Blood transfusion and the risk of acute kidney injury after transcatheter aortic valve implantation

Risk factors of renal function deterioration after radical nephroureterectomy for upper tract urothelial carcinoma

Background and objectives

To investigate the risk factors of renal function deterioration after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

Methods

A total of 153 patients with UTUC who underwent radical surgery at a high-volume center in China from January 2015 to December 2019 were included in this study. The renal function of all patients was evaluated during follow-up. Besides, these patients were grouped according to postoperative renal function. The risk factors of renal function deterioration included age, sex, body mass index (BMI), T stage, tumor location and size, lymph node invasion, lymph node dissection (LND), surgical margin, tumor histology, lymphovascular invasion (LVI), hypertension, diabetes, hematuria, blood transfusion, hydronephrosis on the affected side, urine specific gravity, creatinine, uric acid, and preoperative glomerular filtration rate (GFR) on the healthy and affected sides. The correlation between risk factors and inclusion indexes was analyzed using univariate and multivariate analyses.

Results

A total of 153 patients were enrolled in this study, and the follow-up continued for 14 (11, 24) months. Acute kidney injury (AKI) was diagnosed in 65 patients in the short-term follow-up after RNU, and renal function deterioration was diagnosed in 52 patients in the long-term follow-up after RNU. The univariate analysis of 65 patients with short-term AKI revealed that there were statistically significant differences in preoperative hydronephrosis, hypertension, urinary protein, tumor size, preoperative Hb, preoperative creatinine, blood transfusion, and preoperative GFR of the healthy kidney. The multivariate Logistic regression analysis results showed that preoperative creatinine, GFR of the healthy kidney, and blood transfusion were independent risk factors for AKI. Moreover, The multivariate Logistic regression analysis of 52 patients with long-term renal insufficiency after surgery indicated that there were statistically significant differences in preoperative hydronephrosis, tumor size, preoperative GFR of the healthy kidney, and postoperative AKI.

Conclusion

For patients with UTUC, the preoperative creatinine level is high, blood transfusion was given during or after procedure and the GFR of the healthy kidney is low, it is easy to have AKI in the short term after operation. In addition, there was no hydronephrosis before operation, the tumor size was small, the GFR of the healthy kidney was low before operation, AKI occurred after operation, the renal function was easy to deteriorate for a long time after operation. The above risk factors may aggravate renal function deterioration of these patients after surgery, resulting in the loss of the opportunity to continue treatment.

Baseline NT-proBNP predicts acute kidney injury following transcatheter aortic valve implantation

BACKGROUND/PURPOSE

Acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI) increases morbidity and mortality. Our study aimed to investigate the role of baseline N-terminal pro B-type natriuretic peptide (NT-proBNP) as a predictor of AKI following TAVI.

METHODS

All consecutive TAVI patients were included in the analysis, except patients with dialysis and those with a GFR < 15 ml/min/1.73 m2 at baseline. Rates of AKI after TAVI were assessed according to the updated valve academic research consortium definitions using AKIN classification in three stages. NT-proBNP was measured at baseline. One-year mortality rates were assessed.

RESULTS

We included 1973 patients treated with TAVI between January 2006 and December 2016. Median [IQR] age was 81.0 [77.0;84.0] years, the STS score was 6.2 [3.9;9.0], and the logEuroScore was 14.5 [9.0;23.0]. 30-day and one-year mortality was 5.1 % and 16.1 % for all patients, respectively. Multivariate analysis revealed that patients with NT-proBNP levels higher than two times above the upper level of normal (ULN) had an increased risk for AKI after TAVI compared to patients with NT-proBNP levels < 2× ULN (OR 1.40 [1.03-1.91]).

CONCLUSIONS

Routine assessment of baseline NT-proBNP levels might be an additional tool to identify patients at increased risk for AKI after TAVI.

Evaluation of Hematological Parameters After Transcatheter Aortic Valve Replacement

Although transcatheter aortic valve replacement (TAVR) is safe and effective, mortality and bleeding events post procedure are important. The present study investigated the changes in hematologic parameters to evaluate whether they predict mortality or major bleeding. We enrolled 248 consecutive patients (44.8% male; mean age 79.0 ± 6.4 years) undergoing TAVR. In addition to demographic and clinical examination, blood parameters were recorded before TAVR, at discharge, 1 month and 1 year. Hemoglobin levels before TAVR 12.1 ± 1.8 g/dL, 10.8 ± 1.7 g/dL at discharge, 11.7 ± 1.7 g/dL at first month, 11.8 ± 1.4 g/dL at first year (Hemoglobin values compared with pre-TAVR, P < .001, P = .019, P = .047, respectively). Mean platelet volume (MPV) before TAVR 8.72 ± 1.71 fL, 8.16 ± 1.46 fL at discharge, 8.09 ± 1.44 fL at first month, 7.94 ± 1.18 fL at first year (MPV values compared with pre-TAVR, P < .001, P < .001, P < .001, respectively). Other hematologic parameters were also evaluated. Hemoglobin, platelet count, MPV, and red cell distribution width before the procedure, at discharge, and at the first year did not predict mortality and major bleeding in receiver operating characteristic analysis. After multivariate Cox regression analysis, hematologic parameters were not independent predictors of in-hospital mortality, major bleeding, and death at 1 year after TAVR.

Noradrenaline infusion prevents anesthesia-induced hypotension in severe aortic stenosis patients undergoing transcatheter aortic valve replacement: a retrospective observational study

BACKGROUND

Patients with severe aortic valve stenosis (AS) are particularly prone to developing hypotension during general anesthesia induction, which increases postoperative morbidity and mortality. Although the preventive effect of a single vasopressor dose on anesthesia-induced hypotension has been reported, the effects of continuous vasopressor infusion are unknown. This study aimed to assess the effect of noradrenaline (NAd) infusion on hemodynamic stability during general anesthesia induction in severe AS patients undergoing transcatheter aortic valve replacement (TAVR).

METHODS

This single-center, retrospective study included severe AS patients who underwent elective TAVR. Patients in the NAd group received a continuous prophylactic NAd infusion of 0.1 μg/kg/min from the time of anesthesia induction. The control group received inotropes and vasopressors as indicated by the occurrence of hypotension. The primary outcome was the lowest mean blood pressure (MBP) before the start of surgery.

RESULTS

The study included 68 patients in the NAd group and 113 in the control group. The lowest MBP before the start of surgery was significantly higher in the NAd group than in the control group (63 ± 15 vs 47 ± 13 mmHg, P < 0.01). MBP immediately before intubation was also significantly higher in the NAd group (75 ± 17 vs 57 ± 16 mmHg, P < 0.01). Differences in postoperative complications between the groups were negligible.

CONCLUSION

Continuous administration of NAd at 0.1 μg/kg/min in patients with severe AS might prevent hypotension during general anesthesia induction for TAVR.

Impact of Significant Hemoglobin Drop Without Bleeding in Patients Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

Hemoglobin (Hgb) drop without bleeding is common among patients undergoing transcatheter aortic valve replacement; however, the clinical implications of significant Hgb drop have not been fully evaluated.

