Pub Date : 2023-09-01DOI: 10.1016/j.shj.2023.100183
Takafumi Yamane MD, Ken Kuwajima MD, Shunsuke Kagawa MD, Hiroko Hasegawa MD, Florian Rader MD, MSc, Robert J. Siegel MD, Takahiro Shiota MD
Aims
This study aimed to investigate the symptoms and prognosis of patients with both moderate aortic stenosis (AS) and mitral stenosis (MS).
Methods and Results
We studied 82 patients with moderate AS and MS diagnosed via transthoracic echocardiography. The patients had a mean age of 79 ± 13 years and 95% of patients had degenerative MS. Out of 82 patients, 34 (41%) had heart failure (HF) symptoms (New York Heart Association class ≥ Ⅱ) or a history of HF admission. Left ventricular ejection fraction, stroke volume index, atrial fibrillation, and right ventricular systolic pressure were independent determinants of HF symptoms. The median follow-up duration was 3.2 (interquartile range, 1.0-4.9) years and clinical events occurred in 48 (59%) patients, including death in 11 (13%) patients, aortic or mitral valve interventions in 22 (27%) patients, and HF hospitalization in 15 (18%) patients. The 5-year survival free of the combined endpoint of aortic or mitral valve interventions, HF hospitalization, or death was 19%. A multivariate predictor of clinical events was HF symptoms (hazard ratio [HR], 2.32; 95% confidence interval [CI], 1.30-4.14; p = 0.0045). Kaplan-Meier survival at 5 years was 61% without intervention and HF symptoms were not associated with mortality.
Conclusions
Among patients with both moderate AS and MS, left ventricular ejection fraction, stroke volume index, atrial fibrillation, and right ventricular systolic pressure were strong determinants of HF symptoms. HF symptoms were independently predictive of clinical events.
{"title":"Outcome of Patients With Both Moderate Aortic Stenosis and Moderate Mitral Stenosis","authors":"Takafumi Yamane MD, Ken Kuwajima MD, Shunsuke Kagawa MD, Hiroko Hasegawa MD, Florian Rader MD, MSc, Robert J. Siegel MD, Takahiro Shiota MD","doi":"10.1016/j.shj.2023.100183","DOIUrl":"10.1016/j.shj.2023.100183","url":null,"abstract":"<div><h3>Aims</h3><p>This study aimed to investigate the symptoms and prognosis of patients with both moderate aortic stenosis (AS) and mitral stenosis (MS).</p></div><div><h3>Methods and Results</h3><p>We studied 82 patients with moderate AS and MS diagnosed via transthoracic echocardiography. The patients had a mean age of 79 ± 13 years and 95% of patients had degenerative MS. Out of 82 patients, 34 (41%) had heart failure (HF) symptoms (New York Heart Association class ≥ Ⅱ) or a history of HF admission. Left ventricular ejection fraction, stroke volume index, atrial fibrillation, and right ventricular systolic pressure were independent determinants of HF symptoms. The median follow-up duration was 3.2 (interquartile range, 1.0-4.9) years and clinical events occurred in 48 (59%) patients, including death in 11 (13%) patients, aortic or mitral valve interventions in 22 (27%) patients, and HF hospitalization in 15 (18%) patients. The 5-year survival free of the combined endpoint of aortic or mitral valve interventions, HF hospitalization, or death was 19%. A multivariate predictor of clinical events was HF symptoms (hazard ratio [HR], 2.32; 95% confidence interval [CI], 1.30-4.14; <em>p</em> = 0.0045). Kaplan-Meier survival at 5 years was 61% without intervention and HF symptoms were not associated with mortality.</p></div><div><h3>Conclusions</h3><p>Among patients with both moderate AS and MS, left ventricular ejection fraction, stroke volume index, atrial fibrillation, and right ventricular systolic pressure were strong determinants of HF symptoms. HF symptoms were independently predictive of clinical events.</p></div>","PeriodicalId":36053,"journal":{"name":"Structural Heart","volume":"7 5","pages":"Article 100183"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10512010/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41169909","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1016/j.shj.2023.100180
Seyedvahid Khodaei PhD , Mohamed Abdelkhalek MASc , Nima Maftoon PhD , Ali Emadi PhD , Zahra Keshavarz-Motamed PhD
Background
Despite the demonstrated benefits of transcatheter aortic valve replacement (TAVR), subclinical leaflet thrombosis and hypoattenuated leaflet thickening are commonly seen as initial indications of decreased valve durability and augmented risk of transient ischemic attack.
