Impact of the use of transradial versus transfemoral approach as secondary access in transcatheter aortic valve implantation procedures

No data exist on the impact of vascular complications related to the secondary access site in transcatheter aortic valve implantation (TAVI). The objectives of this nonrandomized study were to determine the rate of vascular complications related to the secondary access site in TAVI procedures and to evaluate the clinical impact of using the radial versus femoral approach as a secondary access in such procedures. A total of 462 consecutive patients (mean age 79 ± 9 years, 50% men) who underwent TAVI were included. The femoral approach (FA) was used as the secondary access (for the insertion of a 5F pigtail catheter) in 335 patients and the radial approach (RA) in 127 patients. Thirty-day events were prospectively collected. There were no baseline differences between groups, except for a higher prevalence of women and peripheral disease in the FA group (p <0.05 for both). A total of 74 vascular access site complications occurred in 70 patients (15%), and 23% of them (29% in the FA group) were related to the secondary access. The use of FA as secondary access was associated with a higher rate of vascular complications (5.0% vs 0% in the RA group, p = 0.005, adjusted p = 0.014). All major vascular complications related to the secondary access occurred in the FA group (3% vs 0% in the RA group, p = 0.040, adjusted p = 0.049), and this translated into a higher rate of major and/or life-threatening bleeding events related to the secondary access in the FA group (3% vs 0% in the RA group, p = 0.040, adjusted p = 0.049). In conclusion, about 1/4 of vascular access site complications in TAVI are related to the secondary access. The use of the RA as a secondary access was associated with a major reduction in vascular complications. These results highlight the impact of secondary access vascular complications in TAVI procedures and support the use of the RA as the preferred secondary access.

Chronic obstructive pulmonary disease in patients undergoing transcatheter aortic valve implantation: insights on clinical outcomes, prognostic markers, and functional status changes

OBJECTIVES

This study sought to determine the effects of chronic obstructive pulmonary disease (COPD) on clinical outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) and to determine the factors associated with worse outcomes in COPD patients.

BACKGROUND

No data exist on the factors determining poorer outcomes in COPD patients undergoing TAVI.

METHODS

A total of 319 consecutive patients (29.5% with COPD) who underwent TAVI were studied. Functional status was evaluated by New York Heart Association (NYHA) functional class, Duke Activity Status Index, and the 6-min walk test (6MWT) at baseline and at 6 to 12 months. The TAVI treatment was considered futile if the patient either died or did not improve in NYHA functional class at 6-month follow-up.

RESULTS

Survival rates at 1 year were 70.6% in COPD patients and 84.5% in patients without COPD (p = 0.008). COPD was an independent predictor of cumulative mortality after TAVI (hazard ratio: 1.84; 95% confidence interval: 1.08 to 3.13; p = 0.026). Improvement in functional status was observed after TAVI (p < 0.001 for NYHA functional class, Duke Activity Status Index, and 6MWT), but COPD patients exhibited less (p = 0.036) improvement in NYHA functional class. Among COPD patients, a shorter 6MWT distance predicted cumulative mortality (p = 0.013), whereas poorer baseline spirometry results (FEV1 [forced expiratory volume in the first second of expiration]) determined a higher rate of periprocedural pulmonary complications (p = 0.040). The TAVI treatment was futile in 40 COPD patients (42.5%) and a baseline 6MWT distance <170 m best determined the lack of benefit after TAVI (p = 0.002).

CONCLUSIONS

COPD was associated with a higher rate of mortality at mid-term follow-up. Among COPD patients, a higher degree of airway obstruction and a lower exercise capacity determined a higher risk of pulmonary complications and mortality, respectively. TAVI was futile in more than one-third of the COPD patients, and a shorter distance walked at the 6MWT predicted the lack of benefit after TAVI. These results may help to improve the clinical decision-making process in this challenging group of patients.

Significant mitral regurgitation left untreated at the time of aortic valve replacement: a comprehensive review of a frequent entity in the transcatheter aortic valve replacement era

Significant mitral regurgitation (MR) is frequent in patients with severe aortic stenosis (AS). In these cases, concomitant mitral valve repair or replacement is usually performed at the time of surgical aortic valve replacement (SAVR). Transcatheter aortic valve replacement (TAVR) has recently been considered as an alternative for patients at high or prohibitive surgical risk. However, concomitant significant MR in this setting is typically left untreated. Moderate to severe MR after aortic valve replacement is therefore a relevant entity in the TAVR era. The purpose of this review is to present the current knowledge on the clinical impact and post-procedural evolution of concomitant significant MR in patients with severe AS who have undergone aortic valve replacement (SAVR and TAVR). This information could contribute to improving both the clinical decision-making process in and management of this challenging group of patients.