METHODS AND RESULTS

Consecutive patients undergoing transcatheter aortic valve replacement at our institution from 2011 to 2021 were retrospectively reviewed. Three groups were assessed: no Hgb drop and no bleed (NoD-NoB [reference group]), Hgb drop with bleed, and Hgb drop and no bleed (D-NoB). Hgb drop was defined as ≥3 g/dL decrease from pre- to post-transcatheter aortic valve replacement. Outcomes of interest were in-hospital death and 1-year all-cause mortality. A total of 1851 cases with complete Hgb data were included: NoD-NoB: n=1579 (85.3%); D-NoB: n=49 (2.6%); Hgb drop with bleed: n=223 (12.6%). Compared with NoD-NoB, the D-NoB group was older (81.1 versus 78.9 years of age) with higher preprocedure Hgb (12.9 versus 11.7 g/dL). In-hospital death rate was higher among patients with D-NoB versus NoD-NoB (4.5% versus 0.8%, P<0.001) and similar to Hgb drop with bleed (4.5% versus 4.1%, P=0.999). Predictors of in-hospital death were D-NoB (odds ratio [OR], 3.45 [95% CI, 1.32-8.69]) and transfusion (OR, 10.6 [95% CI, 4.25-28.2]). Landmark survival analysis found that D-NoB experienced 1-year mortality rate comparable to NoD-NoB, whereas Hgb drop with bleed had higher midterm mortality (hazard ratio [HR], 3.2 [95% CI, 1.83-5.73]), and transfusion continued to impact mortality (HR, 2.5 [95% CI, 1.79-3.63]).

CONCLUSIONS

Hgb drop without bleeding is common among patients undergoing transcatheter aortic valve replacement and may represent a higher risk of periprocedural death. Blood transfusion increases short- and midterm mortality risk in patients with and without bleeding, supporting a restrictive transfusion strategy.

Blood transfusion reactions and risk of acute kidney injury and major adverse kidney events

BACKGROUND

Blood transfusion reactions may have a negative impact on organ function. It is unknown whether this association holds true for acute kidney injury (AKI). Therefore, we conducted a cohort study to assess the association between transfusion reactions and the incidence of AKI and major adverse kidney events.

METHODS

In this retrospective cohort study, we included patients who received transfusion of blood products during hospitalization at the Hospital Civil of Guadalajara. We analyzed them according to the development of transfusion reactions, and the aim was to assess the association between transfusion reactions and AKI during long-term follow-up.

RESULTS

From 2017 to 2021, 81,635 patients received a blood product transfusion, and 516 were included in our study. The most common transfusion was red blood cell packaging (50.4%), fresh frozen plasma (28.7%) and platelets (20.9%); of the 516 patients, 129 (25%) had transfusion reactions. Patients who had transfusion reactions were older and had more comorbidities. The most common type of transfusion reaction was allergic reaction (70.5%), followed by febrile nonhemolytic reaction (11.6%) and anaphylactoid reaction (8.5%). Most cases were considered mild. Acute kidney injury was more prevalent among those who had transfusion reactions (14.7%) than among those who did not (7.8%), p =  < 0.01; those with AKI had a higher frequency of diabetes, vasopressors, and insulin use. Transfusion reactions were independently associated with the development of AKI (RR 2.1, p =  < 0.02). Major adverse kidney events were more common in those with transfusion reactions. The mortality rate was similar between subgroups.

CONCLUSION

In our retrospective cohort of patients who received blood product transfusions, 25% experienced transfusion reactions, and this event was associated with a twofold increase in the probability of developing AKI and some of the major adverse kidney events during long follow-up.

Association between hospital racial composition and aortic valve replacement outcomes: A national inpatients sample database analysis

BACKGROUND

Racial and ethnic disparities exist in the outcomes following surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI). However, it is unclear whether hospital racial composition contributes to these racial disparities.

METHODS

We analyzed the National Inpatient Sample (NIS) database from 2015 to 2019 to identify patients with aortic stenosis (AS) who received SAVR and TAVI. The Racial/Ethnic Diversity Index (RDI) was used to assess hospital racial composition as the proportion of nonwhite patients to total hospital admissions. Hospitals were categorized into RDI quintiles. Textbook outcome (TO) was defined as no in-hospital mortality, no postoperative complications and no prolonged length of stay (LOS). Multivariable mixed generalized linear models were conducted to assess the association between RDI and post-SAVR and post-TAVI outcomes. Moreover, quantile regression was used to assess the additional cost and length of stay associated with the RDI quintile.

RESULTS

The study included 82,502 SAVR or TAVI performed across 3285 hospitals, with 47.4% isolated SAVR and 52.5% isolated TAVI. After adjustment, quintiles 4 and 5 demonstrated significantly lower odds of TO than the lowest RDI quintile in both the SAVR cohort (quintile 4, 0.79 [95% CI, 0.73-0.85]; quintile 5, 0.79 [95% CI, 0.73-0.86]) and TAVI cohort (quintile 4, 0.88 [95% CI, 0.82-0.95]; quintile 5, 0.80 [95% CI, 0.74-0.86]). Despite non-observable differences in in-hospital mortality across all RDI quintiles, the rate of AKI and blood transfusion increased with increasing RDI for both cohorts. Further, Higher RDI quintiles were associated with increased costs and longer LOS. From 2015 to 2019, post-TAVI outcomes improved across all RDI quintiles.

CONCLUSIONS

Hospitals with a higher RDI experienced lower TO achievements, increased AKI, and blood transfusion, along with extended LOS and higher costs. Importantly, post-TAVI outcomes improved from 2015 to 2019 across all RDI groups.

Safety and feasibility of zero-contrast transcatheter aortic valve implantation using balloon-expandable valves in patients with aortic stenosis and severe renal impairment: A single-center study

BACKGROUND

Aortic stenosis (AS) and chronic kidney disease (CKD) can coexist. Repeat exposure to contrast media in patients undergoing transcatheter aortic valve implantation (TAVI) has latent mortality risks and increased risk for acute kidney injury. We aimed to assess our "zero-contrast TAVI" protocol for patients with advanced CKD.

METHODS

Consecutive patients with severe AS who underwent TAVI at a single center registry were enrolled. Zero-contrast TAVI group included patients who underwent TAVI without contrast and who had an estimated glomerular filtration rate <30 mL/min/1.73 m2. Conventional TAVI group included patients who underwent the regular TAVI procedure. Patients using balloon-expandable valves via transfemoral approach were analyzed. Baseline clinical and procedural characteristics and clinical outcomes were compared between two groups. The primary outcome was early safety as defined by Valve Academic Research Consortium Criteria. Secondary outcomes included the presence of severe prosthesis-patient mismatch, moderate or greater perivalvular leakage, and requirement for new dialysis (within 3 months).

RESULTS

A total of 520 patients were analyzed. Among these, 32 (6 %) underwent zero-contrast TAVI and 488 (94 %) conventional TAVI. In the zero-contrast TAVI group, 12 patients (37.5 %) had to use 20.7 (11.0-31.2) mL of contrast media. There were no significant differences in the primary and secondary outcomes between zero-contrast TAVI and conventional TAVI groups (78.1 % vs. 86.8 %, P = 0.184 and 9.4 % vs. 8.1 %, P = 0.738 for the primary and secondary outcomes, respectively).

CONCLUSIONS

Zero-contrast TAVI is feasible, safe, and effective in patients with AS and stage 4 CKD.

