (SHD) or bundle branch block (BBB) are at high risk of having an arrhythmic syncope (AS).  In patients with recurrent syncope episodes (RSE)  complete work-up including electrophysiological study (EPS) and/or implantation of a loop recorder (ILR) is recommended, however patients with their first episode may also be at risk of an AS. AIM To determinate if the patients with SHD or BBB with a single syncope episode (SSE) are at high risk of having an AS and compare it with patients with recurrent episodes (RSE). METHODS Cohort study carried out in a tertiary hospital that is a reference centre for syncope. From January 2008 to August 2020 patients with SHD or BBB with syncope of unknown origin after the initial evaluation and without direct indication of an ICD were included. They were managed according the current ESC guidelines. RESULTS 417patients were included  (74 ±11 y. o; 39% female). Mean follow up was 2.5 ±1 y. 223 patients were diagnosed from an AS [113 (53%) in SSE group and 110 (54%) in RSE group, p = 0.9], 210 were due to bradyarrhythmia (AV block or sinus arrest). No differences in baseline characteristics where found comparing both groups, except that BBB was slightly more prevalent in patients with RSE (81% vs 90%, p = 0.01) (FIGURE- PANEL A). Risk of AS was 53% in patients with SE and 54% (p = 0.9). RSE were not associated with an increased risk of AS in univariate analyses (OR 1.01 IC95% 0.7-1.5) neither in the multivariate (FIGURE- PANEL B). EPS and ILR diagnostic yield was 45% / 32% respectively in SSE group and 44% / 33% in RSE group (p = 0.8) (FIGURE - PANEL C).  After appropriate treatment, recurrence syncope rate was 10% in SSE group and 9% in RSE group (p = 0.8). No significant differences in mortality rate were found. CONCLUSIONS Patients with SHD or BBB and single syncope episode are at a high risk of having AS, and similar to those with RSE. EPS and ILR offer a similar diagnostic yield in both groups. Complete syncope work-up must be recommended in these patients despite having had only a single episode. Abstract Figure


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