The document discusses the TAVR (transcatheter aortic valve replacement) procedure, which is a minimally invasive alternative to open-heart surgery used to replace the aortic valve in patients considered too high risk for open-heart surgery. The TAVR procedure involves inserting an artificial valve through the femoral or apical artery using a catheter. Potential complications include stroke, death, and bleeding issues. Physical therapy implications include screening patients who will be on lifelong aspirin therapy for risk of bleeding complications and addressing mobility issues common in the elderly patient population eligible for TAVR.
The document discusses the role of cardiopulmonary exercise testing (CPET) before, during, and after left ventricular assist device (LVAD) implantation for advanced heart failure. CPET is useful diagnostically and prognostically before LVAD implantation to help determine candidacy. It can also help guide cardiac rehabilitation and monitor recovery after LVAD implantation. CPET values are important criteria used to select candidates for LVAD and heart transplantation.
ACC guide line Cardiovascular risk assessment for non cardiac surgery2Nizam Uddin
This clinical practice guideline from the ACC/AHA provides recommendations for the perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. It was developed by a writing committee and endorsed by several medical societies. The guideline covers clinical risk factors, calculating perioperative risk, approaches to preoperative cardiac testing and therapy, anesthetic considerations, and perioperative surveillance and management. The goal is to reduce perioperative cardiovascular complications for patients undergoing noncardiac surgery.
Cardiovascular risk assessment for non cardiac surgeryNizam Uddin
This document provides recommendations for perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery based on a review of evidence. Key points include:
- It focuses on preoperative risk assessment, cardiovascular testing, perioperative pharmacological management including anesthesia, and perioperative monitoring.
- The goal is to provide patients and providers with information on cardiovascular risk in the context of overall surgery risk to facilitate shared decision making.
- Recommendations are made based on studies of noncardiac surgery patients, extrapolating from other areas only when no other data is available.
This document summarizes the results of a randomized controlled trial comparing transcatheter aortic valve replacement (TAVR) to surgical aortic valve replacement (SAVR) in patients at low surgical risk. The trial found that TAVR was superior to SAVR in reducing the composite outcome of death from any cause, stroke, or rehospitalization at 1 year. TAVR was also associated with lower rates of mortality at 30 days, life-threatening bleeding, and shorter hospital stays compared to SAVR. However, TAVR was associated with higher rates of new-onset left bundle branch block and mild paravalvular regurgitation compared to SAVR.
1) Prior studies have found no class I evidence or randomized data to support performing Allen's test or oximetry prior to radial artery catheterization.
2) Performing Allen's test has been considered a ritual or standard practice without clear data on its predictive value or significance.
3) A recent study found no differences in outcomes between patients with normal, intermediate, or abnormal Allen's test results, suggesting there is no risk from an abnormal test.
4) The focus should be on oximetry-plethysmography and techniques to guide hemostasis after radial procedures to minimize radial artery occlusion, not on pre-procedural testing for dual circulation.
1) The document discusses the learning curve for radial artery procedures in the US based on multiple data sources.
2) Recent data shows the radial learning curve may not be as steep as once believed, with initial competence reached after 25-40 cases, though improvement continues with greater experience and volume.
3) Procedural metrics like fluoroscopy time improve with experience but are influenced by many factors, making direct links to patient outcomes difficult to establish. Nonetheless, radial procedures in the US are being adopted quickly and appear to achieve better safety outcomes than femoral procedures.
Our transcatheter aortic valve implantation (TAVI) program offers a possible alternative to open heart surgery for patients with severe, symptomatic aortic stenosis who are high risk for surgery or who are inoperable.
2017 Barcelona. Acute Cardiac Unloading and Recovery Working Group Meeting.
The Impella ventricular assist device support experience at Texas Children's Hospital.
The document discusses the role of cardiopulmonary exercise testing (CPET) before, during, and after left ventricular assist device (LVAD) implantation for advanced heart failure. CPET is useful diagnostically and prognostically before LVAD implantation to help determine candidacy. It can also help guide cardiac rehabilitation and monitor recovery after LVAD implantation. CPET values are important criteria used to select candidates for LVAD and heart transplantation.
ACC guide line Cardiovascular risk assessment for non cardiac surgery2Nizam Uddin
This clinical practice guideline from the ACC/AHA provides recommendations for the perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. It was developed by a writing committee and endorsed by several medical societies. The guideline covers clinical risk factors, calculating perioperative risk, approaches to preoperative cardiac testing and therapy, anesthetic considerations, and perioperative surveillance and management. The goal is to reduce perioperative cardiovascular complications for patients undergoing noncardiac surgery.
Cardiovascular risk assessment for non cardiac surgeryNizam Uddin
This document provides recommendations for perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery based on a review of evidence. Key points include:
- It focuses on preoperative risk assessment, cardiovascular testing, perioperative pharmacological management including anesthesia, and perioperative monitoring.
- The goal is to provide patients and providers with information on cardiovascular risk in the context of overall surgery risk to facilitate shared decision making.
- Recommendations are made based on studies of noncardiac surgery patients, extrapolating from other areas only when no other data is available.
This document summarizes the results of a randomized controlled trial comparing transcatheter aortic valve replacement (TAVR) to surgical aortic valve replacement (SAVR) in patients at low surgical risk. The trial found that TAVR was superior to SAVR in reducing the composite outcome of death from any cause, stroke, or rehospitalization at 1 year. TAVR was also associated with lower rates of mortality at 30 days, life-threatening bleeding, and shorter hospital stays compared to SAVR. However, TAVR was associated with higher rates of new-onset left bundle branch block and mild paravalvular regurgitation compared to SAVR.