Transcatheter Aortic Valve Replacement in Patients With or Without Active Cancer

Background Data on clinical outcomes after transcatheter aortic valve replacement (TAVR) in specific cancer types or the presence of metastatic disease remain sparse. This study aimed to investigate the impact of active cancer on short-term mortality, complications, and readmission rates after TAVR across different cancer types. Methods and Results The authors assessed the Nationwide Readmissions Database for TAVR cases from 2012 to 2019. Patients were stratified by specific cancer types. Primary outcome was in-hospital mortality. Secondary outcomes included bleeding requiring blood transfusion and readmissions at 30, 90, and 180 days after TAVR. Overall, 122 573 patients undergoing TAVR were included in the analysis, of whom 8013 (6.5%) had active cancer. After adjusting for potential confounders, the presence of active cancer was not associated with increased in-hospital mortality (adjusted odds ratio [aOR], 1.06 [95% CI, 0.89-1.27]; P=0.523). However, active cancer was associated with an increased risk of readmission at 30, 90, and 180 days after TAVR and increased risk of bleeding requiring transfusion at 30 days. Active colon and any type of metastatic cancer were individually associated with readmissions at 30, 90, and 180 days after TAVR. At 30 days after TAVR, colon (aOR, 2.51 [95% CI, 1.68-3.76]; P<0.001), prostate (aOR, 1.40 [95% CI, 1.05-1.86]; P=0.021), and any type of metastatic cancer (aOR, 1.65 [95% CI, 1.23-2.22]; P=0.001) were individually associated with an increased risk of bleeding requiring transfusion. Conclusions Patients with active cancer had similar in-hospital mortality after TAVR but higher risk of readmission and bleeding requiring transfusion, the latter depending on certain types of cancer.

Implications of Renal Disease in Patients Undergoing Structural Interventions

Percutaneous structural interventions have a major impact on the morbidity, mortality, and quality of life of patients by providing a lower-risk alternative to cardiac surgery. However, renal disease has a significant impact on outcomes of these interventions. This review explores the incidence, outcomes, pathophysiology, and preventative measures of acute kidney injury and chronic kidney disease on transcatheter aortic valve replacement, transcatheter mitral valve repair, and percutaneous balloon mitral valvuloplasty. Given the expanding indications for percutaneous structural interventions, further research is needed to identify ideal patients with chronic kidney disease or end-stage renal disease who would benefit from intervention.

Retrospective analysis on incidence and risk factors for early acute renal injury after lung transplantation

BACKGROUND

Acute renal injury (AKI) is a common complication of lung transplantation. However, there has been no related research on whether the relationship between fluid balance and input and output influences the occurrence of early AKI. This study aimed to explore the relationship between early fluid balance and input and output on the incidence of early AKI after lung transplantation.

METHODS

Data from 31 patients who underwent lung transplantation in the Department of Intensive Care Medicine of the Sichuan Academy of Medical Sciences, Sichuan People's Hospital, from August 2018 to July 2021 were collected. To summarize the occurrence of early AKI after lung transplantation, The main indicators of lung transplantation patients were collected. The risk factors for early AKI after lung transplantation were analyzed.

RESULTS

Among the 31 patients who underwent lung transplantation, 21 had early postoperative AKI, with an incidence rate of 67.7%. Compared with the non-AKI group, the hospitalization and ICU hospitalization times of the AKI group were longer (P < 0.05). Multivariate regression analysis showed that intraoperative input volume, BMI, and fluid balance on the first day after lung transplantation were independent risk factors for AKI.

CONCLUSION

Intraoperative input volume, BMI, and fluid balance on the first day after lung transplantation were independent risk factors for AKI.

Prevalence and Risk Factors Associated With Acute Kidney Injury After Transcatheter Aortic Valve Replacement at a Tertiary Hospital in Riyadh, Saudi Arabia

BACKGROUND

Despite recent advancements in techniques, peri- and post-procedural complications still pose a significant challenge in the high-risk transcatheter aortic valve replacement (TAVR) patient population. This study aims to investigate and assess the prevalence of acute kidney injury (AKI) following TAVR, and to identify the risk factors associated with its occurrence.

METHODS

We conducted the study at King Abdulaziz Medical City, Riyadh, Saudi Arabia from January 2016 to December 2022. We extracted data from electronic medical records. We categorized and compared patients based on their diagnosis of AKI+ following TAVR, or their absence of AKI- after the procedure.

RESULTS

The study included a total of 344 patients who underwent TAVR. The mean age of the patients was 77.8 ± 8.9 years, 61.8% were male, and the average body mass index was 30.5±7.0. In terms of comorbidities, 70.8% of the patients had diabetes mellitus, 80.5% had hypertension, 8.7% had hypothyroidism, 2.0% had hematological disorders, 23.6% had congestive heart disease, 20.4% had cerebrovascular disease, 4.1% had peripheral vascular disease, 7.3% had cancer, and 34.4% had other comorbidities. The prevalence of AKI was 60 (17.50%) following the procedure. Cerebrovascular diseases showed a significant association with AKI (OR= 3.381, 95% CI, 1.65-6.91, p = 0.001). Chronic kidney disease has a significant effect on AKI (OR = 2.56, 95%CI, 1.02-6.39, p = 0.044). The creatinine level on Day 0 has a significant association with AKI (OR = 1.01, 95%CI, 1.006-1.017, p = 0.0001).

CONCLUSIONS

These findings highlight the importance of assessing and managing these risk factors (cerebrovascular diseases, chronic kidney disease, and creatinine level on Day 0) in TAVR patients to mitigate the occurrence and severity of AKI. By understanding and addressing these factors, healthcare providers can potentially improve patient outcomes and reduce the incidence of AKI-associated TAVR procedures.

Intraoperative Red Blood Cell Transfusion and Primary Graft Dysfunction After Lung Transplantation

BACKGROUND

In this international, multicenter study of patients undergoing lung transplantation (LT), we explored the association between the amount of intraoperative packed red blood cell (PRBC) transfusion and occurrence of primary graft dysfunction (PGD) and associated outcomes.

METHODS

The Extracorporeal Life Support in LT Registry includes data on LT recipients from 9 high-volume (>40 transplants/y) transplant centers (2 from Europe, 7 from the United States). Adult patients who underwent bilateral orthotopic lung transplant from January 2016 to January 2020 were included. The primary outcome of interest was the occurrence of grade 3 PGD in the first 72 h after LT.

RESULTS

We included 729 patients who underwent bilateral orthotopic lung transplant between January 2016 and November 2020. LT recipient population tertiles based on the amount of intraoperative PRBC transfusion (0, 1-4, and >4 units) were significantly different in terms of diagnosis, age, gender, body mass index, mean pulmonary artery pressure, lung allocation score, hemoglobin, prior chest surgery, preoperative hospitalization, and extracorporeal membrane oxygenation requirement. Inverse probability treatment weighting logistic regression showed that intraoperative PRBC transfusion of >4 units was significantly ( P  < 0.001) associated with grade 3 PGD within 72 h (odds ratio [95% confidence interval], 2.2 [1.6-3.1]). Inverse probability treatment weighting analysis excluding patients with extracorporeal membrane oxygenation support produced similar findings (odds ratio [95% confidence interval], 2.4 [1.7-3.4], P  < 0.001).

CONCLUSIONS

In this multicenter, international registry study of LT patients, intraoperative transfusion of >4 units of PRBCs was associated with an increased risk of grade 3 PGD within 72 h. Efforts to improve post-LT outcomes should include perioperative blood conservation measures.

