Transcatheter aortic valve replacement(TAVR)has emerged as a formidable treatment option for severe symptomatic aortic stenosis ahead of surgical aortic valve replacement.The encouraging results from large randomized ...Transcatheter aortic valve replacement(TAVR)has emerged as a formidable treatment option for severe symptomatic aortic stenosis ahead of surgical aortic valve replacement.The encouraging results from large randomized controlled trials has resulted in an exponential rise in the use of TAVR even in the low-risk patients.However,this is not without challenges.Need for permanent pacemaker(PPM)post-TAVR remains the most frequent and clinically relevant challenge.Naturally,identifying risk factors which predispose an individual to develop high grade conduction block post-TAVR is important.Various demographic factors,electrocardiographic features,anatomic factors and procedural characteristics have all been linked to the development of advanced conduction block and need for PPM following TAVR.Amongst these electrophysiological variables,most notably a prolonged QRS>120 ms regardless of the type of conduction block seems to be one of the strongest predictors on logistic regression models.The index study by Nwaedozie et al highlights that patients requiring PPM post-TAVR had higher odds of having a baseline QRS>120 ms and were more likely to be having diabetes mellitus that those who did not require PPM.展开更多
In this editorial,we comprehensively summarized the preoperative risk factors of early permanent pacemaker implantation after transcatheter aortic valve replacement(TAVR)among patients with severe aortic stenosis from...In this editorial,we comprehensively summarized the preoperative risk factors of early permanent pacemaker implantation after transcatheter aortic valve replacement(TAVR)among patients with severe aortic stenosis from several renowned clinical studies and focused on the primary prevention of managing the modifiable factors,e.g.,paroxysmal atrial fibrillation before the TAVR.展开更多
Since the advent of transcatheter aortic valve replacement(TAVR)in 2002,it has now become the default interventional strategy for symptomatic patients presenting with severe aortic stenosis,particularly in intermediat...Since the advent of transcatheter aortic valve replacement(TAVR)in 2002,it has now become the default interventional strategy for symptomatic patients presenting with severe aortic stenosis,particularly in intermediate to highsurgical risk patients.In 2019,the United States Food and Drug Administration approved TAVR in low-risk patients based on two randomized trials.However,these breakthrough trials excluded patients with certain unfavorable anatomies and odd profiles.While currently there is no randomized study of TAVR in young patients,it may be preferred by the young population given the benefits of early discharge,shorter hospital stay,and expedite recovery.Nonetheless,it is important to ruminate various factors including lifetime expectancy,risk of pacemaker implantation,and the need for future valve or coronary interventions in young cohorts before considering TAVR in these patients.Furthermore,the data on long-term durability(>10 years)of TAVR is still unknown given most of the procedures were initially performed in the high or prohibitive surgical risk population.Thus,this editorial aims to highlight the importance of considering an individualized approach in young patients with consideration of various factors including lifetime expectancy while choosing TAVR against surgical aortic valve replacement.展开更多
Pacemaker post-transcatheter aortic valve replacement is related to multifactorial risk.Nwaedozie et al brought to the body of evidence electrocardiogram and clinical findings.However,procedural characteristics have a...Pacemaker post-transcatheter aortic valve replacement is related to multifactorial risk.Nwaedozie et al brought to the body of evidence electrocardiogram and clinical findings.However,procedural characteristics have at least as much impact on the final need for a permanent pacemaker and potentially on the pacing rate.In this regard,long-term follow-up and understanding of the impact of long-term stimulation is of utmost importance.展开更多
BACKGROUND Conduction and rhythm abnormalities requiring permanent pacemakers(PPM)are short-term complications following transcatheter aortic valve replacement(TAVR),and their clinical outcomes remain conflicting.Pote...BACKGROUND Conduction and rhythm abnormalities requiring permanent pacemakers(PPM)are short-term complications following transcatheter aortic valve replacement(TAVR),and their clinical outcomes remain conflicting.Potential novel predictors of post-TAVR PPM,like QRS duration,QTc prolongation,and supraventricular arrhythmias,have been poorly studied.AIM To evaluate the effects of baseline nonspecific interventricular conduction delay and supraventricular arrhythmia on post-TAVR PPM requirement and determine the impact of PPM implantation on clinical outcomes.METHODS RESULTS Out of the 357 patients that met inclusion criteria,the mean age was 80 years,188(52.7%)were male,and 57(16%)had a PPM implantation.Baseline demographics,valve type,and cardiovascular risk factors were similar except for type II diabetes mellitus(DM),which was more prevalent in the PPM cohort(59.6%vs 40.7%;P=0.009).The PPM cohort had a significantly higher rate of pre-procedure right bundle branch block,prolonged QRS>120 ms,prolonged QTc>470 ms,and supraventricular arrhythmias.There was a consistently significant increase in the odds ratio(OR)of PPM implantation for every 20 ms increase in the QRS duration above 100 ms:QRS 101-120[OR:2.44;confidence intervals(CI):1.14-5.25;P=0.022],QRS 121-140(OR:3.25;CI:1.32-7.98;P=0.010),QRS 141-160(OR:6.98;CI:3.10-15.61;P<0.001).After model adjustment for baseline risk factors,the OR remained significant for type II DM(aOR:2.16;CI:1.18-3.94;P=0.012),QRS>120(aOR:2.18;CI:1.02-4.66;P=0.045)and marginally significant for supraventricular arrhythmias(aOR:1.82;CI:0.97-3.42;P=0.062).The PPM cohort had a higher adjusted OR of heart failure(HF)hospitalization(aOR:2.2;CI:1.1-4.3;P=0.022)and nonfatal myocardial infarction(MI)(aOR:3.9;CI:1.1-14;P=0.031)without any difference in mortality(aOR:1.1;CI:0.5-2.7;P=0.796)at one year.CONCLUSION Pre-TAVR type II DM and QRS duration>120,regardless of the presence of bundle branch blocks,are predictors of post-TAVR PPM.At 1-year post-TAVR,patients with PPM have higher odds of HF hospitalization and MI.展开更多