1) Prior studies have found no class I evidence or randomized data to support performing Allen's test or oximetry prior to radial artery catheterization.
2) Performing Allen's test has been considered a ritual or standard practice without clear data on its predictive value or significance.
3) A recent study found no differences in outcomes between patients with normal, intermediate, or abnormal Allen's test results, suggesting there is no risk from an abnormal test.
4) The focus should be on oximetry-plethysmography and techniques to guide hemostasis after radial procedures to minimize radial artery occlusion, not on pre-procedural testing for dual circulation.
1) The document discusses the learning curve for radial artery procedures in the US based on multiple data sources.
2) Recent data shows the radial learning curve may not be as steep as once believed, with initial competence reached after 25-40 cases, though improvement continues with greater experience and volume.
3) Procedural metrics like fluoroscopy time improve with experience but are influenced by many factors, making direct links to patient outcomes difficult to establish. Nonetheless, radial procedures in the US are being adopted quickly and appear to achieve better safety outcomes than femoral procedures.
Our transcatheter aortic valve implantation (TAVI) program offers a possible alternative to open heart surgery for patients with severe, symptomatic aortic stenosis who are high risk for surgery or who are inoperable.
2017 Barcelona. Acute Cardiac Unloading and Recovery Working Group Meeting.
The Impella ventricular assist device support experience at Texas Children's Hospital.
1) The AURA OF ARTEMIS study was a randomized trial comparing transulnar versus transradial arterial access as the default strategy for coronary procedures.
2) In the interim analysis, the composite primary endpoint was significantly higher in the ulnar arm compared to the radial arm, with a 24.3% difference between arms. The study was terminated early due to the inferiority of the transulnar approach.
3) Complications associated with the transulnar approach included pseudoaneurysms, perforations, occlusions and arteriovenous fistulas. Crossover from ulnar to other access sites was also more common.
This document discusses techniques for transradial access and intervention. It begins by outlining three levels of competency for operators and discusses when radial access may not be appropriate. It then provides a step-by-step guide for radial access procedures, covering patient positioning, arterial puncture, navigating vascular anatomy, catheter selection, and hemostasis. Predictors of procedural failure are presented. The document concludes by providing tips for implementing a successful radial program.
This document discusses iFR and Pd/Pa indices and whether they provide hype or hope. It notes that iFR and FFR have similar diagnostic power in predicting ischemia compared to PET imaging. While FFR adoption is low due to the need for vasodilators, iFR does not require vasodilators and could be more easily adopted. iFR pullbacks may help identify diffuse or tandem disease better than whole cycle Pd/Pa measurements. Physiology combined with angiography can confirm ischemia, identify significant lesions, guide post-PCI assessment, and allow co-registration of anatomical and physiological data.
The Division at St Luke’s–Roosevelt endorses the position of the Society for Vascular Surgery that carotid artery surgery is superior to carotid stenting based on results from the CREST and ICSS trials. While both CEA and CAS can prevent stroke, CEA has fewer complications and is therefore the preferred treatment according to ICSS. CREST showed CEA and CAS were equivalent when measuring all complications together, but strokes occurred more after stenting.
This document discusses treatments for radial artery occlusion (RAO) following transradial catheterization. It describes pharmacological treatments including low molecular weight heparin and anticoagulation as well as non-pharmacological options such as ulnar artery compression, percutaneous interventions, and surgery. Ulnar artery compression is highlighted as a simple, safe, and effective method for treating RAO. A new combined approach using balloon angioplasty and localized intra-arterial abciximab is also discussed but requires further validation. Overall, the best approach is prevention of RAO by ensuring patent hemostasis and using slender techniques.
This document discusses the practice of performing Allen's test or oximetry prior to radial artery catheterization. It summarizes that:
1) There is no Class I evidence or randomized data showing the predictive value of Allen's test, and the significance of an abnormal test is unclear.
2) A study found no differences in outcomes between patients with normal, intermediate, or abnormal Allen's tests, suggesting no risk from an abnormal test.
3) Recommendations are that there is no evidence to support performing Allen's test or testing for dual circulation to prevent ischemic complications of transradial catheterization. Attention should instead focus on techniques to guide hemostasis after the procedure.
The document discusses left atrial appendage (LAA) closure as an alternative to anticoagulation for stroke prevention in atrial fibrillation patients. It summarizes several studies on the Watchman device that found LAA closure to be non-inferior to warfarin for stroke risk reduction, with higher risks of complications. The ACP registry showed periprocedural complication rates with LAA closure decreased over time from 7% to 3.4% as operators gained more experience with the procedure. Overall, LAA closure is a viable alternative to anticoagulation for stroke prevention when anticoagulation is contraindicated or poses high bleeding risks, though periprocedural complications remain higher than medical management
The document summarizes the proposed SAFE-PCI for Women study, which aims to determine the efficacy and feasibility of the transradial approach to PCI in women compared to the transfemoral approach. The randomized controlled trial plans to enroll 1,800 female patients undergoing elective or urgent PCI at 30 sites. The primary endpoint is a composite of major bleeding or major vascular complications within 72 hours or discharge. Secondary endpoints include procedure time and radiation/contrast use. Funding support is provided through the American Recovery and Reinvestment Act.
