Littérature scientifique sur le sujet « TAVI, AVR, carotid stenosis »

Transcatheter aortic valve implantation (TAVI) is an increasingly widespread percutaneous intervention of aortic valve replacement (AVR). The target population for TAVI is mainly composed of elderly, frail patients with severe aortic stenosis (AS), multiple comorbidities, and high perioperative mortality risk for surgical AVR (sAVR). These vulnerable patients could benefit from cardiac rehabilitation (CR) programs after percutaneous intervention. To date, no major guidelines currently recommend CR after TAVI. However, emerging scientific evidence shows that CR in patients undergoing TAVI is safe, and improves exercise tolerance and quality of life. Moreover, preliminary data prove that a CR program after TAVI has the potential to reduce mortality during follow-up, even if randomized clinical trials are needed for confirmation. The present review article provides an overview of all scientific evidence concerning the potential beneficial effects of CR after TAVI, and suggests possible fields of research to improve cardiac care after TAVI.

Conventional surgical aortic valve replacement (AVR) is the ‘gold standard’ for treatment of severe or symptomatic aortic valve stenosis. The increasing age of patients and increasing comorbidities has led to the development of procedures to minimise operative time and reduce risks of surgery. One method of reducing operative times is the use of sutureless aortic valves (SU-AVR). We examine the current literature surrounding the use of SU-AVR. Alternatives to AVR are SU-AVR, sometimes referred to as rapid deployment valves, or transcatheter aortic valve implantation (TAVI). TAVI has been demonstrated to be superior over medical therapy in patients deemed inoperable and non-inferior in high and intermediate-risk patients compared with surgical AVR. However, the lack of excision of the calcified aortic valve and annulus raises concerns regarding long-term durability and possibly thromboembolic complications. TAVI patients have increased rates of paravalvular leaks, major vascular complications and pacemaker implantation when compared with conventional AVR. SU-AVR minimises the need for suturing, leading to reduced operative times, while enabling complete removal of the calcified valve. The increase in use of SU-AVR has been mostly driven by minimally invasive surgery. Other indications include patients with a small and/or calcified aortic root, as well as patients requiring AVR and concomitant surgery. SU-AVR is associated with decreased operative times and possibly improved haemodynamics when compared with conventional AVR. However, this has to be weighed against the increased risk of paravalvular leak and pacemaker implantation when deciding which prosthesis to use for AVR.

Background: When severe aortic stenosis (AS) is concomitant with carotid stenosis, carotid artery stenting (CAS) will become a high-risk procedure because baroreceptor reflex-induced bradycardia and hypotension may cause irreversible circulatory collapse. When carotid stenosis-related misery perfusion is present, the risk of cerebral hyperperfusion syndrome increases after carotid revascularization. We report a case of severe carotid disease concomitant with severe AS successfully treated by a combination of staged angioplasty (SAP) and transcatheter aortic valve implantation (TAVI). Case Description: An 86-year-old man presented with transient deterioration of mental status and sluggish responsiveness continuous from the previous day. Magnetic resonance imaging of the brain revealed a right putaminal infarction, occlusion of the right internal carotid artery (ICA), and severe stenosis of the left ICA. Severe AS was diagnosed and single-photon emission computed tomography showed misery perfusion at the bilateral ICA territories. We performed a staged treatment consisting of SAP for the left carotid stenosis and TAVI. A first-stage carotid angioplasty was performed, followed by TAVI 2 weeks later and second-stage CAS 1 week after that. There were no apparent periprocedural complications throughout the clinical course. Conclusion: Combining SAP and TAVI may be an effective treatment option for severe carotid stenosis with misery perfusion concomitant with severe AS.

BackgroundAn investigation into differences in the management and treatment of severe aortic stenosis (AS) between Germany, France and the UK may allow benchmarking of the different healthcare systems and identification of levers for improvement.MethodsPatients with a diagnosis of severe AS under management at centres within the IMPULSE and IMPULSE enhanced registries were eligible.ResultsData were collected from 2052 patients (795 Germany; 542 France; 715 UK). Patients in Germany were older (79.8 years), often symptomatic (89.5%) and female (49.8%) and had a lower EF (53.8%) than patients in France and UK. Comorbidities were more common and they had a higher mean Euroscore II.Aortic valve replacement (AVR) was planned within 3 months in 70.2%. This was higher (p<0.001) in Germany than France/ UK. Of those with planned AVR, 82.3% received it within 3 months with a gradual decline (Germany>France> UK; p<0.001). In 253 patients, AVR was not performed, despite planned. Germany had a strong transcatheter aortic valve implantation (TAVI) preference (83.2%) versus France/ UK (p<0.001). Waiting time for TAVI was shorter in Germany (24.9 days) and France (19.5 days) than UK (40.3 days).Symptomatic patients were scheduled for an AVR in 79.4% (Germany> France> UK; p<0.001) and performed in 83.6% with a TAVI preference (73.1%). 20.4% of the asymptomatic patients were intervened.ConclusionPatients in Germany had more advanced disease. The rate of intervention within 3 months after diagnosis was startlingly low in the UK. Asymptomatic patients without a formal indication often underwent an intervention in Germany and France.

