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Puehler T, Pommert NS, Freitag-Wolf S, Seoudy H, Ernst M, Haneya A, Sathananthan J, Sellers SL, Meier D, Schöttler J, Müller OJ, Salehi Ravesh M, Saad M, Frank D, Lutter G. Tricuspid Regurgitation and TAVR: Outcomes, Risk Factors and Biomarkers. J Clin Med 2024; 13:1474. [PMID: 38592316 PMCID: PMC10934629 DOI: 10.3390/jcm13051474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/20/2024] [Accepted: 01/29/2024] [Indexed: 04/10/2024] Open
Abstract
Background. The significance of concomitant tricuspid regurgitation (TR) in the context of transcatheter aortic valve replacement (TAVR) remains unclear. This study aimed to analyze the severity of TR before and after TAVR with regard to short- and long-term survival and to analyze the influencing factors. Methods. In our retrospective analysis, TR before and after TAVR was examined and patients were classified into groups accordingly. Special attention was paid to patients with post-interventional changes in TR. Mortality after TAVR was considered the primary endpoint of the analysis and major complications according to the Valve Academic Research Consortium 3 (VARC3) were compared. Moreover, biomarkers and risk factors for worsening or improvement of TR through TAVR were analyzed. Results. Among 775 patients who underwent TAVR in our center between January 2009 and December 2019, 686 patients (89%) featured low- and 89 patients (11%) high-grade TR. High-grade pre-TAVR TR was associated with worse short- (30-day), mid- (2-year) and long-term survival up to 8 years. Even though in nearly half of the patients with high-grade TR the regurgitation improved within seven days after TAVR (n = 42/89), this did not result in a survival benefit for this subgroup. On the other hand, a worsening of low-grade TR was seen in more than 10% of the patients (n = 73/686), which was also associated with a worse prognosis. Predictors of worsening of TR after TAVR were adipositas, impaired right ventricular function and the presence of mild TR. Age, atrial fibrillation, COPD, impaired renal function and elevated cardiac biomarkers were risk factors for mortality after TAVR independent from the grade of TR. Conclusions. Not only pre-interventional, but also post-TAVR high-grade TR is associated with a worse prognosis after TAVR. TAVR can change concomitant tricuspid regurgitation, but improvement does not have any impact on short- and long-term survival. Worsening of TR after TAVR is possible and impairs the prognosis.
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Affiliation(s)
- Thomas Puehler
- Department of Cardiac and Vascular Surgery, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller Strasse 3, D-24105 Kiel, Germany; (N.S.P.); (M.E.); (J.S.); (G.L.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, 23562 Lübeck, Germany; (O.J.M.); (D.F.)
| | - Nina Sophie Pommert
- Department of Cardiac and Vascular Surgery, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller Strasse 3, D-24105 Kiel, Germany; (N.S.P.); (M.E.); (J.S.); (G.L.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, 23562 Lübeck, Germany; (O.J.M.); (D.F.)
| | - Sandra Freitag-Wolf
- Institute of Medical Informatics and Statistics, University Medical Center Schleswig-Holstein, Campus Kiel, D-24105 Kiel, Germany;
| | - Hatim Seoudy
- Department of Internal Medicine III (Cardiology, Angiology, and Critical Care), University Medical Center Schleswig-Holstein, Campus Kiel, D-24105 Kiel, Germany; (H.S.); (M.S.)
| | - Markus Ernst
- Department of Cardiac and Vascular Surgery, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller Strasse 3, D-24105 Kiel, Germany; (N.S.P.); (M.E.); (J.S.); (G.L.)
| | - Assad Haneya
- Department of Cardiac and Vascular Surgery, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller Strasse 3, D-24105 Kiel, Germany; (N.S.P.); (M.E.); (J.S.); (G.L.)
| | - Janarthanan Sathananthan
- Center for Heart Valve Innovation & Cardiovascular Translational Laboratory, St Paul’s Hospital, University of British Columbia, Vancouver, BC V5Z 1M9, Canada; (J.S.); (S.L.S.); (D.M.)
| | - Stephanie L. Sellers
- Center for Heart Valve Innovation & Cardiovascular Translational Laboratory, St Paul’s Hospital, University of British Columbia, Vancouver, BC V5Z 1M9, Canada; (J.S.); (S.L.S.); (D.M.)
| | - David Meier
- Center for Heart Valve Innovation & Cardiovascular Translational Laboratory, St Paul’s Hospital, University of British Columbia, Vancouver, BC V5Z 1M9, Canada; (J.S.); (S.L.S.); (D.M.)
| | - Jan Schöttler
- Department of Cardiac and Vascular Surgery, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller Strasse 3, D-24105 Kiel, Germany; (N.S.P.); (M.E.); (J.S.); (G.L.)
| | - Oliver J. Müller
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, 23562 Lübeck, Germany; (O.J.M.); (D.F.)