- LVADs are increasingly being used as a bridge to transplant or destination therapy for advanced heart failure. The number of LVAD implants has grown significantly in recent years and is projected to continue growing as destination therapy becomes more common. LVADs have been shown to improve functional status and quality of life in heart failure patients. While expensive, LVADs can provide survival benefits over medical management for advanced heart failure when transplant is not available. Ongoing research continues to improve device design and outcomes.
Practice guidelines for_central_venous_access__a.13Felipe Posada
This document provides guidelines for central venous access developed by the American Society of Anesthesiologists Task Force. It defines central venous access, outlines the purposes for developing the guidelines which are to provide guidance on placement and management of central lines and reduce adverse outcomes. It focuses on elective procedures performed by anesthesiologists and provides definitions but does not address clinical indications, emergency placement, peripherally inserted central catheters, pulmonary artery catheters, tunneled lines, or infectious complications treatment. The guidelines are intended for use by anesthesiologists and those under their supervision.
Current concept in the diagnosis, treatment and rehabilitation of patients wi...Ramachandra Barik
This document provides an overview of current concepts in the diagnosis, treatment, and rehabilitation of patients with congestive heart failure (HF). It discusses the classification of HF based on left ventricular ejection fraction into HF with preserved, reduced, or mid-range ejection fraction. The diagnosis of HF is primarily clinical based on symptoms, exam, imaging, and biomarkers. New diagnostic algorithms have been recommended for HF with preserved ejection fraction. Treatment options for HF with reduced ejection fraction have improved outcomes and a new term for recovered left ventricular function has emerged. Cardiac rehabilitation is an important part of HF management and has been shown to improve exercise capacity, quality of life, and reduce hospitalizations.
Radial access for primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients reduces bleeding complications compared to femoral access. Several randomized controlled trials showed lower all-cause mortality with radial versus femoral access when performed by experienced radial operators. However, the studies only included radial operators, so it is unclear if the benefits seen with radial access would apply if femoral operators performed radial procedures or vice versa. Additionally, radial access requires experienced operators at high-volume centers, and the definition of an experienced radial operator remains uncertain due to the steep learning curve for radial procedures. The primary goal of primary PCI in STEMI is restoring blood flow to the heart, not avoiding access site complications.
This document summarizes various studies comparing right and left radial approaches for cardiac catheterization. It begins by outlining several previous studies that found no differences in outcomes between right and left approaches. It then describes a new study comparing right versus left radial access in high-risk patients (elderly, female, hypertensive, short height) done by fellows under supervision. In this study, the left radial approach was associated with shorter fluoroscopy times and less contrast use, suggesting it may be preferable for difficult cases done by new operators.
1) The document describes two studies comparing the left radial approach (LRA) and right radial approach (RRA) for coronary angiography and primary PCI in Chinese patients.
2) In the first study, LRA was associated with shorter procedure time and fluoroscopy time compared to RRA for coronary angiography.
3) In the second study on primary PCI for STEMI, LRA was associated with earlier blood flow restoration in the infarct artery and lower radiation exposure compared to RRA.
4) Based on the results, LRA may be preferable to RRA due to lower subclavian tortuosity, easier catheter manipulation, and less radiation exposure, especially for urgent cases requiring faster procedures.
Manejo perioperatorio de la terapia antitrombótica, chest, 2012Felipe Posada
This guideline addresses the perioperative management of anticoagulant and antiplatelet therapy in patients requiring elective surgery or procedures. Key recommendations include:
1) Stopping vitamin K antagonists (VKAs) 5 days before surgery instead of shorter durations.
2) Bridging anticoagulation for patients at high risk of thrombosis during VKA interruption, such as those with mechanical heart valves or atrial fibrillation.
3) Continuing aspirin in moderate-to-high risk patients undergoing non-cardiac surgery instead of stopping 7-10 days before surgery.
The recommendations aim to simplify management and minimize risks of thrombosis and bleeding in the perioperative period.
This document discusses the learning curve for radial angiography and coronary interventions. It summarizes a study that found procedural success rates increase as operators gain more experience, with odds of failure decreasing by 8% for every 10 additional cases and 32% for 50 cases. The document recommends novice operators complete a minimum of 50 radial cases to achieve success rates similar to experienced operators. It also provides tips for the learning phase, such as using technology like hydrophilic sheaths, selecting less complex patients, and performing radial angiography before radial PCI.
This review article discusses aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI). It notes that AR is more common after TAVI than surgical aortic valve replacement, with mild AR observed in about 70% of TAVI patients. Even mild AR has been linked to decreased survival up to two years after the procedure. The review aims to provide an overview of the three types of AR that can occur after TAVI - transvalvular, paravalvular, and supraskirtal - focusing on their different pathophysiological mechanisms. Accurate evaluation and classification of AR is important for understanding its implications, but challenging due to limitations of echocardiography for assessing transcatheter
1) The AURA OF ARTEMIS study was a randomized trial comparing transulnar versus transradial arterial access as the default strategy for coronary procedures.
2) In the interim analysis, the composite primary endpoint was significantly higher in the ulnar arm compared to the radial arm, with a 24.3% difference between arms. The study was terminated early due to the inferiority of the transulnar approach.
3) Complications associated with the transulnar approach included pseudoaneurysms, perforations, occlusions and arteriovenous fistulas. Crossover from ulnar to other access sites was also more common.
This document discusses techniques for transradial access and intervention. It begins by outlining three levels of competency for operators and discusses when radial access may not be appropriate. It then provides a step-by-step guide for radial access procedures, covering patient positioning, arterial puncture, navigating vascular anatomy, catheter selection, and hemostasis. Predictors of procedural failure are presented. The document concludes by providing tips for implementing a successful radial program.
