Comparison between Society of Thoracic Surgeons Score and logistic EuroSCORE for predicting mortality in patients referred for transcatheter aortic valve implantation

Comparison of American and European Guidelines for the Management of Patients With Valvular Heart Disease

This review compares the recommendations of the recent 2020 American College of Cardiology (ACC)/American Heart Association (AHA) and 2021 European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) guidelines on the management of patients with valvular heart disease (VHD). ACC/AHA and ESC/EACTS guidelines are both the updated versions of previous 2017 documents. Both guidelines fundamentally agree on the extended indications of percutaneous valve interventions, the optimal use of imaging modalities other than 2D echocardiography, the importance of a multidisciplinary Heart Team as well as active patient participation in clinical decision making, more widespread use of NOACs and earlier intervention with lower left ventricular dilatation thresholds to decrease long-term mortality. The differences between the guidelines are mainly related to the classification of the severity of valve pathologies and frequency of follow-up, level of recommendations of valve intervention indications in special patient groups such as frail patients and the left ventricular diameter and ejection fraction thresholds for intervention.

The Evolving Role of the Multidisciplinary Heart Team in Aortic Stenosis

Transcatheter aortic valve replacement has transformed the paradigm of care for patients with severe aortic stenosis (AS). With transcatheter aortic valve replacement now commercially approved for AS patients of all surgical risk, clinical decision-making regarding the initial mode of valve replacement (e.g. surgical versus transcatheter) and prosthesis type has become even more complex. The updated American College of Cardiology/American Heart Association and European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on valvular heart disease offer a strong foundation from which to address the nuances of the treatment of AS; however, there remain several clinical scenarios for which evidence and thus definitive societal recommendations are lacking. As such, the heart team continues to play an invaluable role in the management of the AS patient by combining available scientific evidence, expertise across disciplines, and the patient’s preferences to optimize individualized patient care and healthcare resource usage.

A Sneak-Peek into the Physician's Brain: A Retrospective Machine Learning-Driven Investigation of Decision-Making in TAVR versus SAVR for Young High-Risk Patients with Severe Symptomatic Aortic Stenosis

Transcatheter aortic valve replacement (TAVR) has rapidly become a viable alternative to the conventional isolated surgical aortic valve replacement (iSAVR) for treating severe symptomatic aortic stenosis. However, data on younger patients is scarce and a gap exists between data-based recommendations and the clinical use of TAVR. In our study, we utilized a machine learning (ML) driven approach to model the complex decision-making process of Heart Teams when treating young patients with severe symptomatic aortic stenosis with either TAVR or iSAVR and to identify the relevant considerations. Out of the considered factors, the variables most prominently featured in our ML model were congestive heart failure, established risk assessment scores, previous cardiac surgeries, a reduced left ventricular ejection fraction and peripheral vascular disease. Our study demonstrates a viable application of ML-based approaches for studying and understanding complex clinical decision-making processes.

Assessment of Kidney Function After Transcatheter Aortic Valve Replacement

Background:

Transcatheter aortic valve replacement (TAVR), although associated with an increased risk for acute kidney injury (AKI), may also result in improvement in renal function.

Objective:

The aim of this study is to evaluate the magnitude of kidney function improvement (KFI) after TAVR and to assess its significance on long-term mortality.

Design:

This is a prospective single center study.

Setting:

The study was conducted in cardiology department, interventional unit, in a tertiary hospital.

Patients:

The cohort included 1321 patients who underwent TAVR.

Measurements:

Serum creatinine level was measured at baseline, before the procedure, and over the next 7 days or until discharge.

Methods:

Kidney function improvement was defined as the mirror image of AKI, a reduction in pre-procedural to post-procedural minimal creatinine of more than 0.3 mg/dL, or a ratio of post-procedural minimal creatinine to pre-procedural creatinine of less than 0.66, up to 7 days after the procedure. Patients were categorized and compared for clinical endpoints according to post-procedural renal function change into 3 groups: KFI, AKI, or preserved kidney function (PKF). The primary endpoint was long-term all-cause mortality.

Results:

The incidence of KFI was 5%. In 55 out of 66 patients patients, the improvement in kidney function was minor and of unclear clinical significance. Acute kidney injury occurred in 19.1%. Estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² was a predictor of KFI after multivariable analysis (odds ratio = 0.93 to develop KFI; confidence interval [95% CI]: 0.91-0.95, P < .001). Patients in the KFI group had a higher Society of Thoracic Surgery (STS) score than other groups. Mortality rate did not differ between KFI group and PKF group (43.9% in KFI group and 33.8% in PKF group) but was significantly higher in the AKI group (60.7%, P < .001).

Limitations:

The following are the limitations: heterozygous definitions of KFI within different studies and a single center study. Although data were collected prospectively, analysis plan was defined after data collection.

Conclusions:

Improvement in kidney function following TAVR was not a common phenomenon in our cohort and did not reduce overall mortality rate.

Assessing the Best Prognostic Score for Transcatheter Aortic Valve Implantation (from the RISPEVA Registry)

The ACC/TVT score is a specific predictive model of in-hospital mortality for patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to test its predictive accuracy in comparison with standard surgical risk models (Logistic Euroscore, Euroscore II, and STS-PROM) in the population of TAVI patients included in the multicenter RISPEVA (Registro Italiano GISE sull'impianto di Valvola Aortica Percutanea) registry. The study cohort included 3293 patients who underwent TAVI between 2008 and 2019. The 4 risk scores were calculated for all patients. For all scores, the capability to predict 30-day mortality was assessed by means of several analyses testing calibration and discrimination. The ACC/TVT score showed moderate discrimination, with a C-statistics for 30-day mortality of 0.63, not significantly different from the standard surgical risk models. The ACC/TVT score demonstrated, in contrast, better calibration compared with the other scores, as proved by a greater correspondence between estimated probabilities and the actual observations. However, when the ACC/TVT score was tested in the subgroup of patients treated in a more contemporary period (from 2016 on), it revealed a slight tendency to lose discrimination and to overestimate mortality risk. In conclusion, in comparison with the standard surgical risk models, the ACC/TVT score demonstrated better prediction accuracy for estimation of 30-day mortality in terms of calibration. Nevertheless, its predictive reliability remained suboptimal and tended to worsen in patients treated more recently.

