1
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Walpot J, van Herck P, Collas V, Bossaerts L, Van de Heyning CM, Vandendriessche T, Heidbuchel H, Rodrigus I, De Block C, Small GR, Bosmans J. Adiponectin serum level is an independent and incremental predictor of all-cause mortality after transcatheter aortic valve replacement. Clin Cardiol 2022; 45:1060-1069. [PMID: 35932173 PMCID: PMC9574742 DOI: 10.1002/clc.23892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/20/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022] Open
Abstract
Background Quantifiable biomarkers may be useful for a better risk and frailty assessment of patients referred for transcatheter aortic valve implantation (TAVI). Hypothesis To determine if adiponectin serum concentration predicts all‐cause mortality in patients undergoing TAVI. Methods 77 consecutive patients, undergoing TAVI, were analyzed. The CT axial slices at the level of the fourth lumbar vertebra were used to measure the psoas muscle area, and its low‐density muscle fraction (LDM (%)). To assess the operative risk, the STS (Society of Thoracic Surgeons Predicted Risk of Mortality) score, Log. Euroscore, and Euroscore II were determined. A clinical frailty assessment was performed. ELISA kits were used to measure adiponectin serum levels. We searched for a correlation between serum adiponectin concentration and all‐cause mortality after TAVI. Results The mean age was 80.8 ± 7.4 years. All‐cause mortality occurred in 22 patients. The mean follow‐up was 1779 days (range: 1572–1825 days). Compared with patients with the lowest adiponectin level, patients in the third tertile had a hazards ratio of all‐cause mortality after TAVI of 4.155 (95% CI: 1.364–12.655) (p = .004). In the multivariable model, including STS score, vascular access of TAVI procedure, LDM (%), and adiponectin serum concentration, serum adiponectin level, and LDM(%) were independent predictors of all‐cause mortality after TAVI (p = .178, .303, .042, and .017, respectively). Adiponectin level was a predictor of all‐cause mortality in females and males (p = .012 and 0.024, respectively). Conclusion Adiponectin serum level is an independent and incremental predictor of all‐cause mortality in patients undergoing TAVI.
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Affiliation(s)
- Jeroen Walpot
- Department of Cardiology, University Hospital Antwerp, Edegem, Antwerp, Belgium.,Department of Cardiology, ZorgSaam Hospital, Terneuzen, The Netherlands
| | - Paul van Herck
- Department of Cardiology, University Hospital Antwerp, Edegem, Antwerp, Belgium
| | - Valerie Collas
- Faculty of Health Sciences and Medicine, University of Antwerp, Wilrijk, Belgium
| | - Liene Bossaerts
- Faculty of Biomedical Sciences, University of Antwerp, Wilrijk, Belgium
| | - Caroline M Van de Heyning
- Department of Cardiology, University Hospital Antwerp, Edegem, Antwerp, Belgium.,Faculty of Health Sciences and Medicine, University of Antwerp, Wilrijk, Belgium
| | - Tom Vandendriessche
- Department of Cardiology, University Hospital Antwerp, Edegem, Antwerp, Belgium
| | - Hein Heidbuchel
- Department of Cardiology, University Hospital Antwerp, Edegem, Antwerp, Belgium.,Faculty of Health Sciences and Medicine, University of Antwerp, Wilrijk, Belgium
| | - Inez Rodrigus
- Department of Cardiac Surgery, University Hospital Antwerp, Antwerp, Edegem, Belgium
| | - Christophe De Block
- Department of Endocrinology-Diabetology and Metabolism, Antwerp University Hospital, Edegem, Antwerp, Belgium
| | - Gary R Small
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Johan Bosmans
- Department of Cardiology, University Hospital Antwerp, Edegem, Antwerp, Belgium.,Faculty of Biomedical Sciences, University of Antwerp, Wilrijk, Belgium
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2
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Stickels CP, Nadarajah R, Gale CP, Jiang H, Sharkey KJ, Gibbison B, Holliman N, Lombardo S, Schewe L, Sommacal M, Sun L, Weir-McCall J, Cheema K, Rudd JHF, Mamas M, Erhun F. Aortic stenosis post-COVID-19: a mathematical model on waiting lists and mortality. BMJ Open 2022; 12:e059309. [PMID: 35710248 PMCID: PMC9207579 DOI: 10.1136/bmjopen-2021-059309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 05/20/2022] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To provide estimates for how different treatment pathways for the management of severe aortic stenosis (AS) may affect National Health Service (NHS) England waiting list duration and associated mortality. DESIGN We constructed a mathematical model of the excess waiting list and found the closed-form analytic solution to that model. From published data, we calculated estimates for how the strategies listed under Interventions may affect the time to clear the backlog of patients waiting for treatment and the associated waiting list mortality. SETTING The NHS in England. PARTICIPANTS Estimated patients with AS in England. INTERVENTIONS (1) Increasing the capacity for the treatment of severe AS, (2) converting proportions of cases from surgery to transcatheter aortic valve implantation and (3) a combination of these two. RESULTS In a capacitated system, clearing the backlog by returning to pre-COVID-19 capacity is not possible. A conversion rate of 50% would clear the backlog within 666 (533-848) days with 1419 (597-2189) deaths while waiting during this time. A 20% capacity increase would require 535 (434-666) days, with an associated mortality of 1172 (466-1859). A combination of converting 40% cases and increasing capacity by 20% would clear the backlog within a year (343 (281-410) days) with 784 (292-1324) deaths while awaiting treatment. CONCLUSION A strategy change to the management of severe AS is required to reduce the NHS backlog and waiting list deaths during the post-COVID-19 'recovery' period. However, plausible adaptations will still incur a substantial wait to treatment and many hundreds dying while waiting.