- Department of Internal Medicine III (Cardiology, Angiology, and Critical Care), University Medical Center Schleswig-Holstein, Campus Kiel, D-24105 Kiel, Germany; (H.S.); (M.S.)
| | - Mona Salehi Ravesh
- Department of Radiology and Neuroradiology, University Medical Center Schleswig-Holstein, Campus Kiel, D-24105 Kiel, Germany;
| | - Mohammed Saad
- Department of Internal Medicine III (Cardiology, Angiology, and Critical Care), University Medical Center Schleswig-Holstein, Campus Kiel, D-24105 Kiel, Germany; (H.S.); (M.S.)
| | - Derk Frank
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, 23562 Lübeck, Germany; (O.J.M.); (D.F.)
- Department of Internal Medicine III (Cardiology, Angiology, and Critical Care), University Medical Center Schleswig-Holstein, Campus Kiel, D-24105 Kiel, Germany; (H.S.); (M.S.)
| | - Georg Lutter
- Department of Cardiac and Vascular Surgery, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller Strasse 3, D-24105 Kiel, Germany; (N.S.P.); (M.E.); (J.S.); (G.L.)
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, 23562 Lübeck, Germany; (O.J.M.); (D.F.)
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Horinouchi H, Nagai T, Ohno Y, Miyamoto J, Kamioka N, Murakami T, Yoshioka K, Ikari Y. Mechanisms and implications of mitral regurgitation in patients with severe aortic stenosis who received transcatheter aortic valve replacement. Echocardiography 2023; 40:1187-1195. [PMID: 37715609 DOI: 10.1111/echo.15693] [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: 06/07/2023] [Accepted: 09/08/2023] [Indexed: 09/17/2023] Open
Abstract
INTRODUCTION This study aimed to investigate the mechanisms and clinical implications of mitral regurgitation (MR) in patients with severe aortic stenosis (AS) who received transcatheter aortic valve replacement (TAVR). METHODS We conducted retrospective echocardiographic analyses at baseline and 6 months after TAVR in 140 patients with symptomatic AS (85 ± 5 years) who underwent TAVR. We defined significant MR as ≥ moderate based on evaluation of transthoracic echocardiography (TTE). RESULTS There were 48 patients (34%) with preexisting MR at the baseline. Among measured TTE parameters, end-systolic wall stress (ESWS), mitral annulus area, and mitral valve thickening index were independent factors associated with preexisting MR (odds ratio [OR]: 1.013, 95% confidence interval [CI]: 1.005-1.021; OR: 1.740, 95% CI: 1.314-2.376; OR: 2.306, 95% CI: 1.426-3.848; respectively). Six months after TAVR, there were 34 patients with post-existing MR, A history of atrial fibrillation and ESWS after TAVR were independent factors (OR: 3.013, 95% CI: 1.208-7.556; OR: 1.013, 95% CI: 1.000-1.023; respectively). The Kaplan-Meier plot indicated that preexisting MR was a risk factor for heart failure-related events within 1 year of discharge after TAVR (p = .012). CONCLUSIONS In patients who underwent TAVR for severe AS, preexisting MR was associated with having a thickened mitral valve and large mitral annulus size induced by high ESWS. These patients may have worse prognosis after TAVR and should be closely monitored in the long term.
