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An Impending Physician Shortage: Implications for Structural Heart Disorders 迫在眉睫的医生短缺:对结构性心脏病的影响。
Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2023-09-01 DOI: 10.1016/j.shj.2023.100216
Anthony DeMaria MD
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引用次数: 0
Outcome of Patients With Both Moderate Aortic Stenosis and Moderate Mitral Stenosis 中度主动脉狭窄和中度二尖瓣狭窄患者的预后。
Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2023-09-01 DOI: 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.

目的:本研究旨在探讨中度主动脉瓣狭窄(AS)和二尖瓣狭窄(MS)患者的症状和预后。方法和结果:我们研究了82例经胸超声心动图诊断为中度AS和MS的患者。这些患者的平均年龄为79±13岁,95%的患者患有退行性多发性硬化症。在82名患者中,34名(41%)有心力衰竭(HF)症状(纽约心脏协会≥Ⅱ级)或有HF入院史。左心室射血分数、射血容量指数、心房颤动和右心室收缩压是HF症状的独立决定因素。中位随访时间为3.2年(四分位间距1.0-4.9),48名(59%)患者发生临床事件,其中11名(13%)患者死亡,22名(27%)患者接受主动脉瓣或二尖瓣介入治疗,15名(18%)患者HF住院治疗。无主动脉瓣或二尖瓣介入治疗、HF住院或死亡的联合终点的5年生存率为19%。临床事件的多变量预测因子是HF症状(危险比[HR],2.32;95%置信区间[CI],1.30-4.14;p=0.0045)。在没有干预的情况下,5年的Kaplan-Meier生存率为61%,HF症状与死亡率无关。结论:在中度AS和MS患者中,左心室射血分数、射血容量指数、心房颤动和右心室收缩压是HF症状的重要决定因素。HF症状可独立预测临床事件。
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引用次数: 0
Early Detection of Risk of Neo-Sinus Blood Stasis Post-Transcatheter Aortic Valve Replacement Using Personalized Hemodynamic Analysis 应用个性化血流动力学分析早期检测经导管主动脉瓣置换术后新窦性血瘀的风险。
Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2023-09-01 DOI: 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.

背景:尽管经导管主动脉瓣置换术(TAVR)具有明显的益处,但亚临床小叶血栓形成和小叶增厚减薄通常被视为瓣膜耐久性降低和短暂性脑缺血发作风险增加的初步迹象。方法:我们开发了一个多尺度的患者特异性计算框架,以量化主动脉根和冠状动脉的整体循环功能指标、整体心脏功能指标以及局部心流体动力学。结果:根据我们的研究结果,由于舒张期缺乏足够的血流冲洗,TAVR可能与新窦区域血液停滞的高风险有关(例如,左冠状动脉尖端、右冠状动脉尖端和非冠状动脉尖端的最大血瘀量分别增加了13、8和2.7倍[N=26])。此外在一些患者中,TAVR可能与左心室负荷减轻(例如,左心室负荷仅减少1.2%[N=26])和舒张期冠状动脉流量改善(例如,最大冠状动脉流量在左前降支、左回旋支和右冠状动脉分别减少4.94%、15.05%和23.59%[N=26]TAVR后的改善可能无法转化为充分的窦性血液冲洗、最佳的冠状动脉流量和减少心脏压力。无创个性化计算建模有助于确定TAVR前最有效的血运重建策略,并监测TAVR后小叶血栓形成和冠状动脉斑块进展。
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引用次数: 4
Asymptomatic Severe and Moderate Aortic Stenosis: Time for Appraisal of Treatment Indications 无症状重度和中度主动脉狭窄:评估治疗适应症的时间。
Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2023-09-01 DOI: 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.

