Guideline-defined futility or patient-reported outcomes to assess treatment success after TAVI: what to use? Results from a prospective cohort study with long-term follow-up

Guideline-endorsed follow-up after percutaneous valve therapies-non-attendance of TAVI and MitraClip patients

BACKGROUND

Percutaneous valve therapies (PVT) are performed on a large number of patients. With increasing procedural volume, the need for follow-up has also increased. Follow-up in the heart valve clinic is endorsed by recent guidelines but utilization is unknown, making resource allocation in the clinic difficult. Central follow-up in valve centers may not be feasible for all patients in the future.

METHODS

In our center, follow-up for PVT patients is scheduled at 1 month and 12 months after the index procedure. Patients are reminded of their appointment by invitation letters or phone calls. We analyzed 150 consecutive patients who underwent transcutaneous aortic valve implantation (TAVI) and MitraClip implantation (n = 300) at our center.

RESULTS

At 1 month, 72.7% of patients attended their follow-up, while at 12 months the rate dropped to 58%. Patients who underwent TAVI were older than the MitraClip patients (82.7 vs. 76.1 years) but had lower mean logEuroSCORE (22.6% vs. 25.9%). There was no significant difference in 1‑year mortality between TAVI and MitraClip patients (20% vs. 17.3%). By contrast, the rate of missed follow-up visits was higher for TAVI compared to MitraClip patients (52% vs. 33.3%; p = 0.002). Female patients less frequently attended follow-up (p = 0.005), whereas age, EuroSCORE, NYHA class, ejection fraction, and health status (EQ-5DVAS) were not predictors of attendance in multivariable analysis. Although the result of the EQ-5D assessment was not associated with mortality or attendance, completing the questionnaire was associated with overall survival (p < 0.001).

CONCLUSION

In our heart valve clinic, we observed a high percentage of missed follow-up appointments (42% at 12 months) despite a structured follow-up plan. Factors significantly associated with non-attendance in multivariable analysis were female gender and having a TAVI rather than MitraClip. Future follow-up concepts should take such findings into account, and decentralized approaches need to be explored.

The Role of Comorbidities in Predicting Functional Improvement After Transcatheter Aortic Valve Implantation

BACKGROUND

Patients undergoing transcatheter aortic valve implantation (TAVI) have a high comorbidity burden. We sought to stratify patients into functional outcomes using the Kansas City Cardiomyopathy Questionnaire (KCCQ-12), a patient-reported outcome with benefits over both the New York Heart Association (NYHA) classification and the original 23-item KCCQ, and to evaluate the importance of comorbidities in predicting failure of functional improvement post-TAVI in a contemporary cohort.

METHODS

In total, 366 patients with severe aortic stenosis undergoing TAVI with baseline KCCQ-12 were retrospectively analysed and divided into two groups. Failure to improve was defined as a score <60 and a change in score <10 at 1 year in either overall score (KCCQ-OS) or clinical summary score (KCCQ-CSS).

RESULTS

Failure to improve was noted in 13% of patients, who were more likely to have lower KCCQ-OS at baseline (47 [35-59] vs 56 [42-74]), chronic obstructive pulmonary disease (COPD) (19% vs 8%), severe chronic kidney disease (CKD) (13% vs 2%), a clinical frailty score (CFS) ≥5 (41% vs 14%), and lower serum albumin (36 g/L [34-38] vs 38 g/L [35-40]). On multivariate analysis, with an area under the curve of 0.71 (0.63-0.78), baseline KCCQ-OS (adjusted odds ratio [aOR] 0.3 [0.1-0.6], p=0.04), COPD (aOR 2.8 [1.2-6.5], p=0.02), and severe CKD (aOR 5.7 [1.7-18.5], p=0.004) remained independent predictors. CFS alone had a similar predictive value as the multivariable model (OR 2.0 [1.3-3.4], area under the curve 0.69 [0.59-0.80], p<0.001).

CONCLUSIONS

KCCQ scores were effective in delineating functional outcomes, with most patients in our relatively lower surgical risk cohort showing significant functional improvements post-TAVI. Low baseline KCCQ, moderate or worse COPD, and severe CKD were associated with failure of improvement post-TAVI. Baseline CFS appears to be a good screening tool to predict poor improvement. These factors should be evaluated and weighted accordingly in pre-TAVI assessments and decision-making.

Incidence, predictors, and prognostic significance of impaired functional status early after transcatheter aortic valve replacement

INTRODUCTION AND OBJECTIVES

There are scarce data on the factors associated with impaired functional status after transcatheter aortic valve replacement (TAVR) and its clinical impact. This study aimed to determine the incidence, predictors, and prognostic implications of impaired functional class (NYHA class III-IV) following TAVR.