Long-term prognostic value and serial changes of plasma N-terminal prohormone B-type natriuretic peptide in patients undergoing transcatheter aortic valve implantation

Little is known about the usefulness of evaluating cardiac neurohormones in patients undergoing transcatheter aortic valve implantation (TAVI). The objectives of this study were to evaluate the baseline values and serial changes of N-terminal prohormone B-type natriuretic peptide (NT-proBNP) after TAVI, its related factors, and prognostic value. A total of 333 consecutive patients were included, and baseline, procedural, and follow-up (median 20 months, interquartile range 9 to 36) data were prospectively collected. Systematic NT-proBNP measurements were performed at baseline, hospital discharge, 1, 6, and 12 months, and yearly thereafter. Baseline NT-proBNP values were elevated in 86% of the patients (median 1,692 pg/ml); lower left ventricular ejection fraction and stroke volume index, greater left ventricular mass, and renal dysfunction were associated with greater baseline values (p <0.01 for all). Higher NT-proBNP levels were independently associated with increased long-term overall and cardiovascular mortalities (p <0.001 for both), with a baseline cut-off level of ∼2,000 pg/ml best predicting worse outcomes (p <0.001). At 6- to 12-month follow-up, NT-proBNP levels had decreased (p <0.001) by 23% and remained stable up to 4-year follow-up. In 39% of the patients, however, there was a lack of NT-proBNP improvement, mainly related to preprocedural chronic atrial fibrillation, lower mean transaortic gradient, and moderate-to-severe mitral regurgitation (p <0.01 for all). In conclusion, most patients undergoing TAVI presented high NT-proBNP levels, and a lack of improvement was observed in >1/3 of the patients after TAVI. Also, higher NT-proBNP levels predicted greater overall and cardiac mortalities at a median follow-up of 2 years. These findings support the implementation of NT-proBNP measurements for the clinical decision-making process and follow-up of patients undergoing TAVI.

Cochlear implantation in patients with chronic otitis media and radical mastoidectomy: A single-stage procedure

BACKGROUND

We conducted a retrospective case review of patients with mastoid cavity and active or inactive chronic otitis media (COM) who underwent cochlear implantation and ear obliteration in a single-stage procedure. The objectives of this review are to assess the rates of complications and postoperative infections and to evaluate post-implantation audiologic performance.

MATERIALS AND METHODS

All patients with COM and mastoid cavity, associated or not with active disease, who undergo cochlear implantation and obliteration of the ear as a single-stage procedure from November 2004 to April 2013, were included in the review. All the complications were recorded. Open-set sentence scores were used to evaluate the audiologic gain after implantation.

RESULTS

Twenty-seven patients were included in our review: Ten with active COM and seventeen with inactive COM. Overall, nine patients (9/27) presented post-operative complications (7/9 were minor): three were amongst active COM patients (30%) as compared to six amongst inactive COM patients (35%), which included the two major complications. A mean gain of 55.9% on open-set sentence scores was obtained after cochlear implantation.

DISCUSSION

We found that complications rate of the one-stage cochlear implantation was higher in patients with COM than in global implant population, but most complications were minors and there was no statistical difference between active and inactive COM. In addition, these patients had audiologic scores similar to those found in patients with normal temporal bone anatomy.

CONCLUSION

Cochlear implantation performed as a one-stage procedure could be considered as an option of treatment to avoid staging in patients with active and inactive COM. Although these patients need a regular follow-up, they present good post-implantation audiometric scores.

Coronary obstruction following transcatheter aortic valve implantation: a systematic review

OBJECTIVES

This study sought to evaluate, through a systematic review of the published data, the main baseline characteristics, management, and clinical outcomes of patients suffering coronary obstruction as a complication of transcatheter aortic valve implantation (TAVI).

BACKGROUND

Very few data exist on coronary obstruction after TAVI.

METHODS

Studies published between 2002 and 2012, with regard to coronary obstruction as a complication of TAVI, were identified with a systematic electronic search. Only the studies reporting data on the main baseline and procedural characteristics, management of the complication, and clinical outcomes were analyzed.