This document discusses iFR and Pd/Pa indices and whether they provide hype or hope. It notes that iFR and FFR have similar diagnostic power in predicting ischemia compared to PET imaging. While FFR adoption is low due to the need for vasodilators, iFR does not require vasodilators and could be more easily adopted. iFR pullbacks may help identify diffuse or tandem disease better than whole cycle Pd/Pa measurements. Physiology combined with angiography can confirm ischemia, identify significant lesions, guide post-PCI assessment, and allow co-registration of anatomical and physiological data.
The Division at St Luke’s–Roosevelt endorses the position of the Society for Vascular Surgery that carotid artery surgery is superior to carotid stenting based on results from the CREST and ICSS trials. While both CEA and CAS can prevent stroke, CEA has fewer complications and is therefore the preferred treatment according to ICSS. CREST showed CEA and CAS were equivalent when measuring all complications together, but strokes occurred more after stenting.
This document discusses treatments for radial artery occlusion (RAO) following transradial catheterization. It describes pharmacological treatments including low molecular weight heparin and anticoagulation as well as non-pharmacological options such as ulnar artery compression, percutaneous interventions, and surgery. Ulnar artery compression is highlighted as a simple, safe, and effective method for treating RAO. A new combined approach using balloon angioplasty and localized intra-arterial abciximab is also discussed but requires further validation. Overall, the best approach is prevention of RAO by ensuring patent hemostasis and using slender techniques.
This document discusses the practice of performing Allen's test or oximetry prior to radial artery catheterization. It summarizes that:
1) There is no Class I evidence or randomized data showing the predictive value of Allen's test, and the significance of an abnormal test is unclear.
2) A study found no differences in outcomes between patients with normal, intermediate, or abnormal Allen's tests, suggesting no risk from an abnormal test.
3) Recommendations are that there is no evidence to support performing Allen's test or testing for dual circulation to prevent ischemic complications of transradial catheterization. Attention should instead focus on techniques to guide hemostasis after the procedure.
The document discusses left atrial appendage (LAA) closure as an alternative to anticoagulation for stroke prevention in atrial fibrillation patients. It summarizes several studies on the Watchman device that found LAA closure to be non-inferior to warfarin for stroke risk reduction, with higher risks of complications. The ACP registry showed periprocedural complication rates with LAA closure decreased over time from 7% to 3.4% as operators gained more experience with the procedure. Overall, LAA closure is a viable alternative to anticoagulation for stroke prevention when anticoagulation is contraindicated or poses high bleeding risks, though periprocedural complications remain higher than medical management
The document summarizes the proposed SAFE-PCI for Women study, which aims to determine the efficacy and feasibility of the transradial approach to PCI in women compared to the transfemoral approach. The randomized controlled trial plans to enroll 1,800 female patients undergoing elective or urgent PCI at 30 sites. The primary endpoint is a composite of major bleeding or major vascular complications within 72 hours or discharge. Secondary endpoints include procedure time and radiation/contrast use. Funding support is provided through the American Recovery and Reinvestment Act.
- LVADs are increasingly being used as a bridge to transplant or destination therapy for advanced heart failure. The number of LVAD implants has grown significantly in recent years and is projected to continue growing as destination therapy becomes more common. LVADs have been shown to improve functional status and quality of life in heart failure patients. While expensive, LVADs can provide survival benefits over medical management for advanced heart failure when transplant is not available. Ongoing research continues to improve device design and outcomes.
Practice guidelines for_central_venous_access__a.13Felipe Posada
This document provides guidelines for central venous access developed by the American Society of Anesthesiologists Task Force. It defines central venous access, outlines the purposes for developing the guidelines which are to provide guidance on placement and management of central lines and reduce adverse outcomes. It focuses on elective procedures performed by anesthesiologists and provides definitions but does not address clinical indications, emergency placement, peripherally inserted central catheters, pulmonary artery catheters, tunneled lines, or infectious complications treatment. The guidelines are intended for use by anesthesiologists and those under their supervision.
Current concept in the diagnosis, treatment and rehabilitation of patients wi...Ramachandra Barik
This document provides an overview of current concepts in the diagnosis, treatment, and rehabilitation of patients with congestive heart failure (HF). It discusses the classification of HF based on left ventricular ejection fraction into HF with preserved, reduced, or mid-range ejection fraction. The diagnosis of HF is primarily clinical based on symptoms, exam, imaging, and biomarkers. New diagnostic algorithms have been recommended for HF with preserved ejection fraction. Treatment options for HF with reduced ejection fraction have improved outcomes and a new term for recovered left ventricular function has emerged. Cardiac rehabilitation is an important part of HF management and has been shown to improve exercise capacity, quality of life, and reduce hospitalizations.
Radial access for primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients reduces bleeding complications compared to femoral access. Several randomized controlled trials showed lower all-cause mortality with radial versus femoral access when performed by experienced radial operators. However, the studies only included radial operators, so it is unclear if the benefits seen with radial access would apply if femoral operators performed radial procedures or vice versa. Additionally, radial access requires experienced operators at high-volume centers, and the definition of an experienced radial operator remains uncertain due to the steep learning curve for radial procedures. The primary goal of primary PCI in STEMI is restoring blood flow to the heart, not avoiding access site complications.
