Transcatheter Mitral Valve Therapy in the United States: A Report From the STS-ACC TVT Registry

Data for nearly all patients undergoing transcatheter edge-to-edge repair (TEER) and transcatheter mitral valve replacement (TMVR) with an approved device in the United States is captured in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. All data submitted for TEER or TMVR between 2014 and March 31, 2020, are reported. A total of 37,475 patients underwent a mitral transcatheter procedure, including 33,878 TEER and 3,597 TMVR. Annual procedure volumes for TEER have increased from 1,152 per year in 2014 to 10,460 per year in 2019 at 403 sites and for TMVR from 84 per year to 1,120 per year at 301 centers. Mortality rates have decreased for TEER at 30 days (5.6%-4.1%) and 1 year (27.4%-22.0%). Early off-label use data on TMVR in mitral valve-in-valve therapy led to approval by the U.S. Food and Drug Administration in 2017, and the 2019 30-day mortality rate was 3.9%. Overall improvements in outcomes over the last 6 years are apparent. (STS/ACC TVT Registry Mitral Module; NCT02245763).

Meningitis following cerebrospinal fluid-cutaneous fistula secondary to combined spinal-epidural anaesthesia for elective caesarean delivery

Cerebrospinal fluid-cutaneous fistula is a rare complication associated with neuraxial procedures. Here, we describe a case of fistula formation related to combined spinal-epidural anaesthesia for elective caesarean delivery, where the epidural catheter was removed only two hours later. The clear fluid leaking persistently from the site of the skin puncture associated with the epidural insertion site was confirmed to be cerebrospinal fluid with an increased beta-trace protein, and the fistula was closed with skin sutures. Subsequently, the patient presented with neurological signs and symptoms consistent with meningitis and she was treated empirically with intravenous antibiotics. Cerebrospinal fluid-cutaneous fistula formation with secondary meningitis is an exceptionally rare event in obstetric anaesthesia.

Association of Volume and Outcomes in 234,556 Patients Undergoing Surgical Aortic Valve Replacement

BACKGROUND

The relationship between institutional volume and operative mortality following SAVR remains unclear.

METHODS

From 1/2013 to 6/2018, 234,556 patients underwent isolated SAVR (n=144,177) or SAVR+CABG (n=90,379) within the STS ACSD. The association between annualized SAVR volume [Group 1 (1-25 SAVR), Group 2 (26-50 SAVR), Group 3 (51-100 SAVR), and Group 4 (>100 SAVR)] and operative mortality and composite major morbidity/mortality was assessed. Random effects models were used to evaluate whether historic (2013-2015) SAVR volume or risk-adjusted outcomes explained future (2016-2018) risk-adjusted outcomes.

RESULTS

The annualized median number of SAVRs per site was 35 [IQR: 22-59, isolated AVR: 20, AVR+CABG: 13]. Among isolated SAVR cases, the mean operative mortality and composite morbidity/mortality were 1.5% and 9.7%, respectively, at the highest volume sites (Group 4); with significantly higher rates among progressively lower volume groups (p-trend<0.001). After adjustment, lower volume centers experienced increased odds of operative mortality [Group 1 vs. 4 (Ref): AOR (SAVR), 2.24 (1.91-2.64); AOR (SAVR+CABG), 1.96 (1.67-2.30)] and major morbidity/mortality [AOR (SAVR), 1.53 (1.39-1.69); AOR (SAVR+CABG), 1.46 (1.32-1.61)] compared to the highest volume institutions. Substantial variation in outcomes was observed across hospitals within each volume category and prior outcomes explained a greater proportion of hospital operative outcomes than prior volume.

CONCLUSIONS

Operative outcomes following SAVR±CABG is inversely associated with institutional procedure volumes; however, prior outcomes are more predictive than prior volume of future outcomes. Given excellent outcomes observed at many lower volume hospitals, procedural outcomes may be preferable to procedural volumes as a quality metric.