BackgroundContemporary data regarding the impact of comorbidities on the clinical presentation and management of patients with severe aortic stenosis (AS) are scarce.MethodsProspective registry of severe patients with AS across 23 centres in nine European countries.ResultsOf the 2171 patients, chronic kidney disease (CKD 27.3%), left ventricular ejection fraction (LVEF) <50% (22.0%), atrial fibrillation (15.9%) and chronic obstructive pulmonary disease (11.4%) were the most prevalent comorbidities (49.3% none, 33.9% one and 16.8% ≥2 of these). The decision to perform aortic valve replacement (AVR) was taken in a comparable proportion (67%, 72% and 69%, in patients with 0, 1 and ≥2 comorbidities; p=0.186). However, the decision for TAVI was more common with more comorbidities (35.4%, 54.0% and 57.0% for no, 1 and ≥2; p<0.001), while the decision for surgical AVR (SAVR) was decreased with increasing comorbidity burden (31.9%, 17.4% and 12.3%; p<0.001). The proportion of patients with planned AVRs that were performed within 3 months was significantly higher in patients with 1 or ≥2 comorbidities than in those without (8.7%, 10.0% and 15.7%; p<0.001). Furthermore, the mean time to AVR was significantly shorter in patients with one (30.5 days) or ≥2 comorbidities (30.8 days) than in those without (35.7 days; p=0.012). Patients with reduced LVEF tended to be offered an AVR more frequently and with a shorter delay while patients with CKD were less frequently treated.ConclusionsComorbidities in severe patients with AS affect the presentation and management of patients with severe AS. TAVI was offered more often than SAVR and performed within a shorter time period.

Introduction: Severe Calcific Aortic Stenosis (AS) remains a major cause of morbidity and mortality in aged population. Asymptomatic with reduced LVEF has high risk of sudden death. Aim: To study the complexity of clinical course of Severe Calcific AS with LV Dysfunction. Case Report: A Seventy-Six-year-old male was admitted with ACS, NSTEMI, LVEF 35% and Severe Calcific AS. With plan of AVR, CAG was done and showed Mild CAD. Post-procedure he had sequence of catastrophic clinical events that includes, A systolic Cardiac Arrest (reverted after CPR) and Protracted Pulmonary edema (Connected to Mechanical Ventilation). Later had Malignant Ventricular Arrhythmias, treated with 34 times DC Shocks. He was not suitable for Surgical AVR or TAVI. After high-risk consent, he successfully underwent emergency Aortic Balloon Valvuloplasty (ABV) with significant drop in AV gradients. Post ABV, also had Paroxysmal AF. Arrhythmias were also treated with Beta blocker, Antiarrhythmics, Digoxin and Potassium supplementation. Gradually stabilized, discharged and followed up. Discussion: Aortic stenosis, a disease of elderly age group. Symptomatology varies widely. It has limited management options. In our case, Post CAG critical illness was probably due to “Pre -CAG” LV dysfunction with subclinical symptoms. ABV used as bail out the procedure in high-risk patients. Conclusion: ABV is considered as a viable palliative option, with the introduction of smaller profile balloons, rapid pacing and vascular closure devices. ABV can safely used as bridging procedure before Surgical AVR or TAVI in high-risk patients

