scholarly journals Aortic Valve Disease and Associated Complex CAD: The Interventional Approach

2021 ◽  
Vol 10 (5) ◽  
pp. 946
Author(s):  
Federico Marin ◽  
Roberto Scarsini ◽  
Rafail A. Kotronias ◽  
Dimitrios Terentes Printzios ◽  
Matthew K. Burrage ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Severe Aortic Stenosis ◽  
Myocardial Revascularization ◽  
Coronary Intervention ◽  
Hemodynamic Instability ◽  
Bleeding Complications ◽  
Diagnostic Tools ◽  
Heart Team ◽  
Complex Anatomy ◽  
Increased Risk

Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis (AS). The management of CAD is a central aspect of the work-up of patients undergoing transcatheter aortic valve implantation (TAVI), but few data are available on this field and the best percutaneous coronary intervention (PCI) practice is yet to be determined. A major challenge is the ability to elucidate the severity of bystander coronary stenosis independently of the severity of aortic valve stenosis and subsequent impact on blood flow. The prognostic role of CAD in patients undergoing TAVI is being still debated and the benefits and the best timing of PCI in this context are currently under evaluation. Additionally, PCI in the setting of advanced AS poses some technical challenges, due to the complex anatomy, risk of hemodynamic instability, and the increased risk of bleeding complications. This review aims to provide a comprehensive synthesis of the available literature on myocardial revascularization in patients with severe AS undergoing TAVI. This work can assist the Heart Team in individualizing decisions about myocardial revascularization, taking into account available diagnostic tools as well as the risks and benefits.

A valve-in-valve transcatheter aortic valve implantation with commissural alignment using advanced imaging reconstruction: a case report

2020 ◽  
Vol 3 (10) ◽  
pp. 01-05
Author(s):  
Marco Angelillis
Keyword(s):  
Aortic Valve ◽  
Severe Aortic Stenosis ◽  
Coronary Intervention ◽  
Easy Access ◽  
Surgical Aortic Valve Replacement ◽  
Transcatheter Aortic Valve ◽  
Structural Valve Deterioration ◽  
Valve In Valve ◽  
Transcatheter Valve ◽  
Valve Implantation

Transcatheter valve in valve (ViV) implantation actually represents a valid alternative to surgical reinterventions in patients with previous surgical aortic valve replacement (AVR). In patients less than 80 years old, it is crucial to correctly position the new valve leaving a feasible and easy access to coronary ostia, both for future percutaneous coronary intervention (PCI) than for a future possible TAVinTAV procedure. We report a 71 year old man with prior AVR presented with structural valve deterioration (SVD) leading to severe aortic stenosis. In order to guarantee comfortable coronary access we aligned, the commissures of the new percutaneous valve with the ones of the surgical bioprothesis by reconstructing the headframes of the surgical bioprosthesis with computer tomography (CT) and fluoro-CT.

scholarly journals Left atrial functional assessment and mortality in patients with severe aortic stenosis with sinus rhythm

2021 ◽  
Vol 19 (1) ◽  
Author(s):  
João Ferreira ◽  
Valdirene Gonçalves ◽  
Patrícia Marques-Alves ◽  
Rui Martins ◽  
Sílvia Monteiro ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Left Atrial ◽  
Primary Outcome ◽  
Severe Aortic Stenosis ◽  
Heart Team ◽  
Pump Function ◽  
Volumetric Assessment ◽  
All Cause Mortality ◽  
Echocardiography Laboratory

Abstract Background Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence keeps growing. While other risk factors in severe AS are well documented, little is known about the prognostic value of left atrial (LA) function in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up. Methods We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up. Results A total of 408 patients were included in the analysis, with a median follow-up time of 45 months (interquartile range 54 months). 57.9% of patients underwent AVR and 44.9% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.845, 95%CI 0.81–0.88, P < 0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF < 37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (HR 13.91, 95%CI 6.20–31.19, P < 0.001 and HR 3.40, 95%CI 1.57–7.37, P = 0.002, respectively). After adjustment for AVR, excess risk of LAEF < 37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (HR 11.71, 95%CI 5.20–26.40, P < 0.001 and HR 3.59, 95%CI 1.65–7.78, P = 0.001, respectively). Conclusions In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.

