1
|
Juarez-Casso FM, Singh M, Lewis BR, Sandhu GS, Arghami A, Rowse PG, Bagameri G, Crestanello JA, Greason KL. Long-term Stroke and Mortality Risk in Nonagenarians After Transcatheter Aortic Valve Insertion. Ann Thorac Surg 2024:S0003-4975(24)00372-2. [PMID: 38763221 DOI: 10.1016/j.athoracsur.2024.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 03/05/2024] [Accepted: 04/22/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Limited data exist on the long-term outcomes of transcatheter aortic valve insertion (TAVI) in nonagenarian patients. This study investigated the relationship between patient baseline comorbidity and frailty on the long-term outcome of the nonagenarian population. METHODS A retrospective analysis was conducted of 187 consecutive nonagenarian patients who underwent TAVI from 2009 to 2020. Multivariable models were used to analyze the association between baseline patient and frailty variables and mortality, stroke, and repeat hospitalization. Long-term survival was compared with an age- and sex-matched United States population. RESULTS The median Society of Thoracic Surgeons predicted risk of mortality was 10% (interquartile range, 7%-17%). Frailty was met in 72% of patients based on the 5-meter walk test, 13% based on the Kansas City Cardiomyopathy Questionnaire 12-item instrument score, 12% based on Katz Index of Independence in Activities of Daily Living, and 8% based on serum albumin levels. Procedure-related death occurred in 3 patients (2%) and stroke in 8 (4%). The median duration of follow-up was 3.4 years. Outcomes included death in 150 patients (80%), stroke in 15, and repeat hospitalization in 114. Multivariable analysis identified no association between any of the baseline patient variables with mortality, stroke, repeat hospitalization, or the combined outcomes (all P > .05). The 1- and 5-year survival rates in TAVI-treated nonagenarians were similar to age- and sex-matched controls (P = .27). CONCLUSIONS Long-term death or stroke is independent of The Society of Thoracic Surgeons predicted risk of mortality and frailty risk variables in this nonagenarian patient population who received TAVI. Furthermore, survival is similar to age- and sex-matched controls.
Collapse
Affiliation(s)
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Bradley R Lewis
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Gurpreet S Sandhu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Phillip G Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
2
|
Spiliopoulos K, Magouliotis D, Angelis I, Skoularigis J, Kemkes BM, Salemis NS, Athanasiou T, Gansera B, Xanthopoulos AV. Concomitant Valve Replacement and Coronary Artery Bypass Grafting Surgery: Lessons from the Past, Guidance for the Future? A Mortality Analysis in 294 Patients. J Clin Med 2023; 13:238. [PMID: 38202244 PMCID: PMC10780271 DOI: 10.3390/jcm13010238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/24/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVE The aims of this study were to analyze parameters influencing early and late mortality after concomitant valve replacement and coronary artery bypass grafting surgery, using early and long-term information from an institutionally available data registry, and to discuss the results in relation to the current treatment strategies and perspectives. METHODS The study population consisted of 294 patients after combined valve replacement with mechanical prosthesis and CABG surgery. RESULTS There were 201 men (68.4%) and 93 women (31.6%). Concurrent to the coronary artery bypass grafting, 238 patients (80.9%) underwent aortic-, 46 patients (15.6%) mitral- and 10 patients (3.4%) doublevalve replacement. Cumulative duration of follow up was 1007 patient-years (py) with a maximum of 94 months and was completed in 92.2% (271 cases). Overall hospital mortality (30 days) rate was 6.5% (n = 19). It was significantly higher in patients of female gender, older than 70 y, in those suffering preoperative myocardial infarction, presenting with an additive EuroScore > 8 and being hemodynamically unstable after the operation. Cumulative survival rate at 7.6 y was 78.6%. Determinants of prolonged survival were male gender, age at operation < 70 y, preoperative sinus rhythm, normal renal function, additive EuroScore < 8 and the use of internal thoracic artery for grafting. Subsequent multivariate analysis revealed preoperative atrial fibrillation (HR: 2.1, 95% CI: 0.82-5.44, p: 0.01) and risk group of ES > 8 (HR: 3.63, 95% CI: 1.45-9.07, p < 0.01) as independent predictors for lower long-term survival. CONCLUSIONS Hospital mortality (30 d) was nearly 2.5-fold higher in female and/or older than 70 y patients. Preoperative atrial fibrillation and/ or a calculated ES > 8 were independent predisposing factors of late mortality for combined VR and CABG surgery. Tailoring the approach, with the employment of the newest techniques and hybrid procedures, to the individual patient clinical profile enables favorable outcomes for concomitant valvular disease and CAD, especially in high-risk patients.
Collapse
Affiliation(s)
- Kyriakos Spiliopoulos
- Department of Cardiothoracic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece; (D.M.); (T.A.)
- Department of Cardiovascular Surgery, Klinikum Bogenhausen, 81925 Munich, Germany (B.G.)
| | - Dimitrios Magouliotis
- Department of Cardiothoracic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece; (D.M.); (T.A.)
| | - Ilias Angelis
- Department of Cardiovascular Surgery, Klinikum Bogenhausen, 81925 Munich, Germany (B.G.)
| | - John Skoularigis
- Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece; (J.S.); (A.V.X.)
| | - Bernhard M. Kemkes
- Department of Cardiovascular Surgery, Klinikum Bogenhausen, 81925 Munich, Germany (B.G.)
| | | | - Thanos Athanasiou
- Department of Cardiothoracic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece; (D.M.); (T.A.)
| | - Brigitte Gansera
- Department of Cardiovascular Surgery, Klinikum Bogenhausen, 81925 Munich, Germany (B.G.)
| | - Andrew V. Xanthopoulos
- Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece; (J.S.); (A.V.X.)
