[Prevention of thromboembolic complications in adult congenital heart disease]. / Prévention des complications thromboemboliques des patients adultes porteurs de cardiopathie congénitale.

Thromboembolic complications in adults with congenital heart disease are frequent and responsible for significant morbidity and mortality. Their prevention frequently requires long-term thromboprophylaxis. In this article, we discuss the specificities that must be considered when stratifying the thromboembolic risk in these patients, the different therapeutic strategies, particularly the place of direct oral anticoagulants.

Les complications thromboemboliques des adultes porteurs d'une cardiopathie congénitale sont fréquentes et responsables d'une importante morbi-mortalité. Leur prévention passe fréquemment par la mise en place d'une thromboprophylaxie au long cours. Dans cet article, nous discutons des spécificités qui doivent être prises en compte lors de la stratification du risque thromboembolique de ces patients, des différentes stratégies thérapeutiques et notamment de la place des anticoagulants oraux directs.

Neurovascular Outcomes in Relation With Carotid Artery Stenosis in Patients Undergoing Transcatheter Aortic Valve Implantation.

INTRODUCTION: Data regarding the prevalence of carotid artery stenosis (CAS) in patients undergoing transcatheter aortic valve implantation (TAVI) are scarce. Whether CAS, especially severe or bilateral, is a predictor of worse prognosis after TAVI is unknown. We aimed to address these questions. METHODS: We included all patients who underwent TAVI between 2018 and 2021. Using pre-TAVI carotid Doppler ultrasound, atherosclerosis of the right and left carotid internal arteries was assessed. CAS was defined as moderate (50%-69% stenosis, peak systolic velocity of 125-230 cm/sec) or severe (≥70% stenosis, peak systolic velocity of >230 cm/sec). When both carotid arteries presented with ≥50% stenosis, CAS was defined as bilateral. Endpoints included the 30-day incidence of stroke or transient ischemic attack (TIA), 30-day all-cause mortality, and periprocedural complications. RESULTS: Among 448 patients, 56 (12.5%) had CAS, of which 15 had bilateral and 15 had severe CAS. Patients with CAS were more often men and had higher rates of peripheral artery disease, coronary artery disease, and previous percutaneous coronary intervention. There was no association between CAS and 30-day stroke or TIA (adjusted hazard ratio [aHR], 2.55; 95% confidence interval [CI], 0.73-8.91; P=.14), even when considering severe CAS only. However, a significant association was found between bilateral CAS and 30-day stroke or TIA (aHR, 8.399; 95% CI, 1.603-44.000; P=.01). No association between CAS and 30-day mortality or periprocedural complications was found. CONCLUSIONS: CAS is common among TAVI patients. While CAS as a whole was not a predictor of neurovascular complications, the subgroup of bilateral CAS was associated with an increased risk of stroke.

Meta-Analysis of the Prognostic Significance of Carotid Artery Stenosis in Patients Who Underwent Transcatheter Aortic Valve Implantation.

Stroke is a known complication of both transcatheter aortic valve implantation (TAVI) and carotid artery stenosis (CAS). Whether CAS is a predictor of worse prognosis after TAVI is unclear. We performed a meta-analysis to assess the impact of CAS on the incidence of neurovascular complications and mortality after TAVI. We searched PubMed/MEDLINE and EMBASE databases from inception to January 2023. CAS was defined by ≥50% stenosis of at least 1 carotid artery. Studies comparing CAS versus non-CAS TAVI populations were included. Patients' baseline characteristics and 30-day clinical outcomes were extracted. End points included the 30-day incidence of neurovascular complications (stroke or transient ischemic attack) and 30-day all-cause mortality. We identified six studies, totaling 6,763 patients in the CAS group and 23,861 patients in the non-CAS group. Patients with CAS had a higher prevalence of hypertension, diabetes mellitus, dyslipidemia, previous myocardial infarction, coronary artery bypass graft, peripheral artery disease, previous neurovascular disease, and chronic kidney disease. There was no significant difference in the rates of 30-day neurovascular complications between CAS and non-CAS groups (relative risk 1.23, 95% confidence interval 0.63 to 2.40, p = 0.54). CAS was associated with a higher risk of 30-day all-cause mortality (relative risk 1.28, 95% confidence interval 1.12 to 1.47, p <0.001), not found in a sensitivity analysis. In conclusion, patients with CAS presented with a significantly higher co-morbidity burden. CAS was not associated with an increased risk of 30-day neurovascular complications. 30-day mortality was higher in the CAS group but that may be a surrogate of the heavy co-morbidity burden of patients with CAS.