Similar long-term survival after isolated bioprosthetic versus mechanical aortic valve replacement: A propensity-matched analysis

OBJECTIVES

Improved durability and preference to avoid anticoagulation have led to increasing use of bioprostheses in younger patients despite the need for eventual reoperation. Therefore, we compared in-hospital complications, reoperation, and survival after bioprosthetic and mechanical aortic valve replacement.

METHODS

From January 1990 to January 2020, 6143 patients underwent isolated aortic valve replacement at Cleveland Clinic; 637 patients received a mechanical prosthesis and 5506 a bioprosthesis. Propensity matching identified 527 well-matched pairs (83% of possible matches) for comparison of perioperative outcomes. The average age of patients was 54 years in the bioprosthesis group and 55 years in the mechanical prosthesis group. Random Forest machine-learning analysis was performed to compare survival using the entire cohort of 6143 patients.

RESULTS

Among matched patients, major in-hospital complications, including stroke, deep sternal wound infection, and reoperation for bleeding, were similar, as was in-hospital mortality (2 in the bioprosthesis group [0.38%] vs 3 in the mechanical prosthesis group [0.57%]; P > .9). Patients receiving a bioprosthesis had shorter hospital stays (median 6 vs 7 days, P < .0001). Fifty-one patients (32% at 14 years) in the bioprosthesis group and 17 patients in the mechanical prosthesis group (8% at 14 years) underwent reoperation (P [log-rank] < .0001); 5-year survival after reoperation was 85% versus 82% (P = .6). Risk-adjusted Random Forest prediction of 18-year survival was 60% in the bioprosthetic group and 58% in the mechanical prosthesis group.

CONCLUSIONS

Aortic valve bioprostheses are associated with excellent short-term outcomes and 18-year survival similar to that of patients receiving mechanical valves. Reoperation does not adversely affect survival. These results suggest that risk for reoperation alone should not deter the use of bioprostheses in younger patients.

Outcomes of treatment pathways in 240 patients with congenitally corrected transposition of great arteries

OBJECTIVE

Congenitally corrected transposition of the great arteries (ccTGA) encompasses a diverse morphologic cohort, for which multiple treatment pathways exist. Understanding surgical outcomes among various pathways and their determinants are challenged by limited sample size and follow-up, and heterogeneity. We sought to investigate these questions with a large cohort of ccTGA patients presenting at different ages and representing the full therapeutic spectrum.

METHODS

Retrospective review of 240 patients diagnosed with ccTGA from Cleveland Clinic coupled with prospective cross-sectional follow-up. Forty-six patients whose definitive procedure was completed elsewhere were excluded. Time-related survival was described among treatment pathways using actuarial, time-varying covariate, and competing risks analyses. Temporal trends in longitudinal valve and ventricular function were assessed using nonlinear mixed-effects models.

RESULTS

Median follow-up was 10 years. Seventy-nine patients with ccTGA underwent anatomic repair, 45 physiologic repair, 24 Fontan palliation, and 6 primary transplant. Forty patients managed expectantly had excellent long-term survival when considered from time of presentation, but benefited from failures captured following transition to physiologic repair or transplant. Morphologic right ventricular dysfunction after physiologic repair increased from 68% to 85% after 5 years, whereas morphologic left ventricular function was stable in anatomic repair, especially with early surgery. Transplant-free survival at 15 years for anatomic and physiologic repair was 80% and 71%, respectively.

CONCLUSIONS

Early anatomic repair may be preferable to physiologic repair for select ccTGA patients. Late attrition after physiologic repair represents failure of expectant management and progressive tricuspid valve and morphologic right ventricular dysfunction compared with anatomic repair, where morphologic left ventricular function is relatively preserved.

In Vivo Evaluation of White Matter Abnormalities in Children with Duchenne Muscular Dystrophy Using DTI

BACKGROUND AND PURPOSE

Duchenne muscular dystrophy is an X-linked disorder characterized by progressive muscle weakness and prominent nonmotor manifestations, such as a low intelligence quotient and neuropsychiatric disturbance. We investigated WM integrity in patients with Duchenne muscular dystrophy using DTI.