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Affiliation(s)
- Hitomi Horinouchi
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Tomoo Nagai
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Yohei Ohno
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Junichi Miyamoto
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Norihiko Kamioka
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Tsutomu Murakami
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Koichiro Yoshioka
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
| | - Yuji Ikari
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine, Isehara-shi, Kanagawa, Japan
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Poch F, Thalmann R, Olbrich I, Fellner C, Stundl A, Barthel P, Bradaric C, Laugwitz KL, Kupatt C, Ledwoch J. Changes of Right Ventricular Function After Transcatheter Aortic Valve Replacement and Association With Outcomes. J Card Fail 2021; 27:1337-1344. [PMID: 33839289 DOI: 10.1016/j.cardfail.2021.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Baseline right ventricular (RV) dysfunction represents a predictor for poor outcome in patients undergoing transcatheter aortic valve replacement (TAVR). However, RV function may improve after TAVR, which could have important implications on outcomes. The aim of the present study was to assess changes in RV function after TAVR and its prognostic value regarding clinical outcome. METHODS AND RESULTS Patients undergoing TAVR at our institution were consecutively enrolled and categorized into 4 groups according to changes in RV function during echocardiographic follow-up at 6 months. A total of 188 patients were included. Of those showing normal function at baseline, 87% (130/149) had preserved RV function at follow-up (group 1), whereas 13% (19/149) developed new RV dysfunction (group 2). Of those with RV dysfunction at baseline (39 patients), RV function normalized in 46% (18/39) (group 3) and remained impaired in 54% (21/39) (group 4). The Kaplan-Meier estimated survival at 3 years was highest in patients in group 1 (83%), intermediate in group 2 (65%) and 3 (69%), whereas group 4 had the worst survival (37%; P < .001). Furthermore, new or persistent RV dysfunction was identified to be independently associated with mortality during follow-up (hazard ratio 2.55; interquartile range 1.03-6.47, P = .004). CONCLUSIONS Patients with preserved RV function have a high 3-year survival. Normalization of RV function showed improved survival compared with patients with persistent RV dysfunction, who had a dismal prognosis despite TAVR.
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Affiliation(s)
- Felix Poch
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Ruth Thalmann
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Ida Olbrich
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Carmen Fellner
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Anja Stundl
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Petra Barthel
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Christian Bradaric
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Karl-Ludwig Laugwitz
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Christian Kupatt
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Jakob Ledwoch
- Klinik und Poliklinik für Innere Medizin I, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany.
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Adamo M, Fiorina C, Petronio AS, Giannini C, Tamburino C, Barbanti M, Bedogni F, Testa L, Colombo A, Latib A, Bruschi G, Reimers B, Poli A, Nazzaro MS, Curello S, Ettori F. Comparison of Early and Long-Term Outcomes After Transcatheter Aortic Valve Implantation in Patients with New York Heart Association Functional Class IV to those in Class III and Less. Am J Cardiol 2018; 122:1718-1726. [PMID: 30227961 DOI: 10.1016/j.amjcard.2018.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 08/01/2018] [Accepted: 08/07/2018] [Indexed: 12/12/2022]
Abstract
Our aim was to investigate the impact of a baseline New York Heart Association (NYHA) class IV on clinical outcomes of a large real-world population who underwent transcatheter aortic valve implantation (TAVI). The primary end points were all-cause mortality, cardiovascular mortality, and re-hospitalization, evaluated at the longest available follow-up and by means of a 3-month landmark analysis. The secondary end points were: change in NYHA class, left ventricular ejection fraction, pulmonary pressure and mitral regurgitation. Out of 2,467 patients, 271 (11%) had a NYHA functional class IV at the admission. The latter had higher Society of Thoracic Surgeons (STS) score (9.2% vs 5.5%; p < 0.001) compared to NYHA ≤ III patients, owing to more comorbidities (prior myocardial infarction, severe long-term kidney disease, atrial fibrillation, left ventricular dysfunction, significant mitral regurgitation, pulmonary hypertension). Device success was similar between the two groups (93.7% vs 94.5%; p = 0.583). At a median follow-up of 15 months (interquartile range 4 to 36 months) a lower freedom from primary end points was observed among NYHA IV versus NYHA ≤ III group (survival from all-cause death: 52% vs 58.4%; p = 0.002; survival from cardiovascular death: 72.5% vs 76.5%; p = 0.091; freedom from re-hospitalization: 81.5% vs 85.4%; p = 0.038). However, after adjustment for baseline imbalance, NYHA IV did not influence the relative risk of long-term primary end points. A 3-month landmark analysis showed that NYHA IV independently predicted 3-month all-cause and cardiovascular mortality (hazard ratio: 1.77; 95% CI [1.10 to 2.83]; p = 0.018 and hazard ratio: 1.64; 95% CI [1.03 to 2.59]; p = 0.036, respectively). Instead, after 3-month follow-up NYHA IV did not affect the risk of primary end points. A significant improvement of the secondary end points was noted in both NYHA IV and NYHA ≤≤ III groups. In conclusion, the presence of NYHA class IV in TAVI candidates was associated to a significant increased risk of mortality within 3 months. Patients with baseline NYHA IV who survived at 3 months had a long-term outcome comparable to that of other subjects. Left ventricular systolic function, pulmonary pressure, and mitral insufficiency significantly improved after TAVI regardless of baseline NYHA class IV.