Short- and medium-term survival after TAVI: Clinical predictors and the role of the FRANCE-2 score

Aim

The aim of this study was to explore the value of the FRANCE-2 score in associating with clinical outcome in the medium and short-term after TAVI and to compare its relative merits with other risk score models.

Methods

187 consecutive patients undergoing TAVI in a single UK centre were retrospectively studied. The FRANCE-2, logistic EuroSCORE, EuroSCORE II, German AV and STS/ACC TVT risk scores were calculated retrospectively and c-statistics associating with mortality were applied. Survival outcomes were compared between different risk groups according to the FRANCE-2 scores.

Results

Of the 187 patients, 57.2% were male and their mean age was 80.9 ± 6.9 years. The c-index of FRANCE-2 score for predicting 30-day mortality was 0.793 (p = 0.009), for 1-year mortality 0.679 (p = 0.016) and for 2-year mortality was 0.613 (p = 0.088). The mean survival time for patients with a high FRANCE-2 score (18.6 months) was significantly less than for patients with low and moderate scores (p = 0.0004). The logistic EuroSCORE and EuroSCORE II were poorly associated with 30-day and 1-year mortality. STS/ACC TVT score was best predictive of 1-year mortality and German AV score was moderately predictive of 30-day mortality.

Conclusions

The FRANCE-2 risk score is associated with differential short- and medium-term survival in patients undergoing TAVI. The presence of a high FRANCE-2 score (>5) is associated with poor survival. The FRANCE-2 scoring system could be considered as a useful additional tool by the Heart multidisciplinary team (MDT) in identifying patients who are likely to have limited survival benefit although this requires further prospective evaluation.

Patients at Intermediate Surgical Risk Undergoing Isolated Interventional or Surgical Aortic Valve Implantation for Severe Symptomatic Aortic Valve Stenosis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is increasingly being used for treatment of severe aortic valve stenosis in patients at intermediate risk for surgical aortic valve replacement (SAVR). Currently, real-world data comparing indications and clinical outcomes of patients at intermediate surgical risk undergoing isolated TAVR with those undergoing SAVR are scarce.

METHODS

We compared clinical characteristics and outcomes of patients with intermediate surgical risk (Society of Thoracic Surgeons score 4%-8%) who underwent isolated TAVR or conventional SAVR within the prospective, all-comers German Aortic Valve Registry.

RESULTS

A total of 7613 patients at intermediate surgical risk underwent isolated TAVR (n=6469) or SAVR (n=1144) at 92 sites in Germany between 2012 and 2014. Patients treated by TAVR were significantly older (82.5±5.0 versus 76.6±6.7 years, P<0.001) and had higher risk scores (logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation]: 21.2±12.3% versus 14.2±9.5%, P<0.001; Society of Thoracic Surgeons score: 5.6±1.1 versus 5.2±1.0, P<0.001). Multivariable analyses revealed that advanced age, coronary artery disease, New York Heart Association class III/IV, pulmonary hypertension, prior cardiac decompensation, elective procedure, arterial occlusive disease, no diabetes mellitus, and a smaller aortic valve area were associated with performing TAVR instead of SAVR (all P<0.001). Unadjusted in-hospital mortality rates were equal for TAVR and SAVR (3.6% versus 3.6%, P=0.976), whereas unadjusted 1-year mortality was significantly higher in patients after TAVR (17.5% versus 10.8%, P<0.001). After propensity score matching, the difference in 1-year mortality between patients with TAVR and SAVR was no longer significant (17.1% versus 15.7%, P=0.59).

CONCLUSIONS

Patients at intermediate risk undergoing TAVR differ significantly from those treated with SAVR with regard to age and baseline characteristics. Isolated TAVR and SAVR were associated with an in-hospital mortality rate of 3.6%. In the propensity score analysis, there was no significant difference in 1-year mortality between patients with TAVR and SAVR.

Transapical transcatheter aortic valve implantation in patients with a low ejection fraction

OBJECTIVES

It may be expected that patients with left ventricular dysfunction may be at greater risk of complications after transcatheter aortic valve implantation (TAVI) via transapical (TA) access compared with via transfemoral (TF) access. There is a lack of data comparing the outcomes of TAVI using TA and TF access in patients with a reduced left ventricular ejection fraction (EF).

METHODS

This is a retrospective analysis of data from a high-volume heart centre in Germany. TAVI access route assignment was based on a 'best for TF' approach, where only patients who met a strict set of criteria underwent TF-TAVI, with the remainder receiving TA-TAVI. For this analysis, patients were included if they had a pre-TAVI EF of ≤ 40%. Early mortality and late (1-year) mortality were compared through multivariate logistic regression.

RESULTS

A total of 342 patients in the registry had an EF of ≤ 40%, of which 74.9% underwent TA-TAVI and 25.1% underwent TF-TAVI. Higher proportions of the TA group presented with certain comorbidities, and their logistic EuroSCORE and Society of Thoracic Surgeons (STS) risk scores were higher than in the TF group. At 1 year, TA access was associated with greater mortality in the univariate analysis (odd ratio 2.43; 95% confidence interval 1.04-5.69). However, after multivariate adjustment, no significant differences were found in either 30-day or 1-year mortality rates.

CONCLUSIONS

The data suggest that, for patients with a reduced EF, TA-TAVI is not associated with a poorer outcome compared with TF-TAVI. Therefore, TA access should not be discounted based on the presence of left ventricular dysfunction alone.