MATERIALS AND METHODS

Fractional anisotropy and mean, axial, and radial diffusivity (DTI measures) were used to assess WM microstructural integrity along with neuropsychological evaluation in patients with Duchenne muscular dystrophy (n = 60) and controls (n = 40). Exon deletions in the DMD gene were confirmed using multiplex ligation-dependent probe amplification. Patients were classified into proximal (DMD Dp140+) and distal (DMD Dp140-) subgroups based on the location of the exon deletion and expression of short dystrophin Dp140 isoform. WM integrity was examined using whole-brain Tract-Based Spatial Statistics and atlas-based analysis of DTI data. The Pearson correlation was performed to investigate the possible relationship between neuropsychological scores and DTI metrics.

RESULTS

The mean ages of Duchenne muscular dystrophy and control participants were 8.0 ± 1.2 years and 8.2 ± 1.4 years, respectively. The mean age at disease onset was 4.1 ± 1.8 years, and mean illness duration was 40.8 ± 25.2 months. Significant differences in neuropsychological scores were observed between the proximal and distal gene-deletion subgroups, with more severe impairment in the distal-deletion subgroup (P < .05). Localized fractional anisotropy changes were seen in the corpus callosum, parietal WM, and fornices in the patient subgroup with Dp140+, while widespread changes were noted in the Dp140- subgroup. The Dp140+ subgroup showed increased axial diffusivity in multiple WM regions relative to the Dp140- subgroup. No significant correlation was observed between clinical and neuropsychological scores and diffusion metrics.

CONCLUSIONS

Widespread WM differences are evident in patients with Duchenne muscular dystrophy relative to healthy controls. Distal mutations in particular are associated with extensive WM abnormalities and poor neuropsychological profiles.

Abstract 245: Risk of Readmission With Recurrent Myocardial Infarction After Index Myocardial Infarction

Background: Recurrent Myocardial Infarction (MI) after an index MI is a cause for considerable morbidity and mortality. However, the underlying factors that precipitate patients for a recurrent MI remain unclear. We aimed to assess the effect of index MI treatment strategy on the risk of developing a recurrent MI.

Methods: We reviewed all cases of MI at a single quaternary care medical center from January 1 st , 2010 to January 1 st , 2017 and identified all cases of recurrent MI within 90 days after index MI. Readmissions were further stratified depending on the treatment strategy undertaken during index MI into medically managed and revascularized patients. The instantaneous risk of readmission following each of these treatment strategies was estimated by the parametric method.

Results: We identified 6,626 patients admitted with an index MI, of which 168 patients were readmitted with a recurrent MI within 90 days. Among the index admissions, 4354 (66%) patients underwent revascularization and 2272 (34%) patients underwent medical management. Time-varying instantaneous risk of readmission analysis showed an early peaking risk followed by a late increasing risk in the revascularization group whereas, in the medically managed group, the analysis yielded an early peaking followed by a late almost constant risk of readmission for MI.

Conclusion: Patients with acute MI who are medically treated are at a higher risk of developing a recurrent MI than patients who undergo revascularization. Defining the characteristics and underlying factors contributing to these readmissions can be pivotal in improving patient outcomes.

Abstract 357: Comparison of Comorbidities Between Patients Admitted With Index Myocardial Infarction and Recurrent Myocardial Infarction

Background: Several comorbidities are known to increase the risk of coronary artery disease. However, the relationship between modifiable risk factors and recurrent Myocardial Infarction (MI) has not been clearly defined. The purpose of our study was to assess if there were certain comorbidities that increase the risk of recurrent myocardial infarction.

Methods: We reviewed 6,626 cases of MI at a single quaternary care medical center from January 1 st , 2010 to January 1 st , 2017 (29% STEMI, 71% NSTEMI), and we identified all cases of readmission with a recurrent MI within 90 days after index MI. All patients with index MI were screened for accompanying comorbidities and compared with patients with recurrent MI.

Results: There were a total of 2051 readmissions (31%) within 90-days of index MI, of which 168 readmissions were for recurrent MI. Hypertension and Dyslipidemia appeared to be the most prominent modifiable risk factors in patients with index MI and recurrent MI (86%, 94% for HTN & 81%, 93% for DLP). All comorbidities were substantially more prevalent in patients with recurrent MI than in patients with index MI.