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Affiliation(s)
| | - Ramesh Nadarajah
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Chris P Gale
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Houyuan Jiang
- Judge Business School, University of Cambridge, Cambridge, UK
| | - Kieran J Sharkey
- Department of Mathematical Sciences, University of Liverpool, Liverpool, UK
| | - Ben Gibbison
- Cardiac Anaesthesia and Intensive Care, Bristol Medical School, Bristol, UK
| | - Nick Holliman
- Department of Informatics, King's College London, London, UK
| | - Sara Lombardo
- Department of Mathematical Sciences, Loughborough University, Loughborough, UK
| | - Lars Schewe
- School of Mathematics and Maxwell Institute for Mathematical Sciences, University of Edinburgh, Edinburgh, UK
| | - Matteo Sommacal
- Department of Mathematics, Physics and Electrical Engineering, Northumbria University, Newcastle upon Tyne, UK
| | - Louise Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Cardiovascular Research Program, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jonathan Weir-McCall
- Department of Radiology, University of Cambridge, Cambridge, UK
- Department of Radiology, Royal Papworth Hospital, Cambridge, UK
| | | | - James H F Rudd
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Keele University, Keele, UK
| | - Feryal Erhun
- Judge Business School, University of Cambridge, Cambridge, UK
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3
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Roule V, Rebouh I, Lemaitre A, Sabatier R, Blanchart K, Briet C, Bignon M, Beygui F. Impact of wait times on late postprocedural mortality after successful transcatheter aortic valve replacement. Sci Rep 2022; 12:5967. [PMID: 35395869 PMCID: PMC8993919 DOI: 10.1038/s41598-022-09995-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 03/21/2022] [Indexed: 11/30/2022] Open
Abstract
Wait times are associated with mortality on waiting list for transcatheter aortic valve replacement (TAVR). Whether longer wait times are associated with long term mortality after successful TAVR remains unassessed. Consecutive patients successfully treated with elective TAVR in our center between January 2013 and August 2019 were included. The primary end point was one-year all-cause mortality. TAVR wait times were defined as the interval from referral date for valve replacement to the date of TAVR procedure. A total of 383 patients were included with a mean wait time of 144.2 ± 83.87 days. Death occurred in 55 patients (14.4%) at one year. Increased wait times were independently associated with a relative increase of 1-year mortality by 2% per week after referral (Adjusted Hazard Ratio 1.02 [1.002–1.04]; p = 0.02) for TAVR. Chronic kidney disease, left ventricular ejection fraction ≤ 30%, access site and STS score were other independent correlates of 1-year mortality. Our study shows that wait times are relatively long in routine practice and associated with increased 1-year mortality after successful TAVR. Such findings underscore the need of strategies to minimize delays in access to TAVR.
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Affiliation(s)
- Vincent Roule
- CHU de Caen Normandie, Service de Cardiologie, 14000, Caen, France. .,INSERM UMRS 1237, GIP Cyceron, 14000, Caen, France. .,Cardiology Department, Caen University Hospital, Avenue Cote de Nacre, 14033, Caen, France.
| | - Idir Rebouh
- CHU de Caen Normandie, Service de Cardiologie, 14000, Caen, France
| | - Adrien Lemaitre
- CHU de Caen Normandie, Service de Cardiologie, 14000, Caen, France
| | - Rémi Sabatier
- CHU de Caen Normandie, Service de Cardiologie, 14000, Caen, France
| | | | - Clément Briet
- CHU de Caen Normandie, Service de Cardiologie, 14000, Caen, France
| | - Mathieu Bignon
- CHU de Caen Normandie, Service de Cardiologie, 14000, Caen, France
| | - Farzin Beygui
- CHU de Caen Normandie, Service de Cardiologie, 14000, Caen, France.,INSERM UMRS 1237, GIP Cyceron, 14000, Caen, France.,ACTION Study Group, Cardiology Department, Pitié-Salpêtrière University Hospital, Paris, France
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4
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Ullah W, Zahid S, Zaidi SR, Sarvepalli D, Haq S, Roomi S, Mukhtar M, Khan MA, Gowda SN, Ruggiero N, Vishnevsky A, Fischman DL. Predictors of Permanent Pacemaker Implantation in Patients Undergoing Transcatheter Aortic Valve Replacement - A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 10:e020906. [PMID: 34259045 PMCID: PMC8483489 DOI: 10.1161/jaha.121.020906] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background As transcatheter aortic valve replacement (TAVR) technology expands to healthy and lower‐risk populations, the burden and predictors of procedure‐related complications including the need for permanent pacemaker (PPM) implantation needs to be identified. Methods and Results Digital databases were systematically searched to identify studies reporting the incidence of PPM implantation after TAVR. A random‐ and fixed‐effects model was used to calculate unadjusted odds ratios (OR) for all predictors. A total of 78 studies, recruiting 31 261 patients were included in the final analysis. Overall, 6212 patients required a PPM, with a mean of 18.9% PPM per study and net rate ranging from 0.16% to 51%. The pooled estimates on a random‐effects model indicated significantly higher odds of post‐TAVR PPM implantation for men (OR, 1.16; 95% CI, 1.04–1.28); for patients with baseline mobitz type‐1 second‐degree atrioventricular block (OR, 3.13; 95% CI, 1.64–5.93), left anterior hemiblock (OR, 1.43; 95% CI, 1.09–1.86), bifascicular block (OR, 2.59; 95% CI, 1.52–4.42), right bundle‐branch block (OR, 2.48; 95% CI, 2.17–2.83), and for periprocedural atriorventricular block (OR, 4.17; 95% CI, 2.69–6.46). The mechanically expandable valves had 1.44 (95% CI, 1.18–1.76), while self‐expandable valves had 1.93 (95% CI, 1.42–2.63) fold higher odds of PPM requirement compared with self‐expandable and balloon‐expandable valves, respectively. Conclusions Male sex, baseline atrioventricular conduction delays, intraprocedural atrioventricular block, and use of mechanically expandable and self‐expanding prosthesis served as positive predictors of PPM implantation in patients undergoing TAVR.
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Affiliation(s)
- Waqas Ullah
- Thomas Jefferson University Hospitals Philadelphia PA
| | | | | | | | | | | | - Maryam Mukhtar
- University Hospitals of Leicester NHS Trust Leicester UK
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5
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Lauten A, Rudolph TK, Messika-Zeitoun D, Thambyrajah J, Serra A, Schulz E, Frey N, Maly J, Aiello M, Lloyd G, Bortone AS, Clerici A, Delle-Karth G, Rieber J, Indolfi C, Mancone M, Belle L, Arnold M, Bouma BJ, Lutz M, Deutsch C, Kurucova J, Thoenes M, Bramlage P, Steeds RP. Management of patients with severe aortic stenosis in the TAVI-era: how recent recommendations are translated into clinical practice. Open Heart 2021; 8:openhrt-2020-001485. [PMID: 33431618 PMCID: PMC7802661 DOI: 10.1136/openhrt-2020-001485] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/02/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022] Open
Abstract
Objective Approximately 3.4% of adults aged >75 years suffer from aortic stenosis (AS). Guideline indications for aortic valve replacement (AVR) distinguish between patients with symptomatic and asymptomatic severe AS. The present analysis aims to assess contemporary practice in the treatment of severe AS across Europe and identify characteristics associated with treatment decisions, namely denial of AVR in symptomatic patients and assignment of asymptomatic patients to AVR. Methods Participants of the prospective, multinational IMPULSE database of patients with severe AS were grouped according to AS symptoms, and stratified into subgroups based on assignment to/denial of AVR. Results Of 1608 symptomatic patients, 23.8% did not undergo AVR and underwent medical treatment. Denial was independently associated with multiple factors, including severe frailty (p=0.024); mitral (p=0.002) or tricuspid (p=0.004) regurgitation grade III/IV, and the presence of renal impairment (p=0.017). Of 392 asymptomatic patients, 86.5% had no prespecified indication for AVR. Regardless, 36.3% were assigned to valve replacement. Those with an indexed aortic valve area (AVA; p=0.045) or left ventricular ejection fraction (LVEF; p<0.001) below the study median; or with a left ventricular end systolic diameter above the study median (p=0.007) were more likely to be assigned to AVR. Conclusions There may be considerable discrepancies between guideline-based recommendations and clinical practice decision-making in the treatment of AS. It appears that guidelines may not fully capture the complete clinical spectrum of patients with AS. Thus, there is a need to find ways to increase their acceptance and the rate of adoption.
