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Kirchner J, Rudolph TK. [Conservative treatment of valvular heart disease in adults]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:425-430. [PMID: 38436690 DOI: 10.1007/s00108-024-01676-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/02/2024] [Indexed: 03/05/2024]
Abstract
Currently, there is no specific medication approved for the treatment of valvular heart disease per se. Except for secondary mitral valve insufficiency and tricuspid valve insufficiency in pulmonary hypertension, drug therapy for higher-grade valvular heart disease is limited to diuretic therapy for symptom control. Conservative therapy for comorbidities and potential heart failure can be beneficial regardless of the specific valve lesion. In cases of aortic valve stenosis or insufficiency, controlling arterial hypertension is important. Patients with mitral valve stenosis benefit from rhythm and rate control. Diuretics can help reduce regurgitant volume in patients with primary mitral valve insufficiency and tricuspid valve insufficiency. In addition to drug therapy, maintaining functional capacity is crucial for the outcome of patients. Therefore, it is recommended to engage in active physical activity whenever possible, despite the presence of valvular heart disease.
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Affiliation(s)
- Johannes Kirchner
- Klinik für Allgemeine und Interventionelle Kardiologie/Angiologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland
| | - Tanja K Rudolph
- Klinik für Allgemeine und Interventionelle Kardiologie/Angiologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland.
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2
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Sagmeister P, Rosch S, Fengler K, Kresoja KP, Gori T, Thiele H, Lurz P, Burkhoff D, Rommel KP. Running on empty: Factors underpinning impaired cardiac output reserve in heart failure with preserved ejection fraction. Exp Physiol 2024. [PMID: 38421268 DOI: 10.1113/ep091776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is frequently attributed etiologically to an underlying left ventricular (LV) diastolic dysfunction, although its pathophysiology is far more complex and can exhibit significant variations among patients. This review endeavours to systematically unravel the pathophysiological heterogeneity by illustrating diverse mechanisms leading to an impaired cardiac output reserve, a central and prevalent haemodynamic abnormality in HFpEF patients. Drawing on previously published findings from our research group, we propose a pathophysiology-guided phenotyping based on the presence of: (1) LV diastolic dysfunction, (2) LV systolic pathologies, (3) arterial stiffness, (4) atrial impairment, (5) right ventricular dysfunction, (6) tricuspid valve regurgitation, and (7) chronotopic incompetence. Tailored to each specific phenotype, we explore various potential treatment options such as antifibrotic medication, diuretics, renal denervation and more. Our conclusion underscores the pivotal role of cardiac output reserve as a key haemodynamic abnormality in HFpEF, emphasizing that by phenotyping patients according to its individual pathomechanisms, insights into personalized therapeutic approaches can be gleaned.
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Affiliation(s)
- Paula Sagmeister
- Department of Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Sebastian Rosch
- Department of Cardiology, University Hospital Mainz, Mainz, Germany
| | - Karl Fengler
- Department of Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | | | - Tommaso Gori
- Department of Cardiology, University Hospital Mainz, Mainz, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Philipp Lurz
- Department of Cardiology, University Hospital Mainz, Mainz, Germany
| | | | - Karl-Philipp Rommel
- Department of Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
- Cardiovascular Research Foundation, New York, New York, USA
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3
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von Roeder M, Maeder M, Wahl V, Kitamura M, Rotta Detto Loria J, Dumpies O, Rommel KP, Kresoja KP, Blazek S, Richter I, Majunke N, Desch S, Thiele H, Lurz P, Abdel-Wahab M. Prognostic significance and clinical utility of left atrial reservoir strain in transcatheter aortic valve replacement. Eur Heart J Cardiovasc Imaging 2024; 25:373-382. [PMID: 37862161 DOI: 10.1093/ehjci/jead268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/29/2023] [Accepted: 10/10/2023] [Indexed: 10/22/2023] Open
Abstract
AIMS Patients with diastolic dysfunction (DD) experience worse outcomes after transcatheter aortic valve replacement (TAVR). We investigated the prognostic value and clinical utility of left atrial reservoir strain (LARS) in patients undergoing TAVR for aortic stenosis (AS). METHODS AND RESULTS All consecutive patients undergoing TAVR between January 2018 and December 2018 were included if discharge echocardiography and follow-up were available. LARS was derived from 2D-speckle-tracking. Patients were grouped into three tertiles according to LARS. DD was analysed using the ASE/EACVI-algorithm. The primary outcome was a composite of all-cause death and readmission for worsening heart failure 12 months after TAVR. Overall, 606 patients were available [age 80 years, interquartile range (IQR) 77-84], including 53% women. Median LARS was 13.0% (IQR 8.4-18.3). Patients were classified by LARS tertiles [mildly impaired 21.4% (IQR 18.3-24.5), moderately impaired 13.0% (IQR 11.3-14.6), severely impaired 7.1% (IQR 5.4-8.4), P < 0.0001]. The primary outcome occurred more often in patients with impaired LARS (mildly impaired 7.4%, moderately impaired 13.4%, and severely impaired 25.7%, P < 0.0001). On adjusted multivariable Cox regression analysis, LARS tertiles [hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.44-0.86, P = 0.005] and higher degree of tricuspid regurgitation (HR 1.82, 95% CI 1.23-2.98, P = 0.003) were the only significant predictors of the primary endpoint. Importantly, DD was unavailable in 56% of patients, but LARS assessment allowed for reliable prognostication regarding the primary endpoint in subgroups without DD assessment (HR 0.64, 95% CI 0.47-0.87, P = 0.003). CONCLUSION Impaired LARS is independently associated with worse outcomes in patients undergoing TAVR. LARS allows for risk stratification at discharge even in patients where DD cannot be assessed by conventional echocardiographic means.