BACKGROUND Atrioventricular block requiring permanent pacemaker(PPM)implantation is an important complication of transcatheter aortic valve replacement(TAVR).Application of machine learning could potentially be used t...BACKGROUND Atrioventricular block requiring permanent pacemaker(PPM)implantation is an important complication of transcatheter aortic valve replacement(TAVR).Application of machine learning could potentially be used to predict preprocedural risk for PPM.AIM To apply machine learning to be used to predict pre-procedural risk for PPM.METHODS A retrospective study of 1200 patients who underwent TAVR(January 2014-December 2017)was performed.964 patients without prior PPM were included for a 30-d analysis and 657 patients without PPM requirement through 30 d were included for a 1-year analysis.After the exclusion of variables with near-zero variance or≥50%missing data,167 variables were included in the random forest gradient boosting algorithm(GBM)optimized using 5-fold cross-validations repeated 10 times.The receiver operator curve(ROC)for the GBM model and PPM risk score models were calculated to predict the risk of PPM at 30 d and 1 year.RESULTS Of 964 patients included in the 30-d analysis without prior PPM,19.6%required PPM post-TAVR.The mean age of patients was 80.9±8.7 years.42.1%were female.Of 657 patients included in the 1-year analysis,the mean age of the patients was 80.7±8.2.Of those,42.6%of patients were female and 26.7%required PPM at 1-year post-TAVR.The area under ROC to predict 30-d and 1-year risk of PPM for the GBM model(0.66 and 0.72)was superior to that of the PPM risk score(0.55 and 0.54)with a P value<0.001.CONCLUSION The GBM model has good discrimination and calibration in identifying patients at high risk of PPM post-TAVR.展开更多
Frailty is generally defined as a clinical syndrome of decreased physiologic reserve which drives to increased vulnerability and susceptibility to different stressors together with poor recovery to homeostasis.[1]The ...Frailty is generally defined as a clinical syndrome of decreased physiologic reserve which drives to increased vulnerability and susceptibility to different stressors together with poor recovery to homeostasis.[1]The relevance of frailty status in a wide range of prospective cohorts is mostly related to an increasing burden in both mortality,hospital readmissions,disability,and falls.展开更多
BACKGROUND: Anemia is prevalent in patients undergoing transcatheter aortic valve replacement(TAVR) and has been linked to impaired outcomes after the procedure. Few studies have evaluated the impact of anemia and new...BACKGROUND: Anemia is prevalent in patients undergoing transcatheter aortic valve replacement(TAVR) and has been linked to impaired outcomes after the procedure. Few studies have evaluated the impact of anemia and new ischemic lesions post TAVR.METHODS: We prospectively enrolled 158 patients who received TAVR in our center. Anemia was defined according to the World Health Organization criteria as hemoglobin <12 g/dL in women and <13 g/dL in men. All patients underwent diffusion-weighted magnetic resonance imaging(DW-MRI) procedure before and within 4–7 days after TAVR. RESULTS: Anemia was present in 85(53.8%) patients who underwent TAVR, and 126(79.7%) patients had 718 new DW-MRI positive lesions with a mean of 4.54±5.26 lesions per patient. The incidence of new ischemic lesions was 81.2% in patients with anemia versus 78.1% in patients without anemia(P=0.629). Moreover, anemic patients had bigger total volume/lesions in the anterior cerebral artery/middle cerebral artery(ACA/MCA) and MCA regions compared to the non-anemic patients(31.89±55.78 mm^(3) vs. 17.08±37.39 mm^(3), P=0.049;and 54.54±74.72 mm^(3) vs. 33.75±46.03 mm^(3), P=0.034). Anemia was independently associated with the volume/lesion in the ACA/MCA(β=16.796, 95% confidence interval [95% CI] 2.001 to 31.591, P=0.026) and in the MCA zone(β=0.020, 95% CI 0.001 to 0.040, P=0.041). CONCLUSIONS: Patients with pre-procedural anemia may have bigger total volume/lesions in the ACA/MCA and MCA regions compared to the non-anemic patients. Whether the consequences of bigger total volume/lesions impact neurological and cognitive outcomes remains to be investigated.展开更多
To investigate the effects of transcatheter heart valve(THV)poses and bicuspid aortic valve(BAV)subtypes on coronary hemodynamics after transcatheter aortic valve replacement(TAVR).The computational models for BAV inc...To investigate the effects of transcatheter heart valve(THV)poses and bicuspid aortic valve(BAV)subtypes on coronary hemodynamics after transcatheter aortic valve replacement(TAVR).The computational models for BAV included left-right fusion(LR),non-coronary-left fusion(LN)and non-coronary-right fusion(RN).THV deployment height is defined as the distance below the aortic annulus of the lowest point of the stent,H_(1)=2mm,H_(2)=5mm and H_(3)=8mm,Orientations include O_(1)(one commissure is aligned with the raphe)and O_(2)(one commissure is aligned with the axis of non-fused leaflet symmetry).The maximum flow velocity(Vmax),mean wall shear stress(mWSS)and coronary perfusion pressure(CPP)of coronary were obtained by computational fluid dynamics(CFD)simulation.The CPP was 59%in left coronary and 82%in right coronary higher than that before deployment.At O_(1),the CPP of the LN left coronary and the RN right coronary was 74%and 79%higher than that before deployment.At O_(2),the CPP of the LN right coronary and the RN left coronary was 83%and 82%higher than that before deployment.When the THV deployment height is less than 2mm,Vmax and CPP of coronary arteries do not return to healthy TAV levels or changed weakly.The overlap of the THV commissure with the coronary ostium makes the coronary CPP so large that it exceeds the level of a healthy TAV.展开更多
Background:The past decade has witnessed an ever-increasing momentum of transcatheter aortic valve replacement(TAVR)and a subsequent paradigm shift in the contemporary management of severe aortic stenosis(AS).We condu...Background:The past decade has witnessed an ever-increasing momentum of transcatheter aortic valve replacement(TAVR)and a subsequent paradigm shift in the contemporary management of severe aortic stenosis(AS).We conducted a multi-centric TAVR registry based on Chinese patients(the China Aortic valve tRanscatheter Replacement registrY[CARRY])to delineate the clinical characteristics and outcomes of Chinese patients who underwent TAVR and compare the results between different valve types in different Chinese regions.Methods:CARRY is an all-comer registry of aortic valve disease patients undergoing TAVR across China and was designed as an observational study that retrospectively included all TAVR patients at each participating site.Seven hospitals in China participated in the CARRY,and 1204 patients from April 2012 to November 2020 were included.Categorical variables were compared using the chi-squared test,and continuous variables were analyzed using a t test or analysis of variance(ANOVA)test.The Kaplan–Meier curve was used to estimate the risk of adverse events during follow-up.Results:The mean age of the patients was 73.8±6.5 years and 57.2%were male.The median Society of Thoracic Surgeon-Predicted Risk of Mortality score was 6.0(3.7–8.9).Regarding the aortic valve,the proportion of bicuspid aortic valve(BAV)was 48.5%.During the hospital stay,the stroke rate was 0.7%,and the incidence of high-degree atrioventricular block indicating permanent pacemaker implantation was 11.0%.The in-hospital all-cause mortality rate was 2.2%.After 1 year,the overall mortality rate was 4.5%.Compared to patients with tricuspid aortic valve(TAV),those with BAV had similar in-hospital complication rates,but a lower incidence of in-hospital mortality(1.4%vs.3.3%)and 1 year mortality(2.3%vs.5.8%).Conclusions:TAVR candidates in China were younger,higher proportion of BAV,and had lower rates of post-procedural complications and mortality than other international all-comer registries.Given the use of early generation valves in the majority of the population,patients with BAV had similar rates of complications,but lower mortality than those with TAV.These findings further propel the extension of TAVR in low-risk patients.展开更多