This document summarizes various studies comparing right and left radial approaches for cardiac catheterization. It begins by outlining several previous studies that found no differences in outcomes between right and left approaches. It then describes a new study comparing right versus left radial access in high-risk patients (elderly, female, hypertensive, short height) done by fellows under supervision. In this study, the left radial approach was associated with shorter fluoroscopy times and less contrast use, suggesting it may be preferable for difficult cases done by new operators.
1) The document describes two studies comparing the left radial approach (LRA) and right radial approach (RRA) for coronary angiography and primary PCI in Chinese patients.
2) In the first study, LRA was associated with shorter procedure time and fluoroscopy time compared to RRA for coronary angiography.
3) In the second study on primary PCI for STEMI, LRA was associated with earlier blood flow restoration in the infarct artery and lower radiation exposure compared to RRA.
4) Based on the results, LRA may be preferable to RRA due to lower subclavian tortuosity, easier catheter manipulation, and less radiation exposure, especially for urgent cases requiring faster procedures.
Manejo perioperatorio de la terapia antitrombótica, chest, 2012Felipe Posada
This guideline addresses the perioperative management of anticoagulant and antiplatelet therapy in patients requiring elective surgery or procedures. Key recommendations include:
1) Stopping vitamin K antagonists (VKAs) 5 days before surgery instead of shorter durations.
2) Bridging anticoagulation for patients at high risk of thrombosis during VKA interruption, such as those with mechanical heart valves or atrial fibrillation.
3) Continuing aspirin in moderate-to-high risk patients undergoing non-cardiac surgery instead of stopping 7-10 days before surgery.
The recommendations aim to simplify management and minimize risks of thrombosis and bleeding in the perioperative period.
This document discusses the learning curve for radial angiography and coronary interventions. It summarizes a study that found procedural success rates increase as operators gain more experience, with odds of failure decreasing by 8% for every 10 additional cases and 32% for 50 cases. The document recommends novice operators complete a minimum of 50 radial cases to achieve success rates similar to experienced operators. It also provides tips for the learning phase, such as using technology like hydrophilic sheaths, selecting less complex patients, and performing radial angiography before radial PCI.
This review article discusses aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI). It notes that AR is more common after TAVI than surgical aortic valve replacement, with mild AR observed in about 70% of TAVI patients. Even mild AR has been linked to decreased survival up to two years after the procedure. The review aims to provide an overview of the three types of AR that can occur after TAVI - transvalvular, paravalvular, and supraskirtal - focusing on their different pathophysiological mechanisms. Accurate evaluation and classification of AR is important for understanding its implications, but challenging due to limitations of echocardiography for assessing transcatheter
Carotid vascular disease is a leading cause of stroke in the US. Treatment options include carotid endarterectomy (CEA) surgery and nonsurgical carotid revascularization using angioplasty and stenting. Studies have shown conflicting results comparing the two approaches. CEA is generally recommended but angioplasty and stenting may be better for high-risk surgical patients or those with significant comorbidities. More research is still needed to refine treatment recommendations.
This document provides information about warfarin therapy for patients with mechanical heart valves, including:
1) Warfarin is the anticoagulant most commonly prescribed for patients with mechanical heart valves to reduce the risk of blood clots and thromboembolism by inhibiting vitamin K-dependent clotting factors.
2) The main risk of warfarin is hemorrhage, with 2-5% of patients experiencing major bleeding annually. Intracranial bleeding risk is 0.2-0.4% annually and fatal bleeding risk is 0.5-1.0% annually.
3) Warfarin is given orally once daily and the international normalized ratio (INR)
The FDA approved the anti-clotting drug Savaysa to reduce the risk of stroke and dangerous blood clots in patients with atrial fibrillation or those who have been treated for deep vein thrombosis or pulmonary embolism. Clinical trials showed Savaysa to be as effective as warfarin for atrial fibrillation patients and in reducing the risk of recurrence of blood clots for DVT/PE patients, with significantly less major bleeding compared to warfarin. Savaysa carries a warning about the risk of bleeding and has certain dosage limitations.
This document discusses periprocedural management of new oral anticoagulants in patients undergoing atrial fibrillation ablation. It compares the pharmacological properties of new oral anticoagulants like dabigatran, rivaroxaban, and apixaban to warfarin. It also examines the need for anticoagulation before, during, and after ablation to balance thromboembolic and bleeding risks. Guidelines recommend at least 4 weeks of pre-ablation anticoagulation, anticoagulation during the procedure is important to prevent clots, and post-ablation anticoagulation is needed for weeks due to tissue healing.
The document discusses diagnosis of disease in patients. It states that the first step is understanding a patient's medical history and symptoms. The next step is a physical examination, which includes inspection, palpation, percussion, and auscultation to examine the body. Blood pressure is also measured using a sphygmomanometer. The document then discusses arterial lines that are inserted into arteries to continuously and accurately monitor blood pressure.
1) The document discusses aortoiliac aneurysms, including definitions, epidemiology, risk factors, rupture risk, associated aneurysms, pathophysiology, diagnosis, imaging, decision making for treatment, medical management, and indications for intervention.
2) Key risk factors for aneurysm rupture include diameter greater than 5.5 cm, female sex, smoking, and saccular aneurysm morphology. Imaging recommendations include ultrasound screening and CT or MRI for diagnosis.
3) Treatment is generally recommended for aneurysms greater than 5.5 cm in men or 5 cm in women, or those showing rapid growth. Immediate repair is indicated for ruptured aneurysms.