| |
Collapse
|
3
|
Abdelmottaleb W, Maraey A, Ozbay M, Royfman R, Elsharnoby H, Khalil M, Elzanaty A, Elgendy IY. Contemporary Trends, Characteristics, and Outcomes of Transcatheter Aortic Valve Implantation Among Extreme Elderly Patients. Am J Cardiol 2023; 198:33-35. [PMID: 37196531 DOI: 10.1016/j.amjcard.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 04/04/2023] [Accepted: 04/13/2023] [Indexed: 05/19/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) has been increasingly performed among extreme elderly patients with symptomatic severe aortic stenosis. We aimed to study the trends, characteristics, and outcomes of TAVI among extreme elderly. The National Readmission Database for the years 2016 to 2019 was queried for extreme elderly who underwent TAVI. Linear regression analysis was used to calculate the temporal trends in outcomes. A total of 23,507 TAVI extreme elderly admissions (50.3% women and 95.9% Medicare insurance) were included. The in-hospital mortality and all-cause 30-day readmissions were 2% and 15% and have been stable over years of analysis (p trend = 0.79 and 0.06, respectively). We evaluated complications, such as permanent pacemaker implantation (12%) and stroke (3.2%). Stroke rates did not decrease (3.4% vs 2.9% in 2016 and 2019 [p trend = 0.24]). The mean length of stay improved from 5.5 days in 2016 to 4.3 days in 2019 (p trend <0.01). The rates of early discharge (day ≤3) has improved from 49% in 2016 to 69% in 2019 (p trend <0.01). In conclusion, this nationwide contemporary observational analysis showed that TAVI was associated with low rates of complications in the extreme elderly.
Collapse
Affiliation(s)
- Wael Abdelmottaleb
- Metropolitan Hospital Center, Department of Medicine, New York Medical College, New York City, New York.
| | - Ahmed Maraey
- Department of Internal Medicine, Carle Foundation, Urbana, Illinois
| | - Mustafa Ozbay
- Metropolitan Hospital Center, Department of Medicine, New York Medical College, New York City, New York
| | - Rachel Royfman
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | | | - Mahmoud Khalil
- Department of Internal Medicine, Lincoln Hospital, Bronx, New York
| | - Ahmed Elzanaty
- Department of Cardiovascular Medicine, University of Toledo, Toledo, Ohio
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
| |
Collapse
|
4
|
Clinical outcomes following transapical TAVR with ACURATE neo in the CHANGE neo TA study. IJC HEART & VASCULATURE 2021; 36:100862. [PMID: 34504944 PMCID: PMC8411222 DOI: 10.1016/j.ijcha.2021.100862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/20/2021] [Accepted: 08/21/2021] [Indexed: 11/29/2022]
Abstract
Background A transapical (TA) approach to transcatheter aortic valve replacement (TAVR) may be used when a transfemoral (TF) approach is not feasible. The CHANGE neo TA study evaluated patients treated in routine clinical practice via TA-TAVR with the ACURATE neo bioprosthetic aortic valve. Methods and results This single-arm post-market study had a planned enrolment of 200 subjects; enrolment was terminated early due to declining TA-TAVR procedures at participating centers. Final enrolment was 107 patients (mean age: 79.3 years; 54.2% female; mean STS score at baseline: 6.2%). The mortality rate in the intent-to-treat population was 11.2% at 30 days (primary endpoint) and 25.6% at 12 months. The VARC-2 composite endpoint for 30-day safety occurred in 24.3% of patients. Six patients (5.6%) received a permanent pacemaker within 30 days. Site-reported echocardiographic data showed early improvements in mean aortic valve gradient (baseline: 38.8 [SD 13.1] mmHg, discharge: 6.7 [SD 3.7] mmHg) and effective orifice area (baseline: 0.7 [SD 0.2] cm2, discharge: 1.9 [SD 0.6] cm2), and the discharge rate of paravalvular regurgitation was low (74.7% none/trace, 24.2% mild, 1.1% severe). Conclusions TA-TAVR with the ACURATE neo valve system yields acceptable clinical outcomes, providing an alternative for patients with aortic stenosis who are not candidates for TF-TAVR.
Collapse
|
5
|
Zadrozny M, Hainzer N, Mehilli J, Jochheim D, Gschwendtner S, Steffen J, Theiss H, Braun D, Hagl C, Sadoni S, Massberg S, Hausleiter J, Deseive S. TAVR in nonagenarians: An analysis investigating safety, efficacy, symptomatic improvement, and long-term survival. J Cardiol 2021; 78:44-50. [PMID: 33563507 DOI: 10.1016/j.jjcc.2021.01.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/04/2021] [Accepted: 01/14/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND In the aging western societies, an increasing prevalence of severe, symptomatic aortic stenosis is observed. The aim of this study was to examine the safety and efficacy of transcatheter aortic valve replacement (TAVR) in patients aged 90 years and older. METHODS All patients with severe symptomatic aortic stenosis undergoing TAVR at LMU Munich-University-Hospital between 2013 and 2018 were included. Procedure-related mortality (<30 days) was defined as the primary endpoint and survival rates at two years, device failure, and procedural complications were defined as secondary endpoints according to the Valve Academic Research Consortium II criteria. RESULTS AND CONCLUSIONS Out of 2336 patients, 2183 were younger than 90 years (<90y.-group) and 153 patients were aged 90 or older (≥90y.-group). Procedure-related mortality (3.6% <90y.-group vs. 3.3% ≥90y.-group, log-rank p=0.9) and device success (97.2% <90y.-group vs. 96.0% ≥90y.-group, p=0.44) were similar. Estimated survival rates at 2 years were 62.8% (95% CI 55.3 and 71.4) in the elder and 76.0% (95% CI 74.1 and 77.8) in the younger patients (p<0.01). The incidence of acute kidney injury, stroke, major bleeding, and permanent pacemaker implantations were comparable between both groups. TAVR procedure is equally safe and feasible in patients aged 90 years or older compared to younger patients. Differences in 2-year survival appear to be patient-related rather than procedure-related.
