Impact of cancer in patients with aortic stenosis undergoing transcatheter aortic valve replacement: A systematic review and meta-analysis

Background

Owing to the minimally invasive nature of transcatheter aortic valve replacement (TAVR), TAVR seems to be preferred in patients with cancer; however, related research on the clinical efficacy and safety of TAVR in patients with cancer and severe aortic stenosis is limited, and conclusions are controversial. This study aimed to evaluate the clinical outcomes of patients with cancer who underwent TAVR.

Method and results

We conducted a systematic review and meta-analysis to investigate the clinical outcomes in patients with and without cancer who underwent TAVR. We systematically reviewed and analyzed 15 studies (195,658 patients) published in PubMed and Cochrane Library databases between January 2022 and January 2023. The primary outcomes were short-term (in-hospital or 30-day) and long-term (≥12 months) mortality. The prevalence of current or previous cancer in the patients undergoing TAVR was 19.8 % (38,695 patients). Patients with cancer had a lower risk of short-term mortality (odds ratio [OR] 0.69, 95 % confidence interval [CI] 0.61-0.77, P < 0.001) but a higher risk of long-term mortality (OR 1.54, 95 % CI 1.35-1.76, P < 0.001) than those without cancer. Patients with cancer had a lower incidence of postprocedural stroke and acute kidney injury but a higher incidence of pacemaker implantation than patients without cancer.

Conclusions

Patients with cancer undergoing TAVR have a good short-term prognosis and acceptable perioperative complications compared with patients without cancer. However, the long-term outcomes are contingent on cancer survival.

Obesity and Transcatheter Aortic Valve Replacement

Amidst an aging population and escalating obesity prevalence, elucidating the impact of obesity on transcatheter aortic valve replacement (TAVR) outcomes becomes paramount. The so-called "obesity paradox"-a term denoting the counterintuitive association of obesity, typically a risk factor for cardiovascular diseases, with improved survival outcomes in TAVR patients relative to their leaner or normal-weight counterparts-merits rigorous examination. This review comprehensively investigates the complex relationship between obesity and the clinical outcomes associated with TAVR, with a specific focus on mortality and periprocedural complications. This study aims to deepen our understanding of obesity's role in TAVR and the underlying mechanisms of the obesity paradox, thereby optimizing management strategies for this patient demographic, tailored to their unique physiological and metabolic profiles.

Risk Score for Prediction of Dialysis After Transcatheter Aortic Valve Replacement

BACKGROUND

Dialysis is a rare but serious complication after transcatheter aortic valve replacement. We analyzed the large multicenter TRITAVI (transfusion requirements in transcatheter aortic valve implantation) registry in order to develop and validate a clinical score assessing this risk.

METHODS AND RESULTS

A total of 10 071 consecutive patients were enrolled in 19 European centers. Patients were randomly assigned (2:1) to a derivation and validation cohort. Two scores were developed, 1 including only preprocedural variables (TRITAVIpre) and 1 also including procedural variables (TRITAVIpost). In the 6714 patients of the derivation cohort (age 82±6 years, 48% men), preprocedural factors independently associated with dialysis and included in the TRITAVIpre score were male sex, diabetes, prior coronary artery bypass graft, anemia, nonfemoral access, and creatinine clearance <30 mL/min per m2. Additional independent predictors among procedural features were volume of contrast, need for transfusion, and major vascular complications. Both scores showed a good discrimination power for identifying risk for dialysis with C-statistic 0.78 for TRITAVIpre and C-statistic 0.88 for TRITAVIpost score. Need for dialysis increased from the lowest to the highest of 3 risk score groups (from 0.3% to 3.9% for TRITAVIpre score and from 0.1% to 6.2% for TRITAVIpost score). Analysis of the 3357 patients of the validation cohort (age 82±7 years, 48% men) confirmed the good discrimination power of both scores (C-statistic 0.80 for TRITAVIpre and 0.81 for TRITAVIpost score). Need for dialysis was associated with a significant increase in 1-year mortality (from 6.9% to 54.4%; P=0.0001).

CONCLUSIONS

A simple preprocedural clinical score can help predict the risk of dialysis after transcatheter aortic valve replacement.

Positive blood pressure response may predict the recovery of renal function after transcatheter aortic valve implantation

OBJECTIVE

Transcatheter aortic valve implantation (TAVI) may ameliorate renal function and increase blood pressure (BP). We aimed to investigate the association between increased BP and improved renal function (IRF) after TAVI.

