RESUMO
Frailty is a common clinical syndrome that portends poor peri-procedural outcomes and increased mortality following transcatheter valve interventions. We reviewed frailty assessment tools in transcatheter intervention cohorts to recommend a pathway for preprocedural frailty assessment in patients referred for transcatheter valve procedures, and evaluated current evidence for frailty interventions and their efficacy in transcatheter intervention. We recommend the use of a frailty screening instrument to identify patients as frail, with subsequent referral for comprehensive geriatric assessment in these patients, to assist in selecting appropriate patients and then optimizing them for transcatheter valve interventions. Interventions to reduce preprocedural frailty are not well defined, however, data from limited cohort studies support exercise-based interventions to increase functional capacity and reduce frailty in parallel with preprocedural medical optimization.
Assuntos
Idoso Fragilizado , Fragilidade , Avaliação Geriátrica , Humanos , Fragilidade/diagnóstico , Fragilidade/fisiopatologia , Resultado do Tratamento , Fatores de Risco , Idoso , Medição de Risco , Idoso de 80 Anos ou mais , Fatores Etários , Cateterismo Cardíaco/efeitos adversos , Estado Funcional , Feminino , Masculino , Seleção de Pacientes , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Valor Preditivo dos Testes , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Tomada de Decisão Clínica , Doenças das Valvas Cardíacas/fisiopatologia , Doenças das Valvas Cardíacas/cirurgia , Doenças das Valvas Cardíacas/mortalidade , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/terapia , Nível de SaúdeRESUMO
Transcatheter aortic valve replacement (TAVR) has emerged as a preferred treatment modality for aortic stenosis, marking a significant advancement in cardiac interventions. Transcatheter heart valves (THVs) have also received approval for treating failed bioprosthetic valves and rings across aortic, mitral, tricuspid, and pulmonic positions. Unlike surgically implanted valves, which are sewn into the annulus, THVs are anchored through relative oversizing. Although THVs are designed to function optimally in a fully expanded state, they exhibit a certain degree of tolerance to underexpansion. However, significant deformation beyond this tolerance can adversely affect the valve's hemodynamics and durability, ultimately impacting patient outcomes. Such post-implantation deviations from the valve's intended three-dimensional design are influenced by a variety of physiological and anatomical factors unique to each patient and procedure, leading to underexpansion, eccentric expansion, and vertical deformation. These deformation patterns increase leaflet stress and strain, potentially causing fatigue and damage. This review article delves into the extent of THV deformation, its impact on leaflet function, hypoattenuating leaflet thickening, and structural valve degeneration. It provides an in-depth analysis of deformation specifics in different procedural contexts, including TAVR in native aortic stenosis, aortic and mitral valve-in-valve procedures, and redo-TAVR. Additionally, the review discusses strategies to mitigate THV deformation during the procedure, offering insights into potential solutions to these challenges.
Assuntos
Estenose da Valva Aórtica , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Humanos , Valva Aórtica/cirurgia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Estenose da Valva Aórtica/cirurgia , Resultado do Tratamento , Desenho de PróteseRESUMO
BACKGROUND: The role of percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD) who subsequently undergo transcatheter aortic valve replacement (TAVR) remains uncertain. Therefore, we conducted this study to assess the association of PCI before TAVR with mortality and cardiovascular outcomes. METHODS: We used the TriNetX database (Jan 2012 - Aug 2022) and grouped patients into PCI (3 months or less) before TAVR and no PCI. We performed propensity score matched (PSM) analyses for outcomes at 30 days and 1 year. RESULTS: Of 17,120 patients undergoing TAVR, 2322 (14 %) had PCI, and 14,798 (86 %) did not have PCI before TAVR. In the PSM cohort (2026 patients in each group), PCI was not associated with lower all-cause mortality at 30 days (HR: 1.25, 95 % CI: 0.82-1.90) or 1 year (HR: 1.02, 95 % CI: 0.83-1.24). Frequency of repeat PCI after TAVR was low in both no PCI vs. PCI (2.4 % vs. 1.2 %) at 1 year; PCI was associated with a lower rate of repeat PCI (HR: 0.49, 95 % CI: 0.30-0.80). Sensitivity analysis revealed an E-value of 3.5 for repeat PCI (E-value for lower CI for HR: 1.81). PCI was not linked to reductions in MI, heart failure exacerbation, all-cause hospitalization, major bleeding, or permanent pacemaker/implantable cardioverter defibrillator. CONCLUSION: This analysis showed that PCI prior to TAVR was not associated with improvement in all-cause mortality. However, PCI was associated with a reduced rate of repeat PCI at 1 year.
Assuntos
Estenose da Valva Aórtica , Doença da Artéria Coronariana , Bases de Dados Factuais , Intervenção Coronária Percutânea , Pontuação de Propensão , Substituição da Valva Aórtica Transcateter , Humanos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Masculino , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Feminino , Resultado do Tratamento , Idoso de 80 Anos ou mais , Idoso , Fatores de Tempo , Fatores de Risco , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/terapia , Doença da Artéria Coronariana/diagnóstico por imagem , Medição de Risco , Estenose da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Estudos Retrospectivos , Valva Aórtica/cirurgia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologiaRESUMO
Patients with severe aortic stenosis (AS) may develop heart failure (HF), the presence of which has traditionally been deemed as a final stage in AS progression with poor outcomes. The use of transcatheter aortic valve replacement (TAVR) has become the preferred therapy for most patients with AS and concomitant HF. With its instant afterload reduction, TAVR offers patients with HF significant haemodynamic benefits, with corresponding changes in left ventricular structure and improved mortality and quality of life. The prognostic covariates and optimal timing of TAVR in patients with less than severe AS remain unclear. The purpose of this review is to describe the association between TAVR and outcomes in patients with HF, particularly in the setting of left ventricular systolic dysfunction, acute HF, and right ventricular systolic dysfunction, and to highlight areas for future research.