Transcatheter Mitral Valve Therapy in the United States: A Report from the STS/ACC TVT Registry

Data for nearly all patients undergoing transcatheter edge-to-edge repair (TEER) and transcatheter mitral valve replacement (TMVR) with an approved device in the United States is captured in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. All data submitted for TEER or TMVR between 2014 and March 31, 2020, are reported. A total of 37,475 patients underwent a mitral transcatheter procedure, including 33,878 TEER and 3,597 TMVR. Annual procedure volumes for TEER have increased from 1,152 per year in 2014 to 10,460 per year in 2019 at 403 sites and for TMVR from 84 per year to 1,120 per year at 301 centers. Mortality rates have decreased for TEER at 30 days (5.6%-4.1%) and 1 year (27.4%-22.0%). Early off-label use data on TMVR in mitral valve-in-valve therapy led to approval by the U.S. Food and Drug Administration in 2017, and the 2019 30-day mortality rate was 3.9%. Overall improvements in outcomes over the last 6 years are apparent. (STS/ACC TVT Registry Mitral Module; NCT02245763).

1602 A Quality Improvement Project on The Management of Patients with Traumatic Head Injury Presenting to A District General Hospital

Introduction

Traumatic Brain Injury (TBI) is associated with morbidity and mortality. All District General Hospitals (DGH) in West Midlands liaise with Neurosurgery centres for management of these patients through a referral system (NORSe). The aim of this study was to assess outcomes in TBI following the implementation of vital interventions.

Method

A retrospective data was collected between 1/1/2019 and 1/12/2020. We included all patients admitted with traumatic brain injury over the age of 16. We accessed the data from the hospital database, clinical notes, and NORSe. A re-audit was performed following implementations of recommendations (proforma and care of elderly input). Further data were collected prospectively.

Results

Our cohort included n1=61 patients (first cycle) and n2= 29 (second cycle). The demographic age and gender were comparable in both cycles. The median time for Neurosurgery advice was 229 minutes (IQR 60-690) in the first cycle as compared to 80 minutes (IQR 40-120, P &lt; 0.05) and the main cause for delay was inadequate information transfer. The mortality rate was 24% (5 were attributed to sepsis), as compared to 14% in the second cycle. The median length of stay (LOS) was 4 days (IQR 3-13.5) in the first cycle, which translates to a cost of £26,815 per quarter. In comparison, LOS was 3 days (IQR 2-4), which translates to the cost of bed occupancy of £12,771 and saving of £14,043 per quarter, in the second cycle.

Conclusions

The introduction of simple interventions in a DGH can help to significantly improve patient outcomes in those admitted with Traumatic brain injury.

P–212 Mitochondrial DNA content shows a significant association with timing of human embryo development and fertility diagnosis in euploid embryos

Study question

Does mitochondrial DNA content (mtDNA) correlate with clinical parameters and embryo morphokinetics using advanced time-lapse technology?

Summary answer

mtDNA correlated with embryo morphokinetics and the growth trajectory of euploid embryos. Maternal age, anti-mullerian hormone level and fertility diagnosis were significantly associated with mtDNA.

What is known already

With the push towards single embryo transfers, laboratories are working to improve embryo selection. In addition to conventional microscopy, preimplantation genetic testing and time-lapse microscopy have been utilized to aid in embryo selection. More recently, as mtDNA may represent the energy potential of an embryo, some data have supported the use of mtDNA as an additional tool. Limited studies have suggested that a lower amount of mtDNA is associated with higher rates of implantation and improved embryo quality.

Study design, size, duration

This is a retrospective chart review. All embryos that underwent preimplantation genetic testing for aneuploidy (PGT-A) between January to December of 2020 were studied.

Participants/materials, setting, methods

Women undergoing in vitro fertilization (IVF) with intracytoplasmic sperm injection undergoing PGT-A were studied. All patients were from a single academic institution. This study exclusively examined the characteristics of euploid embryos. Mitochondrial DNA content was expressed as a ratio of mtDNA:nDNA (MitoScore). Time-lapse imaging was utilized to evaluate embryo development every 15 minutes in 5–7 focal planes. Chi square test and Spearman correlation analysis were performed with a p-value of &lt; 0.05 considered significant.

