Comparison of Hospital Outcomes of Transcatheter AorticValve Implantation With Versus Without Hypothyroidism

Comparative outcomes of transcatheter aortic valve implantation (TAVI) in patients with and without hypothyroidism were not previously reported. This study aimed to appraise the clinical outcomes and impact of hypothyroidism on patients who underwent TAVI. Patients with hypothyroidism who underwent TAVI from 2011 to 2014 were identified in the National Inpatient Sample database using the International Classification of Diseases, ninth Revision, Clinical Modification. The primary outcome was the effect of hypothyroidism on inpatient mortality. Secondary outcomes were the impact of hypothyroidism on post-TAVI complications. We also evaluated the length of hospital stay and the cost of hospitalization. Propensity score-matched analysis was performed to address potential confounding. The hypothyroid patients who underwent TAVI had no significant increase in the risk of in-hospital mortality (odds ratio 0.78; 95% confidence interval 0.51 to 1.21, p = 0.282), or most postprocedural complications. However, hypothyroid patients were more likely to develop hemorrhage requiring transfusion (odds ratio 1.36, 95% confidence interval 1.05 to 1.76, p = 0.043). In conclusion, TAVI is a feasible and relatively safe alternative with reasonable in-hospital outcomes in patients with hypothyroidism and severe symptomatic aortic stenosis. However, hypothyroid patients are more likely to require a blood transfusion after TAVI. Additional randomized trials are needed to evaluate TAVR outcomes in hypothyroid patients.

Outcomes and Effects of Hepatic Cirrhosis in Patients Who Underwent Transcatheter Aortic Valve Implantation

Comparative outcomes of transcatheter aortic valve implantation (TAVI) in patients with and without liver cirrhosis are scarce. This study aimed to assess the clinical outcomes and impact of liver cirrhosis on patients who underwent TAVI. Patient with liver cirrhosis who underwent TAVI 2011 to 2014 were identified in the National Inpatient Sample database using the International Classification of Diseases, ninth revision, Clinical Modification (ICD-9-CM). The primary outcome was the effect of liver cirrhosis on inpatient mortality. Secondary outcomes were the impact of liver cirrhosis on post-TAVI complications. We also evaluated the length of hospital stay and the cost of hospitalization. Propensity score-matched analysis was performed to address potential confounding. The cirrhotic patients who underwent TAVI had no significant increase in the risk of in-hospital mortality (odds ratio [OR] 1.12, 95% confidence interval [CI] 0.59 to 2.10, p = 0.734) or after procedural complications. Furthermore, cirrhotic patients were less likely to develop vascular complications requiring surgery (OR 0.47, 95% CI 0.23 to 0.98, p = 0.043), to develop after procedural deep vein thrombosis(OR <0.00, 95% CI <0.001 to <0.0001, p <0.0001), and to require pacemaker implantation. However, cirrhotic patients were more likely to undergo nonroutine hospital discharges (OR 1.50, 95% CI 1.15 to 1.96, p = 0.003). In conclusion, TAVI is a safe and reasonable therapeutic option for cirrhotic patients with severe aortic stenosis, requiring aortic valve replacement.

Clinical End Points of Transcatheter Aortic Valve Implantation Compared With Surgical Aortic Valve Replacement in Patients <65 Years of Age (From the National Inpatient Sample Database)