scholarly journals P1456 Pacemaker and percutaneous aortic valve endocarditis - a complex decision

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
A Cardoso ◽  
G Dias ◽  
P Von Hafe ◽  
B Faria ◽  
M Fernandes ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Enterococcus Faecalis ◽  
Antibiotic Treatment ◽  
Severe Aortic Stenosis ◽  
Blood Cultures ◽  
Chronic Obstructive ◽  
Heart Team ◽  
Complex Situation ◽  
Surgical Risk ◽  
High Surgical Risk

Abstract CASE REPORT We describe the case of a 64-year-old man who was referred because of a fever. He had history of hypertension, dyslipidemia, atrial fibrillation, chronic obstructive pulmonary disease and a right lung pneumectomy due to epidermoid lung cancer diagnosed twenty-five years ago. He implanted dual-chamber definite pacemaker ten years ago and had a transcatheter aortic valve implantation (TAVI) in the previous year due to severe aortic stenosis and a high surgical risk. He was hospitalized 2 months ago because of a respiratory infection. Blood cultures were positive for an Enterococcus faecalis. A transthoracic echocardiogram was performed and had no evidence of vegetations. After one month, he had recurrence of fever and was again admitted. On physical examination he was hemodynamically stable, with signs of peripheral congestion and no heart murmur on cardiac auscultation. Blood cultures were again positive for Enterococcus faecalis. The transesophageal echocardiogram (TEE) showed a biologic aortic valve with thickened leaflets and small nodular structures suggestive of vegetations. There was a small periprosthetic leak and no obstruction or suspected perivalvular abscesses. There was also a small vegetation with 0,45*0,3 cm in the auricular pacemaker lead. A thoraco-abdomino-pelvic computed tomography scan showed no embolic complications. A diagnosis of pacemaker and TAVI endocarditis was made. The patient started directed antibiotic therapy (ceftriaxone and ampicillin). The case was discussed in Heart Team and because of high surgical risk, medical treatment was decided. The patient completed antibiotic treatment with negative blood cultures and apyrexia. A repeated TEE showed persistence of vegetations, without development of local complications. It was decided to discharge the patient under palliative suppressive antibiotic treatment with levofloxacin after discussion with the infectious disease doctor. In a follow-up evaluation, he remained clinically stable, without recurrence of fever. DISCUSSION As TAVI procedures are performed more frequently, a higher number of late complications are expected. Prosthetic valve endocarditis after TAVI is a complex situation, whose treatment strategy is not well-defined, particularly because these patients are usually of high surgical risk. This case describes a complex clinical picture and highlights the difficulty in decision-making in these situations. Also, it pretends to reinforce the need to discuss in a Heart Team the best treatment options.

Asymptomatic Severe Aortic Stenosis and Noncardiac Surgery

2020 ◽  
pp. 108925322096957
Author(s):  
Stephanie K. Whitener ◽  
Loren R. Francis ◽  
Jeffrey D. McMurray ◽  
George B. Whitener
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Severe Aortic Stenosis ◽  
Noncardiac Surgery ◽  
Surgical Aortic Valve Replacement ◽  
Unique Challenge ◽  
Surgical Risk ◽  
Increased Risk

The patient with severe asymptomatic aortic stenosis presenting for elective noncardiac surgery poses a unique challenge. These patients are not traditionally offered surgical aortic valve replacement or transcatheter aortic valve replacement given their lack of symptoms; however, they are at increased risk for postsurgical complications given the severity of their aortic stenosis. The decision to proceed with elective noncardiac surgery should be based on individual and surgical risk factors. However, severity of aortic stenosis is not accounted for in current surgical risk factor assessment scoring; therefore, extensive communication with patients and surgical teams is necessary to minimize a patient’s risk. A clear intraoperative plan should be designed to manage the unique hemodynamics of these patients, and a discussion should address postoperative placement.

scholarly journals Antithrombotic therapy according to baseline bleeding risk in patients with atrial fibrillation undergoing percutaneous coronary intervention: applying the PRECISE-DAPT score in RE-DUAL PCI