RESULTS

A total of 18 publications describing 24 patients were identified. Most (83%) patients were women, with a mean age of 83 ± 7 years and a mean logistic European System for Cardiac Operative Risk Evaluation score of 25.1 ± 12.0%. Mean left coronary artery (LCA) ostium height and aortic root width were 10.3 ± 1.6 mm and 27.8 ± 2.8 mm, respectively. Most patients (88%) had received a balloon-expandable valve, and coronary obstruction occurred more frequently in the LCA (88%). Percutaneous coronary intervention was attempted in 23 cases (95.8%) and was successful in all but 2 patients (91.3%). At 30-day follow-up, there were no cases of stent thrombosis or repeat revascularization, and the mortality rate was 8.3%.

CONCLUSIONS

Reported cases of coronary obstruction after TAVI occurred more frequently in women, in patients receiving a balloon-expandable valve, and the LCA was the most commonly involved artery. Percutaneous coronary intervention was a feasible and successful treatment in most cases. Continuous efforts should be made to identify the factors associated with this life-threatening complication to implement the appropriate measures for its prevention.

Importance of diffuse atherosclerosis in the functional evaluation of coronary stenosis in the proximal-mid segment of a coronary artery by myocardial fractional flow reserve measurements

The objective of this study was to evaluate the impact of diffuse coronary atherosclerosis on the functional evaluation of moderate coronary lesions in the proximal-mid segment of a coronary artery and its clinical implications. This was a prospective study including 100 consecutive patients with a moderate lesion (45 ± 9% diameter stenosis) in the proximal-mid coronary segment who were evaluated with fractional flow reserve (FFR) measurement. No patient had any other angiographic stenosis distal to the evaluated coronary stenosis. FFR measurements were obtained just distal (~2 to 3 cm) to the lesion (FFR proximal measurement [FFR-PM]) and as distally as possible in the artery (FFR distal measurement [FFR-DM]) after administration of the same dose of intracoronary adenosine. Thirty-nine patients underwent dipyridamole or exercise myocardial single-photon emission computed tomography within 3 months of the FFR study. Mean FFR-PM was significantly higher compared to FFR-DM (0.84 ± 0.08 vs 0.78 ± 0.09, median gradient 0.06, 25th to 75th interquartile range 0.02 to 0.10, p <0.0001). FFR-DM was <0.75 in 33% of patients with FFR-PM ≥0.75, leading to the decision of revascularization in these patients. Performing FFR measurement in the left main/left anterior descending artery predicted a higher gradient between FFR-DM and FFR-PM (odds ratio 4.58, 95% confidence interval 1.4 to 15.03, p = 0.007). FFR-DM exhibited a better correlation with results of myocardial single-photon emission computed tomography compared to FFR-PM (kappa 0.33 vs 0.22, p <0.0001). In conclusion, significant differences between FFR-DM and FFR-PM were observed in patients with moderate coronary stenosis in the proximal-mid segment of a coronary artery, with FFR-DM exhibiting a better correlation with results of noninvasive functional tests. These differences influenced the treatment decision in about 1/3 of patients and highlight the potential clinical relevance of coronary pressure wire positioning for functional evaluation of lesions in the proximal-mid segment of the coronary arteries.

The critical role of the MyD88-dependent pathway in non-CNS MPTP-mediated toxicity

A growing body of evidence supports a role of inflammation in the loss of central nervous system neurons both to acute and chronic insults, while its contribution to the loss of neurons in the enteric nervous system remains largely uninvestigated. We have addressed this issue by exploring the role of inflammation in dopaminergic (DAergic) myenteric neuronal degeneration secondary to MPTP lesioning in mice deficient in MyD88, a protein implicated in the cascade of events leading to the innate immune response. Our results show that MPTP-treated MyD88 knock out (MyD88(-/-)) mice were protected against the toxin-induced TH-immunoreactive neuronal degeneration at the level of the myenteric plexus of the distal ileum, which causes a 50% loss of such neurons in MPTP-treated WT mice. Interestingly, the density of macrophages was the same in the MyD88(-/-) mice subjected to MPTP, as opposed to the increase in density observed in wild-type (WT) mice treated with the toxin, which was due to an infiltration of monocyte from the blood to the myenteric tissue. Furthermore, in MPTP-treated MyD88(-/-) mice, resident macrophages exhibited a predominant pro-repair phenotype, which could have contributed to the protection of DAergic neurons in the myenteric plexus. Taken together, our results suggest a critical role for the MyD88-dependent pathway in the gastrointestinal DAergic degeneration induced by MPTP.