Surgical management of valvular heart diseaseSaurabh Potdar
This document discusses the surgical management of valvular heart disease. It covers general considerations for valve disease etiology and diagnosis. It describes the different types of prosthetic valves including mechanical and bioprosthetic options. It provides details on the surgical treatment of specific valve diseases like aortic stenosis, aortic regurgitation, and choices for valve replacement or repair. Surgical intervention is usually recommended for severe symptomatic valve disease and aims to improve hemodynamics and clinical outcomes, though risks vary based on patient factors.
Aim: To evaluate the effectiveness of simultaneous TAVI and coronary stenting in elderly and old patients with AVAS and CAD at high surgical risk.
Methods: The study comprised 121 patients who underwent TAVI. They were assigned to two groups: I–patients who underwent TAVI with simultaneous coronary stenting (n = 30); II–patients with AVAS without severe stenotic changes in the coronary arteries. They underwent only TAVI (n = 91). The in-hospital period and the mid-term results have been studied.
Results: The success of simultaneous TAVI and PCI was 100%. There were no intra- or perioperative deaths, acute myocardial infarction, acute brain stroke, or acute renal failure requiring dialysis. During the 6-month followup, one patient died from cancer. There were no other serious complications. The left bundle branch block occurred in 23.3% of cases and regurgitation (leakage) on the aortic valve in 6.6% of cases. Conclusion: Simultaneous TAVI and coronary stenting in elderly and old patients with severe aortic stenosis and CAD are feasible and safe. Within the first 30 days after the procedure, there were no significant differences in mortality and severe complication rates between the two groups.
This document provides guidelines for the management of patients with valvular heart disease developed by the 2020 ACC/AHA Writing Committee. It summarizes the top 10 key recommendations from the guidelines which include classifying disease stages, evaluating patients with noninvasive testing and further testing as needed, treating severe valve disease based on symptoms, involving a multidisciplinary team for severe cases, expanding indications for transcatheter interventions, and treating atrial fibrillation in patients with valvular heart disease with oral anticoagulants. It also provides tables outlining diagnostic testing, disease stages, secondary prevention of rheumatic fever, and anticoagulation recommendations for atrial fibrillation in patients with valvular heart disease.
This document discusses methods for preventing deep vein thrombosis (DVT) in hospitalized patients. It describes risk factors for DVT including Virchow's triad of stasis, vessel injury, and hypercoagulability. Guidelines recommend different prophylaxis methods depending on patient risk factors and surgery type, including mechanical methods, anticoagulants, and combination approaches. Outcomes of interest include asymptomatic and symptomatic DVT and pulmonary embolism.
Reversal of warfarin associated coagulopathy prothrombin complex concentratesTÀI LIỆU NGÀNH MAY
Để xem full tài liệu Xin vui long liên hệ page để được hỗ trợ
: https://www.facebook.com/thuvienluanvan01
HOẶC
https://www.facebook.com/garmentspace/
https://www.facebook.com/thuvienluanvan01
https://www.facebook.com/thuvienluanvan01
tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
The document discusses major late bleeding complications (MLBCs) occurring between 30 days and 1 year after transcatheter aortic valve replacement (TAVR) based on results from the PARTNER trial. It was found that MLBCs occurred in around 6% of patients and were associated with increased mortality. Experts discussed that while MLBCs were frequent in PARTNER, TAVR remains a viable option for inoperable or high-risk patients. With improvements to antithrombotic therapy and device technology, the risk of MLBCs can be reduced, allowing TAVR to be more widely used in clinical practice for treating severe aortic stenosis.
This randomized controlled trial studied whether continuing or stopping aspirin before coronary artery surgery affected outcomes. Over 5,000 patients undergoing coronary artery surgery were assessed for eligibility, and 2,100 were enrolled and randomly assigned to receive preoperative aspirin (1,047 patients) or placebo (1,053 patients). The primary outcome, a composite of death or thrombotic complications within 30 days, occurred in 19.3% of the aspirin group and 20.4% of the placebo group, with no significant difference. Major hemorrhage rates were also similar between groups, though cardiac tamponade occurred slightly more in the aspirin group. The study found that preoperative aspirin did not reduce thrombotic risks or increase
Preop evaluation of cardiac patient postd=ed for non cardiac surgery Rajesh Munigial
This document discusses pre-operative evaluation and preparation of cardiac patients for non-cardiac surgeries. It outlines that patients with coronary artery disease undergoing non-cardiac surgery are at increased risk of complications. A thorough pre-operative evaluation including history, physical exam, diagnostic tests, and knowledge of the planned surgery is important to assess risk factors and develop a management plan. Tests like ECG, stress testing, echocardiogram and in some cases angiography help evaluate cardiac status. Medical optimization including management of angina, heart failure, diabetes, etc. can help reduce perioperative risk. Timing of surgery depends on the clinical status and risk of delay. Intraoperative management focuses on preventing ischemia.
Statin therapy associated with improved thrombus resolution in patients with ...TÀI LIỆU NGÀNH MAY
Để xem full tài liệu Xin vui long liên hệ page để được hỗ trợ
: https://www.facebook.com/thuvienluanvan01
HOẶC
https://www.facebook.com/garmentspace/
https://www.facebook.com/thuvienluanvan01
https://www.facebook.com/thuvienluanvan01
tai lieu tong hop, thu vien luan van, luan van tong hop, do an chuyen nganh
Trasnscatheter Aortic Valve Replacement and AnesthesiaCarlos D A Bersot
1) The document discusses the use of prophylactic vasopressor infusions such as epinephrine and norepinephrine during transcatheter aortic valve replacement (TAVR) procedures.