Conclusion: Patients with recurrent MI have a higher risk factor burden than the general population with MI. This highlights the importance of risk factor management in patients with acute Myocardial infarction.

Abstract 383: Effect of Race on Risk of Recurrent Myocardial Infarction After Index Myocardial Infarction

Background: Though the prevalence of coronary artery disease is known to be highest in African Americans, it is unclear if there are any racial factors predisposing patients for a recurrent Myocardial Infarction (MI) after index MI.

Methods: We reviewed 6,626 cases of MI at a single quaternary care medical center from January 1 st , 2010 to January 1 st , 2017 (29% STEMI, 71% NSTEMI), and we identified all cases of recurrent MI within 90 days of discharge after index MI. The patients were categorized according to their corresponding races into White Americans, African Americans, and Others.

Result: Out of the 6626 initial cases of MI, 72% were white patients, 25% were African Americans and 3% belonged to other races. A total of 2051 patients were readmitted within 90 days of index admission, of which 168 patients were readmitted with an MI. Only 2.1% of White patients developed a recurrent MI whereas 4% of African Americans were readmitted with a recurrent MI (P=0.003).

Conclusion: We observed that African Americans were more likely to be readmitted with a recurrent MI than White Americans. Understanding the reasons for this increased risk in MI can translate into improved care for African Americans.

Abstract 225: Impact of Revascularization Strategy on Risk of Readmission After Non-ST Elevation Myocardial Infarction

Background: It is unclear how revascularization strategy (medical management vs percutaneous coronary intervention vs coronary artery bypass surgery), affects 90-day readmissions after Non-ST Elevation Myocardial Infarction (NSTEMI).

Methods: We identified cases of NSTEMI at a single quaternary care medical center between January 1 st , 2010 to January 1 st , 2017 and readmissions within 90 days. Cases were categorized based on revascularization strategy into medical management, PCI (percutaneous coronary intervention) or CABG (coronary artery bypass surgery). The readmissions were categorized according to the time of readmission into early (0-30 days) and late (31-90 days) after discharge. The instantaneous risk of readmission following each treatment option was calculated using the parametric method.

Results: We identified 6626 patients with index MI, of which 4692 patients had NSTEMI. There were a total of 2051 readmissions within 90 days. The risk of readmission for CABG and PCI treatment groups yielded an early peaking phase followed by a constant risk whereas the risk of readmission in the medically managed group showed an early decreasing phase followed by a constant risk. An unadjusted comparison of the risk of readmission between the three groups showed that the PCI group had the lowest early risk of readmission (P=0.03). The medically managed group had the highest risk of readmission.

Conclusion: Patients with NSTEMI who are medically managed appear to be at higher risk for readmission than revascularized patients. Understanding the care processes for these patients may serve as a future opportunity to improve outcomes in these high-risk patients.

Abstract 246: Effect of Racial Factors on Timing of Readmissions After Myocardial Infarction

Background: Readmissions following acute myocardial infarction (MI) are associated with increased cost, healthcare utilization, and morbidity. The purpose of this study was to assess racial factors in influencing time for readmission after being admitted with myocardial infarction.

Methods: We reviewed 6,626 cases of MI at a single quaternary care medical center from January 1 st , 2010 to January 1 st , 2017 (29% STEMI, 71% NSTEMI), and we identified all readmissions within 90 days after index MI. The patients were categorized according to their race into White Americans (72%), African Americans (25%) and others (3%). Readmissions were stratified into early (0-30 days) and late (31-90 days) time periods depending on the timing of readmission and these readmissions were also separated according to their corresponding race into White Americans (62%), African Americans (35%) and others (3%). Since White Americans and African Americans contributed to the bulk of our patient population, we analyzed the difference between these two groups.

Results: There were a total of 2051 readmissions within 90 days after index MI. Overall, 50% of readmissions were in the early time period and 50% in the late period (after 30 days). 46% of African Americans were readmitted in the early time period compared to 52% of white patients whereas 54% of African Americans were readmitted in the late time period compared to 48% of white patients (P=0.0037).