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Affiliation(s)
| | - Tanja K Rudolph
- Department of Cardiology, Hear and Diabetes Center Bad Oeynhausen, Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | | | | | - Antonio Serra
- Interventional Cardiology Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain
| | - Eberhard Schulz
- Cardiology Department, AKH Celle, Celle, Niedersachsen, Germany
| | - Norbert Frey
- Department of Cardiology and Angiology, University of Kiel, Kiel, Schleswig-Holstein, Germany
| | - Jiri Maly
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marco Aiello
- Department of Cardiothoracic Surgery, Foundation IRCCS Policlinico S.Matteo, Pavia, Italy
| | - Guy Lloyd
- St Bartholomew's Hospital, London, UK
| | | | | | | | - Johannes Rieber
- Herzkatheterlabor Nymphenburg and Department of Cardiology, University of Munich, Munich, Bayern, Germany
| | - Ciro Indolfi
- Division of Cardiology and URT CNR of IFC, University Magna Graecia, Catanzaro, Calabria, Italy
| | | | - Loic Belle
- Centre Hospital d'Annecy, Annecy, France
| | - Martin Arnold
- Department of Cardiology, University Hospital Erlangen, Erlangen, Bayern, Germany
| | | | - Matthias Lutz
- Department of Cardiology and Angiology, University of Kiel, Kiel, Schleswig-Holstein, Germany
| | - Cornelia Deutsch
- Institut für Pharmakologie und Präventive Medizin GmbH, Cloppenburg, Germany
| | | | | | - Peter Bramlage
- Institut für Pharmakologie und Präventive Medizin GmbH, Cloppenburg, Germany
| | - Richard Paul Steeds
- Queen Elizabeth Hospital & Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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6
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Matsuda Y, Nai Fovino L, Giacoppo D, Scotti A, Massussi M, Ueshima D, Sasano T, Fabris T, Tarantini G. Association between surgical risk and 30‐day stroke after transcatheter versus surgical aortic valve replacement: a systematic review and meta‐analysis. Catheter Cardiovasc Interv 2020; 97:E536-E543. [DOI: 10.1002/ccd.29105] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/07/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Yuji Matsuda
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
- Department of Cardiovascular Medicine Graduate School of General Medical and Dental Science, Tokyo Medical and Dental University Tokyo Japan
| | - Luca Nai Fovino
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Daniele Giacoppo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Andrea Scotti
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Mauro Massussi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Daisuke Ueshima
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine Graduate School of General Medical and Dental Science, Tokyo Medical and Dental University Tokyo Japan
| | - Tommaso Fabris
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health University of Padua Medical School Padua Italy
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7
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Henning KA, Ravindran M, Qiu F, Fam NP, Seth TN, Austin PC, Wijeysundera HC. Impact of procedural capacity on transcatheter aortic valve replacement wait times and outcomes: a study of regional variation in Ontario, Canada. Open Heart 2020; 7:openhrt-2020-001241. [PMID: 32393658 PMCID: PMC7223466 DOI: 10.1136/openhrt-2020-001241] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/05/2020] [Accepted: 04/21/2020] [Indexed: 01/05/2023] Open
Abstract
Background There has been rapid growth in the demand for transcatheter aortic valve replacement (TAVR), which has the potential to overwhelm current capacity. This imbalance between demand and capacity may lead to prolonged wait times, and subsequent adverse outcomes while patients are on the waitlist. We sought to understand the relationship between regional differences in capacity, TAVR wait times and morbidity/mortality on the waitlist. Methods and results We modelled the effect of TAVR capacity, defined as the number of TAVR procedures per million residents/region, on the hazard of having a TAVR in Ontario from April 2012 to March 2017. Our primary outcome was the time from referral to a TAVR procedure or other off-list reasons on the waitlist/end of the observation period as measured in days. Clinical outcomes of interest were all-cause mortality, all-cause hospitalisations or heart failure-related hospitalisations while on the waitlist for TAVR. There was an almost fourfold difference in TAVR capacity across the 14 regions in Ontario, ranging from 31.5 to 119.5 TAVR procedures per million residents. The relationship between TAVR capacity and wait times was complex and non-linear. In general, increased capacity was associated with shorter wait times (p<0.001), reduced mortality (HR 0.94; p=0.08) and all-cause hospitalisations (p=0.009). Conclusions The results of the present study have important policy implications, suggesting that there is a need to improve TAVR capacity, as well as develop wait-time strategies to triage patients, in order to decrease wait times and mitigate the hazard of adverse patient outcomes while on the waitlist.
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Affiliation(s)
- Kayley A Henning
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Mithunan Ravindran
- Department of Cardiology, Schulich Heart Centre, University of Toronto, Toronto, Ontario, Canada
| | - Feng Qiu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Neil P Fam
- Division of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Tej N Seth
- Department of Cardiology, McMaster University, Hamilton, Ontario, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Harindra C Wijeysundera
- Department of Cardiology, Schulich Heart Centre, University of Toronto, Toronto, Ontario, Canada
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8
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van Beek-Peeters JJAM, van Noort EHM, Faes MC, de Vos AJBM, van Geldorp MWA, Minkman MMN, van der Meer NJM. Shared decision making in older patients with symptomatic severe aortic stenosis: a systematic review. Heart 2020; 106:647-655. [PMID: 32001621 DOI: 10.1136/heartjnl-2019-316055] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/24/2019] [Accepted: 12/19/2019] [Indexed: 12/18/2022] Open
Abstract
This review provides an overview of the status of shared decision making (SDM) in older patients regarding treatment of symptomatic severe aortic stenosis (SSAS). The databases Embase, Medline Ovid, Cinahl and Cochrane Dare were searched for relevant studies from January 2002 to May 2018 regarding perspectives of professionals, patients and caregivers; aspects of decision making; type of decision making; application of the six domains of SDM; barriers to and facilitators of SDM. The systematic search yielded 1842 articles, 15 studies were included. Experiences of professionals and informal caregivers with SDM were scarcely found. Patient refusal was a frequently reported result of decision making, but often no insight was given into the decision process. Most studies investigated the 'decision' and 'option' domains of SDM, yet no study took all six domains into account. Problem analysis, personalised treatment aims, use of decision aids and integrating patient goals in decisions lacked in all studies. Barriers to and facilitators of SDM were 'individualised formal and informal information support' and 'patients' opportunity to use their own knowledge about their health condition and preferences for SDM'. In conclusion, SDM is not yet common practice in the decision making process of older patients with SSAS. Moreover, the six domains of SDM are not often applied in this process. More knowledge is needed about the implementation of SDM in the context of SSAS treatment and how to involve patients, professionals and informal caregivers.