Background. The resistive (RI) and pulsatile (PI) indices are markers of vascular stiffness (VS) which are associated with outcomes in patients with cardiovascular disease. We aimed to assess whether VS might predict incidence of cardiovascular death (CVD) and heart failure (HF) episodes following intervention on degenerative aortic valve stenosis (DAS). Methods. The distribution of increased VS (RI ≥ 0.7 and PI ≥ 1.3) from supra-aortic arteries was assessed in patients with symptomatic DAS who underwent aortic valve replacement (AVR, n = 127) or transcatheter aortic valve implantation (TAVI, n = 119). During a 3-year follow-up period (FU), incidences of composite endpoint (CVD and HF) were recorded. Results. Increased VS was found in 100% of TAVI patients with adverse event vs. 88.9% event-free TAVI patients (p = 0.116), and in 93.3% of AVR patients with event vs. 70.5% event-free (p = 0.061). Kaplan–Mayer free-survival curves at 1-year and 3-year FU were 90.5% vs. 97.1 % and 78% vs. 97.1% for patients with increased vs. lower VS. (p = 0.014). In univariate Cox analysis, elevated VS (HR 7.97, p = 0.04) and age (HR 1.05, p = 0.024) were associated with risk of adverse outcomes; however, both failed in Cox multivariable analysis. Conclusions. Vascular stiffness is associated with outcome after DAS intervention. However, it cannot be used as an independent outcome predictor.

Balloon valvuloplasty of the aortic valve (BAV) in aortic stenosis has been practiced for over 35 years. The initial enthusiasm caused by the excellent immediate hemodynamic effect of the procedure disappears due to the rapid restenosis of the aortic valve after intervention. The results of modern methods for defi nitive treatment of aortic valve stenosis &ndash; AVR and TAVI are excellent, thanks to which they are fi rmly rooted in treatment guidelines. However, BAV has its indications in symptomatic patients who are not suitable for defi nitive interventions. This publication discusses current indications for BAV, the main stages of the procedure, possible complications, and treatment outcomes.

ObjectivesTo investigate symptoms and self-reported health of patients conservatively treated for aortic stenosis (AS) and to identify factors associated with treatment decision and patient outcomes.DesignA cross-sectional survey with an 18-month follow-up.SettingOne tertiary university hospital in Western Norway.ParticipantsIn all, 1436 patients were diagnosed with AS between 2000 and 2012, and those 245 still under conservative treatment in 2013 were included in this study.Primary and secondary outcome measuresPrimary outcome measures were symptoms and self-reported health status. Secondary outcomes were treatment decision and patient survival after 18 months.ResultsA total of 136 patients with mean (SD) age 79 (12) years, 52% men responded. Among conservatively treated patients 77% were symptomatic. The symptom most frequently experienced was dyspnoea. Symptomatic patients reported worse physical and mental health compared with asymptomatic patients (effect size 1.24 and 0.74, respectively). In addition, symptomatic patients reported significantly higher levels of anxiety and depression compared with asymptomatic patients. However, symptom status did not correlate with haemodynamic severity of AS. After 18 months, 117 (86%) were still alive, 20% had undergone surgical aortic valve replacement (AVR) and 7% transcatheter aortic valve implantation (TAVI). When adjusting for age, gender, symptomatic status, severity of AS and European system for cardiac operative risk evaluation (EuroSCORE), patients with severe AS had more than sixfold chance of being scheduled for AVR or TAVI compared with those with moderate AS (HR 6.3, 95% CI 1.9 to 21.2, p=0.003). Patients with EuroSCORE ≥11 had less chance for undergoing AVR or TAVI compared with those with EuroSCORE ≤5 (HR 0.06, 95% CI 0.01 to 0.46, p=0.007).ConclusionsSymptoms affected both physical and mental health in conservatively treated patients with AS. Many patients with symptomatic severe AS are not scheduled for surgery, despite the recommendations in current guidelines. The referral practice for AVR is a path for further investigation.

ObjectiveApproximately 3.4% of adults aged >75 years suffer from aortic stenosis (AS). Guideline indications for aortic valve replacement (AVR) distinguish between patients with symptomatic and asymptomatic severe AS. The present analysis aims to assess contemporary practice in the treatment of severe AS across Europe and identify characteristics associated with treatment decisions, namely denial of AVR in symptomatic patients and assignment of asymptomatic patients to AVR.MethodsParticipants of the prospective, multinational IMPULSE database of patients with severe AS were grouped according to AS symptoms, and stratified into subgroups based on assignment to/denial of AVR.ResultsOf 1608 symptomatic patients, 23.8% did not undergo AVR and underwent medical treatment. Denial was independently associated with multiple factors, including severe frailty (p=0.024); mitral (p=0.002) or tricuspid (p=0.004) regurgitation grade III/IV, and the presence of renal impairment (p=0.017). Of 392 asymptomatic patients, 86.5% had no prespecified indication for AVR. Regardless, 36.3% were assigned to valve replacement. Those with an indexed aortic valve area (AVA; p=0.045) or left ventricular ejection fraction (LVEF; p<0.001) below the study median; or with a left ventricular end systolic diameter above the study median (p=0.007) were more likely to be assigned to AVR.ConclusionsThere may be considerable discrepancies between guideline-based recommendations and clinical practice decision-making in the treatment of AS. It appears that guidelines may not fully capture the complete clinical spectrum of patients with AS. Thus, there is a need to find ways to increase their acceptance and the rate of adoption.