METHODS

A total of 176 patients who had undergone TAVI were evaluated retrospectively. BP records that were taken 24 h before and 72 h after TAVI were reviewed. Pre-procedural, post-procedural 48 h, and the first month estimated glomerular filtration rate (eGFR) levels were noted. IRF was accepted as a ≥ 10% increase in eGFR. The predictors of acute kidney injury (AKI) development at 48 h and IRF at 1 month were investigated. The association between mortality and BP response was assessed.

RESULTS

A total of 157 patients were included in this study after exclusion as defined in the methodology. Mean age was 78.1 ± 7,1 and 51.6% were female. AKI occurred in 25.5% of patients and baseline eGFR and male gender were found as independent predictors for AKI development. IRF was observed in 16% at 48 h and 31.8% of patients at 1-month follow-up. Positive BP response was seen in 42% of patients. Pre-procedural chronic kidney disease, positive BP response, and an early increase in eGFR emerged as independent predictors of IRF at the first month. The patients with positive BP response were found to have decreased mortality at 710 days follow-up.

CONCLUSION

Positive BP response after TAVI is related to improved survival and renal functions. The beneficial effect of TAVI on renal function may be precisely evaluated at 1st month rather than 48 h.

Rapid Assessment and Treatment In Decompensated Aortic Stenosis (ASTRID-AS study)- A pilot study

BACKGROUND

Acute decompensated aortic stenosis (ADAS) is common and associated with higher mortality, acute kidney injury (AKI) and longer hospital length of stay (LoS) compared with electively treated stable AS. The aim of this study was to assess the impact of a dedicated pathway that reduces time to transcatheter aortic valve implantation (TAVI) in ADAS, hypothesizing that LoS can be reduced without compromising patient safety.

METHODS AND RESULTS

Using a prospective, open label, cluster design, patients from 5 referring centres were allocated to the ASessment and TReatment In Decompensated Aortic Stenosis (ASTRID-AS) pathway where the diagnosis, referral, investigations and treatment of ADAS were prioritised and expedited. 15 hospitals remained on the conventional pathway that followed the same process, albeit according to a waiting list. The primary efficacy endpoint was hospital LoS and the secondary safety endpoint, a composite of death or AKI at 30 days post-TAVI. 58 conventional patients and 25 ASTRID-AS patients were included in this study. Time to TAVI in the conventional vs. ASTRID-AS cohort was 22 (15-30) vs. 10 (6-12) days; P < 0.001, respectively. Length of hospital stay was 24 (18-33) vs. 13 (8-18) days; P < 0.001, respectively. 13.4 bed days were saved per patient using the ASTRID-AS pathway. Secondary safety endpoint occurred in 12 (20.7%) vs. 1 (4.0%) patients; P = 0.093, respectively. Procedural complications were similar between the two cohorts.

CONCLUSION

A dedicated pathway for ADAS that shortens time to TAVI demonstrated reduced hospital LoS without compromising patient safety and a trend towards improving clinical outcomes.

Definition, Staging, and Role of Biomarkers in Acute Kidney Injury in the Context of Cardiovascular Interventions

Acute kidney injury (AKI) is a frequently occurring complication of cardiovascular interventions, and associated with adverse outcomes. Therefore, a clear definition of AKI is of paramount importance to enable timely recognition and treatment. Historically, changes in the serum creatinine and urine output have been used to define AKI, and the criteria have evolved over time with better understanding of the impact of AKI on the outcomes. However, the reliance on serum creatinine for these AKI definitions carries numerous limitations including delayed rise, inability to differentiate between hemodynamics versus structural injury and assay variability to name a few.

Implications of Renal Disease in Patients Undergoing Structural Interventions

Percutaneous structural interventions have a major impact on the morbidity, mortality, and quality of life of patients by providing a lower-risk alternative to cardiac surgery. However, renal disease has a significant impact on outcomes of these interventions. This review explores the incidence, outcomes, pathophysiology, and preventative measures of acute kidney injury and chronic kidney disease on transcatheter aortic valve replacement, transcatheter mitral valve repair, and percutaneous balloon mitral valvuloplasty. Given the expanding indications for percutaneous structural interventions, further research is needed to identify ideal patients with chronic kidney disease or end-stage renal disease who would benefit from intervention.