Pre-procedural risk models for patients undergoing transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has emerged as the standard treatment option for patients with symptomatic aortic stenosis who are considered intermediate to high surgical risk. Nonetheless, optimal clinical outcomes following the procedure require careful consideration of procedural risk by the Heart Team. While this decision-making could be supported through the development of TAVI-specific clinical prediction models (CPMs), current models remain suboptimal. In this review paper, we aimed to outline the performance of several recently derived TAVI CPMs that predict mortality and present some future research directions. We discuss how the existing risk models have achieved only moderate discrimination but highlight that some of the models are well calibrated across multiple populations, indicating the feasibility of using them to aid benchmarking analyses. Moreover, we suggest that future work should focus on the development of CPMs in cohorts of patients with aortic stenosis that include multiple treatment modalities. Supported by appropriate modelling of 'what if' scenarios, this would allow the Heart Teams to predict and compare outcomes across surgical aortic valve replacement, medical management and TAVI, thereby allowing one to personalise treatment decisions to the individual patient. Such a goal could be facilitated by considering novel risk factors, shifting the focus to endpoints other than mortality, and through collaborative efforts to combine the evidence base and existing models across wider populations.

A peripheral blood transcriptome biomarker test to diagnose functional recovery potential in advanced heart failure

Heart failure (HF) is a complex clinical syndrome that causes systemic hypoperfusion and failure to meet the body’s metabolic demands. In an attempt to compensate, chronic upregulation of the sympathetic nervous system and renin-angiotensin-aldosterone leads to further myocardial injury, HF progression and reduced O₂ delivery. This triggers progressive organ dysfunction, immune system activation and profound metabolic derangements, creating a milieu similar to other chronic systemic diseases and presenting as advanced HF with severely limited prognosis. We hypothesize that 1-year survival in advanced HF is linked to functional recovery potential (FRP), a novel clinical composite parameter that includes HF severity, secondary organ dysfunction, co-morbidities, frailty, disabilities as well as chronological age and that can be diagnosed by a molecular biomarker.

Comparison of Carbohydrate Antigen 125 and N-Terminal Pro-Brain Natriuretic Peptide for Risk Prediction After Transcatheter Aortic Valve Implantation

Elevated carbohydrate antigen 125 (CA125) and N-terminal pro-brain natriuretic peptide (NTproBNP) have been associated with adverse outcome after transcatheter aortic valve implantation (TAVI). This study performs a comparison of both biomarkers for prognosis after TAVI. The study includes 363 patients. The primary end point was all-cause death or readmission for worsening congestive heart failure within 1 year after TAVI, and this end point occurred in 16% of the population. The optimal cutoff to predict the primary end point was 18.4 U/ml for CA125 and 2,570 ng/L for NTproBNP. Elevated CA125 levels were present in 52% and were associated with a higher rate of the primary end point (27% vs 3%; p <0.001). In parallel, elevated NTproBNP levels were present in 42% and were also associated with a higher rate of the primary end point (27% vs 8%; p <0.001). After multivariable adjustment, elevated CA125 (hazard ratio [HR] 5.26; p <0.001) and elevated NTproBNP (HR 2.12; p = 0.022) were independent predictors of the primary end point. To explore the utility of combining both biomarkers, CA125 was added to the model containing baseline variables and NTproBNP. Elevated CA125 (HR 4.62; p = 0.001), but not NTproBNP (HR 1.58; p = 0.194), persisted as an independent predictor of the primary end point. Addition of CA125 significantly improved the predictive capability of the model (C-statistic: 0.805 vs 0.776) and the net reclassification index (50%, 95% confidence interval [20 to 84]) with an integrated discriminative improvement of 3.0%. In conclusion, elevated CA125 and NTproBNP predict adverse clinical outcome after TAVI. However, when combining both biomarkers, the predictive capacity of CA125 was superior.

Comprehensive geriatric assessment in patients undergoing transcatheter aortic valve implantation - results from the CGA-TAVI multicentre registry

Background

In older patients with aortic stenosis (AS) undergoing TAVI, the potential role of prior CGA is not well established. To explore the value of comprehensive geriatric assessment (CGA) for predicting mortality and/or hospitalisation within the first 3 months after transcatheter aortic valve implantation (TAVI).

Methods

An international, multi-centre, prospective registry (CGA-TAVI) was established to gather data on CGA results and medium-term outcomes in geriatric patients undergoing TAVI. Logistic regression was used to evaluate the predictive value of a multidimensional prognostic index (MPI); a short physical performance battery (SPPB); and the Silver Code, which was based on administrative data, for predicting death and/or hospitalisation in the first 3 months after TAVI (primary endpoint).

Results

A total of 71 TAVI patients (mean age 85.4 years; mean log EuroSCORE I 22.5%) were enrolled. Device success according to VARC criteria was 100%. After adjustment for selected baseline characteristics, a higher (poorer) MPI score (OR: 3.34; 95% CI: 1.39–8.02; p = 0.0068) and a lower (poorer) SPPB score (OR: 1.15; 95% CI: 1.01–1.54; p = 0.0380) were found to be associated with an increased likelihood of the primary endpoint. The Silver Code did not show any predictive ability in this population.

Conclusions

Several aspects of the CGA have shown promise for being of use to physicians when predicting TAVI outcomes. While the MPI may be useful in clinical practice, the SPPB may be of particular value, being simple and quick to perform. Validation of these findings in a larger sample is warranted.

Trial registration

The trial was registered in ClinicalTrials.gov on November 7, 2013 (NCT01991444).

Novel United Kingdom prognostic model for 30-day mortality following transcatheter aortic valve implantation

OBJECTIVE

Existing clinical prediction models (CPM) for short-term mortality after transcatheter aortic valve implantation (TAVI) have limited applicability in the UK due to moderate predictive performance and inconsistent recording practices across registries. The aim of this study was to derive a UK-TAVI CPM to predict 30-day mortality risk for benchmarking purposes.