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Affiliation(s)
| | | | - Miriam C Faes
- Department of Geriatrics, Amphia Hospital, Breda, The Netherlands
| | | | | | - Mirella M N Minkman
- TIAS, School for Business and Society, Tilburg University, Tilburg, The Netherlands.,Vilans, Centre of Expertise for Long-term Care, Utrecht, The Netherlands
| | - Nardo J M van der Meer
- TIAS, School for Business and Society, Tilburg University, Tilburg, The Netherlands.,Department of Anesthesiology, Amphia Hospital, Breda, The Netherlands
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9
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Abstract
Background Rapid growth in transcatheter aortic valve replacement (TAVR) demand has translated to inadequate access, reflected by prolonged wait times. Increasing wait times are associated with important adverse outcomes while on the wait‐list; however, it is unknown if prolonged wait times influence postprocedural outcomes. Our objective was to determine the association between TAVR wait times and postprocedural outcomes. Methods and Results In this population‐based study in Ontario, Canada, we identified all TAVR procedures between April 1, 2010, and March 31, 2016. Wait time was defined as the number of days between initial referral and the procedure. Primary outcomes of interest were 30‐day all‐cause mortality and all‐cause readmission. Multivariable regression models incorporated wait time as a nonlinear variable, using cubic splines. The study cohort included 2170 TAVR procedures, of which 1741 cases were elective and 429 were urgent. There was a significant, nonlinear relationship between TAVR wait time and post‐TAVR 30‐day mortality, as well as 30‐day readmission. We observed an increased hazard associated with shorter wait times that diminished as wait times increased. This statistically significant nonlinear relationship was seen in the unadjusted model as well as after adjusting for clinical variables. However, after adjusting for case urgency status, there was no relationship between wait times and postprocedural outcomes. In sensitivity analyses restricted to either only elective or only urgent cases, there was no relationship between wait times and postprocedural outcomes. Conclusions Wait time has a complex relationship with postprocedural outcomes that is mediated entirely by urgency status. This suggests that further research should elucidate factors that predict hospitalization requiring urgent TAVR while on the wait list.
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10
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Faridi KF, Yeh RW, Poulin M. Treating Symptomatic Aortic Stenosis With Transcatheter Aortic Valve Replacement: Is There Time to Wait? J Am Heart Assoc 2019; 8:e011527. [PMID: 30612523 PMCID: PMC6405731 DOI: 10.1161/jaha.118.011527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kamil F. Faridi
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA
| | - Marie‐France Poulin
- Division of CardiologyDepartment of MedicineRush University Medical CenterChicagoIL
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11
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Elbaz-Greener G, Masih S, Fang J, Ko DT, Lauck SB, Webb JG, Nallamothu BK, Wijeysundera HC. Temporal Trends and Clinical Consequences of Wait Times for Transcatheter Aortic Valve Replacement. Circulation 2018; 138:483-493. [DOI: 10.1161/circulationaha.117.033432] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Transcatheter aortic valve replacement (TAVR) represents a paradigm shift in the therapeutic options for patients with severe aortic stenosis. However, rapid and exponential growth in TAVR demand may overwhelm capacity, translating to inadequate access and prolonged wait times. Our objective was to evaluate temporal trends in TAVR wait times and the associated clinical consequences.
Methods:
In this population-based study in Ontario, Canada, we identified all TAVR referrals from April 1, 2010, to March 31, 2016. The primary outcome was the median total wait time from referral to procedure. Piecewise regression analyses were performed to assess temporal trends in TAVR wait times, before and after provincial reimbursement in September 2012. Clinical outcomes included all-cause death and heart failure hospitalizations while on the wait list.
Results:
The study cohort included 4461 referrals, of which 50% led to a TAVR, 39% were off-listed for other reasons, and 11% remained on the wait list at the conclusion of the study. For patients who underwent a TAVR, the estimated median wait time in the postreimbursement period stabilized at 80 days and has remained unchanged. The cumulative probability of wait-list mortality and heart failure hospitalization at 80 days was ≈2% and 12%, respectively, with a relatively constant increase in events with increased wait times.
Conclusions:
Postreimbursement wait time has remained unchanged for patients undergoing a TAVR procedure, suggesting the increase in capacity has kept pace with the increase in demand. The current wait time of almost 3 months is associated with important morbidity and mortality, suggesting a need for greater capacity and access.
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Affiliation(s)
- Gabby Elbaz-Greener
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (G.E-G., D.T.K., H.C.W.)
| | - Shannon Masih
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (S.M., J.F., D.T.K., H.C.W.)
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (S.M., J.F., D.T.K., H.C.W.)
| | - Dennis T. Ko
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (G.E-G., D.T.K., H.C.W.)
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (S.M., J.F., D.T.K., H.C.W.)
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada (D.T.K., H.C.W.)
- Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (D.T.K., H.C.W.)
| | - Sandra B. Lauck
- Center for Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (S.B.L., J.G.W.)
| | - John G. Webb
- Center for Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (S.B.L., J.G.W.)
| | - Brahmajee K. Nallamothu
- Division of Cardiovascular Disease and Department of Internal Medicine, University of Michigan, Ann Arbor, MI (B.K.N.)
| | - Harindra C. Wijeysundera
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (G.E-G., D.T.K., H.C.W.)
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (S.M., J.F., D.T.K., H.C.W.)
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada (D.T.K., H.C.W.)
- Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (D.T.K., H.C.W.)