2020 ◽  
Author(s):  
Francesco Costa ◽  
Marco Valgimigli ◽  
Philippe Gabriel Steg ◽  
Deepak L Bhatt ◽  
Stefan H Hohnloser ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Antithrombotic Therapy ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Bleeding Complications ◽  
Event Analysis ◽  
Increased Risk ◽  
Safety Endpoint ◽  
High Bleeding Risk ◽  
The Impact

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.

scholarly journals Left atrial functional assessment and mortality in patients with severe aortic stenosis with sinus rhythm

2020 ◽  
Author(s):  
João Ferreira ◽  
Valdirene Gonçalves ◽  
Patrícia Marques-Alves ◽  
Rui Martins ◽  
Sílvia Monteiro ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Left Atrial ◽  
Primary Outcome ◽  
Severe Aortic Stenosis ◽  
Heart Team ◽  
Pump Function ◽  
Volumetric Assessment ◽  
All Cause Mortality ◽  
Echocardiography Laboratory

Abstract Background: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence keeps growing. While other risk factors in severe AS are well documented, little is known about the prognostic value of left atrial (LA) function in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up. Methods: We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up. Results: A total of 408 patients were included in the analysis, with a median follow-up time of 45 months (interquartile range 54 months). 57.9% of patients underwent AVR and 44.9% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.845, 95%CI 0.81-0.88, P <0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF <37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (HR 13.91, 95%CI 6.20-31.19, P <0.001 and HR 3.40, 95%CI 1.57-7.37, P =0.002, respectively). After adjustment for AVR, excess risk of LAEF <37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (HR 11.71, 95%CI 5.20-26.40, P <0.001 and HR 3.59, 95%CI 1.65-7.78, P =0.001, respectively). Conclusions: In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.

scholarly journals The Role of the Transradial Approach for Complex Coronary Interventions in Patients with Acute Coronary Syndrome

2013 ◽  
Vol 8 (2) ◽  
pp. 81
Author(s):  
Sasko Kedev ◽  
Keyword(s):  
Acute Coronary Syndrome ◽  
Significant Proportion ◽  
Vascular Complications ◽  
Coronary Intervention ◽  
Bleeding Complications ◽  
Elderly Subjects ◽  
Emergency Setting ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
Increased Risk

Despite advances in antithrombotic and antiplatelet therapy, bleeding complications remain an important cause of morbidity and mortality in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). A significant proportion of such bleedings are related to the access site, and adoption of transradial access (TRA) may reduce these complications. In patients with ST-segment elevation myocardial infarction (STEMI), TRA reduced cardiac mortality in comparison with the femoral approach (TFA). High-risk patients such as women, obese patients and elderly subjects who are at increased risk for vascular complications and bleeding, might particularly benefit from the TRA. However, specific radial expertise providing procedural time and a success rate comparable to those with the TFA are strongly recommended before using this technique in the emergency setting.

scholarly journals Acute normovolemic hemodilution for a patient with secondary polycythemia undergoing aortic valve replacement due to severe aortic stenosis - A case report -

2020 ◽  
Vol 15 (2) ◽  
pp. 181-186
Author(s):  
Ilsang Han ◽  
Young Woo Cho ◽  
Soon Eun Park ◽  
Min Gi An ◽  
Ho June Kang ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Stenosis ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Severe Aortic Stenosis ◽  
Hematocrit Level ◽  
Acute Normovolemic Hemodilution ◽  
Increased Risk ◽  
Normovolemic Hemodilution ◽  
Secondary Polycythemia

Background: A high hematocrit level in patients with erythrocytosis is linked with increased blood viscosity and increased risk of thromboembolism. Therefore, it is necessary to adequately lower the hematocrit level before performing a high-risk surgery. Case: A 67-year-old man was scheduled for aortic valve replacement due to severe aortic stenosis. The preoperative hematocrit level of this patient was very high due to secondary polycythemia by hypoxia. We decided to perform acute normovolemic hemodilution after anesthetic induction to reduce the risk of thromboembolism in the patient. The patient was discharged after a successful surgery and a post-operative period without any side effects.Conclusions: We estimate that patients with secondary polycythemia may benefit from acute normovolemic hemodilution to reduce their hematocrit levels while undergoing cardiac surgery using cardiopulmonary bypass. However, it is necessary to control the hematocrit level, since a significant decrease can cause side effects.

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