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Chew PG, Dobson LE, Garg P, Fairbairn TA, Musa TA, Uddin A, Swoboda PP, Foley JR, Fent GJ, Brown LAE, Onciul S, Plein S, Blackman DJ, Greenwood JP. CMR quantitation of change in mitral regurgitation following transcatheter aortic valve replacement (TAVR): impact on left ventricular reverse remodeling and outcome. Int J Cardiovasc Imaging 2018; 35:161-170. [PMID: 30182320 PMCID: PMC6373302 DOI: 10.1007/s10554-018-1441-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 08/13/2018] [Indexed: 12/11/2022]
Abstract
Current echocardiographic data reporting the impact of concomitant mitral regurgitation (MR) on outcome in patients who undergo transcatheter aortic valve replacement (TAVR) are conflicting. Using cardiovascular magnetic resonance (CMR) imaging, this study aimed to assess the impact of MR severity on cardiac reverse remodeling and patient outcome. 85 patients undergoing TAVR with CMR pre- and 6 m post-TAVR were evaluated. The CMR protocol included cines for left (LV) and right ventricular (RV) volumes, flow assessment, and myocardial scar assessment by late gadolinium enhancement (LGE). Patients were dichotomised according to CMR severity of MR fraction at baseline (‘non-significant’ vs ‘significant’) and followed up for a median duration of 3 years. Forty-two (49%) patients had ‘significant MR’ at baseline; they had similar LV and RV size and function compared to the ‘non-significant MR’ group but had greater LV mass at baseline. In those with significant MR at baseline, 77% (n = 32) had a reduction in MR post-TAVR, moving them into the ‘non-significant’ category at 6-months, with an overall reduction in MR fraction from 34 to 17% (p < 0.001). Improvement in MR was not associated with more favourable cardiac reverse remodeling when compared with the ‘non-improvers’. Significant MR at baseline was not associated with increased mortality at follow-up. Significant MR is common in patients undergoing TAVR and improves in the majority post-procedure. Improvement in MR was not associated with more favourable LV reverse remodeling and baseline MR severity was not associated with mortality.
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Affiliation(s)
- Pei G Chew
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Laura E Dobson
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Pankaj Garg
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Timothy A Fairbairn
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Tarique A Musa
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Akhlaque Uddin
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Peter P Swoboda
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - James R Foley
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Graham J Fent
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Louise A E Brown
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Sebastian Onciul
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK
| | | | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, LS2 9JT, UK.
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Predictors of Persistent Tricuspid Regurgitation after Transcatheter Aortic Valve Replacement in Patients with Baseline Tricuspid Regurgitation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:190-199. [DOI: 10.1097/imi.0000000000000504] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective This study sought to analyze outcomes in patients with moderate-severe tricuspid regurgitation (TR) undergoing transcatheter aortic valve replacement (TAVR). The consequences of uncorrected significant TR in patients undergoing TAVR remain undefined. Methods Between 2009 and 2014, 369 patients underwent TAVR at our institution, and 58 of these had baseline moderate-severe TR. Preoperative, 30-day, and 1-year transthoracic echocardiograms were analyzed. Predictors of persistent TR at 30 days and survival were assessed. Results Fifty-eight patients with baseline moderate-severe TR underwent TAVR. Transcatheter aortic valve replacement resulted in significant reductions in pulmonary artery pressures and TR severity (100% vs 64%; P < 0.001) at 30 days. This was sustained at 1 year and was associated with significant improvements in stroke volume index and New York Heart Association functional class. No changes in right ventricular function or size were noted. The only independent predictor of persistent moderate-severe TR at 30 days was preoperative atrial fibrillation [AF; odds ratio (OR), 4.56; 95% confidence interval, 1.1–18.3; P = 0.033]. Independent predictors of overall long-term survival included AF (OR, 0.41; P = 0.001) and chronic lung disease (OR, 0.47; P = 0.011), but not baseline moderate-severe TR. In patients with baseline moderate-severe TR, persistent moderate-severe TR at 30 days was associated with worsened overall survival (log-rank P = 0.02). Conclusions Baseline moderate-severe TR is not uncommon in patients undergoing TAVR, and frequently improves. However, the presence of AF suggests that that TR is likely to persist after TAVR and is also indicative of a poor long-term outcome. Whether redirecting such patients to surgery for concomitant tricuspid valve repair will further improve outcomes requires further study.
