Risk stratification using lean body mass in patients undergoing transcatheter aortic valve replacement

Pre-Existing Left Bundle Branch Block and Clinical Outcomes After Transcatheter Aortic Valve Replacement

Background

Few reports on pre-existing left bundle branch block (LBBB) in patients undergoing transcatheter aortic valve replacement (TAVR) are currently available. Further, no present studies compare patients with new onset LBBB with those with pre-existing LBBB.

Objectives

This study aimed to investigate the association between pre-existing or new onset LBBB and clinical outcomes after TAVR.

Methods

Using data from the Japanese multicenter registry, 5,996 patients who underwent TAVR between October 2013 and December 2019 were included. Patients were classified into 3 groups: no LBBB, pre-existing LBBB, and new onset LBBB. The 2-year clinical outcomes were compared between 3 groups using Cox proportional hazards models and propensity score analysis to adjust the differences in baseline characteristics.

Results

Of 5,996 patients who underwent TAVR, 280 (4.6%) had pre-existing LBBB, while 1,658 (27.6%) experienced new onset LBBB. Compared with the no LBBB group, multivariable Cox regression analysis showed that pre-existing LBBB was associated not only with a higher 2-year all-cause (adjusted HR: 1.39; 95% CI: 1.06-1.82; P = 0.015) and cardiovascular (adjusted HR: 1.60; 95% CI: 1.04-2.48; P = 0.031) mortality, but also with higher all-cause (adjusted HR: 1.43, 95% CI: 1.07-1.91; P = 0.016) and cardiovascular (adjusted HR: 1.81, 95% CI:1.12-2.93; P = 0.014) mortality than the new onset LBBB group. Heart failure was the most common cause of cardiovascular death, with more heart failure deaths in the pre-existing LBBB group.

Conclusions

Pre-existing LBBB was independently associated with poor clinical outcomes, reflecting an increased risk of cardiovascular mortality after TAVR. Patients with pre-existing LBBB should be carefully monitored.

Midterm Outcomes of Underweight Patients Undergoing Transcatheter Aortic Valve Implantation: Insight From the LAPLACE-TAVR Registry

Background

Obesity is a major risk factor for cardiovascular disease; however, a paradoxical effect of obesity has been reported in patients with heart failure or myocardial infarction. Although several studies have suggested the same obesity paradox in patients undergoing transcatheter aortic valve replacement (TAVR), they included a limited number of underweight patients.

Objectives

This study aimed to clarify the effect of being underweight on TAVR outcomes.

Methods

We retrospectively analyzed 1,693 consecutive patients undergoing TAVR between 2010 and 2020. The patients were categorized according to body mass index: underweight (<18.5 kg/m²; n = 242), normal weight (18.5 to 25 kg/m²; n = 1,055), and overweight (>25 kg/m²; n = 396). We compared midterm outcomes after TAVR among the 3 groups; all clinical events were in accordance with the Valve Academic Research Consortium-2 criteria.

Results

Underweight patients were more likely to be women and have severe heart failure symptoms, peripheral artery disease, anemia, hypoalbuminemia, and pulmonary dysfunction. They also had lower ejection fractions, smaller aortic valve areas, and higher surgical risk scores. Device failure, life-threatening bleeding, major vascular complications, and 30-day mortality occurred more frequently in underweight patients. The midterm survival rate of the underweight group was inferior to those of the other 2 groups (P < 0.0001; average follow-up, 717 days). In the multivariate analysis, underweight was associated with noncardiovascular mortality (HR: 1.78; 95% CI: 1.16-2.75) but not cardiovascular mortality (HR: 1.28; 95% CI: 0.58-1.88) after TAVR.

Conclusions

Underweight patients had a worse midterm prognosis, demonstrating the obesity paradox in this TAVR population. (Outcomes of transcatheter aortic valve implantation in Japanese patients with aortic stenosis: multi-center registry; UMIN000031133).

Effect of BMI on patients undergoing transcatheter aortic valve implantation: A systematic review and meta-analysis

BACKGROUND

The relationship of body mass index (BMI) and an "obesity paradox" with cardiovascular risk prediction is controversial. This systematic review and meta-analysis aims to compare the associations of different BMI ranges on transcatheter aortic valve implantation (TAVI) outcomes.

METHODS

International databases, including PubMed, the Web of Science, and the Cochrane Library, were systematically searched for observational and randomized controlled trial studies investigating TAVI outcomes in any of the four BMI categories: underweight, normal weight, overweight, and obese with one of the predefined outcomes. Primary outcomes were in-hospital, 30-day, and long-term all-cause mortality. Random-effects meta-analysis was performed to calculate the odds ratio (OR) or standardized mean differences (SMD) with 95% confidence interval (CI) for each paired comparison between two of the BMI categories.