Transcatheter aortic valve replacement(TAVR)has been performed for nearly 20years,with reliable safety and efficacy in moderate-to high-risk patients with aortic stenosis or regurgitation,with the advantage of less tr...Transcatheter aortic valve replacement(TAVR)has been performed for nearly 20years,with reliable safety and efficacy in moderate-to high-risk patients with aortic stenosis or regurgitation,with the advantage of less trauma and better prognosis than traditional open surgery.However,because surgeons have not been able to obtain a full view of the aortic root,3-dimensional printing has been used to reconstruct the aortic root so that they could clearly and intui-tively understand the specific anatomical structure.In addition,the 3D printed model has been used for the in vitro simulation of the planned procedures to predict the potential complications of TAVR,the goal being to provide guidance to reasonably plan the procedure to achieve the best outcome.Postprocedural 3D printing can be used to understand the depth,shape,and distribution of the stent.Cardiovascular 3D printing has achieved remarkable results in TAVR and has a great potential.展开更多
Background:The study aimed to describe the aortic valve morphology in Chinese patients underwent transcatheter aortic valve replacement(TAVR)for symptomatic severe aortic stenosis(AS),and the impact of sizing strategi...Background:The study aimed to describe the aortic valve morphology in Chinese patients underwent transcatheter aortic valve replacement(TAVR)for symptomatic severe aortic stenosis(AS),and the impact of sizing strategies and related procedural outcomes.Methods:Patients with severe AS who underwent TAVR were consecutively enrolled from 2012 to 2019.The anatomy and morphology of the aortic root were assessed."Downsize"strategy was preformed when patients had complex morphology.The clinical outcomes of patients who performed downsize strategy were compared with those received annular sizing strategy.The primary outcome was device success rate,and secondary outcomes included Valve Academic Research Consortium-3 clinical outcomes variables based on 1-year follow-up.Results:A total of 293 patients were enrolled.Among them,95 patients(32.4%)had bicuspid aortic valve.The calcium volume(Hounsfield Unit-850)of aortic root was 449.90(243.15-782.15)mm3.Calcium is distributed mostly on the leaflet level.Downsize strategy was performed in 204 patients(69.6%).Compared with the patients who performed annular sizing strategy,those received downsize strategy achieved a similar device success rate(82.0%[73]vs.83.3%[170],P=0.79).Aortic valve gradients(downsize strategy group vs.annular sizing group,11.28 mmHg vs.11.88 mmHg,P=0.64)and percentages of patients with moderate or severe paravalvular regurgitation 2.0%(4/204)vs.4.5%(4/89),P=0.21were similar in the two groups at 30 days after TAVR.These echocardiographic results were sustainable for one year.Conclusions:Chinese TAVR patients have more prevalent bicuspid morphology and large calcium volume of aortic root.Calcium is distributed mostly on the leaflet level.Compare with annular sizing strategy,downsize strategy provided a non-inferior device success rate and transcatheter heart valve hemodynamic performance in self-expanding TAVR procedure.展开更多
Background Transcatheter aortic valve replacement(TAVR)for the treatment symptomatic severe aortic stenosis(AS)is indicated in patients with intermediate or higher surgical risk.Latest trials showed TAVR,and surgical ...Background Transcatheter aortic valve replacement(TAVR)for the treatment symptomatic severe aortic stenosis(AS)is indicated in patients with intermediate or higher surgical risk.Latest trials showed TAVR,and surgical aortic valve replacement(SAVR)perform similarly at 1-year for the composite outcomes of mortality,stroke and rehospitalization.We performed a comprehensive meta-analysis to compare individual outcomes at 1-year for TAVR compared to SAVR in low-risk patients.Methods Pub Med,Embase,and Cochrane central were searched for all the randomized controlled trials(RCTs)that reported 1-year comparative outcomes of TAVR and surgical aortic valve replacement(SAVR).Our conclusions are based upon the random-effects model using Der Simonian-Laird estimator.Results Data from 4 trials and 2887 randomized patients showed that TAVR had lower rates of all-cause mortality,cardiovascular mortality,and atrial fibrillation compared to SAVR at 1-year follow-up(P<0.05 for all).Also,TAVR was also associated with a significantly higher risk of permanent pacemaker implantation and moderate-severe paravalvular leak(P<0.05).Conclusions The latest randomised trial data demonstrates that in short-term,TAVR is safe and effective in reducing all-cause mortality or stroke.Longer follow-up of RCTs is needed to determine the durability of clinical benefits in TAVR over SAVR in low-risk patients.展开更多
Introduction: This is the first case of Transcatheter Aortic Valve Replacement(TAVR) in the prefecture level hospital of Xinjiang Province in China. It also proves that severe left main coronary artery disease(LM)is n...Introduction: This is the first case of Transcatheter Aortic Valve Replacement(TAVR) in the prefecture level hospital of Xinjiang Province in China. It also proves that severe left main coronary artery disease(LM)is not the contraindication to this operation of TAVR. Patient concerns:The patient had dyspnea for two years, with the 4/6 spurious murmur at the aortic valve. The cardiac ultrasound revealed a severe aortic valve stenosis(AS) and severe mitral regurgitation(MR). Coronary angiography(CAG)showed 80% stenosis of the left main artery. Diagnosis: The severe aortic valve stenosis(AS). Interventions: He received the TAVR, which also is the first case in the First People's Hospital of Kashi Prefecture. Outcomes: The patient's symptoms were significantly improved. The cardiac ultrasound showed that no obvious regurgitation was found in the implanted artificial aortic valve and the MR was significantly reduced. So far, the patient has recovered well for five months after TAVR. Conclusion:TAVR is an effective method for the severe AS patients with serve LM and loss of surgical opportunity.展开更多
INTRODUCTION Aortic stenosis is one of the major causes of death in cardiovascular diseases,and transcatheter aortic valve implantation(TAVI)is a milestone in the field of cardiovascular intervention.Since the first i...INTRODUCTION Aortic stenosis is one of the major causes of death in cardiovascular diseases,and transcatheter aortic valve implantation(TAVI)is a milestone in the field of cardiovascular intervention.Since the first implementation in October 2010,this technology has been展开更多