Main results and the role of chance

A total of 494 embryos from 52 women who underwent 58 IVF cycles were cultured to blastocyst and 331 embryos were biopsied for PGT-A evaluation. Of these, 132 embryos were diagnosed as euploid. A moderate positive correlation was found between MitoScore and time to morula, time to blast and time to expanded blast (correlation value 0.54, 0.50 and 0.54, respectively; p &lt; 0.001). Consistent with this trend, day 5 blastocysts had a significantly lower MitoScore values than day 6 blastocysts (20.2 v. 29.2; p &lt; 0.001). When examining all biopsied euploid embryos, no significant association was found between MitoScore, blastocyst maturity, trophectoderm or inner cell mass scores.

Our data also demonstrated a positive correlation between MitoScore and maternal age (correlation factor 0.33; p &lt; 0.001). A negative association between MitoScore and serum anti-mullerian hormone levels (correlation factor –0.20; p &lt; 0.021) was also noted. Of particular interest was the significant association between fertility diagnosis and mitochondrial score (p &lt; 0.001).

Even amongst euploid embryos, mtDNA content varied widely, potentially reflecting differences in embryo potential and quality. Additionally, the significant difference in MitoScore between that day 5 and day 6 blastocysts may reflect a fundamental difference in cytoplasmic characteristics and requires further study.

Limitations, reasons for caution

Due to the study cohort of euploid embryos undergoing PGT-A, this study was biased for the selection of high grade embryos. This limited diversity in embryo quality may have masked other potential associations between mitochondrial content and blastocyst quality.

Wider implications of the findings: mtDNA may be additional tool aiding in embryo selection as IVF labs work to improve pregnancy rates while minimizing the risks of transferring multiple embryos. To our knowledge, this is the largest study assessing the relationship of mtDNA content of blastocysts and the timing of embryo development using time-lapse imaging.

Trial registration number

None

Aortic arch stenting: current strategies, new technologies and future directions

Operating on the aortic arch is a formidable challenge. Open operations remain the gold standard, but despite improvement in technique and outcomes, they are still associated with significant morbidity and mortality. The last 20 years have seen a remarkable reduction in the operative morbidity associated with treatment of the descending thoracic aorta using thoracic endovascular aneurysm repair (TEVAR). To improve outcomes following arch repair, new TEVAR devices, including both single-branched and multibranched designs, have come to clinical trial. This review discusses the modern state of open and hybrid repairs while introducing the reader to technology for endovascular therapy of the aortic arch. We describe important anatomical and operative considerations for the devices. Given these nuances, we believe the future of the aortic arch to be patient-individualised hybrid repairs, involving both open and endovascular options with a multidisciplinary 'thoracic aorta team' at the helm.

Long-term outcomes of the conformable TAG thoracic endoprosthesis in a prospective multicenter trial

BACKGROUND

The Gore conformable TAG thoracic endoprosthesis (CTAG) was engineered to enhance conformability in the thoracic aorta and has demonstrated greater deployment accuracy and wall apposition than the original TAG device. The Food and Drug Administration approved the CTAG in 2011 based on the 1-year results of the pivotal trial for the CTAG device. In the present report, we have documented the outcomes for those patients through 5 years.

METHODS

The CTAG aneurysm study was a prospective, multicenter trial that assessed the safety and effectiveness of the CTAG device as treatment of descending thoracic aortic aneurysms. Follow-up imaging assessments consisted of radiographs and computed tomography at annual intervals through 5 years. A core imaging laboratory was used to assess the aneurysm size, device integrity, and endoleaks.

RESULTS

A total of 66 patients were enrolled (51 pivotal arm patients and 15 continued access patients) from October 2009 through September 2011. The baseline characteristics, procedural characteristics, and outcomes through 2 years were reported previously. Through 5 years, five patients (7.6%) had required device-related reintervention (one type Ia endoleak or contained rupture of the descending thoracic aorta, one type Ib endoleak, two indeterminate endoleaks, and one thoracic aortic pseudoaneurysm). Four patients (6.1%) had died of aneurysm-related causes, with one death occurring within 30 days of the index procedure. A total of 24 patients (36.3%) had died during the 5-year study period. Seven patients (10.6%) had experienced stroke or transient ischemic attack through 5 years, with one early stroke (postoperative day 28). Prosthesis or intercomponent migration was observed in six patients (9.1%) through 5 years; however, no patient had developed a type III junctional endoleak. No stent-graft fracture or compression was observed through 5 years. At 5 years, 14 patients (50.0%) showed sac regression, 5 (17.9%) showed sac expansion, and 9 (32.1%) showed sac stability using on a 5-mm threshold for change.