METHODS

This multicenter study included 3462 transarterial TAVR patients receiving newer generation devices. The patients were compared according to their NYHA class at 1 month of follow-up (NYHA I-II vs NYHA III-IV). A multivariate logistic regression was performed to identify the predictors of 30-day NYHA class III-IV. Patient survival was compared with the Kaplan-Meier method and factors associated with decreased survival were identified with Cox regression analysis.

RESULTS

The mean age of the study population was 80.3±7.3 years, with 47% of women, and a median Society of Thoracic Surgeons score of 3.8% [IQR, 2.5-5.8]. A total of 208 patients (6%) were in NYHA class III-IV 1 month after TAVR. Predictors of 30-day NYHA class III-IV were baseline NYHA class III-IV (OR, 1.76; 95%CI, 1.08-2.89; P=.02), chronic pulmonary obstructive disease (OR, 1.80; 95%CI, 1.13-2.83; P=.01), and post-TAVR severe mitral regurgitation (OR, 2.00; 95%CI, 1.21-3.31; P<.01). Patients in NYHA class III-IV 1 month after TAVR were at higher risk of death (HR, 3.68; 95%CI, 2.39-5.70; P<.01) and heart failure-related hospitalization (HR, 6.00; 95%CI, 3.76-9.60; P<.01) at 1-year follow-up.

CONCLUSIONS

Up to 6% of contemporary TAVR patients exhibited an impaired functional status following TAVR. Worse baseline NYHA class, chronic pulmonary obstructive disease, and severe mitral regurgitation predicted 30-day NYHA class III/IV, and this determined a higher risk of mortality and heart failure hospitalization at 1-year follow-up. Further studies on the prevention and treatment optimization of patients with impaired functional status after TAVR are needed.

Higher Edmonton Frail Scale prior to transcatheter Aortic Valve Implantation is related to longer hospital stay and mortality

BACKGROUND

International guidelines for the management of valvular heart disease recommend frailty assessment prior to Transcatheter Aortic Valve Implantation (TAVI), however there is no consensus how to assess frailty. We investigated whether frailty status assessed with the Edmonton Frail Scale (EFS, range 0-17 points) relates to length of stay (LOS), short- and long-term mortality and adverse outcomes after TAVI.

METHODS

In this study we included 357 patients between April 2016 till December 2018. EFS was assessed at baseline. Patients were classified into low (0-3), intermediate (4-7) or high frailty status (8-17). LOS was defined as the number of days between admission and discharge. Mortality data were obtained up to four years after TAVI. Adverse events were defined by Valve Academic Research Consortium (VARC)-2 criteria and collected <30 days after TAVI.

RESULTS

Patients with higher frailty status had longer median LOS (days (IQR): low 5 (3), intermediate 6 (4) and high 7 (5), p < 0.001) and higher mortality: low vs intermediate vs high at 30 days 0.5%, 2.2%, 7.0% (p = 0.050), 1 year 3.7%, 10.0%, 15.2% (p = 0.052), 2 years 9.2%, 17.8%, 31.7% (p = 0.003), 3 years 17.2%, 24.0, 47.0% (p = 0.001) and 4 years 19.6%, 30.8%, 55.6% (p < 0.001). Frail patients received more often a pacemaker (2.6%, 6.6%, 13.5%, p = 0.048).

CONCLUSION

In clinical practice, the EFS is a useful tool to screen for frailty in TAVI patients. This tool may possibly be expanded to determine benefit versus harm-risk in these patients and whether specific pre-procedurally interventions are needed in order to reduce mortality.

Clinical Features and Mortality Rate of Infective Endocarditis in Intensive Care Unit: A Large-Scale Study and Literature Review

BACKGROUND

Large-scale multicentric studies reported that, despite advances in diagnosis, antibiotics, and surgical treatment, infective endocarditis (IE) in-hospital mortality remains high. Most data have been obtained from patients treated in infective disease wards, internal medicine, cardiology, or cardiac surgery departments and are therefore heterogeneous. The few studies focused on complicated IE patients leading to intensive care unit (ICU) admission have reported different methodologies and results. The aim of our study was to describe the epidemiological, clinical, and microbial features of critically ill patients admitted to the ICU with a definite IE diagnosis.

METHODS

We conducted a prospective case-series population study from January 1, 1998, to December 31, 2020. Patients were divided into 2 groups: 'Ward' (group 1) and 'ICU' patients (group 2), and a 1-year follow-up was performed.

