A Difficult Case With Combined Carotid, Aortic Valve and Coronary Artery Disease: A Rational Approach And Patient Management

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Siemens Healthineers Introduction Coronary CT angiography (CCTA) plays an increasing role in the detection and risk stratification of patients with coronary artery disease (CAD). The Coronary Artery Disease – Reporting and Data System (CAD-RADS) allows for standardized classification of CCTA results and, thus, may improve patient management. Purpose Aim of this study was to assess the impact of CCTA in combination with CAD-RADS on patient management and to identify the impact of cardiovascular risk factors (CVRF) on CAD severity. Methods CCTA was performed on a third-generation dual-source CT scanner in patients, who were referred to a radiology centre by their attending physicians. In a total of 4801 patients, CVRF were derived from medical reports and anamnesis. Results The study population consisted of 4770 patients (62.0 (54.0-69.0) years, 2841 males) with CAD (CAD-RADS 1-5), while 31 patients showed no CAD and were excluded from further analyses. Age, male gender and the number of CVRF were associated with more severe CAD stages (all p < 0.001). 3040 patients (63.7 %) showed minimal or mild CAD requiring optimization of CVRF i.e. medical therapy but no further assessment at his time. A group of 266 patients (5.6 %) had a severe CAD defined as CAD-RADS 4B/5. In the multivariate regression analysis, age, male gender, history of smoking, diabetes mellitus and hyperlipidaemia were significant predictors for severe CAD, whereas arterial hypertension and family history of CAD did not reach significance. Of note, a subgroup of 28 patients (10.5 %) with a severe CAD (68.5 (65.5-70.0) years, 26 males, both p = n.s.) had no CVRF. Conclusions CCTA in combination with the CAD-RADS allowed for effective risk stratification of CAD patients. The majority of the patients showed non-obstructive CAD and, thus, could be treated conservatively without the need for further CAD assessment. CVRF out of arterial hypertension and family history had an impact on CAD severity reflected in higher CAD-RADs gradings. Of note, a relevant fraction of patients with CAD did not have any CVRF and, thus, may not be covered by risk stratification models. CAD-RADS n Age (years) Males (%) 1 1453 56.0 (50.0-62.0) 623 (42.9 %) 2 1587 62.0 (55.0-69.0) 918 (57.8 %) 3 1067 66.0 (59.0-71.0) 749 (70.2 %) 4A 397 66.0 (59.0-72.0) 317 (79.8 %) 4B 162 67.0 (61.0-74.0) 139 (85.8 %) 5 104 66.0 (58.5.0-77.0) 95 (91.3 %)

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Use and outcomes of emergency treatment strategies in patients with aortic valve stenosis

European Heart Journal ◽

10.1093/ehjci/ehaa946.2598 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

S.M Piepenburg ◽

K Kaier ◽

C Olivier ◽

M Zehender ◽

C Bode ◽

...

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Hospital Mortality ◽

Valve Replacement ◽

Aortic Valve Stenosis ◽

Emergency Treatment ◽

Funding Source ◽

Artery Disease

Abstract Introduction and aim Current emergency treatment options for severe aortic valve stenosis include surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR) and balloon valvuloplasty (BV). So far no larger patient population has been evaluated regarding clinical characteristics and outcomes. Therefore we aimed to describe the use and outcome of the three therapy options in a broad registry study. Method and results Using German nationwide electronic health records, we evaluated emergency admissions of symptomatic patients with severe aortic valve stenosis between 2014 and 2017. Patients were grouped according to SAVR, TAVR or BV only treatments. Primary outcome was in-hospital mortality. Secondary outcomes were stroke, acute kidney injury, periprocedural pacemaker implantation, delirium and prolonged mechanical ventilation >48 hours. Stepwise multivariable logistic regression analyses including baseline characteristics were performed to assess outcome risks. 8,651 patients with emergency admission for severe aortic valve stenosis were identified. The median age was 79 years and comorbidities included NYHA classes III-IV (52%), coronary artery disease (50%), atrial fibrillation (41%) and diabetes mellitus (33%). Overall in-hospital mortality was 6.2% during a mean length of stay of 22±15 days. TAVR was the most common treatment (6,357 [73.5%]), followed by SAVR (1,557 [18%]) and BV (737 8.5%]). Patients who were treated with TAVR or BV were significantly older than patients with SAVR (mean age 81.3±6.5 and 81.2±6.9 versus 67.2±11.0 years, p<0.001), had more relevant comorbidities (coronary artery disease 52–91% vs. 21.8%; p<0.001), worse NYHA classes III-IV (55–65% vs. 34.5%; p<0.001) and higher EuroSCORES (24.6±14.3 and 23.4±13.9 vs. 9.5±7.6; p<0.001) than SAVR patients. Patients treated with BV only had the highest in-hospital mortality compared with TAVR or SAVR (20.9% vs. 5.1 and 3.5%; p<0.001). Compared with BV only, SAVR patients (adjusted odds ratio [aOR] 0.25; 95% confidence interval [CI] 0.14–0.46; p<0.001) and TAVR patients (aOR 0.37; 95% CI 0.28–0.50; p<0.001) had a lower risk for in-hospital mortality. Conclusion In-hospital mortality for emergency patients with symptomatic severe aortic valve stenosis is high. Our results showed that BV only therapy was associated with highest mortality, which is in line with current research. Yet, there is a trend towards more TAVR interventions and this study might imply that balloon valvuloplasty alone is insufficient. The role of BV as a bridging strategy to TAVR or SAVR needs to be further investigated. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany

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Bicuspid Aortic Valve Is Associated with Less Coronary Calcium and Coronary Artery Disease Burden

Journal of Clinical Medicine ◽

10.3390/jcm10143070 ◽

2021 ◽

Vol 10 (14) ◽

pp. 3070

Author(s):

Gudrun Feuchtner ◽

Sven Bleckwenn ◽

Leon Stoessl ◽

Fabian Plank ◽

Christoph Beyer ◽

...

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

Aortic Valve ◽

Bicuspid Aortic Valve ◽

Coronary Artery Calcium ◽

Coronary Artery Calcium Score ◽

Calcium Score ◽

Coronary Calcium ◽

Retrospective Case ◽

Artery Disease

(1) Background. Bicuspid aortic valve (BAV) is associated with genetic defects (NOTCH 1, GATA 5) and aortopathy. Differences in the flow patterns and a genetic predisposition could also affect coronary arteries. The objective was to assess the coronary artery calcium score (CACS) and coronary artery disease (CAD) burden by coronary computed tomography angiography (CTA) in patients with BAV stenosis, as compared to stenotic tricuspid aortic valves (TAV). (2) Methods. A retrospective case–control study. A total of 47 patients with BAV stenosis (68.9 years ± 12.9, 38.3% females) who underwent CTA were matched with 47 TAV stenosis patients for age, gender, smoking, arterial hypertension, dyslipidemia, diabetes, body-mass-index and chronic kidney disease. (3) Results. The coronary artery calcium score (CACS) was lower in BAV (237.4 vs. 1013.3AU; p < 0.001) than in TAV, and stenosis severity was less (CAD-RADTM: p < 0.001). More patients with BAV had CACS zero (27.7% vs. 0%; p < 0.001). The majority (68.1%) of patients with BAV had no or non-obstructive CAD but only 25.5% of TAV (p < 0.001). Obstructive CAD (>50% stenosis) by CTA was more frequently observed in patients with TAV (68.1%; p < 0.001). (4) Conclusions and Relevance. Patients with BAV stenosis have markedly less coronary calcium and less severe coronary stenosis. CTA succeeds to rule out obstructive CAD in the majority of BAV, with adherent implications for TAVR planning.

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Use of extracorporeal membrane oxygenation as a bridge to transcatheter aortic valve replacement in a patient with aortic stenosis and severe coronary artery disease: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa567 ◽

2021 ◽

Vol 5 (1) ◽

Author(s):

Majid Ahsan ◽

Rolf Alexander Jánosi ◽

Tienush Rassaf ◽

Alexander Lind

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

High Risk ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Transcatheter Aortic Valve ◽

Risk Patients ◽

Artery Disease

Abstract Background Patients with severe aortic stenosis (AS) often present with multiple comorbidities and suffer from critical coronary artery disease (CAD). Transcatheter aortic valve replacement (TAVR) has become the therapy of choice for moderate to high-risk patients. Venoarterial extracorporeal membrane oxygenation (v-a-ECMO) offers the possibility of temporary cardiac support to manage life-threatening critical situations. Case summary Here, we describe the management of a patient with severe AS and CAD with impaired left ventricular ejection fraction (LVEF). We used v-a-ECMO as an emergency strategy in cardiogenic shock during a high-risk coronary intervention to stabilize the patient, and as a further bridge to TAVR. Discussion Very high-risk patients with severe AS are unlikely to tolerate the added risk of surgical aortic valve replacement. Using ECMO may help them to benefit from TAVR as the only treatment option available.

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