Aortic valve and vascular calcium score in pre-TAVI CT: correlation with early post-procedural complications

PURPOSE

The aim of our study was to evaluate the prevalence of early complications after Transcatheter Aortic Valve Implantation (TAVI) and their correlation with the Calcium Score (CS) of the aortic valve, aorta and ilio-femoral arteries derived from pre-procedural computed tomography (CT).

MATERIALS AND METHODS

We retrospectively reviewed 226 patients (100 males, mean age 79.4 ± 6.7 years) undergoing 64-slice CT for pre-TAVI evaluation from January 2018 to April 2021. The population was divided into CS quartiles.

RESULTS

Overall, 173 patients underwent TAVI procedure, of whom 61% presented paravalvular leak after the procedure, 28% presented bleeding or vascular complications, 25% presented atrioventricular block, and 8% developed acute kidney injury. The prevalence of paravalvular leak and vascular complications was higher in the upper CS quartiles for aortic valve and ilio-femoral arteries.

CONCLUSIONS

Aortic valve and vascular CS could help to predict post-TAVI early complications.

Gastrointestinal bleeding during the transcatheter aortic valve replacement perioperative period: A Review

With the aging of the population, the incidence of senile degenerative valvular heart disease is expected to increase. Transcatheter aortic valve replacement (TAVR) has been used for patients at lower surgical risk with symptomatic severe aortic valve stenosis. Because of the improvements in TAVR technology and increasing experience of the operators, TAVR is regarded as a safe and feasible procedure. Bleeding events during the TAVR perioperative period, especially gastrointestinal (GI) bleeding, have been proven to be related to the long-term prognosis and mortality. Elderly patients with valvular heart disease are susceptible to GI bleeding because of their use of antithrombotic drugs, physical damage of coagulation factors, and GI angiodysplasia. Frequent GI bleeding and low levels of preoperative hemoglobin increase the risk of TAVR, especially for elderly patients. Because of these risks, which are easily overlooked, we should focus more attention on the perioperative management of TAVR. Reasonable screening tools, including blood examinations, risk evaluation scales, and endoscopy, are beneficial to the prevention of complications that can occur during the perioperative period. Additionally, medical therapy can safely help patients at high-risk for bleeding patients throughout the perioperative period. This study aimed to characterize the pathology of TAVR patients and discuss treatment strategies for GI bleeding during the perioperative period.

Relation of Subacute Kidney Injury to Mortality After Transcatheter Aortic Valve Implantation

Acute kidney injury after transcatheter aortic valve implantation (TAVI) has been associated with adverse outcomes; however, data are limited on the subacute changes in renal function that occur after discharge and their impact on clinical outcomes. This study investigates the relation between subacute changes in kidney function at 30 days after TAVI and survival. Patients from 2 centers who underwent TAVI and survived beyond 30 days with baseline, in-hospital, and 30-day measures of renal function were retrospectively analyzed. Patients were stratified based on change in estimated glomerular filtration rate (eGFR) from baseline to 30 days as follows: improved (≥15% higher than baseline), worsened (≤15% lower), or unchanged (values in between). Univariable and multivariable models were constructed to identify predictors of subacute changes in renal function and of 2-year mortality. Of the 492 patients who met inclusion criteria, eGFR worsened in 102 (22%), improved in 110 (22%), and was unchanged in 280 (56%). AKI occurred in 90 patients (18%) and in only 27% of patients with worsened eGFR at 30 days. After statistical adjustment, worsened eGFR at 30 days (hazard ratio vs unchanged eGFR 2.09, 95% CI 1.37 to 3.19, p <0.001) was associated with worse survival, whereas improvement in renal function was not associated with survival (hazard ratio vs unchanged eGFR 1.30, 95% CI 0.79 to 2.11, p = 0.30). Worsened renal function at 30 days after TAVI is associated with increased mortality after TAVI. In conclusion, monitoring renal function after discharge may identify patients at high risk of adverse outcomes.

Baseline Anemia Is an Independent Predictor of Long-Term Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation

This study aimed to investigate the relationship between baseline anemia and long-term mortality in a single-center retrospective study involving patients undergoing transcatheter aortic valve implantation (TAVI). The study population included 412 consecutive patients undergoing TAVI at a center for severe aortic valve stenosis between August 2011 and November 2018. The primary end point of the study was all-cause mortality. Baseline anemia was present in 50% of our study cohort. During the median follow-up of 29 months, all-cause mortality was observed in 40.3% of the whole study population and was more frequently observed in the anemic group compared with the nonanemic group (53.5% vs 27.1%, P < .001, respectively). Cox-regression analysis revealed that Society of Thoracic Surgeons Predicted Risk of Mortality score, previous stroke, pericardial tamponade, and neutrophil-lymphocyte ratio count are independent predictors of long-term mortality after TAVI. Additionally, the presence of anemia at baseline was an independent predictor of long-term mortality with a 2.3-fold difference in the anemic group compared with the nonanemic group (hazard ratio: 2.31, 95% CI: 1.59-3.37, P < .001). Baseline anemia was observed in half of our patient population undergoing TAVI, and baseline anemia was found to be an independent predictor of long-term mortality after TAVI.

Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research

Aims 

The Valve Academic Research Consortium (VARC), founded in 2010, was intended to (i) identify appropriate clinical endpoints and (ii) standardize definitions of these endpoints for transcatheter and surgical aortic valve clinical trials. Rapid evolution of the field, including the emergence of new complications, expanding clinical indications, and novel therapy strategies have mandated further refinement and expansion of these definitions to ensure clinical relevance. This document provides an update of the most appropriate clinical endpoint definitions to be used in the conduct of transcatheter and surgical aortic valve clinical research.

Methods and results 

Several years after the publication of the VARC-2 manuscript, an in-person meeting was held involving over 50 independent clinical experts representing several professional societies, academic research organizations, the US Food and Drug Administration (FDA), and industry representatives to (i) evaluate utilization of VARC endpoint definitions in clinical research, (ii) discuss the scope of this focused update, and (iii) review and revise specific clinical endpoint definitions. A writing committee of independent experts was convened and subsequently met to further address outstanding issues. There were ongoing discussions with FDA and many experts to develop a new classification schema for bioprosthetic valve dysfunction and failure. Overall, this multi-disciplinary process has resulted in important recommendations for data reporting, clinical research methods, and updated endpoint definitions. New definitions or modifications of existing definitions are being proposed for repeat hospitalizations, access site-related complications, bleeding events, conduction disturbances, cardiac structural complications, and bioprosthetic valve dysfunction and failure (including valve leaflet thickening and thrombosis). A more granular 5-class grading scheme for paravalvular regurgitation (PVR) is being proposed to help refine the assessment of PVR. Finally, more specific recommendations on quality-of-life assessments have been included, which have been targeted to specific clinical study designs.

Conclusions 

Acknowledging the dynamic and evolving nature of less-invasive aortic valve therapies, further refinements of clinical research processes are required. The adoption of these updated and newly proposed VARC-3 endpoints and definitions will ensure homogenous event reporting, accurate adjudication, and appropriate comparisons of clinical research studies involving devices and new therapeutic strategies.