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Affiliation(s)
- Maximilian von Roeder
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
| | - Mauritius Maeder
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
| | - Vincent Wahl
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
| | - Mitsunobu Kitamura
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
| | - Johannes Rotta Detto Loria
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
| | - Oliver Dumpies
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
| | - Karl-Philipp Rommel
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
- Cardiovascular Research Foundation, NewYork, NY, USA
| | - Karl-Patrik Kresoja
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
| | - Stephan Blazek
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
| | - Ines Richter
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
| | - Nicolas Majunke
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
| | - Steffen Desch
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
| | - Philipp Lurz
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
- Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Mohamed Abdel-Wahab
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Struempellstrasse 39, D-04289 Leipzig, Germany
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4
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Stalikas N, Anastasiou V, Botis I, Daios S, Karagiannidis E, Zegkos T, Karamitsos T, Vassilikos V, Ziakas A, Kamperidis V, Giannakoulas G, Giannopoulos G. The prognostic impact of diastolic dysfunction after transcatheter aortic valve replacement: A systematic review and meta-analysis. Curr Probl Cardiol 2024; 49:102228. [PMID: 38043876 DOI: 10.1016/j.cpcardiol.2023.102228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 11/28/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Diastolic dysfunction (DD) is a long-established marker of disease progression in patients with aortic valve stenosis (AS), indicating valvular myocardial damage. Recently, substantial observational data have emerged demonstrating that worse pre-operative DD assessed using echocardiography is associated with adverse long-term clinical outcomes after transcatheter aortic valve replacement (TAVR). AIM To systematically appraise and quantitatively synthesize current evidence on the prognostic impact of echocardiographic severe DD derived by echocardiography before TAVR. METHODS A systemic literature review was undertaken in electronic databases to identify studies reporting the predictive value of severe DD in AS subjects undergoing TAVR. A random-effects meta-analysis was conducted to quantify the adjusted and unadjusted hazard ratios (HRs) for all-cause mortality and major adverse cardiovascular events (MACEs) for the presence of severe DD. RESULTS Ten studies were deemed eligible for inclusion. Of those, 9 provided appropriate quantitative data for the meta-analysis, encompassing a total of 4,619 patients. The presence of severe DD was associated with increased risk for all-cause mortality (pooled unadjusted HR=2.56 [1.46-4.48]; p<0.01; I2=76 %) and MACEs (pooled unadjusted HR=1.82 [1.29-2.58]; p<0.01; I2=86 %). When adjusted for clinically-relevant parameters, the presence of severe DD retained independent association with all-cause mortality (pooled adjusted HR=2.35 [1.26-4.37]; p<0.01; I2=79 %) and MACEs (pooled adjusted HR= 2.52 [1.72-3.65]; p<0.01; I2=0 %). In subgroup analysis there was no difference on post-TAVR risk between the use of different diastolic function grading scores. CONCLUSION Presence of severe DD assessed by echocardiography pre-TAVR is a major determinant of long-term adverse outcomes after the procedure.
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Affiliation(s)
- Nikolaos Stalikas
- AHEPA Hospital, Medical School, Aristotle University, St. Kiriakidi 1, Thessaloniki GR54636, Greece.
| | - Vasileios Anastasiou
- AHEPA Hospital, Medical School, Aristotle University, St. Kiriakidi 1, Thessaloniki GR54636, Greece
| | - Ioannis Botis
- AHEPA Hospital, Medical School, Aristotle University, St. Kiriakidi 1, Thessaloniki GR54636, Greece
| | - Stylianos Daios
- AHEPA Hospital, Medical School, Aristotle University, St. Kiriakidi 1, Thessaloniki GR54636, Greece
| | | | - Thomas Zegkos
- AHEPA Hospital, Medical School, Aristotle University, St. Kiriakidi 1, Thessaloniki GR54636, Greece
| | - Theodoros Karamitsos
- AHEPA Hospital, Medical School, Aristotle University, St. Kiriakidi 1, Thessaloniki GR54636, Greece
| | - Vassilios Vassilikos
- Ippokratio General Hospital, Medical School, Aristotle University, Thessaloniki, Greece
| | - Antonios Ziakas
- AHEPA Hospital, Medical School, Aristotle University, St. Kiriakidi 1, Thessaloniki GR54636, Greece
| | - Vasileios Kamperidis
- AHEPA Hospital, Medical School, Aristotle University, St. Kiriakidi 1, Thessaloniki GR54636, Greece
| | - George Giannakoulas
- AHEPA Hospital, Medical School, Aristotle University, St. Kiriakidi 1, Thessaloniki GR54636, Greece
| | - George Giannopoulos
- Ippokratio General Hospital, Medical School, Aristotle University, Thessaloniki, Greece
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5
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El-Zein RS, Malik AO, Cohen DJ, Spertus JA, Saxon JT, Pibarot P, Hahn RT, Alu MC, Shang K, Kodali SK, Thourani VH, Leon MB, Mack MJ, Chhatriwalla AK. Diastolic Dysfunction and Health Status Outcomes After Transcatheter Aortic Valve Replacement. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2024; 8:100225. [PMID: 38283566 PMCID: PMC10818150 DOI: 10.1016/j.shj.2023.100225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/16/2023] [Accepted: 08/24/2023] [Indexed: 01/30/2024]
Abstract
Background Baseline left ventricular diastolic dysfunction (LVDD) is associated with poor health status in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), but health status improvement after TAVR appears similar across all grades of LVDD. Here, we aim to examine the relationship between changes in LVDD severity and health status outcomes following TAVR. Methods Patients who underwent TAVR and had evaluable LVDD at both baseline and 1 year in the PARTNER (Placement of Aortic Transcatheter Valves) 2 SAPIEN 3 registries and PARTNER 3 trial were analyzed. LVDD grade was evaluated using echocardiography core lab data and an adapted definition of American Society of Echocardiography guidelines. Health status was assessed using the Kansas City Cardiomyopathy Questionnaire Overall Summary (KCCQ-OS) score. The association between ΔLVDD severity and ΔKCCQ-OS was examined using linear regression models adjusted for baseline KCCQ-OS. Results Of 1100 patients, 724 (65.8%), 283 (25.7%), and 93 (8.5%) had grade 0/1, 2, and 3 LVDD at baseline, respectively. At 1 year, LVDD severity was unchanged in 790 (71.8%) patients, improved in 189 (17.2%), and worsened in 121 (11.0%). Among 376 patients with baseline grade 2 or 3 LVDD, 50.3% had improvement in LVDD. In the overall cohort, KCCQ-OS score improved by 21.9 points at 1 year. There was a statistically significant association between change in LVDD severity (improved, unchanged, and worsened) and ΔKCCQ-OS at 1 year (p = 0.007). Conclusions Change in LVDD grade was associated with change in health status 1 year following TAVR.