Collapse
Affiliation(s)
- Magda Zadrozny
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians University, Munich, Germany; DZHK - German Centre for Cardiovascular Research, partner site Munich, Munich, Germany
| | - Nathalie Hainzer
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians University, Munich, Germany
| | - Julinda Mehilli
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians University, Munich, Germany; DZHK - German Centre for Cardiovascular Research, partner site Munich, Munich, Germany
| | - David Jochheim
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians University, Munich, Germany; DZHK - German Centre for Cardiovascular Research, partner site Munich, Munich, Germany
| | - Sarah Gschwendtner
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians University, Munich, Germany; DZHK - German Centre for Cardiovascular Research, partner site Munich, Munich, Germany
| | - Julius Steffen
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians University, Munich, Germany; DZHK - German Centre for Cardiovascular Research, partner site Munich, Munich, Germany
| | - Hans Theiss
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians University, Munich, Germany; DZHK - German Centre for Cardiovascular Research, partner site Munich, Munich, Germany
| | - Daniel Braun
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians University, Munich, Germany; DZHK - German Centre for Cardiovascular Research, partner site Munich, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, Munich University Clinic, Ludwig-Maximilians University, Munich, Germany
| | - Sebastian Sadoni
- Department of Cardiac Surgery, Munich University Clinic, Ludwig-Maximilians University, Munich, Germany
| | - Steffen Massberg
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians University, Munich, Germany; DZHK - German Centre for Cardiovascular Research, partner site Munich, Munich, Germany
| | - Joerg Hausleiter
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians University, Munich, Germany; DZHK - German Centre for Cardiovascular Research, partner site Munich, Munich, Germany
| | - Simon Deseive
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians University, Munich, Germany; DZHK - German Centre for Cardiovascular Research, partner site Munich, Munich, Germany.
| |
Collapse
|
6
|
Takagi K, Arinaga K, Takaseya T, Otsuka H, Shojima T, Shintani Y, Zaima Y, Saku K, Oryoji A, Hiromatsu S. Aortic valve replacement with or without concomitant coronary artery bypass grafting in very elderly patients aged 85 years and older. Heart Vessels 2020; 35:1409-1418. [PMID: 32394242 DOI: 10.1007/s00380-020-01620-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/01/2020] [Indexed: 11/28/2022]
Abstract
Degenerative aortic stenosis is the most common structural heart valve disease affecting the aging population. Catheter-based heart valve interventions are less invasive and very useful for very elderly patients. However, we often consider open heart surgery for these patients because of anatomical reasons and co-existing cardiac diseases, i.e., severe coronary artery disease. We aimed to analyze the outcomes of very elderly patients aged ≥ 85 years undergoing aortic valve replacement (AVR) with or without coronary artery bypass grafting (CABG). Twenty-nine very elderly patients aged ≥ 85 years who underwent AVR with CABG (n = 11, Group AC) or isolated AVR (n = 18, Group A) were examined. The overall mean age of the patients was 87.2 ± 2.6 (range 85-94) years. The estimated operative mortality rate, calculated using the Japan score, EuroSCORE II, and STS risk score, was 5.72%-10.88% in Group AC and 5.63%-8.30% in Group A. Aortic cross-clamp time (126.5 ± 29.0 vs. 96.9 ± 29.2 min, p = 0.016) was significantly longer in Group AC than in Group A. Although the major morbidity rate was higher in Group AC than in Group A (36% vs. 6%, p = 0.0336), the length of intensive care unit stay and hospital stay was comparable between both groups. There was no 30-day and hospital mortality in both groups. Eleven patients died during follow-up (senility, 5; cerebrovascular events, 2; renal failure, 1; unknown, 3). There were no significant differences in survival rates during follow-up (log-rank p value = 0.1051). The 1-, 2-, 3-, 4- and 5-year survival rates were 91%, 80%, 69%, 69% and 69%, respectively, in Group AC and 94%, 94%, 94%, 94% and 88%, respectively, in Group A. In conclusion, AVR with or without CABG could be safely performed in carefully selected very elderly patients with acceptable early- and long-term results. AVR with CABG in very elderly patients aged ≥ 85 offers similar results to isolated AVR in terms of 30-day mortality, hospital mortality, and long-term survival.
Collapse
Affiliation(s)
- Kazuyoshi Takagi
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan.
| | - Koichi Arinaga
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Tohru Takaseya
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Hiroyuki Otsuka
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Takahiro Shojima
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Yusuke Shintani
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Yasuyuki Zaima
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Kosuke Saku
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Atsunobu Oryoji
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Shinichi Hiromatsu
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| |
Collapse
|
7
|
Lin N, Nores MA, James TM, Rothenberg M, Stamou SC. Alternative Access Transcatheter Aortic Valve Replacement in Nonagenarians versus Younger Patients. Thorac Cardiovasc Surg 2020; 69:437-444. [PMID: 32252113 DOI: 10.1055/s-0040-1708478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Numerous studies have documented the safety of alternatives access (AA) transcatheter aortic valve replacement (TAVR) for patients who are not candidates for transfemoral or surgical approach. There is a scarcity of studies relating use of AA TAVR in nonagenarian patients, a high-risk, frail group. Our study sought to investigate the clinical outcomes of nonagenarians who underwent AA TAVR for aortic stenosis, with comparison of nonagenarians age ≥90 years with patients age <90 years. METHODS A cohort study of 171 consecutive patients undergoing AA TAVR (transapical [TA, n = 101, 59%], transaxillary [TAX, n = 56, 33%], transaortic [TAO, n = 11, 6%], and transcarotid [TC, n = 3, 2%]) from 2012 to 2019 was analyzed. Baseline, operative, and postoperative characteristics, as well as actuarial survival outcomes, were compared. RESULTS AA TAVR patients had decreased aortic valve gradients with no difference detected in nonagenarians and younger patients. Operative mortality was 8% (n = 14; nine TA, three TAO, and two TAX). Compared to younger patients, significantly more nonagenarians were recorded to have new onset atrial fibrillation (7 vs. 5%, p < 0.01*). No significant difference in mortality or postoperative complications, such as stroke, pacemaker requirements, was detected. Actuarial survival at 1 and 5 years was 86 versus 87% (nonagenarians vs younger patients) and 36 versus 22%, respectively, with log-rank = 0.97. CONCLUSION AA TAVR in nonagenarian patients who are not candidates for transfemoral approach can be efficaciously performed with comparable clinical outcomes to younger patients, age <90 years. Furthermore, some access sites should be avoided when possible; notably TA was associated with increased mortality, stroke, and new onset atrial fibrillation.