It is unknown if transcatheter aortic valve implantation (TAVI) is a safe alternative to surgical aortic valve replacement (SAVR) in patients <65 years old. Data from the National Inpatient Sample database were utilized. Patients from 2011 to 2015, ages 18 to 64 years old (inclusive) who underwent TAVI and SAVR were included. Patients who underwent SAVR and who also received a concomitant nonaortic valve surgery were excluded. A propensity score analysis was used. A total of 18,970 (528 TAVI and 18,442 SAVR) patients were identified. Patients who underwent TAVI were older (57 ± 7 vs 54 ± 10 years old, p <0.001) with more frequent co-morbidities. Overall in-hospital mortality was similar between TAVI and SAVR (odds ratio [OR] = 0.52, p = 0.12). Postprocedure stroke (OR = 0.50, p = 0.24), acute kidney injury (OR = 0.98, p = 0.89), acute myocardial infarction (OR = 0.48, p = 0.08), and vascular complication requiring surgery (OR = 0.20, p = 0.11) were similar between patients who underwent TAVI and SAVR. Bleeding requiring transfusion (OR = 0.32, p <0.01) was less frequent in patients who underwent TAVI, but new pacemakers (OR = 1.7, p = 0.02) were more frequent in these patients. Patients who underwent TAVI had shorter hospital stays (7.9 vs 10.0 days, p <0.001) and were more likely to be discharged to home. Cost between TAVI and SAVR was similar ($49,014 vs $42,907, respectively, p = 0.82). In the <65 years old patient population, TAVI also conferred similar overall in-hospital mortality compared with patients who underwent SAVR. TAVI resulted in fewer major complications, shorter hospital stay, and more frequent discharge to home, but higher rates of pacemaker implantation compared with SAVR. Therefore, TAVI appears to be a safe alternative to SAVR in patients <65 years old.

Financial Implications and Impact of Pre-existing Atrial Fibrillation on In-Hospital Outcomes in Patients Who Underwent Transcatheter Aortic Valve Implantation (from the National Inpatient Database)

The objective of this study was to evaluate the financial implications and the impact of pre-existing atrial fibrillation (AF) on in-hospital outcomes in patients who underwent transcatheter aortic valve implantation (TAVI) using the Nationwide Inpatient Sample (NIS) database. We identified patients who underwent TAVI from 2011 to 2014. The primary end point was the effect of pre-existing AF on in-hospital mortality. Secondary end points included periprocedural cardiac complications, stroke, and hemorrhage requiring transfusion. We also assessed length of stay (LOS) and cost of hospitalization. A mixed-effect logistic model was used for clinical end points, and a linear mixed model was used for cost and LOS. In 6,778 patients who underwent TAVI (46.1% women and 81.4 ± 8.5 years old), the incidence of AF was 43.3%. After adjusting for patient- and hospital-level characteristics, pre-existing AF was not found to influence in-hospital mortality (odds ratio 1.05, 95% confidence interval 0.80 to 1.36). AF was associated with an increased risk of periprocedural cardiac complications (odds ratio 1.46, 95% confidence interval 1.22 to 1.75), longer LOS (p <0.001) and an increased cost of hospitalization (US$51,852 vs US$49,599). In conclusion, pre-existing AF did not impact in-hospital mortality in TAVI patients but was associated with increased cardiac complications, a longer hospital LOS, and a higher cost of hospitalization.

Is Transcatheter Aortic Valve Replacement Better Than Surgical Aortic Valve Replacement in Patients With Chronic Obstructive Pulmonary Disease? A Nationwide Inpatient Sample Analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) patients are at increased risk of respiratory related complications after cardiac surgery. It is unclear whether transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) results in favorable outcomes among COPD patients.

METHODS AND RESULTS

Patients were identified from the Nationwide Inpatient Sample database from 2011 to 2014. Patients with age ≥60, COPD, and either went transarterial TAVR or SAVR were included in the analysis. A 1:1 propensity-matched cohort was created to examine the outcomes. A matched pair of 1210 TAVR and 1208 SAVR patients was identified. Respiratory-related complications such as tracheostomy (0.8% versus 5.8%; odds ratio [OR], 0.14; P<0.001), acute respiratory failure (16.4% versus 23.7%; OR, 0.63; P=0.002), reintubation (6.5% versus 10.0%; OR, 0.49; P<0.001), and pneumonia (4.5% versus 10.1%; OR, 0.41; P<0.001) were significantly less frequent with TAVR versus SAVR. Use of noninvasive mechanical ventilation was similar between TAVR and SAVR (4.1% versus 4.8%; OR, 0.84; P=0.41). Non-respiratory-related complications, such as in-hospital mortality (3.3% versus 4.2%; OR, 0.64; P=0.035), bleeding requiring transfusion (9.9% versus 21.7%; OR, 0.38; P<0.001), acute kidney injury (17.7% versus 25.3%; OR, 0.63; P<0.001), and acute myocardial infarction (2.4% versus 8.4%; OR, 0.19; P<0.001), were significantly less frequent with TAVR than SAVR. Cost ($56 099 versus $63 146; P<0.001) and hospital stay (mean, 7.7 versus 13.0 days; P<0.001) were also more favorable with TAVR than SAVR.