Valve Academic Research Consortium 3: Updated Endpoint Definitions for Aortic Valve Clinical Research

AIMS

The Valve Academic Research Consortium (VARC), founded in 2010, was intended to (i) identify appropriate clinical endpoints and (ii) standardize definitions of these endpoints for transcatheter and surgical aortic valve clinical trials. Rapid evolution of the field, including the emergence of new complications, expanding clinical indications, and novel therapy strategies have mandated further refinement and expansion of these definitions to ensure clinical relevance. This document provides an update of the most appropriate clinical endpoint definitions to be used in the conduct of transcatheter and surgical aortic valve clinical research.

METHODS AND RESULTS

Several years after the publication of the VARC-2 manuscript, an in-person meeting was held involving over 50 independent clinical experts representing several professional societies, academic research organizations, the US Food and Drug Administration (FDA), and industry representatives to (i) evaluate utilization of VARC endpoint definitions in clinical research, (ii) discuss the scope of this focused update, and (iii) review and revise specific clinical endpoint definitions. A writing committee of independent experts was convened and subsequently met to further address outstanding issues. There were ongoing discussions with FDA and many experts to develop a new classification schema for bioprosthetic valve dysfunction and failure. Overall, this multi-disciplinary process has resulted in important recommendations for data reporting, clinical research methods, and updated endpoint definitions. New definitions or modifications of existing definitions are being proposed for repeat hospitalizations, access site-related complications, bleeding events, conduction disturbances, cardiac structural complications, and bioprosthetic valve dysfunction and failure (including valve leaflet thickening and thrombosis). A more granular 5-class grading scheme for paravalvular regurgitation (PVR) is being proposed to help refine the assessment of PVR. Finally, more specific recommendations on quality-of-life assessments have been included, which have been targeted to specific clinical study designs.

CONCLUSIONS

Acknowledging the dynamic and evolving nature of less-invasive aortic valve therapies, further refinements of clinical research processes are required. The adoption of these updated and newly proposed VARC-3 endpoints and definitions will ensure homogenous event reporting, accurate adjudication, and appropriate comparisons of clinical research studies involving devices and new therapeutic strategies.

Identification of Anemia for Predicting Mid-Term Prognosis After Transcatheter Aortic Valve Implantation in Japanese Patients - Insights From the OCEAN-TAVI Registry

Background: Patients with anemia have a poor prognosis following transcatheter aortic valve implantation (TAVI). Given the unique distribution of hemoglobin levels in the Japanese cohort, the optimal cut-off hemoglobin value may help stratify Japanese patients’ mortality following TAVI.

Methods and Results: Data of patients who underwent TAVI were collected from the prospective multicenter Optimized transCathEter vAlvular iNtervention (OCEAN)-TAVI Registry. Receiver operating characteristic analysis was used to calculate a hemoglobin cut-off value to stratify 2-year mortality following TAVI. In all, 2,588 patients (mean [±SD] age 84.4±5.2 years, 795 men) were included in the study. Of these patients, 909 (35.1%) had anemia, which was defined as hemoglobin <10.9 g/dL for men and <10.4 g/dL for women. The presence of anemia, uniquely defined for the Japanese cohort, was independently associated with 2-year mortality following TAVI, with an odds ratio of 1.77 (95% confidence interval 1.39–2.25) adjusted for 14 other clinical variables.

Conclusions: The existence of anemia, uniquely defined for the Japanese cohort, was associated with mid-term mortality following TAVI.

Antithrombotic therapy in patients undergoing transcatheter aortic valve replacement: the complexity of the elderly

Along with epidemiologic transitions of the global population, the burden of aortic stenosis (AS) is rapidly increasing and transcatheter aortic valve replacement (TAVR) has quickly spread; indeed, it is nowadays also employed in treating patients with AS at intermediate operative risk. Nonetheless, the less invasive interventional strategy still carries relevant issues concerning post-procedural optimal antithrombotic strategy, given the current indications provided by guidelines are not completely supported by evidence-based data. Geriatric patients suffer from high bleeding and thromboembolic risks, whose balance is particularly subtle due to the presence of concomitant conditions, such as atrial fibrillation and chronic kidney disease, that make the post-TAVR antithrombotic management particularly insidious. This scenario is further complicated by the lack of specific evidence regarding the 'real-life' complex conditions typical of the geriatric syndromes, thus, the management of such a heterogeneous population, ranging from healthy ageing to frailty, is far from being defined. The aim of the present review is to summarize the critical points and the most updated evidence regarding the post-TAVR antithrombotic approach in the geriatric population, with a specific focus on the most frequent clinical settings.

Intravascular Ultrasound-Guided Contrast-Free Transcatheter Aortic Valve Implantation: A Porcine Feasibility Study

OBJECTIVE

Patients undergoing transcatheter aortic valve implantation (TAVI) frequently present with chronic kidney disease and are therefore particularly susceptible to nephrotoxic influences like iodinated contrast media. Acute kidney injury after TAVI is a severe complication that independently predicts short- and long-term mortality. The present study investigates the feasibility of a contrast-free approach by using intravascular ultrasound (IVUS) in conjunction with fluoroscopy.

METHODS

Six domestic pigs (60 ± 5 kg) were anesthetized and underwent transapical implantation of a balloon-expandable transcatheter heart valve. In the control group (n = 3), the procedures were guided by fluoroscopy/angiography. In the study group (n = 3), the procedures were guided by IVUS for preimplantation evaluation, intra-procedural guidance, and post-implantation evaluation, in conjunction with fluoroscopy without contrast. The procedures were evaluated by IVUS, fluoroscopy, aortic root angiography, and explantation and dissection of the hearts.

RESULTS

Relevant anatomical landmarks for correct implantation were assessed by IVUS. The following annulus measurements were obtained: area (359.67 ± 29.58 mm²), perimeter (68.28 ± 2.63 mm), maximum diameter (22.20 ± 1.22 mm), minimum diameter (20.43 ± 1.12 mm), mean diameter (21.32 ± 0.70 mm), ellipticity index (1.09 ± 0.10), and area-derived diameter (21.39 ± 0.87 mm). IVUS-guided valve deployment resulted in correct expansion within the aortic annulus without signs of paravalvular leak, compromised mitral valve, or coronary obstruction. IVUS-guided post-implantation assessment confirmed circular expansion (25.88 ± 0.30 mm) of the valves.

CONCLUSIONS

IVUS-guided, contrast-free transapical TAVI is feasible in a porcine model.

Low hemoglobin levels are independently associated with neonatal acute kidney injury: a report from the AWAKEN Study Group

BACKGROUND

Studies in adults showed a relationship between low hemoglobin (Hb) and acute kidney injury (AKI). We performed this study to evaluate this association in newborns.

METHODS

We evaluated 1891 newborns from the Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN) database. We evaluated the associations for the entire cohort and 3 gestational age (GA) groups: <29, 29-<36, and ≥36 weeks' GA.

RESULTS

Minimum Hb in the first postnatal week was significantly lower in neonates with AKI after the first postnatal week (late AKI). After controlling for multiple potential confounders, compared to neonates with a minimum Hb ≥17.0 g/dL, both those with minimum Hb ≤12.6 and 12.7-14.8 g/dL had an adjusted increased odds of late AKI (aOR 3.16, 95% CI 1.44-6.96, p = 0.04) and (aOR 2.03, 95% CI 1.05-3.93; p = 0.04), respectively. This association was no longer evident after controlling for fluid balance. The ability of minimum Hb to predict late AKI was moderate (c-statistic 0.68, 95% CI 0.64-0.72) with a sensitivity of 65.9%, a specificity of 69.7%, and a PPV of 20.8%.