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Affiliation(s)
- Rayan S. El-Zein
- Division of Cardiology, University of Missouri-Kansas City, Missouri, USA
- Division of Cardiology, Saint Luke’s Mid America Heart Institute, Missouri, USA
| | - Ali O. Malik
- Division of Cardiology, University of Missouri-Kansas City, Missouri, USA
- Division of Cardiology, Saint Luke’s Mid America Heart Institute, Missouri, USA
| | - David J. Cohen
- Division of Cardiology, Saint Francis Hospital, New York, USA
- Clinical Trials Center, Cardiovascular Research Foundation, New York, USA
| | - John A. Spertus
- Division of Cardiology, University of Missouri-Kansas City, Missouri, USA
- Division of Cardiology, Saint Luke’s Mid America Heart Institute, Missouri, USA
| | - John T. Saxon
- Division of Cardiology, Saint Luke’s Mid America Heart Institute, Missouri, USA
| | | | - Rebecca T. Hahn
- Clinical Trials Center, Cardiovascular Research Foundation, New York, USA
- Division of Cardiology, Columbia University Irving Medical Center, New York, USA
| | - Maria C. Alu
- Clinical Trials Center, Cardiovascular Research Foundation, New York, USA
| | - Kan Shang
- Edwards Lifesciences, California, USA
| | - Susheel K. Kodali
- Division of Cardiology, Columbia University Irving Medical Center, New York, USA
| | - Vinod H. Thourani
- Division of Cardiothoracic Surgery, Piedmont Heart Institute, Georgia, USA
| | - Martin B. Leon
- Clinical Trials Center, Cardiovascular Research Foundation, New York, USA
- Division of Cardiology, Columbia University Irving Medical Center, New York, USA
| | - Michael J. Mack
- Division of Cardiothoracic Surgery, Baylor Scott & White Health, Texas, USA
| | - Adnan K. Chhatriwalla
- Division of Cardiology, University of Missouri-Kansas City, Missouri, USA
- Division of Cardiology, Saint Luke’s Mid America Heart Institute, Missouri, USA
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6
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Holste G, Oikonomou EK, Mortazavi BJ, Coppi A, Faridi KF, Miller EJ, Forrest JK, McNamara RL, Ohno-Machado L, Yuan N, Gupta A, Ouyang D, Krumholz HM, Wang Z, Khera R. Severe aortic stenosis detection by deep learning applied to echocardiography. Eur Heart J 2023; 44:4592-4604. [PMID: 37611002 PMCID: PMC11004929 DOI: 10.1093/eurheartj/ehad456] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 06/21/2023] [Accepted: 07/11/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND AND AIMS Early diagnosis of aortic stenosis (AS) is critical to prevent morbidity and mortality but requires skilled examination with Doppler imaging. This study reports the development and validation of a novel deep learning model that relies on two-dimensional (2D) parasternal long axis videos from transthoracic echocardiography without Doppler imaging to identify severe AS, suitable for point-of-care ultrasonography. METHODS AND RESULTS In a training set of 5257 studies (17 570 videos) from 2016 to 2020 [Yale-New Haven Hospital (YNHH), Connecticut], an ensemble of three-dimensional convolutional neural networks was developed to detect severe AS, leveraging self-supervised contrastive pretraining for label-efficient model development. This deep learning model was validated in a temporally distinct set of 2040 consecutive studies from 2021 from YNHH as well as two geographically distinct cohorts of 4226 and 3072 studies, from California and other hospitals in New England, respectively. The deep learning model achieved an area under the receiver operating characteristic curve (AUROC) of 0.978 (95% CI: 0.966, 0.988) for detecting severe AS in the temporally distinct test set, maintaining its diagnostic performance in geographically distinct cohorts [0.952 AUROC (95% CI: 0.941, 0.963) in California and 0.942 AUROC (95% CI: 0.909, 0.966) in New England]. The model was interpretable with saliency maps identifying the aortic valve, mitral annulus, and left atrium as the predictive regions. Among non-severe AS cases, predicted probabilities were associated with worse quantitative metrics of AS suggesting an association with various stages of AS severity. CONCLUSION This study developed and externally validated an automated approach for severe AS detection using single-view 2D echocardiography, with potential utility for point-of-care screening.
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Affiliation(s)
- Gregory Holste
- Department of Electrical and Computer Engineering, The University of Texas at Austin, Austin, TX, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Evangelos K Oikonomou
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Bobak J Mortazavi
- Department of Computer Science & Engineering, Texas A&M University, College Station, TX, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, USA
| | - Andreas Coppi
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, USA
| | - Kamil F Faridi
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - John K Forrest
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Robert L McNamara
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Lucila Ohno-Machado
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT, USA
| | - Neal Yuan
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Division of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Aakriti Gupta
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Ouyang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Artificial Intelligence in Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Zhangyang Wang
- Department of Electrical and Computer Engineering, The University of Texas at Austin, Austin, TX, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church St 5th Floor, New Haven, CT, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT, USA
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, 60 College St, New Haven, CT, USA
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7
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Emelianova M, Sciacca V, Brinkmann R, Scholtz S, Rudolph V, Bleiziffer S, Rudolph TK, Gerçek M, Vanezi M. Impact of left ventricular end-diastolic pressure as a marker for diastolic dysfunction on long-term outcomes in patients undergoing transcatheter aortic valve replacement. Hellenic J Cardiol 2023:S1109-9666(23)00196-3. [PMID: 37944865 DOI: 10.1016/j.hjc.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/03/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVE The aim of this study was to investigate the proportion of elevated left ventricular end-diastolic pressure (LVEDP) as an indicator of diastolic function after transcatheter aortic valve replacement (TAVR) and its implication in predicting long-term mortality. METHODS We analyzed retrospectively collected data on 3328 patients with severe aortic stenosis undergoing TAVR in our institution between July 2009 and June 2021. Patients were stratified into two groups based on invasive post-procedural LVEDP measurements: normal (<15 mmHg) vs. elevated (≥15 mmHg) LVEDP. RESULTS Mean age of the patients was 81.6 years, and 53.3% were female. Elevated post-procedural LVEDP was identified in 2408 (72.3%) patients. The 5-year mortality rates were higher in the group with elevated LVEDP compared with the group with normal LVEDP (27.4% vs. 8.3%, p = 0.01; hazard ratio [HR] 1.22, 95% CI 1.05-1.41). A multivariate model revealed the following independent predictors of mortality after TAVR: post-procedural elevated LVEDP (HR 1.24, 95% CI 1.01-1.53), pre-procedural significant tricuspid regurgitation (HR 1.24, 95% CI 1.02-1.52) and pulmonary hypertension (PH) (HR 1.53, 95% CI 1.26-1.86). In the present study, a significant paravalvular leak after TAVR was not associated with higher mortality (HR 1.45, 95% CI-0.95-2.19, p = 0.75). CONCLUSION Elevated post-procedural LVEDP in patients who undergo TAVR is an independent predictor of all-cause mortality. Furthermore, PH and tricuspid regurgitation were also identified as predictors of mortality. These data confirm that diastolic dysfunction is an important predictor of mortality in TAVR and should be considered to guide procedure timing, favoring an early interventional approach and management in aortic stenosis patients.