Factors Associated With Acute Kidney Injury in Patients Undergoing Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-Analysis

The aim of this meta-analysis is to assess the effect of different independent predictors on acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI). This meta-analysis adhered to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive database search was conducted using PubMed, Web of Science, and Scopus for the period from January 1, 2015, to August 15, 2023. The following key terms were employed: "transcatheter aortic valve implantation" OR "transcatheter aortic valve replacement" AND "acute kidney injury" OR "acute renal failure." Our search was limited to studies published exclusively in the English language. The statistical analysis was conducted using RevMan version 5.4.1 (The Cochrane Collaboration). Estimates were presented as odds ratio (OR) with 95% confidence interval (CI) for categorical variables, while continuous variables were reported as mean difference (MD) with 95% CI. A total of 19 studies met the selection criteria and were included in the meta-analysis. The pooled incidence of AKI was reported as 20% (95% CI: 18-20%). Factors significantly associated with post-TAVI AKI encompass hypertension, chronic kidney disease (CKD), low estimated glomerular filtration rate (eGFR), high baseline creatinine levels, peripheral vascular disease (PVD), Society of Thoracic Surgeons (STS) score, European System for Cardiac Operative Risk Evaluation (EUROscore) II, and the transfemoral surgical approach.

Valve Academic Research Consortium 3: Updated Endpoint Definitions for Aortic Valve Clinical Research

AIMS

The Valve Academic Research Consortium (VARC), founded in 2010, was intended to (i) identify appropriate clinical endpoints and (ii) standardize definitions of these endpoints for transcatheter and surgical aortic valve clinical trials. Rapid evolution of the field, including the emergence of new complications, expanding clinical indications, and novel therapy strategies have mandated further refinement and expansion of these definitions to ensure clinical relevance. This document provides an update of the most appropriate clinical endpoint definitions to be used in the conduct of transcatheter and surgical aortic valve clinical research.

METHODS AND RESULTS

Several years after the publication of the VARC-2 manuscript, an in-person meeting was held involving over 50 independent clinical experts representing several professional societies, academic research organizations, the US Food and Drug Administration (FDA), and industry representatives to (i) evaluate utilization of VARC endpoint definitions in clinical research, (ii) discuss the scope of this focused update, and (iii) review and revise specific clinical endpoint definitions. A writing committee of independent experts was convened and subsequently met to further address outstanding issues. There were ongoing discussions with FDA and many experts to develop a new classification schema for bioprosthetic valve dysfunction and failure. Overall, this multi-disciplinary process has resulted in important recommendations for data reporting, clinical research methods, and updated endpoint definitions. New definitions or modifications of existing definitions are being proposed for repeat hospitalizations, access site-related complications, bleeding events, conduction disturbances, cardiac structural complications, and bioprosthetic valve dysfunction and failure (including valve leaflet thickening and thrombosis). A more granular 5-class grading scheme for paravalvular regurgitation (PVR) is being proposed to help refine the assessment of PVR. Finally, more specific recommendations on quality-of-life assessments have been included, which have been targeted to specific clinical study designs.

CONCLUSIONS

Acknowledging the dynamic and evolving nature of less-invasive aortic valve therapies, further refinements of clinical research processes are required. The adoption of these updated and newly proposed VARC-3 endpoints and definitions will ensure homogenous event reporting, accurate adjudication, and appropriate comparisons of clinical research studies involving devices and new therapeutic strategies.

Renal function and outcomes in TAVR patients: Complexity in real world

Renal dysfunction is a relevant medical issue for patients undergoing TAVR. Chronic kidney disease and postprocedural acute kidney injury are independent predictors of worse outcome after TAVR procedure. Meticulous preprocedural planning and multidisciplinary heart-team management could mitigate renal damage.

Prognostic Value of Improved Kidney Function After Transcatheter Aortic Valve Implantation for Aortic Stenosis

Transcatheter aortic valve implantation (TAVI) is associated with acute kidney injury (AKI), but can also improve the kidney function (IKF). We assessed the effects of kidney function changes in relation to baseline kidney function on 2-year clinical outcomes after TAVI. In total, 639 consecutive patients with aortic stenosis who underwent TAVI were stratified into 3 groups according to the ratio of serum creatinine post- to pre-TAVI: IKF (≤0.80; n = 95 [15%]), stable kidney function (0.80 to 1.5; n = 477 [75%]), and AKI (≥1.5; n = 67 [10%]). Different AKI risk scores were compared using receiving-operator characteristics. Median follow-up was 24 (8 to 44) months. At 3 months, the increase in estimated glomerular filtration rate in the IKF group remained, and the decreased estimated glomerular filtration rate in the AKI group recovered. Compared with a stable kidney function, AKI showed a higher 2-year mortality rate (adjusted hazard ratio [HR] 3.69, 95% confidence interval [CI] 2.43 to 5.62) and IKF a lower mortality rate (adjusted hazard ratio 0.53, 95% CI 0.30 to 0.93). AKI also predicted major and life-threatening bleeding (adjusted odds ratio 2.94, 95% CI 1.27 to 6.78). Independent predictors of AKI were chronic kidney disease and pulmonary hypertension. Independent predictors of IKF were female gender, a preserved kidney function, absence of atrial fibrillation, and hemoglobin level. Established AKI risk scores performed moderately and did not differentiate between AKI and IKF. In conclusion, AKI is transient and is independently associated with a higher mortality rate, whereas IKF is sustained and is associated with a lower mortality rate. These effects are independent of baseline kidney function. Further studies are warranted to investigate the role of IKF and generate a dedicated prediction model.