Systematic resequencing of X-chromosome synaptic genes in autism spectrum disorder and schizophrenia

Autism spectrum disorder (ASD) and schizophrenia (SCZ) are two common neurodevelopmental syndromes that result from the combined effects of environmental and genetic factors. We set out to test the hypothesis that rare variants in many different genes, including de novo variants, could predispose to these conditions in a fraction of cases. In addition, for both disorders, males are either more significantly or more severely affected than females, which may be explained in part by X-linked genetic factors. Therefore, we directly sequenced 111 X-linked synaptic genes in individuals with ASD (n = 142; 122 males and 20 females) or SCZ (n = 143; 95 males and 48 females). We identified >200 non-synonymous variants, with an excess of rare damaging variants, which suggest the presence of disease-causing mutations. Truncating mutations in genes encoding the calcium-related protein IL1RAPL1 (already described in Piton et al. Hum Mol Genet 2008) and the monoamine degradation enzyme monoamine oxidase B were found in ASD and SCZ, respectively. Moreover, several promising non-synonymous rare variants were identified in genes encoding proteins involved in regulation of neurite outgrowth and other various synaptic functions (MECP2, TM4SF2/TSPAN7, PPP1R3F, PSMD10, MCF2, SLITRK2, GPRASP2, and OPHN1).

Adiponectin and risk of coronary heart disease in apparently healthy men and women (from the EPIC-Norfolk Prospective Population Study)

The objective of the present study was to evaluate the association between adiponectin levels and incidence of coronary heart disease (CHD). We performed a prospective case-control analysis nested in the EPIC-Norfolk cohort. Participants were apparently healthy men and women 45 to 79 years of age who developed fatal or nonfatal CHD during an average follow-up period of 7.7 ± 1.1 years. In total 1,035 participants with incident CHD were matched for age, gender, and enrollment time to 1,920 controls who remained free of CHD over the study follow-up. Baseline nonfasting plasma adiponectin concentrations were determined by enzyme-linked immunosorbent assay. Adiponectin levels were lower in participants with CHD than in matched controls (men 8.74 vs 9.13 μg/ml, p = 0.01; women 12.6 vs 13.4 μg/ml, p = 0.03). A 1-μg/ml increment in adiponectin was associated with decreased CHD risk (odds ratio 0.78, 95% confidence interval 0.63 to 0.96, p = 0.02, in men; odds ratio 0.73, 95% confidence interval 0.55 to 0.96, p = 0.03, in women). However, this association was no longer significant after adjustment for established cardiovascular risk factors. Stratification of participants according to metabolic syndrome status showed that men and women with metabolic syndrome had a higher CHD risk, irrespective of their adiponectin levels. In conclusion, although a low adiponectin concentration is associated with an increased CHD risk, findings of the present study do not suggest that its measurement is useful to refine CHD risk assessment once traditional risk factors and clinical features of the metabolic syndrome have been considered.

Exercise capacity in patients with severe symptomatic aortic stenosis before and six months after transcatheter aortic valve implantation

Few data exist on the use of the 6-minute walk test (6MWT) to measure the exercise capacity of patients with severe symptomatic aortic stenosis considered at very high surgical risk. The objectives of the present prospective study were (1) to determine the feasibility and safety of the 6MWT as a measure of exercise capacity before and after transcatheter aortic valve implantation (TAVI), and (2) to determine the clinical and hemodynamic parameters associated with the exercise capacity changes in such patients. A total of 64 patients (age 80 ± 8 years, logistic European System for Cardiac Operative Risk Evaluation score 21 ± 15%, Society of Thoracic Surgeons' score 7.5 ± 3.9%) who had undergone successful TAVI were included. The 6MWT was performed within the month before TAVI and at the 6-month follow-up visit. The mean distance walked increased from 165.3 ± 79.7 to 231.7 ± 88.9 m (p <0.0001); however, up to 25% of the patients did not improve or even decreased their exercise capacity. After adjustment for the baseline distance walked, multilinear regression analysis showed that a greater degree of renal dysfunction, as evaluated by the serum creatinine levels (r(2) = 0.05, p = 0.03), lower postprocedural hemoglobin values (r(2) = 0.13, p = 0.0012), and a longer hospitalization length (r(2) = 0.08, p = 0.007) were associated with lower improvement in exercise capacity. In conclusion, exercise capacity, as evaluated by the 6MWT, was very poor in patients with severe symptomatic aortic stenosis considered at very high surgical risk. TAVI was associated with a significant increase in exercise capacity, although no improvement was observed in 1/4 of the patients. A greater degree in renal dysfunction, lower postprocedural hemoglobin values, and longer hospitalization stay were predictors of lower improvement in exercise capacity after TAVI. These results suggest that the 6MWT might become an important tool as a part of the evaluation process for TAVI candidates.

