Prognostic impact of baseline C‐reactive protein levels on mortality after transcatheter aortic valve implantation

The impact of elevated C-reactive protein levels on long-term outcomes of patients undergoing transcatheter aortic valve replacement

BACKGROUND

In patients undergoing transcatheter aortic valve replacement (TAVR), elevated pre-procedural C-reactive protein (CRP) levels are frequently observed. Its impact on long-term results of TAVR is unclear. The aim of the study was to investigate the long-term (up to six years) clinical outcomes of TAVR patients with normal compared to elevated CRP levels before TAVR.

METHODS

Consecutive patients undergoing TAVR between August 2012 and January 2023 at a tertiary cardiology facility were included. Patients were divided into two cohorts based on the baseline CRP levels: normal CRP (≤ 5 mg/l) and elevated CRP (>5 mg/l). The cohorts were followed clinically for up to six years after TAVR.

RESULTS

From a total of 1000 TAVR patients (mean age 81 ± 6 years), 268 patients (27 %) were found to have elevated baseline CRP (>5 mg/l). Such patients had significantly more co-morbidities (e.g. chronic obstructive pulmonary disease, atrial fibrillation, heart failure, concomitant valvopathies). They also developed periprocedural infections more frequently (3 % vs. 1 %, p = 0.007) and required more commonly repeat hospitalizations for infections during follow-up (HR 1.97, CI 1.47-2.64, p < 0.001). All-cause mortality and development of valve dysfunction did not significantly differ between patients with elevated and normal baseline CRP levels.

CONCLUSION

Albeit long-term results of TAVR patients with elevated pre-procedural CRP levels seem favorable in terms of survival and development of valve dysfunction, they have an increased risk for periprocedural infections and re-admissions due to infections of any type during the follow-up period.

Clinical implication of the Naples prognostic score on transcatheter aortic valve replacement in patients with severe aortic stenosis

BACKGROUND

One of the hallmarks of frailty in patients with severe aortic stenosis (AS) is malnutrition, for which one of the most up-to-date scoring systems is the Naples prognostic score (NPS). This study sought to investigate the predictive role of the NPS in determining mortality in patients undergoing transcatheter aortic valve replacement (TAVR) under long-term follow-up.

METHODS

A total of 430 consecutive patients with symptomatic severe AS who underwent TAVR were included retrospectively. The primary endpoint of the study was the long-term all-cause mortality. The study population was divided into two groups according to the NPS value, including Group 1 (NPS 0-2) and Group 2 (NPS 3-4).

RESULTS

The all-cause mortality occurred in 250 patients (62.5%) patients during a follow-up time of 40.6 (22.0-69.4) months. During the follow-up period, all-cause mortality was higher in Group 2 compared with Group 1 (87.9% vs. 42.9%, p < 0.001). Older age (p < 0.001), chronic obstructive pulmonary disease (p = 0.015), left ventricular ejection fraction (p = 0.021), and being in Group 2 (high NPS) (hazard ratio: 7.058, 95% confidence interval: 5.174-9.629, p < 0.001) were found to be independent predictors of all-cause mortality at long-term follow-up.

CONCLUSION

The NPS as a malnutrition and inflammation marker in patients with severe aortic stenosis who underwent TAVR provides valuable information for all-cause mortality under long-term follow-up.

Prognostic role of CA-125 in patients undergoing transcatheter aortic valve replacement: A systematic review and meta-analysis