Conclusions: The temporal pattern of readmissions after myocardial infarction differed between Whites and African Americans. These findings may have implications regarding the development of readmission reduction strategies.

Long-Term Time-Varying Risk of Readmission After Acute Myocardial Infarction

Background

Readmission after myocardial infarction (MI) is a publicly reported quality metric with hospital reimbursement linked to readmission rates. We describe the timing and pattern of readmission by cause within the first year after MI in consecutive patients, regardless of revascularization strategy, payer status, or age.

Methods and Results

We identified patients discharged after an MI from April 2008 to June 2012. Readmission within 12 months was the primary end point. Readmissions were classified into 4 groups: MI related, other cardiovascular, noncardiovascular, and planned. A total of 3069 patients were discharged after an MI (average age, 65±13 years; and 1941 [63%] men). A total of 655 patients (21.3%) were readmitted at least once (897 total readmissions). A total of 147 patients (4.8%) were readmitted ≥2 times, accounting for 389 readmissions (43%). The instantaneous risk of all‐cause readmission was highest (15 readmissions/100 patients per month; 95% confidence interval, 12–19 readmissions/100 patients per month) immediately after discharge, decreased by almost half (8.1 readmissions/100 patients per month; 95% confidence interval, 7.2–9.0 readmissions/100 patients per month) within 15 days, and was substantially lower and relatively constant (1.4 readmissions/100 patients per month; 95% confidence interval, 1.2–1.6 readmissions/100 patients per month) out to 1 year. Cardiovascular causes of readmission were more common early after discharge.

Conclusions

Most patients with MI are never readmitted, whereas a small minority (≈5%) account for nearly half of 1‐year readmissions. The readmission pattern after MI is characterized by an early peak (first 15 days) of cardiovascular readmissions, followed by a middle period (months 1–4) of noncardiovascular readmissions, and ending with a low‐risk period (>4 months) during which the risk appears independent of cause.

See Editorial by Levy and Allen

Stroke After Surgical Versus Transfemoral Transcatheter Aortic Valve Replacement in the PARTNER Trial

BACKGROUND

Transfemoral-transcatheter aortic valve replacement (TF-TAVR) is increasingly used to treat aortic stenosis, but risk of post-procedure stroke is uncertain.

OBJECTIVES

The purpose of this study was to assess stroke risk and its association with quality of life after surgical aortic valve replacement (SAVR) versus TF-TAVR.

METHODS

The authors performed a propensity-matched study of 1,204 pairs of patients with severe aortic stenosis treated with SAVR versus TF-TAVR in the PARTNER (Placement of AoRTic TraNscathetER Valves) trials from April 2007 to October 2014. Outcomes were: 1) 30-day neurological events; 2) time-varying risk of neurological events early (≤7 days) and late (7 days to 48 months) post-procedure; and 3) association between stroke and quality of life 1 year post-procedure by the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score.

RESULTS

Thirty-day stroke (5.1% vs. 3.7%; p = 0.09) was similar, but 30-day major stroke (3.9% vs. 2.2%; p = 0.018) was lower after TF-TAVR than SAVR. In both groups, risk of stroke peaked in the first post-procedure day, followed by a near-constant low-level risk to 48 months. Major stroke was associated with a decline in quality of life at 1 year in both SAVR (KCCQ score median [15th, 85th percentile]: 79 [53, 94] without major stroke vs. 64 [30, 94] with major stroke; p = 0.03) and TF-TAVR (78 [49, 96] without major stroke vs. 60 [8, 99] with major stroke; p = 0.04).

CONCLUSIONS

Despite similar early-peaking (<1 day post-procedure) neurological risk profiles, SAVR is associated with a higher risk of early major stroke than TF-TAVR. Periprocedural strategies are needed to reduce stroke risk after aortic valve procedures. (Placement of AoRTic TraNscathetER Valve Trial [PARTNER]; NCT00530894).

Continuously Updated Estimation of Heart Transplant Waitlist Mortality

BACKGROUND

Heart transplant allocation in the United States is made on the basis of coarse tiers, defined by mechanical circulatory devices and therapy for advanced heart failure, updated infrequently as a patient's condition deteriorates. Thus, many patients die awaiting heart transplantation. What is needed is a tool that continuously updates risk of mortality as a patient's condition changes to inform clinical decision making.