Methods
We developed a multiscale patient-specific computational framework to quantify metrics of global circulatory function, metrics of global cardiac function, and local cardiac fluid dynamics of the aortic root and coronary arteries.
Results
Based on our findings, TAVR might be associated with a high risk of blood stagnation in the neo-sinus region due to the lack of sufficient blood flow washout during the diastole phase (e.g., maximum blood stasis volume increased by 13, 8, and 2.7 fold in the left coronary cusp, right coronary cusp, and noncoronary cusp, respectively [N = 26]). Moreover, in some patients, TAVR might not be associated with left ventricle load relief (e.g., left ventricle load reduced only by 1.2 % [N = 26]) and diastolic coronary flow improvement (e.g., maximum coronary flow reduced by 4.94%, 15.05%, and 23.59% in the left anterior descending, left circumflex coronary artery, and right coronary artery, respectively, [N = 26]).
Conclusions
The transvalvular pressure gradient amelioration after TAVR might not translate into adequate sinus blood washout, optimal coronary flow, and reduced cardiac stress. Noninvasive personalized computational modeling can facilitate the determination of the most effective revascularization strategy pre-TAVR and monitor leaflet thrombosis and coronary plaque progression post-TAVR.
{"title":"Early Detection of Risk of Neo-Sinus Blood Stasis Post-Transcatheter Aortic Valve Replacement Using Personalized Hemodynamic Analysis","authors":"Seyedvahid Khodaei PhD , Mohamed Abdelkhalek MASc , Nima Maftoon PhD , Ali Emadi PhD , Zahra Keshavarz-Motamed PhD","doi":"10.1016/j.shj.2023.100180","DOIUrl":"10.1016/j.shj.2023.100180","url":null,"abstract":"<div><h3>Background</h3><p>Despite the demonstrated benefits of transcatheter aortic valve replacement (TAVR), subclinical leaflet thrombosis and hypoattenuated leaflet thickening are commonly seen as initial indications of decreased valve durability and augmented risk of transient ischemic attack.</p></div><div><h3>Methods</h3><p>We developed a multiscale patient-specific computational framework to quantify metrics of global circulatory function, metrics of global cardiac function, and local cardiac fluid dynamics of the aortic root and coronary arteries.</p></div><div><h3>Results</h3><p>Based on our findings, TAVR might be associated with a high risk of blood stagnation in the neo-sinus region due to the lack of sufficient blood flow washout during the diastole phase (e.g., maximum blood stasis volume increased by 13, 8, and 2.7 fold in the left coronary cusp, right coronary cusp, and noncoronary cusp, respectively [N = 26]). Moreover, in some patients, TAVR might not be associated with left ventricle load relief (e.g., left ventricle load reduced only by 1.2 % [N = 26]) and diastolic coronary flow improvement (e.g., maximum coronary flow reduced by 4.94%, 15.05%, and 23.59% in the left anterior descending, left circumflex coronary artery, and right coronary artery, respectively, [N = 26]).</p></div><div><h3>Conclusions</h3><p>The transvalvular pressure gradient amelioration after TAVR might not translate into adequate sinus blood washout, optimal coronary flow, and reduced cardiac stress. Noninvasive personalized computational modeling can facilitate the determination of the most effective revascularization strategy pre-TAVR and monitor leaflet thrombosis and coronary plaque progression post-TAVR.</p></div>","PeriodicalId":36053,"journal":{"name":"Structural Heart","volume":"7 5","pages":"Article 100180"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/52/c8/main.PMC10512011.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41172120","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1016/j.shj.2023.100201
Marko Banovic MD, PhD , Bernard Iung MD, PhD , Wojtek Wojakowski MD, PhD , Nicholas Van Mieghem MD, PhD , Jozef Bartunek MD, PhD
Over the last decades, we have witnessed considerable improvements in diagnostics and risk stratification of patients with significant aortic stenosis (AS), paralleled by advances in operative and anesthetic techniques. In addition, accumulating evidence points to the potential benefit of early valve replacement in such patients prior to the onset of symptoms. In parallel, interventional randomized trials have proven the benefit of transcatheter aortic valve replacement in comparison to a surgical approach to valve replacement over a broad risk spectrum in symptomatic patients with AS. This article reviews contemporary management approaches and scrutinizes open questions regarding timing and mode of intervention in asymptomatic patients with severe AS. We also discuss the challenges surrounding the management of symptomatic patients with moderate AS as well as emerging dilemmas related to the concept of a life-long treatment strategy for patients with AS.