Impact of Acute Kidney Injury on Short- and Long-term Outcomes After Transcatheter Aortic Valve Implantation

INTRODUCTION AND OBJECTIVES

Acute kidney injury (AKI) is frequently observed after transcatheter aortic valve implantation (TAVI) and is associated with higher mortality. However, the impact of AKI on long-term outcomes remains controversial. Therefore, we sought to evaluate the impact of AKI on short- and long-term outcomes following TAVI using the Valve Academic Research Consortium 2 criteria.

METHODS

Consecutive patients (n = 794) with severe aortic stenosis who underwent TAVI were included in a multicenter Brazilian registry. Logistic regression analysis was used to identify predictors of AKI. Four-year outcomes were determined as Kaplan-Meier survival curves, and an adjusted landmark analysis was used to test the impact of AKI on mortality among survivors at 12 months.

RESULTS

The incidence of AKI after TAVI was 18%. Independent predictors of AKI were age, diabetes mellitus, major or life-threatening bleeding and valve malpositioning. Acute kidney injury was independently associated with higher risk of all-cause death (adjusted HR, 2.8; 95%CI, 2.0-3.9; P < .001) and cardiovascular mortality (adjusted HR, 2.9; 95%CI, 1.9-4.4; P < .001) over the entire follow-up period. However, when considering only survivors at 12 months, there was no difference in both clinical endpoints (adjusted HR, 1.2; 95%CI, 0.5-2.4; P = .71, and HR, 0.7; 95%CI, 0.2-2.1; P = .57, respectively).

CONCLUSIONS

Acute kidney injury is a frequent complication after TAVI. Older age, diabetes, major or life-threatening bleeding, and valve malpositioning were independent predictors of AKI. Acute kidney injury is associated with worse short- and long-term outcomes. However, the major impact of AKI on mortality is limited to the first year after TAVI.

Multimodality imaging evaluation before transcatheter aortic valve implantation: incidence of contrast medium-induced acute kidney injury, risk factors and prognosis

AIM

To evaluate the incidence, risk factors, and prognostic implications of contrast medium-induced acute kidney injury (CI-AKI) in patients undergoing transcatheter aortic valve implantation (TAVI) evaluation.

MATERIALS AND METHODS

Datasets from 98 out of 207 consecutive patients referred for multidetector computed tomography (MDCT) for TAVI evaluation were eligible for evaluation and were analysed retrospectively. The incidence of CI-AKI was correlated to outcome and to potential risk factors: kidney function (estimated glomerular filtration rate [eGFR]), heart failure, diabetes, amount of contrast medium, and duration of examination period.

RESULTS

CI-AKI occurred in 67 patients (68.4%) and mainly correlated with eGFR (p=0.01) and the amount of contrast medium as a function of eGFR (p=0.04). CI-AKI occurred before TAVI in 36 (53.7%) patients of which 13 (19.4%) did not undergo TAVI. In-hospital all-cause mortality was 21.4%, and of those 21 patients, 18 (85.7%) had CI-AKI and nine (42.9%) did not undergo TAVI. One-year all-cause mortality was 39.8%, and of those 39 patients who died within 1 year, 31 (79.5%) had CI-AKI.

CONCLUSION

CI-AKI mostly occurs already before TAVI as a consequence of pre-procedural imaging, which therefore represents the main contributor for CI-AKI in relation to TAVI. Regarding the observation that some patients will ultimately have no benefit because TAVI is not performed and the poor prognosis linked to CI-AKI should encourage improvement in patient selection when referring to pre-procedural imaging.

