RESUMEN
BACKGROUND: Inflammation following transcatheter aortic valve implantation (TAVI) is associated with an increased risk of adverse outcomes. The aim of this study was to compare the inflammatory response between low radial force valves (Acurate neo2, Boston Scientific) and high radial force valves (Evolut R/Pro, Medtronic; SAPIEN Edwards Lifesciences; and Myval, Meril valves). METHODS: We conducted a retrospective study of patients with severe aortic stenosis treated with TAVI between 2021 and 2022. The primary endpoint was the difference in the inflammatory response between low radial force valves and high radial force valves, measured as the difference between post-procedural and pre-procedural high-sensitivity C-reactive protein levels (hsCRP delta). RESULTS: A total of 114 patients were included, of which 65 patients (57%) received a low radial force valve. The hsCRP delta was lower in the low radial force valve group compared to the high radial force valve group (8.7 [2.1-15.6] mg/L vs. 18.8 mg/dL [6.4-19] mg/L; P=0.003), due to a lower post-implantation hsCRP (8.9 [5.45-19.6] mg/L vs. 15.8 [9.8-27.3] mg/L; P=0.013). The incidence of new left bundle branch block (LBBB) after TAVI was lower in the low radial force valve group compared to the high radial force valve group (11 [17%] vs. 18 [37%]; P=0.020). CONCLUSIONS: Low radial force TAVI prostheses were associated with a lower inflammatory response, and a lower incidence of new LBBB compared to the radial force valve group, suggesting that inflammation may contribute to the increased risk of conduction disturbances.
Asunto(s)
Estenosis de la Válvula Aórtica , Proteína C-Reactiva , Prótesis Valvulares Cardíacas , Inflamación , Índice de Severidad de la Enfermedad , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Estenosis de la Válvula Aórtica/cirugía , Masculino , Femenino , Estudios Retrospectivos , Anciano de 80 o más Años , Inflamación/etiología , Proteína C-Reactiva/análisis , Proteína C-Reactiva/metabolismo , Anciano , Prótesis Valvulares Cardíacas/efectos adversos , Diseño de Prótesis , Resultado del TratamientoAsunto(s)
Estenosis de la Válvula Aórtica , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Estenosis de la Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Válvula Aórtica/diagnóstico por imagen , Prótesis Valvulares Cardíacas/efectos adversos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/diagnóstico , MasculinoRESUMEN
BACKGROUND: While surgery still remains the gold standard treatment for mechanical prosthetic valve thrombosis (MPVT) by many guidelines, the ultraslow low-dose thrombolytic regimen has been reported as a promising alternative. METHODS: In this prospective single-center cohort, patients with acute MPVT were treated with an ultraslow low-dose thrombolytic regimen consisting of 25 mg infusion of recombinant tissue-type plasminogen activator (rtPA) over 25 h. The regimen could be repeated in case of failure until resolution/occurrence of adverse events or a maximum cumulative dose of 150 mg. The primary outcome was the complete MPVT resolution rate; other outcomes included first-dose success rate, major bleeding, thromboembolic events, mortality, and total thrombolytic dose/duration. RESULTS: Between April 2018 to January 2024, 135 episodes of acute MPVT were treated with an ultraslow low-dose thrombolytic regimen in 118 patients. In 118/135 (87.4 %) episodes, right-sided prosthetic valve was involved. Complete success was achieved in 88.1 % of cases, with 39.5 % responding after the first dose. The median total dose was 50 mg over a median of 30 h. Only one fatal intracranial hemorrhage occurred (0.7 %), with no other bleeding or thromboembolic complications. CONCLUSION: The ultraslow low-dose thrombolytic regimen appears to exhibit high efficacy and acceptable safety in treating acute MPVT. Further large clinical trials are essential for validating these preliminary findings.
Asunto(s)
Fibrinolíticos , Prótesis Valvulares Cardíacas , Terapia Trombolítica , Trombosis , Humanos , Femenino , Masculino , Estudios Prospectivos , Terapia Trombolítica/métodos , Prótesis Valvulares Cardíacas/efectos adversos , Persona de Mediana Edad , Trombosis/tratamiento farmacológico , Trombosis/etiología , Fibrinolíticos/administración & dosificación , Fibrinolíticos/uso terapéutico , Anciano , Estudios de Cohortes , Activador de Tejido Plasminógeno/administración & dosificación , Activador de Tejido Plasminógeno/uso terapéutico , Adulto , Relación Dosis-Respuesta a Droga , Resultado del Tratamiento , Enfermedad AgudaRESUMEN
We present here a case of documented paraprosthetic valvular leak following TAVI treated medically initially. This led to a poorly tolerated hemolytic anemia. We were able to correct this paraprosthetic valvular leak by a postdilation of the TAVI valve with a good result and uncomplicated follow-up.