{"title":"Asymptomatic Severe and Moderate Aortic Stenosis: Time for Appraisal of Treatment Indications","authors":"Marko Banovic MD, PhD , Bernard Iung MD, PhD , Wojtek Wojakowski MD, PhD , Nicholas Van Mieghem MD, PhD , Jozef Bartunek MD, PhD","doi":"10.1016/j.shj.2023.100201","DOIUrl":"10.1016/j.shj.2023.100201","url":null,"abstract":"<div><p>Over the last decades, we have witnessed considerable improvements in diagnostics and risk stratification of patients with significant aortic stenosis (AS), paralleled by advances in operative and anesthetic techniques. In addition, accumulating evidence points to the potential benefit of early valve replacement in such patients prior to the onset of symptoms. In parallel, interventional randomized trials have proven the benefit of transcatheter aortic valve replacement in comparison to a surgical approach to valve replacement over a broad risk spectrum in symptomatic patients with AS. This article reviews contemporary management approaches and scrutinizes open questions regarding timing and mode of intervention in asymptomatic patients with severe AS. We also discuss the challenges surrounding the management of symptomatic patients with moderate AS as well as emerging dilemmas related to the concept of a life-long treatment strategy for patients with AS.</p></div>","PeriodicalId":36053,"journal":{"name":"Structural Heart","volume":"7 5","pages":"Article 100201"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10512009/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41161806","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1016/j.shj.2023.100199
Osamah Z. Badwan MD , Habib Layoun MD, MS , Joseph Kassab MD, MS , Joseph El Dahdah MD , Michel Chedid El Helou MD, MS , Amar Krishnaswamy MD , Rishi Puri MD, PhD , Samir R. Kapadia MD , Rhonda L. Miyasaka MD , Serge C. Harb MD
{"title":"Venae Cavae Anatomic Characteristics in Severe Tricuspid Regurgitation: Implications for Transcatheter Interventions","authors":"Osamah Z. Badwan MD , Habib Layoun MD, MS , Joseph Kassab MD, MS , Joseph El Dahdah MD , Michel Chedid El Helou MD, MS , Amar Krishnaswamy MD , Rishi Puri MD, PhD , Samir R. Kapadia MD , Rhonda L. Miyasaka MD , Serge C. Harb MD","doi":"10.1016/j.shj.2023.100199","DOIUrl":"10.1016/j.shj.2023.100199","url":null,"abstract":"","PeriodicalId":36053,"journal":{"name":"Structural Heart","volume":"7 5","pages":"Article 100199"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/9a/b9/main.PMC10512007.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41165253","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-07-01DOI: 10.1016/j.shj.2023.100185
Anita w. Asgar MD, MSc
{"title":"Editorial: Antiplatelet Therapy Post-Transcatheter Aortic Valve Replacement — Less Is More but Is There a Better Option Than Aspirin?","authors":"Anita w. Asgar MD, MSc","doi":"10.1016/j.shj.2023.100185","DOIUrl":"10.1016/j.shj.2023.100185","url":null,"abstract":"","PeriodicalId":36053,"journal":{"name":"Structural Heart","volume":"7 4","pages":"Article 100185"},"PeriodicalIF":0.0,"publicationDate":"2023-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/96/be/main.PMC10382957.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9906720","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-07-01DOI: 10.1016/j.shj.2023.100169
Mina Iskander MD , Yasser Jamil MD , John K. Forrest MD , Mahesh V. Madhavan MD, MS , Raj Makkar MD , Martin B. Leon MD , Alexandra Lansky MD , Yousif Ahmad MD, PhD
Transcatheter aortic valve replacement (TAVR) is a treatment option for patients with symptomatic severe aortic stenosis across the entire spectrum of surgical risk. Recent trial data have led to the expansion of TAVR into lower-risk patients. With iterative technological advances and successive increases in procedural experience, the occurrence of complications following TAVR has declined. One of the most feared complications remains stroke, and patients consider stroke a worse outcome than death. There has therefore been great interest in strategies to mitigate the risk of stroke in patients undergoing TAVR. In this paper, we will discuss mechanisms and predictors of stroke after TAVR and describe the currently available cerebral embolic protection devices, including their design and relevant clinical studies pertaining to their use. We will also review the current overall evidence base for cerebral embolic protection during TAVR and ongoing randomized controlled trials. Finally, we will discuss our pragmatic recommendations for the use of cerebral embolic protection devices in patients undergoing TAVR.