Collapse
Affiliation(s)
- Nicole Lin
- Department of Graduate Education, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Marcos A Nores
- Department of Cardiothoracic Surgery, John Fitzgerald Kennedy Medical Center, Atlantis, Florida, United States
| | - Taylor M James
- Department of Graduate Education, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Mark Rothenberg
- Department of Cardiothoracic Surgery, John Fitzgerald Kennedy Medical Center, Atlantis, Florida, United States
| | - Sotiris C Stamou
- Department of Cardiothoracic Surgery, John Fitzgerald Kennedy Medical Center, Atlantis, Florida, United States
| |
Collapse
|
8
|
Galatas C, Afilalo J. Transcatheter aortic valve replacement over age 90: Risks vs benefits. Clin Cardiol 2019; 43:156-162. [PMID: 31840834 PMCID: PMC7021650 DOI: 10.1002/clc.23310] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 11/20/2019] [Indexed: 12/16/2022] Open
Abstract
As the population ages, clinicians will encounter a growing number of nonagenarians suffering from severe aortic stenosis who may be candidates for transcatheter aortic valve replacement (TAVR). By virtue of a healthy survivor effect or a referral bias, these patients may paradoxically have greater resilience and fewer comorbidities than their octogenarian counterparts. They tend to, on average, tolerate the TAVR procedure quite well with low in‐hospital and 1‐year mortality rates of 5.5% and 23%, respectively. Appropriate patient selection should consider individualized estimates of procedural risk, potential for functional recovery and for improved quantity and quality of life. Frailty is much more revealing than chronological age, and it can be measured by brief tools such as the Essential Frailty Toolset. Ultimately, the process of shared decision‐making is paramount to ensure that the course of action is patient‐centered and balances the procedure's expected risks and benefits with the nonagenarian's preferences and values.
Collapse
Affiliation(s)
- Christos Galatas
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jonathan Afilalo
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
9
|
Does additional coronary artery bypass grafting to aortic valve replacement in elderly patients affect the early and long-term outcome? Heart Vessels 2019; 35:487-501. [PMID: 31642980 PMCID: PMC7222122 DOI: 10.1007/s00380-019-01519-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 10/02/2019] [Indexed: 11/18/2022]
Abstract
Early and long-term outcomes in elderly patients who underwent isolated aortic valve replacement (iAVR) are well defined. Conflicting data exist in elderly patients who underwent AVR plus coronary artery bypass grafting (CABG). We sought to evaluate the early and long-term outcomes of combined AVR + CABG in patients older than 75 years of age. From June 1999 to June 2018, 402 patients ≥ 75 years who underwent iAVR (n = 200; 49.7%) or combined AVR plus CABG (n = 202; 50.3%) were retrospectively analysed. AVR + CABG patients were older than iAVR patients (78.5 ± 2.5 vs 77.6 ± 2.8 years; p < 0.0001), with greater co-morbidities and more urgent/emergency surgery. 30-day mortality was 6.5% in the AVR + CABG and 4.5% in the iAVR group (p = 0.38). Multivariate analysis identified EuroSCORE II [odd ratio (OR) 1.13] postoperative stroke (OR 12.53), postoperative low cardiac output syndrome (OR 8.72) and postoperative mechanical ventilation > 48 h (OR 8.92) as independent predictors of 30-day mortality; preoperative cerebrovascular events (OR 3.43), creatinine (OR 7.27) and extracorporeal circulation time (OR 1.01) were independent predictors of in-hospital major adverse cardiovascular and cerebral events (MACCE). Treatment was not an independent predictor of 30-day mortality and in-hospital MACCE. Survival at 1, 5 and 10 years was 94.7 ± 1.6%, 72.6 ± 3.6% and 31.7 ± 4.8% for iAVR patients and 89.1 ± 2.3%, 73.9 ± 3.5% and 37.2 ± 4.8% for AVR + CABG subjects (p = 0.99). Using adjusted Cox regression model, creatinine [hazard ration (HR) 1.50; p = 0.018], COPD (HR 1.97; p = 0.003) and NYHA class (HR 1.39; p < 0.0001) were independent predictors of late mortality; the combined AVR + CABG was not associated with increased risk of late mortality (HR 0.83; p = 0.30). In patients aged ≥ 75 years, combined AVR + CABG was not associated with increased 30-day mortality, in-hospital MACCE and long-term mortality. Surgical revascularization can be safely undertaken at the time of AVR in elderly patients.
Collapse
|
10
|
Clinical Outcomes of Transcatheter Aortic Valve Replacement in Nonagenarians: A Systematic Review and Meta-Analysis. J Interv Cardiol 2019; 2019:5819232. [PMID: 31772536 PMCID: PMC6739765 DOI: 10.1155/2019/5819232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/11/2019] [Indexed: 01/11/2023] Open
Abstract
Objectives To compare the incidence of mortality and complications between nonagenarians and younger patients undergoing transcatheter aortic valve replacement (TAVR). Background TAVR has become an alternative treatment for nonagenarian patients with severe aortic stenosis. Previous studies have reported conflicting results regarding the clinical outcomes between nonagenarians and younger patients who underwent TAVR. Methods We searched PubMed, EMBASE, and Cochrane Library databases with predefined criteria from the inception dates to July 8, 2018. The primary clinical endpoint was 30-day and 1-year all-cause mortalities. Secondary outcomes were considered the rates of stroke, myocardial infarction, any bleeding, any acute kidney injury, any vascular complications, new pacemaker implantation, and conversion to surgical aortic valve replacement. Results A total of 5 eligible studies with 25,371 patients were included in this meta-analysis. Compared with younger patients who underwent TAVR, nonagenarians had a significantly higher mean Society of Thoracic Surgeons score (STS score) (MD, 2.80; 95%CI: 2.58, 3.30; P<0.00001) and logistic European System for Cardiac Operative Risk Evaluation (logistic EuroSCORE) (MD, 2.72; 95%CI: 1.01, 4.43; P=0.002). Nonagenarians were associated with significantly higher 30-day mortality (6.2% vs. 3.7%; OR, 1.73; 95%CI: 1.49, 2.00) and 1-year mortality (15.5% vs. 11.8%; OR, 1.39; 95%CI: 1.26, 1.53), without significant statistical heterogeneity. Nonagenarians were associated with significantly increased rates of major or life-threatening bleeding, vascular complications and stroke of 20%, 35%, and 32%, respectively. There were no significant differences in the rate of myocardial infarction, stage 2 or 3 acute kidney injury, new pacemaker implantation, or conversion to surgical aortic valve replacement. Conclusions Nonagenarians showed worse clinical outcomes than younger patients after TAVR, while the incidence of mortality was acceptable. TAVR remains an option for nonagenarian patients with severe aortic stenosis and should be comprehensively evaluated by the heart valve team.