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Makki N, Lilly SM. Advanced chronic kidney disease: Relationship to outcomes post-TAVR, a meta-analysis. Clin Cardiol 2018; 41:1091-1096. [PMID: 29896847 DOI: 10.1002/clc.22993] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 06/04/2018] [Accepted: 06/10/2018] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) is associated with worse outcomes in high-surgical-risk patients undergoing transcatheter aortic valve replacement (TAVR). However, it is unclear whether this relationship is apparent in lower-surgical-risk patients. We sought to analyze existing literature to assess whether or not advanced CKD is associated with increased mortality or a greater incidence of adverse events (specifically major stroke, bleeding, and vascular complications). We searched PubMed and Embase (2008-2017) for relevant studies. Studies with <1 year follow-up and those not evaluating advanced CKD or outcomes post-TAVR were excluded. Our co-primary endpoints were the incidence of short-term mortality (defined as in-hospital or 30-day mortality) and long-term mortality (1 year). Our secondary endpoints included incidence of major stroke, life-threatening bleeding, and major vascular complications. Eleven observational studies with a total population of 10709 patients met the selection criteria. Among patients with CKD there was an increased risk of short- and long-term mortality in high-surgical-risk patients who underwent TAVR (hazard ratio [HR]: 1.51, 95% confidence interval [CI]: 1.22-1.88 and HR: 1.56, 95% CI: 1.38-1.77, respectively; P < 0.01). However, there was no association between CKD and mortality in low- to intermediate-risk patients (HR: 1.35, 95% CI: 0.98-1.84, P = 0.06 in short-term and HR: 1.08, 95% CI: 0.92-1.27, P = 0.34 in long-term). In low- to intermediate-risk TAVR patients, advanced CKD is not associated with increased mortality or poorer safety outcomes. These findings should be factored into the clinical decision-making process regarding TAVR candidacy.
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Affiliation(s)
- Nader Makki
- Department of Cardiology, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Scott M Lilly
- Department of Cardiology, Ohio State University Wexner Medical Center, Columbus, Ohio
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Ak A, Porokhovnikov I, Kuethe F, Schulze PC, Noutsias M, Schlattmann P. Transcatheter vs. surgical aortic valve replacement and medical treatment : Systematic review and meta-analysis of randomized and non-randomized trials. Herz 2017; 43:325-337. [PMID: 28451702 DOI: 10.1007/s00059-017-4562-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) has emerged as the procedure of choice for patients with severe aortic stenosis (AS) and high perioperative risk. We performed a meta-analysis to compare the mortality related to TAVR with medical therapy (MT) and surgical aortic valve replacement (SAVR). METHODS A systematic literature search was conducted by two independent investigators from the database inception to 30 December 2014. Relative risk (RR) and odds ratio (OR) were calculated and graphically displayed in forest plots. We used I 2 for heterogeneity (meta-regression) and Egger's regression test of asymmetry (funnel plots). RESULTS We included 24 studies (n = 19 observational studies; n = 5 randomized controlled trials), with a total of 7356 patients in this meta-analysis. Mean age had a substantial negative impact on the long-term survival of AS patients (OR = 1.544; 95% CI: 1.25-1.90). Compared with MT, TAVR showed a statistically significant benefit for all-cause mortality at 12 months (OR = 0.68; 95% CI: 0.49-0.95). Both TAVR and SAVR were associated with better outcomes compared with MT. TAVR showed lower all-cause mortality over SAVR at 12 months (OR = 0.81; 95% CI: 0.68-0.97). The comparison between SAVR and TAVR at 2 years revealed no significant difference (OR = 1.09; 95% CI: 1.01-1.17). CONCLUSION In AS, both TAVR and SAVR provide a superior prognosis to MT and, therefore, MT is not the preferred treatment option for AS. Furthermore, our data show that TAVR is associated with lower mortality at 12 months compared with SAVR. Further studies are warranted to compare the long-term outcome of TAVR versus SAVR beyond a 2-year follow-up period.
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Affiliation(s)
- A Ak
- Institute of Medical Statistics, Informatics and Documentation (IMSID), Friedrich-Schiller University and University Hospital Jena, Bachstraße 18, 07743, Jena, Germany
| | - I Porokhovnikov
- Institute of Medical Statistics, Informatics and Documentation (IMSID), Friedrich-Schiller University and University Hospital Jena, Bachstraße 18, 07743, Jena, Germany
| | - F Kuethe
- Department of Internal Medicine I, Division of Cardiology, Pneumology, Angiology and Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University Jena, Jena, Germany
| | - P C Schulze
- Department of Internal Medicine I, Division of Cardiology, Pneumology, Angiology and Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University Jena, Jena, Germany
| | - M Noutsias
- Department of Internal Medicine I, Division of Cardiology, Pneumology, Angiology and Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University Jena, Jena, Germany
| | - P Schlattmann
- Institute of Medical Statistics, Informatics and Documentation (IMSID), Friedrich-Schiller University and University Hospital Jena, Bachstraße 18, 07743, Jena, Germany.
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Chen C, Zhao ZG, Liao YB, Peng Y, Meng QT, Chai H, Li Q, Luo XL, Liu W, Zhang C, Chen M, Huang DJ. Impact of renal dysfunction on mid-term outcome after transcatheter aortic valve implantation: a systematic review and meta-analysis. PLoS One 2015; 10:e0119817. [PMID: 25793780 PMCID: PMC4368625 DOI: 10.1371/journal.pone.0119817] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 01/16/2015] [Indexed: 02/05/2023] Open
Abstract
Background There is conflicting evidence regarding the impact of preexisting renal dysfunction (RD) on mid-term outcomes after transcatheter aortic valve implantation (TAVI) in patients with symptomatic aortic stenosis (AS). Methods and results Forty-seven articles representing 32,131 patients with AS undergoing a TAVI procedure were included in this systematic review and meta-analysis. Pooled analyses were performed with both univariate and multivariate models, using a fixed or random effects method when appropriate. Compared with patients with normal renal function, mid-term mortality was significantly higher in patients with preexisting RD, as defined by the author (univariate hazard ratio [HR]: 1.69; 95% confidence interval [CI]: 1.50–1.90; multivariate HR: 1.47; 95% CI: 1.17–1.84), baseline estimated glomerular filtration rate (eGFR) (univariate HR: 1.65; 95% CI: 1.47–1.86; multivariate HR: 1.46; 95% CI: 1.24–1.71), and serum creatinine (univariate HR: 1.69; 95% CI: 1.48–1.92; multivariate HR: 1.65; 95% CI: 1.36–1.99). Advanced stage of chronic kidney disease (CKD stage 3–5) was strongly related to bleeding (univariate HR in CKD stage 3: 1.30, 95% CI: 1.13–1.49; in CKD stage 4: 1.30, 95% CI: 1.04–1.62), acute kidney injure (AKI) (univariate HR in CKD stage 3: 1.28, 95% CI: 1.03–1.59; in CKD stage 4: 2.27, 95% CI: 1.74–2.96), stroke (univariate HR in CKD stage 4: 3.37, 95% CI: 1.52–7.46), and mid-term mortality (univariate HR in CKD stage 3: 1.57, 95% CI: 1.26–1.95; in CKD stage 4: 2.77, 95% CI: 2.06–3.72; in CKD stage 5: 2.64, 95% CI: 1.91–3.65) compared with CKD stage 1+2. Patients with CKD stage 4 had a higher incidence of AKI (univariate HR: 1.70, 95% CI: 1.34–2.16) and all-cause death (univariate HR: 1.60, 95% CI: 1.28–1.99) compared with those with CKD stage 3. A per unit decrease in serum creatinine was also associated with a higher mortality at mid-term follow-up (univariate HR: 1.24, 95% CI: 1.18–1.30; multivariate HR: 1.19, 95% CI: 1.08–1.30). Conclusions Preexisting RD was associated with increased mid-term mortality after TAVI. Patients with CKD stage 4 had significantly higher incidences of peri-procedural complications and a poorer prognosis, a finding that should be factored into the clinical decision-making process regarding these patients.