RESULTS

A total of 38 studies were included in our analysis, investigating 99,829 patients undergoing TAVI. There was a trend toward higher comorbidities such as hypertension, diabetes, and dyslipidemia in overweight patients and individuals with obesity. Compared with normal-weight, patients with obesity had a lower rate of 30-day mortality (OR 0.42, 95% CI 0.25-0.72, p < 0.01), paravalvular aortic regurgitation (OR 0.63, 95% CI 0.44-0.91, p = 0.01), 1-year mortality (OR 0.48, 95% CI 0.24-0.96, p = 0.04), and long-term mortality (OR 0.69, 95% CI 0.51-0.94, p = 0.02). However, acute kidney injury (OR 1.16, 95% CI 1.04-1.30, p = 0.01) and permanent pacemaker implantation (OR 1.25, 95% CI 1.05-1.50, p = 0.01) odds were higher in patients with obesity. Noteworthy, major vascular complications were significantly higher in underweight patients in comparison with normal weight cases (OR 1.62, 95% CI 1.07-2.46, p = 0.02). In terms of left ventricular ejection fraction (LVEF), patients with obesity had higher post-operative LVEF compared to normal-weight individuals (SMD 0.12, 95% CI 0.02-0.22, p = 0.02).

CONCLUSION

Our results suggest the presence of the "obesity paradox" in TAVI outcomes with higher BMI ranges being associated with lower short- and long-term mortality. BMI can be utilized for risk prediction of patients undergoing TAVI.

Outcome of Nonagenarians Undergoing Transfemoral Transcatheter Aortic Valve Replacement: A Nationwide Registry Analysis From Japan

Background

Nonagenarians are a growing age group in patients undergoing transcatheter aortic valve replacement (TAVR); however, the appropriate use of TAVR in this population remains discussed because of their limited life expectancy and worse outcome reported.

Objectives

The authors aimed to evaluate clinical characteristics and the prognostic impact of nonagenarians.

Methods

We analyzed consecutive patients undergoing transfemoral TAVR and were registered in the nationwide registry for TAVR in Japan (Japanese Transcatheter Valvular Therapies registry) between 2013 and 2018. The rate of 30-day and 1-year mortality and composite adverse event, comprising all-cause death, all stroke, and life-threatening/major bleeding, were assessed.

Results

Of the 15,028 registered patients during the study period, 2,215 (14.7%) were nonagenarians. Although the nonagenarians were less likely to have comorbid conditions (eg, diabetes mellitus and malignancy) than patients aged <90 y, they had a higher Society of Thoracic Surgeons risk score (8.8% vs 5.6%), mainly owing to their advanced age. The procedural characteristics were identical between 2 groups. The rate of 30-day mortality and composite endpoint was similar, whereas 1-year mortality and composite adverse events were increased among nonagenarians (10.3% vs 6.8% and 13.5% vs 9.2%, respectively), and nonagenarians were independently associated with these endpoints (HR: 1.21; 95% CI: 1.03-1.42; P = 0.023; HR: 1.24; 95% CI: 1.07-1.42; P = 0.004).

Conclusions

Of the 15,028 TAVR procedures performed in Japan between 2013 and 2018, 14.7% were performed in nonagenarians. These patients were carefully selected by a multidisciplinary heart team and showed 21% and 24% increase of 1-year mortality and composite adverse outcome.

The Impact of Goal-Directed Fluid Therapy on Postoperative Nausea and Vomiting in High-Risk Patients Undergoing Laparoscopic Sleeve Gastrectomy

PURPOSE

Patients with laparoscopic sleeve gastrectomy (LSG) are at high risk of postoperative nausea and vomiting (PONV). Goal-directed fluid therapy (GDFT) has been proven effective in improving postoperative gastrointestinal function in patients with obesity, but its effect on prevention of PONV remains controversial. This study aimed to investigate the impact of GDFT on PONV in high-risk patients with LSG.

METHODS

In a randomized, single-blinded, two-arm trial, patients with an Apfel score ≥ 3 and scheduled for LSG were included. Patients in the GDFT group received stroke volume-guided fluid therapy. Patients in the control group received conventional fluid therapy. The primary outcome was the incidence of PONV within 48 h after LSG. The second outcome included intensity of PONV, use of rescue therapy, recovery of gastrointestinal function, and postoperative length of stay (LOS).

RESULTS

A total of 137 patients were analyzed. The incidence of PONV in the GDFT group was lower than that in the control group (47.1% vs. 71.6%; odds ratio [95%CI], 0.35 [0.17-0.72]; P = 0.004). Fewer patients in the GDFT group received rescue therapy (30% vs. 58.2%; P = 0.001). Patients following GDFT protocol had a faster return of flatus (27.5 (19, 31) vs. 31 (20, 48) hours, P = 0.037) and shorter postoperative LOS (6.1 ± 1.0 vs. 6.6 ± 1.1 days; P = 0.007).