Asunto(s)
Anemia Hemolítica , Estenosis de la Válvula Aórtica , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Estenosis de la Válvula Aórtica/cirugía , Anemia Hemolítica/etiología , Falla de Prótesis , Anciano de 80 o más Años , Prótesis Valvulares Cardíacas/efectos adversos , Anciano , Femenino , Masculino , Complicaciones Posoperatorias/etiologíaRESUMEN
Percutaneous treatment of para-prosthetic valve leaks (PVL) is an alternative to redo surgery. Based on the clinical case of an unusual aortic para-prosthetic leak closure (PVLc), are presented successively the diagnostic difficulties of PVL, the modalities of therapeutic choice, the main technical steps of PVLc followed by a review of results and complications.
Asunto(s)
Prótesis Valvulares Cardíacas , Falla de Prótesis , Humanos , Prótesis Valvulares Cardíacas/efectos adversos , Reoperación , Implantación de Prótesis de Válvulas Cardíacas , Masculino , Válvula Aórtica/cirugía , Complicaciones Posoperatorias/cirugía , Complicaciones Posoperatorias/etiología , Femenino , AncianoRESUMEN
PURPOSE: Staphylococcus aureus prosthetic valve endocarditis (SAPVE) is a serious infection with high mortality. The main objective of this study was to identify factors associated with in-hospital mortality. METHODS: From January 2008 to December 2021, consecutive patients from a Spanish cohort of infective endocarditis with a definitive diagnosis of SAPVE were analyzed. RESULTS: During the study period, 219 cases of definitive SAPVE were diagnosed, which accounted for 16.7% of a total of 1309 cases of definitive prosthetic valve endocarditis (PVE). Patients presented advanced age and marked comorbidity. There was a higher incidence of persistent bacteremia, septic shock, stroke, and acute kidney injury than in cases of PVE caused by other microorganisms. Methicillin resistance was not associated with differences in clinical presentation, echocardiographic findings, or mortality. Only 50.6% of the patients with surgical indications (88 patients) underwent surgery. Overall, in-hospital mortality was 47.9%. The variables associated with in-hospital mortality were age (OR:1.03, 95% CI: 1.00-1.05; p = 0.016), heart failure (OR:2.86, 95% CI: 1.53-5.32; p = 0.001), acute kidney injury (OR:2.42, 95%CI:1.28-4.58; p = 0.006), stroke (OR:3.53, 95%CI:1.79-6.96; p < 0.001) and surgery indicated but not performed (OR:2.01, 95%CI:1.06-3.8; p = 0.030). On the other hand, the performance of surgery per se in patients with SAPVE, regardless of whether there was a surgical indication according to the guidelines, was not associated with a reduction in in-hospital mortality. CONCLUSIONS: SAPVE is characterized by high mortality, which is more marked in patients who present a surgical indication but do not undergo surgery.