OBJECTIVES

This study sought to develop a decision aid that aggregates adverse events and measures of end-organ function into a continuously updated waitlist mortality estimate.

METHODS

From 2008 to 2013, 414 patients were listed for heart transplantation at Cleveland Clinic, Cleveland, Ohio. The endpoint was waitlist death. Pre-listing patient characteristics and events and laboratory results during listing were analyzed. At each event or measurement change, mortality was recomputed from the resulting model.

RESULTS

There were 77 waitlist deaths, with 1- and 4-year survival of 85% and 57%, respectively. When time-varying events and measurements were incorporated into a mortality model, pre-listing patient characteristics became nonsignificant. Neurological events (hazard ratio [HR]: 13.5; 95% confidence interval [CI]: 7.63 to 23.8), new requirement for dialysis (HR: 3.67; 95% CI: 1.88 to 7.14), more respiratory complications (HR: 1.79 per episode; 95% CI: 1.23 to 2.59), and higher serum bilirubin (p < 0.0001) and creatinine (p < 0.0001) yielded continuously updated estimates of patient-specific mortality across the waitlist period.

CONCLUSIONS

Mortality risk for patients with advanced heart failure who are listed for transplantation is related to adverse events and end-organ dysfunction that change over time. A continuously updated mortality estimate, combined with clinical evaluation, may inform status changes that could reduce mortality on the heart transplant waiting list.

Dynamic prediction of left ventricular assist device pump thrombosis based on lactate dehydrogenase trends

Aims

The risk of HeartMate II (HMII) left ventricular assist device (LVAD) thrombosis has been reported, and serum lactate dehydrogenase (LDH), a biomarker of haemolysis, increases secondary to LVAD thrombosis. This study evaluated longitudinal measurements of LDH post‐LVAD implantation, hypothesizing that LDH trends could timely predict future LVAD thrombosis.

Methods and results

From October 2004 to October 2014, 350 HMIIs were implanted in 323 patients at Cleveland Clinic. Of these, patients on 339 HMIIs had at least one post‐implant LDH value (7996 total measurements). A two‐step joint model combining longitudinal biomarker data and pump thrombosis events was generated to assess the effect of changing LDH on thrombosis risk. Device‐specific LDH trends were first smoothed using multivariate boosted trees, and then used as a time‐varying covariate function in a multiphase hazard model to analyse time to thrombosis. Pre‐implant variables associated with time‐varying LDH values post‐implant using boostmtree were also investigated. Standardized variable importance for each variable was estimated as the difference between model‐based prediction error of LDH when the variable was randomly permuted and prediction error without permuting the values. The larger this difference, the more important a variable is for predicting the trajectory of post‐implant LDH. Thirty‐five HMIIs (10%) had either confirmed (18) or suspected (17) thrombosis, with 15 (43%) occurring within 3 months of implant. LDH was associated with thrombosis occurring both early and late after implant (P < 0.0001 for both hazard phases). The model demonstrated increased probability of HMII thrombosis as LDH trended upward, with steep changes in LDH trajectory paralleling trajectories in probability of pump thrombosis. The most important baseline variables predictive of the longitudinal pattern of LDH were higher bilirubin, higher pre‐implant LDH, and older age. The effect of some pre‐implant variables such as sodium on the post‐implant LDH longitudinal pattern differed across time.

Conclusions

Longitudinal trends in surveillance LDH for patients on HMII support are useful for dynamic prediction of pump thrombosis, both early after implant and late. Incorporating upward and downward trends in LDH that dynamically update a model of LVAD thrombosis risk provides a useful tool for clinical management and decisions.

EEG Neurofeedback Training in Children With Attention Deficit/Hyperactivity Disorder: A Cognitive and Behavioral Outcome Study

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) is a highly prevalent childhood disorder with symptoms of inattention, impulsivity, and hyperactivity. EEG neurofeedback training (NFT) is a new intervention modality based on operant conditioning of brain activity, which helps reduce symptoms of ADHD in children.