CONCLUSION

GDFT is conducive to deceasing PONV occurrence, restoring intestinal function, and shortening postoperative LOS in high-risk patients undergoing LSG.

Heart valve surgery and the obesity paradox: A systematic review

Obesity has been associated with increased incidence of comorbidities and shorter life expectancy, and it has generally been assumed that patients with obesity should have inferior outcomes after surgery. Previous literature has often demonstrated equivalent or even improved rates of mortality after cardiac surgery when compared to their lower-weight counterparts, coined the obesity paradox. Herein, we aim to review the literature investigating the impact of obesity on surgical valve interventions. PubMed and Embase were systematically searched for articles published from 1 January 2000 to 15 October 2021. A total of 1315 articles comparing differences in outcomes between patients of varying body mass index (BMI) undergoing valve interventions were reviewed and 25 were included in this study. Patients with higher BMI demonstrated equivalent or reduced rates of postoperative myocardial infarction, stroke, reoperation rates, acute kidney injury, dialysis and bleeding. Two studies identified increased rates of deep sternal wound infection in patients with higher BMI, although the majority of studies found no significant difference in deep sternal wound infection rates. The obesity paradox has described counterintuitive outcomes predominantly in coronary artery bypass grafting and transcatheter aortic valve replacement. Recent literature has identified similar trends in other heart valve interventions. While the obesity paradox has been well characterized, its causes are yet to be identified. Further study is essential in order to identify the causes of the obesity paradox so patients of all body sizes can receive optimal care.

Small Left Ventricle and Clinical Outcomes After Transcatheter Aortic Valve Replacement

Background

In patients undergoing transcatheter aortic valve replacement (TAVR), those with small left ventricle (LV) may have an increased risk of poor outcomes, because small LV is associated with low‐flow (LF), left ventricular hypertrophy. However, the impact of small LV on patients undergoing TAVR remains unknown.

Methods and Results

We examined 2584 patients who underwent TAVR between October 2013 and May 2017 using data from the Japanese multicenter registry. On the basis of the American Society of Echocardiography guidelines, small LV was defined as left ventricular end‐diastolic dimension <42.0 mm for men or <37.8 mm for women. The 2‐year clinical outcomes were compared between patients with and without small LV using multivariable Cox regression analyses and propensity score matching. Subgroup analyses by LF, left ventricular hypertrophy were performed. Of 2584 patients who underwent TAVR, 466 (18.0%) had small LV. Patients with small LV had smaller body size and less comorbidity, and were more likely to have LF status compared with those without. Small LV was associated with a higher 2‐year all‐cause (20.8% versus 14.3%; adjusted hazard ratio [HR],1.58 [95% CI, 1.20–2.09]; P=0.0013) and cardiovascular mortality (8.8% versus 5.5%; adjusted HR, 1.93 [95% CI, 1.25–2.98]; P=0.0028). Propensity score matching analysis showed consistent findings. In subgroup analyses, LF, left ventricular hypertrophy did not interact with small LV.

Conclusions

Small LV, determined by a simple echocardiographic parameter, was associated with poorer clinical outcomes after TAVR regardless of LF, left ventricular hypertrophy. LV size may be useful for assessing clinical outcomes after TAVR.

Registration

URL: https://www.umin.ac.jp/ctr/index.htm; Unique identifier: UMIN000020423.

Clinical risk model for predicting 1-year mortality after transcatheter aortic valve replacement

Objectives

Estimating 1‐year life expectancy is an essential factor when evaluating appropriate indicators for transcatheter aortic valve replacement (TAVR).

Background

It is clinically useful in developing a reliable risk model for predicting 1‐year mortality after TAVR.

Methods

We evaluated 2,588 patients who underwent TAVR using data from the Optimized CathEter vAlvular iNtervention (OCEAN) Japanese multicenter registry from October 2013 to May 2017. The 1‐year clinical follow‐up was achieved by 99.5% of the entire population (n = 2,575). Patients were randomly divided into two cohorts: the derivation cohort (n = 1,931, 75% of the study population) and the validation cohort (n = 644). Considerable clinical variables including individual patient's comorbidities and frailty markers were used for predicting 1‐year mortality following TAVR.

Results

In the derivation cohort, a multivariate logistic regression analysis demonstrated that sex, body mass index, Clinical Frailty Scale, atrial fibrillation, peripheral artery disease, prior cardiac surgery, serum albumin, renal function as estimated glomerular filtration rate, and presence of pulmonary disease were independent predictors of 1‐year mortality after TAVR. Using these variables, a risk prediction model was constructed to estimate the 1‐year risk of mortality after TAVR. In the validation cohort, the risk prediction model revealed high discrimination ability and acceptable calibration with area under the curve of 0.763 (95% confidence interval, 0.728–0.795, p < .001) in the receiver operating characteristics curve analysis and a Hosmer–Lemeshow χ² statistic of 5.96 (p = .65).