Asunto(s)
Endocarditis Bacteriana , Prótesis Valvulares Cardíacas , Mortalidad Hospitalaria , Infecciones Relacionadas con Prótesis , Infecciones Estafilocócicas , Staphylococcus aureus , Humanos , Masculino , Femenino , Anciano , Infecciones Estafilocócicas/mortalidad , Infecciones Estafilocócicas/microbiología , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Relacionadas con Prótesis/mortalidad , Staphylococcus aureus/aislamiento & purificación , Persona de Mediana Edad , Prótesis Valvulares Cardíacas/efectos adversos , Prótesis Valvulares Cardíacas/microbiología , Pronóstico , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/mortalidad , Endocarditis Bacteriana/cirugía , Endocarditis Bacteriana/diagnóstico , España/epidemiología , Anciano de 80 o más Años , Estudios Retrospectivos , Factores de Riesgo , Bacteriemia/microbiología , Bacteriemia/mortalidadRESUMEN
BACKGROUND: Transcatheter aortic valve implantation (TAVI) is indicated for elderly patients who often have severe comorbidities and high operative risk. Despite many advantages, it carries the potential for both early and late complications. The literature reports mainly periprocedural problems. This case report describes a rare instance of ascending aortic rupture as a late complication following TAVI. CASE PRESENTATION: An 81-year-old male with severe aortic stenosis (AS) was a non-surgical patient due to a high operative risk (EuroSCORE II 14.08%) and comorbidities, including cardiovascular problems, chronic obstructive pulmonary disease, myelodysplastic syndrome. During the TAVI procedure Medtronic CoreValve™ Evolut™ R-26 was implanted via the right femoral artery. Postoperative period elapsed without complications and the patient was discharged home. Six months later, the patient was re-admitted to the hospital on an emergency basis and transferred directly to the operating room due to ascending aortic rupture (EuroSCORE II 53.20%, GERAADA score 64.9%). Computed tomography angiography (CTA) showed aortic rupture with a multiple fresh blood reservoirs and thrombus around the ascending aorta originating from the spot where the nitinol frame of the TAVI valve was attached to the native aorta. Supracoronary excision of the ascending aorta with implantation of a vascular graft (Intergard Woven Graft 34 mm) was performed, preserving the earlier implanted TAVI valve. On the 9th day after surgery the patient's general condition deteriorated, he suffered from circulatory and respiratory insufficiency. Furthermore, a gastrointestinal bleeding with the need for gastro-, and colonoscopy and multiple blood transfusions occurred. Patient developed urosepsis and acute renal failure with the need for hemodiafiltration. Despite intensive treatment, further deterioration of the medical condition of the patient. and finally the multiple organ failure was observed. Patient died on the 50th postoperative day. CONCLUSIONS: TAVI is a safe method of treating severe AS, especially recommended for non-surgical candidates. Rupture of the ascending aorta is a rare but serious complication of TAVI that usually occur during or shortly after the procedure. This case report highlights the importance of post-procedural monitoring for such TAVI complications, even in the late period following TAVI, and if such complications occur, taking the risk to perform a life-saving operation.
Asunto(s)
Rotura de la Aorta , Estenosis de la Válvula Aórtica , Reemplazo de la Válvula Aórtica Transcatéter , Anciano de 80 o más Años , Humanos , Masculino , Aorta/diagnóstico por imagen , Aorta/cirugía , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/etiología , Rotura de la Aorta/cirugía , Estenosis de la Válvula Aórtica/cirugía , Angiografía por Tomografía Computarizada , Prótesis Valvulares Cardíacas/efectos adversos , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentaciónAsunto(s)
Fibrilación Atrial , Bioprótesis , Fibrinolíticos , Prótesis Valvulares Cardíacas , Sistema de Registros , Humanos , Fibrilación Atrial/tratamiento farmacológico , Prótesis Valvulares Cardíacas/efectos adversos , Fibrinolíticos/uso terapéutico , Fibrinolíticos/administración & dosificación , Estudios Prospectivos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/efectos adversosRESUMEN
A 48-year-old man with a history of mitral valve replacement (MVR) in March 2019 for rheumatic heart disease (RHD) and ischemic stroke in August 2019 presented with a history of sudden onset angina of 6 hours duration. He admits to defaulting oral anticoagulant (OAC) intake for the last 50 days. On arrival, he had atrial fibrillation with hemodynamic instability [blood pressure (BP) 70/40 mm Hg, saturation of peripheral oxygen (SpO2) 80% at room air and heart rate approx 140/minute], which was managed with intravenous diltiazem and hemodynamic stability achieved (BP 116/72 mm Hg, heart rate 86/minute). Urgent transthoracic echocardiogram (TTE) and fluoroscopy confirmed obstructive prosthetic mitral valve thrombosis. Though available recommendations suggest surgical intervention for the left-sided valve involvement in a stable patient, in view of the nonavailability of a surgical facility, the patient was thrombolyzed with Alteplase, a recombinant tissue plasminogen activator (rtPA). Since the patient was stable, a "long fibrinolytic protocol" of Alteplase 10 mg bolus, 50 mg during the 1st hour, and 20 mg each during the 2nd and 3rd hour (total of 100 mg) was given. Subsequent TTE revealed a mean gradient of 5 mm Hg, and cine fluoroscopy showed improved mitral valve motion, thereby indicating successful thrombolysis. The patient felt symptomatically relieved within 6 hours and is presently on OAC therapy with strict drug compliance.