在过去的几十年里,我们见证了严重主动脉瓣狭窄(AS)患者的诊断和风险分层的显著改善,同时手术和麻醉技术也取得了进步。此外,越来越多的证据表明,在这些患者出现症状之前,早期瓣膜置换术有潜在的好处。同时,在有症状的AS患者中,介入性随机试验已经证明,与外科瓣膜置换术相比,经导管主动脉瓣置换术在广泛的风险范围内是有益的。本文回顾了当代的管理方法,并仔细研究了关于严重AS无症状患者干预时机和模式的悬而未决的问题。我们还讨论了围绕中度AS症状患者管理的挑战,以及与AS患者终身治疗策略概念相关的新出现的困境。
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引用次数: 0
Venae Cavae Anatomic Characteristics in Severe Tricuspid Regurgitation: Implications for Transcatheter Interventions 严重三尖瓣反流的胎膜解剖特征:经导管介入治疗的意义。
Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2023-09-01 DOI: 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
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引用次数: 0
The PASCAL Transcatheter Valve Repair System: A User’s Guide PASCAL导管瓣膜维修系统:用户指南。
Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2023-09-01 DOI: 10.1016/j.shj.2023.100204
Brian Whisenant MD , Firas Zahr MD
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引用次数: 0
In-Series Transcatheter Aortic Valve Replacement-in-Transcatheter Aortic Valve Replacement: ACURATE neo Transcatheter Heart Valve Degeneration Successfully Managed with Myval, Avoiding Coronary Flow Obstruction—A Case Report 串联经导管主动脉瓣置换术中经导管主动脉瓣膜置换术:应用Myval成功治疗ACURATE neo经导管心脏瓣膜退行性变,避免冠状动脉血流阻塞一例报告。
Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2023-09-01 DOI: 10.1016/j.shj.2023.100181
Joao Felipe Barros de Toledo MD , Pablo Tome Teixeirense MD , Wilson Guimaraes MD , Julio Motta MD , Marcos Rogerio Joaquim MD , Vinicius Odone MD , Juliana Mantovani MD , Raphael Alves MD , Luiz Antonio Gubolino MD
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引用次数: 1
Editorial: Antiplatelet Therapy Post-Transcatheter Aortic Valve Replacement — Less Is More but Is There a Better Option Than Aspirin? 社论:经导管主动脉瓣置换术后抗血小板治疗-少即是多,但是否有比阿司匹林更好的选择?
Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2023-07-01 DOI: 10.1016/j.shj.2023.100185
Anita w. Asgar MD, MSc
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引用次数: 0
Cerebral Embolic Protection in Transcatheter Aortic Valve Replacement 经导管主动脉瓣置换术中的脑栓塞保护
Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2023-07-01 DOI: 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.

经导管主动脉瓣置换术(TAVR)是一种治疗方案,适用于有严重症状的主动脉瓣狭窄患者。最近的试验数据导致TAVR扩展到低风险患者。随着技术的不断进步和手术经验的不断增加,TAVR术后并发症的发生率已经下降。中风是最可怕的并发症之一,患者认为中风的后果比死亡还要糟糕。因此,人们对降低TAVR患者卒中风险的策略非常感兴趣。在本文中,我们将讨论TAVR后卒中的机制和预测因素,并描述目前可用的脑栓塞保护装置,包括它们的设计和与它们的使用相关的临床研究。我们还将回顾目前TAVR期间脑栓塞保护的总体证据基础和正在进行的随机对照试验。最后,我们将讨论我们对TAVR患者使用脑栓塞保护装置的实用建议。
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引用次数: 20
Platelet and Monocyte Activation After Transcatheter Aortic Valve Replacement (POTENT-TAVR): A Mechanistic Randomized Trial of Ticagrelor Versus Clopidogrel 经导管主动脉瓣置换术后血小板和单核细胞活化(pott - tavr):替格瑞洛与氯吡格雷的随机机制试验
Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2023-07-01 DOI: 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.

研究背景:经导管主动脉瓣置换术(TAVR)后,炎症和血栓形成通常具有机械联系,并与不良事件相关。当使用氯吡格雷时,高残余血小板反应性(HRPR)尤其常见,但其与免疫激活的相关性尚不清楚。我们试图确定嘌呤能受体P2Y12 (P2Y12)的残留活性是否在TAVR的情况下促进血栓前免疫激活。方法:这是一项随机试验,60名患者(2015年7月至2018年12月入组)在TAVR之前和之后30天内被分配到氯吡格雷(负荷300mg,每天75mg)或替格瑞洛(负荷180mg, 90 mg,每天两次)。共同主要终点是p2y12依赖性血小板活性(血小板反应单位;VerifyNow)和TAVR后1天炎症(分化簇[CD] 14+/CD16+)单核细胞比例。结果与氯吡格雷相比,随机分配替格瑞洛组的血小板抑制作用更强(血小板反应性单位中位数[四分位数范围]:234[170.0-282.3]对128.5 [86.5-156.5],p <0.001),但TAVR后1天炎症单核细胞比例相似(22.2%[18.0%-30.2%]对25.1% [22.1%-31.0%],p = 0.201)。循环单核细胞血小板聚集物、可溶性CD14水平、白细胞介素6和8水平以及d -二聚体在各治疗组之间也相似。在63%的氯吡格雷组中观察到HRPR,并与较高的炎症单核细胞比例相关。大出血事件、起搏器放置和死亡率没有因治疗分配而不同。结论氯吡格雷治疗TAVR后残留P2Y12活性普遍存在,但替格瑞洛没有显著改变血栓前免疫激活的生物标志物。在这种情况下,HRPR似乎是先天免疫激活的一个指标(而不是原因)。
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引用次数: 0
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Structural Heart
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