Collapse
|
11
|
Elgendy IY, Mahmoud AN, Elbadawi A, Elgendy AY, Omer MA, Megaly M, Mojadidi MK, Jneid H. In-hospital outcomes of transcatheter versus surgical aortic valve replacement for nonagenarians. Catheter Cardiovasc Interv 2018; 93:989-995. [PMID: 30569661 DOI: 10.1002/ccd.28050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/24/2018] [Accepted: 12/04/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To compare the in-hospital outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in nonagenarians. BACKGROUND Data comparing the outcomes of TAVR versus SAVR in nonagenarians are limited. METHODS Using the National Inpatient Sample years 2012-2014, hospitalization data were retrieved for subjects aged ≥90 years who underwent TAVR or SAVR for severe aortic stenosis. The incidence of in-hospital mortality and peri-procedural outcomes were compared using unadjusted, multivariate logistic regression, and propensity score matched analyses. RESULTS The final cohort included 6,680 records of nonagenarians undergoing aortic valve replacement, among which 5,840 (87.4%) underwent TAVR. There was no difference in the incidence of in-hospital mortality between both groups in the unadjusted (5.8% versus 6.0% P = 0.95), multivariate (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.35-1.74), and propensity score matched (OR 1.07, 95% CI 0.75-1.51) analyses. In the propensity-matched analysis, TAVR was associated with a lower incidence of acute kidney injury (OR 0.58, 95% CI 0.47-0.72), post-operative blood transfusion (OR 0.51, 95% CI 0.43-0.61), a higher likelihood of discharge to home (OR 4.71, 95% 3.44-5.06), and a similar incidence of pacemaker placement (OR 1.16, 95% 0.89-1.53) and stroke (OR 1.34, 0.90-1.99). CONCLUSIONS In this nationwide analysis, TAVR was associated with an overall similar incidence of in-hospital mortality and less morbidity compared with SAVR. These findings suggest that TAVR is effective and safe in nonagenarians.
Collapse
Affiliation(s)
- Islam Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
| | - Ahmed N Mahmoud
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
| | - Ayman Elbadawi
- Department of Medicine, Rochester General Hospital, Rochester, New York
| | - Akram Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, Florida
| | - Mohamed A Omer
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Michael Megaly
- Division of Cardiovascular Medicine, Minneapolis Heart Institute, Abbot Northwestern Hospital, Minneapolis, Minnesota
| | - Mohammad K Mojadidi
- Division of Cardiovascular Medicine, Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Hani Jneid
- Division of Cardiovascular Medicine, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
12
|
Impact of N-terminal pro-B-type natriuretic peptide response on long-term prognosis after transcatheter aortic valve implantation for severe aortic stenosis and heart failure. Heart Vessels 2018; 34:777-783. [DOI: 10.1007/s00380-018-1297-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 11/02/2018] [Indexed: 10/27/2022]
|
13
|
Predictors of permanent pacemaker implantation after transcatheter aortic valve implantation for aortic stenosis using Medtronic new generation self-expanding CoreValve Evolut R. Heart Vessels 2018; 34:360-367. [DOI: 10.1007/s00380-018-1236-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 07/27/2018] [Indexed: 12/19/2022]
|
14
|
Vendrik J, van Mourik MS, van Kesteren F, Henstra MJ, Piek JJ, Henriques JPS, Wykrzykowska JJ, de Winter RJ, Vis MM, Koch KT, Baan J. Comparison of Outcomes of Transfemoral Aortic Valve Implantation in Patients <90 With Those >90 Years of Age. Am J Cardiol 2018; 121:1581-1586. [PMID: 29627110 DOI: 10.1016/j.amjcard.2018.02.056] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 02/14/2018] [Accepted: 02/26/2018] [Indexed: 01/18/2023]
Abstract
In patients who underwent transcatheter aortic valve implantation (TAVI), postoperative mortality risk is commonly assessed with risk scores such as the Society of Thoracic Surgeons-Postoperative Risk of Mortality (STS-PROM) and EuroSCORE II, in which age plays a dominant role. However, we reason that in the naturally selected oldest-old patients (nonagenarians), this may not be completely justified and that therefore age should play a minor role in decision-making. The objective of this study was to compare procedural outcome and mid-term mortality of transfemoral (TF)-TAVI patients aged ≥90 years with patients aged <90 years. In this single-center analysis of 599 prospectively acquired consecutive TF-TAVI patients between 2009 and 2017, we compared patients aged ≥90 (i.e., nonagenarians, n = 47) with patients aged <90 years (n = 552), using Kaplan-Meyer analysis and multivariate logistic regression. In the nonagenarians, we found more aortic regurgitation, moderate to severe paravalvular leakage, strokes and vascular complications, and less device success and bleeding complications compared with patients <90 years. Both groups showed similar symptomatic improvement. The predicted (STS-PROM) and actual procedural mortality were 8.033% and 2.1% (3.8×) and 4.868% and 1.8% (2.7×) for the nonagenarians and controls, respectively. Survival was not statistically different at the 1-, 2-, 3-, 4-, and 5-year mark. In conclusion, nonagenarians had similar symptomatic improvement and acceptable procedural outcome and mid-term survival to TF-TAVI patients aged <90 years. Thus, age is not a risk factor in predicting postoperative outcome and mortality and therefore should not be a reason to deny the oldest-old patient transfemoral TAVI.
