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Swiss Medical Weekly Nov 2018BACKGROUND The term “predisposition” is used as an indication of antimicrobial prophylaxis to prevent infective endocarditis and as a criterion for diagnosing... (Review)
Review
BACKGROUND The term “predisposition” is used as an indication of antimicrobial prophylaxis to prevent infective endocarditis and as a criterion for diagnosing infective endocarditis according to the modified Duke criteria. The criterion for diagnosing infective endocarditis in native valves is not well defined. OBJECTIVES To identify conditions that increase the risk for infective endocarditis in native valves, for the diagnosis of infective endocarditis according to the modified Duke criteria. In parallel, we compared the results with the year of patient inclusion for each study and echocardiographic techniques. RESULTS Our systematic review included 207 studies published from January 1970 to August 2015. Studies that focused on mitral valve prolapse (112 studies), prior infective endocarditis (96) and bicuspid aortic valve (78) provided the most data. However, only six (5.3%), three (3.1%) and one (1.3%) of these studies, respectively, used analytical statistical methods. Three (2.7%), two (2.1%) and one (1.3%), respectively, were graded as good quality studies. Odds ratios (ORs) for developing infective endocarditis were 3.5–8.2 for mitral valve prolapse, and 2.2 and 2.8 for prior infective endocarditis. The hazard ratio for developing infective endocarditis was 6.3 for bicuspid aortic valve. The mean prevalence proportion of infective endocarditis in patients with these three heart conditions were 8.5% (mitral valve prolapse), 8.3% (prior infective endocarditis) and 8.8% (bicuspid aortic valve). The proportions of publications prior to the publication of the modified Duke criteria were 81.8, 75.6 and 74%, respectively. Evolution of the imaging method and echocardiographic technique was estimated to be considerable for mitral valve prolapse. The literature review on aortic valve stenosis (46 studies), mitral valve insufficiency (41) and aortic valve insufficiency (39) provided two analytical studies for aortic stenosis. One study was graded as good quality and reported a hazard ratio 4.9. The mean prevalence of these heart conditions in patients with infective endocarditis were 7.3, 19.9 and 10.2%, respectively. The proportions of publications prior to the publication of the modified Duke criteria were 78, 75.6 and 79.5%, respectively. The evolution of both the echocardiographic technique and the categorisation of valve disease severity was considerable for all three entities. CONCLUSIONS The evidence for native valve heart conditions predisposing to infective endocarditis is mainly based on studies with only descriptive statistics published prior to the release of the modified Duke criteria. Mitral valve prolapse, prior infective endocarditis and bicuspid aortic valve are frequently cited as predisposing heart conditions for infective endocarditis. The evolution in echocardiographic techniques over the past decades and its influence on diagnosis was considerable for mitral valve prolapse, aortic stenosis, mitral insufficiency and aortic insufficiency.
Topics: Aortic Valve; Aortic Valve Insufficiency; Bicuspid Aortic Valve Disease; Echocardiography; Endocarditis; Guidelines as Topic; Heart Valve Diseases; Humans; Mitral Valve Prolapse; Risk Factors
PubMed: 30440064
DOI: 10.4414/smw.2018.14675 -
Clinical Cardiology Jun 2017Direct oral anticoagulants (DOACs) are indicated for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF), which, according to the American College... (Review)
Review
Direct oral anticoagulants (DOACs) are indicated for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF), which, according to the American College of Cardiology/American Heart Association/Heart Rhythm Society atrial fibrillation (AF) guidelines, excludes patients with rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair. However, the data regarding use of DOACs in AF patients with other types of valvular heart disease (VHD) are unclear. We aimed to summarize and evaluate the literature regarding the safety and efficacy of DOAC use in NVAF patients with other types of VHD. After an extensive literature search, a total of 1 prospective controlled trial, 4 subanalyses, and 1 abstract were identified. Efficacy of the DOAC agents in NVAF patients with VHD mirrored the overall trial results. Bleeding risk was significantly increased in VHD patients treated with rivaroxaban, but not for dabigatran or apixaban. Of the bioprosthetic valve patients enrolled in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial, no safety or efficacy concerns were identified. In conclusion, subanalyses of DOAC landmark AF trials revealed that dabigatran, rivaroxaban, and apixaban may be safely used in AF patients with certain types of VHD: aortic stenosis, aortic regurgitation, and mitral regurgitation. More evidence is needed before routinely recommending these agents for patients with bioprosthetic valves or mild mitral stenosis. Patients with moderate to severe mitral stenosis or mechanical valves should continue to receive warfarin, as these patients were excluded from all landmark AF trials.
Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Heart Valve Diseases; Humans; Risk Factors; Stroke
PubMed: 28004413
DOI: 10.1002/clc.22659 -
International Journal of Clinical... Feb 2019Background Patients with mitral valve stenosis have increased heart rate. HR reduction is known as an important treatment and therapy strategy for patients with mitral... (Comparative Study)
Comparative Study Meta-Analysis
Background Patients with mitral valve stenosis have increased heart rate. HR reduction is known as an important treatment and therapy strategy for patients with mitral valve stenosis. Aim of the review The aim of this systematic review and meta-analysis was to compare the efficacy of ivabradine versus beta-blockers in patients with mitral stenosis in sinus rhythm. Methods Randomized controlled trials were searched in Cochrane Library, PubMed, Web of Science, CRD, Scopus, and Google Scholar with no start time limitation and ending June 2018. Risk of bias across was assessed by the Cochrane Risk of Bias Assessment tool. Fixed effects models were used to combine the results and the mean difference with a 95% confidence interval. This meta-analysis was performed using Meta Package in R software. Results Five studies entered meta-analysis. The total number of patients treated with ivabradine and beta-blockers was 178 and 178 respectively. The results showed that the mean of maximum HR and HR at rest was lower at about 5.03 units and upper 4.32 units respectively with use of ivabradine compared with the use of beta-blockers. These values were statistically significant. Conclusion It seems that the efficacy of ivabradine is good in comparison with betablockers, but it still requires more clinical trials.
Topics: Adrenergic beta-Antagonists; Arrhythmias, Cardiac; Cardiovascular Agents; Heart Rate; Humans; Ivabradine; Mitral Valve Stenosis; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 30659493
DOI: 10.1007/s11096-018-00778-z -
American Heart Journal Aug 2014The introduction of transcatheter aortic valve replacement (TAVR) in clinical practice has widened options for symptomatic patients at high surgical risk; however, it is... (Review)
Review
UNLABELLED
The introduction of transcatheter aortic valve replacement (TAVR) in clinical practice has widened options for symptomatic patients at high surgical risk; however, it is not known whether TAVR has equivalent or prolonged benefits in terms of left ventricular (LV) remodeling.
METHODS
To explore the relative hemodynamic benefits and postoperative LV remodeling associated with TAVR and surgical aortic valve replacement (SAVR), we performed a critical review of the available literature. A total of 67 studies were included in this systematic review.
RESULTS
There is at least equivalent if not slightly superior hemodynamic performance of TAVR over SAVR, and TAVR showed lower prosthesis-patient mismatch compared with SAVR. However, LV mass appears to regress to a greater degree after SAVR compared with TAVR. Aortic regurgitation, paravalvular in particular, is more common after TAVR than SAVR, although it is rarely more than moderate in severity. Improvements in diastolic function and mitral regurgitation are reported in only a handful of studies each and could not be compared across prosthesis types.
CONCLUSIONS
The published data support the hemodynamic comparability of SAVR and TAVR, with the higher incidence of prosthesis-patient mismatch in SAVR offset by higher incidence of paravalvular leak in TAVR. These results highlight the need for further studies focusing on hemodynamic changes after valve therapy.
Topics: Aortic Valve; Aortic Valve Stenosis; Bioprosthesis; Cardiac Catheterization; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Hypertrophy, Left Ventricular; Mitral Valve Insufficiency; Postoperative Complications; Prosthesis Design; Ventricular Function, Left; Ventricular Remodeling
PubMed: 25066553
DOI: 10.1016/j.ahj.2014.04.015 -
Interventional Cardiology Clinics Jul 2017Valvular heart diseases such as aortic stenosis and mitral regurgitation are often associated with heart failure, which in turn increases patients' Surgical Thoracic...