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Affiliation(s)
- Mariia Emelianova
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany.
| | - Vanessa Sciacca
- Clinic for Electrophysiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Regine Brinkmann
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Smita Scholtz
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Volker Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Sabine Bleiziffer
- Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum, Germany
| | - Tanja K Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Muhammed Gerçek
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Maria Vanezi
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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8
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Dweck MR, Loganath K, Bing R, Treibel TA, McCann GP, Newby DE, Leipsic J, Fraccaro C, Paolisso P, Cosyns B, Habib G, Cavalcante J, Donal E, Lancellotti P, Clavel MA, Otto CM, Pibarot P. Multi-modality imaging in aortic stenosis: an EACVI clinical consensus document. Eur Heart J Cardiovasc Imaging 2023; 24:1430-1443. [PMID: 37395329 DOI: 10.1093/ehjci/jead153] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 07/04/2023] Open
Abstract
In this EACVI clinical scientific update, we will explore the current use of multi-modality imaging in the diagnosis, risk stratification, and follow-up of patients with aortic stenosis, with a particular focus on recent developments and future directions. Echocardiography is and will likely remain the key method of diagnosis and surveillance of aortic stenosis providing detailed assessments of valve haemodynamics and the cardiac remodelling response. Computed tomography (CT) is already widely used in the planning of transcutaneous aortic valve implantation. We anticipate its increased use as an anatomical adjudicator to clarify disease severity in patients with discordant echocardiographic measurements. CT calcium scoring is currently used for this purpose; however, contrast CT techniques are emerging that allow identification of both calcific and fibrotic valve thickening. Additionally, improved assessments of myocardial decompensation with echocardiography, cardiac magnetic resonance, and CT will become more commonplace in our routine assessment of aortic stenosis. Underpinning all of this will be widespread application of artificial intelligence. In combination, we believe this new era of multi-modality imaging in aortic stenosis will improve the diagnosis, follow-up, and timing of intervention in aortic stenosis as well as potentially accelerate the development of the novel pharmacological treatments required for this disease.
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Affiliation(s)
- Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Krithika Loganath
- Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Rong Bing
- Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Thomas A Treibel
- Barts Heart Centre, Bart's Health NHS Trust, W Smithfield, EC1A 7BE, London, UK
- University College London Institute of Cardiovascular Science, 62 Huntley St, WC1E 6DD, London, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester, University Rd, Leicester LE1 7RH, UK
- The NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Jonathon Leipsic
- Centre for Cardiovascular Innovation, St Paul's and Vancouver General Hospital, 1081 Burrard St Room 166, Vancouver, British Columbia V6Z 1Y6, Canada
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Science and Public Health, Via Giustiniani, 2 - 35128, Padua, Italy
| | - Pasquale Paolisso
- Cardiovascular Center Aalst, OLV Clinic, Moorselbaan 164, 9300 Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples, Federico II, 80125 Naples, Italy
| | - Bernard Cosyns
- Department of Cardiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Gilbert Habib
- Cardiology Department, Hôpital La Timone, 264 Rue Saint-Pierre, 13005 Marseille, France
| | - João Cavalcante
- Allina Health Minneapolis Heart Institute, Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN 55407, USA
| | - Erwan Donal
- Cardiology and CIC, Université Rennes, 2 Rue Henri Le Guilloux, 35033 Rennes, France
| | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences, Department of Cardiology, University of Liège Hospital, CHU Sart Tilman, Liège, Belgium
- Gruppo Villa Maria Care and Research, Corso Giuseppe Garibaldi, 11, 48022 Lugo RA, Italy
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, 2725 Ch Ste-Foy, Québec, QC G1V 4G5, Canada
- Faculté de Médecine-Département de Médecine, Université Laval, Ferdinand Vandry Pavillon, 1050 Av. de la Médecine, Québec City, Quebec G1V 0A6, Canada
| | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, 4333 Brooklyn Ave NE Box 359458, Seattle, WA 98195-9458, USA
| | - Phillipe Pibarot
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, 2725 Ch Ste-Foy, Québec, QC G1V 4G5, Canada
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9
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Left-atrial volume reduction reflects improvement of cardiac sympathetic nervous function in patients with severe aortic stenosis after transcatheter aortic valve replacement. Heart Vessels 2023:10.1007/s00380-023-02257-6. [PMID: 36928668 DOI: 10.1007/s00380-023-02257-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/01/2023] [Indexed: 03/18/2023]
Abstract
Trans-catheter aortic valve replacement (TAVR) is an excellent alternative intervention for surgical aortic valve replacement. Cardiac sympathetic nervous (CSN) function and left atrial (LA) volume are both important prognostic factors in patients with aortic stenosis (AS) after TAVR. The relationship between the two clinical factors is unknown, however. This retrospective observational study aimed to assess the correlation between CSN function and LA volume in 48 symptomatic patients with severe AS (median age: 85 years, IQR 82-88 years; 81% female) before and after TAVR. CSN function was assessed by performing 123I-metaiodobenzylguanidine (MIBG) scintigraphy before and 6 months after TAVR, and the delayed heart-to-mediastinum ratio (dHMR) and washout rate (WR) were calculated. We also performed transthoracic echocardiography near the same time. TAVR improved the dHMR, WR, and LA volume index (LAVI) (dHMR: median 2.89 [IQR 2.62-3.23] vs. 2.98 [2.49-3.25], p = 0.0182; WR: 28% [24-38] vs. 23% [16-32], p < 0.0001; LAVI: 47.7 mL/m2 [37.8-56.3] vs. 41.2 mL/m2 [33.7-56.1], p = 0.0024). In multiple linear regression analysis, the percentage change in LAVI from baseline to post-TAVR (∆LAVI%) was an independent predictor of change in dHMR from baseline to post-TAVR (β = - 0.35, p = 0.0110). In conclusion, LA volume reduction reflected CSN functional improvement after TAVR. In patients with TAVR, ∆LAVI% might be a valuable parameter for evaluating CSN functional recovery.