BACKGROUND Complications of transcatheter aortic valve implantation(TAVI)procedures include bleeding,vascular complications,and strokes.These complications are often associated with the type of access used.The two typ...BACKGROUND Complications of transcatheter aortic valve implantation(TAVI)procedures include bleeding,vascular complications,and strokes.These complications are often associated with the type of access used.The two types of access in TAVI procedures are primary and secondary.The main use of the primary access is for valve delivery,while secondary access is used for angiography and hemodynamic monitoring.While there are many options for primary access,those for secondary access are transfemoral and transradial.AIM To compare outcomes between transradial vs transfemoral secondary access(TFSA).METHODS A systematic search was conducted using major databases(EMBASE,PubMed,Cochrane Central,Google Scholar),which resulted in 5 studies that met the criteria for study selection.Outcomes of interest were 30-d rates each of major/life-threatening bleeding,vascular complications,strokes,and mortality.All 5 studies were observational.Only adjusted or matched data were used when available in this meta-analysis.RESULTS A total of 5065 patients underwent TAVI,with 1453 patients(28.7%)having undergone transradial secondary access(TRSA)and 3612 patients(71.3%)TFSA.Irrespective of the site of primary access,the odds of having major or lifethreatening bleeding were 60%lower in the TRSA group than the TFSA group(P<0.00001).The odds of having major vascular complications were 52%lower in the TRSA group(P<0.0001)with no difference in minor vascular complications between the 2 groups.Similarly,the odds of mortality in 30-d after the procedure were 41%lower(P=0.006)and the odds of stroke were 54%lower(P=0.001)in the TRSA group than the TFSA group.CONCLUSION The transradial secondary approach appears to be a safer alternative to the transfemoral secondary approach in TAVI procedures.展开更多
<strong>Background:</strong> Transcatheter aortic valve implantation (TAVI) is a widely used treatment of severe aortic stenosis. Implantation of a self-expanding valve into a dense calcified aortic annulu...<strong>Background:</strong> Transcatheter aortic valve implantation (TAVI) is a widely used treatment of severe aortic stenosis. Implantation of a self-expanding valve into a dense calcified aortic annulus can be challenging and may result in device malposition and malfunction.<strong> Aim: </strong>The aim of our case report is to present a novel technique of transcatheter aortic valve dislocation treatment. <strong>Case presentation:</strong> An 86-year-old woman with severely calcified aortic valve underwent TAVI using a 27-mm self-expanding Portico valve (Abbott Vasc, USA). In the last phase of implantation, the valve dislocated deep into the left ventricular outflow tract resulting in significant paravalvular regurgitation and patient instability. Repositioning of the valve with a single snare was ineffective because of severe aortic ring calcifications. A novel “double snare” technique was applied and the valve was successfully repositioned upward with an excellent anatomic and haemodynamic result. <strong>Conclusion:</strong> “Double snare” technique can be an effective strategy for repositioning of deeply implanted self-expanding transcatheter aortic valves. It represents an efficient bailout strategy in case of single snare approach failure, especially in cases of severe aortic ring calcifications.展开更多
BACKGROUND: No retrievable and repositionable second generation transcatheter aortic valve is available in China. Here, we report the first-in-man implantation of the retrievable and repositionable VenusA-Plus valve. ...BACKGROUND: No retrievable and repositionable second generation transcatheter aortic valve is available in China. Here, we report the first-in-man implantation of the retrievable and repositionable VenusA-Plus valve. METHODS: A 76-year-old patient with symptomatic severe aortic stenosis and high surgical risk(STS 13.8%) was recommended for transcatheter aortic valve replacement(TAVR) by heart valve team. Type 0 bicuspid aortic valve with asymmetric calcification was identified by dual source computed tomography, and the unfavorable anatomies increased the possibility of malposition and paravalvular leakage during TAVR. Therefore, we used the retrievable and repositionable Venus APlus valve for the patient.RESULTS: Transfemoral TAVR was performed under local anesthesia with sedation, and a 26-mm VenusA-Plus valve was successfully implanted. No transvalvular pressure gradient and trace paravalvular leakage were found. CONCLUSION: The successful first-in-man implantation indicates the retrievable and repositionable Venus A-Plus valve is feasible in complicated TAVR cases such as bicuspid aortic valve.展开更多
Heyde’s syndrome is an under reported systemic disease of gastrointestinal and cardiac manifestation in older adults.It is characterized by a triad of aortic stenosis,angiodysplasia with bleeding and acquired von Wil...Heyde’s syndrome is an under reported systemic disease of gastrointestinal and cardiac manifestation in older adults.It is characterized by a triad of aortic stenosis,angiodysplasia with bleeding and acquired von Willebrand syndrome.It is characterized by proteolysis of high molecular weight multimers of von Willebrand Factor and loss of platelet mediated homeostasis.Heyde’s syndrome is a treatable condition in most cases,especially in the current era of evolution in interventional cardiology and gastroenterology.There are currently no established guidelines in the management of this condition due to paucity of high quality studies,which warrant future trials.High index of suspicion and increasing the awareness of the syndrome among the general practitioners and sub-specialists will improve the diagnostic potential of Heyde’s syndrome.Future studies may change the management aspect of Heyde's syndrome and pave a path for drawing specific guidelines and algorithms.The aim of our review article is to summarize the basic pathophysiology,diagnostics and management of Heyde’s syndrome with a special attention to Transcatheter aortic valve replacement.展开更多
Objective:Diverse antithrombotic strategies were applied to patients undergoing aortic valve replacement.However,the optimal therapeutic regimen for patients undergoing transcatheter aortic valve implantation/replacem...Objective:Diverse antithrombotic strategies were applied to patients undergoing aortic valve replacement.However,the optimal therapeutic regimen for patients undergoing transcatheter aortic valve implantation/replacement(TAVI/TAVR)remains unclear.The purpose of this study was to compare the efficacy and safety of various antithrombotic therapies following TAVI/TAVR.Methods:Relevant clinical trials evaluating the effect of anticoagulation or antiplatelet regimens on patients after TAVI/TAVR from inception to September 2020 were identified using the PubMed,EMBASE,and the Cochrane Library databases.The inclusion criteria including(1)all patients underwent TAVI/TAVR;(2)the interventions were antithrombotic strategies that prevent the occurrence of thrombotic events in patients;(3)randomized controlled trials or prospective observational studies;and(4)investigation of at least 1 outcome with a follow-up period of≥3 months.The exclusion criteria including(1)research content was identical or irrelevant to the purpose of the present study;(2)lack of the required outcome index or availability of fragmentary original information;and(3)the full text is not available.The major outcomes were all-cause mortality,thromboembolic complications,and bleeding events.The Cochrane Collaboration’s tool and the Newcastle-Ottawa Scale were used for assessing the risk of bias in included studies.Results:Thirteen studies(3 randomized controlled trials and 10 non-randomized studies)were