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Worku B, Valovska MT, Elmously A, Kampaktsis P, Castillo C, Wong SC, Salemi A. Predictors of Persistent Tricuspid Regurgitation after Transcatheter Aortic Valve Replacement in Patients with Baseline Tricuspid Regurgitation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018. [DOI: 10.1177/155698451801300306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Berhane Worku
- Department of Cardiothoracic Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY USA
- Department of Cardiothoracic Surgery, New York Presbyterian/Brooklyn Methodist Hospital, Brooklyn, NY USA
| | - Marie-Therese Valovska
- Department of Cardiothoracic Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY USA
| | - Adham Elmously
- Department of Cardiothoracic Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY USA
| | - Polydoros Kampaktsis
- Division of Cardiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY USA
| | - Catherine Castillo
- Department of Cardiothoracic Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY USA
- Department of Cardiothoracic Surgery, New York Presbyterian/Brooklyn Methodist Hospital, Brooklyn, NY USA
| | - Shing-Chiu Wong
- Division of Cardiology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY USA
| | - Arash Salemi
- Department of Cardiothoracic Surgery, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY USA
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La insuficiencia tricúspide, y no la insuficiencia mitral, determina la mortalidad en pacientes que presentan insuficiencia mitral no grave previa a TAVI. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2017.08.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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9
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Okada A, Kanzaki H, Amaki M, Kataoka Y, Miyamoto K, Hamatani Y, Fujino M, Takahama H, Hasegawa T, Shimahara Y, Morita Y, Sugano Y, Kusano K, Ohnishi Y, Fujita T, Kobayashi J, Anzai T, Yasuda S. Successful Treatment of Mitral Regurgitation after Transapical Transcatheter Aortic Valve Implantation by Percutaneous Edge-to-edge Mitral Valve Repair (MitraClip ®) -The First Combination Therapy Performed in Japan. Intern Med 2018; 57:1105-1109. [PMID: 29269670 PMCID: PMC5938500 DOI: 10.2169/internalmedicine.9663-17] [Citation(s) in RCA: 6] [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] [Indexed: 11/06/2022] Open
Abstract
A 75-year old man with a history of inferior myocardial infarction was admitted with symptoms of progressive heart failure 3 months after undergoing transapical transcatheter aortic valve implantation (TAVI). Echocardiography revealed severe mitral regurgitation (MR) caused by posterior leaflet tethering, without traumatic injury of the mitral valve or chordae. The patient was successfully treated by percutaneous edge-to-edge mitral valve repair (MitraClip®). This case highlights the role of MitraClip® in high-risk patients suffering from MR, and suggests that apical contractile loss or adhesion caused by apical puncture and suturing in transapical TAVI may be one of the mechanisms of worsening MR.
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Affiliation(s)
- Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yasuhiro Hamatani
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Masashi Fujino
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Hiroyuki Takahama
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Takuya Hasegawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yusuke Shimahara
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Japan
| | - Yoshiaki Morita
- Department of Radiology, National Cerebral and Cardiovascular Center, Japan
| | - Yasuo Sugano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Yoshihiko Ohnishi
- Department of Anesthesiology, National Cerebral and Cardiovascular Center, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Japan
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10
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Right ventricular systolic function in patients undergoing transcatheter aortic valve implantation: A systematic review and meta-analysis. Int J Cardiol 2018; 257:40-45. [DOI: 10.1016/j.ijcard.2018.01.117] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/15/2018] [Accepted: 01/26/2018] [Indexed: 11/15/2022]
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11
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Amat-Santos IJ, Castrodeza J, Nombela-Franco L, Muñoz-García AJ, Gutiérrez-Ibanes E, de la Torre Hernández JM, Córdoba-Soriano JG, Jiménez-Quevedo P, Hernández-García JM, González-Mansilla A, Ruano J, Tobar J, Del Trigo M, Vera S, Puri R, Hernández-Luis C, Carrasco-Moraleja M, Gómez I, Rodés-Cabau J, San Román JA. Tricuspid but not Mitral Regurgitation Determines Mortality After TAVI in Patients With Nonsevere Mitral Regurgitation. ACTA ACUST UNITED AC 2017; 71:357-364. [PMID: 29079280 DOI: 10.1016/j.rec.2017.