Valvular heart diseases such as aortic stenosis and mitral regurgitation are often associated with heart failure, which in turn increases patients' Surgical Thoracic Society (STS) score. A high STS score means the patient is high risk for surgical aortic valve replacement and mitral valve repair/replacement. Transcatheter aortic valve replacement and percutaneous mitral valve repair offer a minimally invasive alternative for the treatment of valvular heart disease in patients with severe heart failure. We aim to review the current evidence on the safety, efficacy, and outcomes of these devices in patients with severe heart failure.
Topics: Aortic Valve; Heart Failure; Heart Valve Prosthesis; Humans; Prosthesis Design; Transcatheter Aortic Valve Replacement
PubMed: 28600091
DOI: 10.1016/j.iccl.2017.03.007 -
European Heart Journal. Quality of Care... Apr 2018Transcatheter aortic valve implantation (TAVI) and transcatheter mitral valve repair (TMVR) are increasingly used for managing patients with valvular heart disease to...
Transcatheter aortic valve implantation (TAVI) and transcatheter mitral valve repair (TMVR) are increasingly used for managing patients with valvular heart disease to whom surgery presents a high-risk. As these are costly procedures, a systematic review of studies concerned with their economic assessment was undertaken. The search was performed in PubMed and the Cochrane Library and followed recommended methodological steps. Studies were screened and their data were retrieved and were synthesized using a narrative approach. Twenty-four, good to high quality, evaluations were identified, representing different viewpoints, modelling techniques and willingness-to-pay thresholds. Studies show that in high-risk patients with symptomatic aortic stenosis, TAVI may be cost-effective compared with medical management (MM) across many health care settings. In contrast, studies of TAVI compared with surgical aortic valve replacement (SAVR) yield conflicting and inconclusive results. The limited data available show that TMVR may also be cost-effective relative to MM in mitral valve disease. Existing evidence indicates that transcatheter techniques may be cost-effective options, relative to MM, in high-risk patients with valvular disease. Nonetheless, more research is needed to establish their economic value further, to investigate the drives of cost-effectiveness, and to evaluate surgical with transcatheter techniques in aortic valvular disease.
Topics: Cardiac Catheterization; Cost-Benefit Analysis; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Humans; Models, Economic
PubMed: 29325012
DOI: 10.1093/ehjqcco/qcx049 -
Cardiovascular Revascularization... 2018Transcatheter aortic valve implantation (TAVI) is a safe and effective alternative to surgical aortic valve replacement (SAVR) for the treatment of severe aortic valve... (Meta-Analysis)
Meta-Analysis
The predictive value of baseline pulmonary hypertension in early and long term cardiac and all-cause mortality after transcatheter aortic valve implantation for patients with severe aortic valve stenosis: A systematic review and meta-analysis.
BACKGROUND
Transcatheter aortic valve implantation (TAVI) is a safe and effective alternative to surgical aortic valve replacement (SAVR) for the treatment of severe aortic valve stenosis (AS). The impact of concomitant baseline elevated pulmonary artery pressures on outcomes after TAVI has not been established, since different studies used different definitions of pulmonary hypertension (PH).
OBJECTIVE
To determine the association of PH with early and late cardiac and all-cause mortality after TAVI.
METHODS
We performed a meta-analysis of studies comparing patients with elevated pulmonary artery pressures (defined as pulmonary hypertension or not) versus patients without elevated pulmonary artery pressures undergoing TAVI. We first performed stratified analyses based on the different PH cut-off values utilized by the included studies and subsequently pooled the studies irrespective of their cut-off values. We used a random effects model for the meta-analysis and assessed heterogeneity with I-square. Separate meta-analyses were performed for studies reporting outcomes as hazards ratios (HRs) and relative risks (RRs). Subgroup analyses were performed for studies published before and after 2013. Meta-regression analysis in order to assess the effect of chronic obstructive pulmonary disease and mitral regurgitation were performed.