METHODS AND PROCEDURES

To examine the efficacy of NFT in children with ADHD, an experimental longitudinal design with pre-post comparison was adopted. A total of 30 children in the age range of 6 to 12 years diagnosed as ADHD with or without comorbid conditions were assigned to treatment group (TG; n = 15) and treatment as usual group (TAU; n = 15). TG received EEG-NFT along with routine clinical management and TAU received routine clinical management alone. Forty sessions of theta/beta NFT at the C3 scalp location, 3 to 4 sessions in a week for a period of 3.5 to 5 months were given to children in TG. Children were screened using sociodemographic data and Binet-Kamat test of intelligence. Pre-and postassessment tools were neuropsychological tests and behavioral scales. Follow-up was carried out on 8 children in TG using parent-rated behavioral measures.

RESULTS

Improvement was reported in TG on cognitive functions (sustained attention, verbal working memory, and response inhibition), parent- and teacher-rated behavior problems and on academic performance rated by teachers. Follow-up of children who received NFT showed sustained improvement in ADHD symptoms when assessed 6 months after receiving NFT.

CONCLUSION

The present study suggests that NFT is an effective method to enhance cognitive deficits and helps reduce ADHD symptoms and behavior problems. Consequently, academic performance was found to be improved in children with ADHD. Improvement in ADHD symptoms induced by NFT were maintained at 6-month follow-up in children with ADHD.

Longitudinal Hemodynamics of Transcatheter and Surgical Aortic Valves in the PARTNER Trial

Importance

Use of transcatheter aortic valve replacement (TAVR) for severe aortic stenosis is growing rapidly. However, to our knowledge, the durability of these prostheses is incompletely defined.

Objective

To determine the midterm hemodynamic performance of balloon-expandable transcatheter heart valves.

Design, Setting, and Participants

In this study, we analyzed core laboratory-generated data from echocardiograms of all patients enrolled in the Placement of Aortic Transcatheter Valves (PARTNER) 1 Trial with successful TAVR or surgical AVR (SAVR) obtained preimplantation and at 7 days, 1 and 6 months, and 1, 2, 3, 4, and 5 years postimplantation. Patients from continued access observational studies were included for comparison.

Interventions

Successful implantation after randomization to TAVR vs SAVR (PARTNER 1A; TAVR, n = 321; SAVR, n = 313), TAVR vs medical treatment (PARTNER 1B; TAVR, n = 165), and continued access (TAVR, n = 1996). Five-year echocardiogram data were available for 424 patients after TAVR and 49 after SAVR.

Main Outcomes and Measures

Death or reintervention for aortic valve structural indications, measured using aortic valve mean gradient, effective orifice area, Doppler velocity index, and evidence of hemodynamic deterioration by reintervention, adverse hemodynamics, or transvalvular regurgitation.

Results

Of 2795 included patients, the mean (SD) age was 84.5 (7.1) years, and 1313 (47.0%) were female. Population hemodynamic trends derived from nonlinear mixed-effects models showed small early favorable changes in the first few months post-TAVR, with a decrease of -2.9 mm Hg in aortic valve mean gradient, an increase of 0.028 in Doppler velocity index, and an increase of 0.09 cm2 in effective orifice area. There was relative stability at a median follow-up of 3.1 (maximum, 5) years. Moderate/severe transvalvular regurgitation was noted in 89 patients (3.7%) after TAVR and increased over time. Patients with SAVR showed no significant changes. In TAVR, death/reintervention was associated with lower ejection fraction, stroke volume index, and aortic valve mean gradient up to 3 years, with no association with Doppler velocity index or valve area. Reintervention occurred in 20 patients (0.8%) after TAVR and in 1 (0.3%) after SAVR and became less frequent over time. Reintervention was caused by structural deterioration of transcatheter heart valves in only 5 patients. Severely abnormal hemodynamics on echocardiograms were also infrequent and not associated with excess death or reintervention for either TAVR or SAVR.

Conclusions and Relevance

This large, core laboratory-based study of transcatheter heart valves revealed excellent durability of the transcatheter heart valves and SAVR. Abnormal findings in individual patients, suggestive of valve thrombosis or structural deterioration, were rare in this protocol-driven database and require further investigation.

Trial Registration

clinicaltrials.gov Identifier: NCT00530894.