Asunto(s)
Fibrinolíticos , Prótesis Valvulares Cardíacas , Válvula Mitral , Trombosis , Activador de Tejido Plasminógeno , Humanos , Masculino , Persona de Mediana Edad , Activador de Tejido Plasminógeno/uso terapéutico , Fibrinolíticos/uso terapéutico , Fibrinolíticos/administración & dosificación , Trombosis/tratamiento farmacológico , Trombosis/etiología , Prótesis Valvulares Cardíacas/efectos adversos , Válvula Mitral/cirugía , Terapia Trombolítica/métodos , Cardiopatía Reumática/complicaciones , Cardiopatía Reumática/tratamiento farmacológico , EcocardiografíaRESUMEN
Transcatheter aortic valve (TAV) thrombosis may manifest as subclinical leaflet thrombosis (SLT) and clinical valve thrombosis. SLT is relatively common (10%-20%) after transcatheter aortic valve replacement, but clinical implications are uncertain. Clinical valve thrombosis is rare (1.2%) and associated with bioprosthetic valve failure, neurologic or thromboembolic events, heart failure, and death. Treatment for TAV thrombosis has been understudied. In principle, anticoagulation may prevent TAV thrombosis. Non-vitamin K oral anticoagulants, as compared to antiplatelet therapy, are associated with reduced incidence of SLT, although at the cost of higher bleeding and all-cause mortality risk. We present an overview of existing literature for management of TAV thrombosis and propose a rational treatment algorithm. Vitamin K antagonists or non-vitamin K oral anticoagulants are the cornerstone of antithrombotic treatment. In therapy-resistant or clinically unstable patients, ultraslow, low-dose infusion of thrombolytics seems effective and safe and may be preferred over redo-transcatheter aortic valve replacement or explant surgery.
Asunto(s)
Trombosis , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Trombosis/prevención & control , Trombosis/etiología , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Fibrinolíticos/uso terapéutico , Válvula Aórtica/cirugía , Prótesis Valvulares Cardíacas/efectos adversosAsunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Humanos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Prótesis Valvulares Cardíacas/efectos adversos , Válvula Mitral/cirugía , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Resultado del Tratamiento , Falla de Prótesis , Femenino , Masculino , Cateterismo Cardíaco/instrumentación , Cateterismo Cardíaco/métodos , Cateterismo Cardíaco/efectos adversos , Anciano , Ecocardiografía TransesofágicaRESUMEN
As a consequence of the growing number of implanted transcatheter aortic valve prostheses, the increasing incidence of early and late complications of biological valves requires in several cases surgical explantation of the transcatheter valve and subsequent aortic root or surgical aortic valve replacement. In this video tutorial, we show how to avoid aortic root damage in the surgical explantation of a transcatheter aortic valve bioprosthesis in a patient with a dysfunctional transcatheter aortic valve prosthesis affected by endocarditis 15 months after implantation. The infected prosthesis and all foreign materials, concomitant to the calcified native valve, were excised en bloc in preparation for the extensive debridement of infected tissue in the abscess cavity. The defect on the aortic annulus was reconstructed using a pericardial patch, followed by a surgical valve implant.