METHODS

A two-step modelling strategy was undertaken: first, data from the UK-TAVI Registry between 2009 and 2014 were used to develop a multivariable logistic regression CPM using backwards stepwise regression. Second, model-updating techniques were applied using the 2013-2014 data, thereby leveraging new approaches to include frailty and to ensure the model was reflective of contemporary practice. Internal validation was performed by bootstrapping to estimate in-sample optimism-corrected performance.

RESULTS

Between 2009 and 2014, up to 6339 patients were included across 34 centres in the UK-TAVI Registry (mean age, 81.3; 2927 female (46.2%)). The observed 30-day mortality rate was 5.14%. The final UK-TAVI CPM included 15 risk factors, which included two variables associated with frailty. After correction for in-sample optimism, the model was well calibrated, with a calibration intercept of 0.02 (95% CI -0.17 to 0.20) and calibration slope of 0.79 (95% CI 0.55 to 1.03). The area under the receiver operating characteristic curve, after adjustment for in-sample optimism, was 0.66.

CONCLUSION

The UK-TAVI CPM demonstrated strong calibration and moderate discrimination in UK-TAVI patients. This model shows potential for benchmarking, but even the inclusion of frailty did not overcome the need for more wide-ranging data and other outcomes might usefully be explored.

Mid-regional pro-adrenomedullin (MR-proADM) and mid-regional pro-atrial natriuretic peptide (MR-proANP) in severe aortic valve stenosis: association with outcome after transcatheter aortic valve implantation (TAVI)

BACKGROUND

This study aimed to assess the association of mid-regional (MR) pro-adrenomedullin (MR-proADM) and MR-pro-A-type natriuretic peptide (MR-proANP) in comparison to N-terminal pro-natriuretic peptide (NT-proBNP) with outcome in patients with aortic stenosis (AS) treated with transcatheter aortic valve implantation (TAVI).

METHODS

One hundred consecutive TAVI patients were included in this prospective study. Association of preinterventional levels of MR-proADM, MR-proANP, NT-proBNP, C-reactive protein (CrP), and high-sensitive cardiac Troponin T (hsTN) with 30-day and 1-year outcome was analyzed.

RESULTS

There was no association with 30-day outcome, but all markers were associated with 1-year cardiovascular events and all-cause mortality. The combined biomarker analysis further improved risk prediction.

CONCLUSIONS

In TAVI patients MR-proADM, MR-proANP, and NT-proBNP are promising predictors of adverse events within 1 year. Integration of these biomarkers into decision pathways may help to identify patients at higher risk.

Inadequacy of existing clinical prediction models for predicting mortality after transcatheter aortic valve implantation

BACKGROUND

The performance of emerging transcatheter aortic valve implantation (TAVI) clinical prediction models (CPMs) in national TAVI cohorts distinct from those where they have been derived is unknown. This study aimed to investigate the performance of the German Aortic Valve, FRANCE-2, OBSERVANT and American College of Cardiology (ACC) TAVI CPMs compared with the performance of historic cardiac CPMs such as the EuroSCORE and STS-PROM, in a large national TAVI registry.

METHODS

The calibration and discrimination of each CPM were analyzed in 6676 patients from the UK TAVI registry, as a whole cohort and across several subgroups. Strata included gender, diabetes status, access route, and valve type. Furthermore, the amount of agreement in risk classification between each of the considered CPMs was analyzed at an individual patient level.

RESULTS

The observed 30-day mortality rate was 5.4%. In the whole cohort, the majority of CPMs over-estimated the risk of 30-day mortality, although the mean ACC score (5.2%) approximately matched the observed mortality rate. The areas under ROC curve were between 0.57 for OBSERVANT and 0.64 for ACC. Risk classification agreement was low across all models, with Fleiss's kappa values between 0.17 and 0.50.

CONCLUSIONS

Although the FRANCE-2 and ACC models outperformed all other CPMs, the performance of current TAVI-CPMs was low when applied to an independent cohort of TAVI patients. Hence, TAVI specific CPMs need to be derived outside populations previously used for model derivation, either by adapting existing CPMs or developing new risk scores in large national registries.

Preoperative Risk Levels and Vascular Access in Transcatheter Aortic Valve Implantation-A Single-Institute Analysis

Although transcatheter aortic valve implantation (TAVI) has been indicated for patients with high surgical risk, indications for or against the procedure become more difficult as vascular access becomes more proximal and/or invasive in order to accommodate patients with even higher risks. We compared preoperative factors including the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Society of Thoracic Surgeons Predicted Risk of Mortality (STS) score with postoperative survival in 195 patients undergoing TAVI during 2.5 years (January 2010 to June 2012), when vascular access routes were developed from iliofemoral (IL/Fm access, n = 149), axillo-clavicular, apical, and direct aortic approaches (alternative access, n = 46). Logistic regression analyses showed that alternative access was associated with reduced 30-day survival (P = 0.024), while high surgical risk (>15% in both EuroSCORE and STS score) was associated with reduced 1-year survival (P = 0.046). Thus, patients treated via IL/Fm access had acceptable outcome regardless of preoperative risk levels while patients with low surgical risk (<15%) had favorable outcome irrespective of access route. Since the remaining patients with combined risk factors, high preoperative risk level (>15%) requiring alternative access, had a prohibitive risk in our experience, they might have been considered untreatable or not amenable even to TAVI and offered medical or alternative managements.

Improvement in Risk Stratification in Transcatheter Aortic Valve Implantation Using a Combination of the Tumor Marker CA125 and the Logistic EuroSCORE

INTRODUCTION AND OBJECTIVES

Conventional risk scores have not been accurate in predicting peri- and postprocedural risk of patients undergoing transcatheter aortic valve implantation (TAVI). Elevated levels of the tumor marker carbohydrate antigen 125 (CA125) have been linked to adverse outcomes after TAVI. We studied the additional value of CA125 to that of the EuroSCORE in predicting long-term mortality after TAVI.