Transcatheter aortic valve replacement (TAVR) has become a widely used therapy for patients with severe aortic stenosis. Carbohydrate antigen 125 (CA-125) is a promising biomarker in some cardiovascular diseases. This systematic review aims to assess the prognostic role of CA-125 in patients undergoing TAVR. We searched electronic databases from inception to March 2023 to include cohort studies evaluating the association between preprocedural CA-125 levels and mortality or heart failure (HF) readmission at 12 months in patients undergoing TAVR. We pooled crude (cHR) and adjusted hazard ratios (aHR) with their 95% confidence interval (CI) using a random-effects model. The risk of bias was evaluated using the QUIPS tool. The certainty of the evidence was assessed using the GRADE approach. We included five cohort studies involving 1594 patients. Higher levels of CA-125 were significantly associated with an increased risk of mortality or HF readmission using crude (cHR 2.79, 95% CI 1.45-5.36, I2  =  72%) and adjusted (aHR 3.27, 95% CI 2.07-5.18, I2  =  0%, high certainty) effect estimates compared with lower levels. Similarly, there was also associated with increased mortality using crude (cHR 2.68, 95% CI 1.99-3.60, I2  =  0%) and adjusted (aHR 2.17, 95% CI 1.54-3.07, I2  =  0%, high certainty) effect estimates. The risk of bias varied between low to moderate across studies. Our meta-analysis suggests that CA-125 has incremental prognostic value in patients undergoing TAVR. Further studies are needed to determine the clinical utility of CA-125 in guiding treatment decisions in this population.

The Impact of Monocyte to High-Density Lipoprotein Cholesterol Ratio on All-Cause and Cardiovascular Mortality in Patients with Transcatheter Aortic Valve Replacement

BACKGROUND

Inflammation plays a significant role in the pathogenesis of aortic stenosis. This study aimed to investigate the prognostic value of the monocyte-HDL cholesterol ratio (MHR), a new inflammatory marker, in severe aortic stenosis (AS) patients who underwent transcatheter aortic valve replacement (TAVR).

METHODS

A total of 125 patients with severe AS who underwent TAVR were assessed. Clinical, echocardiographic and laboratory data relevant to the research were retrospectively obtained from the patients' records. The MHR was determined by dividing the absolute monocyte count by the HDL-C value. The primary endpoints were overall and cardiovascular mortality.

RESULTS

During a median follow-up time of 39 months, primary endpoints were developed in 51 (40.8%) patients (overall mortality) and 21 (16.8%) patients (cardiovascular mortality). A receiver operating characteristic (ROC) analysis showed that by using a cut-off level of 16.16, the MHR predicted the all-cause mortality with a sensitivity of 50.9% and specificity of 89.1%. In predicting cardiovascular mortality, the MHR exhibited a sensitivity of 80.9% and specificity of 70.1% when a cut-off level of 13.56 was used. In the multivariate analysis, the MHR (p < 0.0001; 95% CI: 1.06-1.15) and atrial fibrillation (p = 0.018; 95% CI: 1.11-3.38) were found to be significant predictors of overall mortality.

CONCLUSIONS

This study showed a significant elevation in the MHR among patients who experienced all-cause and cardiovascular mortality and this ratio emerged as an independent predictor of all-cause death in patients with severe AS undergoing TAVR.

Circulating Monocyte Subsets and Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR), as an alternative to open heart surgery, has revolutionized the treatment of severe aortic valve stenosis (AVS), the most common valvular disorder in the elderly. AVS is now considered a form of atherosclerosis and, like the latter, partly of inflammatory origin. Patients with high-grade AVS have a highly disturbed blood flow associated with high levels of shear stress. The immediate reopening of the valve during TAVR leads to a sudden restoration of a normal blood flow hemodynamic. Despite its good prognosis for patients, TAVR remains associated with bleeding or thrombotic postprocedural complications, involving mechanisms that are still poorly understood. Many studies report the close link between blood coagulation and inflammation, termed thromboinflammation, including monocytes as a major actor. The TAVR procedure represents a unique opportunity to study the influence of shear stress on human monocytes, key mediators of inflammation and hemostasis processes. The purpose of this study was to conduct a review of the literature to provide a comprehensive overview of the impact of TAVR on monocyte phenotype and subset repartition and the association of these parameters with the clinical outcomes of patients with severe AVS who underwent TAVR.