RESULTS
In total 22 studies were included in this systematic review. Among studies presenting results as HR, PH was associated with increased late cardiac mortality (HR: 1.8. 95% CI: 1.3-2.3) and late all-cause mortality (HR: 1.56; 95% CI: 1.1-2). The PH cut-off value that was most likely to be associated with worst outcomes among the different endpoints was pulmonary artery systolic pressure of 60 mm Hg (HR: 1.8; 95% CI: 1.3-2.3; I = 0, for late cardiac mortality and HR: 1.52; 95% CI: 1-2.1; I = 85% for late all-cause mortality).
CONCLUSION
This systematic review and meta-analysis emphasizes the importance of baseline PH in predicting mortality outcomes after TAVI. Additional studies are needed to clarify the association between elevated baseline pulmonary artery pressures and outcomes after TAVI.
Topics: Aged; Aged, 80 and over; Aortic Valve; Aortic Valve Stenosis; Arterial Pressure; Cause of Death; Female; Humans; Hypertension, Pulmonary; Male; Pulmonary Artery; Risk Assessment; Risk Factors; Severity of Illness Index; Time Factors; Transcatheter Aortic Valve Replacement; Treatment Outcome
PubMed: 29724516
DOI: 10.1016/j.carrev.2018.03.015 -
JACC. Cardiovascular Interventions Mar 2022The authors aimed to identify risk factors and outcomes associated with new-onset atrial fibrillation (NOAF) after transcatheter aortic valve replacement (TAVR). (Meta-Analysis)
Meta-Analysis
OBJECTIVES
The authors aimed to identify risk factors and outcomes associated with new-onset atrial fibrillation (NOAF) after transcatheter aortic valve replacement (TAVR).
BACKGROUND
NOAF is a common complication after TAVR, although estimates of the precise occurrence are variable. This study sought to quantify the occurrence of NOAF after TAVR and to explore the outcomes and predictors associated with this complication.
METHODS
We searched Medline, EMBASE, and the Cochrane database from 2016 to 2020 for articles that reported NOAF after TAVR. We extracted data for studies published before 2016 from a previous systematic review. We pooled data using a random effects model.
RESULTS
We identified 179 studies with 241,712 total participants (55,271 participants with pre-existing atrial fibrillation (AF) were excluded) that reported NOAF from 2008 to 2020. The pooled occurrence of NOAF after TAVR was 9.9% (95% CI: 8.1%-12%). NOAF after TAVR was associated with a longer index hospitalization (mean difference = 2.66 days; 95% CI: 1.05-4.27), a higher risk of stroke in the first 30 days (risk ratio [RR]: 2.35; 95% CI: 2.12-2.61), 30-day mortality (RR: 1.76; 95% CI: 1.12-2.76), major or life-threatening bleeding (RR: 1.60; 95% CI: 1.39-1.84), and permanent pacemaker implantation (RR: 1.12; 95% CI: 1.05-1.18). Risk factors for the development of NOAF after TAVR included higher Society of Thoracic Surgeons score, transapical access, pulmonary hypertension, chronic kidney disease, peripheral vascular disease, and severe mitral regurgitation, suggesting that the risk for NOAF is highest in more comorbid TAVR patients.
CONCLUSIONS
NOAF is common after TAVR. Whether AF after TAVR is a causal factor or a marker of sicker patients remains unclear.
Topics: Aortic Valve Stenosis; Atrial Fibrillation; Humans; Risk Factors; Transcatheter Aortic Valve Replacement; Treatment Outcome
PubMed: 35331452
DOI: 10.1016/j.jcin.2022.01.018 -
Cardiology 2020Mitral regurgitation (MR) is commonly encountered in patients with severe aortic stenosis (AS). However, its independent impact on mortality in patients undergoing... (Meta-Analysis)
Meta-Analysis
Does the Presence of Significant Mitral Regurgitation prior to Transcatheter Aortic Valve Implantation for Aortic Stenosis Impact Mortality? - Meta-Analysis and Systematic Review.
BACKGROUND
Mitral regurgitation (MR) is commonly encountered in patients with severe aortic stenosis (AS). However, its independent impact on mortality in patients undergoing transcatheter aortic valve implantation (TAVI) has not been established.