{"title":"Cerebral Embolic Protection in Transcatheter Aortic Valve Replacement","authors":"Mina Iskander MD , Yasser Jamil MD , John K. Forrest MD , Mahesh V. Madhavan MD, MS , Raj Makkar MD , Martin B. Leon MD , Alexandra Lansky MD , Yousif Ahmad MD, PhD","doi":"10.1016/j.shj.2023.100169","DOIUrl":"10.1016/j.shj.2023.100169","url":null,"abstract":"<div><p>Transcatheter aortic valve replacement (TAVR) is a treatment option for patients with symptomatic severe aortic stenosis across the entire spectrum of surgical risk. Recent trial data have led to the expansion of TAVR into lower-risk patients. With iterative technological advances and successive increases in procedural experience, the occurrence of complications following TAVR has declined. One of the most feared complications remains stroke, and patients consider stroke a worse outcome than death. There has therefore been great interest in strategies to mitigate the risk of stroke in patients undergoing TAVR. In this paper, we will discuss mechanisms and predictors of stroke after TAVR and describe the currently available cerebral embolic protection devices, including their design and relevant clinical studies pertaining to their use. We will also review the current overall evidence base for cerebral embolic protection during TAVR and ongoing randomized controlled trials. Finally, we will discuss our pragmatic recommendations for the use of cerebral embolic protection devices in patients undergoing TAVR.</p></div>","PeriodicalId":36053,"journal":{"name":"Structural Heart","volume":"7 4","pages":"Article 100169"},"PeriodicalIF":0.0,"publicationDate":"2023-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10382985/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9906722","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-07-01DOI: 10.1016/j.shj.2023.100182
David A. Zidar MD, PhD , Sadeer Al-Kindi MD , Chris T. Longenecker MD , Sahil A. Parikh MD , Carl B. Gillombardo MD , Nicholas T. Funderburg PhD , Steven Juchnowski , Lauren Huntington , Trevor Jenkins MD , Christopher Nmai , Michael Osnard MD , Mehdi Shishebhor DO, PhD , Steven Filby MD , Curtis Tatsuoka PhD , Michael M. Lederman MD , Eugene Blackstone MD , Guilherme Attizzani MD, PhD , Daniel I. Simon MD
Background
Inflammation and thrombosis are often linked mechanistically and are associated with adverse events after transcatheter aortic valve replacement (TAVR). High residual platelet reactivity (HRPR) is especially common when clopidogrel is used in this setting, but its relevance to immune activation is unknown. We sought to determine whether residual activity at the purinergic receptor P2Y12 (P2Y12) promotes prothrombotic immune activation in the setting of TAVR.
Methods
This was a randomized trial of 60 patients (enrolled July 2015 through December 2018) assigned to clopidogrel (300mg load, 75mg daily) or ticagrelor (180mg load, 90 mg twice daily) before and for 30 days following TAVR. Co-primary endpoints were P2Y12-dependent platelet activity (Platelet Reactivity Units; VerifyNow) and the proportion of inflammatory (cluster of differentiation [CD] 14+/CD16+) monocytes 1 day after TAVR.