CONCLUSIONS

Thoracic endovascular aortic repair with the CTAG device was associated with low rates of aneurysm-related mortality and reintervention through 5 years. Proximal endoleak was rare, and most patients showed sac regression or stability at 5 years after the initial thoracic endovascular aortic repair.

822 Lessons Learnt During the COVID-19 Pandemic on Emergency Surgical Admissions in A District General Hospital

Introduction

Coronavirus disease (COVID-19) is an acute severe respiratory distress syndrome which resulted in an unprecedented impact on NHS service provision. We aimed to assess the impact of COVID-19 on general surgical services in a district general hospital.

Method

Electronic health care record data was retrospectively collected from 6th of April to 6th of May for both 2019 and 2020.

Results

Despite fewer referrals and admissions in 2020 (133 vs 177 admissions in 2019), there were more failed discharges (29 vs 17 in 2019) and higher associated costs. Higher numbers of biliary related pathologies and pancreatitis (50 in 2020 vs 25 in 2019), and fewer complaints of non-specific abdominal pain (10 in 2020 vs 22 in 2019) were observed. The use of outpatient investigations decreased by approximately 40% in 2020; however, utilisation of inpatient investigations was comparable.

Conclusions

Better utilisation of outpatient investigations and virtual clinic services may surmount pressures from further peaks of COVID-19. The increase in biliary related cases and pancreatitis may be consequent upon lifestyle changes during lockdown. This merits further investigation and if appropriate, public health intervention. In the absence of an efficacious vaccine, further research would be essential to streamline general surgical services based on clinical risk stratification.

STS Adult Cardiac Surgery Database: 2021 Update on Outcomes, Quality, and Research

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It has been the foundation for quality measurement and improvement activities in cardiac surgery, facilitated the generation of accurate risk adjusted performance benchmarks and serves as a platform for novel research. Recent enhancements have added to the database's functionality, ease of use, and value to multiple stakeholders. This report is the sixth in a series of annual reports that provide updated volumes, outcomes, database-related developments, quality improvement initiatives, and research summaries using the Adult Cardiac Surgery Database in the past year.

Clinical trial outcomes and thoracic aortic morphometry after one year with the Valiant Navion stent graft system

AUTHORS' NOTE

On February 17, 2021, Medtronic Incorporated issued a global voluntary recall of the Valiant Navion Thoracic Stent Graft System (the device under study in the Valiant Evo Global Clinical Program that is the subject of this publication), and instructed physicians to immediately cease use of the Valiant Navion system and return any unused product. Medtronic initiated the recall in response to three clinical trial subjects recently observed with stent fractures, two of whom have confirmed type IIIb endoleaks. The data collection, analysis, and manuscript submission occurred before the notice of this recall, and, specifically, the 100 procedures reviewed for this series were free of events at 1 year related to the reason for this device recall. The authors of this article and the manufacturer were unaware of the recently detected adverse events at the time of the preparation of the manuscript, and the 1-year trial results, and imaging-based analyses described are unchanged. Management of thoracic aortic aneurysms continues to be a challenging problem and outcomes are dependent on patient anatomy. The present publication focuses on the importance of achieving proximal and distal seals and the consideration of the temporal changes of the aortic morphology as a part of the TEVAR planning process. The authors believe there is still scientific merit in disclosing this information, despite the current nonavailability of the Valiant Navion system.

OBJECTIVE

The Valiant Navion stent graft system (Medtronic Inc, Santa Rosa, Calif) is a third-generation device with improved conformability. We have reported the 1-year clinical trial outcomes, with a focus on an imaging-based analysis of the aortic morphology. We assessed the effects of graft implantation on the native anatomy and the effects of the 1-year changes in thoracic aorta morphology on the original seal zones of the stent graft.

METHODS

A total of 100 subjects were enrolled in a prospective single-arm clinical trial investigating the Valiant Navion stent graft system. An independent core laboratory (Syntactx, New York, NY) assessed the anatomic characteristics and performance outcomes.

