Acquired thrombocytopenia after transcatheter aortic valve replacement: clinical correlates and association with outcomes

Dvir, Danny; Généreux, Philippe; Barbash, Israel M.; Kodali, Susheel; Ben‐Dor, Itsik; Williams, Mathew; Torguson, Rebecca; Kirtane, Ajay J.; Minha, Sa’ar; Badr, Salem; Pendyala, Lakshmana; Loh, Joshua P.; Okubagzi, Petros; Fields, Jessica N.; Xu, Ke; Chen, Fang; Hahn, Rebecca T.; Satler, Lowell F.; Smith, Craig R.; Pichard, Augusto D.; Leon, Martin B.; Waksman, Ron

doi:10.1093/eurheartj/ehu082

Cited by 77 publications

(116 citation statements)

References 30 publications

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“…Declines in platelet count, diagnosed as thrombocytopenic events, are commonly found in critically ill patients 5, 6. Postoperative thrombocytopenia was associated with worsened outcomes after VRS 7, 8. However, few studies have explored the prognostic value of baseline platelet counts in patients who underwent VRS, especially in the context of RHD.…”

Section: Introductionmentioning

confidence: 99%

Thrombocytopenia as a Preoperative Risk Assessment Tool in Patients With Rheumatic Heart Disease Undergoing Valve Replacement Surgery

Wei

Jiang

Liu

et al. 2017

JAHA

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BackgroundPostoperative thrombocytopenia has been reported to be correlated with adverse events, but the prognostic value of baseline thrombocytopenia is unclear. This study was undertaken to evaluate the relationship between preoperative thrombocytopenia and adverse outcomes in patients with rheumatic heart disease who underwent valve replacement surgery.Methods and ResultsA total of 1789 patients with rheumatic heart disease undergoing valve replacement surgery were consecutively enrolled and postoperatively followed up for 1 year. Patients were stratified on the basis of presence (n=495) or absence (n=1294) of thrombocytopenia (platelet count, <150×109/L), according to hospital admission platelet counts. During the hospitalization period, 69 patients (3.9%) died. The in‐hospital all‐cause mortality rate was significantly higher in the thrombocytopenic group (6.9% versus 2.7%; P<0.001). Multivariate analyses revealed that thrombocytopenia was independently associated with in‐hospital all‐cause mortality (odds ratio, 2.21; 95% confidence interval, 1.29–3.80; P=0.004). Platelet counts could predict in‐hospital all‐cause mortality for patients both with and without previous atrial fibrillation (areas under the curve, 0.708 [P<0.001] and 0.610 [P=0.025], respectively). One‐year survival was significantly lower in patients with thrombocytopenia compared with controls (91.3% versus 96.1%; log‐rank=14.65; P<0.001). In addition, thrombocytopenia was an independent predictor for postoperative 1‐year all‐cause mortality in multivariate Cox regression analysis.ConclusionsPlatelet counts, as simple and inexpensive indexes, were reliable to be used as a preoperative risk assessment tool for patients with rheumatic heart disease undergoing valve replacement surgery.

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Section: Introductionmentioning

confidence: 99%

Thrombocytopenia as a Preoperative Risk Assessment Tool in Patients With Rheumatic Heart Disease Undergoing Valve Replacement Surgery

Wei

Jiang

Liu

et al. 2017

JAHA

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“…Thrombocytopenia is common after TAVI, occurring in more than one-third of patients to a significant degree, mostly within the first three postoperative days. [34][35][36] The cause of thrombocytopenia after TAVI is currently unknown, and could be a consumptive mechanism at the valve site, hemolysis, or bone marrow suppression. 34) Although it is also unknown whether the hyper-response to clopidogrel is related to thrombocytopenia after TAVI, the potential risk of bleeding should be considered in patients undergoing TAVI.…”

Section: Discussionmentioning

confidence: 99%

Hyper-Response to Clopidogrel in Japanese Patients Undergoing Transcatheter Aortic Valve Implantation