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10
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Thellier N, Altes A, Layec J, Castel AL, Delelis F, Hubert T, Outerryck F, Appert L, Tribouilloy C, Maréchaux S. Impact of left atrial and diastolic ventricular dysfunction on mortality in patients with aortic stenosis. Arch Cardiovasc Dis 2023; 116:126-135. [PMID: 36739188 DOI: 10.1016/j.acvd.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/17/2022] [Accepted: 12/20/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Diastolic dysfunction (DD) is common in severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF≥50%). AIM To determine the impact of American Society of Echocardiography/European Association of Cardiovascular Imaging-recommended DD grading and left atrial strain on mortality in a cohort of patients with severe AS and preserved LVEF. METHODS We studied patients with severe AS (aortic valve area indexed<0.6 cm2/m2 and/or aortic valve area<1cm2), LVEF≥50% and no or mild AS-related symptoms. The endpoint was all-cause mortality. RESULTS A total of 387 patients (median age 76years; 53% women) were studied. During a median follow-up of 57 (interquartile range 37; 83) months, 158 patients died. After adjustment for prognostic factors, patients with grade II or III DD had an increased mortality risk versus patients with grade I DD (adjusted hazard ratio (aHR) 1.62, 95% confidence interval (CI) 1.11-2.38; P=0.013; aHR 4.73, 95% CI 2.49-8.99; P<0.001; respectively). Adding peak atrial longitudinal strain (PALS)≤14% to a multivariable model including DD grade improved predictive performance, with better global model fit, reclassification and discrimination. Patients with grade III DD or grade II DD+PALS≤14% displayed an increased mortality risk versus patients with grade I DD+PALS>14% (aHR 4.17, 95% CI 2.46-7.06; P<0.0001). Those with grade I DD+PALS≤14% or grade II DD+PALS>14% were at intermediate risk (aHR 1.63, 95% CI 1.07-2.49; P=0.024). CONCLUSIONS Our results demonstrate the strong relationship between DD and mortality in patients with severe AS and preserved LVEF. Patients with grade III or grade II DD and impaired PALS are at very high risk. These data demonstrate the importance of a comprehensive assessment of diastolic function in patients with severe AS.
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Affiliation(s)
- Nicolas Thellier
- Cardiology Department, Heart Valve Centre, Lille Catholic Hospitals, ETHICS EA 7446, Lille Catholic University, 59462 Lomme Cedex, France
| | - Alexandre Altes
- Cardiology Department, Heart Valve Centre, Lille Catholic Hospitals, ETHICS EA 7446, Lille Catholic University, 59462 Lomme Cedex, France
| | - Jeremy Layec
- Cardiology Department, Heart Valve Centre, Lille Catholic Hospitals, ETHICS EA 7446, Lille Catholic University, 59462 Lomme Cedex, France
| | - Anne Laure Castel
- Cardiology Department, Heart Valve Centre, Lille Catholic Hospitals, ETHICS EA 7446, Lille Catholic University, 59462 Lomme Cedex, France
| | - François Delelis
- Cardiology Department, Heart Valve Centre, Lille Catholic Hospitals, ETHICS EA 7446, Lille Catholic University, 59462 Lomme Cedex, France
| | - Tiffany Hubert
- Cardiology Department, Heart Valve Centre, Lille Catholic Hospitals, ETHICS EA 7446, Lille Catholic University, 59462 Lomme Cedex, France
| | - François Outerryck
- Cardiology Department, Heart Valve Centre, Lille Catholic Hospitals, ETHICS EA 7446, Lille Catholic University, 59462 Lomme Cedex, France
| | - Ludovic Appert
- Cardiology Department, Heart Valve Centre, Lille Catholic Hospitals, ETHICS EA 7446, Lille Catholic University, 59462 Lomme Cedex, France
| | - Christophe Tribouilloy
- Centre Hospitalier Universitaire d'Amiens, 80054 Amiens, France; EA 7517 MP3CV, Jules Verne University of Picardie, 80054 Amiens, France
| | - Sylvestre Maréchaux
- Cardiology Department, Heart Valve Centre, Lille Catholic Hospitals, ETHICS EA 7446, Lille Catholic University, 59462 Lomme Cedex, France; EA 7517 MP3CV, Jules Verne University of Picardie, 80054 Amiens, France.
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11
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Lewandowski D, Yang EY, Nguyen DT, Khan MA, Malahfji M, El Tallawi C, Chamsi Pasha MA, Graviss EA, Shah DJ, Nagueh SF. Relation of Left Ventricular Diastolic Function to Global Fibrosis Burden: Implications for Heart Failure Risk Stratification. JACC Cardiovasc Imaging 2023:S1936-878X(23)00032-3. [PMID: 37038874 DOI: 10.1016/j.jcmg.2022.12.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 04/12/2023]
Abstract
BACKGROUND Left ventricular (LV) diastolic function is primarily assessed by means of echocardiography, which has limited utility in detecting fibrosis. Cardiac magnetic resonance (CMR) readily detects and quantifies fibrosis. OBJECTIVES In this study, the authors sought to determine the association of LV diastolic function by to echocardiography with CMR-determined global fibrosis burden and the incremental value of fibrosis with diastolic function grade in prediction of total mortality and heart failure hospitalizations. METHODS A total of 549 patients underwent comprehensive echocardiography and CMR within 30 days. Echocardiography was used to assess LV diastolic function, and CMR was used to determine LV volumes, mass, ejection fraction, replacement fibrosis, and percentage extracellular volume fraction (ECV). RESULTS Normal diastolic function was present in 142 patients; the rest had diastolic dysfunction grades I to III, except for 18 (3.3%) with indeterminate results. The event rate was higher in patients with diastolic dysfunction compared with patients with normal diastolic function (33.4% vs 15.5; P < 0.001). The model including LV diastolic function grades II and III predicted composite outcome (C-statistic: 0.71; 95% CI: 0.67-0.76), which increased by adding global fibrosis burden (C-statistic: 0.74, 95% CI: 0.70-0.78; P = 0.02). For heart failure hospitalizations, the competing risk model with LV diastolic function grades II and III was good (C-statistic: 0.78; 95% CI: 0.74-0.83) and increased significantly with the addition of global fibrosis burden (C-statistic: 0.80; 95% CI: 0.76-0.85; P = 0.03). CONCLUSIONS Higher grades of diastolic dysfunction are seen in patients with replacement fibrosis and increased ECV. Fibrosis burden as determined with the use of CMR provides incremental prognostic information to echocardiographic evaluation of LV diastolic function.
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Affiliation(s)
| | - Eric Y Yang
- University of Texas Health Science Center, San Antonio, Texas, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, Texas, USA
| | - Mohammad A Khan
- University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Maan Malahfji
- Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | | | | | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, Texas, USA; Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Dipan J Shah
- Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Sherif F Nagueh
- Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA.