C-Reactive Protein to Albumin Ratio in Patients Undergoing Transcatheter Aortic Valve Replacement

OBJECTIVE

To evaluate whether the serum C-reactive protein to albumin ratio (CAR) could be used for risk stratification of patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS).

PATIENTS AND METHODS

Frailty is a predictor of poor outcomes in patients undergoing AS interventions. The CAR reflects key components of frailty (systemic inflammation and nutrition) and could potentially be implemented into assessment and management strategies for patients with AS. From March 1, 2010, through February 29, 2020, 1836 patients were prospectively enrolled in an observational TAVR database. Patients (prospective development cohort, n=763) were grouped into CAR quartiles to compare the upper quartile (CAR Q4) with the lower quartiles (CAR Q1-3). Primary end point was all-cause mortality. Results were verified in an independent retrospective cohort (n=1403).

RESULTS

The CAR Q4 had a higher prevalence of impaired left ventricular function, atrial fibrillation, diabetes, and cerebrovascular disease and a higher median logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) vs CAR Q1-3. After median follow-up of 15.0 months, all-cause mortality was significantly higher in CAR Q4 vs CAR Q1-3 (P<.001). In multivariable analyses, risk factors for all-cause mortality were CAR Q4 (>0.1632; hazard ratio, 1.45; 95% confidence interval, 1.05 to 2.00; P=.03), N-terminal pro-B-type natriuretic peptide Q4 (>3230 pg/mL [to convert to ng/L, multiply by 1), high-sensitivity troponin T Q4 (>0.0395 ng/mL [to convert to μg/L, multiply by 1]), above-median logistic EuroSCORE (16.1%), myocardial infarction, Acute Kidney Injury Network stage 3, and life-threatening bleeding.

CONCLUSION

Elevated CAR was associated with increased risk of all-cause mortality in patients undergoing transfemoral TAVR. The CAR, a simple, objective tool to assess frailty, could be incorporated into assessing patients with AS being considered for TAVR.

C-reactive protein predicts early clinical outcomes and long-term mortality after left ventricular assisted device

OBJECTIVES

Left ventricular assist device (LVAD) implantation has become a reliable therapeutic strategy in patients with advanced heart failure. C-reactive protein (CRP) is a well-established biomarker of inflammation. This study aims to determine the prognostic effect of CRP level on clinical outcomes of patients who undergo LVAD implantation.

METHODS

This is a single-center, observational, retrospective study. One hundred fifty-three patients who received continuous-flow LVAD implantation were included and were divided into two groups of high (>3.9 mg/dL) versus low CRP (⩽3.9 mg/dL).

RESULTS

Patients with high pre-implant CRP levels were prone to severe preoperative clinical conditions and complicated intraoperative procedures. Compared with patients in the low CRP group, elevated pre-implant CRP was associated with increased hospital mortality (31.4% vs 8.4%, p < 0.001), postoperative right ventricular failure (47.1% vs 30.1%, p = 0.031), right ventricular assist device use (34.3% vs 16.9%, p = 0.013), AKI (70% vs 51.8%, p = 0.022) and significantly prolonged duration of postoperative mechanical ventilation and intensive care unit length of stay. Univariate Cox regression showed that high pre-implant CRP was significantly associated with increased risk of long-term mortality (Hazard ratio (HR) 2.632 95%; CI: 1.657-4.183, p < 0.001), and multivariable Cox regression also revealed the higher risk of long-term mortality in patients with elevated pre-implant CRP (HR, 2.848 95%CI: 1.659-4.888, p < 0.001). These results remained stable when treating pre-implant CRP as a continuous variable. Besides, the prognostic effect of post-implant CRP was also observed.

CONCLUSIONS

CRP is a reliable risk-stratification biomarker in patients receiving continuous-flow -LVAD and can be used as a predictor for short- and long-term outcomes.

Risk assessment in patients with left ventricular systolic dysfunction following transcatheter aortic valve replacement

BACKGROUND

Mortality following transcatheter aortic valve replacement (TAVR) in patients with post-procedural left ventricular systolic dysfunction remains high. We investigated clinical variables associating with worse clinical outcomes following TAVR in patients with systolic dysfunction.