RESULTS

Through 1 year of follow-up, the freedom from all-cause mortality, aneurysm-related mortality, and secondary procedures was 89.8%, 97.0%, and 94.8% respectively. Of the 100 patients, 5 had undergone a total of six secondary procedures, and 9 patients had developed an endoleak (type Ia and Ib in 1, type Ia in 1, type Ib in 3, and type II in 4 patients) within the first year. After 1 year, 2 of 76 patients (2.6%) had had an increase in their maximum aneurysm diameter of ≥5 mm, 62 (81.6%) had had stable sacs, and 12 (15.8%) had experienced sac shrinkage. Although no deployment failures had occurred, 36 of the 100 proximal (36%) and 31 of the 100 distal (31%) attachment zones were considered short according to our definitions. The stent graft had conformed to the native anatomy at implantation, because the preprocedural thoracic aorta tortuosity (1.45 ± 0.02) had not significantly changed at 1 month after implantation (1.46 ± 0.02). Despite a natural increase in thoracic tortuosity after 1 year (1.49 ± 0.02), wall apposition had been maintained over time, as evidenced by the low endoleak rates. Aortic elongation and dilation had occurred at the proximal end of the graft by an average of 1.2 mm and 1.6 mm, respectively. Aortic remodeling was more pronounced at the distal end, with an average increase of 4.2 mm in length and 2.8 mm in diameter.

CONCLUSIONS

The included patients had had positive 1-year outcomes with high freedom from mortality, endoleak development, and secondary procedures. Aortic elongation and dilation were more prevalent at the distal end, emphasizing the importance of distal attachment zone consideration as part of preoperative planning. Because aortic remodeling can be expected to continue over time, additional follow-up and imaging analysis in the trial will be necessary to assess the aortic morphology and its effects on stent graft performance.

Development of intractable ascites due to thoracic duct hypertension

We describe a 69-year-old dialysis-dependent patient who developed intractable ascites after zone 2 aortic reconstruction for a type IA thoracic endovascular aneurysm repair endoleak. Investigation as to the cause of ascites revealed a unique set of clinical circumstances leading to intractable bloody ascites. Investigation included imaging and invasive testing to diagnose the culprit mechanism. Ultimately, interventional catherization of the left subclavian vein illustrated an abnormally elevated pressure in the left subclavian vein. It was thus determined that, owing to the combination of a left brachiocephalic (innominate) vein occlusion after surgical ligation and in situ left brachiobasilic arteriovenous dialysis graft, there was overcirculation through the thoracic duct. Retrograde flow through the pop-off thoracic duct led to hematogenous ascites. Ligation of the left brachiobasilic arteriovenous dialysis graft resulted in near instantaneous and complete resolution of the ascites.

Local anaesthetic adjuncts for peripheral regional anaesthesia: a narrative review

Moderate-to-severe postoperative pain persists for longer than the duration of single-shot peripheral nerve blocks and hence continues to be a problem even with the routine use of regional anaesthesia techniques. The administration of local anaesthetic adjuncts, defined as the concomitant intravenous or perineural injection of one or more pharmacological agents, is an attractive and technically simple strategy to potentially extend the benefits of peripheral nerve blockade beyond the conventional maximum of 8-14 hours. Historical local anaesthetic adjuncts include perineural adrenaline that has been demonstrated to increase the mean duration of analgesia by as little as just over 1 hour. Of the novel local anaesthetic adjuncts, dexmedetomidine and dexamethasone have best demonstrated the capacity to considerably improve the duration of blocks. Perineural dexmedetomidine and dexamethasone increase the mean duration of analgesia by up to 6 hour and 8 hour, respectively, when combined with long-acting local anaesthetics. The evidence for the safety of these local anaesthetic adjuncts continues to accumulate, although the findings of a neurotoxic effect with perineural dexmedetomidine during in-vitro studies are conflicting. Neither perineural dexmedetomidine nor dexamethasone fulfils all the criteria of the ideal local anaesthetic adjunct. Dexmedetomidine is limited by side-effects such as bradycardia, hypotension and sedation, and dexamethasone slightly increases glycaemia. In view of the concerns related to localised nerve and muscle injury and the lack of consistent evidence for the superiority of the perineural vs. systemic route of administration, we recommend the off-label use of systemic dexamethasone as a local anaesthetic adjunct in a dose of 0.1-0.2 mg.kg^-1 for all patients undergoing surgery associated with significant postoperative pain.

