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Transcatheter aortic valve implantation
Published in John Edward Boland, David W. M. Muller, Interventional Cardiology and Cardiac Catheterisation, 2019
In the early years of TAVI, predilatation using balloon aortic valvuloplasty was considered a mandatory step before TAVI, since it facilitates valve crossing and prosthesis delivery, ensures optimal valve expansion and improves haemodynamic stability during valve deployment. However, as a result of procedural evolution over time, direct TAVI (without pre-implantation balloon aortic valvuloplasty) has emerged as an option to simplify the procedure and to avoid potential valvuloplasty-related complications. Several real-world retrospective studies have shown that direct TAVI (with both self-expanding and balloon-expandable prostheses) is feasible, safe and associated with outcomes similar to standard TAVI with pre-implantation balloon aortic valvuloplasty.45,46 The DIRECTTAVI randomised study is enrolling patients to explore this concept, but many operators have already switched to performing predilatation-only on selected patients.
Perioperative cardiovascular evaluation and treatment of elderly patients undergoing noncardiac surgery
Published in Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich, Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
Dipika Gopal, Monika Sanghavi, Lee A. Fleisher
Aortic stenosis is more common in men, is particularly a condition of the elderly, and usually results from degenerative calcific aortic valve disease in this population. Kertai has reported a substantially higher rate of perioperative complications in patients with severe aortic stenosis, compared with patients with moderate aortic stenosis—31% (5/16) versus 11% (10/92) (16). If the aortic stenosis is symptomatic, elective noncardiac surgery should generally be postponed or canceled. Such patients require aortic valve replacement (AVR) before elective but necessary noncardiac surgery. A transcatheter AVR might be an option for patients who are at high risk or prohibitive risk for open aortic valve surgery. If a patient is not a candidate for AVR, percutaneous balloon aortic valvuloplasty may be reasonable as a bridge to surgery in hemodynamically unstable adult patients with aortic stenosis who require urgent noncardiac surgery (1).
Valve disease
Published in Clive Handler, Gerry Coghlan, Nick Brown, Management of Cardiac Problems in Primary Care, 2018
Clive Handler, Gerry Coghlan, Nick Brown
Aortic valvuloplasty for aortic stenosis is a percutaneous procedure that is used only occasionally to widen (or crack open) a calcified and severely narrowed aortic valve. It is only occasionally used for elderly patients with severe aortic stenosis who, because of coexisting conditions, are considered too high risk for aortic valve replacement. The procedure has a high mortality rate and a high risk of cerebral emboli, and restenosis within one year. Complications occur in at least 10% of patients.
Long-term patency of rescue stenting of an anomalous left circumflex coronary artery after transcatheter aortic valve replacement
Published in Baylor University Medical Center Proceedings, 2023
Corry B. Sanford, Jonathan P. Urbanczyk, Timothy A. Mixon
Various outcomes have occurred during TAVR with an anomalous LCX, ranging from nonocclusion to acute occlusion requiring bailout stenting.2,3 In one case report, pre-TAVR balloon aortic valvuloplasty was performed to assess for potential occlusion. Compromise was noted and the patient’s management was altered to a surgical approach.4 Although rare, acute coronary obstruction after TAVR (0.7% of all cases) can be fatal.5 A systematic review described 24 patients with acute coronary artery obstruction after TAVR. Intervention was performed in all but one and was successful in all but two, leading to a mortality rate of 8.3%.6 Acute obstruction typically occurs in the procedure lab but may rarely occur hours or days later. Delayed coronary artery obstruction after TAVR has been described in 0.224% of patients and leads to an in-hospital death rate of 50%.7 The incidence of coronary artery occlusion during TAVR may be decreased with careful preprocedural anatomic evaluation. In a patient like ours with an 80% proximal anomalous LCX lesion, it is imperative to prepare for complications; in this case, such preparation led to a successful procedure. It is unknown whether pre-TAVR stenting would be sufficiently safe and effective, or if the type of valvular prosthesis chosen might mitigate the risk.
Sex differences in aortic stenosis: from pathophysiology to treatment
Published in Expert Review of Cardiovascular Therapy, 2020
Sahrai Saeed, Marc R Dweck, John Chambers
The prognosis is good when the patient is asymptomatic. However, as soon as symptoms develop, there is a sharp increase in the risk of sudden death both in men and women if left untreated [80–83]. No medical treatment has so far been shown to reduce the rate of progression of aortic valve calcification or the risk of clinical events. Specifically, three major randomized clinical trials (the Scottish Aortic Stenosis and Lipid-Lowering Trial [SALTIRE], the Simvastatin and Ezetimibe in Aortic Stenosis [SEAS], and the AS Progression Observation: Measuring Effects of Rosuvastatin [ASTRONOMER]) studies have failed to show any benefit from lipid-lowering therapy on AS progression rate or outcome [84–86]. Hence, surgical AVR or TAVI are the only treatment options. Balloon aortic valvuloplasty may be considered as a palliative treatment option or bridge to AVR or TAVI in patients with severe AS. In a study by Daniec et al. no differences was found in the indications or long-term outcome after balloon aortic valvuloplasty in men and women with AS, although there were some sex differences in baseline characteristics and vascular complications [87].
Beyond the Valve and into the Muscle: A Review of Coexisting Aortic Stenosis and Transthyretin Cardiac Amyloidosis
Published in Structural Heart, 2019
Hannah Rosenblum, David L. Narotsky, Nadira Hamid, Rebecca T. Hahn, Susheel Kodali, Tamim Nazif, Omar K. Khalique, Sabahat Bokhari, Mathew S. Maurer, Adam Castaño
Long-term mortality data for patients with ATTR-CA and severe AS undergoing aortic valve replacement are lacking, but these data would have an important clinical impact. There remains equipoise even with the few available studies on the impact of concurrent ATTR-CA among patients with severe AS undergoing aortic valve replacement. Short-term follow-up from two of the aforementioned studies suggests decreased survival in severe AS patients with ATTR-CA undergoing aortic valve replacement compared with patients without ATTR-CA (Table 1).12,21 Additionally, a study of 171 consecutive patients with ATTR-CA, both with (N = 27) and without AS (N = 144), found a similar mortality at 2 years, even in 11 of the 27 patients with ATTR-CA who underwent surgical AVR.23 The authors proposed that the mortality in patients with both diseases may be driven by ATTR-CA, as opposed to the severe AS, and therefore mortality was not mitigated by aortic valve replacement. A single center experience of five patients, who were referred for aortic valve surgery and found to have ATTR-CA, ultimately underwent balloon aortic valvuloplasty as a bridge to further evaluation before pursuing more invasive procedures.24 These patient outcomes have not been reported, but emphasize the need for future studies to understand the trajectory of patients with concurrent disease states and to determine appropriate management strategies.