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Tirado-Conte G, Espejo-Paeres C, Nombela-Franco L, Jimenez-Quevedo P, Cobiella J, Vivas D, de Agustín JA, McInerney A, Pozo E, Salinas P, Nuñez-Gil I, Gonzalo N, Villagran E, de Hoyos A, Mejia-Renteria H, Macaya F, Carnero M, Vilacosta I, Fernández-Ortiz A, Escaned J, Maroto L, Macaya C. Performance of the heart team approach in daily clinical practice in high-risk patients with aortic stenosis. J Card Surg 2020; 36:31-39. [PMID: 33085128 DOI: 10.1111/jocs.15116] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/27/2020] [Accepted: 09/29/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The heart team (HT) approach plays a key role in selecting the optimal treatment strategy for patients with aortic stenosis (AS). However, little is known about the HT decision process and its impact on outcomes. The aim of this study was to identify the factors associated with the HT decision and evaluate clinical outcomes according to the treatment choice. METHODS The study included a total of 286 consecutive patients with AS referred for discussion in the weekly HT meeting in a cardiovascular institute over 2 years. Patients were stratified according to the selected therapeutic approach: medical treatment (MT), surgical (SAVR), or transcatheter (TAVR) aortic valve replacement. Baseline characteristics involved in making a therapeutic choice were identified and a decision-making tree was built using classification and regression tree methodology. RESULTS Based on HT discussion, 53 patients were assigned to SAVR, 210 to TAVR, and 23 to MT. Older patients (≥88 years old) were mainly assigned to TAVR or MT according to the logistic EuroSCORE (<or≥28, respectively). While among younger patients (<88 years), significant mitral regurgitation (≥grade III), frailty, Society of Thoracic Surgeons score, and estimated glomerular filtration rate were the most relevant factors influencing treatment allocation. One-year all-cause mortality was 16.6% in the invasive groups (TAVR = 17.2%, SAVR = 14.0%) and 68.7% in the MT arm. CONCLUSION The HT decision was determined by well-recognized risk factors that were used to define a treatment decision algorithm. Future studies with younger and lower-risk patients may identify new contributory factors that may alter the selection process and treatment choice.
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Affiliation(s)
- Gabriela Tirado-Conte
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Carolina Espejo-Paeres
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Luis Nombela-Franco
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Pilar Jimenez-Quevedo
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Javier Cobiella
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - David Vivas
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Jose Alberto de Agustín
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Angela McInerney
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Eduardo Pozo
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Pablo Salinas
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Ivan Nuñez-Gil
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Nieves Gonzalo
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Enrique Villagran
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Alfonso de Hoyos
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Hernán Mejia-Renteria
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Fernando Macaya
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Manuel Carnero
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Isidre Vilacosta
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Antonio Fernández-Ortiz
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Javier Escaned
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Luis Maroto
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Carlos Macaya
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
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Gouda P, Paterson C, Meyer S, Shanks M, Butler C, Taylor D, Tyrrell B, Welsh R. Effects of Transcatheter Aortic Valve Implantation on Frailty and Quality of Life. CJC Open 2020; 2:79-84. [PMID: 32462120 PMCID: PMC7242504 DOI: 10.1016/j.cjco.2019.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/31/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) is an effective alternative to surgical valve replacement in high-risk patients with severe aortic stenosis. Although measures of frailty have been used to attempt to predict outcomes in this population, few studies have demonstrated changes in these measures. METHODS We performed a prospective, observational study of 171 patients undergoing TAVI, of whom 44 had maximal follow-up of 1 month and 50 had maximal follow-up of 1 year. Quality of life was assessed using the Minnesota Living With Heart Failure Questionnaire, Katz Index of Independence in Activities of Daily Living questionnaire, and patient perception of overall well-being. Frailty was measured using the 10-m walk test and handgrip strength testing. RESULTS In the overall cohort, participants demonstrated improvements in quality of life metrics, but deterioration in 10-m walk test and handgrip at 1 month. These trends continued at 1 year. However, patients in the lowest quintile of handgrip and 10-m walk test demonstrated a trend of improvements in these metrics during follow-up. CONCLUSIONS Despite improvements in quality of life after TAVI, no improvements in frailty were observed in patients at 1 year.