RESULTS

After performing a univariate and multivariate logistic regression analysis, we found that the independent predictors of ICU admission were vegetation diameter >10 mm, abnormal PaO2/FiO2 ratio, and acute heart failure. Five independent mortality risk factors were identified: SOFA score >14, not performing surgery, age >70 years, acute heart failure, and embolic complications.

CONCLUSIONS

Infective endocarditis in-hospital mortality remains high. ICU admission and mortality can be predicted by independent risk factors.

Safety and performance of the Vienna self-expandable transcatheter aortic valve system: 6-month results of the VIVA first-in-human feasibility study

Background

The novel Vienna TAVI system is repositionable and retrievable, already pre-mounted on the delivery system, eliminating the need for assembly and crimping of the device prior to valve implantation.

Aims

The purpose of this first-in-human feasibility study was to determine the safety, feasibility, clinical and hemodynamic performance of the Vienna TAVI system at 6-month follow-up. (ClinicalTrials.gov identifier NCT04861805).

Methods

This is a prospective, non-randomized, single-arm, single-center, first-stage FIH feasibility study, which is followed by a second-stage pivotal, multicenter, multinational study in symptomatic patients with severe aortic stenosis (SAS). The first-stage FIH study evaluated the safety and feasibility, clinical and hemodynamic performance of the device in 10 patients with SAS based on recommendations by the VARC-2.

Results

All patients were alive at 3-month follow-up. 1 non-cardiovascular mortality was reported 5 months after implantation. There were no new cerebrovascular events, life-threatening bleeding or conduction disturbances observed at 6-month follow-up. The mean AV gradient significantly decreased from 48.7 ± 10.8 to 7.32 ± 2.0 mmHg and mean AVA increased from 0.75 ± 0.18 to 2.16 ± 0.42 cm² (p < 0.00001). There was no incidence of moderate or severe total AR observed. In the QoL questionnaires, the patients reported a significant improvement from the baseline 12-KCCQ mean score 58 ± 15 to 76 ± 20. NYHA functional class improved in two patients, remained unchanged in one patient. There was an increase in mean 6-min-walk distance from baseline 285 ± 97 to 347 ± 57 m.

Conclusions

This study demonstrates that using Vienna TAVI system has favourable and sustained 6-month safety and performance outcomes in patients with symptomatic severe aortic stenosis.

Patient-reported outcome measures in cardiovascular disease

In today's medical ecosystem, it is vital to measure the outcomes that are most important to the patients. As such, patient-reported outcome measures (PROMS) can be an essential metric to deliver high-quality cardiovascular care, particularly in the subset of patients who remain disappointed with their outcomes. PROMS should be a reproducible and reflective report of what is fundamental to a patient over time and across treatments with proper standards in the analysis, interpretation, and reporting of the collected data. These reports can also be sensitive to changes, whether improvements or deteriorations in the quality of care and medical attitude, but a lack of standardization makes it difficult to draw robust conclusions and compare findings across treatments. As a research tool, PROMS can have a significant prognostic prominence, offering a powerful instrument of comparison between different treatment modalities. With the information technology (IT) abilities of today, we can leverage mobile tools and powerful computer systems to perform sophisticated data analysis using patient-derived data and randomization. This may eliminate guesswork and generate impactful metrics to better inform the decision-making process. PROMS analysed by proper standardized algorithms can avoid physician bias and be integrated into the hospital teamwork. Therefore, there is a strong need for integration of PROMS into the evaluation of cardiovascular interventions and procedures, and establishment of international standards in the analyses of patient-reported outcomes and quality of life data to address this need and develop therapeutic recommendations.

Challenging Decision-Making Between Transcatheter Aortic Valve Implantation and Aortic Valve Surgery: A Case of a Jehovah's Witness Patient With Severe Symptomatic Aortic Stenosis Coexisting With Severe Mitral Regurgitation and Bicuspid Aortic Valve

A 73-year-old Jehovah's witness man with a bicuspid aortic valve and a history of epilepsy presented to the emergency room with chest pain and dyspnea. Echocardiography revealed normal left ventricular systolic function, but also revealed severe aortic stenosis and severe mitral regurgitation. Coronary angiography and computerized tomography angiography ruled out any significant coronary artery disease and aortic dissection, respectively. In view of his religious views, transcatheter aortic valve implantation was considered more suitable than aortic valve surgery and was successful with a stable postoperative state. This case reaffirms that autonomy should be maintained while considering the best interest of patients in decision-making.