CONCLUSIONS

Lower Hb in the first postnatal week was associated with late AKI, though the association no longer remained after fluid balance was included.

IMPACT

The current study suggests a possible novel association between low serum hemoglobin (Hb) and neonatal acute kidney injury (AKI). The study shows that low serum Hb levels in the first postnatal week are associated with increased risk of AKI after the first postnatal week. This study is the first to show this relationship in neonates. Because this study is retrospective, our observations cannot be considered proof of a causative role but do raise important questions and deserve further investigation. Whether the correction of low Hb levels might confer short- and/or long-term renal benefits in neonates was beyond the scope of this study.

Early Adverse Impact of Transfusion After Transcatheter Aortic Valve Replacement: A Propensity-Matched Comparison From the TRITAVI Registry

BACKGROUND

There is no consensus on the benefit of red blood cell (RBC) transfusion after transcatheter aortic valve replacement.

METHODS

The multicenter Transfusion Requirements in Transcatheter Aortic Valve Implantation (TRITAVI) registry retrospectively included patients after transfemoral transcatheter aortic valve replacement; propensity score-matching identified pairs of patients with and without RBC transfusion. The primary end point was 30-day mortality; nonfatal myocardial infarction, cerebrovascular accident, and stage 2 to 3 acute kidney injury at 30 days were secondary end points. We repeated propensity score-matching according to the hemoglobin nadir, hemoglobin drop, and in the subgroup of uncomplicated patients, without major vascular complications or major bleeding.

RESULTS

Among 2587 patients, RBC transfusion was administered in 421 cases (16%). The primary end point occurred in 104 (4.0%) patients, myocardial infarction in 9 (0.4%), cerebrovascular accident in 38 (1.5%), and acute kidney injury in 125 (4.8%) cases. In the 842 propensity-matched patients, RBC transfusion was associated with increased mortality (hazard ratio, 2.07 [95% CI, 1.06-4.05]; P=0.034) and acute kidney injury (hazard ratio, 4.35 [95% CI, 2.21-8.55]; P<0.001). Interaction testing between RBC transfusion and mortality was not statistically significant in the above-mentioned subgroups, and such association was not documented in the corresponding propensity score-matched cohorts. In the multivariable Cox proportional hazards regression model, major vascular complications (P=0.044), major bleeding (P=0.041), and RBC transfusion (P=0.048) were independent correlates of 30-day mortality.

CONCLUSIONS

RBC transfusion correlates with increased mortality and acute kidney injury early after transcatheter aortic valve replacement and is an independent predictor of 30-day mortality, irrespective of periprocedural major bleeding and vascular complications. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03740425.

Frailty and Bleeding in Older Adults Undergoing TAVR or SAVR: Insights From the FRAILTY-AVR Study

OBJECTIVES

The aim of this study was to examine the value of frailty to predict in-hospital major bleeding and determine its impact on mid-term mortality following transcatheter (TAVR) or surgical (SAVR) aortic valve replacement.

BACKGROUND

Bleeding complications are harbingers of mortality and major morbidity in patients undergoing TAVR or SAVR. Despite the high prevalence of frailty in this population, little is known about its effects on bleeding risk.

METHODS

A post hoc analysis was performed of the multinational FRAILTY-AVR (Frailty Aortic Valve Replacement) cohort study, which prospectively enrolled older adults ≥70 years of age undergoing TAVR or SAVR. Trained researchers assessed frailty using a questionnaire and physical performance battery pre-procedure and ascertained clinical data from the electronic health record. The primary endpoint was major or life-threatening bleeding during the index hospitalization, and the secondary endpoint was units of packed red blood cells transfused.

RESULTS

The cohort consisted of 1,195 patients with a mean age of 81.3 ± 6.0 years. The incidence of life-threatening bleeding, major bleeding with a clinically apparent source, and major bleeding without a clinically apparent source was, respectively, 3%, 6%, and 9% in the TAVR group and 8%, 10%, and 31% in the SAVR group. Frailty measured using the Essential Frailty Toolset was an independent predictor of major bleeding and packed red blood cell transfusions in both groups. Major bleeding was associated with a 3-fold increase in 1-year mortality following TAVR (odds ratio: 3.40; 95% confidence interval: 2.22 to 5.21) and SAVR (odds ratio: 2.79; 95% confidence interval: 1.25 to 6.21).

CONCLUSIONS

Frailty is associated with post-procedural major bleeding in older adults undergoing TAVR and SAVR, which is in turn associated with a higher risk for mid-term mortality.

Deep-learning-based real-time prediction of acute kidney injury outperforms human predictive performance

Acute kidney injury (AKI) is a major complication after cardiothoracic surgery. Early prediction of AKI could prompt preventive measures, but is challenging in the clinical routine. One important reason is that the amount of postoperative data is too massive and too high-dimensional to be effectively processed by the human operator. We therefore sought to develop a deep-learning-based algorithm that is able to predict postoperative AKI prior to the onset of symptoms and complications. Based on 96 routinely collected parameters we built a recurrent neural network (RNN) for real-time prediction of AKI after cardiothoracic surgery. From the data of 15,564 admissions we constructed a balanced training set (2224 admissions) for the development of the RNN. The model was then evaluated on an independent test set (350 admissions) and yielded an area under curve (AUC) (95% confidence interval) of 0.893 (0.862-0.924). We compared the performance of our model against that of experienced clinicians. The RNN significantly outperformed clinicians (AUC = 0.901 vs. 0.745, p < 0.001) and was overall well calibrated. This was not the case for the physicians, who systematically underestimated the risk (p < 0.001). In conclusion, the RNN was superior to physicians in the prediction of AKI after cardiothoracic surgery. It could potentially be integrated into hospitals' electronic health records for real-time patient monitoring and may help to detect early AKI and hence modify the treatment in perioperative care.

Acute kidney injury after transcatheter aortic valve implantation and mortality risk-long-term follow-up

BACKGROUND

Acute kidney injury (AKI) complicating transcatheter aortic valve implantation (TAVI) is relatively frequent and associated with significant morbidity. Previous studies have shown a higher 30-day and 1-year mortality risk in patients with periprocedural AKI. Our aim was to identify the prognostic impact of periprocedural AKI on long-term follow-up.

METHODS

This is a single-center prospective study evaluating patients undergoing TAVI for severe aortic stenosis. AKI was defined according to the Valve Academic Research Consortium 2 definition, as an absolute increase in serum creatinine ≥0.3 mg/dL or an increase >50% within the first week following TAVI. Mortality data were compared between patients who developed AKI and those who did not. Logistic and Cox regressions were used for survival analysis.

RESULTS

The final analysis included 1086 consecutive TAVI patients. AKI occurred in 201 patients (18.5%). During the follow-up period, 289 patients died. AKI was associated with an increased risk of 30-day mortality {4.5 versus 1.9% in the non-AKI group; hazard ratio [HR] 3.70 [95% confidence interval (CI) 1.35-10.13]}. Although 1-year mortality was higher in the AKI group in univariate analysis, it was not significant after a multivariate regression. AKI was a strong predictor of longer-term mortality [42.3 versus 22.7% for 7-year mortality; HR 1.71 (95% CI 1.30-2.25)]. In 189 of 201 patients we had data regarding recovery from AKI up to 30 days after discharge. In patients with recovery from AKI, the mortality rate was lower (38.2 versus 56.6% in the nonrecovery group; P = 0.022).

