Bridging Anticoagulation

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JACC VOL. 67, NO. 7, 2016

Letters

FEBRUARY 23, 2016:889–94

The procedure was performed with the patient

When considering the percutaneous mitral valve

under general anesthesia with access from the right

repair system for tricuspid valve repair, several

femoral vein. The 24-F steerable guide catheter was

requirements must be met: 1) a large right atrium

positioned over a stiff guidewire into the right atrium.

for guide catheter steering; 2) sufficient coaptation

The guide catheter was then slightly pulled back, and

to get enough tissue for the (first) clip; 3) good

the tip was flexed. Thereafter, the clip was advanced

echocardiographic visibility, which is crucial and

forward until the bullet nose protruded from the tip of

might be a problem in the presence of valve pros-

the guide catheter. The clip was positioned perpen-

thesis or severe calcification of the mitral annulus;

dicular to the tricuspid valve by anterior movement

4) avoiding deep diving into or extensive move-

and bending of the guide catheter. Using deep trans-

ments of the clip in the right ventricle to prevent

gastric mid- and deep esophageal 2- and 3-dimensional

chordae rupture.

transesophageal echocardiography views, the appro-

This is the first description of a new interventional

priate clip arm orientation was adjusted, the clip was

approach for transfemoral tricuspid repair using the

advanced into the right ventricle slightly under the

percutaneous mitral valve repair system. Larger

leaflets, which were then captured. After implantation of a single clip, TR was reduced from severe to mild (Figure 1). At discharge, the

studies are required to confirm the feasibility, safety, and efficacy of the percutaneous mitral valve repair therapy in patients with severe TR.

patient’s symptoms significantly improved, transthoracic echocardiography demonstrated a stable clip position and sustained reduction of TR. We report the first transfemoral implantation of the MitraClip in a tricuspid valve with severe functional TR that resulted in a significant TR reduction. Therapeutic options for those patients are limited. Therefore, less invasive and safer therapeutic solutions are needed for this ever-growing patient population. A few transcatheter-based treatment options for TR are currently under evaluation. Laule et al. (1) reported on 3 patients with single or dual implantation with the SAPIEN XT prosthesis (Edwards Lifesciences, Irvine, California) for severe TR. This approach does not address TR itself, but may reduce the regurgitation of blood into the vena cava. With

*Joachim Schofer, MD, PhD Claudia Tiburtius, MD Christoph Hammerstingl, MD Per-Olof Dickhaut, MD Julian Witt, MD Lorenz Hansen, MD Friedrich-Christian Riess, MD, PhD Klaudija Bijuklic, MD *Albertinen Heart Center Süntelstrasse 11a 22457 Hamburg, Germany E-mail: [email protected] http://dx.doi.org/10.1016/j.jacc.2015.11.047 Please note: Dr. Hammerstingl has received honoraria from Abbott, Mitralign, and Valtech for serving as a proctor. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

improvement in 2- and 3-dimensional TEE, advanced imaging of the tricuspid valve became possible.

REFERENCES

Targeting malcoaptation, the results of 7 high-risk

1. Laule M, Stangl V, Sanad W, et al. Percutaneous transfemoral management of severe secondary tricuspid regurgitation with Edwards Sapien XT bio-

patients with severe TR who received the Forma Repair System (Edwards Lifesciences) were recently published (2). We reported on the first-in-humans transcatheter tricuspid valve repair by using a pledgeted suture (Mitralign System, Mitralign Inc., Tewksbury, Massachusetts) (3).

prosthesis: first-in-man experience. J Am Coll Cardiol 2013;61:1929–31. 2. Campelo-Parada F, Perlman G, Philippon F, et al. First-in-man experience of a novel transcatheter repair system for treating severe tricuspid regurgitation. J Am Coll Cardiol 2015;66:2475–83. 3. Schofer J, Bijuklic K, Tiburtius C, et al. First-in-human transcatheter tricuspid valve repair in a patient with severely regurgitant tricuspid valve. J Am Coll Cardiol 2015;65:1190–5.

Our patient had no shelf to use for pledget placement, but the right atrium was large enough to steer

Bridging Anticoagulation

the guide catheter and a coaptation was sufficient to grasp the leaflets in the area of significant TR. Therefore, she was deemed a suitable candidate for

The recent comprehensive and thoughtful review by

the percutaneous mitral valve repair procedure.