Incidence and outcomes of healthcare-associated COVID-19 infections: significance of delayed diagnosis and correlation with staff absence

BACKGROUND

The sudden increase in COVID-19 admissions in hospitals during the SARS-CoV-2 pandemic of 2020 led to onward transmissions among vulnerable inpatients.

AIMS

This study was performed to evaluate the prevalence and clinical outcomes of healthcare-associated COVID-19 infections (HA-COVID-19) during the 2020 epidemic and study factors which may promote or correlate with its incidence and transmission in a Teaching Hospital NHS Trust in London, UK.

METHODS

Electronic laboratory, patient and staff self-reported sickness records were interrogated from 1st March to 18th April 2020. HA-COVID-19 was defined as COVID-19 with symptom onset within >14 days of admission. Test performance of a single combined throat and nose swab (CTNS) for patient placement was calculated. The effect of delayed RNA positivity (DRP, defined as >48 h delay), staff self-reported COVID-19 sickness absence, hospital bed occupancy, and community incidence of COVID-19 was compared for HA-COVID-19. The incidence of other significant hospital-acquired bacterial infections (HAB) was compared with previous years.

RESULTS

Fifty-eight HA-COVID-19 (7.1%) cases were identified. When compared with community-acquired admitted cases (CA-COVID-19), significant differences were observed in age (P=0.018), ethnicity (P<0.001) and comorbidity burden (P<0.001) but not in 30-day mortality. CTNS-negative predictive value was 60.3%. DRP was associated with greater mortality (P=0.034) and incidence of HA-COVID-19 correlated positively with DRP (R = 0.7108) and staff sickness absence (R = 0.7815). For the study period HAB rates were similar to the previous 2 years.

CONCLUSIONS

Early diagnosis and isolation of COVID-19 patients would help to reduce transmission. A single CTNS has limited value in segregating patients into positive and negative pathways.

STS-ACC TVT Registry of Transcatheter Aortic Valve Replacement

The STS-ACC TVT Registry (Society of Thoracic Surgeons-American College of Cardiology Transcatheter Valve Therapy Registry) from 2011 to 2019 has collected data on 276,316 patients undergoing transcatheter aortic valve replacement (TAVR) at sites in all U.S. states. Volumes have increased every year, exceeding surgical aortic valve replacement in 2019 (72,991 vs. 57,626), and it is now performed in all U.S. states. TAVR now extends from extreme- to low-risk patients. This is the first presentation on 8,395 low-risk patients treated in 2019. In 2019, for the entire cohort, femoral access increased to 95.3%, hospital stay was 2 days, and 90.3% were discharged home. Since 2011, the 30-day mortality rate has decreased (7.2% to 2.5%), stroke has started to decrease (2.75% to 2.3%), but pacemaker need is unchanged (10.9% to 10.8%). Alive with acceptable patient-reported outcomes is achieved in 8 of 10 patients at 1 year. The Registry is a national resource to improve care and analyze TAVR's evolution. Real-world outcomes, site performance, and the impact of coronavirus disease 2019 will be subsequently studied. (STS/ACC Transcatheter Valve Therapy Registry [TVT Registry]; NCT01737528).

STS-ACC TVT Registry of Transcatheter Aortic Valve Replacement

The STS-ACC TVT Registry (Society of Thoracic Surgeons-American College of Cardiology Transcatheter Valve Therapy Registry) from 2011 to 2019 has collected data on 276,316 patients undergoing transcatheter aortic valve replacement (TAVR) at sites in all U.S. states. Volumes have increased every year, exceeding surgical aortic valve replacement in 2019 (72,991 vs. 57,626), and it is now performed in all U.S. states. TAVR now extends from extreme- to low-risk patients. This is the first presentation on 8,395 low-risk patients treated in 2019. In 2019, for the entire cohort, femoral access increased to 95.3%, hospital stay was 2 days, and 90.3% were discharged home. Since 2011, the 30-day mortality rate has decreased (7.2% to 2.5%), stroke has started to decrease (2.75% to 2.3%), but pacemaker need is unchanged (10.9% to 10.8%). Alive with acceptable patient-reported outcomes is achieved in 8 of 10 patients at 1 year. The Registry is a national resource to improve care and analyze TAVR's evolution. Real-world outcomes, site performance, and the impact of coronavirus disease 2019 will be subsequently studied. (STS/ACC Transcatheter Valve Therapy Registry [TVT Registry]; NCT01737528).