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Affiliation(s)
- Pishoy Gouda
- University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Chai Paterson
- University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Steven Meyer
- University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Miriam Shanks
- University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Craig Butler
- University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Dylan Taylor
- University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Benjamin Tyrrell
- University of Alberta, Edmonton, Alberta, Canada
- CK Hui Heart Centre, Edmonton, Alberta, Canada
| | - Robert Welsh
- University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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Gorecka M, Reddin C, Madders G, Monaghan L, Neylon A, Sharif F, Hynes B, Fennelly E, McHugh F, Martin N, Mohammed K, Bijjam VR, Veerasingam D, Soo A, DaCosta M, Wijns W, Mylotte D. Patient Disposition and Clinical Outcome After Referral to a Dedicated TAVI Clinic. Front Cardiovasc Med 2020; 6:188. [PMID: 31998755 PMCID: PMC6965013 DOI: 10.3389/fcvm.2019.00188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 12/11/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: Transcatheter aortic valve implantation (TAVI) is the standard of care for the majority of patients with severe symptomatic aortic stenosis (AS) at excessive-, high- and intermediate-surgical risk. A proportion of patients referred for TAVI do not undergo the procedure and proceed with an alternate treatment strategy. There is scarce data describing the final treatment allocation of such patients. Hence, we sought to evaluate the final treatment allocation of patients referred for TAVI in contemporary practice. Methods: We performed a single center prospective observational study, including all patients referred to our institution for treatment of severe aortic stenosis between February 2014 and August 2017. Baseline demographic and clinical data were recorded. Patients were categorized according to treatment allocation: TAVI, surgical aortic valve replacement (SAVR) or optimal medical therapy (OMT). Clinical outcomes were adjudicated according to VARC-2 definitions. All patients were discussed at a dedicated Heart Team meeting. Results: Total of 245 patients were referred for assessment to a dedicated TAVI clinic during the study period. Patients with moderate (N = 32; 13.1%) and asymptomatic (N = 31; 13.1%) AS were excluded. Subsequently, 53.9% (N = 132) received TAVI, 12.7% (N =31) were managed with OMT, and 7.3% (N =18) had SAVR. Reasons for OMT included primarily: patient's preference (N = 12; 38.7%); excessive surgical risk (N = 4; 12.9%) and severe frailty (N = 5; 16.1%). Reasons for surgical referral included low surgical risk (N = 11; 61.1%), excessive annulus size (N = 5; 27.8%), and aortic root dilatation (N = 2; 11.1%). Patients proceeding to SAVR had lower surgical risk than those in either the OMT or TAVI cohorts (P < 0.001). Mean STS score in SAVR group was 2.2 ± 1.3 vs. 4.5 ± 2.4 in OMT cohort and 6.1 ± 4.9 in TAVI cohort. Six-month all-cause mortality was 16.7, 19.4, and 9.3% among those receiving SAVR, OMT, and TAVI, respectively. Conclusions: Almost half of all patients with severe AS referred to a dedicated TAVI clinic did not receive a TAVI. A considerable proportion of patients were reclassified as moderate AS (13%), were asymptomatic (13%), or intervention was determined to be futile (13%) due to advanced frailty. Early detection and increased awareness of valvular heart disease are required to increase the number of patients that can benefit from TAVI.
