Cardiovascular disease is the leading cause of death in patients with peripheral arterial disease(PAD). Coro-nary artery disease(CAD) is highly prevalent, and often times coexist, in patients with PAD. The management ...Cardiovascular disease is the leading cause of death in patients with peripheral arterial disease(PAD). Coro-nary artery disease(CAD) is highly prevalent, and often times coexist, in patients with PAD. The management of patients with PAD that requires a high-risk vascular surgical procedure for intermittent claudication, critical limb ischemia or expanding abdominal aortic aneurysm requires risk stratification with the revised cardiac risk index, optimization of medical therapies, and limited use of cardiac imaging prior to surgery. Preventive re-vascularization in patients with stable CAD, with the sole intention to mitigate the risk of cardiac complica-tions in the peri-operative period, is not effective and may be associated with significant bleeding and throm-botic risks, in particular if stents are used. A strategy of universal use of cardiac troponins in the perioperative period for active surveillance of myocardial ischemia may be more reasonable and cost-effective than the current standard of care of widespread use of cardiac imaging prior to high-risk surgery. An elevated cardiactroponin after vascular surgery is predictive of long-term mortality risk. Medical therapies such as aspirin and statins are recommended for patients with post-operative myocardial ischemia. Ongoing trials are as-sessing the role of novel anticoagulants. Additional research is needed to define the role of cardiac imaging and invasive angiography in this population.展开更多
<strong>Background:</strong><span style="font-family:;" "=""><span style="font-family:Verdana;"> Despite expanding indications, data regarding the long-term d...<strong>Background:</strong><span style="font-family:;" "=""><span style="font-family:Verdana;"> Despite expanding indications, data regarding the long-term durability of transcatheter heart valves (THV) are limited. </span><b><span style="font-family:Verdana;">Methods:</span></b><span style="font-family:Verdana;"> We performed a systematic review and meta-analysis of all published studies with ≥5</span></span><span style="font-family:;" "=""></span><span style="font-family:;" "=""><span style="font-family:Verdana;">years of follow-up reporting aortic valve reintervention rates of transcatheter (TAVR) and surgical aortic valve replacement (SAVR). </span><span style="font-family:Verdana;">Randomized controlled trials (n = 4) and propensity-matched observational studies (n = 1) involving all surgical risk categories were included. The primary endpoint was the composite of aortic valve reintervention and death. </span><b><span style="font-family:Verdana;">Results:</span></b><span style="font-family:Verdana;"> The meta-</span></span><span style="font-family:Verdana;"> </span><span style="font-family:;" "=""><span style="font-family:Verdana;">analysis included 4145 patients: 2101 underwent TAVR (mean age 81.7 ± 6.7 years, 54% male) and 2044 SAVR (mean age 81.8 ± 6.6 years, 54% male)</span><span style="font-family:Verdana;">. All TAVR procedures were performed with early</span></span><span style="font-family:Verdana;"> </span><span style="font-family:Verdana;">generations of THV. At</span><span style="font-family:;" "=""><span style="font-family:Verdana;"> a median follow-up of 5 years (range 5 - 6 years), TAVR had higher reintervention rates (odds ratio (OR) 3.33;95% CI: [1.78, 6.24], p < 0.001, I</span><sup><span style="font-size:12px;font-family:Verdana;">2</span></sup><span style="font-family:Verdana;"> = 0%), all-cause mortality (OR 1.45;95% CI: [1.22, 1.75], p < 0.001, I</span><sup><span style="font-size:12px;font-family:Verdana;">2</span></sup><span style="font-family:Verdana;"> = 44%) and the composite of reintervention and death (OR 1.47;95% CI: [1.14, 1.91], p < 0.001, I</span><sup><span style="font-size:12px;font-family:Verdana;">2</span></sup><span style="font-family:Verdana;"> = 64%). Rates of myocardial infarction, transient ischemic attack, stroke, endocarditis, and the composite of endocarditis and thrombosis were similar between the groups. </span><b><span style="font-family:Verdana;">Conclusion</span></b><span style="font-family:Verdana;">: Despite comparable short and medium-term results, TAVR with early-generation THV has higher rates of reintervention and the composite of reintervention and death. Further studies employing newer definitions of structural valve deterioration and bioprosthetic valve failure are needed to assess whether technological enhancements in THV technology will improve long-term outcomes.</span></span>展开更多