Asunto(s)
Válvula Aórtica , Bioprótesis , Prótesis Valvulares Cardíacas , Infecciones Relacionadas con Prótesis , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Válvula Aórtica/cirugía , Prótesis Valvulares Cardíacas/efectos adversos , Bioprótesis/efectos adversos , Infecciones Relacionadas con Prótesis/cirugía , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/diagnóstico , Endocarditis/cirugía , Endocarditis/etiología , Remoción de Dispositivos/métodos , Masculino , Estenosis de la Válvula Aórtica/cirugía , Reoperación , Anciano de 80 o más Años , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Endocarditis Bacteriana/cirugía , Endocarditis Bacteriana/etiología , Endocarditis Bacteriana/diagnóstico , AncianoAsunto(s)
Anticoagulantes , Prótesis Valvulares Cardíacas , Humanos , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Prótesis Valvulares Cardíacas/efectos adversos , Estudios Prospectivos , Factores de Tiempo , Hemorragias Intracraneales/inducido químicamenteRESUMEN
BACKGROUND AND OBJECTIVES: In patients with mechanical heart valves and recent intracranial hemorrhage (ICH), clinicians need to balance the risk of thromboembolism during the period off anticoagulation and the risk of hematoma expansion on anticoagulation. The optimal timing of anticoagulation resumption is unknown. We aimed to investigate the relationship between reversal therapy and ischemic stroke, between duration off anticoagulation and risk of ischemic strokes or systemic embolism and between timing of anticoagulation resumption and risk of rebleeding and ICH expansion. METHODS: We conducted a retrospective cohort observational study in 3 tertiary hospitals. Consecutive adult patients with mechanical heart valves admitted for ICH between January 1, 2000, and July 13, 2022, were included. The primary end points of our study were thromboembolic events (cerebral, retinal, or systemic) while off anticoagulation and ICH expansion after anticoagulation resumption (defined by the following criteria: increase by one-third in intracerebral hematoma volume, increase by one-third in convexity subdural hemorrhage diameter, or visually unequivocal expansion of other ICH locations to the naked eye). RESULTS: A total of 171 patients with mechanical heart valves who experienced ICH were included in the final analysis. Most of the patients (79.5%) received reversal therapy for anticoagulation. Patients who received anticoagulation reversal therapy did not have increased risk of thromboembolic complications. Time off anticoagulation was not associated with risk of ischemic stroke; only 2 patients had a stroke within 7 days of the ICH, and both had additional major risk factors of thromboembolism. The rate of ischemic stroke/transient ischemic attack while off anticoagulation was lower than the rate of ICH expansion once anticoagulation was resumed (6.4% vs 9.9%). Furthermore, patients who developed ICH expansion had higher mortality compared with patients who had ischemic stroke while being off anticoagulation (41% vs 9%). Use of intravenous heparin bridging upon resumption of warfarin was strongly associated with increased risk of ICH expansion as compared with restarting warfarin without a heparin bridge. DISCUSSION: Withholding anticoagulation for at least 7 days after ICH may be safe in patients with mechanical heart valves. Heparin bridging during anticoagulation resumption may be associated with increased risk of bleeding.
Asunto(s)
Anticoagulantes , Hemorragias Intracraneales , Tromboembolia , Humanos , Masculino , Femenino , Anticoagulantes/efectos adversos , Anticoagulantes/administración & dosificación , Anciano , Estudios Retrospectivos , Persona de Mediana Edad , Hemorragias Intracraneales/inducido químicamente , Hemorragias Intracraneales/epidemiología , Tromboembolia/prevención & control , Tromboembolia/etiología , Prótesis Valvulares Cardíacas/efectos adversos , Accidente Cerebrovascular Isquémico , Factores de Tiempo , Factores de Riesgo , Anciano de 80 o más AñosRESUMEN
Infective endocarditis, particularly after implanting valve prostheses, poses significant surgical challenges, often requiring complex interventions. We describe a case of a 37-year-old male with Staphylococcus aureus endocarditis, unsuccessfully treated with mechanical valve prostheses. Continued infection led to the destruction of the intervalvular fibrous body, necessitating a Commando procedure involving radical debridement and replacement of both aortic and mitral valves with complex patch reconstruction. Prosthesis selection remains contentious, considering recurrence risk and long-term prognosis. Our case underscores timely intervention and meticulous technique in managing such complex situations. It highlights successful strategies for treating infective endocarditis with destruction of aortomitral continuity, emphasizing the pivotal role of the Commando procedure.