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12
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Martín de Miguel I, Jain CC, Egbe AC, Hagler DJ, Connolly HM, Miranda WR. Surgical Repair of Truncus Arteriosus: A Long-Term Hemodynamic Assessment. World J Pediatr Congenit Heart Surg 2022; 13:716-722. [DOI: 10.1177/21501351221114779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Unrepaired truncus arteriosus (TA) carries poor prognosis due to complications of unrestricted pulmonary flow, truncal valve insufficiency, and pulmonary vascular disease. Currently, the hemodynamic profile of adults late after TA repair is unknown. We reviewed the hemodynamics, prevalence, and pathophysiology of pulmonary hypertension (PH) in this population. Methods: Eighteen adult patients with repaired TA who underwent cardiac catheterization at Mayo Clinic, MN, between 1997 and 2021 were identified. PH was defined as either precapillary (mean pulmonary artery pressure [mPAP] ≥25 mm Hg, pulmonary artery wedge pressure [PAWP] ≤15 mm Hg, and pulmonary vascular resistance [PVR] >3 Wood units), isolated postcapillary (mPAP ≥25, PAWP >15, PVR ≤3), or combined (mPAP ≥25, PAWP >15, and PVR >3). Diastolic pressure and transpulmonary gradients were used as ancillary data for classification. Results: Mean age at catheterization was 34 ± 10 years. Mean right ventricular (RV) systolic pressure was 82 ± 22.6 mm Hg, mean right and left mPAPs 28.1 ± 16.2 and 27.9 ± 11.9 mm Hg, respectively. Seven patients (41.2%) had PAWP >15 mm Hg and, among those undergoing arterial catheterization, 7 (53.8%) had a left ventricular (LV) end-diastolic pressure >15 mm Hg. PH was diagnosed in 13 patients (72.2%): 6 (33.3%) precapillary, 4 (22.2%) isolated postcapillary, and 3 (16.7%) combined. PAWP >15 mm Hg was associated with male sex ( P = .049), <moderate RV dysfunction ( P = .049), and lesser RV conduit mean systolic gradient ( P = .02). Patients with PH with precapillary component were older at catheterization ( P = .046). Conclusions: In adults with repaired TA, precapillary PH was only present in one-third of patients with mPAPs not significantly increased in most, whereas elevated PAWP and left-heart disease were common.
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Affiliation(s)
| | - C. Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alexander C. Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Donald J. Hagler
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Heidi M. Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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13
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Wan L, Tang J, Xiao Y, Li H, Peng Z, Xu DY, Shen L. Improvement of hemodynamic parameters in aortic stenosis patients with transcatheter valve replacement by using impedance cardiography. Front Cardiovasc Med 2022; 9:950437. [PMID: 36204567 PMCID: PMC9530126 DOI: 10.3389/fcvm.2022.950437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background The hemodynamic changes of patients with aortic stenosis (AS) who underwent transcatheter valve replacement (TAVR) have not been completely investigated. Methods and results We enrolled 74 patients with AS who underwent TAVR and assessed cardiac function changes at 1 week post-operation by impedance cardiography (ICG) in a supine position at rest for more than 15 min. Of the 74 patients, 47 had preserved left ventricular ejection fraction (LVEF ≥ 50%; preserved-LVEF group) and 27 had reduced LVEF (LVEF <50%; reduced-LVEF group). TAVR improved the cardiac structure and function, as evidenced by the decrease in the left ventricular end-diastolic (LVED), left atrial diameter (LAD), and an increase in the LVEF. We observed a decrease in N-terminal pro-brain natriuretic peptide (NT-proBNP) level compared to that before treatment. Moreover, patients with reduced LVEF had a more significant reduction of NT-proBNP than those with preserved LVEF. Meanwhile, the blood pressure of patients had no significant differences pre- and post-operation. Based on ICG, there were no changes in the parameter of cardiac preload [thoracic fluid content (TFC)]. We observed an improvement in parameters of diastolic cardiac function [left ventricular ejection time (LVET) and pre-ejection period (PEP)]. And we detected converse results in parameters of heart systolic function [systolic time ratio (STR), cardiac output (CO), cardiac index (CI), stroke index (SI), and stroke volume (SV)] and cardiac afterload [stroke systemic vascular resistance (SSVR) and SSVR-index (SSVRI)]. In addition, TFC level was decreased in patients with thoracic volume overload after valve replacement. Subgroup analysis showed that the changes in those parameters were more noticeable in patients with reduced LVEF than that with preserved LVEF. Moreover, we observed no effects on parameters of heart systolic function and heart afterload in the LVEF ≥ 50% group before and after TAVR. Conclusion Our data revealed a beneficial effect of TAVR in diastolic function and preload as detected by the ICG. But the LV systolic function and cardiac afterload were not improved in patients with LVEF <50%. The result indicated that ICG could be used as an important technique to monitor the cardiac condition of patients after aortic valve replacement.
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14
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Popevska S, Rademakers F. Prolonged Asynchronous Left Ventricular Isovolumic Relaxation Constant in Ascending Compared to Descending Thoracic Aortic Stenosis for Chronic Early Left Ventricular Afterload and Late Left Ventricular Afterload Increase. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2022; 43:89-99. [PMID: 35843925 DOI: 10.2478/prilozi-2022-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Background: In arterial hypertension, left ventricular relaxation is affected early on in relation to a chronic difference in peak left ventricular afterload with early development of HF. Objective: in ascending compares to descending thoracic aortic stenosis, resulting in chronic late and early LV afterload increase, to assess the left ventricular isovolumic relaxation pressure decay constant through regression analysis, a parameter of left ventricular relaxation on the 4th and 8th week period from invasive left ventricular pressure measurements. Methods: fourteen pigs underwent posterolateral thoracotomy for ascending aortic stenosis, resulting in chronic early left ventricular afterload increase (EL = 6], or descending thoracic aortic stenosis creating chronic late systolic left ventricular load (LL = 8]. Exponential regression with nonzero asymptote for τ assessment, with linear and nonlinear regression were performed on isovolumic relaxation pressure decay from the left ventricular invasive pressure measurements on 4th and 8th week. Two-way repeated measurement ANOVA, post-hoc Tukey test and linear regression were performed for statistical analysis. Results presented are mean ± SEM or median (quartiles], with significance is at p < 0.05. Results: The ascending aortic stenosis associated with prolonged biexponential asynchronous τ, compared to the descending thoracic aorta stenosis, resulted in data that were different at the 8th week in presence of respirations (interaction p < 0.05]. Monoexponential and linear τ were not different in either respiration being preserved or suspended transitionally and in preload reduction. Preload sensitive response of τ was found in ascending compared to descending thoracic aortic banding that reduced in EL and in LL it increased with load reduction (p < 0.05]. These results indicated that τ is not different in and between LV afterloading conditions in a chronic setting, although it indicates that myocardial ischemia is present and that it is greater in ascending aortic banding, compared to descending thoracic aorta banding at the 8th week. Conclusion: In different sequence of the left ventricular afterload, ventricular relaxation is affected early on, having in EL compared to LL prolonged biexponential asynchronous left ventricular relaxation constant, thus indicating the development left ventricular myocardial ischemia and different elastic recoil in an invasive left ventricular hemodynamic assessment.