CONCLUSIONS

TAVR portended significantly fewer respiratory-related complications compared with SAVR in COPD patients. TAVR may be a preferable mode of aortic valve replacement in COPD patients.

Meta-Analysis Comparing Patent Foramen Ovale Closure Versus Medical Therapy to Prevent Recurrent Cryptogenic Stroke

New evidence suggests that closure of a patent foramen ovale (PFO) plus medical therapy (MT; antiplatelet or anticoagulation) is superior to MT alone to prevent recurrent cryptogenic stroke. We performed a meta-analysis of randomized controlled trials that compared PFO closure plus MT with MT alone in patients with cryptogenic stroke. The efficacy end points were recurrent stroke, transient ischemia attack, and death. The safety end points were major bleeding and newly detected atrial fibrillation. Trials were pooled using random effects and fixed effects models. A trial sequential analysis was performed to assess if the current evidence is sufficient. Risk ratios (RR) were calculated for pooled estimates of risk. Five randomized controlled trials (3,440 patients) were included. Mean follow-up was 4.1 years. PFO closure reduced the risk of recurrent stroke by 58% (RR 0.42, 95% CI 0.20 to 0.91, p = 0.03). The number needed to treat was 38. The cumulative Z-line crossed the trial sequential boundary, suggesting there is adequate evidence to conclude that PFO closure reduces the risk of recurrent stroke by 60%. PFO closure did not reduce the risk of transient ischemia attack (RR 0.78, 95% CI 0.53 to 1.15, p = 0.21), mortality (RR 0.74, 95% CI 0.35 to 1.60, p = 0.45), or major bleeding (RR 0.96, 95% CI 0.42 to 2.20, p = 0.93); it did increase the risk of atrial fibrillation (RR 4.69, 95% CI 2.17 to 10.12, p <0.0001).

Red cell distribution width and risk of cardiovascular mortality: Insights from National Health and Nutrition Examination Survey (NHANES)-III

INTRODUCTION

Red cell distribution width (RDW) has been linked to cardiovascular disease. We sought to determine whether addition of RDW improved the Framingham risk score (FRS) model to predict cardiovascular mortality in a healthy US cohort.

METHODS

We performed a post-hoc analysis of the National Health and Nutritional Examination Survey-III (1988-94) cohort, including non-anemic subjects aged 30-79years. Primary endpoint was death from coronary heart disease (CHD). We divided the cohort into three risk categories: <6%, 6-20% and >20%. RDW>14.5 was considered high. Kaplan-Meier survival curves and Cox proportional hazards models were created. Discrimination, calibration and reclassification were used to assess the value of addition of RDW to the FRS model.

RESULTS

We included 7005 subjects with a mean follow up of 14.1years. Overall, there were 233 (3.3%) CHD deaths; 27 (8.2%) in subjects with RDW>14.5 compared to 206 (3.1%) in subjects with RDW≤14.5 (p<0.001). Adjusted hazard ratio of RDW in predicting CHD mortality was 2.02 (1.04-3.94, p=0.039). Addition of RDW to FRS model showed significant improvement in C-statistic (0.8784 vs. 0.8751, p=0.032) and area under curve (0.8565 vs. 0.8544, p=0.05). There was significant reclassification of FRS with a net reclassification index (NRI) of 5.6% (p=0.017), and an intermediate-risk NRI of 9.6% (p=0.011). Absolute integrated discrimination index (IDI) was 0.004 (p=0.02), with relative IDI of 10.4%.

CONCLUSIONS

Our study demonstrates that RDW is a promising biomarker which improves prediction of cardiovascular mortality over and above traditional cardiovascular risk factors.