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/02/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES Many patients undergoing transcatheter aortic valve implantation (TAVI) have concomitant mitral regurgitation (MR) of moderate grade or less. The impact of coexistent tricuspid regurgitation (TR) remains to be determined. We sought to analyze the impact of moderate vs none-to-mild MR and its trend after TAVI, as well as the impact of concomitant TR and its interaction with MR. METHODS Multicenter retrospective study of 813 TAVI patients treated through the transfemoral approach with MR ≤ 2 between 2007 and 2015. RESULTS The mean age was 81 ± 7 years and the mean Society of Thoracic Surgeons score was 6.9% ± 5.1%. Moderate MR was present in 37.3% of the patients, with similar in-hospital outcomes and 6-month follow-up mortality to those with MR < 2 (11.9% vs 9.4%; P = .257). However, they experienced more rehospitalizations and worse New York Heart Association class (P = .008 and .001, respectively). Few patients (3.8%) showed an increase in the MR grade to > 2 post-TAVI. The presence of concomitant moderate/severe TR was associated with in-hospital and follow-up mortality rates of 13% and 34.1%, respectively, regardless of MR grade. Moderate-severe TR was independently associated with mortality (HR, 18.4; 95%CI, 10.2-33.3; P < .001). CONCLUSIONS The presence of moderate MR seemed not to impact short- and mid-term mortality post-TAVI, but was associated with more rehospitalizations. The presence of moderate or severe TR was associated with higher mortality. This suggests that a thorough evaluation of the mechanisms underlying concomitant mitral and tricuspid valve regurgitation should be performed to determine the best strategy for avoiding TAVI-related futility.
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Affiliation(s)
- Ignacio J Amat-Santos
- Departamento de Cardiología, CIBERCV, Hospital Clínico Universitario, Valladolid, Spain.
| | - Javier Castrodeza
- Departamento de Cardiología, CIBERCV, Hospital Clínico Universitario, Valladolid, Spain
| | - Luis Nombela-Franco
- Departamento de Cardiología, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | - Enrique Gutiérrez-Ibanes
- Departamento de Cardiología, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | | | | | - Pilar Jiménez-Quevedo
- Departamento de Cardiología, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | - Ana González-Mansilla
- Departamento de Cardiología, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Javier Ruano
- Departamento de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Javier Tobar
- Departamento de Cardiología, CIBERCV, Hospital Clínico Universitario, Valladolid, Spain
| | - María Del Trigo
- Departamento de Cardiología, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Silvio Vera
- Departamento de Cardiología, CIBERCV, Hospital Clínico Universitario, Valladolid, Spain
| | - Rishi Puri
- Departament of Cardiology, Quebec Heart and Lung Institute, Quebec, Canada
| | | | | | - Itziar Gómez
- Departamento de Cardiología, CIBERCV, Hospital Clínico Universitario, Valladolid, Spain
| | - Josep Rodés-Cabau
- Departament of Cardiology, Quebec Heart and Lung Institute, Quebec, Canada
| | - José A San Román
- Departamento de Cardiología, CIBERCV, Hospital Clínico Universitario, Valladolid, Spain
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12
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Nijenhuis VJ, Huitema MP, Vorselaars VMM, Swaans MJ, de Kroon T, van der Heyden JAS, Rensing BJWM, Heijmen R, Ten Berg JM, Post MC. Echocardiographic pulmonary hypertension probability is associated with clinical outcomes after transcatheter aortic valve implantation. Int J Cardiol 2016; 225:218-225. [PMID: 27732925 DOI: 10.1016/j.ijcard.2016.10.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 10/01/2016] [Accepted: 10/04/2016] [Indexed: 11/17/2022]
Abstract
AIMS Pulmonary hypertension (PH) is associated with mortality after transcatheter aortic valve implantation (TAVI). However, diagnosis based on tricuspid regurgitant velocity (TRV) is often inaccurate and unreliable. The updated PH guidelines introduced a PH probability grading implementing additional PH signs on transthoracic echocardiography (TTE), from which we aimed to analyse its effects on clinical outcomes in patients undergoing TAVI. METHODS AND RESULTS We included 591 consecutive patients (mean age 80.2±8.4years, 58.0% female, mean STS risk score 6.2±3.8%) undergoing TAVI. Patients were divided into "low" (n=270; TRV ≤2.8m/s without additional PH signs), "intermediate" (n=131; TRV ≤2.8m/s with additional PH signs, or TRV 2.9-3.4m/s without additional PH signs), and "high" PH probability (n=190; TRV 2.9-3.4m/s with additional PH signs, or TRV >3.4m/s). The overall 30-day and 2-year mortality rates were 10.2% and 33.8%, respectively. "High" PH probability was an independent predictor of mortality at 30days (HR 3.68, 95% CI 2.03 to 6.67, p<0.01) and 2years (HR 2.19, 95% CI 1.57 to 3.04, p<0.01), compared to "low" PH probability. The "intermediate" group did not show an increased risk. The presence of additional PH signs resulted in a significantly higher mortality at 30days (19.6% vs. 5.1%, p<0.01) and two years (54.2% vs. 22.5%, p<0.01). CONCLUSIONS The updated echocardiographic PH probability model incorporating additional PH signs independently predicts early and late mortality after TAVI. Additional PH signs are of great value in assessing one's risks since its presence is strongly associated with early and late mortality.