METHODS
We performed a systematic search for studies reporting characteristics and outcome of patients with and without significant MR and/or adjusted mortality associated with MR post-TAVI. We conducted a meta-analysis of quantitative data.
RESULTS
Seventeen studies with 20,717 patients compared outcomes and group characteristics. Twenty-one studies with 32,257 patients reported adjusted odds of mortality associated with MR. Patients with MR were older, had a higher Society of Thoracic Surgeons score, lower left ventricular ejection fraction, a higher incidence of prior myocardial infarction, atrial fibrillation, and a trend towards higher NYHA class III/IV, but had similar mean gradient, gender, and chronic kidney disease. The MR patients had a higher unadjusted short-term (RR = 1.46, 95% CI 1.30-1.65) and long-term mortality (RR = 1.40, 95% CI 1.18-1.65). However, 16 of 21 studies with 27,777 patients found no association between MR and mortality after adjusting for baseline variables. In greater than half of the patients (0.56, 95% CI 0.45-0.66) MR improved by at least one grade following TAVI.
CONCLUSION
The patients with MR undergoing TAVI have a higher burden of risk factors which can independently impact mortality. There is a lack of robust evidence supporting an increased mortality in MR patients, after adjusting for other compounding variables. MR tends to improve in the majority of patients post-TAVI.
Topics: Aortic Valve Stenosis; Cardiac Catheterization; Cause of Death; Humans; Incidence; Mitral Valve Insufficiency; Risk Assessment; Risk Factors; Severity of Illness Index; Time Factors; Transcatheter Aortic Valve Replacement
PubMed: 32460301
DOI: 10.1159/000506624 -
A review of indications and comorbidities in which warfarin may be the preferred oral anticoagulant.Journal of Clinical Pharmacy and... Jun 2021Direct oral anticoagulants (DOACs) are increasingly prescribed instead of warfarin for chronic anticoagulation for ease of dosing, fewer interactions, and less stringent...
WHAT IS KNOWN AND OBJECTIVE
Direct oral anticoagulants (DOACs) are increasingly prescribed instead of warfarin for chronic anticoagulation for ease of dosing, fewer interactions, and less stringent monitoring. However, it is important to consider indications and comorbidities for which warfarin is still the preferred anticoagulant. This review aims to capture these clinical scenarios in which warfarin may still be preferred over DOACs.
METHODS
We undertook a comprehensive literature search using the PubMed database. Key search terms were based on DOAC clinical trial exclusion criteria, as well as indications and conditions in which the use of DOACs for anticoagulation has suggested harm. Society guidelines and tertiary literature were used to inform expert opinion where necessary. Studies were included if they investigated the use of DOACs or warfarin in the identified indications or conditions.
RESULTS AND DISCUSSION
Currently, evidence for the use of warfarin over DOACs for anticoagulation is strongest for patients with prosthetic valves, antiphospholipid syndrome, or a high risk of gastrointestinal bleeding. For several clinical situations, including mitral stenosis, obesity, altered gastrointestinal anatomy, pulmonary arterial hypertension, renal or hepatic impairment, and left ventricular thrombus, evidence is lacking but may eventually support the use of DOACs. Depending on indication and condition, appropriateness of DOAC use may vary by agent.
WHAT IS NEW AND CONCLUSION
New evidence continues to support new indications and conditions in which DOACs may be appropriate to use for anticoagulation. There are key clinical scenarios, however, in which emerging literature continues to support warfarin as the preferred anticoagulant.
Topics: Anticoagulants; Antiphospholipid Syndrome; Atrial Fibrillation; Blood Coagulation; Comorbidity; Drug Interactions; Factor Xa Inhibitors; Gastrointestinal Hemorrhage; Heart Valve Prosthesis; Humans; Liver Failure; Medication Adherence; Mitral Valve Stenosis; Overweight; Pulmonary Arterial Hypertension; Renal Insufficiency; Stroke; Warfarin
PubMed: 33393699
DOI: 10.1111/jcpt.13343