METHODS

We retrospectively investigated 2588 patients with severe aortic stenosis who received TAVR and were enrolled in the optimized transcatheter valvular intervention (OCEAN-TAVI) multicenter registry (UMIN000020423). The association between the clinical variables following TAVR and 2-year cardiovascular mortality was investigated among those with post-TAVR left ventricular ejection fraction less than 50%.

RESULTS

A total of 298 patients (median 85 years old, 131 men) were included. The presence of moderate or greater tricuspid regurgitation following TAVR was independently associated with 2-year mortality (adjusted hazard ratio 3.41, 95% confidence interval 1.15-10.1), and significantly discriminated 2-year cardiovascular mortality (30% vs. 12%, p = 0.001). No patients with any improvement in tricuspid regurgitation had cardiovascular death.

CONCLUSION

Following TAVR, the existence of significant tricuspid regurgitation was associated with cardiovascular mortality in patients with heart failure with reduced ejection fraction.

Prognostic Value of Systemic Immune-Inflammation Index for Major Adverse Cardiac Events and Mortality in Severe Aortic Stenosis Patients after TAVI

Background and objectives: In this study, we aimed to evaluate whether the systemic immune-inflammation index (SII) has a prognostic value for major adverse cardiac events (MACEs), including stroke, re-hospitalization, and short-term all-cause mortality at 6 months, in aortic stenosis (AS) patients who underwent transcatheter aortic valve implantation (TAVI). Materials and Methods: A total of 120 patients who underwent TAVI due to severe AS were retrospectively included in our study. The main outcome of the study was MACEs and short-term all-cause mortality at 6 months. Results: The SII was found to be higher in TAVI patients who developed MACEs than in those who did not develop them. Multivariate Cox regression analysis revealed that the SII (HR: 1.002, 95%CI: 1.001–1.003, p < 0.01) was an independent predictor of MACEs in AS patients after TAVI. The optimal value of the SII for MACEs in AS patients following TAVI was >1.056 with 94% sensitivity and 96% specificity (AUC (the area under the curve): 0.960, p < 0.01). We noted that the AUC value of SII in predicting MACEs was significantly higher than the AUC value of the C-reactive protein (AUC: 0.960 vs. AUC: 0.714, respectively). Conclusions: This is the first study to show that high pre-procedural SII may have a predictive value for MACEs and short-term mortality in AS patients undergoing TAVI.

Gender Difference Is Associated With Severity of Coronavirus Disease 2019 Infection: An Insight From a Meta-Analysis

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Objectives:

Coronavirus disease 2019 is a novel infection now causing pandemic around the world. The gender difference in regards to the severity of coronavirus disease 2019 infection has not been well described thus far. Our aim was to investigate how gender difference can affect the disease severity of coronavirus disease 2019 infection.

Data Sources:

A comprehensive literature search of PubMed and Embase databases was conducted from December 1, 2019, to March 26, 2020. An additional manual search of secondary sources was conducted to minimize missing relevant studies. There were no language restrictions.

Study Selection:

Studies were included in our meta-analysis if it was published in peer-reviewed journals and recorded patient characteristics of severe versus nonsevere or survivor versus nonsurvivor in coronavirus disease 2019 infection.

Data Extraction:

Two investigators independently screened the search, extracted the data, and assessed the quality of the study.

Data Synthesis:

Our search identified 15 observational studies with a total of 3,494 patients (1,935 males and 1,559 females) to be included in our meta-analysis. Males were more likely to develop severe coronavirus disease 2019 infection compared with females (odds ratio, 1.31; 95% CI, 1.07–1.60). There was no significant heterogeneity (I² = 12%) among the studies.

Conclusions:

This meta-analysis suggests that the male gender may be a predictor of more severe coronavirus disease 2019 infection. Further accumulation of evidence from around the world is warranted to confirm our findings.