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Affiliation(s)
- V J Nijenhuis
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - M P Huitema
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - V M M Vorselaars
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - T de Kroon
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - B J W M Rensing
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - R Heijmen
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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13
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Mitral regurgitation prior to transcatheter aortic valve implantation influences survival but not symptoms. Int J Cardiol 2015; 204:95-100. [PMID: 26655549 DOI: 10.1016/j.ijcard.2015.11.129] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 11/16/2015] [Accepted: 11/22/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Current data about the impact of concomitant mitral regurgitation (MR) on outcome in patients who undergo transcatheter aortic valve implantation (TAVI) are conflicting. Our purpose was to analyze the clinical course of MR and to assess the influence of MR on survival and clinical status after TAVI. METHODS We included 375 consecutive patients who underwent TAVI. MR grade and NYHA class were determined before TAVI and at follow-up. RESULTS In total 171 patients (46%) had MR grade ≥ 2 at baseline and of these 29% improved to MR grade ≤ 1 after TAVI. MR grade ≤ 1 at baseline was present in 204 patients (54%) and of these 17% worsened to grade ≥ 2 after TAVI. Improvement of MR was associated with absence of atrial fibrillation (OR: 2.35, 95%CI: 1.17-4.71, p = 0.02). Worsening of MR was associated with moderate or more aortic valve regurgitation after TAVI (OR: 4.2, CI: 1.83-9.49, p = 0.001). NYHA class improved at follow-up. Baseline MR grade did not determine the degree of clinical improvement (MR grade ≤ 1: NYHA ≥ 3 from 67% to 17%; MR grade ≥ 2: NYHA ≥ 3 from 69% to 14%). Although patients with MR grade ≥ 2 at baseline improved symptomatically, this degree of MR was associated with reduced two year survival compared with patients with MR grade ≤ 1(mortality 37% vs 26%; HR 1.99; 95% CI 1.27-3.13; p = 0.003). CONCLUSION In patients who undergo TAVI almost half have MR grade ≥ 2 prior to the procedure. TAVI had no influence on MR grade at follow-up. Although patients with MR grade ≥ 2 at baseline improved symptomatically after TAVI, concomitant MR at baseline significantly reduced two year survival.
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14
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Barbash IM, Escarcega RO, Minha S, Ben-Dor I, Torguson R, Goldstein SA, Wang Z, Okubagzi P, Satler LF, Pichard AD, Waksman R. Prevalence and impact of pulmonary hypertension on patients with aortic stenosis who underwent transcatheter aortic valve replacement. Am J Cardiol 2015; 115:1435-42. [PMID: 25776456 DOI: 10.1016/j.amjcard.2015.02.022] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 02/13/2015] [Accepted: 02/13/2015] [Indexed: 10/24/2022]
Abstract
Limited amount of data suggest that patients with aortic stenosis and pulmonary hypertension (PH) who undergo transcatheter aortic valve replacement (TAVR) experience decrease in PH postprocedure. Inconsistent use of systolic pulmonary artery pressure cut-off values in previous studies limits our ability to draw meaningful conclusions regarding the prognostic role of PH in assessment of TAVR candidates. A total of 415 consecutive patients who underwent TAVR were included in the present study. Two groups were compared based on receiver-operating characteristics curve analysis for the best SPAP value to predict outcome, yielding 2 study groups of no/mild PH (≤50 mm Hg; n = 172, 41%) versus moderate/severe PH (>50 mm Hg; n = 243, 59%). Demographics and co-morbidities were comparable between the 2 groups; however, right-sided cardiac failure (35% vs 19.8%, p = 0.02) and mitral regurgitation (18.4% vs 8.6%, p = 0.007) were more frequent in patients with moderate/severe PH. Procedural characteristics and complications were comparable between the groups. Although there was an early overall decrease in SPAP postprocedure, only 26% of moderate/severe patients with PH experienced a significant decrease in SPAP (>10 mm Hg). The 30-day (14.5% vs 7.4%, p = 0.02) and 1-year mortality (30.8% vs 21%, p = 0.02) was higher in moderate/severe patients with PH. In multivariate analysis, systolic pulmonary artery pressure and chronic lung disease were identified as independent predictors for mortality at 1 year. PH is a frequent co-morbidity in patients with severe aortic stenosis who underwent TAVR. Significantly elevated pulmonary artery pressures at baseline may serve as a poor prognostic factor when performing preprocedural assessment of the patients.
