Essay on Transcatheter Aortic Valve Replacement Example For Students

Essay on Transcatheter Aortic Valve Replacement Transcatheter aortic valve replacement (TAVR) introduction to the clinical practice revolutionized the interventional cardiology ,it is a valuable option for a non –operable patient with sever aortic stenosis or high risk population however ,TAVR is associated with a risk of cerebral embolization and ischemic vascular events and possible neurological impairment the estimate of these complication is vary but it have been reported early and late after the procedure moreover the reported incidence of bleeding associated with TAVI is relatively high .with this given incident of complication required adequate antithrombotic therapy during and following procedure ,however despite the current guidelines recommendation the optimal antithrombotic is not very well established . Introduction: Sever Aortic Stenosis (AS) is a major cause of mortality and morbidity in elderly duo to a bimodal age distribution ,degenerative calcification of Tricuspid valve is the major cause of AS in the population ,unlike the younger patient etiology which is : bicuspid valve calcification or rheumatic heart disease .1 The Burden of the disease is high with a prevalence of 3.4% 2. With the progressive nature of the disease and the increased severity of the symptoms made the surgery the gold standard for symptomatic AS patients ,however up to 30% of cases are considered too high risk for classical valve replacement surgery and remain untreated and experiencing poor prognosis . Fortunately , with the introduction of TAVR its offer a valuable option for the inoperable or at high risk of surgery patients3..the annual eligible candidate for this procedure expected to be 27,000 in 19 European countries and North America according to recent meta-analysis and modeling study2, TAVI is associated with a high risk of stroke ,transient ischemic stroke ,Atrial Fibrillation and myocardial infarction and the long term outcome associated with bleeding complication mainly duo to the use of Dual antiplatlets therapy (DAPT) which raise the need to find the optimal regimen of antithrombotic to avoid the early cerebrovascular complication ,provide optimum stroke prevention and avoid the bleeding as a long term outcome . This article will review the current recommendation of antithrombotic during and following TAVI and the recent evidence and advancement in this unique procedure. TAVI Versus SAVR : Although there are cumulative data suggesting superior survival and symptomatic outcomes for inoperable patients who undergo TAVI versus medical palliation4,5 The available data on TAVI versus AVR showed that major adverse outcomes such as mortality and stroke appeared to be similar between the two treatment modalities. Evidence on the outcomes of TAVI compared with AVR in the current literature is limited by inconsistent patient selection criteria, heterogeneous definitions of clinical endpoints and relatively short follow-up periods. two meta-analysis have been conducted that include TAVR and SAVR studies in their evaluation .one meta-analysis compared TAVR to AVR combining the results from two randomized controlled trials and 11 observational reports comparing TAVI with AVR in patients with severe aortic stenosis6. Interestingly, selected studies identified no significant differences in mortality and stroke between the two treatment groups. However, vascular complications, permanent pacemaker insertion and significant aortic regurgitation were relatively common after TAVI, and significantly more frequent than after conventional AVR. Conversely, major bleeding was more likely to occur after surgical AVR than TAVI. The second meta-analysis of seventeen studies in (n=4,659) comparing TAVR (n=2,267) and SAVR ( n2,392) was conducted to determine the differences in postprocedural mortality and major adverse cardiovascular and cerebrovascular events between the two attack, and major bleeding interventions .7 End points were baseline logistic European System for Cardiac Operative Risk Evaluation score, all-cause mortality, cardiovascular mortality, myocardial infarction, stroke,transient ischemic events. There was no significant difference in cardiovascular mortality (p[0.54) as well as the incidence of myocardial infarction (p[0.59), stroke (p[0.36), and transient ischemic attack (p [ 0.85) at averages of 86, 72, 66, and 89 weeks, respectively Similar to the previous meta-analysis ,TAVI WAS noninferior to SAVR for postprocedural myocardial infarctions and cerebrovascular events but it was superior to SAVR for major bleeding complications. therfore TAVR should be considered in selected high risk elde rly patients and the use of TAVR for eligible surgical candidate should be considered within the boundaries of clinical trials duo to the importan;t cerebrovascular and cardiovascular debilitating adverse events which is a significant predictor of mortality the suggested predisposing factors for the occurrence of stroke are a newly onset of atrial fibrillation and a higher-grade mitral valve insufficiency8,9.Moreover, the antithrombotic regimen appear to play a major role in prevention of those fatal complications.10 however , it is unclear what is the optimal antithrombotic regimen to provide protection for early and late thrombotic events in patients who undergoing to TAVR11 in the absence of randomized control trials and lack of evidence base recommendation from the international societies who based their recommendation on observational studies 12 Antithrombotic Prior TAVR: Up to our knowledge there is no specific recommendation for antithrombotic prior TAVR ,however ,few recent study suggested bridging with unfractionated heparin For those who required anticoagulation therapy before TAVR (e.g. mechanic mitral valve),,13,14,15Recent study evaluated the early and long term bleeding complications after TAVR suggest to avoid pre-treatment with clopidogrel in patient with advanced age, BMI, and a history of anemia who have increased the risk for early bleeding and suggested Vitamin K natagonists with clopidogrel seems to be thesafest therapy in the early post-TAVI period13. 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Arch Med Sci 2013; 9, 6: 1062–1070 14-Nijenhuis VJ1, Stella PR, Baan J, Brueren BR, de Jaegere PP, den Heijer P, Hofma SH, Kievit P, Slagboom T, van den Heuvel AF, van der Kley F, van Garsse L, van Houwelingen KG, Vant Hof AW, Ten Berg JMAntithrombotic therapy in patients undergoing TAVI: an overview of Dutch hospitals. Neth Heart J. 2014 ;22(2):64-9. 15- Katarzyna Czerwinska-Jelonkiewicz1, Adam Witkowski2, Maciej Dabrowski2, Marek Banaszewski,Ewa Ksiezycka-Majczynska, Zbigniew Chmielak, Krzysztof Kusmierski, Tomasz Hryniewiecki,Marcin Demkow, Ewa OrÅ‚owska-Baranowska, Janina Stepinska. Antithrombotic therapy – predictor of early and longterm bleeding complications after transcatheter aortic valve implantation Arch Med Sci 2013; 9, 6: 1062–1070 16- Holmes DR Jr, Mack MJ, Kaul S, Agnihotri A, Alexander KP, Bailey SR et al (2012) ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement. 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Available at: http://clinicaltrials.gov/ct2/show/nct01559298?term ¼nct01559298rank ¼1.Accessed May 30, 2012. 29-Jean-Philippe Collet, Gilles Montalescot, Antithrombotic and antiplatelet therapy in TAVI patients:a fallow field? EuroIntervention 2013;9:S43-S47