Usefulness of TEE as the primary imaging technique to guide transcatheter transapical aortic valve implantation

OBJECTIVES

The aim of this study was to: 1) determine the usefulness of transesophageal echocardiography (TEE) as the primary technique to guide transapical (TA) transcatheter aortic valve implantation (TAVI); and 2) to compare TEE with angiography as the primary imaging modality for TA-TAVI guidance.

BACKGROUND

TEE has been routinely used as an adjunct to angiography during TA-TAVI procedures, but very few data exist on the use of TEE as the primary imaging technique guiding TA-TAVI.

METHODS

One hundred consecutive high-risk patients (mean age 79 ± 9 years, mean logistic EuroSCORE: 25.8 ± 17.6%) who underwent TA-TAVI in our center were included. The Edwards valve was used in all cases, and all procedures were performed in an operating room without hybrid facilities. The TA-TAVI was primarily guided by angiography in the first 25 patients (A-TAVI group) and by TEE in the last 75 patients (TEE-TAVI group). Procedural, 30-day, and follow-up results were evaluated.

RESULTS

No differences were observed between groups at baseline except for a higher (p = 0.001) prevalence of moderate or severe mitral regurgitation in the TEE-TAVI group. The procedure was successful in 97.3% and 100% of the patients in the TEE-TAVI and A-TAVI groups, respectively (p = 1.0), and a lower contrast volume was used in the TEE-TAVI group (12 [5 to 20] ml vs. 40 [20 to 50] ml, p < 0.0001). There were no differences between groups in the occurrence of valve malposition needing a second valve (TEE-TAVI: 5.3%; A-TAVI: 4%; p = 1.0) or valve embolization (TEE-TAVI: 1.3%; A-TAVI: 4%; p = 0.44). The results regarding post-procedural valve hemodynamic status and aortic regurgitation were similar between groups. The survival rates at 30-day and 1-year follow-up were 87% and 75% in the TEE-group and 88% and 84% in the A-TAVI group, respectively (log-rank = 0.49).

CONCLUSIONS

TEE-TAVI was associated with similar acute and midterm results as A-TAVI and significantly reduced contrast media use during the procedures. These results suggest the feasibility and safety of performing TA-TAVI procedures in an operating room without hybrid facilities, but larger studies are needed to confirm these findings.

Performance-based functional assessment of patients undergoing transcatheter aortic valve implantation

BACKGROUND

Very few data exist on the functional evaluation of patients with severe symptomatic aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). The aims of this prospective study were (1) to evaluate the Duke Activity Status Index (DASI) as a measure of functional status pre-TAVI and post-TAVI, (2) to determine the clinical parameters associated with DASI changes after TAVI, and (3) to compare functional status as evaluated by DASI and the New York Heart Association (NYHA) class with exercise capacity as evaluated by the 6-minute walk test (6MWT) in such patients.

METHODS

A total of 76 patients (80 ± 8 years old) who underwent successful TAVI were included. All patients completed the DASI self-questionnaire at baseline and at 6 months after TAVI, and 46 patients also performed a 6MWT.

RESULTS

The mean DASI increased from 10.3 ± 5.4 to 16.3 ± 8.3 at 6 months after TAVI (P < .0001). However, the DASI did not change or even decreased to some extent in 30% of patients after TAVI. Renal dysfunction as evaluated by the estimated glomerular filtration rate was identified as the independent predictor of DASI impairment after TAVI (OR 1.7 for each decrease in estimated glomerular filtration rate of 10 mL/min/1.73 m(2), 95% CI 1.3-2.3, P = .005). The mean distance walked increased from 165.9 ± 77.6 to 211.8 ± 78.7 m (P = .0001) at follow-up. The DASI showed a good correlation with the distance walked at baseline (r = 0.55, P < .0001) and at follow-up (r = 0.66, P < .0001). The NYHA class improved to some degree in all but 5 patients; however, the NYHA class did not correlate with the results of DASI and the 6MWT.

CONCLUSIONS

Transcatheter aortic valve implantation was associated with a significant increase in functional status at 6-month follow-up as evaluated by the DASI, although no improvement was observed in about one third of patients. The presence of baseline renal dysfunction better determined this lack of improvement in functional status. The DASI, but not the NYHA class, correlated with distance walked in the 6MWT. These results suggest that the DASI might become a useful tool for evaluating both candidates for and the impact of TAVI procedures.