Asunto(s)
Válvula Aórtica , Endocarditis Bacteriana , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Infecciones Relacionadas con Prótesis , Infecciones Estafilocócicas , Humanos , Masculino , Adulto , Endocarditis Bacteriana/cirugía , Endocarditis Bacteriana/diagnóstico , Endocarditis Bacteriana/etiología , Prótesis Valvulares Cardíacas/efectos adversos , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/cirugía , Infecciones Estafilocócicas/etiología , Infecciones Relacionadas con Prótesis/cirugía , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/etiología , Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Válvula Mitral/cirugía , Staphylococcus aureus/aislamiento & purificación , Reoperación , Desbridamiento/métodosAsunto(s)
Válvula Aórtica , Bioprótesis , Prótesis Valvulares Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Válvula Aórtica/cirugía , Prótesis Valvulares Cardíacas/efectos adversos , Masculino , Anciano , Falla de Prótesis , Femenino , Estenosis de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Complicaciones Posoperatorias/etiologíaRESUMEN
BACKGROUND: Prevalence of bioprosthetic valve degeneration (BVD) is rising as the use of bioprosthetic aortic valves increases. Detecting early signs of BVD remains a challenge, with conventional imaging methods often failing to identify early deterioration stages. 18F-fuoride positron emission tomography (PET-CT) is an emerging technique that offers promising prospects to detect subclinical BVD. This study aimed to compare early PET parameters of fluoride uptake with echocardiographic hemodynamic parameters and compare outcomes according to anticoagulation in patients who received bioprosthetic valves. METHODS: This is a sub-study of the ANTIPRO clinical trial, which involved patients undergoing surgical aortic valve replacement (SAVR) with a porcine bioprosthesis and randomized them into anticoagulated and non-anticoagulated groups. Hemodynamic changes were assessed by transthoracic echocardiography (TTE), while 18F-fluoride PET-CT quantified fluoride uptake and divided the patients in two groups: high-uptake and low-uptake. Mean and maximum gradients by TTE at three years were compared between the two uptake groups. Fluoride uptake was also compared between the anticoagulated and control groups. RESULTS: We found no significant differences in transprosthetic gradients between high-uptake(21.4 ± 8.6 mmHg) and low-uptake(17.3 ± 11.2 mmHg.p = 0.244) PET-defined groups in this specific timeframe. Notably, anticoagulated patients exhibited significantly risk of higher fluoride uptake(OR = 4.34;95%CI:1.04-18.21.p = 0.045). CONCLUSIONS: No association was found between fluoride uptake and hemodynamic evaluation. Anticoagulation was associated with higher fluoride uptake. These findings highlight the emerging role of PET-CT in studying bioprosthetic aortic valves and emphasize the need for extended follow-up to evaluate the impact of anticoagulation on valve degeneration.
Asunto(s)
Anticoagulantes , Válvula Aórtica , Bioprótesis , Prótesis Valvulares Cardíacas , Warfarina , Bioprótesis/efectos adversos , Humanos , Femenino , Masculino , Prótesis Valvulares Cardíacas/efectos adversos , Anticoagulantes/administración & dosificación , Anciano , Warfarina/administración & dosificación , Warfarina/farmacocinética , Warfarina/uso terapéutico , Válvula Aórtica/cirugía , Válvula Aórtica/diagnóstico por imagen , Radioisótopos de Flúor , Tomografía Computarizada por Tomografía de Emisión de Positrones/métodos , Persona de Mediana Edad , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estudios de Seguimiento , Falla de Prótesis , Tomografía de Emisión de Positrones/métodosRESUMEN
BACKGROUND: Most evidence for anticoagulation in aortic bioprosthesis is centered on embolic events, bleeding and re-intervention risk. The effect of anticoagulation on hemodynamics has not been previously assessed. Our hypothesis was that patients with anticoagulation (AC) early after aortic valve replacement (AVR) with porcine bioprosthesis have better hemodynamics at 3 years of follow-up. METHODS: This is a follow-up evaluation of the ANTIPRO trial. All patients undergoing AVR with porcine bioprosthesis were consecutively recruited. The AC group received warfarin+aspirin and the non-AC(control) only aspirin. The primary outcome was mean gradient after 3 years of AVR and change in New York Heart Association (NYHA) class. Secondary outcomes were major and minor bleeding and embolic events. RESULTS: Of 140 participants in the study, 71 were assigned to the AC group and 69 to the control group. Mean age of the overall population was 72.4(SD: 7.1) years. Global euroSCORE was 7.65(SD: 5.73). At 3 years the mean gradient was similar between both groups (19.4(SD: 9.6 mmHg) and 18.6(SD: 8.2 mmHg) in the control and AC group respectively, p = 0.7). No differences in functional class at 3 years were found among groups. No differences were found among groups in the secondary outcomes. CONCLUSIONS: The addition of 3 months of oral anticoagulation to anti-aggregation treatment did not affect bioprosthetic hemodynamics nor functional class at years after AVR.