Immediate reduction in left ventricular ejection time following TAVI is associated with improved quality of life

Background

TAVI has shown to result in immediate and sustained hemodynamic alterations and improvement in health-related quality of life (HRQoL), but previous studies have been suboptimal to predict who might benefit from TAVI. The relationship between immediate hemodynamic changes and outcome has not been studied before. This study sought to assess whether an immediate hemodynamic change, reflecting myocardial contractile reserve, following TAVI is associated with improved HRQoL. Furthermore, it assessed whether pre-procedural cardiac power index (CPI) and left ventricular ejection fraction (LVEF) could predict these changes.

Methods

During the TAVI procedure, blood pressure and systemic hemodynamics were prospectively collected with a Nexfin® non-invasive monitor. HRQoL was evaluated pre-procedurally and 12 weeks after the procedure, using the EQ-5D-5L classification tool.

Results

Overall, 97/114 (85%) of the included patients were eligible for analyses. Systolic, diastolic and mean arterial pressure, heart rate, and stroke volume increased immediately after TAVI (all p &lt; 0.005), and left ventricular ejection time (LVET) immediately decreased with 10 ms (95%CI = −4 to −16, p &lt; 0.001). Overall HRQoLindex increased from 0.810 [0.662–0.914] before to 0.887 [0.718–0.953] after TAVI (p = 0.016). An immediate decrease in LVET was associated with an increase in HRQoLindex (0.02 index points per 10 ms LVET decrease, p = 0.041). Pre-procedural CPI and LVEF did not predict hemodynamic changes or change in HRQoL.

Conclusion

TAVI resulted in an immediate hemodynamic response and increase in HRQoL. Immediate reduction in LVET, suggesting unloading of the ventricle, was associated with an increase in HRQoL, but neither pre-procedural CPI nor LVEF predicted these changes.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03088787

Preoperative hypoalbuminemia in patients undergoing cardiac surgery: a meta-analysis

The preoperative serum albumin level has been shown to be associated with adverse postoperative complications, meaning that hypoalbuminemia may also be a risk factor. We performed a meta-analysis to evaluate the association of serum albumin levels with survival and complication rates after cardiac surgery. Relevant articles were identified through seven databases. Twenty studies with 22553 patients (hypoalbuminemia group, n = 9903; normal group, n = 12650) who underwent cardiac surgery met the inclusion criteria after screening. The primary outcomes were that hypoalbuminemia was significantly correlated with serious long-term all-cause mortality (hazard ratio [HR]: 1.95 [1.54-2.48]; P < 0.00001) and increased mortality (risk ratio [RR] = 1.91 [1.61-2.27], P < 0.00001). Hypoalbuminemic patients with cardiopathy were more likely to suffer postoperative complications (bleeding, infections, renal injury, and others) than those whose serum albumin levels were normal. Furthermore, hypoalbuminemia increased the time in the intensive-care unit (ICU) (mean difference [MD] = 1.18 [0.49-1.87], P = 0.0008), length of hospital stay (LOS) (MD = 3.34, 95% CI: 1.88-4.80, P < 0.00001), and cardiopulmonary bypass time (CPB) (MD = 12.40 [1.13-23.66], P = 0.03). Hypoalbuminemia in patients undergoing cardiac surgery appears to have a poor all-cause mortality or increased risk of complications. Adjusted perioperative serum albumin levels and treatment strategies for this high-risk population have the potential to improve the survival.

A Novel Method to Predict Mortality and Length of Stay after Transfemoral Transcatheter Aortic Valve Implantation

Background and Objectives: We tested if a novel combination of predictors could improve the accuracy of outcome prediction after transfemoral transcatheter aortic valve implantation (TAVI). Materials and Methods: This prospective study recruited 169 participants (49% female; median age 81 years). The primary endpoint was midterm mortality; secondary endpoints were acute Valve Academic Research Consortium (VARC)-3 complication rate and post-TAVI in-hospital length of stay (LoS). EuroSCORE II (ESII), comorbidities (e.g., coronary artery disease), eGFR (estimated glomerular filtration rate; based on cystatin C), hemoglobin, creatinine, N-Terminal pro-Brain Natriuretic Peptide (NTproBNP) levels and patient-reported outcome measures (PROMs, namely EuroQol-5-Dimension-5-Levels, EQ5D5L; Kansas City Cardiomyopathy Questionnaire, KCCQ; clinical frailty scale, CFS) at baseline were tested as predictors. Regression (uni- and multi-variate Cox; linear; binary logistic) and receiver operating characteristic (ROC)-curve analysis were applied. Results: Within a median follow-up of 439 (318–585) days, 12 participants died (7.1%). Independent predictors of mortality using multivariate Cox regression were baseline eGFR (p = 0.001) and KCCQ (p = 0.037). Based on these predictors, a Linear Prediction Score (LPS1) was calculated. The LPS1-area under the curve (AUC)-value (0.761) was significantly higher than the ESII-AUC value (0.597; p = 0.035). Independent predictors for LoS > 6 days (the median LoS) were eGFR (p = 0.028), NTproBNP (p = 0.034), and EQ5D5L values (p = 0.002); a respective calculated LPS2 provided an AUC value of 0.677 (p < 0.001). Eighty participants (47.3%) experienced complications. Male sex predicted complications only in the univariate analysis. Conclusions: The combination of KCCQ and eGFR can better predict midterm mortality than ES II alone. Combining eGFR, NTproBNP, and EQ5D5L can reliably predict LoS after TAVI. This novel method improves personalized TAVI risk stratification and hence may help reduce post-TAVI risk.