Independent Risk Factors Contributing to Acute Kidney Injury According to Updated Valve Academic Research Consortium-2 Criteria After Transcatheter Aortic Valve Implantation: A Meta-analysis and Meta-regression of 13 Studies

OBJECTIVES

This study aimed to examine the risk factors for transcatheter aortic valve implantation (TAVI)-associated acute kidney injury (AKI) according to the AKI definition from the Valve Academic Research Consortium-2 (VARC-2).

SETTING

A meta-analysis.

PARTICIPANTS

A total of 661 patients with post-TAVI AKI according to the VARC-2 definition and 2,012 controls were included in the meta-analysis.

INTERVENTIONS

Patients undergoing TAVI were included in this meta-analysis.

MEASUREMENTS AND MAIN RESULTS

Multiple electronic databases were searched using predefined criteria. The diagnosis of AKI was based on the VARC-2 classification. The authors found that preoperative New York Heart Association class IV (odds ratio [OR], 7.77; 95% confidence interval [CI], 3.81-15.85), previous chronic renal disease (CKD) (OR, 2.81; 95% CI, 1.96-4.03), and requirement for transfusion (OR, 2.03; 95% CI, 1.59-2.59) were associated significantly with an increased risk for post-TAVI AKI. Furthermore, previous peripheral vascular disease (PVD), hypertension, atrial fibrillation, congestive heart failure, diabetes mellitus, and stroke were also risk factors for TAVI-associated AKI. Additionally, transfemoral access significantly correlated with a reduced risk for post-TAVI AKI (OR, 0.43; 95% CI, 0.33-0.57). The potential confounders, including Society of Thoracic Surgeons Score, the logistic European System for Cardiac Operative Risk Evaluation, aortic valve area, mean pressure gradient, left ventricular ejection fraction, age, body mass index, contrast volume, and valve type, had no impact on the association between the risk factors and post-TAVI AKI. Subgroup analysis of the eligible studies presenting multivariate logistic regression analysis on the independent risk factors for post-TAVI AKI revealed that previous CKD, previous PVD, and transapical access were independent risk factors for TAVI-associated AKI.

CONCLUSIONS

The current meta-analysis suggested that previous CKD, previous PVD, and transapical access may be independent risk factors for TAVI-associated AKI.

Acute kidney injury after TAVI: Predict, detect, and prevent

Acute kidney injury (AKI) is frequently observed immediately after transcatheter aortic valve implantation (TAVI). Both classifications, the RIFLE (the Risk, Injury, Failure, Loss, and End-stage Kidney) and the KDIGO (Kidney Disease: Improving Global Outcomes) from the VARC-2 (Valve Academic Research Consortium-2) are fairly interchangeable and performed well as clinical predictors of all-cause mortality. Patients with baseline reduced glomerular filtration rate (GFR) or known atherosclerotic arterial disease are at increased risk of AKI.

Mid-term results of 150 TAVI comparing apical versus femoral approaches

Background

Transcatheter aortic-valve implantation (TAVI) is a new therapeutic choice for treating aortic stenosis in patients considered high risk for surgery. This blooming therapeutic technique still requires evaluation of medium and long term outcome.

Method

We hereby report our results of the first 150 consecutive patients to receive TAVI implants in our population recruited from July 2009 to March 2013 in a retrospective and monocentric study. We analyzed long term morbidity and mortality criteria. We compared the apical and femoral approach results and researched predictors of cardiac mortality.

Results

The mean monitoring period was 387.62 days, mean Euroscore was 21.8, and mean Society of Thoracic Surgeons (STS) risk score was 9.2. The success rate for the procedure was 94.6 %. A total of 39 patients died. The mortality rates at the immediate perioperative point, 30 days, 1 year, and 2 years, were 4 %, 11.3 %, 22.7 %, and 26 %, respectively. As regards complications, there were 10 hemodynamic complications (6.6 %) and 20 vascular (13.3 %), 11 cardiac tamponades (7.4 %), eight mechanical (5.3 %), ten major hemorrhagic (6.7 %), 14 pulmonary (9.3 %), and 18 infectious complications (12 %). When comparing the rates of reported complications in terms of different approaches, we observed significantly more hemodynamic complications in the apical group (p = 0.049). Pulmonary complications were also significantly more common in cases of apical approach (p = 0.029). The majority of the patients reported clear functional improvement throughout their follow-up.

Conclusion

The results of the first 150 patients to receive the implant at the Nancy University Teaching Hospital (CHU Nancy) were consistent with findings in the literature. TAVI proved a credible and effective alternative to surgical valve replacement for patients at high risk during surgery.