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Affiliation(s)
- Sofija Popevska
- Imaging and Dynamics, Department of Cardiovascular Sciences, Katholieke Universitet Leuven, Medical Faculty Leuven, Belgium
| | - Frank Rademakers
- Imaging and Dynamics, Department of Cardiovascular Sciences, Katholieke Universitet Leuven, Medical Faculty Leuven, Belgium
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15
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Kusunose K. Is diastolic dysfunction a red flag sign in moderate aortic stenosis? BRITISH HEART JOURNAL 2022; 108:1340-1341. [PMID: 35688474 DOI: 10.1136/heartjnl-2022-321137] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
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16
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Stassen J, Ewe SH, Butcher SC, Amanullah MR, Mertens BJ, Hirasawa K, Singh GK, Sin KY, Ding ZP, Pio SM, Sia CH, Chew N, Kong W, Poh KK, Cohen D, Généreux P, Leon MB, Ajmone Marsan N, Delgado V, Bax JJ. Prognostic implications of left ventricular diastolic dysfunction in moderate aortic stenosis. Heart 2022; 108:1401-1407. [PMID: 35688475 DOI: 10.1136/heartjnl-2022-320886] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/13/2022] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE To investigate the prognostic impact of left ventricular (LV) diastolic dysfunction in patients with moderate aortic stenosis (AS) and preserved LV systolic function. METHODS Patients with a first diagnosis of moderate AS (aortic valve area >1.0 and ≤1.5 cm2) and preserved LV systolic function (LV ejection fraction ≥50%) were identified. LV diastolic function was evaluated using echocardiographic criteria according to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Clinical outcomes were defined as all-cause mortality and a composite of all-cause mortality and aortic valve replacement (AVR). RESULTS Of 1247 patients (age 74±10 years, 47% men), 535 (43%) had LV diastolic dysfunction at baseline. Patients with LV diastolic dysfunction showed significantly higher mortality rates at 1-year, 3-year and 5-year follow-up (13%, 30% and 41%, respectively) when compared with patients with normal LV diastolic function (6%, 17% and 29%, respectively) (p<0.001). On multivariable analysis, LV diastolic dysfunction was independently associated with all-cause mortality (HR 1.368; 95% CI 1.085 to 1.725; p=0.008) and the composite endpoint of all-cause mortality and AVR (HR 1.241; 95% CI 1.035 to 1.488; p=0.020). CONCLUSIONS LV diastolic dysfunction is independently associated with all-cause mortality and the composite endpoint of all-cause mortality and AVR in patients with moderate AS and preserved LV systolic function. Assessment of LV diastolic function therefore contributes significantly to the risk stratification of patients with moderate AS. Future clinical trials are needed to investigate whether patients with moderate AS and LV diastolic dysfunction may benefit from earlier valve intervention.
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Affiliation(s)
- Jan Stassen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - See Hooi Ewe
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Steele C Butcher
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Bart J Mertens
- Department of Bioinformatics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Kensuke Hirasawa
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gurpreet K Singh
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kenny Y Sin
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Zee Pin Ding
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Stephan M Pio
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore
| | - Nicholas Chew
- Department of Cardiology, National University Heart Centre, Singapore
| | - William Kong
- Department of Cardiology, National University Heart Centre, Singapore
| | - Kian Keong Poh
- Department of Cardiology, National University Heart Centre, Singapore
| | - David Cohen
- Department of Cardiology, Saint Francis Hospital The Heart Center, Roslyn, New York, USA
| | - Philippe Généreux
- Department of Cardiology, Morristown Medical Center, Morristown, New Jersey, USA
| | - Martin B Leon
- Department of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands .,Department of Cardiology, Turku Heart Center, Turku, Finland
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17
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Nair RM, Chawla S, Verma B, Kumar S, Abou Hassan O, Ghimire B, Lak HM, Chahine J, Yun J, Puri R, Reed GW, Krishnaswamy A, Harb SC, Kapadia S. Impact of elevated left ventricular filling pressure on long-term outcomes after transcatheter aortic valve replacement. Open Heart 2022; 9:openhrt-2022-002015. [PMID: 35728890 PMCID: PMC9214428 DOI: 10.1136/openhrt-2022-002015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/11/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Increase in left ventricular filling pressure (FP) and diastolic dysfunction are established consequences of progressive aortic stenosis (AS). However, the impact of elevated FP as detected by pretranscatheter aortic valve replacement (TAVR) echocardiogram on long-term outcomes after TAVR remains unclear. OBJECTIVE To understand the impact of elevated FP in patients with severe AS who undergo TAVR. METHODS This was a retrospective study of all patients who underwent TAVR between 1 January 2014 and 31 December 2017. The presence of elevated FP was determined in accordance with the latest guidelines using the last available comprehensive echocardiogram prior to TAVR. RESULTS Of 983 patients who were included in our study, 422 patients (43%) were found to have elevated FP and 561 patients (57%) had normal FP prior to TAVR. Patients with elevated FP had a mean age of 81.2±8.6 years and were more likely to be males (62%), diabetic (41% vs 35%, p=0.046), and have a higher prevalence of atrial fibrillation (Afib) (53% vs 39%, p<0.001). The 5-year all-cause mortality after TAVR was significantly higher in patients with elevated FP when compared with patients with normal FP (32% vs 24%, p=0.006). The presence of elevated FP, history of Afib and prior PCI emerged as independent predictors of long-term mortality after TAVR. CONCLUSION Elevated FP is associated with increased mortality in patients with severe AS undergoing TAVR. Assessment of FP should be incorporated into the risk assessment of AS patients to identify those who may benefit from early intervention.
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Affiliation(s)
- Raunak M Nair
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sanchit Chawla
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Beni Verma
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sachin Kumar
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ossama Abou Hassan
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Bindesh Ghimire
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hassan Mehmood Lak
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Johnny Chahine
- Department of Cardiovascular Medicine, University of Minnesota System, Minneapolis, Minnesota, USA
| | - James Yun
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rishi Puri
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Grant W Reed
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amar Krishnaswamy
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Serge C Harb
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Samir Kapadia
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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18
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Rahman F, Resar JR. TAVI Beyond 3 Years: Durability and Predictors for Survival. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:417-425. [PMID: 34182824 DOI: 10.1177/15569845211017558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The use of transcatheter aortic valve implantation (TAVI) has greatly increased over the past 2 decades and now has overtaken surgical aortic valve replacement. We have limited data regarding the long-term durability of TAVI and the predictors of survival. Calcification, inflammation, fibrous tissue deposition, and mechanical stress are important in the structural deterioration of surgical bioprosthetic valves and likely contribute to TAVI durability. However, TAVI has several differences to surgical valve replacement such as valve preparation, valve to native anatomy interaction, and valve sizing which all likely contribute to durability and long-term survival. Most procedures have been performed on older patients and therefore long-term follow-up studies have noted mortality of approximately 50% at 5 years and 75% by 7 years. Current data are limited by the high mortality of patients who have received TAVI often as a result of age, frailty, and other competing comorbidities. TAVI as compared with surgical valve replacement is associated with several differences including higher conduction abnormalities (i.e., need for pacemakers) and paravalvular leak, both of which may affect long-term morbidity and mortality. In this review, we discuss the current status of our knowledge and identify areas that require further investigation.