Collapse
Affiliation(s)
- Jeroen Vendrik
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Martijn S van Mourik
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Floortje van Kesteren
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Marieke J Henstra
- Departments of Internal Medicine and Geriatric Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan J Piek
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Jose P S Henriques
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Joanna J Wykrzykowska
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - M Marije Vis
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Karel T Koch
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan Baan
- Heart Centre, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| |
Collapse
|
15
|
Management of Nonagenarian Patients With Severe Aortic Stenosis: The Role of Comorbidity. Heart Lung Circ 2018; 27:219-226. [DOI: 10.1016/j.hlc.2017.02.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 01/25/2017] [Accepted: 02/28/2017] [Indexed: 11/23/2022]
|
16
|
Abstract
Transcatheter aortic valve implantation (TAVI) is currently performed through an alternative access in 15% of patients. The transapical access is progressively being abandoned as a result of its invasiveness and poor outcomes. Existing data does not allow TAVI operators to favour one access over another - between transcarotid, trans-subclavian and transaortic - because all have specific strengths and weaknesses. The percutaneous trans-subclavian access might become the main surgery-free alternative access, although further research is needed regarding its safety. Moreover, the difficult learning curve might compromise its adoption. The transcaval access is at an experimental stage and requires the development of dedicated cavo-aortic crossing techniques and closure devices.
Collapse
Affiliation(s)
- Pavel Overtchouk
- Centre Hospitalier Regional et Universitaire de Lille Lille, France
| | - Thomas Modine
- Centre Hospitalier Regional et Universitaire de Lille Lille, France
| |
Collapse
|
17
|
Yamawaki M, Iwasaki K, Araki M, Ito T, Ito Y, Tada N, Takagi K, Yamanaka F, Watanabe Y, Yamamoto M, Shirai S, Hayashida K. A proctoring system to manage the learning curve associated with the introduction of transcatheter aortic valve implantation in Japan. Heart Vessels 2017; 33:630-639. [PMID: 29230569 DOI: 10.1007/s00380-017-1098-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 12/01/2017] [Indexed: 11/25/2022]
Abstract
As transcatheter aortic valve implantation (TAVI) requires multidisciplinary collaboration, operators and the entire heart team must overcome a steep learning curve. A web-based screening and traditional on-site proctoring system were developed for the introduction of TAVI in Japan. To assess the learning curve involved with the introduction of TAVI under the supervision of a novel proctoring system. We divided 749 consecutive patients enrolled in the OCEAN-TAVI study between October 2013 and August 2015 into the trans-femoral (TF, n = 608) and transapical (TA, n = 141) approach groups to compare outcomes in patients who underwent TAVI during the early proctoring period (proctoring group) and after the procedures began to be performed independently (independent group). The primary endpoint was the rate of composite events regarding early safety (at 30 days) according to the valve academic research consortium-2 criteria. For TF-TAVI, the logistic EuroSCORE and the rate of peripheral artery disease were significantly lower during the independent period. The rate of device success significantly increased during the independent period (90.5 vs. 81.8%, p = 0.005). The rate of the primary endpoint was significantly reduced during the independent period compared to that during the proctoring period for TA-TAVI (21.3 vs. 37.9%, p = 0.031); however, no difference was observed for TF-TAVI (16.8 vs. 13.1%, p = 0.283). No deaths occurred within 30 days during the proctoring period for TF-TAVI. After adjustment using propensity score matching, the procedure time for TF-TAVI (88 ± 43 vs. 102 ± 36 min, p = 0.004) and the rate of life-threatening bleeding for TA-TAVI (3.6 vs. 25%, p = 0.026) reduced during the independent period compared to the values during the proctoring period. During the introduction of TAVI under the supervision of a new proctoring system in Japan, clinical outcomes and technical aspects improved significantly. There are differences in the steepness of the learning curve between TF-TAVI and TA-TAVI.
Collapse
Affiliation(s)
- Masahiro Yamawaki
- Department of Cardiology, Saiseikai Yokohama City Eastern Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, 230-8765, Japan.
- Tokyo Women's Medical University/Waseda University Joint Institution for Advanced Biomedical Science, Tokyo, Japan.
| | - Kiyotaka Iwasaki
- Tokyo Women's Medical University/Waseda University Joint Institution for Advanced Biomedical Science, Tokyo, Japan
| | - Motoharu Araki
- Department of Cardiology, Saiseikai Yokohama City Eastern Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, 230-8765, Japan
| | - Tsutomu Ito
- Department of Cardiovascular Surgery, Saiseikai Yokohama City Eastern Hospital, Yokohama, Japan
| | - Yoshiaki Ito
- Department of Cardiology, Saiseikai Yokohama City Eastern Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, 230-8765, Japan
| | - Norio Tada
- Department of Cardiology, Sendai Kousei Hospital, Sendai, Japan
| | - Kensuke Takagi
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Futoshi Yamanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Masanori Yamamoto
- Department of Cardiology, Toyohashi Heart Center, Toyohashi, Japan
- Department of Cardiology, Nagoya Heart Center, Nagoya, Japan
| | - Shinichi Shirai
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| |
Collapse
|
18
|
Yamawaki M, Araki M, Ito T, Honda Y, Tokuda T, Ito Y, Ueno H, Mizutani K, Tabata M, Higashimori A, Tada N, Takagi K, Yamanaka F, Naganuma T, Watanabe Y, Yamamoto M, Shirai S, Hayashida K. Ankle–brachial pressure index as a predictor of the 2-year outcome after transcatheter aortic valve replacement: data from the Japanese OCEAN-TAVI Registry. Heart Vessels 2017; 33:640-650. [DOI: 10.1007/s00380-017-1096-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 12/01/2017] [Indexed: 12/19/2022]
|
19
|
Manolis AS, Manolis AA. Transcatheter aortic valve implantation in nonagenarians: selectively feasible or extravagantly futile? Ann Cardiothorac Surg 2017; 6:524-531. [PMID: 29062749 DOI: 10.21037/acs.2017.07.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A growing number of nonagenarians is recorded as life expectancy increases. Unfortunately, this extreme-aged group is plagued by increased prevalence of aortic stenosis amidst a higher occurrence of comorbidities that pose dilemmas to cardiologists and cardiac surgeons when having to choose a conservative or interventional treatment modality, and a surgical or transcatheter aortic valve implantation (TAVI) approach. TAVI is an expensive procedure, which also confers a higher mortality and morbidity risk in nonagenarians, compared to younger patients. Considering the physiologic rather the chronologic age alone, and adopting a shared-decision making approach (participatory medicine), it may be more realistic to determine a patient's candidacy for this non-surgical therapeutic modality. Thus, it comes down to the patient selection process by having the heart team review each nonagenarian case individually and getting the patient and the family involved, always aiming to prolong and improve patient's quality of life (QoL), but also taking into consideration patient preferences and values, sharing and respecting goals, realistic expectations, and end-of-life views and ideas. One should keep in mind that there is always the possibility that TAVI may be clinically futile for patients who have a multitude of comorbidities and extreme frailty, for whom a transition to palliative care might be prudent. Selecting nonagenarian patients with low comorbidity index and with no extreme frailty, adopting a minimalistic approach and paying attention to vascular access hemostasis may provide the elements that may lead to a successful, desirable and hopefully cost-effective outcome.