Results
Compared to clopidogrel, those randomized to ticagrelor had greater platelet inhibition (median Platelet Reactivity Unit [interquartile range]: (234 [170.0-282.3] vs. 128.5 [86.5-156.5], p < 0.001), but similar inflammatory monocyte proportions (22.2% [18.0%-30.2%] vs. 25.1% [22.1%-31.0%], p = 0.201) 1 day after TAVR. Circulating monocyte-platelet aggregates, soluble CD14 levels, interleukin 6 and 8 levels, and D-dimers were also similar across treatment groups. HRPR was observed in 63% of the clopidogrel arm and was associated with higher inflammatory monocyte proportions. Major bleeding events, pacemaker placement, and mortality did not differ by treatment assignment.
Conclusions
Residual P2Y12 activity after TAVR is common in those treated with clopidogrel but ticagrelor does not significantly alter biomarkers of prothrombotic immune activation. HRPR appears to be an indicator (not a cause) of innate immune activation in this setting.
{"title":"Platelet and Monocyte Activation After Transcatheter Aortic Valve Replacement (POTENT-TAVR): A Mechanistic Randomized Trial of Ticagrelor Versus Clopidogrel","authors":"David A. Zidar MD, PhD , Sadeer Al-Kindi MD , Chris T. Longenecker MD , Sahil A. Parikh MD , Carl B. Gillombardo MD , Nicholas T. Funderburg PhD , Steven Juchnowski , Lauren Huntington , Trevor Jenkins MD , Christopher Nmai , Michael Osnard MD , Mehdi Shishebhor DO, PhD , Steven Filby MD , Curtis Tatsuoka PhD , Michael M. Lederman MD , Eugene Blackstone MD , Guilherme Attizzani MD, PhD , Daniel I. Simon MD","doi":"10.1016/j.shj.2023.100182","DOIUrl":"10.1016/j.shj.2023.100182","url":null,"abstract":"<div><h3>Background</h3><p>Inflammation and thrombosis are often linked mechanistically and are associated with adverse events after transcatheter aortic valve replacement (TAVR). High residual platelet reactivity (HRPR) is especially common when clopidogrel is used in this setting, but its relevance to immune activation is unknown. We sought to determine whether residual activity at the purinergic receptor P2Y12 (P2Y12) promotes prothrombotic immune activation in the setting of TAVR.</p></div><div><h3>Methods</h3><p>This was a randomized trial of 60 patients (enrolled July 2015 through December 2018) assigned to clopidogrel (300mg load, 75mg daily) or ticagrelor (180mg load, 90 mg twice daily) before and for 30 days following TAVR. Co-primary endpoints were P2Y12-dependent platelet activity (Platelet Reactivity Units; VerifyNow) and the proportion of inflammatory (cluster of differentiation [CD] 14+/CD16+) monocytes 1 day after TAVR.</p></div><div><h3>Results</h3><p>Compared to clopidogrel, those randomized to ticagrelor had greater platelet inhibition (median Platelet Reactivity Unit [interquartile range]: (234 [170.0-282.3] vs. 128.5 [86.5-156.5], <em>p</em> < 0.001), but similar inflammatory monocyte proportions (22.2% [18.0%-30.2%] vs. 25.1% [22.1%-31.0%], <em>p</em> = 0.201) 1 day after TAVR. Circulating monocyte-platelet aggregates, soluble CD14 levels, interleukin 6 and 8 levels, and D-dimers were also similar across treatment groups. HRPR was observed in 63% of the clopidogrel arm and was associated with higher inflammatory monocyte proportions. Major bleeding events, pacemaker placement, and mortality did not differ by treatment assignment.</p></div><div><h3>Conclusions</h3><p>Residual P2Y12 activity after TAVR is common in those treated with clopidogrel but ticagrelor does not significantly alter biomarkers of prothrombotic immune activation. HRPR appears to be an indicator (not a cause) of innate immune activation in this setting.</p></div>","PeriodicalId":36053,"journal":{"name":"Structural Heart","volume":"7 4","pages":"Article 100182"},"PeriodicalIF":0.0,"publicationDate":"2023-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10382989/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9906713","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}