Introduction Stroke is a potential major complication of aortic valve replacement (AVR), transcatheter aortic valve implantation (TAVI), and balloon aortic valvuloplasty (BAV). Although its occurrence is rare, stroke significantly affects survival and quality of life. Peripheral vascular disease and carotid artery disease are independent risk factors that have been identified as predictors of operative death according to surgical risk scores. The presence of a significant carotid stenosis may increase the surgical risk leading to the choice of a percutaneous transaortic valve implantation rather than a surgical AVR. At present there is no evidence that describes the impact of asymptomatic significant carotid stenosis detected accidentally during preoperative evaluation on the onset of cerebrovascular periprocedural events after TAVI. Population In this first analysis we considered 521 patients with severe aortic stenosis (AS) and cardiac symptoms (New York Heart Association [NYHA] class II function or worse). A score of at least 20 % on the EuroSCORE (European System for Cardiac Operative Risk Evaluation) and 10% on the risk model developed by the Society for Thoracic Surgeons (STS)., Follow-up All patients underwent clinical surveillance, bio-chemical tests, electrocardiogram and echocardiogram before hospital discharge. The follow-up assessment included medical examination, electrocardiogram and echocardiogram to perform valve imaging and hemodynamic evaluation. It was performed at our Center or at the treating cardiologist ambulatory 30 days and one year after the procedure. The events considered were mortality (by all-cause and cardiovascular death), myocardial infarction, stroke and transient ischemic attack (TIA), bleeding (minor and life-threatening bleeding), acute renal failure, vascular complications, disturb of conduction and arrhythmias and the combined criteria of safety, according to VARC and VARC 2 definitions. Procedure The coexistence of carotid and peripheral artery diseases not only further increases risk and long-term mortality but influences also technical approaches since all centers adopt a policy of using the transfemoral approach first, with criteria for the use of non-transfemoral approaches that are based on the size and degree of tortuosity, calcifications, and atheroma of the aorto-iliofemoral arterial tree, as assessed by the multidisciplinary team. In our Center, preventive measures have been taken to limit the risk associated to the procedure in our patients presenting carotid artery stenosis. Results The main findings of the current study are the following: (a) no correlation has been observed about the presence of an asymptomatic carotid artery stenosis discovered before the TAVI procedure and mortality, rate of cerebrovascular events (stroke or TIA) and myocardial infarction during the first postoperative month; (b) no differences concerning all-causes and cardiovascular mortality and onset of cerebrovascular events (stroke/TIA) at long-term have been shown between patients with and without CAS. Conclusion The presence of asymptomatic carotid stenosis is not a risk factor for cerebrovascular events after percutaneous aortic valve implantation at 30 days and one-year follow-up. Cerebrovascular events after TAVI occur in a vulnerability period extending to 1 month post-procedure. No difference exists in the CVE rate with regard to the type of valve or the access route. Coronary, carotid, aortic, iliac and femoral artery disease are often found in elderly patients presenting with severe symptomatic AS undergoing TAVI. These patients are also affected by several clinical factors and frailty that correlate with the presence and severity of arterial pathologies and can impact on incidence of CVEs and longterm survival