identified,with a total of 23,497 patients.Four studies compared direct oral anticoagulants(DOACs)with warfarin,1 study compared aspirin with warfarin,6 studies compared aspirin plus clopidogrel(dual antiplatelet therapy(DAPT))with aspirin monotherapy,and 2 studies compared DAPT and aspirin monotherapy with warfarin concurrently.There were no significant differences found between the DOAC and warfarin groups regarding all-cause mortality(risk ratio(RR):1.03;95%confidence interval(CI):0.65–1.64;P=0.909;Phet=0.105),clinical adverse events(RR:1.59;95%CI:0.99–2.58;P=0.057;Phet=0.738),or bleeding events(RR:0.93;95%CI:0.78–1.11;P=0.437;Phet=0.338).The rates of all-cause mortality(RR:0.71;95%CI:0.54–0.93;P=0.012;Phet=0.845)and bleeding events(RR:0.43;95%CI:0.22–0.83;P=0.012;P_(het)=0.569)were lower in the aspirin group versus the warfarin group;however,there was no difference in the rate of clinical adverse events(RR:0.38;95%CI:0.14–1.07;P=0.068;Phet=0.593).The DAPT group had an advantage versus the aspirin group in all-cause mortality(RR:0.89;95%CI:0.82–0.98;P=0.013;Phet=0.299);however,the incidence of bleeding events(RR:2.06;95%CI:1.39–3.07;P<0.001;Phet=0.001)exhibited an increasing trend.Notably,there was a slight decrease in the incidence of clinical adverse events(RR:1.09;95%CI:0.94–1.26;P=0.268;Phet=0.554).Conclusion:The present meta-analysis integrates the latest published results on antithrombotic strategies in patients after TAVI/TAVR.Aspirin showed a favorable risk-benefit profile versus warfarin,with lower rates of all-cause mortality and bleeding events.Although DAPT was also associated with a significantly lower rate of all-cause mortality,it was linked to a higher incidence of bleeding events.The DOACs did not show significant benefits compared with warfarin.Some certain limitations should be noted,such as different types of trails produce heterogeneity and finite inclusion of TAVI/TAVR patients increased selection bias.展开更多
文摘Transcatheter aortic valve replacement(TAVR)has emerged as a formidable treatment option for severe symptomatic aortic stenosis ahead of surgical aortic valve replacement.The encouraging results from large randomized controlled trials has resulted in an exponential rise in the use of TAVR even in the low-risk patients.However,this is not without challenges.Need for permanent pacemaker(PPM)post-TAVR remains the most frequent and clinically relevant challenge.Naturally,identifying risk factors which predispose an individual to develop high grade conduction block post-TAVR is important.Various demographic factors,electrocardiographic features,anatomic factors and procedural characteristics have all been linked to the development of advanced conduction block and need for PPM following TAVR.Amongst these electrophysiological variables,most notably a prolonged QRS>120 ms regardless of the type of conduction block seems to be one of the strongest predictors on logistic regression models.The index study by Nwaedozie et al highlights that patients requiring PPM post-TAVR had higher odds of having a baseline QRS>120 ms and were more likely to be having diabetes mellitus that those who did not require PPM.
文摘In this editorial,we comprehensively summarized the preoperative risk factors of early permanent pacemaker implantation after transcatheter aortic valve replacement(TAVR)among patients with severe aortic stenosis from several renowned clinical studies and focused on the primary prevention of managing the modifiable factors,e.g.,paroxysmal atrial fibrillation before the TAVR.
文摘Since the advent of transcatheter aortic valve replacement(TAVR)in 2002,it has now become the default interventional strategy for symptomatic patients presenting with severe aortic stenosis,particularly in intermediate to highsurgical risk patients.In 2019,the United States Food and Drug Administration approved TAVR in low-risk patients based on two randomized trials.However,these breakthrough trials excluded patients with certain unfavorable anatomies and odd profiles.While currently there is no randomized study of TAVR in young patients,it may be preferred by the young population given the benefits of early discharge,shorter hospital stay,and expedite recovery.Nonetheless,it is important to ruminate various factors including lifetime expectancy,risk of pacemaker implantation,and the need for future valve or coronary interventions in young cohorts before considering TAVR in these patients.Furthermore,the data on long-term durability(>10 years)of TAVR is still unknown given most of the procedures were initially performed in the high or prohibitive surgical risk population.Thus,this editorial aims to highlight the importance of considering an individualized approach in young patients with consideration of various factors including lifetime expectancy while choosing TAVR against surgical aortic valve replacement.
文摘Pacemaker post-transcatheter aortic valve replacement is related to multifactorial risk.Nwaedozie et al brought to the body of evidence electrocardiogram and clinical findings.However,procedural characteristics have at least as much impact on the final need for a permanent pacemaker and potentially on the pacing rate.In this regard,long-term follow-up and understanding of the impact of long-term stimulation is of utmost importance.
文摘BACKGROUND Conduction and rhythm abnormalities requiring permanent pacemakers(PPM)are short-term complications following transcatheter aortic valve replacement(TAVR),and their clinical outcomes remain conflicting.Potential novel predictors of post-TAVR PPM,like QRS duration,QTc prolongation,and supraventricular arrhythmias,have been poorly studied.AIM To evaluate the effects of baseline nonspecific interventricular conduction delay and supraventricular arrhythmia on post-TAVR PPM requirement and determine the impact of PPM implantation on clinical outcomes.METHODS RESULTS Out of the 357 patients that met inclusion criteria,the mean age was 80 years,188(52.7%)were male,and 57(16%)had a PPM implantation.Baseline demographics,valve type,and cardiovascular risk factors were similar except for type II diabetes mellitus(DM),which was more prevalent in the PPM cohort(59.6%vs 40.7%;P=0.009).The PPM cohort had a significantly higher rate of pre-procedure right bundle branch block,prolonged QRS>120 ms,prolonged QTc>470 ms,and supraventricular arrhythmias.There was a consistently significant increase in the odds ratio(OR)of PPM implantation for every 20 ms increase in the QRS duration above 100 ms:QRS 101-120[OR:2.44;confidence intervals(CI):1.14-5.25;P=0.022],QRS 121-140(OR:3.25;CI:1.32-7.98;P=0.010),QRS 141-160(OR:6.98;CI:3.10-15.61;P<0.001).After model adjustment for baseline risk factors,the OR remained significant for type II DM(aOR:2.16;CI:1.18-3.94;P=0.012),QRS>120(aOR:2.18;CI:1.02-4.66;P=0.045)and marginally significant for supraventricular arrhythmias(aOR:1.82;CI:0.97-3.42;P=0.062).The PPM cohort had a higher adjusted OR of heart failure(HF)hospitalization(aOR:2.2;CI:1.1-4.3;P=0.022)and nonfatal myocardial infarction(MI)(aOR:3.9;CI:1.1-14;P=0.031)without any difference in mortality(aOR:1.1;CI:0.5-2.7;P=0.796)at one year.CONCLUSION Pre-TAVR type II DM and QRS duration>120,regardless of the presence of bundle branch blocks,are predictors of post-TAVR PPM.At 1-year post-TAVR,patients with PPM have higher odds of HF hospitalization and MI.