2) TAVR involves rapid ventricular pacing which can cause hemodynamic instability, so prophylactic vasopressor infusion may help with hemodynamic recovery after pacing.
3) The authors comment that maintaining adequate blood pressure and volume status prior to pacing, as well as vasopressor support if needed after, can help prevent complications from hypotension during the TAVR procedure.
Trasnscatheter Aortic Valve Replacement and Anesthesia
TAVRb
1. K E L S E Y T E R R E S O N , S P T
M E M O R I A L H E R M A N N S O U T H W E S T H O S P I T A L
TAVR Procedure and Physical
Therapy Implications
2. Objectives
Know what the TAVR procedure is
Understand the patient population that is
appropriate for a TAVR
Understand the PT implications for patients with a
TAVR
Know where to find more information about TAVRs
3. What is a TAVR?
Transcatheter Aortic Valve Replacement procedure
or TAVR was approved by the FDA in 2011 to replace
the aortic valve in patients that would be considered
too risky for an open heart AVR (Surgical AVR,
SAVR or simply AVR). (1)
4. Quick Video
Video shows the procedure
https://www.youtube.com/watch?v=csxJYTLXNJY
6. TAVR
Can be performed without cardiac arrest or
cardiopulmonary bypass, so the procedure is minimally
invasive
The artificial valve is inserted through a catheter through
a transfemoral or a transapical incision.
Surgeon preference (2)
State of patient vascular disease
Transfemoral more common (2).
As of Fall 2012, 45,000 TAVRs had been performed
worldwide (3).
Ruben et al estimated that there are approximately 290,000 elderly
candidates for the TAVR in Europe and North America, and that
approximately 27,000 become candidates each year (4)
7. A procedure for severe Aortic stenosis…
AS can be caused by congenital defect or rheumatic
diseases.
In the elderly, calcium deposits can build up on the aortic
valve leaflets making it more difficult for them to open
and close. (5)
Stenosis of the aortic valves increases the resistance the
heart has to pump against in order to pump blood to the
tissues.
Additionally, aortic stenosis decreases the amount of
blood that can be pumped as the opening to the aorta is
narrowed
Symptomatic patients often present with chest pain,
dizziness, and fatigue.
Patients are not generally symtomatic until the stenosis is fairly
severe.
8. …for patients who are NOT candidates for Open
Heart Surgery
Candidacy for open heart surgery is determined with a
thorough evaluation of risk factors, generally with the use
of the Society of Thoracic Surgeons (STS) scale.
The scale and risk classification themselves are very
complicated.
There AVR subportion give a patient’s relative risks and probabilites
of undergoing specific adverse events such as stroke post-operatively
or their likelhood of having a longer length of stay This is all based
on age, gender, race and an extensive look at the patient’s
comorbitities.
In general increased age, multiple comorbities or
chronic diseases, poor health habits, and obesity
are risk factors for open heart surgery.
9. Who is a TAVR for?
Patients with severe, symptomatic aortic stenosis
that are not appropriate for the SAVR procedure.
Mild levels of stenosis will likely be medically managed.
Moderate levels of stenosis are sometimes medically managed
and sometimes SAVRs are done.
These patients often have multiple other health
complications, are often in their 60s, 70s or 80s
10. Who is it NOT for?
Patients with bleeding disorders
Patients who can’t tolerate anticoagulant therapy
Other heart valve disease or replacement
Patients whose aortic valve is not calcified
Severe pre-existing kidney disease
Abnormal growth in their heart or abdomen
11. Additional Information
Patients with severe symptomatic aortic stenosis that
do not receive the TAVR tend do poorly and have
extremely high mortality rates, especially in
nonsurgical groups, and loss of quality of life in
surgical groups (6)
Compared the SAVR decreased risk of bleeding
complications (7)
Among patients with diabetes, severe aortic stenosis
and high risk for AVR there was a decreased risk of
renal failure, survival benefit and no increase in
stroke (8)
12. Potential Complications
Because this procedure was so recently approved the
long term complications are not fully known.
The PARTNER I and PARTNER II trials are investigating this
In a TAVR the stenotic valves are not removed, but
just moved aside.
Complications include:
Stroke 11/100 within one year (9)
Death 31/100 within one year (9)
13. Risks within 1 Year after the TAVR (9)
TAVR Standard Medical
Therapy
Death
- From any cause
- From CV cause
- 31/100 patients
- 20/100 patients
-50/100 patients
- 42/100 patients
Repeat hospitalizations 22/100 patients 44/100 patients
Major vascular
complications
17/100 2/100
Bleeding event 17/100 2/100
Stroke 11/100 5/100
14. Physical Therapy Implications
Patients should experience improved blood flow
immediately after the procedure. ICU and HV care
will be directed at getting the patient moving
again.(10)
Chances are, due to to their advanced age and
comorbities will likely have other orthopedic and
potentially neurologic problems.
15. Physical Therapy Implications Continued
Good for us to screen for gastric bleeding, as use of
ibuprofen, corticosteroids, heparin and some
antidepressants can increase the risk for generalized
bleeding when used with aspirin therapy. (11)
Patients may be more likely to bruise.
If they are in additional pain they can still take ibuprofen, but
they shouldn’t take it at the same time as the aspirin. (11)
16. Physical Therapy Implications Continued
U.S. Department of Health and Human Services (12)
Aspirin therapy increases risk for hemorrhagic stroke in males by a
factor of 1.7. Does not appear to increase the risk of hemorrhagic
stroke in females.