Identifying Patients without a Survival Benefit following Transfemoral and Transapical Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) offers a novel treatment option for patients with severe symptomatic aortic valve stenosis, particularly for patients who are unsuitable candidates for surgical intervention. However, high therapeutical costs, socio-economic considerations, and numerous comorbidities make it necessary to target and allocate available resources efficiently. In the present study, we aimed to identify risk factors associated with futile treatment following transfemoral (TF) and transapical (TA) TAVR. Five hundred and thirty-two consecutive patients (82 ± 9 years, female 63%) who underwent TAVR between June 2009 and December 2016 at the Vienna Heart Center Hietzing were retrospectively analyzed to identify predictors of futility, defined as all-cause mortality at one year following the procedure for the overall patient cohort, as well as the TF and TA cohort. Out of 532 patients, 91 (17%) did not survive the first year after TAVR. A multivariate logistic model identified cerebrovascular disease, home oxygen dependency, wheelchair dependency, periinterventional myocardial infarction, and postinterventional renal replacement therapy as the factors independently associated with an increased one-year mortality. Our findings underscore the significance of a precise preinterventional evaluation, as well as illustrating the subtle differences in baseline characteristics in the TF and TA cohort and their impact on one-year mortality.

Staging classification for cardiac damage associated with aortic stenosis

Okuno et al's staging classification of cardiac damage associated with aortic stenosis predicts prognosis following TAVI. More research is required, not only to further improve risk stratification, particularly at the higher and lower end of the risk spectrum, but also to assess the value of aortic valve intervention in such patient groups.

Machine Learning for Predicting Mortality in Transcatheter Aortic Valve Implantation: An Inter-Center Cross Validation Study

Current prognostic risk scores for transcatheter aortic valve implantation (TAVI) do not benefit yet from modern machine learning techniques, which can improve risk stratification of one-year mortality of patients before TAVI. Despite the advancement of machine learning in healthcare, data sharing regulations are very strict and typically prevent exchanging patient data, without the involvement of ethical committees. A very robust validation approach, including 1300 and 631 patients per center, was performed to validate a machine learning model of one center at the other external center with their data, in a mutual fashion. This was achieved without any data exchange but solely by exchanging the models and the data processing pipelines. A dedicated exchange protocol was designed to evaluate and quantify the model's robustness on the data of the external center. Models developed with the larger dataset offered similar or higher prediction accuracy on the external validation. Logistic regression, random forest and CatBoost lead to areas under curve of the ROC of 0.65, 0.67 and 0.65 for the internal validation and of 0.62, 0.66, 0.68 for the external validation, respectively. We propose a scalable exchange protocol which can be further extended on other TAVI centers, but more generally to any other clinical scenario, that could benefit from this validation approach.

Safety and feasibility of dobutamine stress echocardiography in symptomatic high gradient aortic stenosis patients scheduled for transcatheter aortic valve implantation

PURPOSE

We aimed to study the safety and feasibility of low-dose dobutamine stress echocardiography in a symptomatic high gradient aortic stenosis population scheduled for transfemoral transcatheter aortic valve implantation (TAVI) and to quantify left ventricular (LV) flow reserve.

METHODS

Fifty patients underwent dobutamine stress echocardiography with 5 minutes increments of 5 μg/kg/min up to 20 μg/kg/min until the heart rate increased ≥20 beats/min from baseline or exceeded 100 beats/min. Other criteria for discontinuing the infusion were major adverse events: ventricular arrhythmia, persistent supraventricular arrhythmia, pulmonary edema, chest pain with significant ST-changes, or minor events: ST-changes, drop in systolic blood pressure >30 mmHg, mild chest pain, and/or dyspnea. LV flow reserve was defined as an increase in stroke volume ≥20% during the test.