基金funded by Mayo Clinic Arizona Cardiovascular Clinical Research Center (MCA CV CRC)
文摘BACKGROUND Atrioventricular block requiring permanent pacemaker(PPM)implantation is an important complication of transcatheter aortic valve replacement(TAVR).Application of machine learning could potentially be used to predict preprocedural risk for PPM.AIM To apply machine learning to be used to predict pre-procedural risk for PPM.METHODS A retrospective study of 1200 patients who underwent TAVR(January 2014-December 2017)was performed.964 patients without prior PPM were included for a 30-d analysis and 657 patients without PPM requirement through 30 d were included for a 1-year analysis.After the exclusion of variables with near-zero variance or≥50%missing data,167 variables were included in the random forest gradient boosting algorithm(GBM)optimized using 5-fold cross-validations repeated 10 times.The receiver operator curve(ROC)for the GBM model and PPM risk score models were calculated to predict the risk of PPM at 30 d and 1 year.RESULTS Of 964 patients included in the 30-d analysis without prior PPM,19.6%required PPM post-TAVR.The mean age of patients was 80.9±8.7 years.42.1%were female.Of 657 patients included in the 1-year analysis,the mean age of the patients was 80.7±8.2.Of those,42.6%of patients were female and 26.7%required PPM at 1-year post-TAVR.The area under ROC to predict 30-d and 1-year risk of PPM for the GBM model(0.66 and 0.72)was superior to that of the PPM risk score(0.55 and 0.54)with a P value<0.001.CONCLUSION The GBM model has good discrimination and calibration in identifying patients at high risk of PPM post-TAVR.
文摘Frailty is generally defined as a clinical syndrome of decreased physiologic reserve which drives to increased vulnerability and susceptibility to different stressors together with poor recovery to homeostasis.[1]The relevance of frailty status in a wide range of prospective cohorts is mostly related to an increasing burden in both mortality,hospital readmissions,disability,and falls.
基金funded by Zhejiang Province Science and Technology Department Key R&D Program(2018C03084,2021C03097).
文摘BACKGROUND: Anemia is prevalent in patients undergoing transcatheter aortic valve replacement(TAVR) and has been linked to impaired outcomes after the procedure. Few studies have evaluated the impact of anemia and new ischemic lesions post TAVR.METHODS: We prospectively enrolled 158 patients who received TAVR in our center. Anemia was defined according to the World Health Organization criteria as hemoglobin <12 g/dL in women and <13 g/dL in men. All patients underwent diffusion-weighted magnetic resonance imaging(DW-MRI) procedure before and within 4–7 days after TAVR. RESULTS: Anemia was present in 85(53.8%) patients who underwent TAVR, and 126(79.7%) patients had 718 new DW-MRI positive lesions with a mean of 4.54±5.26 lesions per patient. The incidence of new ischemic lesions was 81.2% in patients with anemia versus 78.1% in patients without anemia(P=0.629). Moreover, anemic patients had bigger total volume/lesions in the anterior cerebral artery/middle cerebral artery(ACA/MCA) and MCA regions compared to the non-anemic patients(31.89±55.78 mm^(3) vs. 17.08±37.39 mm^(3), P=0.049;and 54.54±74.72 mm^(3) vs. 33.75±46.03 mm^(3), P=0.034). Anemia was independently associated with the volume/lesion in the ACA/MCA(β=16.796, 95% confidence interval [95% CI] 2.001 to 31.591, P=0.026) and in the MCA zone(β=0.020, 95% CI 0.001 to 0.040, P=0.041). CONCLUSIONS: Patients with pre-procedural anemia may have bigger total volume/lesions in the ACA/MCA and MCA regions compared to the non-anemic patients. Whether the consequences of bigger total volume/lesions impact neurological and cognitive outcomes remains to be investigated.
基金This research was supported by the National Natural Science Foundation of China[grant number 12172018,12202023]China Postdoctoral Science Foundation funded project[No.2021TQ0020]CAMS Innovation Fund for Medical Sciences(CIFMS)[2022-I2M-C&T-B-037].
文摘To investigate the effects of transcatheter heart valve(THV)poses and bicuspid aortic valve(BAV)subtypes on coronary hemodynamics after transcatheter aortic valve replacement(TAVR).The computational models for BAV included left-right fusion(LR),non-coronary-left fusion(LN)and non-coronary-right fusion(RN).THV deployment height is defined as the distance below the aortic annulus of the lowest point of the stent,H_(1)=2mm,H_(2)=5mm and H_(3)=8mm,Orientations include O_(1)(one commissure is aligned with the raphe)and O_(2)(one commissure is aligned with the axis of non-fused leaflet symmetry).The maximum flow velocity(Vmax),mean wall shear stress(mWSS)and coronary perfusion pressure(CPP)of coronary were obtained by computational fluid dynamics(CFD)simulation.The CPP was 59%in left coronary and 82%in right coronary higher than that before deployment.At O_(1),the CPP of the LN left coronary and the RN right coronary was 74%and 79%higher than that before deployment.At O_(2),the CPP of the LN right coronary and the RN left coronary was 83%and 82%higher than that before deployment.When the THV deployment height is less than 2mm,Vmax and CPP of coronary arteries do not return to healthy TAV levels or changed weakly.The overlap of the THV commissure with the coronary ostium makes the coronary CPP so large that it exceeds the level of a healthy TAV.
基金the grants from the National Natural Science Foundation of China(No.81970325)the 1.3.5 Project for Disciplines of Excellence,West China Hospital,Sichuan University-“Percutaneous trans-catheter aortic valve implantation”and“Mechanisms of aortic stenosis and the clinical applications.”。
文摘Background:The past decade has witnessed an ever-increasing momentum of transcatheter aortic valve replacement(TAVR)and a subsequent paradigm shift in the contemporary management of severe aortic stenosis(AS).We conducted a multi-centric TAVR registry based on Chinese patients(the China Aortic valve tRanscatheter Replacement registrY[CARRY])to delineate the clinical characteristics and outcomes of Chinese patients who underwent TAVR and compare the results between different valve types in different Chinese regions.Methods:CARRY is an all-comer registry of aortic valve disease patients undergoing TAVR across China and was designed as an observational study that retrospectively included all TAVR patients at each participating site.Seven hospitals in China participated in the CARRY,and 1204 patients from April 2012 to November 2020 were included.Categorical variables were compared using the chi-squared test,and continuous variables were analyzed using a t test or analysis of variance(ANOVA)test.The Kaplan–Meier curve was used to estimate the risk of adverse events during follow-up.Results:The mean age of the patients was 73.8±6.5 years and 57.2%were male.The median Society of Thoracic Surgeon-Predicted Risk of Mortality score was 6.0(3.7–8.9).Regarding the aortic valve,the proportion of bicuspid aortic valve(BAV)was 48.5%.During the hospital stay,the stroke rate was 0.7%,and the incidence of high-degree atrioventricular block indicating permanent pacemaker implantation was 11.0%.The in-hospital all-cause mortality rate was 2.2%.After 1 year,the overall mortality rate was 4.5%.Compared to patients with tricuspid aortic valve(TAV),those with BAV had similar in-hospital complication rates,but a lower incidence of in-hospital mortality(1.4%vs.3.3%)and 1 year mortality(2.3%vs.5.8%).Conclusions:TAVR candidates in China were younger,higher proportion of BAV,and had lower rates of post-procedural complications and mortality than other international all-comer registries.Given the use of early generation valves in the majority of the population,patients with BAV had similar rates of complications,but lower mortality than those with TAV.These findings further propel the extension of TAVR in low-risk patients.