CONCLUSIONS

Periprocedural AKI following TAVI is a strong risk factor for short-term as well as long-term mortality (up to 7 years). Therefore more effort is needed to reduce this complication.

Kidney injury as post-interventional complication of TAVI

Transcatheter aortic valve implantation (TAVI) is an accepted treatment approach of aortic stenosis. In the beginning, this technique was executed in high-risk patients only. Today, intermediate-risk patients are also amenable for TAVI, as long as the transfemoral approach is chosen. Numerous predictors have been identified that could lead to periprocedural complications and are defined by patient co-morbidities as well as being inherent to the technical approach. Although vascular complications and postinterventional paravalvular regurgitation have been minimized over the past years by revised technologies and techniques, there is a prevailing individual risk brought about by the specific pathophysiology of the cardiorenal syndrome.

A meta-analysis comparing transaxillary and transaortic transcatheter aortic valve replacement

BACKGROUND

The alternative access route of choice for transcatheter aortic valve replacement (TAVR) remains to be elucidated due to lack of evidences. We performed a meta-analysis comparing the outcomes of two common alternative access routes, transaxillary (TAx) and transaortic (TAo) approaches.

METHODS

The PubMed/MEDLINE, Embase, and Cochrane library from inception to December 2018 were searched to identify the articles reporting data on both TAx-TAVR and TAo-TAVR. Patients' baseline characteristics, procedural outcomes, and clinical outcomes were extracted from the articles and pooled for analysis.

RESULTS

Four studies, a total of 750 (374 TAo and 376 TAx) patients were included in the study. The two groups were similar in patients' baseline characteristics, although the TAx group comprised few female patients. The two groups differ in outcomes including 30-day mortality, rates of pacemaker implant and acute kidney injury, and length of hospital stay. There were no differences between the two groups with regard to device success, paravalvular leak, stroke, vascular complications, and 1-year mortality.

CONCLUSION

Compared with the TAo approach, the TAx approach is associated with favorable short-term mortality, lower incidence of acute kidney injury, and shorter length of hospital stay, but increased pacemaker requirement. TAx could be considered over TAo as the preferred alternative access for TAVR.

Contemporary Results of Transcatheter Aortic Valve Replacement in Obese Patients

Background. Little research has been conducted to explore the postoperative outcomes of obese patients after transfemoral transcatheter aortic valve replacement (TF-TAVR). Objective. We investigated the influence of body mass index (BMI) on 1-year outcomes after TF-TAVR. Methods. We included retrospectively 1609 high- and intermediate-risk TAVR patients (mean EuroSCORE II 21 ± 11) operated under general anesthesia between March 2014 and March 2018 in central hospital, Bad Berka, Germany. We stratified the patients according to BMI. Results. Our demographic data analysis showed 41% of patients were male and the mean age was 78 (range, 61–92 years). According to the WHO classification, 33% patients had normal weight, 42% were defined as overweight, and 22% were obese. Obese patients showed statistically significant difference in their clinical parameters as having higher incidence of hypertension, diabetes mellitus, pulmonary hypertension, and chronic obstructive pulmonary disease; on the contrary, obese patients were found to be younger than others. We found no differences in valve types and sizes among the different BMI categories. Our mortality rate during the 1-year follow-up period was 17.8% (287 patients). Mortality was significantly higher in patients with BMI < 25 kg/m2 (1 year mortality 149 patients 28.2% in patients with BMI < 25 kg/m2 vs. 138 patients 12.6% in patients with BMI ≥ 25 kg/m2; P=0.0001). Even after considering the confounding risk factors, BMI ≥ 25 kg/m2 was independently associated with reduced 1 year mortality (odds ratio (OR): 0.36, 95% confidence interval (CI): 0.21–0.6; P=0.01) in multivariate logistic regression analysis. The rate of vascular complication was higher in patients with BMI ≥ 25 kg/m2. However, the rate of blood transfusion was higher in patients with BMI < 25 kg/m2. All other serious complications occurred with equal distribution in both groups. Conclusion. In our single-center study, BMI ≥ 25 kg/m2 was independently associated with lower 1 year mortality after TF-TAVR.

Acute Renal Failure/Acute Kidney Injury (AKI) Associated with Endovascular Procedures

AKI is one of the most common yet underdiagnosed postoperative complications that can occur after any type of surgery. Contrast-induced nephropathy (CIN) is still poorly defined and due to a wide range of confounding individual variables, its risk is difficult to determine. CIN mainly affects patients with underlying chronic kidney disease, diabetes, sepsis, heart failure, acute coronary syndrome and cardiogenic shock. Further research is necessary to better understand pathophysiology of contrast-induced AKI and consequent implementation of effective prevention and therapeutic strategies. Although many therapies have been tested to avoid CIN, the only potent preventative strategy involves aggressive fluid administration and reduction of contrast volume. Regardless of surgical technique—open or endovascular—perioperative AKI is associated with significant morbidity, mortality and cost. Endovascular procedures always require administration of a contrast media, which may cause acute tubular necrosis or renal vascular embolization leading to renal ischemia and as a consequence, contribute to increased number of post-operative AKIs.

Blood Disorders in Patients Undergoing Transcatheter Aortic Valve Replacement: A Review

Transcatheter aortic valve replacement (TAVR) is well established for treating patients with severe aortic stenosis considered at intermediate to high surgical risk. Blood disorders such as anemia, thrombocytopenia, and acquired type 2A von Willebrand disease are relatively frequent in TAVR candidates, and multiple studies to date have highlighted their potential clinical association with mortality and/or bleeding complications post-TAVR. The present review provides an overview of various blood disorders observed pre- and post-TAVR, with special focus on their incidence, etiology, clinical association, and management.

Causes and predictors of readmission after transcatheter aortic valve implantation : A meta-analysis and systematic review

BACKGROUND

Since readmission rate is an important clinical index to determine the quality of inpatient care and hospital performance, the aim of this study was to explain the causes and predictors of readmission following transcatheter aortic valve implantation (TAVI) at short-term and mid-term follow-up.

METHODS AND RESULTS

A systematic review and meta-analysis of all published articles from Embase, Pubmed/MEDLINE, and Ovid was carried out. In all, 10 studies including 52,702 patients were identified. The pooled estimate for the overall event rate was 0.15, and cardiovascular causes were the main reason for 30-day readmission (0.42, 95% confidence interval [CI]: 0.39-0.45). In addition, the pooled incidence of 1‑year readmission was 0.31, and cardiovascular events were still the main cause (0.41, 95% CI: 0.33-0.48). Patients with major and life-threatening bleeding, new permanent pacemaker implantation, and clinical heart failure were associated with a high risk for early readmission after TAVI. Moreover, an advanced (≥3) New York Heart Association classification, acute kidney injury, paravalvular leak, mitral regurgitation (≥ moderate), and major bleeding predicted unfavorable outcome to 1‑year readmission. Female gender and transfemoral TAVI was associated with a lower risk for unplanned rehospitalization.

CONCLUSIONS

This meta-analysis found cardiovascular factors to be the main causes for both 30-day and 1‑year rehospitalization. Heart failure represented the most common cardiovascular event at both short-term and mid-term follow-up. Several baseline characteristics and procedure-related factors were deemed unfavorable predictors of readmission. Importantly, transfemoral access and female gender were associated with a lower risk of readmission.