METHODS AND RESULTS

During a median follow-up of 59 weeks, 115 of 422 patients (27%) died after TAVI. Mortality was higher with elevated CA125 (> 30 U/mL) and EuroSCORE (> median) (47% vs 20%, P<.001 and 38% vs 16%, P<.001, respectively). In the multivariable analysis, CA125 (> 30 U/mL) remained an independent predictor of mortality (hazard ratio [HR], 2.16; 95% confidence interval [95%CI], 1.48-3.15; P<.001) and improved the predictive capability of the model (C-statistic: 0.736 vs 0.731) and the net reclassification index (51% 95%CI, 33-73) with an integrated discriminative improvement of 3.5% (95%CI, 0.5-8.4). A new variable (CA125-EuroSCORE) was created, with the combinations of the 2 possible binary states of these variables (+, elevated, -, not elevated; C1: CA125- EuroSCORE-; C2: CA125+ EuroSCORE-; C3: CA125- EuroSCORE+; C4: CA125+ EuroSCORE+). Patients in C1 exhibited the lowest cumulative mortality rate (14% [26 of 181]). Mortality was intermediate for C2 (CA125 > 30 U/mL and EuroSCORE ≤ median) and C3 (CA125 ≤ 30 U/mL and EuroSCORE > median): 27% (8 of 30) and 28% (37 of 131), respectively. Patients in C4 (CA125 > 30 U/mL and EuroSCORE > median) exhibited the highest mortality (55% [44 of 80], P-value for trend<.001).

CONCLUSIONS

CA125 offers additional prognostic information beyond that obtained by the EuroSCORE. Elevation of both markers was associated with a poor prognosis.

Mid-term study of transcatheter aortic valve implantation in an Asian population with severe aortic stenosis: two-year Valve Academic Research Consortium-2 outcomes

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) is an effective treatment for high-risk or inoperative patients with severe aortic stenosis. Given the unique characteristics of Asian populations, questions regarding mid-term outcomes in Asians undergoing TAVI have yet to be addressed. We evaluated the two-year clinical outcomes of TAVI in an Asian population using Valve Academic Research Consortium-2 definitions.

METHODS

This prospective study recruited 59 patients from a major academic medical centre in Singapore. The main outcomes were two-year survival rates, peri-procedural complications, symptom improvement, valvular function and assessment of learning curve.

RESULTS

Mean age was 76.8 years (61.0% male), mean body surface area 1.6 m² and mean logistic EuroSCORE 18.7%. Survival was 93.2%, 86.0% and 79.1% at 30 days, one year and two years, respectively. At 30 days post TAVI, the rate of stroke was 1.7%, life-threatening bleeding 5.1%, acute kidney injury 25.0%, major vascular complication 5.1%, and new permanent pacemaker implantation 6.8%. 29.3% of TAVI patients were rehospitalised (47.1% cardiovascular-related) within one year. These composite outcomes were measured: device success (93.2%); early safety (79.7%); clinical efficacy (66.1%); and time-related valve safety (84.7%). Univariate analysis found these predictors of two-year all-cause mortality: logistic EuroSCORE (hazard ratio [HR] 1.07; p < 0.001); baseline estimated glomerular filtration rate (HR 0.97; p = 0.048); and acute kidney injury (HR 5.33; p = 0.022). Multivariate analysis identified non-transfemoral TAVI as a predictor of cardiovascular-related two-year mortality (HR 14.64; p = 0.008).

CONCLUSION

Despite the unique clinical differences in Asian populations, this registry demonstrated favourable mid-term clinical and safety outcomes in Asians undergoing TAVI.

Mortality prediction following transcatheter aortic valve replacement: A quantitative comparison of risk scores derived from populations treated with either surgical or percutaneous aortic valve replacement. The Israeli TAVR Registry Risk Model Accuracy Assessment (IRRMA) study

BACKGROUND

Accurate risk stratification is pivotal for appropriate selection of patients with severe symptomatic aortic stenosis for either surgical or transcatheter aortic valve replacement (TAVR). We sought to determine whether recent risk prediction models developed specifically in TAVR patients enhance prognostication in comparison with previous surgical scores used in clinical practice (EuroScore I, EuroScore II, STS).

METHODS

The Israeli TAVR Registry Risk Model Accuracy Assessment (IRRMA) study utilized a multicenter prospective TAVR database (n=1327) to perform a quantitative comparison between previous risk scores developed in either surgical or TAVR populations, with the present registry serving as an independent external validation set.

RESULTS

In the IRRMA population, 4 variables (NYHA functional class IV, chronic obstructive pulmonary disease, systolic pulmonary artery pressure ≥60mmHg, vascular access other than by the femoral route) identified by cross-validation and leave-one-out analyses provided the most discriminative model (C-statistic=0.63) for predicting 30-day mortality. Previous scores developed in surgical (EuroScores I and II, STS), TAVR (FRANCE-2, OBSERVANT), or mixed (German AV score) populations were applied to the IRRMA cohort. Resultant C-statistics ranged between 0.52-0.71 (for the German AV and FRANCE-2 scores, respectively) and did not differ significantly (p=0.07 for the comparison between the lowest and highest C-statistics). The observed C-statistic for 5 of these 6 scores was lower than originally reported when applied to the IRRMA population.

CONCLUSION

Available TAVR risk scores showed limited accuracy when applied to an independent validation set and did not enhance prognostication in comparison to previous surgical scores.

Successful fast track protocol implementation for patients undergoing transapical transcatheter aortic valve implantation

Background

The aim of the current study is to report our experience with fast-track treatment of patients undergoing transapical transcatheter aortic valve implantation (TA-TAVI) and to determine perioperative predictors for fast-track protocol failure.

Methods

Being one of the pioneering centers to start performing TA-TAVI back in 2005, we routinely included patients undergoing this procedure into our fast-track management program since 2008. Between January 2008 and June 2013, 207 consecutive high-risk patients (mean age 79 ± 7 years, mean Log. EuroSCORE 24 ± 10) who underwent TA-TAVI accordingly to our institutional fast-track approach were prospectively collected and analyzed. Uni- and multivariate analysis were performed to identify independent pre- and perioperative predictors of fast-track protocol failure, defined as inability to discharge the patient from the intensive care unit (ICU) on the day of surgery or as readmission to the ICU 48 h after the initial discharge.

