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Systemic Inflammation Syndrome Response after Transcatheter Aortic Valve Implantation

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Systemic Inflammation Syndrome Response after Transcatheter Aortic Valve Implantation

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Abstract


Transcatheter aortic valve implantation (TAVI) has become the standard of care in high-risk patients with severe aortic valve stenosis who are not eligible for conventional aortic valve replacement. Despite the less invasive nature of TAVI, mortality remains high. Prior studies1,2 reported that TAVI is associated with the development of systemic inflammatory response syndrome (SIRS). SIRS is a serious condition in which there is an abnormal regulation of various cytokines that directly cause a decline in remote organ function by mediating the production of nitric oxide leading to a condition of cellular inability to use oxygen. This may lead to multiple organ dysfunction syndrome (MODS), multiple organ failure syndrome (MOFS) and ultimately to death. The reason why SIRS develops following TAVI is yet unclear. It is hypothesized that due to periods of low cardiac output during the procedure, ischemia-reperfusion injury and subsequent SIRS might occur. Other studies3 suggest that bacterial translocation during low cardiac output may induce SIRS.

The main study objectives were to determine if inflammatory biomarkers can confirm and predict post-procedural SIRS and to determine if ischemia/organ damage biomarkers and gram- negative bacteria biomarkers are associated with SIRS after TAVI.

Between July 2014 and January 2015, 19 patients were enrolled for this pilot study. Blood samples were obtained pre-, peri- and post- TAVI procedure. Biomarkers that cause immunological activation or indicate ischemia/organ damage were analysed in patients plasma, using a multiplex fluorescent immunoassay (Luminex) and enzyme-linked immunosorbent assay (ELISA). Pro-inflammatory cytokines IL-1β, IL-6, IL-8, TNFα and anti-inflammatory cytokines IL-1RA (receptor antagonist), IL-10 are expected to reach high concentrations soon after the infectious stimulus. Furthermore, resulting acute phase proteins CRP and Pentraxin 3 were tested. Ischemia/ organ damage markers I-FABP (intestine) and KIM-1 (kidney) were tested in addition to LAL, LBP, EndoCab, sTREM-1 and sCD14, which could indicate translocation of gram-negative bacteria.

In the first 48 hours following TAVI, 11 patients (57,9%), developed SIRS. Four of these patients (36.4%) died during hospital intake. Peri-and post -procedural characteristics that could be potential risk factors for the development of SIRS did not show any significant difference between the SIRS and non-SIRS group. Such as use of rapid ventricular pacing (RVP) (9 vs. 7 P=1.000) number of RVP (1(IQR 0-4) vs. 1 (IQR 0-3) P=0,604) and duration of RVP (14(IQR 9-40) vs. 13 seconds (IQR 10-24) P=0.533), pre-dilatation of the native aortic valve (54.5% vs. 71.4%; P=0,637), valve- in-valve implantation (10% vs. 0%; P=1.000), post-dilatation of the valve prosthesis (45.5% vs.16.7%; P=0.333), and intervention time (89±16 v. 78±11 minutes; P=0,245).

SIRS after TAVI is common and associated with increased levels of pro-inflammatory cytokines IL-6 and IL-8 and resulting acute phase protein CRP. The combination of these cytokines can reliably and early predict the risk of developing SIRS and might enabling early treatment and increase long- term survival. Ischemia/organ damage biomarkers I-FABP and KIM-1 did not show a difference between the SIRS and non-SIRS group. Furthermore, bacterial translocation is not associated with the occurrence of SIRS, despite the elevated concentrations of gram-negative bacteria (LPS) in both groups. Our limited data do not support the hypothesis that SIRS after TAVI is caused by ischemia-reperfusion injury and/ or bacterial translocation. However, it should be noted that due to the small population, this study is purely observational, and interpretation is speculative.

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OrganisatieAvans Hogeschool
OpleidingBiologie en Medisch Laboratoriumonderzoek-Breda
AfdelingATGM Academie voor de technologie van Gezondheid en Milieu
Jaar2015
TypeBachelor
TaalOnbekend

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