Asunto(s)
Anticoagulantes , Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Humanos , Bioprótesis/efectos adversos , Femenino , Anticoagulantes/administración & dosificación , Anticoagulantes/uso terapéutico , Masculino , Anciano , Estudios de Seguimiento , Prótesis Valvulares Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Animales , Porcinos , Válvula Aórtica/cirugía , Factores de Tiempo , Aspirina/uso terapéutico , Aspirina/administración & dosificación , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/cirugía , Warfarina/uso terapéutico , Warfarina/administración & dosificación , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND: Current guidelines recommend direct oral anticoagulants (DOACs) and warfarin for patients with atrial fibrillation (AF) who have a bioprosthetic valve (BPV). However, the data related to elderly patients (aged ≥80 years) with BPV replacement and AF are limited. METHODS: This post-hoc subgroup analysis of a BPV-AF Registry enrolled 752 patients with BPV replacement and AF. The primary net outcome was a composite of cardiac death, stroke, systemic embolism, major bleeding, and cardiovascular events. RESULTS: Among 752 patients, 429 (57%) patients were ≥ 80 and 323 (43%) were < 80 years old. The higher risk in patients aged ≥80 than <80 years was significant for the net outcome (hazard ratio [HR], 2.04; 95% confidence interval [CI], 1.31-3.17; P = 0.001). After adjustment for confounders, there was no statistically significant difference between warfarin (reference) and DOAC users in the risk of net outcomes (adjusted HR, 1.26; 95% CI, 0.71-2.24; P = 0.44), stroke and systemic embolism (adjusted HR, 2.01; 95% CI, 0.48-8.38; P = 0.34), and major bleeding (adjusted HR, 0.73; 95% CI, 0.11-4.98; P = 0.75) in patients aged ≥80 years old as well as those aged <80 years. Among 489 warfarin users, the cumulative incidence of net outcomes tended to be higher in patients aged ≥80 than <80 years (12.2% vs. 5.7% at 1 year, log-rank P = 0.002). Among 263 DOAC users, however, it was similar between patients aged ≥80 and < 80 years. CONCLUSIONS: The present study demonstrated that DOAC showed similar efficacy and safety compared with warfarin even in elderly patients aged ≥80 years with BPV replacement and AF.
Asunto(s)
Anticoagulantes , Fibrilación Atrial , Bioprótesis , Prótesis Valvulares Cardíacas , Sistema de Registros , Humanos , Fibrilación Atrial/tratamiento farmacológico , Masculino , Femenino , Anciano de 80 o más Años , Anciano , Bioprótesis/efectos adversos , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Administración Oral , Prótesis Valvulares Cardíacas/efectos adversos , Resultado del Tratamiento , Warfarina/administración & dosificación , Warfarina/uso terapéutico , Warfarina/efectos adversos , Estudios de SeguimientoRESUMEN
To compare the long-term outcomes of mechanical versus bioprosthetic aortic valve replacement (AVR) in patients aged <50 years, we performed a study-level meta-analysis with reconstructed time-to-event data including studies published by December of 2023. The primary outcome was overall survival. Secondary outcomes included reoperation, major bleeding, and stroke. A total of 5 studies met our inclusion criteria, with a total of 4,245 patients (2,311 mechanical and 1,934 bioprosthetic). All studies were observational and the mean age of groups across the studies ranged from 38.2 to 43.0 years. The median follow-up time was 11.4 years (interquartile range 6.9 to 15.0). Bioprosthetic AVR was associated with reduced overall survival and higher risk of all-cause death (hazard ratio [HR] 1.170 95% confidence interval [CI] 1.002 to 1.364, p = 0.046), increased risk of reoperation over time (HR 2.581, 95% CI 2.102 to 3.168, p <0.001), decreased risk of major bleeding (HR 0.500, 95% CI 0.367 to 0.682, p <0.001), and decreased risk of stroke (HR 0.751, 95% C, 0.565 to 0.998, p = 0.049) compared with mechanical AVR in patients aged <50 years. In conclusion, for patients aged <50 years, bioprosthetic AVR is associated with increased mortality and risk of reoperation compared with mechanical valves. In contrast, mechanical AVR is associated with an increased risk of major bleeding events and stroke. These aspects should be carefully considered during the selection of valve type in this age group; however, we should keep in mind that the statistically significant differences in the risk of all-cause death and stroke might not be clinically relevant (because of marginal statistical significance).