Conclusions

This risk prediction model for 1‐year mortality may be a reliable tool for risk stratification and identification of adequate candidates in patients undergoing TAVR.

Sex difference in the prognostic role of body composition parameters in Taiwanese patients undergoing transcatheter aortic valve implantation

Background

Evidence on association between body composition and outcomes of transcatheter aortic valve implantation (TAVI) is limited for Asian patients. This study investigated the prognostic role of body composition parameters in Taiwanese patients undergoing TAVI.

Materials and methods

Data of consecutive patients undergoing TAVI for severe aortic stenosis between May 1, 2010 and August 31, 2019 were prospectively collected in this observational study. The association between body composition parameters (body mass index [BMI], body surface area [BSA], lean body mass [LBM], and LBM index) and cumulative mortality was analyzed using Cox proportional hazard regression model.

Results

A total of 221 patients (mean age 81.4 years), including 125 (56.6%) males, were included with median follow-up duration of 23.8 months. In males, multivariate analysis revealed that higher BMI (P = 0.035), BMI ≥ 20 kg/m² (P = 0.026), and higher LBM index (P = 0.023) significantly predicted lower overall all-cause cumulative mortality. In females, none of the body composition parameters was significantly associated with all-cause cumulative mortality. Paradoxical association between BMI and estimated all-cause cumulative mortality was only significant among male patients.

Conclusion

In Taiwanese TAVI patients, the prognostic effects of BMI and LBM index on cumulative mortality were only observed in males, not in females. Sex differences must be considered when stratifying risk among patients undergoing TAVI.

Preoperative frailty parameters as predictors for outcomes after transcatheter aortic valve implantation: a systematic review and meta-analysis

Guidelines suggest using frailty characteristics in the work-up for a transcatheter aortic valve implantation (TAVI). There are many frailty-screening tools with different components. The prognostic value of the individual parameters in frailty is as yet unclear. The objective of this systematic review and meta-analysis was to find and pool predictors for 1‑year mortality after TAVI. We followed a two-step approach. First, we searched for randomised controlled trials on TAVI to identify frailty parameters used in these studies. Second, we searched for publications on these frailty parameters. Articles were included for pooled analysis if the studied frailty parameters were dichotomised with clear cut-off values based on common standards or clinical practice and reported adjusted hazard ratios (HR) of 1‑year mortality after TAVI. We calculated pooled effect estimates of 49 studies based on dichotomised frailty scores (HR: 2.16, 95% CI: 1.57–3.00), chronic lung disease (HR: 1.57, 95% CI: 1.45–1.70), estimated glomerular filtration rate <30 ml/min (HR: 1.95, 95% CI: 1.68–2.29), body mass index <20 kg/m² (HR: 1.49, 95% CI: 1.09–2.03), hypoalbuminaemia (HR: 1.77, 95% CI: 1.38–2.25), anaemia (HR: 2.08, 95% CI: 0.93–4.66), low gait speed (HR: 13.33, 95% CI: 1.75–101.49) and Katz activities of daily living (ADL) score of 1 or more deficits (HR: 5.16, 95% CI: 0.77–34.47). Chronic lung disease, chronic kidney disease, underweight, hypoalbuminaemia, a low frailty score, anaemia, low gait speed and an ADL deficiency were associated with worse 1‑year outcomes after TAVI.

Does Heart Valve Team Risk Assessment Predict Outcomes after Transcatheter Aortic Valve Replacement?

Consideration for transcatheter aortic valve replacement (TAVR) necessitates an integrated risk assessment by members of the Heart Valve Team. The utility of the integrated risk assessment for predicting TAVR outcomes is not established. This article aims to compare the utility of the integrated risk assessment to that of the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score for predicting patient outcomes after TAVR. A total of 274 patients who underwent TAVR from January 2016 to August 2017 were included in this study. Patients were deemed intermediate or high risk by two surgeons on the Heart Valve Team based on an integrated risk assessment that incorporates the STS-PROM score, fragility measures, end-organ dysfunction, and surgeon evaluation. Patients were also deemed low, intermediate, or high risk based solely on their STS-PROM scores of <3%, ≥3% to <8%, and ≥8%, respectively. Differences in postoperative outcomes between intermediate- and high-risk groups as categorized by the integrated risk assessment versus STS-PROM were compared. There were no statistically significant differences in postoperative outcomes between patients who were deemed high and intermediate risk by the Heart Valve Team risk assessment. In contrast, postoperative complication rates were significantly higher in patients deemed high risk as compared with intermediate risk by STS-PROM. Integrated risk assessment by the Heart Valve Team is not superior to STS-PROM in predicting postoperative outcomes in patients undergoing TAVR.