et al. 2016

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SummaryDual antiplatelet therapy is empirically recommended following transcatheter aortic valve implantation (TAVI). The aims of the present study were to analyze the effect of clopidogrel on platelet function and to determine the relative contribution of each CYP2C19 loss-of-function genotype undergoing TAVI.Thirty-two patients undergoing TAVI and with clopidogrel treatment were studied. All patients were treated with an Edwards SapienXT valve. Platelet reactivity was measured by the VerifyNow P2Y12 point-of-care assay at 7 days and 30 days after the procedure and a cutoff value of 95 PRU was used to identify a hyper-response of platelet reactivity. The Spartan RX TM sample-to-result point-of-care DNA testing system was used to identify CYP2C19 loss-of-function genotypes. Hyper-response of platelet reactivity was identified in 11 (34.3%) patients, although 24 (80%) were carriers of at least one CYP2C19 reduced-function allele. The PRU values did not change significantly from 7 days to 30 days after TAVI (136.7 ± 73.4 versus 150.4 ± 83.2, P = 0.13). The incidences of life-threatening bleeding, minor bleeding, and transfusion were significantly higher among the hyper-response of platelet reactivity group (27.3% versus 0%, P = 0.03, 36.4% versus 4.8%, P = 0.04, 81.8% versus 42.9%, P = 0.04, respectively).A hyper-response to clopidogrel was observed in one-third of patients undergoing TAVI and was related to bleeding events, even though 80% of the patients were carriers of the CYP2C19 reduced-function allele. (Int Heart J 2016; 57: 190-197) Key words: Platelet function tests, Antiplatelet therapy T ranscatheter aortic valve implantation (TAVI) has emerged as a viable therapeutic option for patients with severe symptomatic aortic stenosis (AS). 1,2)However, special attention should be paid to potential periprocedural and early complications, including ischemic (stroke, myocardial infarction) or bleeding (access site complication) events. 3,4) After TAVI, guidelines recommend the use of clopidogrel in addition to aspirin for a 3-to 6-month period. 5-7)While this strategy has been accepted as the usual practice following TAVI, the recommendation remains empirical and prospective controlled trials are lacking. Few data have been reported regarding the effectiveness of clopidogrel in the TAVI setting or its possible impact on adverse events.Results from previous studies in patients treated with clopidogrel have shown wide variability in platelet responsiveness, and high platelet reactivity under clopidogrel treatment has been linked to stent thrombosis and adverse cardiovascular events after coronary stenting. [8][9][10][11][12][13][14] Notably, there exists a subset of patients with a hyper-response to clopidogrel who may be at increased risk of bleeding complications. 15,16) Genetic polymorphism of the CYP2C19 allele, crucial to the metabolism of clopidogrel into its active metabolite, has been implicated as a mechanism of both hyper-and hypo-response. A loss-of-function polymorphism in CYP2C19, known as the CYP2...

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“…Studies have shown that TP can be caused by hemodilution, platelet activation, bone marrow suppression, and mechanical destruction [6,7,8]. Post-TAVR TP has been compared with TP after other cardiac interventions and surgery, and study results reveal that TP is more common and severe after TAVR than after percutaneous coronary intervention and balloon aortic valvuloplasty, but similar to after surgical aortic valve replacement [9,10,11,12,13,14]. A 2-center, large-scale study proved that severe TP can lead to poor clinical outcomes, thus highlighting its significance in post-TAVR management [10].…”

Section: Introductionmentioning

confidence: 99%

“…Post-TAVR TP has been compared with TP after other cardiac interventions and surgery, and study results reveal that TP is more common and severe after TAVR than after percutaneous coronary intervention and balloon aortic valvuloplasty, but similar to after surgical aortic valve replacement [9,10,11,12,13,14]. A 2-center, large-scale study proved that severe TP can lead to poor clinical outcomes, thus highlighting its significance in post-TAVR management [10]. Several studies concerning post-TAVR TP have been conducted, but their conclusions about the predictors and clinical outcomes of TP differ.…”

Section: Introductionmentioning

confidence: 99%

Predictors of Thrombocytopenia after Self-Expandable Transcatheter Aortic Valve Replacement: A Single-Center Experience from China

Zhu¹,

Liu²,

et al. 2018

Cardiology

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Objectives: The importance of thrombocytopenia (TP) has been discussed previously. However, data are still limited, especially on predictors of TP. We sought to investigate predictors of TP after transcatheter aortic valve replacement (TAVR), in particular, clinically significant TP. Methods: We reviewed a total of 123 consecutive patients undergoing TAVR in our medical center. They were stratified into 3 groups according to the nadir platelet count post-TAVR: no/mild TP, moderate TP, and severe TP. Clinically significant TP, also known as major TP, was defined as moderate-to-severe TP (a nadir platelet count <100 × 10⁹/L and a >50% decrease in platelet count). Results: Baseline platelet, baseline hemoglobin, general anesthesia (GA), valve malpositioning and post-TAVR left ventricular ejection fraction were found to be predictors of post-TAVR nadir platelet count. Major TP was associated with a higher risk of major bleeding (OR 3.524, 95% CI 1.546-8.031) and 1-month mortality (OR 11.226, 95% CI 1.208-104.328). Age (OR 1.110, 95% CI 1.014-1.215) and GA (OR 6.494, 95% CI 2.058-20.408) were predictors of major TP. Conclusion: Post-TAVR nadir platelet count can be predicted based on baseline and procedural data. Old age and GA contribute to clinically significant TP.

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Acquired thrombocytopenia after transcatheter aortic valve replacement: clinical correlates and association with outcomes

Abstract: Acquired thrombocytopenia was common after TAVR and was mostly resolved at patient discharge. The severity of thrombocytopenia after TAVR could be used as an excellent, easily obtainable, marker for worse short- and long-term outcomes after the procedure.

Cited by 77 publications

References 30 publications

Thrombocytopenia as a Preoperative Risk Assessment Tool in Patients With Rheumatic Heart Disease Undergoing Valve Replacement Surgery

Thrombocytopenia as a Preoperative Risk Assessment Tool in Patients With Rheumatic Heart Disease Undergoing Valve Replacement Surgery

Hyper-Response to Clopidogrel in Japanese Patients Undergoing Transcatheter Aortic Valve Implantation

Predictors of Thrombocytopenia after Self-Expandable Transcatheter Aortic Valve Replacement: A Single-Center Experience from China

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