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Affiliation(s)
- Faisal Rahman
- 1501 Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jon R Resar
- 1501 Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Jin XY, Petrou M, Hu JT, Nicol ED, Pepper JR. Challenges and opportunities in improving left ventricular remodelling and clinical outcome following surgical and trans-catheter aortic valve replacement. Front Med 2021; 15:416-437. [PMID: 34047933 DOI: 10.1007/s11684-021-0852-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 02/20/2021] [Indexed: 11/26/2022]
Abstract
Over the last half century, surgical aortic valve replacement (SAVR) has evolved to offer a durable and efficient valve haemodynamically, with low procedural complications that allows favourable remodelling of left ventricular (LV) structure and function. The latter has become more challenging among elderly patients, particularly following trans-catheter aortic valve implantation (TAVI). Precise understanding of myocardial adaptation to pressure and volume overloading and its responses to valve surgery requires comprehensive assessments from aortic valve energy loss, valvular-vascular impedance to myocardial activation, force-velocity relationship, and myocardial strain. LV hypertrophy and myocardial fibrosis remains as the structural and morphological focus in this endeavour. Early intervention in asymptomatic aortic stenosis or regurgitation along with individualised management of hypertension and atrial fibrillation is likely to improve patient outcome. Physiological pacing via the His-Purkinje system for conduction abnormalities, further reduction in para-valvular aortic regurgitation along with therapy of angiotensin receptor blockade will improve patient outcome by facilitating hypertrophy regression, LV coordinate contraction, and global vascular function. TAVI leaflet thromboses require anticoagulation while impaired access to coronary ostia risks future TAVI-in-TAVI or coronary interventions. Until comparable long-term durability and the resolution of TAVI related complications become available, SAVR remains the first choice for lower risk younger patients.
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Affiliation(s)
- Xu Yu Jin
- Surgical Echo-Cardiology Services, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK.
- Cardiac Surgical Physiology and Genomics Group, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK.
| | - Mario Petrou
- Department of Cardiac Surgery, Royal Brompton Hospital, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, SW3 6LY, UK
| | - Jiang Ting Hu
- Cardiac Surgical Physiology and Genomics Group, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Ed D Nicol
- National Heart and Lung Institute, Imperial College London, London, SW3 6LY, UK
- Department of Cardiology, Royal Brompton Hospital, London, SW3 6NP, UK
| | - John R Pepper
- Department of Cardiac Surgery, Royal Brompton Hospital, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, SW3 6LY, UK
- NIHR Imperial Biomedical Research Centre, London, W2 1NY, UK
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20
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Nazir S, Ahuja KR, Ariss RW, Changal K, Khuder SA, Moukarbel GV. Home health care utilization trend, predictors, and association with early rehospitalization following endovascular transcatheter aortic valve replacement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 36:1-6. [PMID: 34045166 DOI: 10.1016/j.carrev.2021.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Home healthcare (HHC) utilization is associated with higher rates of rehospitalization in patients with heart failure and transcatheter mitral valve repair. This study sought to assess the utilization, predictors, and the association of HHC with 30-day readmission in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS/MATERIALS We queried the Nationwide Readmission Database from January 2012 to December 2017 for TAVR discharges with and without HHC referral. Using multivariate analysis, we identified predictors of HHC utilization, and its association with outcomes. RESULTS Of 60,950 TAVR discharges, 21,724 (35.7%) had HHC referral. On multivariable analysis, female sex (OR, 1.34; 95% CI, 1.29-1.40), non-elective admission (OR, 1.49; 95% CI, 1.42-1.56), diabetes mellitus (OR, 1.09; 95% CI, 1.05-1.13), prior stroke (OR, 1.06; 95% CI, 1.01-1.12), anemia (OR, 1.16; 95% CI, 1.11-1.21), and in-hospital complications including cardiogenic shock (OR, 1.37; 95% CI, 1.16-1.50), cardiac arrest (OR, 1.22; 95% CI, 1.00-1.50), stroke (OR, 2.62; 95% CI, 2.20-3.18), and new Permanent pacemaker (OR, 1.49; 95% CI, 1.41-1.58) were identified as independent predictors of HHC referral. HHC utilization was associated with longer median length of stay (4 days vs. 2 days, P < 0.001), higher rate of 30-day all-cause (15.5% vs. 10.6%, P < 0.001) and heart failure (2.1%vs. 1.1%, P < 0.001) readmission rates compared to those without HHC. CONCLUSIONS Our study identified a vulnerable group of TAVR patients that are at higher risk of 30-day readmission. Evidence-based interventions proven effective in reducing the burden of readmissions should be pursed in these patients to improve outcomes and quality of life.
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Affiliation(s)
- Salik Nazir
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Keerat Rai Ahuja
- Department of Cardiology, Reading Hospital-Tower Health System, West Reading, PA, USA
| | - Robert W Ariss
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Khalid Changal
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Sadik A Khuder
- Department of Medicine and Public Health, University of Toledo, Toledo, OH, USA
| | - George V Moukarbel
- Division of Cardiovascular Medicine, Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA.
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21
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Aortic Stenosis and Diastolic Dysfunction: Partners in Crime. J Am Coll Cardiol 2021; 76:2952-2955. [PMID: 33334423 DOI: 10.1016/j.jacc.2020.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 10/19/2020] [Indexed: 01/28/2023]
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22
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Fuster V. Editor-in-Chief's Top Picks From 2020. J Am Coll Cardiol 2021; 77:937-997. [PMID: 33602476 DOI: 10.1016/j.jacc.2020.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Each week, I record audio summaries for every paper in JACC, as well as an issue summary. Although this process is quite time-consuming, I have become familiar with every paper that we publish. Thus, I have personally selected the top 100 papers (both Original Investigations and Review Articles) from the distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC, as well as their Central Illustrations. The highlights comprise the following sections: Basic & Translational Research, Cardiac Failure & Myocarditis, Cardiomyopathies & Genetics, Cardio-Oncology, Congenital Heart Disease, Coronary Disease & Interventions, Coronavirus (as a NEW section), Hypertension, Imaging, Metabolic & Lipid Disorders, Neurovascular Disease & Dementia, Promoting Health & Prevention, Rhythm Disorders & Thromboembolism, Valvular Heart Disease, and Vascular Medicine (1-100).
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