Mortality and readmission in non-ischemic compared with ischemic cardiomyopathies after implantable cardioverter-defibrillator implantation

Background/Introduction

Uncertainty remains regarding the benefit of primary prevention ICDs overall in contemporary practice, and particularly in those with NICM compared with ICM.

Purpose

To evaluate the contemporary risk of death and readmission following following implantable cardioverter-defibrillator (ICD) implantation in patients with non-ischemic cardiomyopathies (NICM) compared with ischemic cardiomyopathies (ICM) in a large nationally representative cohort in the United States.

Methods

We used data from the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) ICD Registry linked with Medicare claims from April 1, 2010 to December 31, 2013 to establish a cohort of NICM and ICM patients with a left ventricular ejection fraction ≤35% who received a de novo, primary prevention ICD. We compared mortality, all-cause readmission, and heart failure readmission using Kaplan-Meier curves and Cox proportional hazard regressions models. We also evaluated temporal trends in mortality.

Results

Among 31,044 NICM and 68,458 ICM patients with a median follow up of 2.4 years, one-year mortality was significantly higher in ICM patients (12.3%) compared with NICM (7.9%, p&lt;0.001). The higher mortality in ICM patients remained significant after adjustment for covariates (hazard ratio (HR) 1.40; 95% confidence interval (CI) 1.36 to 1.45), and was consistent in subgroup analyses. These findings were consistent across the duration of the study. ICM patients were also significantly more likely to be readmitted for all causes (adjusted HR 1.15, CI 1.12 to 1.18) and for heart failure (adjusted HR 1.25, CI 1.21 to 1.31).

Conclusions

The risks of mortality and hospital readmission after primary prevention ICD implantation were significantly higher in patients with ICM compared with NICM, and these findings were consistent across all patient subgroups tested and over the duration of the study.

Funding Acknowledgement

Type of funding source: None

Aortic remodelling after thoracic endovascular aortic repair in acute and chronic type B aortic dissections

OBJECTIVES

Type B aortic dissections are routinely treated with thoracic endovascular aortic repair (TEVAR). The timing for TEVAR remains controversial and might have an impact on the remodelling capacity of the aorta. This study analyses and compares aortic remodelling in acute (ABD) and chronic (CBD) type B aortic dissections after TEVAR.

METHODS

This retrospective study analysed the preoperative, postoperative and at least 1-year follow-up computed tomography of 53 TEVAR patients (36 ABD, 17 CBD) at a single institution between May 2005 and May 2016. The volumes of aortic lumen (AL), true lumen, false lumen (FL) and perfused FL were measured at the stent graft level (A), from the stent graft to the coeliac trunk (B) and from the coeliac trunk to the bifurcation (C). The absolute volumes, normalized volume changes and FL thrombosis rate of ABD and CBD patients were compared.

RESULTS

Absolute AL and FL of segment A were significantly larger in CBD patients compared to ABD patients preoperatively (AL: 354 ± 68 vs 255 ± 51 ml, P = 0.023, FL: 253 ± 56 vs 183 ± 35 ml, P = 0.028) until last follow-up (AL: 462 ± 52 vs 246 ± 52 ml, P = 0.003, FL: 268 ± 202 vs 91 ± 31 ml, P = 0.004). The true lumen in segment A increased more in ABD than in CBD patients preoperatively to postoperatively (112% vs 36% P < 0.001) and within the first year postoperatively (171% vs 80% P < 0.001). FL in segment A decreased more in ABD compared to CBD patients within the first year (-42% vs -13% P < 0.001) and thereafter (-50% vs +6% P = 0.002). In segments B and C, the FL thrombosis rate was higher in ABD than in CBD patients at all time points and significantly higher in segment A after the first year (91% vs 98% P = 0.035).

CONCLUSIONS

Aortic remodelling after TEVAR is significantly different in acute and chronic dissection patients. TEVAR promotes aortic remodelling in both acute and chronic dissections in terms of true lumen increase at stent graft level. Nevertheless, significant AL reduction by FL shrinkage is primarily found in ABD.