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Schewel D, Schewel J, Martin J, Voigtländer L, Frerker C, Wohlmuth P, Thielsen T, Kuck KH, Schäfer U. Impact of transcatheter aortic valve implantation (TAVI) on pulmonary hyper-tension and clinical outcome in patients with severe aortic valvular stenosis. Clin Res Cardiol 2014; 104:164-74. [DOI: 10.1007/s00392-014-0772-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 10/14/2014] [Indexed: 10/24/2022]
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16
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Khawaja MZ, Williams R, Hung J, Arri S, Asrress KN, Bolter K, Wilson K, Young CP, Bapat V, Hancock J, Thomas M, Redwood S. Impact of preprocedural mitral regurgitation upon mortality after transcatheter aortic valve implantation (TAVI) for severe aortic stenosis. Heart 2014; 100:1799-803. [PMID: 25155800 PMCID: PMC4215343 DOI: 10.1136/heartjnl-2014-305775] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective To identify the effects of preprocedural significant mitral regurgitation (MR) and change in MR severity upon mortality after transcatheter aortic valve implantation (TAVI) using the Edwards SAPIEN system. Methods A retrospective analysis of 316 consecutive patients undergoing TAVI for aortic stenosis at a single centre in the UK between March 2008 and January 2013. Patients were stratified into two groups according to severity of MR: ≥grade 3 were classed as significant and ≤grade 2 were non-significant. Change in MR severity was assessed by comparison of baseline and 30-day echocardiograms. Results 60 patients had significant MR prior to TAVI (19.0%). These patients were of higher perioperative risk (logistic EuroScore 28.7±16.6% vs 20.3±10.7%, p=0.004) and were more dyspnoeic (New York Heart Association class IV 20.0% vs 7.4%, p=0.014). Patients with significant preprocedural MR displayed greater 12-month and cumulative mortality (28.3% vs 20.2%, log-rank p=0.024). Significant MR was independently associated with mortality (HR 4.94 (95% CI 2.07 to 11.8), p<0.001). Of the 60 patients with significant MR only 47.1% had grade 3–4 MR at 30 days (p<0.001). Patients in whom MR improved had lower mortality than those in whom it deteriorated (log-rank p=0.05). Conclusions Significant MR is frequently seen in patients undergoing TAVI and is independently associated with increased all-cause mortality. Yet almost half also exhibit significant improvements in MR severity. Those who improve have better outcomes, and future work could focus upon identifying factors independently associated with such an improvement.
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Affiliation(s)
- M Z Khawaja
- Cardiovascular Division, King's College, British Heart Foundation Centre of Research Excellence, The Rayne Institute, London, UK Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - R Williams
- Cardiovascular Division, King's College, British Heart Foundation Centre of Research Excellence, The Rayne Institute, London, UK Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - J Hung
- Cardiovascular Division, King's College, British Heart Foundation Centre of Research Excellence, The Rayne Institute, London, UK
| | - S Arri
- Cardiovascular Division, King's College, British Heart Foundation Centre of Research Excellence, The Rayne Institute, London, UK Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - K N Asrress
- Cardiovascular Division, King's College, British Heart Foundation Centre of Research Excellence, The Rayne Institute, London, UK Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - K Bolter
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - K Wilson
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - C P Young
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - V Bapat
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - J Hancock
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - M Thomas
- Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - S Redwood
- Cardiovascular Division, King's College, British Heart Foundation Centre of Research Excellence, The Rayne Institute, London, UK Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
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