基金This work was supported by the National Key R&D Program of China(No.2020YFC2008100)the Shaanxi Province Innovation Capability Support Plan-Innovative Talent Promotion Plan(No.2020TD-034)the Discipline Boosting Program of Xijing Hospital(No.XJZT18MJ69).
文摘Transcatheter aortic valve replacement(TAVR)has been performed for nearly 20years,with reliable safety and efficacy in moderate-to high-risk patients with aortic stenosis or regurgitation,with the advantage of less trauma and better prognosis than traditional open surgery.However,because surgeons have not been able to obtain a full view of the aortic root,3-dimensional printing has been used to reconstruct the aortic root so that they could clearly and intui-tively understand the specific anatomical structure.In addition,the 3D printed model has been used for the in vitro simulation of the planned procedures to predict the potential complications of TAVR,the goal being to provide guidance to reasonably plan the procedure to achieve the best outcome.Postprocedural 3D printing can be used to understand the depth,shape,and distribution of the stent.Cardiovascular 3D printing has achieved remarkable results in TAVR and has a great potential.
基金National Key Research&Development Program of China(No.2020YFC2008100)Project of Capital Clinical Treatment Technology Research and Translation Application(No.Z201100005520068)。
文摘Background:The study aimed to describe the aortic valve morphology in Chinese patients underwent transcatheter aortic valve replacement(TAVR)for symptomatic severe aortic stenosis(AS),and the impact of sizing strategies and related procedural outcomes.Methods:Patients with severe AS who underwent TAVR were consecutively enrolled from 2012 to 2019.The anatomy and morphology of the aortic root were assessed."Downsize"strategy was preformed when patients had complex morphology.The clinical outcomes of patients who performed downsize strategy were compared with those received annular sizing strategy.The primary outcome was device success rate,and secondary outcomes included Valve Academic Research Consortium-3 clinical outcomes variables based on 1-year follow-up.Results:A total of 293 patients were enrolled.Among them,95 patients(32.4%)had bicuspid aortic valve.The calcium volume(Hounsfield Unit-850)of aortic root was 449.90(243.15-782.15)mm3.Calcium is distributed mostly on the leaflet level.Downsize strategy was performed in 204 patients(69.6%).Compared with the patients who performed annular sizing strategy,those received downsize strategy achieved a similar device success rate(82.0%[73]vs.83.3%[170],P=0.79).Aortic valve gradients(downsize strategy group vs.annular sizing group,11.28 mmHg vs.11.88 mmHg,P=0.64)and percentages of patients with moderate or severe paravalvular regurgitation 2.0%(4/204)vs.4.5%(4/89),P=0.21were similar in the two groups at 30 days after TAVR.These echocardiographic results were sustainable for one year.Conclusions:Chinese TAVR patients have more prevalent bicuspid morphology and large calcium volume of aortic root.Calcium is distributed mostly on the leaflet level.Compare with annular sizing strategy,downsize strategy provided a non-inferior device success rate and transcatheter heart valve hemodynamic performance in self-expanding TAVR procedure.
文摘Background Transcatheter aortic valve replacement(TAVR)for the treatment symptomatic severe aortic stenosis(AS)is indicated in patients with intermediate or higher surgical risk.Latest trials showed TAVR,and surgical aortic valve replacement(SAVR)perform similarly at 1-year for the composite outcomes of mortality,stroke and rehospitalization.We performed a comprehensive meta-analysis to compare individual outcomes at 1-year for TAVR compared to SAVR in low-risk patients.Methods Pub Med,Embase,and Cochrane central were searched for all the randomized controlled trials(RCTs)that reported 1-year comparative outcomes of TAVR and surgical aortic valve replacement(SAVR).Our conclusions are based upon the random-effects model using Der Simonian-Laird estimator.Results Data from 4 trials and 2887 randomized patients showed that TAVR had lower rates of all-cause mortality,cardiovascular mortality,and atrial fibrillation compared to SAVR at 1-year follow-up(P<0.05 for all).Also,TAVR was also associated with a significantly higher risk of permanent pacemaker implantation and moderate-severe paravalvular leak(P<0.05).Conclusions The latest randomised trial data demonstrates that in short-term,TAVR is safe and effective in reducing all-cause mortality or stroke.Longer follow-up of RCTs is needed to determine the durability of clinical benefits in TAVR over SAVR in low-risk patients.
文摘Introduction: This is the first case of Transcatheter Aortic Valve Replacement(TAVR) in the prefecture level hospital of Xinjiang Province in China. It also proves that severe left main coronary artery disease(LM)is not the contraindication to this operation of TAVR. Patient concerns:The patient had dyspnea for two years, with the 4/6 spurious murmur at the aortic valve. The cardiac ultrasound revealed a severe aortic valve stenosis(AS) and severe mitral regurgitation(MR). Coronary angiography(CAG)showed 80% stenosis of the left main artery. Diagnosis: The severe aortic valve stenosis(AS). Interventions: He received the TAVR, which also is the first case in the First People's Hospital of Kashi Prefecture. Outcomes: The patient's symptoms were significantly improved. The cardiac ultrasound showed that no obvious regurgitation was found in the implanted artificial aortic valve and the MR was significantly reduced. So far, the patient has recovered well for five months after TAVR. Conclusion:TAVR is an effective method for the severe AS patients with serve LM and loss of surgical opportunity.
文摘INTRODUCTION Aortic stenosis is one of the major causes of death in cardiovascular diseases,and transcatheter aortic valve implantation(TAVI)is a milestone in the field of cardiovascular intervention.Since the first implementation in October 2010,this technology has been
文摘BACKGROUND Complications of transcatheter aortic valve implantation(TAVI)procedures include bleeding,vascular complications,and strokes.These complications are often associated with the type of access used.The two types of access in TAVI procedures are primary and secondary.The main use of the primary access is for valve delivery,while secondary access is used for angiography and hemodynamic monitoring.While there are many options for primary access,those for secondary access are transfemoral and transradial.AIM To compare outcomes between transradial vs transfemoral secondary access(TFSA).METHODS A systematic search was conducted using major databases(EMBASE,PubMed,Cochrane Central,Google Scholar),which resulted in 5 studies that met the criteria for study selection.Outcomes of interest were 30-d rates each of major/life-threatening bleeding,vascular complications,strokes,and mortality.All 5 studies were observational.Only adjusted or matched data were used when available in this meta-analysis.RESULTS A total of 5065 patients underwent TAVI,with 1453 patients(28.7%)having undergone transradial secondary access(TRSA)and 3612 patients(71.3%)TFSA.Irrespective of the site of primary access,the odds of having major or lifethreatening bleeding were 60%lower in the TRSA group than the TFSA group(P<0.00001).The odds of having major vascular complications were 52%lower in the TRSA group(P<0.0001)with no difference in minor vascular complications between the 2 groups.Similarly,the odds of mortality in 30-d after the procedure were 41%lower(P=0.006)and the odds of stroke were 54%lower(P=0.001)in the TRSA group than the TFSA group.CONCLUSION The transradial secondary approach appears to be a safer alternative to the transfemoral secondary approach in TAVI procedures.