RESULTS

Of 50 patients, 45 completed the test according to protocol. No patient had major adverse event. Five patients experienced minor side effects: mild chest pain/dyspnea in three, self-terminating atrial flutter in one, and decrease in blood pressure in one. Significant LV flow reserve was observed in 20 patients (40%).

CONCLUSION

Low-dose dobutamine stress test appeared safe and feasible patients with high gradient aortic stenosis, and showed LV flow reserve in a minority of them.

Transcatheter Aortic Valve Implantation in Patients With Severe Aortic Valve Stenosis at Low Surgical Risk: A Health Technology Assessment

BACKGROUND

Surgical aortic valve replacement (SAVR) is the conventional treatment for patients with severe aortic valve stenosis at low surgical risk. Transcatheter aortic valve implantation (TAVI) is a less invasive procedure. We conducted a health technology assessment (HTA) of TAVI for patients with severe aortic valve stenosis at low surgical risk, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding TAVI, and patient preferences and values.

METHODS

We used the 2016 Health Quality Ontario HTA on TAVI² as a source of eligible studies and performed a systematic literature search for studies published since the 2016 review. Eligible primary studies identified both through the 2016 HTA and through our complementary literature search were used in a de novo analysis. We assessed the risk of bias of each included study using the Cochrane risk-of-bias tool and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria.An applicable, previously conducted cost-effectiveness analysis was available, so we did not conduct a primary economic evaluation. We analyzed the budget impact of publicly funding TAVI in people at low surgical risk in Ontario. We also performed a literature survey of the quantitative evidence of preferences and values of patients for TAVI. The Canadian Agency for Drugs and Technologies in Health (CADTH) conducted a review to evaluate the qualitative literature on patient and provider preferences and values for TAVI. To contextualize the potential value of TAVI, we spoke with people with severe aortic valve stenosis.

RESULTS

We identified two randomized controlled trials that compared TAVI (transfemoral route) and SAVR in patients with severe aortic valve stenosis at low surgical risk. Both studies have an ongoing follow-up of 10 years, but 1-year and limited 2-year follow-up results are currently available. At 30 days, compared with SAVR, TAVI had a slightly lower risk of mortality (risk difference -0.8%, 95% confidence interval [CI] -1.5% to -0.1%, GRADE: Moderate) and disabling stroke (risk difference -0.8%, 95% CI -1.8% to -0.2%, GRADE: Moderate), and resulted in more patients with symptom improvement (risk difference 11.8%, 95% CI 8.2% to 15.5%, GRADE: High) and in a greater improvement in quality of life (GRADE: High). At 1 year, TAVI and SAVR were similar with regard to mortality (GRADE: Low), although TAVI may result in a slightly lower risk of disabling stroke (GRADE: Moderate). Both TAVI and SAVR resulted in a similar improvement in symptoms and quality of life at 1 year (GRADE: Moderate). Compared with SAVR, TAVI had a higher risk of some complications and a lower risk of others.Device-related costs for TAVI (about $25,000) are higher than for SAVR (about $6,000). A published cost-effectiveness analysis conducted from an Ontario Ministry of Health perspective showed TAVI to be more expensive and, on average, slightly more effective (i.e., it was associated with more quality-adjusted life-years [QALYs]) than SAVR. Compared with SAVR, the incremental cost-effectiveness ratios (ICERs) were $27,196 per QALY and $59,641 per QALY for balloon-expandable and self-expanding TAVI, respectively. Balloon-expandable TAVI was less costly (by $2,330 on average) and slightly more effective (by 0.02 QALY on average) than self-expanding TAVI. Among the three interventions, balloon-expandable TAVI had the highest probability of being cost-effective. It was the preferred option in 53% and 59% of model iterations, at willingness-to-pay values of $50,000 and $100,000 per QALY, respectively. Self-expanding TAVI was preferred in less than 10% of iterations. The budget impact of publicly funding TAVI in Ontario is estimated to be an additional $5 to $8 million each year for the next 5 years. The budget impact could be significantly reduced with reductions in the device price.We did not find any quantitative or qualitative evidence on patient preferences and values specific to the low-risk surgical group. Among a mixed or generally high-risk and population, people typically preferred the less invasive nature and the faster recovery time of TAVI compared with SAVR, and people were satisfied with the TAVI procedure. Patients with severe aortic valve stenosis at low surgical risk and their caregivers perceived that TAVI minimized pain and recovery time. Most patients who had TAVI returned to their usual activities more quickly than they would have if they had had SAVR. Our direct patient and caregiver consultations indicated a preference for TAVI over SAVR.