Results

Fast-track management was successful in 83 % of the patients. 30-day mortality was 8 %. Fast-track protocol failure (17 %) was associated with an outcome worsening compared to the remaining patients (mortality: 40 % vs. 2 % and mean hospital stay: 19 ± 12 vs. 10 ± 9 days; P = .002). Independent predictors of fast-track protocol failure were age ≥85 years (OR 3.1; CI 95 % 1.89–6.21), ejection fraction (EF) ≤30 % (OR 2.6; CI 95 % 1.99–7.52), moderate to severe preoperative mitral valve regurgitation (OR 2.7; CI 95 % 1.27–6.43) and fluoroscopy time ≥12 min (OR 2.9; CI 95 % 1.28–7.46).

Conclusions

Fast-track patient management following TA-TAVI is safe and reproducible in the majority of patients. Besides patient-related preoperative risk factors (age ≥85 years, EF ≤30 % and moderate to severe preoperative mitral valve regurgitation) a technically challenging intraoperative course as evidenced in a prolonged fluoroscopy time are independent predictors of fast-track protocol failure which is associated with high loss of patient outcome.

Does the disparity in baseline characteristics of patients undergoing transcatheter aortic valve replacement with 23 mm vs. 26 mm valves impact clinical outcome?

OBJECTIVES

We sought to identify if baseline characteristic differences in patients who receive a 23 mm vs. 26 mm valve impact clinical outcomes.

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is currently an approved therapy for patients with severe aortic stenosis who are considered inoperable or are at high risk.

METHODS

We retrospectively examined baseline characteristics and outcomes of patients receiving a 23 mm (n = 132) vs. 26 mm valve (n = 81) via the transfemoral approach.

RESULTS

Gender (P < 0.01), previous coronary artery bypass surgery (P < 0.01), history of atrial fibrillation (P = 0.04), and mean Society of Thoracic Surgeons (STS) score (P < 0.01) were significantly different between groups. There were no significant differences in the rates of minor/major vascular complications (2.2 vs. 3.7%, P = 0.68 and 13.0 vs. 12.3%, P = 0.89, respectively). Bleeding complications were also comparable (major bleed 2.3 vs. 1%, P >0.99, minor bleed 19.0 vs. 22.0%, P = 0.67 and life threatening bleed 7.0 vs. 5.0%, P = 0.77). In-hospital death (6.0 vs. 5.0%, P >0.99), 30-day all-cause death (7.6 vs. 6.2%, P = 0.69), and all-cause death at 1 year (17.4 vs. 25.9%, P = 0.13) were also similar between groups. Gender, valve size, previous coronary bypass surgery and atrial fibrillation were not independently associated with mortality; however, on multivariate analysis STS score was (HR 1.11; 95% CI 1.02-1.19; P = 0.01).

CONCLUSION

Patients undergoing TAVR with 23 and 26 mm valves have similar clinical outcomes despite significant differences in baseline characteristics. © 2015 Wiley Periodicals, Inc.

Outcomes of Patients at Estimated Low, Intermediate, and High Risk Undergoing Transcatheter Aortic Valve Implantation for Aortic Stenosis

Intermediate- or low-risk patients with severe aortic stenosis were excluded from earlier transcatheter aortic valve implantation (TAVI) clinical trials; however, they are already being treated by TAVI despite a lack of data regarding the safety and efficacy in these patients. We aimed to assess the safety and efficacy of TAVI in patients at intermediate or low risk. Patients undergoing TAVI during 2008 to 2014 were included into a shared database (n = 1,327). Procedural outcomes were adjudicated according to Valve Academic Research Consortium 2 definitions. Patients were stratified according to their Society of Thoracic Surgeons (STS) score into 3 groups: high (STS ≥8, n = 223, 17%), intermediate (STS 4 to 8; n = 496, 38%), or low risk (STS <4; n = 576, 45%). Low-risk patients were significantly younger and more likely to be men compared to intermediate- and high-risk patients. Baseline characteristics differed significantly between the groups with a gradual increase in the rates of previous bypass surgery, stroke, peripheral vascular disease, renal failure, lung disease, and frailty scores, from low to high risk groups. Compared with intermediate- and high-risk patients, low-risk patients were more likely to undergo TAVI through the transfemoral route (81% vs 88% vs 95%, p <0.001) and under conscious sedation (69% vs 72% vs 81%, <0.001). There were no significant differences in the rates of procedural complications apart from acute kidney injury (19% vs 17% vs 13%, p = 0.03) and stroke rates (4.5% vs 2% vs 2.3%, p = 0.1). Short- and long-term mortality rates were significantly higher for intermediate- (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.2 to 2.9) and high-risk patients (HR 4.1, 95% CI 2.7 to 6.4) than low-risk patients also after multivariate adjustment (HR 1.6, 95% CI 1 to 2.6 and HR 2.7, 95% CI 1.7 to 4.5, respectively; all p <0.05). In conclusion, TAVI for intermediate- and low-risk patients is safe and associated with improved outcome compared with high-risk patients.

[Experience of transcatheter aortic valve implantation in the Central Military Hospital]

OBJECTIVE

Transcatheter aortic valve implantation (TAVI) is an alternative treatment for patients with severe symptomatic aortic stenosis, inoperable or at high surgical risk. The purpose of this communication is to report the results of the experience of this new technique and compare them with literature.

METHODS

Review of 17 patients data with symptomatic severe aortic stenosis at high surgical risk or inoperable, treated with a transcatheter implantation aortic valve (TAVI) via femoral surgical access with Core Valve (Medtronic, EE.UU.) between September 2013 and July 2014.

