P3590Impact of right ventricular branch slow flow phenomenon post percutaneous coronary intervention for acute coronary syndrome to predict sustained right ventricular dysfunction

Background

Although Right Ventricular dysfunction (RVD) is one of the predictor of poor prognosis, it is believed that ischemic RVD after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) restores quickly. Because right ventricular perfusion has more ischemic preconditioning compared with left ventricle, due to their complex perfusion system. However, little is known about the time courses of RVD after ACS-PCI andtheir prognosis. We evaluated the relationship between right ventricular branch slow flow phenomenon (RVB-SF) post ACS-PCI in right coronary artery (RCA) and RVD at 6–8 months follow-up.

Method

We retrospectively analyzed consecutive 82 patients who underwent PCI for ACS in proximal or mid portion of RCA from August 2011 to March 2018 in our institution. Finally, both baseline and follow-up data were obtained from 70 patients. We analyzed TIMI frame count (TFC) to confirm the presence of RVB-SF (TFC ≥40 frame) after PCI. We also analyzed right ventricular fractional area change (RVFAC) at baseline and follow-up using echocardiography to detect sustained RVD (RVFAC ≤35%).

Result

We divided the patients into two groups (RVB-SF: 36 patients, RVB non-SF: 34 patients). Patient clinical characteristics were similar in both groups (sex, age, risk factors, medication, onset to balloon time, left ventricular stroke volume, max creatine kinase). Baseline RVFAC and follow-up RVFAC was significantly smaller in RVB-SF than in RVB non-SF, respectively. (27.1±1.7% vs. 38.3±1.8%, 31.4±1.0% vs. 48.7±1.1%, P<0.0001). However, ΔRVFAC (follow-up RVFAC – baseline RVFAC) was similar between groups. The size of inferior vena cava and systolic pulmonary artery pressure at follow-up were similar in both groups (12.1±0.6 mm vs. 11.7±0.7 mm, P=0.67, 25.7±1.5 mmHg vs. 25.2±1.5 mmHg, P=0.82). In RVB non-SF, 10 patients (29.4%) were diagnosed clinical RVAMI. However, follow-up RVFAC were similar and preserved in both groups (RVAMI: 48.1±1.3%, non-RVAMI: 49.9±1.9%, P=0.85). In RVB-SF, 19 patients (52.7%) were diagnosed clinical RVAMI. Follow-up RVFAC did not improved significantly in both groups (RVAMI: 30.4±1.4% vs. non-RVAMI: 32.6±1.5%, P=0.70). Multivariate analysis showed RVB-SF was the only independent predictor of sustained RVD at 6–8 months follow-up after ACS-PCI.

Conclusion

RVB-SF findings after ACS-PCI for RCA could predict sustained RVD at mid-term follow-up, which may indicate future prolonged RVD.

Prognostic impact of postprocedure stroke volume in patients with low-gradient aortic stenosis

Objective

The effect of postoperative blood flow status on the prognosis of patients with low-gradient severe aortic stenosis (AS) has not been examined. Severe AS is associated with a higher mortality rate after transcatheter aortic valve implantation (TAVI). We examined the prognostic value of low-flow status by comparing stroke volume indices (SVi) before and after TAVI in patients with symptomatic, low-gradient severe AS.

Methods

A total of 1613 patients with severe symptomatic AS who underwent TAVI in 14 Japanese institutes for low-gradient severe AS (418 patients, median age 84 years, 32.5% men) were prospectively enrolled. The primary endpoint was cardiovascular mortality during follow-up after TAVI, and independent predictors were evaluated. Receiver operating characteristic curves were generated to determine the optimal cut-off value of post-TAVI SVi for predicting cardiovascular mortality, and the receiver operating characteristic curves of pre-TAVI and post-TAVI SVi were compared.

Results

The cardiovascular mortality rate was 4.1% (17 patients) during follow-up (median 9.2 months). Multivariate analysis revealed post-TAVI SVi to be an independent predictor of cardiovascular mortality (per 10 mL/m² decrease; HR, 2.0; 95% CI 1.28 to 3.12). The optimal cut-off value of post-TAVI SVi was 41.4 mL/m². Post-TAVI SVi showed significantly larger area under the curve than pre-TAVI SVi (0.74 (95% CI 0.69 to 0.79) vs 0.61 (95% CI 0.56 to 0.65), p<0.05).

Conclusions

Post-TAVI SVi is a better predictor of cardiovascular mortality than pre-TAVI SVi in patients with symptomatic low-gradient severe AS. Low-flow and low-normal-flow status (35≤ SVi <40 mL/m²) require careful management after TAVI.

Update on the clinical impact of mild aortic regurgitation after transcatheter aortic valve implantation: Insights from the Japanese multicenter OCEAN-TAVI registry

OBJECTIVES

This study aimed to compare the clinical impact of mild postprocedural aortic regurgitation (post-AR) to that of none-trivial post-AR after transcatheter aortic valve implantation (TAVI) and to identify the vulnerability factors to mild post-AR.