CONCLUSIONS

Both TAVI (transfemoral route) and SAVR resulted in improved patient symptoms and quality of life during the 1 year of follow-up. The TAVI procedure is less invasive and resulted in greater symptom improvement and quality of life than SAVR 30 days after surgery. The TAVI procedure also resulted in a small improvement in mortality and disabling stroke at 30 days. At 1 year, TAVI and SAVR were similar with regard to mortality, although TAVI may result in a slightly lower risk of disabling stroke. According to the study authors, longer follow-up is needed to better understand how long TAVI valves last and to draw definitive conclusions on the long-term outcomes of TAVI compared with SAVR beyond 1 year.The TAVI procedure might be cost-effective for patients at low surgical risk; however, there is some uncertainty in this result. We estimated that the additional cost to provide public funding for TAVI in people with severe aortic valve stenosis at low surgical risk would range from about $5 million to $8 million over the next 5 years.Among a mixed or generally high-risk population, people typically preferred the less invasive nature and the faster recovery time of TAVI compared with SAVR.

Delirium, functional decline and quality of life after transcatheter aortic valve implantation: An explorative study

AIM

Transcatheter aortic valve implantation (TAVI) has become an important treatment option for older patients with severe aortic stenosis. However, not all patients benefit from this procedure in terms of functional outcome and quality of life. This complicates patient selection and shared decision-making. Postoperative delirium might negatively affect patient outcomes after TAVI. We therefore studied the potential relationship between postoperative delirium and functional outcome, and how this impacts quality of life after TAVI.

METHODS

This was a prospective cohort study of 91 consecutive patients undergoing TAVI between 2015 and 2017 at an academic medical center. All patients underwent a Comprehensive Geriatric Assessment before TAVI. Delirium symptoms were assessed daily during hospitalization. Follow up was carried out between 6 and 12 months postprocedure. The primary outcome was functional decline or death at follow up. Secondarily, we measured quality of life at follow up.

RESULTS

The incidence of postoperative delirium was 15.4%. In total, 38.5% of patients experienced functional decline, and 11.0% died during a median follow-up period of 7 months. Delirium resulted in a fourfold increased odds of the combined outcome of functional decline or death. Quality of life was lower in patients that experienced this outcome.

CONCLUSION

In a cohort of TAVI patients, functional decline or death was a frequent outcome in the first year postprocedure. Postoperative delirium increased the odds for this outcome substantially. This suggests that delirium risk should be an important factor to consider in shared decision-making for TAVI patients. Geriatr Gerontol Int 2020; 20: 1202-1207.

Transcatheter aortic valve replacement in patients with paradoxical low-flow, low-gradient aortic stenosis: Incidence and predictors of treatment futility

BACKGROUND

Few and controversial data exist on the outcomes of patients with paradoxical low-flow, low-gradient aortic stenosis (PLFLG-AS) following transcatheter aortic valve replacement (TAVR). This study aims to better characterize clinical outcomes and predictors of treatment futility in PLFLG-AS patients undergoing TAVR.

METHODS

In this multicenter study, 318 patients with PLFLG-AS undergoing TAVR were categorized according to treatment futility, defined as all-cause mortality, poor functional status (NYHA class III-IV) or deterioration in functional class at 1-year follow-up. Clinical outcomes and the factors associated with treatment futility were assessed.

RESULTS

The mean age of the patients was 81.0 ± 8.3 years and 50.3% were women. At 1-year follow-up, 17.6% died and 12.9% had heart failure hospitalization. Residual impaired functional capacity (NYHA ≥ II) was present in 54.4% of patients who were alive at 1-year, and 9.8% remained in NYHA III/IV. The primary endpoint was observed in 103 (32.4%) patients, of which 54% died and 46% had a poor or worsening functional class. Factors independently associated with treatment futility were the presence of atrial fibrillation (AF) (OR:1.79, 95%CI, 1.04-3.10), chronic obstructive pulmonary disease (COPD) (OR:2.66, 95%CI, 1.50-4.74) and a lower SVi (OR per each decrease in 10 ml/m²:1.89, 95%CI, 1.06-3.45). The risk of treatment futility of patients with AF, COPD and a SVi < 30 ml/m² was 66.38% (95%CI, 54.29%-78.48%).