Increases the risk of GI bleeding, and that risk increases with age
Concomitant use of NSAIDS with aspirin increases the risk of GI
bleeding or GI pain by a factor of 2-3. Concomitant use increases the
risk of serious GI complication by a factor of 3-4.
Bissonault and Meek. Risk factors for anti-inflammatory-
drug or aspirin induced gastrointestinal complications in
individuals receiving outpatient physical therapy
services. (13)
22.3% of respondents reported concomitant use of aspirin and
ibuprofen.
15.7% were over the age of 61
17. Where to find out more
https://www.youtube.com/watch?v=QkQ5tdL15GI
Interview discussing what a TAVR is, more on the patient
population, and post-op care looks like
http://www.uclahealth.org/site.cfm?id=2139
Information from UCLA health on the procedure, the
bioprosthesis
Edwards Lifesciences, “Transcatheter Aortic Valve
Replacement for Patients who Cannot Have Open-
Heart Surgery”. (6)
18. Next Steps in Research
Should evaluate and explore the effectiveness of PT
in caring for these patients post-operatively
PARTNER Trials will continue to look at these
patients long term.
19. Summary
TAVR is a minimally invasive procedure to correct
severe aortic stenosis
Patients that have the TAVR procedure will be on
aspirin for the rest of their lives and therefore may be
at an increased risk for bleeding, bruising, stroke
Patients that are candidates for the TAVR, but not
for SAVR are likely older or in generally poorer
health
Additional information about the TAVR procedure
can be found by looking at the previous slide
Treat the whole patient Like always.
22. References
1. FDA. Medical Devices: Edwards SAPIEN Transcatheter Heart Valve (THV). FDA website. 2013. Available at
http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DevicesApprovalsandClearances/Recently-
ApprovedDevices/UCM280840.Accessed November 30, 2013.
2. Walther, T., Kemfert, J. (2012). Transapical vs. transfemoral aortic valve implantation: Which approach for which patient, from a
surgeons standpoint. Annals of Cardiothoracic Surgery, 1,(2). 216-219
3. St. Joseph’s Healthcare Services. Transcatheter Aortic Valve Replacement (TAVR) Program. St. Joseph’s Patient Care Services
website.2012. http://www.sjhsyr.org/TAVR#.UqZcT2RDsxI. Accessed December 8, 2013.
4. Osnabrugge, R, Mylotte, D, Head, S et al. Aortic Stenosis in the elderly: Disease Prevalence and number of Candidates
Transcatheter Aortic Valve Replacement: A Meta-analysis and Modeling study. Journal of American College of Cardiology.
September 10, 2013. 62(11):1002-1012.
5. Penn Medicine. Severe Aortic Stenosis and Transcatheter Aortic Replacement. Penn Medicine Heart Disease website. Available at:
http://www.pennmedicine.org/heart/patient/clinical-services/heart-valve-disease/tavr-faq.html. Accessed December 1, 2013.
6. Ben-Dor, I, MD, Pichard, A, MD, et al. Correlates and Causes of Death in Patients with Severe Symptomatic Aortic Stenosis Who
are Not Eligible to Participate in a Clinical Trial of Transcatheter Aortic Valve Implantation. Circulation. 2010: 122[suppl 1]:S37–
S42.
7.. Genereaux, P, MD, Cohen, D, MD, MSc, et al. Bleeding Complications After Surgical Aortic Valve Replacement (SAVR) versus the
Transcatheter Aortic Valve Replacement (TAVR). Journal of American College of Cardiology. Available online November 27, 2013.
8 Selkow, W. Candidates for Open Heart Surgery or Who is Most Likely to Survive Open Heart Surgery. Simple Hand Website. 2010.
Available at http://www.simplehand.org/heart-surgery/. Accessed November 22, 2013.
9. Edwards Lifesciences. Transcatheter Aortic Valve Replacement for Patients who Cannot Have Open-Heart Surgery. Irvine, USA.:
Edwards Lifesciences Corporation; 2011. Available at: http://www.mainehealth.org/workfiles/mmc_cardiac/TAVR-Patient-
Brochure.pdf. Accessed December 1, 2013.
10. Lindman, M, MD, MSCI, Pibarot, P, DVM, PhD, et al. Transcatheter versus Surgical Aortic Valve Replacement in Patients with
Diabetes and Severe Aortic Stenosis at High Risk for Surgery: An Analysis of the PARTNER Trial. Journal of American College of
Cardiology. Available online November 27, 2013.
11. Mayo Clinic. Daily aspirin therapy: Understand the risks and benefits. Mayo Clinic Heart Disease website. April 6, 2012.
http://www.mayoclinic.com/health/daily-aspirin-therapy/HB00073/NSECTIONGROUP=2. Accessed December 8,2013.
12. U.S. Department of Human and Health Services. Using Aspirin for the Primary Prevention of Cardiovascular Disease. Agency for
Healthcare Research Quality. June 2009. http://www.ahrq.gov/professionals/clinicians-providers/resources/aspprovider.html.
Accessed December 8, 2013.
13. Bissonault, WG, Meek, PD. Risk factors for anti-inflammatory-drug or aspirin induced gastrointestinal complications in
individuals receiving outpatient physical therapy services. Journal of Orthopedic Sports Physical Therapy. (Oct 2002). 32: 510-517.
14. UCLA Health. Transcatheter Aortic Valve Replacement (TAVR). UCLA Health website.
http://www.uclahealth.org/site.cfm?id=2139. Accessed November 27, 2013.