BACKGROUND

Moderate-severe post-AR, associated with increased mortality, is an important issue. However, the clinical impact of mild post-AR remains controversial.

METHODS AND RESULTS

We analyzed data from 1,572 consecutive patients (1,026 of none-trivial post-AR and 546 of mild post-AR) obtained from the Optimized transCathEter vAlvular Intervention (OCEAN-TAVI) Japanese multicenter registry. We evaluated the 1-year cumulative cardiovascular death and re-hospitalization rates for heart failure (HF) after TAVI according to the degree of post-AR. Kaplan-Meier curves showed no significant difference between "none-trivial post-AR" and "mild post-AR" in terms of cardiovascular death, but a significant difference was noted in the cumulative incidence of re-hospitalization for HF between the two groups (hazard ratio 1.57, 95% confidence interval 1.02-2.41, p = .04). In the stratified analysis, only in patients with not more than 50% of left ventricular ejection fraction (LVEF), concentric left ventricular hypertrophy (LVH), and none-trivial pre-procedural aortic regurgitation (pre-AR), mild post-AR resulted in a higher incidence of re-hospitalization for HF.

CONCLUSIONS

In this study, the clinical impact of mild post-AR compared to none-trivial post-AR tended to be augmented in the presence of reduced LVEF, concentric LVH, and none-trivial pre-AR. Pre-procedure echocardiographic findings including LVEF, left ventricular geometry, and pre-AR may help to judge the necessity of postdilatation in case of mild post-AR just after the bioprosthesis deployment.

Comparison of Balloon Angioplasty and Stent Implantation for Femoropopliteal Disease According to Patient and Lesion Subgroup

Background: Little is known about the superiority of balloon angioplasty vs. stent implantation for femoropopliteal (FP) lesions according to subgroup.

Methods and Results: This study involved 1,018 de novo (balloon angioplasty, n=462; stent implantation, n=556) and 114 in-stent restenosis (ISR) FP lesions (balloon angioplasty, n=69; stent implantation, n=45) treated with endovascular therapy. For de novo FP lesions, the 3-year primary patency rate was significantly better with stent implantation than with balloon angioplasty (61% vs. 69%, log-rank P=0.001), but it was similar for ISR FP lesions (40% vs. 43%, log-rank P=0.83). For de novo FP lesions, stent implantation was favorable in all subgroups except for female sex (hazard ratio [HR], 0.92; 95% CI: 0.65–1.31, P=0.66), critical limb ischemia (CLI; HR, 0.70; 95% CI: 0.46–1.06, P=0.10), calcified lesion (HR, 0.81; 95% CI: 0.46–1.39, P=0.44), and poor tibial run-off (HR, 0.86; 95% CI: 0.59–1.25, P=0.42) subgroups. No difference was found between the 2 treatment strategies for ISR FP lesions in the majority of subgroups. Stent implantation, however, was favorable in totally occluded ISR FP lesions (HR, 0.45; 95% CI: 0.21–1.01, P=0.05).

Conclusions: The primary patency rate in de novo FP lesions for the 2 treatment strategies was similar in the female, calcified lesion, CLI, and poor tibial run-off subgroups. Stent implantation was superior to balloon angioplasty for totally occluded ISR FP lesions.

Association between valvuloarterial impedance after transcatheter aortic valve implantation and 2-year mortality in elderly patients with severe symptomatic aortic stenosis: the OCEAN-TAVI registry

Pre-procedural valvuloarterial impedance (Zva) is considered as a useful predictor of mortality in patients diagnosed as having severe aortic stenosis (AS) who undergo transcatheter aortic valve implantation (TAVI). However, the prognostic significance of post-procedural Zva remains unclear. We aimed to evaluate the prognostic significance of Zva after TAVI. We retrospectively analyzed the clinical and echocardiographic data of 1004 consecutive elderly patients (median 84 years old, 27.5% men) who underwent TAVI for severe symptomatic AS. Zva was calculated after TAVI, and patients were divided into three groups based on tertile values: the high [> 3.33 (n = 335)], intermediate [2.49-3.33 (n = 334)], and low Zva groups [< 2.49 (n = 335)]. The estimated 2-year all-cause and cardiovascular mortalities using Kaplan-Meier analysis were 16.2% [95% confidence interval (CI) 11.8-20.4] and 5.9% (95% CI 3.2-8.6), respectively. There were no significant intergroup differences in each endpoint (long-rank p = 0.518 for all-cause mortality, p = 0.757 for cardiovascular mortality). Multivariable Cox regression analyzes with adjustments of patient characteristics and medications showed that the post-procedural Zva was not associated with the 2-year all-cause mortality [intermediate Zva group versus (vs.) low Zva group: adjusted hazard ratio (aHR) = 1.34, 95% CI 0.75-2.40, p = 0.316; high Zva group vs. low Zva group: aHR = 1.17, 95% CI 0.64-2.16, p = 0.613] and cardiovascular mortality (intermediate Zva group vs. low Zva group: aHR = 1.50, 95% CI 0.56-4.06, p = 0.421; high Zva group vs. low Zva group: aHR = 1.25, 95% CI 0.43-3.65, p = 0.682). Our results suggest that post-procedural Zva was not associated with 2-year all-cause or cardiovascular mortalities in patients with severe symptomatic AS who underwent TAVI.