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Affiliation(s)
- Chi Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Zhen-Gang Zhao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yan-Biao Liao
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Qing-Tao Meng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Hua Chai
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Qiao Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Xiao-Lin Luo
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Wei Liu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Chen Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, PR China
- * E-mail:
| | - De-Jia Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, PR China
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15
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Bicuspid aortic valve; optimal diagnosis and latest interventional treatment. Neth Heart J 2015; 23:149-50. [PMID: 25626694 PMCID: PMC4352156 DOI: 10.1007/s12471-015-0649-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 01/05/2015] [Indexed: 11/15/2022] Open
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Impact of Wait Times on the Effectiveness of Transcatheter Aortic Valve Replacement in Severe Aortic Valve Disease: A Discrete Event Simulation Model. Can J Cardiol 2014; 30:1162-9. [DOI: 10.1016/j.cjca.2014.03.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 03/07/2014] [Accepted: 03/10/2014] [Indexed: 11/18/2022] Open
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Nuis RJ, Sinning JM, Rodés-Cabau J, Gotzmann M, van Garsse L, Kefer J, Bosmans J, Yong G, Dager AE, Revilla-Orodea A, Urena M, Nickenig G, Werner N, Maessen J, Astarci P, Perez S, Benitez LM, Amat-Santos IJ, López J, Dumont E, van Mieghem N, van Gelder T, van Domburg RT, de Jaegere PP. Prevalence, factors associated with, and prognostic effects of preoperative anemia on short- and long-term mortality in patients undergoing transcatheter aortic valve implantation. Circ Cardiovasc Interv 2013; 6:625-34. [PMID: 24280965 DOI: 10.1161/circinterventions.113.000409] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is scant information on the prevalence and factors associated with preoperative anemia in patients undergoing transcatheter aortic valve implantation (TAVI) and whether it is associated with mortality. We sought to determine the prevalence and factors associated with preoperative anemia in addition to the prognostic effects of the various levels of preoperative hemoglobin level on mortality in patients undergoing TAVI. METHODS AND RESULTS Ten-center observational study encompassing 1696 patients with aortic stenosis who underwent TAVI was conducted. Anemia was defined by the World Health Organization criteria (hemoglobin <12.0 g/dL in women and <13.0 g/dL in men). The prevalence of preoperative anemia was 57%. Patient-related factors associated with preoperative anemia were (descending order of odds ratio [95% confidence interval]) as follows: anemia-related medication (4.90 [3.08-7.80]), history of heart failure (1.77 [1.43-2.20]), male sex (1.69 [1.32-2.16]), mitral regurgitation grade ≥III (1.61 [1.15-2.25]), history of malignancy (1.44 [1.03-2.09]), and peripheral vascular disease (1.33 [1.04-1.70]). The creatinine clearance was inversely associated with preoperative anemia (odds ratio, 0.92 [0.87-0.97]). In multivariable analyses, preoperative anemia was not associated with 30-day mortality (1.72 [0.96-3.12]; P=0.073) but showed the strongest association with 1-year mortality with a hazard ratio (95% confidence interval) of 2.78 (1.60-4.82) in patients with hemoglobin <10 g/dL. Patients with anemia received ≥1 blood transfusion 2× more often, but the indication of transfusion was unrelated to overt bleeding in 60%. Blood transfusion was associated with mortality at 30 days (odds ratio, 1.25 [95% confidence interval, 1.08-3.67]) and during follow-up (hazard ratio, 1.09 [95% confidence interval, 1.03-1.14]). CONCLUSIONS Preoperative anemia is prevalent in >50% of patients undergoing TAVI. Various baseline factors were related to anemia, which in turn was associated with 1-year mortality. Patients with anemia received more transfusions but mostly for indications unrelated to overt bleeding, whereas transfusion was independently associated with both early and 1-year mortality. These findings indicate that optimization of baseline factors related to preoperative anemia, in addition to more strict criteria of the use of blood products, may improve outcome after TAVI.
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Affiliation(s)
- Rutger-Jan Nuis
- From the Department of Cardiology, ThoraxCenter (R.-J.N., N.v.M., R.T.v.D., P.P.d.J.) and Department of Nephrology (T.v.G.), Erasmus Medical Center, Rotterdam, The Netherlands; Department of Medicine II-Cardiology, University Hospital Bonn, Bonn, Germany (J.-M.S., G.N., N.W.); Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (J.R.-C., M.U., E.D.); Department of Cardiology, Bergmannsheil, Ruhr-University Bochum, Bochum, Germany (M.G.); Department of Cardiothoracic Surgery, University Hospital Maastricht, Maastricht, The Netherlands (L.v.G., J.M.); Department of Cardiology, University Hospital Saint-Luc, Brussels, Belgium (J.K., P.A.); Department of Cardiology, University Hospital Antwerp, Antwerp, Belgium (J.B.); Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia (G.Y.); Department of Cardiology, Angiografia de Occidente S.A., Cali, Colombia (A.E.D., S.P., L.M.B.); and Department of Cardiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain (A.R.-O., I.J.A.-S., J.L.)