Trabalho Final do Mestrado Integrado em Medicina apresentado à Faculdade de Medicina
Objetivos: A implantação percutânea da válvula aórtica (TAVI) tem levantado cada vez mais questões quanto ao uso da cirurgia convencional de substituição da válvula aórtica (AVR) em doentes com risco cirúrgico intermédio a elevado, particularmente em octogenários. No entanto, a AVR tornou-se menos invasiva e os resultados cirúrgicos melhoraram nos últimos anos. Neste estudo avaliamos os resultados peri-operatórios, a sobrevida e o estado funcional dos doentes octogenários, submetidos a AVR isolada.Métodos: De janeiro de 2006 a dezembro de 2016, 2947 doentes foram submetidos a AVR isolada, dos quais 385 (13.1%) eram octogenários e constituem a população deste estudo. A média de idades foi de 82.1 ± 2,0 anos, 57.7% eram mulheres e 47.3% estavam em classe NYHA III-IV. A mediana do EuroSCORE-II foi de 3.6 ± 3.9. O alargamento da raiz da aorta foi realizado em 105 casos (27.1%).Resultados: Houve apenas um caso de mortalidade intra-hospitalar e a mortalidade total nos primeiros 30 dias foi de 0,8% (2 doentes). Verificou-se a implantação definitiva de pacemaker em 3.5% dos casos, 0.8% tiveram como complicação acidente vascular cerebral e 0,8% enfarte agudo do miocárdio. Não se verificaram casos de regurgitação peri-protésica grave ou moderada e apenas 18 doentes tiveram regurgitação mínima ou ligeira. A média de permanência hospitalar foi de 8,0 ± 3,2 dias. A mediana de tempo de seguimento foi de 4.4±2.64 anos. A sobrevida aos 1, 5 e 10 anos foi de 95.1±1.1%, 76.3±2.5% e 41.7±5.3%, respetivamente, significativamente melhor do que a sobrevivência da população em geral com idade e género correspondentes. A presença de fibrilação auricular (HR:2.428; CI:1.552-3.798, p=0.008), insuficiência renal (HR:1.404; CI:1.037-1.902, p=0.028) e classes de NYHA mais altas (HR:1.464; CI:1.106-1.939, p=0.007) foram fatores de risco independentes de mortalidade tardia. A maioria dos doentes (97%) demonstrou alto grau de satisfação com a cirurgia e 82,9% estavam na classe I-II de NYHA.Conclusões: A AVR isolada convencional em octogenários tem mortalidade e morbidade muito baixas. Na nossa série de doentes, os scores de risco sobrevalorizaram a mortalidade. Estes resultados devem ser vistos como referência e devem ser comparados com os procedimentos percutâneos.
Background: Transcatheter aortic valve implantation (TAVI) increasingly questions the use of conventional aortic valve replacement (AVR) in high-intermediate risk patients, particularly in octogenarians. Nevertheless, AVR has become less-invasive and surgical outcomes have improved in the last years. In this study, we evaluate the perioperative outcomes, survival and functional status after AVR in octogenarian patients.Methods: From Jan-2006 to Dec-2016, 2947 patients were submitted to AVR, of whom 385 (13.1%) were octogenarians and constitute the subject of this study. Mean age was 82.1±2.0 years, 57.7% female, and 47.3% were in New York Heart Association (NYHA) class III-IV. Median EuroSCORE-II: 3.6 ± 3.9. Aortic root enlargement was performed in 105 cases (27.1%).Results: Only one patient died during hospitalization (0.3%) and thirty-day mortality was 0.8% (3 patients). Permanent pacemaker implantation occurred in 3.5%, stroke in 0.8% and acute myocardial infarction in 0.8%. Only 18 patients had peri-prosthetic leak (minimal or mild), no moderate or severe leakage was observed. Mean hospital stay was 8.0±3.2 days. Median follow-up time was 4.4±2.64 years (range: 1-12 years). Survival at 1, 5 and 10 years was 95.1±1.1%, 76.3±2.5% and 41.7±5.3%, respectively, significantly better than the expected survival of the general population (age and gender-matched). Atrial fibrillation (HR:2.428; CI:1.552-3.798, p=0.008), renal failure (HR:1.404; CI:1.037-1.902, p=0.028) and higher NYHA classes (HR:1.464; CI:1.106-1.939, p=0.007) were independent risk factors of late mortality. The majority of subjects (97%) showed a high degree of satisfaction with the surgery and 82.9% were in NYHA class I-II. Colocar o resultado da comparação com a população geral Conclusions: Contemporary isolated AVR in octogenarians carries very low mortality and morbidity. In our series, the risk-score calculators overvalued mortality. These results should be viewed as benchmark to which transcatheter procedures should be compared.

The aortic valve may become dysfunctional due to degenerative, rheumatic, and congenital causes leading to leaflet calcification and, in turn, obstruction of blood flow from the left ventricle into the aorta. Generally, an aortic valve area <1 cm² is considered severe and is commonly treated with aortic valve replacement (AVR) and trans-arterial valve implantation (TAVI). Most patients with aortic stenosis are elderly and, hence, with the aging population, the prevalence and incidence of aortic stenosis has increased remarkably. Left untreated, aortic stenosis leads to angina pectoris, exercise intolerance, heart failure, arrhythmias, and premature death. Even after surgical AVR or TAVI, outcomes are less favourable then in healthy, age-matched, control populations.