CONCLUSION

Close to one-third of patients with PLFLG-AS failed to derive a benefit from TAVR. The presence of AF, COPD and a low SVi were predictors of treatment futility. Being able to identify patients less likely to improve after the procedure may help to guide management and improve outcomes in patients with PLFLG-AS.

Preoperative frailty parameters as predictors for outcomes after transcatheter aortic valve implantation: a systematic review and meta-analysis

Guidelines suggest using frailty characteristics in the work-up for a transcatheter aortic valve implantation (TAVI). There are many frailty-screening tools with different components. The prognostic value of the individual parameters in frailty is as yet unclear. The objective of this systematic review and meta-analysis was to find and pool predictors for 1‑year mortality after TAVI. We followed a two-step approach. First, we searched for randomised controlled trials on TAVI to identify frailty parameters used in these studies. Second, we searched for publications on these frailty parameters. Articles were included for pooled analysis if the studied frailty parameters were dichotomised with clear cut-off values based on common standards or clinical practice and reported adjusted hazard ratios (HR) of 1‑year mortality after TAVI. We calculated pooled effect estimates of 49 studies based on dichotomised frailty scores (HR: 2.16, 95% CI: 1.57–3.00), chronic lung disease (HR: 1.57, 95% CI: 1.45–1.70), estimated glomerular filtration rate <30 ml/min (HR: 1.95, 95% CI: 1.68–2.29), body mass index <20 kg/m² (HR: 1.49, 95% CI: 1.09–2.03), hypoalbuminaemia (HR: 1.77, 95% CI: 1.38–2.25), anaemia (HR: 2.08, 95% CI: 0.93–4.66), low gait speed (HR: 13.33, 95% CI: 1.75–101.49) and Katz activities of daily living (ADL) score of 1 or more deficits (HR: 5.16, 95% CI: 0.77–34.47). Chronic lung disease, chronic kidney disease, underweight, hypoalbuminaemia, a low frailty score, anaemia, low gait speed and an ADL deficiency were associated with worse 1‑year outcomes after TAVI.

Meta-Analysis of the Impact of Pre-Procedural Serum Albumin on Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement

Pre-procedural serum albumin's impact on prognosis after transcatheter aortic valve replacement (TAVR) has been studied. Literature on the prognostic role of serum albumin in the survival of patients undergoing TAVR shows conflicting results. This meta-analysis was conducted to evaluate the impact of pre-procedural serum albumin on outcomes after TAVR. A comprehensive literature search of EMBASE, MEDLINE, and the Cochrane Library was undertaken through July 2019. The primary end points were 30-day and one-year all-cause mortality after TAVR. Risk ratios (HRs) and 95% confidence intervals (CIs) were calculated using the random-effect model. Ten eligible studies with 8,236 patients were analyzed. Of the 8,236 patients undergoing TAVR, with a mean age of 83 years, 48.8% were men and were categorized into two groups according to low and normal serum albumin (cut-off value: 3.5 or 4 g/dL). Overall, low albumin was significantly associated with an approximately two-fold increase in 30-day all-cause mortality (HR, 2.09; 95% CI, 1.53-2.86) and a 61% increase risk for one-year mortality (HR, 1.61; 95% CI, 1.31-1.98) in patients after TAVR. Sensitivity analyses showed the results to be robust. The association of low albumin level with an increase in one-year mortality risk was not modified by study design, albumin cut-off value, Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM), and study quality. In conclusion, low albumin levels were associated with poor prognosis in patients after TAVR. Pre-procedural albumin can be used as a simple tool related to prognosis after TAVR.

Value of machine learning in predicting TAVI outcomes

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has become a commonly applied procedure for high-risk aortic valve stenosis patients. However, for some patients, this procedure does not result in the expected benefits. Previous studies indicated that it is difficult to predict the beneficial effects for specific patients. We aim to study the accuracy of various traditional machine learning (ML) algorithms in the prediction of TAVI outcomes.

METHODS AND RESULTS

Clinical and laboratory data from 1,478 TAVI patients from a single centre were collected. The outcome measures were improvement of dyspnoea and mortality. Three experiments were performed using (1) screening data, (2) laboratory data, and (3) the combination of both. Five well-established ML techniques were implemented, and the models were evaluated based on the area under the curve (AUC). Random forest classifier achieved the highest AUC (0.70) for predicting mortality. Logistic regression had the highest AUC (0.56) in predicting improvement of dyspnoea.

CONCLUSIONS

In our single-centre TAVI population, the tree-based models were slightly more accurate than others in predicting mortality. However, ML models performed poorly in predicting improvement of dyspnoea.