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Transapical versus transfemoral aortic valve implantation: a multicenter collaborative study. Ann Thorac Surg 2013; 97:22-8. [PMID: 24263012 DOI: 10.1016/j.athoracsur.2013.09.088] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 08/25/2013] [Accepted: 09/04/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND There are no direct comparisons between transapical aortic valve implantation (TA-AVI) and transfemoral aortic valve implantation (TF-AVI). Therefore, the aim of this study was to compare the short-term and midterm outcomes of TA-AVI versus TF-AVI. METHODS Data from four European centers were pooled and analyzed. To minimize differences between TA-AVI and TF-AVI multivariable analysis was used. Study endpoints were defined according to the Valve Academic Research Consortium-I criteria at 30 days and 1 year. Primary endpoints of this study were 30-day all-cause mortality and mortality during follow-up. RESULTS A total of 882 patients underwent TAVI, of whom 793 (89.9%) underwent TF-AVI and 89 (10.1%) underwent TA-AVI. Patients undergoing TA-AVI had a higher estimated risk of mortality as defined by the logistic European System for Cardiac Operative Risk Evaluation score (median 27.0, interquartile range [IQR]: 20.2 to 33.8 versus median 20.0, IQR: 12.3 to 27.7; p < 0.001) and The Society of Thoracic Surgeons Score (median 10.2, IQR: 5.3 to 9.9 versus median 6.7, IQR: 3.5 to 9.9; p < 0.001) and had more comorbidities. At 30 days, there was an increased risk of all-cause mortality in the TA-AVI group (odds ratio [OR] 3.12, 95% confidence interval [CI]: 1.43 to 6.82; p = 0.004). TF-AVI was associated with a higher frequency of major (OR 0.33, 95% CI: 0.12 to 0.90; p = 0.031) and minor vascular complications (OR 0.17, 95% CI: 0.04 to 0.71; p = 0.0015). In-hospital stay was significantly longer among patients undergoing TA-AVI (OR 2.29, 95% CI: 1.28 to 4.09; p = 0.05). During a median follow-up of 365 days (IQR: 174 to 557), TA-AVI was associated with an increased risk of all-cause mortality (hazard ratio 1.88, 95% CI: 1.23 to 2.87; p = 0.004). CONCLUSIONS In institutions performing a low volume of TA-AVI, the technique is associated with an increased risk of all-cause mortality and longer hospital stay but less vascular complications in comparison with TF-AVI. The interaction between experience and type of treatment on outcome requires further investigation before advocating one treatment over the other.
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A meta-analysis comparing observed 30-day all-cause mortality with the Society of Thoracic Surgeons Predicted Risk of Mortality in contemporary studies using Valve Academic Research Consortium definitions. Int J Cardiol 2013; 168:1598-602. [DOI: 10.1016/j.ijcard.2013.01.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 01/18/2013] [Indexed: 10/27/2022]
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van der Boon RM, Nuis RJ, Benitez LM, Van Mieghem NM, Perez S, Cruz L, van Geuns RJ, Serruys PW, van Domburg RT, Dager AE, de Jaegere PP. Frequency, determinants and prognostic implications of infectious complications after transcatheter aortic valve implantation. Am J Cardiol 2013; 112:104-10. [PMID: 23566540 DOI: 10.1016/j.amjcard.2013.02.061] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 02/28/2013] [Accepted: 02/28/2013] [Indexed: 01/08/2023]
Abstract
In-hospital infection (IHI) after transcatheter aortic valve implantation (TAVI) has received little attention, although it may have a significant effect on outcomes and costs because of prolonged hospital stay. Therefore, the aim of this study was to determine the incidence, type, predictors, and prognostic effects of IHI after TAVI. This study included 298 consecutive patients from 2 centers who underwent TAVI from November 2005 to November 2011. IHI during the hospital stay was defined on the basis of symptoms and signs assessed by the attending physician in the cardiac care unit or medium care unit in combination with all technical examinations performed to confirm infection. IHI after TAVI was observed in 58 patients (19.5%): urinary tract infections in 25 patients (43.1%), pneumonia in 12 patients (20.7%), and access-site infections in 7 patients (12.1%). In 12 patients (20.7%), the site of infection could not be determined, and 2 patients (3.4%) had multiple infection sites. Multivariate analysis revealed that surgical access through the femoral artery was the most important determinant of infection (odds ratio [OR] 4.18, 95% confidence interval [CI] 1.02 to 17.19), followed by perioperative major stroke (OR 3.21, 95% CI 1.01 to 9.52) and overweight (body mass index ≥25 kg/m²; OR 2.27, 95% CI 1.12 to 4.59). The length of hospital stay in patients with IHIs was 15.0 days (interquartile range 8.0 to 22.0) compared with 7.0 days (interquartile range 4.0 to 10.0) in patients without infections (p <0.0001). Kaplan-Meier estimates of survival at 1 year were 76.6% and 74.4% (log-rank, p = 0.61), respectively. Unadjusted and adjusted OR analysis revealed that IHI did not predict mortality at 30 days (OR 1.27, 95% CI 0.49 to 3.30) or at 1 year (hazard ratio 1.24, 95% CI 0.68 to 2.25). In conclusion, IHI occurred in 19.5% of the patients. Patient-related and, more important, procedure-related variables play a role in the occurrence of infection, indicating that improvements in the execution of TAVI may lead to a reduction of this complication.
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Ungar A, Bramlage P, Thoenes M, Zannoni S, Michel JP. A call to action - Geriatricians’ experience in treatment of aortic stenosis and involvement in transcatheter aortic valve implantation. Eur Geriatr Med 2013. [DOI: 10.1016/j.eurger.2013.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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van der Boon RM, Chieffo A, Dumonteil N, Tchetche D, Van Mieghem NM, Buchanan GL, Vahdat O, Marcheix B, Serruys PW, Fajadet J, Colombo A, Carrié D, van Domburg RT, de Jaegere PP. Effect of body mass index on short- and long-term outcomes after transcatheter aortic valve implantation. Am J Cardiol 2013; 111:231-6. [PMID: 23102879 DOI: 10.1016/j.amjcard.2012.09.022] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 09/18/2012] [Accepted: 09/18/2012] [Indexed: 12/20/2022]
Abstract
Better outcomes have been reported after percutaneous cardiac intervention in obese patients ("obesity paradox"). However, limited information is available on the effect of the body mass index on the outcomes after transcatheter aortic valve implantation (TAVI). We, therefore, sought to determine the effect of the body mass index on the short- and long-term outcomes in patients who underwent TAVI. The population consisted of 940 patients, of whom 25 (2.7%) were underweight, 384 had a (40.9%) normal weight, 372 (39.6%) were overweight, and 159 (16.9%) were obese. Overall, the obese patients were younger (79.7 ± 6.4 years vs 81.7 ± 7.3 and 80.8 ± 7.0 years, p = 0.008) and had a greater prevalence of preserved left ventricular and renal function. On univariate analysis, obese patients had a greater incidence of minor stroke (1.3% vs 0 and 0.3%, p = 0.03), minor vascular complications (15.7% vs 9.1% and 11.6%, p = 0.028) and acute kidney injury stage I (23.3% vs 10.7% and 16.1%, p <0.001). After adjustment, body mass index, as a continuous variable, was associated with a lower risk of mortality at 30 days (odds ratio 0.93, 95% confidence interval 0.86 to 0.98, p = 0.023) and no effect on survival after discharge (hazard ratio 1.01, 95% confidence interval 0.96 to 1.07, p = 0.73). In conclusion, obesity was associated with a greater incidence of minor, but no major, perioperative complications after TAVI. After adjustment, obesity was associated with a lower risk of 30-day mortality and had no adverse effect on mortality after discharge, underscoring the "obesity paradox" in patients undergoing TAVI.