RESULTS

All patients had severe aortic stenosis with a mean gradient of 46̊æ14 mmHg received CoreValveTM (Medtronic, USA). Half of patients was performed under general anesthesia, the other half with regional and local anesthesia. In-hospital mortality was 11.7% and one death in follow-up from September 2013 until the time of preparing this report (5.9%).Total mortality at one year follow-up was 17.6%. The technical success rate was 82.4%, with an immediate post-implantation gradient of 5.4̊æ3.4 mmHg. Aortic regurgitation I degree was observed in 5 patients (29.4%); 2 patients (11.7%) had aortic regurgitation grade II. Post dilatation was made in 6 patients (35.2%). We did not have any vascular complications. Permanent pacemaker implantation was needed in 6 patients (35.2%). One patient complicated with acute renal failure, 2 had in-hospital ischemic stroke (11.7%), none had need for cardiac surgery; 2 patients had major bleeding complications that required transfusion.

CONCLUSIONS

In patients with high surgical risk or inoperable, TAVI is a treatment option that improves life quality, survival and diminsh the need of hospitalizations. There can be some complications and even death, so that a proper patient selection and a multidisciplinary team is needed and fundamental for a successful procedure.

[From FRANCE 2 to FRANCE TAVI: are indications, technique and results of transcatheter aortic valve replacement the same?]

Transcatheter aortic valve implantation (TAVI) is indicated in patients with severe symptomatic aortic stenosis who are not suitable for surgery or should be considered when there is a high surgical risk as assessed by a heart team. There is a decrease in mean logistic EuroSCORE since January 2010, which translates a gradual evolution in patients' selection. Expertise of geriatricians to further assess frailty is a key step in the risk stratification process of this elderly population (mean age: 83.4±7.3 years). Femoral access is used in 80% of cases with a procedural success rate higher than 95%. In-hospital mortality rate is 5.9%. The main complications of the procedure are aortic annulus rupture (0.9% in FRANCE TAVI), tamponade (2.3%), stroke (2.2%), severe paravalvular leak (1.3%) and permanent pacemaker implantation (15%). The awaited results of PARTNER II and SURTAVI may lead to expand the indications to lower-risk patients if it is shown that TAVI is non-inferior to surgery in this population which has been suggested by the recent randomized NOTION Trial while the CoreValve Pivotal Trial even points in the direction of a possible superiority of the percutaneous technique over surgery.

Transcatheter aortic valve implantation despite challenging vascular access

We describe transcatheter aortic valve implantation in a patient who had severe peripheral artery disease. The patient's vascular condition required additional preliminary peripheral intervention to enable adequate vascular access. A 78-year-old man with severe aortic stenosis, substantial comorbidities, and severe heart failure symptoms was referred for aortic valve replacement. The patient's 20-mm aortic annulus necessitated the use of a 23-mm Edwards Sapien valve inserted through a 22F sheath, which itself needed a vessel diameter of at least 7 mm for percutaneous delivery. The left common femoral artery was selected for valve delivery. The left iliac artery and infrarenal aorta underwent extensive intervention to achieve an intraluminal diameter larger than 7 mm. After aortic valvuloplasty, valve deployment was successful, and the transaortic gradient decreased from 40 mmHg to less than 5 mmHg. The patient was discharged from the hospital 4 days postoperatively. We conclude that transcatheter aortic valve implantation can be successfully performed in patients with obstructed vascular access, including stenosis of the infrarenal aorta and the subclavian and coronary arteries.

Long-Term Outcomes of Inoperable Patients With Aortic Stenosis Randomly Assigned to Transcatheter Aortic Valve Replacement or Standard Therapy

Background—

The long-term outcomes of transcatheter aortic valve replacement (TAVR) in inoperable patients with severe aortic stenosis remain unknown.

Methods and Results—

In the Placement of Aortic Transcatheter Valves (PARTNER) study, 358 patients were randomly assigned to TAVR or standard therapy. We report the 3-year outcomes on these patients, and the pooled outcomes for all randomly assigned inoperable patients (n=449) in PARTNER, as well, including the randomized portion of the continued access study (n=91). The 3-year mortality rate in the TAVR and standard therapy groups was 54.1% and 80.9%, respectively ( P <0.001; hazard ratio, 0.53; 95% confidence interval, 0.41–0.68; P <0.001). In survivors, there was significant improvement in New York Heart Association functional class sustained at 3 years. The cumulative incidence of strokes at 3-year follow-up was 15.7% in TAVR patients versus 5.5% in patients undergoing standard therapy (hazard ratio, 2.81; 95% confidence interval, 1.26–6.26; P =0.012); however, the composite of death or strokes was significantly lower after TAVR versus standard therapy (57.4% versus 80.9%, P <0.001;

hazard ratio, 0.60; 95% confidence interval, 0.46–0.77; P <0.001). Echocardiography showed a sustained increase in aortic valve area and decrease in transvalvular gradient after TAVR. Analysis of the 449 pooled randomly assigned patients (TAVR, n=220; standard therapy, n=229) demonstrated significant improvement in all-cause mortality and functional status during early and 3-year follow-up. The results of the pooled cohort were similar to the results obtained from the pivotal PARTNER trial.

Conclusions—

TAVR resulted in better survival and functional status in inoperable patients with severe aortic stenosis with durable hemodynamic benefit on long-term follow-up. However, high residual mortality, even in successfully treated TAVR patients, highlights the need for more strategic patient selection.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00530894.

Patient evaluation and selection for transcatheter aortic valve replacement: the heart team approach

Transcatheter aortic valve replacement (TAVR) has been shown to significantly impact mortality and quality of life in patients with severe aortic stenosis (AS) who are deemed high risk for surgical aortic valve replacement (SAVR). Essential to these outcomes is proper patient selection. The multidisciplinary TAVR heart team was created to provide comprehensive patient evaluation and aid in proper selection. This review with outline the history and components of the heart team, and delineate the team's role in risk and frailty assessment, evaluation of common co-morbidities that impact outcomes, and the complex multi-modality imaging necessary for procedural planning and patient selection. The heart team is critical in determining patient eligibility and benefit and the optimal operative approach for TAVR. The future of structural heart disease will certainly require a team approach, and the TAVR heart team will serve as the successful model.