基金Supported by A career development award from the VA Office of Research and Development,No.1IK2CX000699-01
文摘Cardiovascular disease is the leading cause of death in patients with peripheral arterial disease(PAD). Coro-nary artery disease(CAD) is highly prevalent, and often times coexist, in patients with PAD. The management of patients with PAD that requires a high-risk vascular surgical procedure for intermittent claudication, critical limb ischemia or expanding abdominal aortic aneurysm requires risk stratification with the revised cardiac risk index, optimization of medical therapies, and limited use of cardiac imaging prior to surgery. Preventive re-vascularization in patients with stable CAD, with the sole intention to mitigate the risk of cardiac complica-tions in the peri-operative period, is not effective and may be associated with significant bleeding and throm-botic risks, in particular if stents are used. A strategy of universal use of cardiac troponins in the perioperative period for active surveillance of myocardial ischemia may be more reasonable and cost-effective than the current standard of care of widespread use of cardiac imaging prior to high-risk surgery. An elevated cardiactroponin after vascular surgery is predictive of long-term mortality risk. Medical therapies such as aspirin and statins are recommended for patients with post-operative myocardial ischemia. Ongoing trials are as-sessing the role of novel anticoagulants. Additional research is needed to define the role of cardiac imaging and invasive angiography in this population.
文摘<strong>Background:</strong><span style="font-family:;" "=""><span style="font-family:Verdana;"> Despite expanding indications, data regarding the long-term durability of transcatheter heart valves (THV) are limited. </span><b><span style="font-family:Verdana;">Methods:</span></b><span style="font-family:Verdana;"> We performed a systematic review and meta-analysis of all published studies with ≥5</span></span><span style="font-family:;" "=""></span><span style="font-family:;" "=""><span style="font-family:Verdana;">years of follow-up reporting aortic valve reintervention rates of transcatheter (TAVR) and surgical aortic valve replacement (SAVR). </span><span style="font-family:Verdana;">Randomized controlled trials (n = 4) and propensity-matched observational studies (n = 1) involving all surgical risk categories were included. The primary endpoint was the composite of aortic valve reintervention and death. </span><b><span style="font-family:Verdana;">Results:</span></b><span style="font-family:Verdana;"> The meta-</span></span><span style="font-family:Verdana;"> </span><span style="font-family:;" "=""><span style="font-family:Verdana;">analysis included 4145 patients: 2101 underwent TAVR (mean age 81.7 ± 6.7 years, 54% male) and 2044 SAVR (mean age 81.8 ± 6.6 years, 54% male)</span><span style="font-family:Verdana;">. All TAVR procedures were performed with early</span></span><span style="font-family:Verdana;"> </span><span style="font-family:Verdana;">generations of THV. At</span><span style="font-family:;" "=""><span style="font-family:Verdana;"> a median follow-up of 5 years (range 5 - 6 years), TAVR had higher reintervention rates (odds ratio (OR) 3.33;95% CI: [1.78, 6.24], p < 0.001, I</span><sup><span style="font-size:12px;font-family:Verdana;">2</span></sup><span style="font-family:Verdana;"> = 0%), all-cause mortality (OR 1.45;95% CI: [1.22, 1.75], p < 0.001, I</span><sup><span style="font-size:12px;font-family:Verdana;">2</span></sup><span style="font-family:Verdana;"> = 44%) and the composite of reintervention and death (OR 1.47;95% CI: [1.14, 1.91], p < 0.001, I</span><sup><span style="font-size:12px;font-family:Verdana;">2</span></sup><span style="font-family:Verdana;"> = 64%). Rates of myocardial infarction, transient ischemic attack, stroke, endocarditis, and the composite of endocarditis and thrombosis were similar between the groups. </span><b><span style="font-family:Verdana;">Conclusion</span></b><span style="font-family:Verdana;">: Despite comparable short and medium-term results, TAVR with early-generation THV has higher rates of reintervention and the composite of reintervention and death. Further studies employing newer definitions of structural valve deterioration and bioprosthetic valve failure are needed to assess whether technological enhancements in THV technology will improve long-term outcomes.</span></span>