Distal embolization of coronary calcified nodule after rotational atherectomy

A 62-year-old man with effort angina underwent percutaneous coronary intervention in our hospital. The target lesion was severely calcified at the mid part of the right coronary artery. Pre-procedural intravascular imaging and optical frequency domain imaging showed a calcified nodule at the lesion. We performed rotational atherectomy with a 2.0 mm burr and observed an increase in the lumen area; however, a large amount of calcified nodule persisted. We decided to perform rotational atherectomy with a burr size of 2.25 mm; however, distal embolization of the calcified nodule occurred. We failed to retrieve the embolus; hence, we performed balloon dilatation with a 2.0-mm balloon, which was successfully performed. Yet, the lesion with the embolus immediately recoiled. Finally, a drug-eluting stent was implanted in both the distal lesion with the embolus and the lesion with the calcified nodule. Final coronary angiography showed good results. We confirmed good stent expansion and that calcified nodule was compressed outside the stent. Atherectomy of a calcified nodule is effective at achieving sufficient stent expansion and reducing the risk of vessel perforation. However, we experienced distal embolization of the calcified nodule at the time of rotational atherectomy and so distal embolization should be considered at the time of treatment of calcified nodule.

Frequency and Consequences of Cognitive Impairmentin Patients Underwent Transcatheter Aortic Valve Implantation

Cognitive impairment is common in patients underwent transcatheter aortic valve implantation (TAVI) and might affect procedure outcomes. This study evaluated the incidence of preprocedural cognitive impairment and its impact on clinical outcomes after TAVI. We analyzed the data of 1,111 patients (age ≥70 years) obtained from the Optimized CathEter vAlvular iNtervention (OCEAN-TAVI) registry. The cognitive performance of all patients was assessed using the Mini-Mental State Examination (MMSE) at baseline. We evaluated the 1-year cumulative mortality after TAVI according to the MMSE performance. Cognitive impairment was present in 420 (38%) of 1,111 patients. Compared with patients with normal cognition, those with cognitive impairment showed higher cumulative all-cause and noncardiovascular mortality rates at 1 year (14% vs. 8%, p = 0.001; 11% vs. 5%, p <0.001, respectively). Moreover, cognitive impairment increased the risk of mortality from sepsis (2% vs. 0.4%; hazard ratio, 4.2; 95% confidence interval, 1.3 to 13.5; p = 0.02). In adjusted models, cognitive impairment was an independent risk factor for 1-year all-cause mortality (adjusted hazard ratio, 2.1; 95% confidence interval, 1.1 to 4.0; p = 0.02). Although patients with cognitive impairment had more in-hospital adverse outcomes, including prolonged hospital stays, major bleeding and vascular complications, and acute kidney injury, than did those with normal cognition, the 30-day mortality was similar between the groups (1% in the two groups; p >0.99). In conclusion, cognitive impairment based on the MMSE score was an independent predictor of mortality at 1 year after TAVI.

Is elevation of N-terminal pro-B-type natriuretic peptide at discharge associated with 2-year composite endpoint of all-cause mortality and heart failure hospitalisation after transcatheter aortic valve implantation? Insights from a multicentre prospective OCEAN-TAVI registry in Japan

OBJECTIVES

The aim of this study was to investigate the 2-year prognostic impact of N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels at discharge following transcatheter aortic valve implantation (TAVI).

DESIGN

Multicentre prospective observational study.

SETTINGS

Seven institutions from multicentre, observational registry of symptomatic patients with severe aortic stenosis who undergo TAVI.

PARTICIPANTS

We enrolled 500 consecutive patients who underwent TAVI with measurements of NT-proBNP at discharge between 2013 and 2016. Study patients were stratified into two groups according to survival classification and regression tree (CART) analysis: high versus low NT-proBNP groups.

INTERVENTIONS

The impact of high NT-proBNP on a 2-year composite endpoint consisting of all-cause mortality and heart failure hospitalisation was evaluated using a multivariable Cox model.

RESULTS

Median age was 86 years (quartile 82-89), and 24.2% of the study population were men. Median Society of Thoracic Surgeon score was 7.1 (5.1-9.8), and NT-proBNP at discharge was 1381 (653-3136) pg/mL. The composite endpoint incidence was 13.0% (95% CI 9.5% to 16.3%) at 1 year and 22.3% (95% CI 16.1%-27.9%) at 2 years. The survival CART analysis revealed that the NT-proBNP level required to discern the 2-year composite endpoint was 4288 pg/mL. Elevated NT-proBNP had a statistically significant impact on outcomes, with adjusted HR of 2.21 (95% CI 1.21 to 4.04, p=0.010), and with a significant sex difference (P for interaction=0.003).

CONCLUSION

Elevation of NT-proBNP at discharge is associated with higher incidence of the 2-year composite endpoint after TAVI.

TRIAL REGISTRATION NUMBER

000020423.