Transcatheter Aortic Valve Replacement: Game-Changing Innovation for Patients with Aortic Stenosis

Transcatheter aortic valve replacement (TAVR) is an emerging technology for the management of patients with severe aortic stenosis (AS). First reported in 2002, TAVR has made remarkable progress in the past decade with completion of major randomized clinical trials, multiple observational registries, and evolution of several new devices. This article is a brief introductory overview of the TAVR procedure, devices, trials and registries, and newer developments in the field.

In-hospital mortality risk assessment in elective and non-elective cardiac surgery: a comparison between EuroSCORE II and age, creatinine, ejection fraction score

OBJECTIVES

Age, creatinine, ejection fraction (ACEF) score is a simplified algorithm for prediction of mortality after elective cardiac surgery. Although mainly conceived for elective cardiac surgery, no information is available on its performance in non-elective surgery and on comparison with the new EuroSCORE II. This study was undertaken to compare the performance of ACEF score and EuroSCORE II within classes of urgency.

METHODS

Complete data on 13 871 consecutive patients who underwent major cardiac surgery in a 6-year period were retrieved from three prospective institutional databases. Discriminatory power was assessed using the c-index and h with Delong, bootstrap and Venkatraman methods. Calibration was evaluated with calibration curves and associated statistics.

RESULTS

The in-hospital mortality rate was 2.5%. The discriminatory power of ACEF score within elective and non-elective surgery was similar (area under the curve (AUC) 0.71, 95% confidence interval (CI) 0.67-0.74 and AUC 0.68, 95% CI 0.62-0.73, respectively) but significantly lower than that of EuroSCORE II (AUC 0.80, 95% CI 0.77-0.83 for elective surgery; AUC 0.82, 95% CI 0.78-0.85 for non-elective surgery). The calibration patterns were different in the two subgroups, but the summary statistics underscored a miscalibration in both of them (U-statistic and Spiegelhalter Z-test P-values <0.05). Even the calibration of EuroSCORE II was insufficient, although it was demonstrated to be well calibrated in the first tertile of predicted risk.

CONCLUSIONS

This study demonstrated that the performance of ACEF score in predicting in-hospital mortality in elective and non-elective cardiac surgery is comparable. Nonetheless, it is not as satisfactory as the new EuroSCORE II, as its discrimination is significantly lower and it is also miscalibrated.

The revised EuroSCORE II for the prediction of mortality in patients undergoing transcatheter aortic valve implantation

BACKGROUND

The assessment of procedural risk is crucial in patients with severe symptomatic aortic stenosis. Logistic EuroSCORE and STS score are currently used to estimate procedural risk and mortality for surgical and transcatheter aortic valve implantation (TAVI). The recently published EuroSCORE II might provide a helpful tool.

METHODS

The new EuroSCORE II was calculated in 206 patients undergoing transfemoral TAVI and compared to the established logistic EuroSCORE and STS mortality score. Discriminative power and calibration of each test was statistically evaluated.

RESULTS

30-day and 1-year mortality rates were 6.8 % (14/206) and 27.2 % (56/206). In-hospital mortality rate was 29.2 ± 17.8 % with logistic EuroSCORE, 9.5 ± 6.8 % with STS score, and 9.22 ± 7.12 % with EuroSCORE II: Logistic EuroSCORE and EuroSCORE II were significantly increased in non-survivors compared to survivors at 30 days and at 1 year. EuroSCORE II and STS score (r = 0.49, p < 0.001) showed moderate correlation, whereas strong correlation was found between EuroSCORE II and logistic EuroSCORE (r = 0.71, p < 0.001). ROC curve analyses for the prediction of 30-day mortality (AUC 0.79 vs. 0.69 vs. 0.71) and 1-year mortality (AUC 0.72 vs. 0.70 vs. 0.70) were performed. Statistical comparison revealed no difference between the AUCs (p > 0.05).

CONCLUSION

In percutaneous TAVI patients, 30-day mortality was best approximated by the new EuroSCORE II, whereas the logistic EuroSCORE best reflected 1-year mortality. However, EuroSCORE II does not provide additional prognostic information beyond the established logistic EuroSCORE. For more exact risk prediction in TAVI, a distinct TAVI risk score would be desirable.

A meta-analysis of transcatheter aortic valve implantation versus surgical aortic valve replacement

BACKGROUND

Our preliminary meta-analysis suggests that transcatheter aortic valve implantation (TAVI) may not reduce the 30-day mortality rate over surgical aortic valve replacement (AVR) in high-risk patients with severe aortic stenosis (AS). We performed an updated formal meta-analysis of TAVI vs AVR for reduction not only of early but also of late all-cause mortality in AS.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched through October 2012. Eligible studies were randomized controlled trials or adjusted observational comparative studies of TAVI vs AVR enrolling individuals with AS and reporting early (30-day or in-hospital) or late all-cause mortality, or both, as an outcome. Odds ratios or hazard ratios with 95% confidence intervals (adjusted odds ratios or hazard ratios in case of observational studies) were abstracted from each study.

RESULTS

We identified two randomized trials and 15 adjusted observational studies enrolling 4,873 patients with severe AS. Pooled analysis suggested no significant difference in early (odds ratio, 0.92; 95% confidence interval, 0.70 to 1.19) and midterm (3-month to 3-year) total mortality (hazard ratio, 0.99; 95% confidence interval, 0.83 to 1.17) among patients assigned to TAVI vs AVR. Exclusion of any single study from the analysis did not substantively alter the overall result of our analysis. No evidence of significant publication bias was found.

CONCLUSIONS

Our meta-analysis of data of approximately 5,000 patients from 17 studies showed that TAVI is likely ineffective in reducing early and midterm all-cause mortality vs AVR in high-risk patients with AS.