Collapse
Affiliation(s)
- Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | - Antonis A Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
| |
Collapse
|
20
|
Heger T, Strauß S, Blessing E, Andrassy M, Erbel C, Müller OJ, Chorianopoulos E, Pleger S, Leuschner F, Korosoglou G, Bekeredjian R, Katus HA, Vogel B. Short and long-term results after endovascular management of vascular complications during transfemoral aortic valve implantation. Acta Cardiol 2017; 72:474-482. [PMID: 28705072 DOI: 10.1080/00015385.2017.1335455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Vascular injury and access site complications in the contemporary setting of transcatheter aortic valve implantation (TAVI) are known to be associated with increased mortality and morbidity. The aim of our study was to analyse the feasibility and safety of percutaneous treatment of such vascular complications using a stent graft. Methods Between January 2010 and April 2013, 36 TAVI patients developed severe access site complications and underwent subsequent interventional treatment with a covered stent. Acute treatment success was confirmed by angiography immediately after the implantation of the stent graft, with clinical long-term patency follow-up being assessed by duplex ultrasound. Results Of the 36 patients evaluated, percutaneous treatment of the acute access site bleeding was successful in 35 patients (97%), with one patient requiring surgical intervention due to insufficient haemostasis after stent graft implantation. A subset of 5 patients underwent successful ipsilateral stent graft implantation, either because crossover sheath placement was not feasible (n = 1), or intentionally with an even sheathless approach in an effort to reduce vessel injury (n = 4). After a mean follow-up of 22 ± 8 months, stent graft patency was confirmed by duplex ultrasound in 13 patients with an additional 5 patients reporting to be free from symptoms and claudication. Thirteen patients died within the first 24 months after the procedure, however, none was due to access vessel complications. Five patients were lost for follow-up. Conclusions Our data confirm that endovascular treatment of access site complications related to TAVI is feasible, safe and efficacious, resulting in long-term vascular patency.
Collapse
Affiliation(s)
- Thomas Heger
- Department of Cardiology, Angiology, and Pulmology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefanie Strauß
- Department of Cardiology, Angiology, and Pulmology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Christian Erbel
- Department of Cardiology, Angiology, and Pulmology, Heidelberg University Hospital, Heidelberg, Germany
| | - Oliver J. Müller
- Department of Cardiology, Angiology, and Pulmology, Heidelberg University Hospital, Heidelberg, Germany
| | - Emmanuel Chorianopoulos
- Department of Cardiology, Angiology, and Pulmology, Heidelberg University Hospital, Heidelberg, Germany
| | - Sven Pleger
- Department of Cardiology, Angiology, and Pulmology, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Leuschner
- Department of Cardiology, Angiology, and Pulmology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Raffi Bekeredjian
- Department of Cardiology, Angiology, and Pulmology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hugo A. Katus
- Department of Cardiology, Angiology, and Pulmology, Heidelberg University Hospital, Heidelberg, Germany
| | - Britta Vogel
- Department of Cardiology, Angiology, and Pulmology, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
21
|
Okoh AK, Chauhan D, Kang N, Haik N, Merlo A, Cohen M, Haik B, Chen C, Russo MJ. The impact of frailty status on clinical and functional outcomes after transcatheter aortic valve replacement in nonagenarians with severe aortic stenosis. Catheter Cardiovasc Interv 2017; 90:1000-1006. [PMID: 28463403 DOI: 10.1002/ccd.27083] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/13/2017] [Accepted: 03/25/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND The impact of frailty status on TAVR outcomes in nonagenarians is unknown. The present study aims to investigate the impact of frailty status on procedural outcomes and overall survival in nonagenarians after TAVR. METHODS A frailty score (FS) was derived by using preoperative grip strength, gait speed, serum albumin, and daily activities. Patients were divided into two groups: Frail (FS ≥ 3/4) and Non-Frail (FS <3/4). Health status was assessed using the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ). Baseline demographic and clinical characteristics were compared in both groups. The effect of frailty status on outcomes was investigated. Cox regression analyses were performed to determine predictors of overall all-cause mortality. Kaplan-Meier survival curves were used to estimate survival. RESULTS Seventy-five patients >90 years underwent full assessment for frailty status. There was a significant improvement in overall health status of non-frail patients (mean difference: 11.03, P = 0.032). Unadjusted 30-day and 2-year mortality rates were higher in the frail group than the non-frail group. (14% vs. 2% P = 0.059; 31% vs. 9% P = 0.018). Kaplan-Meier estimated all-cause mortality to be significantly higher in the frail group (log-rank test; P = 0.042). Frailty status was independently associated with increased mortality (hazard ratio: 1.84, 95% C.I: 1.06-3.17; P = 0.028) after TAVR. CONCLUSION Among nonagenarians selected to undergo TAVR for severe aortic stenosis, a considerable number are frail. Nonfrail patients report a significant improvement in overall health status in the short term. Worse frailty is strongly associated with diminished long-term survival. © 2017 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Alexis K Okoh
- Department of Cardiothoracic Surgery, RWJ Barnabas Health-Newark Beth Israel Medical Center, Newark, New Jersey
| | - Dhaval Chauhan
- Department of Cardiothoracic Surgery, RWJ Barnabas Health-Newark Beth Israel Medical Center, Newark, New Jersey
| | - Nathan Kang
- Department of Cardiothoracic Surgery, RWJ Barnabas Health-Newark Beth Israel Medical Center, Newark, New Jersey
| | - Nicky Haik
- Department of Cardiothoracic Surgery, RWJ Barnabas Health-Newark Beth Israel Medical Center, Newark, New Jersey
| | - Aurelie Merlo
- Department of Cardiothoracic Surgery, RWJ Barnabas Health-Newark Beth Israel Medical Center, Newark, New Jersey