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Parenica J, Nemec P, Tomandl J, Ondrasek J, Pavkova-Goldbergova M, Tretina M, Jarkovsky J, Littnerova S, Poloczek M, Pokorny P, Spinar J, Cermakova Z, Miklik R, Malik P, Pes O, Lipkova J, Tomandlova M, Kala P. Prognostic utility of biomarkers in predicting of one-year outcomes in patients with aortic stenosis treated with transcatheter or surgical aortic valve implantation. PLoS One 2012; 7:e48851. [PMID: 23272045 PMCID: PMC3522688 DOI: 10.1371/journal.pone.0048851] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 10/01/2012] [Indexed: 11/26/2022] Open
Abstract
Objectives The aim of the work was to find biomarkers identifying patients at high risk of adverse clinical outcomes after TAVI and SAVR in addition to currently used predictive model (EuroSCORE). Background There is limited data about the role of biomarkers in predicting prognosis, especially when TAVI is available. Methods The multi-biomarker sub-study included 42 consecutive high-risk patients (average age 82.0 years; logistic EuroSCORE 21.0%) allocated to TAVI transfemoral and transapical using the Edwards-Sapien valve (n = 29), or SAVR with the Edwards Perimount bioprosthesis (n = 13). Standardized endpoints were prospectively followed during the 12-month follow-up. Results The clinical outcomes after both TAVI and SAVR were comparable. Malondialdehyde served as the best predictor of a combined endpoint at 1 year with AUC (ROC analysis) = 0.872 for TAVI group, resp. 0.765 (p<0.05) for both TAVI and SAVR groups. Increased levels of MDA, matrix metalloproteinase 2, tissue inhibitor of metalloproteinase (TIMP1), ferritin-reducing ability of plasma, homocysteine, cysteine and 8-hydroxy-2-deoxyguanosine were all predictors of the occurrence of combined safety endpoints at 30 days (AUC 0.750–0.948; p<0.05 for all). The addition of MDA to a currently used clinical model (EuroSCORE) significantly improved prediction of a combined safety endpoint at 30 days and a combined endpoint (0–365 days) by the net reclassification improvement (NRI) and the integrated discrimination improvement (IDI) (p<0.05). Cystatin C, glutathione, cysteinylglycine, asymmetric dimethylarginine, nitrite/nitrate and MMP9 did not prove to be significant. Total of 14.3% died during 1-year follow-up. Conclusion We identified malondialdehyde, a marker of oxidative stress, as the most promising predictor of adverse outcomes during the 30-day and 1-year follow-up in high-risk patients with symptomatic, severe aortic stenosis treated with TAVI. The development of a clinical “TAVIscore” would be highly appreciated. Such dedicated scoring system would enable further testing of adjunctive value of various biomarkers.
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Affiliation(s)
- Jiri Parenica
- University Hospital Brno, Brno, Czech Republic
- Medical Faculty, Masaryk University, Brno, Czech Republic
- International Clinical Research Center–Department of Cardiovascular Disease, University Hospital St. Anne's, Brno, Czech Republic
| | - Petr Nemec
- International Clinical Research Center–Department of Cardiovascular Disease, University Hospital St. Anne's, Brno, Czech Republic
- Center of Cardiovascular Surgery and Transplantations, Brno, Czech Republic
| | - Josef Tomandl
- Institute of Biochemistry, Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Jiri Ondrasek
- Center of Cardiovascular Surgery and Transplantations, Brno, Czech Republic
| | | | - Martin Tretina
- Center of Cardiovascular Surgery and Transplantations, Brno, Czech Republic
| | - Jiri Jarkovsky
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Simona Littnerova
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Poloczek
- University Hospital Brno, Brno, Czech Republic
- Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Petr Pokorny
- Center of Cardiovascular Surgery and Transplantations, Brno, Czech Republic
| | - Jindrich Spinar
- University Hospital Brno, Brno, Czech Republic
- Medical Faculty, Masaryk University, Brno, Czech Republic
- International Clinical Research Center–Department of Cardiovascular Disease, University Hospital St. Anne's, Brno, Czech Republic
| | - Zdenka Cermakova
- Biochemistry Department, Faculty Hospital Brno, Brno, Czech Republic
- Institute of Laboratory Methods, Masaryk University, Brno, Czech Republic
| | | | - Petr Malik
- Center of Cardiovascular Surgery and Transplantations, Brno, Czech Republic
| | - Ondrej Pes
- Institute of Biochemistry, Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Jolana Lipkova
- Institute of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marie Tomandlova
- Institute of Biochemistry, Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Petr Kala
- University Hospital Brno, Brno, Czech Republic
- Medical Faculty, Masaryk University, Brno, Czech Republic
- * E-mail:
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Nuis RJ, Van Mieghem NM, Schultz CJ, Moelker A, van der Boon RM, van Geuns RJ, van der Lugt A, Serruys PW, Rodés-Cabau J, van Domburg RT, Koudstaal PJ, de Jaegere PP. Frequency and causes of stroke during or after transcatheter aortic valve implantation. Am J Cardiol 2012; 109:1637-43. [PMID: 22424581 DOI: 10.1016/j.amjcard.2012.01.389] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 01/17/2012] [Accepted: 01/17/2012] [Indexed: 10/28/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is invariably associated with the risk of clinically manifest transient or irreversible neurologic impairment. We sought to investigate the incidence and causes of clinically manifest stroke during TAVI. A total of 214 consecutive patients underwent TAVI with the Medtronic-CoreValve System from November 2005 to September 2011 at our institution. Stroke was defined according to the Valve Academic Research Consortium recommendations. Its cause was established by analyzing the point of onset of symptoms, correlating the symptoms with the computed tomography-detected defects in the brain, and analyzing the presence of potential coexisting causes of stroke, in addition to a multivariate analysis to determine the independent predictors. Stroke occurred in 19 patients (9%) and was major in 10 (5%), minor in 3 (1%), and transient (transient ischemic attack) in 6 (3%). The onset of symptoms was early (≤24 hours) in 8 patients (42%) and delayed (>24 hours) in 11 (58%). Brain computed tomography showed a cortical infarct in 8 patients (42%), a lacunar infarct in 5 (26%), hemorrhage in 1 (5%), and no abnormalities in 5 (26%). Independent determinants of stroke were new-onset atrial fibrillation after TAVI (odds ratio 4.4, 95% confidence interval 1.2 to 15.6), and baseline aortic regurgitation grade III or greater (odds ratio 3.2, 95% confidence interval 1.1 to 9.3). In conclusion, the incidence of stroke was 9%, of which >1/2 occurred >24 hours after the procedure. New-onset atrial fibrillation was associated with a 4.4-fold increased risk of stroke. In conclusion, these findings indicate that improvements in postoperative care after TAVI are equally, if not more, important for the reduction of periprocedural stroke than preventive measures during the procedure.
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