Drs. Rechenmacher and Fang (1) emphasizes that the

Theoretically, this procedure can be performed from

benefit of bridging anticoagulation therapy (i.e.,

the internal jugular or femoral vein. We chose the

decreasing thromboembolic events by limiting the

femoral vein as the access site because it gives more

duration of anticoagulation interruption) must be

stability to the guide catheter and facilitates steering

carefully balanced against its risk of untoward peri-

maneuvers.

procedural bleeding.

JACC VOL. 67, NO. 7, 2016

Letters

FEBRUARY 23, 2016:889–94

In our clinical experience, bleeding complications are mainly due to premature full anticoagulation in

*Stephen J. Rechenmacher, MD James C. Fang, MD

the post-procedure period. Although there is a lack of

*Department of Cardiology

supporting data, in high-risk patients (as defined in

University of Utah Health Science Center

Table 1 in their article), we use bridging anti-

30 N 1900 E, Room 4A100

coagulation only during the pre-procedure period.

Salt Lake City, Utah 84132

Post-procedure, warfarin alone is restarted. This

E-mail: [email protected]

approach was not noted by the authors in their re-

http://dx.doi.org/10.1016/j.jacc.2015.11.053

view. We feel that this strategy offers the high-risk patient the benefit of pre-procedure bridged anti-

Please note: Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.

coagulation while limiting the risk for significant post-procedure bleeding.

REFERENCE 1. Rechenmacher SJ, Fang JC. Bridging anticoagulation: primum non nocere. J Am Coll Cardiol 2015;66:1392–403.

*Marc L. Schwartz, MD Steven W. Breecker, MD *Division of Cardiology Thomas Jefferson University Hospital Suite 1518 1015 Chestnut Street Philadelphia, Pennsylvania 19107 E-mail: [email protected] http://dx.doi.org/10.1016/j.jacc.2015.10.100 Please note: Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Incidence of Stent Thrombosis With Bioresorbable Vascular Scaffolds in Comparison With Drug-Eluting Stents In evaluating the effectiveness of bioresorbable

REFERENCE

vascular scaffolds (BVS) in comparison with tradi-

1. Rechenmacher SJ, Fang JC. Bridging anticoagulation: primum non nocere. J Am Coll Cardiol 2015;66:1392–403.

tional drug-eluting stents (DES), the ABSORB China trial (1) found a remarkably low incidence of stent thrombosis in both treatment arms. This finding,

REPLY: Bridging Anticoagulation

however, differs to some extent from that found in other randomized trials aimed at this comparison.

We appreciate the interest of Drs. Schwartz and

In the same issue of the Journal, Windecker et al.

Breecker in our review (1) and appreciate their

(2) described a pairwise meta-analysis (including

approach to anticoagulation bridging. Their practice

the ABSORB China trial and 4 other randomized

of pre-procedural–only bridging may reduce throm-

controlled trials) that found no significant difference

botic events without causing hemorrhagic compli-

in stent thrombosis between BVS and DES (pooled

cations, and could be considered along with the

odds ratio for BVS vs. DES 1.86; 95% confidence in-

alternative

review

terval 0.55 to 6.27). Very recently, the results of a

(Figure 3 [1]). However, because the risk of bleeding

large-scale randomized trial comparing these 2 stents

and thrombosis varies considerably throughout the

(ABSORB III) have also been made available (3).

strategies

described

in

our

periprocedural period, only until a prospective ran-

To shed light on this controversy, we updated the

domized trial of any bridging practice is studied can a

meta-analysis of Windecker et al. (2) by including

specific practice be embraced. We agree that the

also the data of the ABSORB III trial. Although

attenuation of thromboembolism risk with bridging

Windecker et al. (2) tested both the random-effects

immediately post-procedure may paradoxically in-

model and the fixed-effects model, our results were

crease the bleeding risk during this most vulnerable

computed only according to the fixed-effects model,

period for bleeding. For this reason, we emphasize

which is the most appropriate in the presence of rare

the

events (4).

importance

of

individually

tailoring

anti-

coagulation therapy to the patient, procedure, and

According to our results (Figure 1), BVS showed, in

dynamic risk of bleeding and thrombosis. In many, if

comparison with DES, a higher incidence of stent

not most, situations, warfarin interruptions and

thrombosis that reached the threshold of statistical

bridging anticoagulation can be avoided (Central

significance

Illustration [1]).

(risk difference þ0.67%; 95% confidence interval

when

expressed

as

risk

difference

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