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Affiliation(s)
- Miroslawa Gorecka
- Department of Cardiology, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland
| | - Catriona Reddin
- Department of Cardiology, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland
| | - Gillian Madders
- Department of Cardiology, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland
| | - Laura Monaghan
- Department of Cardiology, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland
| | - Antoinette Neylon
- Department of Cardiology, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland
| | - Faisal Sharif
- Department of Cardiology, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
| | - Brian Hynes
- Department of Cardiology, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland
| | - Evelyn Fennelly
- Department of Cardiology, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland
| | - Fiachra McHugh
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Niamh Martin
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Khalid Mohammed
- Department of Cardiology, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland
| | - Venu Reddy Bijjam
- Department of Cardiology, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland
| | - David Veerasingam
- Department of Cardiothoracic Surgery, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland
| | - Alan Soo
- Department of Cardiothoracic Surgery, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland
| | - Mark DaCosta
- Department of Cardiothoracic Surgery, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland
| | - William Wijns
- School of Medicine, National University of Ireland, Galway, Ireland.,The Lambe Institute for Translational Medicine and Curam, SAOLTA University Healthcare Group, National University of Ireland Galway, Galway, Ireland
| | - Darren Mylotte
- Department of Cardiology, Galway University Hospital, SAOLTA Healthcare Group, Galway, Ireland.,School of Medicine, National University of Ireland, Galway, Ireland
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Bergmann T, Sengupta PP, Narula J. Is TAVR Ready for the Global Aging Population? Glob Heart 2017; 12:291-299. [PMID: 28433492 DOI: 10.1016/j.gheart.2017.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/24/2017] [Accepted: 02/14/2017] [Indexed: 11/26/2022] Open
Abstract
The emergence of the global pandemic of chronic diseases necessitates critical assessment of interventions that can be targeted at both the individual and population levels. Among cardiovascular diseases, the increasing prevalence of valvular heart diseases such as aortic stenosis parallels the rising burden of atherosclerotic cardiovascular diseases. As an alternative to surgical aortic valve replacement, technological innovation has allowed development of minimally invasive transcatheter aortic valve replacement (TAVR). This review examines whether TAVR can be applicable in low-resource regions across the world. Although revolutionary, TAVR is currently complex and requires a "Heart Team" approach for optimized patient care. We propose the emergence of telemedicine networks, newer valve designs that allow implementation of minimal approaches, and the use of minimal numbers of specialists for adapting TAVR to settings where surgical backup is not available. With efforts to reduce resource utilization, these alternate strategies have the potential to affect implementation of TAVR globally.
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Affiliation(s)
- Travis Bergmann
- Cardiac Ultrasound Research and Core Lab, Department of Medicine, Mount Sinai's Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, New York, NY, USA
| | - Partho P Sengupta
- Cardiac Ultrasound Research and Core Lab, Department of Medicine, Mount Sinai's Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, New York, NY, USA.
| | - Jagat Narula
- Cardiac Ultrasound Research and Core Lab, Department of Medicine, Mount Sinai's Zena and Michael A. Wiener Cardiovascular Institute and Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, New York, NY, USA
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Kaier K, Gutmann A, Vach W, Sorg S, Siepe M, von Zur Mühlen C, Moser M, Blanke P, Beyersdorf F, Zehender M, Bode C, Reinöhl J. "Heart Team" decision making in elderly patients with symptomatic aortic valve stenosis who underwent AVR or TAVI - a look behind the curtain. Results of the prospective TAVI Calculation of Costs Trial (TCCT). EUROINTERVENTION 2016; 11:793-8. [PMID: 25499832 DOI: 10.4244/eijy14m12_06] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Little is known about how "Heart Team" treatment decisions among patients suitable for either surgical aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI) are made under routine conditions. METHODS AND RESULTS The "Heart Team" decision-making process was analysed with respect to124 patients of a non-randomised prospective clinical trial that included patients aged ≥75 years: 41 patients underwent AVR and 83 underwent TAVI. By use of the non-parametric classification and regression tree (CART) methodology, 21 baseline parameters were tested to reconstruct the decision process retrospectively. Next, multivariate logistic and Cox regression models were fitted to evaluate the decision and outcome relevance (two-year survival) of the parameters as identified in the CART procedure. For patients with a baseline EuroSCORE I ≥13.48%, no further cut-off points were identified and the majority of these patients underwent TAVI. Among patients with a baseline EuroSCORE I <13.48%, age and left ventricular ejection fraction (LVEF) were identified as further relevant decision parameters. The decision relevance of EuroSCORE I (p=0.003), age (p=0.024) and LVEF (p=0.047) were confirmed by multivariate analysis; however, outcome relevance can be confirmed for EuroSCORE I (p=0.015) only, while treatment decision (TAVI or AVR) was not a significant predictor of mortality (p=0.655). CONCLUSIONS Despite or even because of the systematic risk selection according to EuroSCORE I values, we observed two-year survival rates of about 75% regardless of whether the patient received TAVI or AVR, suggesting that the decisions made by the "Heart Team" were appropriate.
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Affiliation(s)
- Klaus Kaier
- Clinical Epidemiology, Center for Medical Biometry and Medical Informatics, Medical Center - University of Freiburg, Freiburg, Germany
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