| | - Mark Cohen
- Department of Cardiothoracic Surgery, RWJ Barnabas Health-Newark Beth Israel Medical Center, Newark, New Jersey
| | - Bruce Haik
- Department of Cardiothoracic Surgery, RWJ Barnabas Health-Newark Beth Israel Medical Center, Newark, New Jersey
| | - Chunguang Chen
- Department of Cardiothoracic Surgery, RWJ Barnabas Health-Newark Beth Israel Medical Center, Newark, New Jersey
| | - Mark J Russo
- Department of Cardiothoracic Surgery, RWJ Barnabas Health-Newark Beth Israel Medical Center, Newark, New Jersey
| |
Collapse
|
22
|
Sharma M, Mascarenhas DAN. Do all Critical Aortic Stenosis with Chest Pain Need Aortic Valve Replacement? A Case Report. Clin Pract 2016; 6:887. [PMID: 27994841 PMCID: PMC5136738 DOI: 10.4081/cp.2016.887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 09/26/2016] [Accepted: 10/11/2016] [Indexed: 11/30/2022] Open
Abstract
Aortic valve replacement (AVR) remains the cornerstone of treatment for symptomatic critical aortic stenosis (AS). It is a Class I indication that symptomatic patients with critical AS undergo either surgical or transcatheter aortic valve replacement (TAVR). We present a patient with critical AS and new angina that was managed successfully with percutaneous coronary intervention (PCI) of the Right coronary artery. Physicians should consider that not all patients with critical AS and angina necessarily require AVR. Concomitant pathology leading to the symptoms should be carefully ruled out. This leads to a less invasive, cost effective care plan especially in patients with advanced age and comorbidities for which any type of surgical valvular intervention may pose high risk.
Collapse
Affiliation(s)
- Munish Sharma
- Department of Internal Medicine, Easton Hospital , Easton, PA
| | - Daniel A N Mascarenhas
- Drexel University College of Medicine , Philadelphia, PA; and Interventional Cardiologist, Easton Hospital, Easton, PA, USA
| |
Collapse
|
23
|
Mesquita J, Teles RC, Neves JP, Abecasis J, Carmo P, Brito J, Abecasis M, Almeida MS, Trabulo M, Ribeiras R, Seabra-Gomes R, Mendes M. Transcatheter tricuspid valve-in-valve replacement: one-year results : Alternative to surgery in high-risk patients. Heart Vessels 2016; 32:495-500. [PMID: 27848007 DOI: 10.1007/s00380-016-0921-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 11/11/2016] [Indexed: 10/20/2022]
Abstract
Although rheumatic heart disease is becoming uncommon in industrialized countries, its global burden is still significant. We report the case of a 70-year-old male with rheumatic heart disease, who underwent 4 previous heart valve replacement surgeries, and presented to our hospital with refractory heart failure (NYHA functional class IV) due to severe stenosis of a previously implanted tricuspid bioprosthesis. The Heart Team deemed the patient as inoperable/high-risk for surgery. As an alternative, a transcatheter tricuspid valve-in-valve replacement was decided upon and later executed through the right femoral vein, with the insertion of an Edwards SAPIEN XT 29 no. (Edwards Lifesciences, Irvine, CA, USA) through the inferior vena cava, towards the RV, followed by direct implantation in the tricuspid bioprosthesis (valve-in-valve), under rapid pacing, without complications. A substantial clinical and echocardiographic improvement was noted after the procedure and the patient was subsequently discharged in NYHA functional class II. These favourable outcomes persisted through the 1-year follow-up period. This case report adds to the current body of evidence that tricuspid valve implantation stands as a viable and reliable alternative in the treatment of degenerated bioprosthesis in high-surgical-risk patients.
Collapse
Affiliation(s)
- João Mesquita
- Cardiology Department, Hospital de Santa Cruz, Av. Prof. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal.
| | - Rui Campante Teles
- Cardiology Department, Hospital de Santa Cruz, Av. Prof. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal.,CEDOC, NOVA Medical School, Lisbon, Portugal
| | - José Pedro Neves
- Cardiothoracic Surgery Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
| | - João Abecasis
- Cardiology Department, Hospital de Santa Cruz, Av. Prof. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | - Pedro Carmo
- Cardiology Department, Hospital de Santa Cruz, Av. Prof. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | - João Brito
- Cardiology Department, Hospital de Santa Cruz, Av. Prof. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | - Miguel Abecasis
- Cardiothoracic Surgery Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
| | - Manuel Sousa Almeida
- Cardiology Department, Hospital de Santa Cruz, Av. Prof. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | - Marisa Trabulo
- Cardiology Department, Hospital de Santa Cruz, Av. Prof. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | - Regina Ribeiras
- Cardiology Department, Hospital de Santa Cruz, Av. Prof. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | | | - Miguel Mendes
- Cardiology Department, Hospital de Santa Cruz, Av. Prof. Reinaldo dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| |
Collapse
|
24
|
Abstract
OPINION STATEMENT Transcatheter aortic valve replacement (TAVR) has emerged as an effective treatment alternative in patients with severe aortic stenosis (AS) who are deemed surgically high-risk or ineligible for surgery. Pre-procedural imaging, in particular computed tomography (CT), plays an integral part in the planning and performance of TAVR and is crucial for a successful treatment. Novel technological advances in CT include high-pitch, low kV acquisitions, and iterative reconstruction resulting in high image quality at substantially reduced scan duration, contrast volume, and radiation exposure. Given the high spatial and temporal resolution of the acquisitions, CT angiography provides critical information on the eligibility for the peripheral vascular access, aortic root assessment, as well as the aortic annulus measurements, including the coronary ostia and concomitant cardiac pathology. Pre-procedural CT imaging is key for appropriate device size selection to minimize peri-procedural complications and optimize procedural success. In this article, we review the current state of imaging in the pre-interventional setting of TAVR with a special emphasis on CT.
Collapse
|