文摘<strong>Background:</strong> Transcatheter aortic valve implantation (TAVI) is a widely used treatment of severe aortic stenosis. Implantation of a self-expanding valve into a dense calcified aortic annulus can be challenging and may result in device malposition and malfunction.<strong> Aim: </strong>The aim of our case report is to present a novel technique of transcatheter aortic valve dislocation treatment. <strong>Case presentation:</strong> An 86-year-old woman with severely calcified aortic valve underwent TAVI using a 27-mm self-expanding Portico valve (Abbott Vasc, USA). In the last phase of implantation, the valve dislocated deep into the left ventricular outflow tract resulting in significant paravalvular regurgitation and patient instability. Repositioning of the valve with a single snare was ineffective because of severe aortic ring calcifications. A novel “double snare” technique was applied and the valve was successfully repositioned upward with an excellent anatomic and haemodynamic result. <strong>Conclusion:</strong> “Double snare” technique can be an effective strategy for repositioning of deeply implanted self-expanding transcatheter aortic valves. It represents an efficient bailout strategy in case of single snare approach failure, especially in cases of severe aortic ring calcifications.
基金supported by Advanced Technique Research of Valvular Heart Disease Treatment Project(2015C03028)
文摘BACKGROUND: No retrievable and repositionable second generation transcatheter aortic valve is available in China. Here, we report the first-in-man implantation of the retrievable and repositionable VenusA-Plus valve. METHODS: A 76-year-old patient with symptomatic severe aortic stenosis and high surgical risk(STS 13.8%) was recommended for transcatheter aortic valve replacement(TAVR) by heart valve team. Type 0 bicuspid aortic valve with asymmetric calcification was identified by dual source computed tomography, and the unfavorable anatomies increased the possibility of malposition and paravalvular leakage during TAVR. Therefore, we used the retrievable and repositionable Venus APlus valve for the patient.RESULTS: Transfemoral TAVR was performed under local anesthesia with sedation, and a 26-mm VenusA-Plus valve was successfully implanted. No transvalvular pressure gradient and trace paravalvular leakage were found. CONCLUSION: The successful first-in-man implantation indicates the retrievable and repositionable Venus A-Plus valve is feasible in complicated TAVR cases such as bicuspid aortic valve.
文摘Heyde’s syndrome is an under reported systemic disease of gastrointestinal and cardiac manifestation in older adults.It is characterized by a triad of aortic stenosis,angiodysplasia with bleeding and acquired von Willebrand syndrome.It is characterized by proteolysis of high molecular weight multimers of von Willebrand Factor and loss of platelet mediated homeostasis.Heyde’s syndrome is a treatable condition in most cases,especially in the current era of evolution in interventional cardiology and gastroenterology.There are currently no established guidelines in the management of this condition due to paucity of high quality studies,which warrant future trials.High index of suspicion and increasing the awareness of the syndrome among the general practitioners and sub-specialists will improve the diagnostic potential of Heyde’s syndrome.Future studies may change the management aspect of Heyde's syndrome and pave a path for drawing specific guidelines and algorithms.The aim of our review article is to summarize the basic pathophysiology,diagnostics and management of Heyde’s syndrome with a special attention to Transcatheter aortic valve replacement.
基金supported by the Foundation for Talent in Clinical Research of The Army Medical University(No.2018XLC3021).
文摘Objective:Diverse antithrombotic strategies were applied to patients undergoing aortic valve replacement.However,the optimal therapeutic regimen for patients undergoing transcatheter aortic valve implantation/replacement(TAVI/TAVR)remains unclear.The purpose of this study was to compare the efficacy and safety of various antithrombotic therapies following TAVI/TAVR.Methods:Relevant clinical trials evaluating the effect of anticoagulation or antiplatelet regimens on patients after TAVI/TAVR from inception to September 2020 were identified using the PubMed,EMBASE,and the Cochrane Library databases.The inclusion criteria including(1)all patients underwent TAVI/TAVR;(2)the interventions were antithrombotic strategies that prevent the occurrence of thrombotic events in patients;(3)randomized controlled trials or prospective observational studies;and(4)investigation of at least 1 outcome with a follow-up period of≥3 months.The exclusion criteria including(1)research content was identical or irrelevant to the purpose of the present study;(2)lack of the required outcome index or availability of fragmentary original information;and(3)the full text is not available.The major outcomes were all-cause mortality,thromboembolic complications,and bleeding events.The Cochrane Collaboration’s tool and the Newcastle-Ottawa Scale were used for assessing the risk of bias in included studies.Results:Thirteen studies(3 randomized controlled trials and 10 non-randomized studies)were identified,with a total of 23,497 patients.Four studies compared direct oral anticoagulants(DOACs)with warfarin,1 study compared aspirin with warfarin,6 studies compared aspirin plus clopidogrel(dual antiplatelet therapy(DAPT))with aspirin monotherapy,and 2 studies compared DAPT and aspirin monotherapy with warfarin concurrently.There were no significant differences found between the DOAC and warfarin groups regarding all-cause mortality(risk ratio(RR):1.03;95%confidence interval(CI):0.65–1.64;P=0.909;Phet=0.105),clinical adverse events(RR:1.59;95%CI:0.99–2.58;P=0.057;Phet=0.738),or bleeding events(RR:0.93;95%CI:0.78–1.11;P=0.437;Phet=0.338).The rates of all-cause mortality(RR:0.71;95%CI:0.54–0.93;P=0.012;Phet=0.845)and bleeding events(RR:0.43;95%CI:0.22–0.83;P=0.012;P_(het)=0.569)were lower in the aspirin group versus the warfarin group;however,there was no difference in the rate of clinical adverse events(RR:0.38;95%CI:0.14–1.07;P=0.068;Phet=0.593).The DAPT group had an advantage versus the aspirin group in all-cause mortality(RR:0.89;95%CI:0.82–0.98;P=0.013;Phet=0.299);however,the incidence of bleeding events(RR:2.06;95%CI:1.39–3.07;P<0.001;Phet=0.001)exhibited an increasing trend.Notably,there was a slight decrease in the incidence of clinical adverse events(RR:1.09;95%CI:0.94–1.26;P=0.268;Phet=0.554).Conclusion:The present meta-analysis integrates the latest published results on antithrombotic strategies in patients after TAVI/TAVR.Aspirin showed a favorable risk-benefit profile versus warfarin,with lower rates of all-cause mortality and bleeding events.Although DAPT was also associated with a significantly lower rate of all-cause mortality,it was linked to a higher incidence of bleeding events.The DOACs did not show significant benefits compared with warfarin.Some certain limitations should be noted,such as different types of trails produce heterogeneity and finite inclusion of TAVI/TAVR patients increased selection bias.