Incidence, Predictors, and Prognostic Value of Acute Kidney Injury Among Patients Undergoing Left Atrial Appendage Closure

OBJECTIVES

The aims of this registry were to determine the incidence, predictors, and prognostic value of periprocedural acute kidney injury (AKI) after left atrial appendage closure (LAAC).

BACKGROUND

No data exist on the occurrence of AKI after LAAC.

METHODS

A total of 355 patients undergoing LAAC were included in the study. AKI was defined as an absolute or a relative increase in serum creatinine of >0.3 mg/dl or ≥50%, respectively, after the procedure or the need for hemodialysis during index hospitalization.

RESULTS

The incidence of AKI was 9%, and patients with worse baseline renal function were at higher risk for developing AKI (odds ratio: 1.32; 95% confidence interval [CI]: 1.09 to 1.61; p = 0.004 for each 10 ml/min decrease in glomerular filtration rate). In-hospital bleeding events occurred more frequently in the AKI group (5.3% vs. 15.6%; p = 0.037). After a median follow-up period of 18 months, patients in the AKI group had higher mortality (hazard ratio [HR]: 2.59; 95% CI: 1.36 to 4.92; p = 0.004), more embolic events (HR: 6.14; 95% CI: 2.23 to 16.92; p = 0.001) and major bleeding events (HR: 2.36; 95% CI: 0.89 to 6.24; p = 0.083). The occurrence of AKI was an independent predictor of midterm mortality (HR: 2.00; 95% CI: 1.02 to 3.91; p = 0.044).

CONCLUSIONS

The occurrence of AKI was relatively frequent following LAAC, and patients with lower renal glomerular filtration rates were at high risk for developing this complication. AKI identified a group of patients with worse midterm outcomes, highlighting the importance of further preventive strategies in this population.

Prevalence and Clinical Impact of Iron Deficiency in Patients With Severe Aortic Stenosis Referred for Transcatheter Aortic Valve Implantation

Patients referred for transcatheter aortic valve implantation (TAVI) are typically elderly with several co-morbidities, which might limit prognosis despite successful procedural outcome. To date, the prevalence and clinical impact of iron deficiency (ID) in patients with severe aortic stenosis who underwent TAVI remains poorly defined. This study included 495 patients who underwent transfemoral TAVI for severe symptomatic aortic stenosis. ID was defined as ferritin <100 ng/ml or ferritin 100 to 300 ng/ml, when transferrin saturation was <20%. The primary end point of the study was a composite of all-cause mortality, unplanned readmission for worsening heart failure or red blood cell transfusions during the first year after TAVI, which occurred in 22% (109 of 495) of the population. ID was present in 54% (268 of 495) of the entire cohort and was associated with a higher rate of the primary end point (27.6% [74 of 268] vs 15.4% [35 of 227]; p = 0.001). After multivariable adjustment, the association of ID with the primary end point remained significant (hazard ratio 1.64, 95% confidence interval [1.08 to 2.48]; p = 0.019). In a subgroup of ferropenic patients (n = 56), treatment with intravenous iron before TAVI was feasible, resulting in a considerable improvement of ferritin, transferrin saturation and symptoms at 30-day follow-up. In conclusion, ID is common in TAVI patients and is associated with adverse clinical outcome after TAVI. Correction of ID with intravenous iron seems feasible in contemporary TAVI patients. Whether this reduces transfusion rates and impacts clinical outcome after TAVI remains to be investigated in future prospective trials.

Influence of preoperative serum creatinine level and intraoperative volume of contrast medium on the risk of acute kidney injury after transfemoral transcatheter aortic valve implantation: a retrospective observational study

Objective

This study aimed to determine if contrast medium volume (CMV) is a risk factor for acute kidney injury (AKI) during transcatheter aortic valve implantation (TAVI) via a transfemoral approach performed without major complications. All TAVI procedures performed at our institution between March 2014 and March 2018 were retrospectively reviewed. AKI was diagnosed using the Acute Kidney Injury Network classification based on the Valve Academic Research Consortium-2 definition. Procedures performed via a transapical approach and those in which circulatory dynamics failed intraoperatively were excluded.

Results

Eighty-one (96.4%) of 100 patients scheduled for TAVI were enrolled; seven (8.6%) developed AKI and 74 (91.4%) did not. The serum creatinine (SCr) level was significantly higher (p < 0.05) and the estimated glomerular filtration rate was significantly lower in the AKI group (p < 0.05). The CMV was significantly higher in the AKI group (103 ml vs 84 ml, p < 0.05), as was the CMV × SCr/BW value (3.34 vs 1.49, p < 0.01). The area under the curve for CMV × SCr/BW was 0.9228 and the cut-off value was 2.99. The CMV, SCr, and estimated glomerular filtration rate affect the likelihood of AKI after transfemoral TAVI and a CMV × SCr/BW value > 2.99 accurately predicts AKI.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4527-2) contains supplementary material, which is available to authorized users.

Forced diuresis with matched hydration during transcatheter aortic valve implantation for Reducing Acute Kidney Injury: a randomized, sham-controlled study (REDUCE-AKI)

Aims

Acute kidney injury (AKI) is a common complication following transcatheter aortic valve implantation (TAVI) and is associated with increased risk for short- and long-term mortality. In patients undergoing percutaneous coronary intervention (PCI), forced diuresis with matched hydration has been shown to reduce the incidence of AKI by ∼50%. The aim of the present study was to evaluate whether forced diuresis with matched intravenous hydration reduces AKI in patients undergoing TAVI.

Methods and results

Reducing Acute Kidney Injury (REDUCE-AKI) was a single-centre, prospective, randomized, double-blind sham-controlled clinical trial, designed to examine the effect of an automated matched saline infusion with urine output for the prevention of AKI in patients undergoing TAVI. A total of 136 TAVI patients were randomized, 68 in each group. Mean age was 83.9 ± 5 years and 41.2% were males. There were no differences in baseline characteristics between the two groups. The rate of AKI was not statistically different between the groups (25% in the active group vs. 19.1% in the sham group, P = 0.408). There was a significant increase in long-term mortality in the active group (27.9% vs. 13. 2% HR 3.744, 95% CI 1.51–9.28; P = 0.004). The study was terminated prematurely by the Data Safety Monitoring Board for futility and a possible signal of harm.

Conclusions

Unlike in PCI, forced diuresis with matched hydration does not prevent AKI in patients undergoing TAVI, and might be associated with increased long-term mortality. Future studies should focus on understanding the mechanisms behind these findings.

Clinicaltrials.gov registration

NCT01866800, 30 April 2013.

Complications after Transfemoral Transcatheter Aortic Valve Replacement with a Balloon-Expandable Prosthesis: The Importance of Preventative Measures and Contingency Planning

Transcatheter aortic valve replacement (TAVR) with balloon-expandable Edwards-SAPIEN valve was superior to standard therapy in inoperable patients and noninferior to surgical aortic valve replacement in high surgical-risk, but operable patients, with severe symptomatic aortic stenosis in the randomized controlled PARTNER trial. Since the first case of TAVR with a balloon-expandable valve in 2002, several groups have reported their experience with balloon-expandable valves with high-procedural success. In the United States, the balloon-expandable Edwards-SAPIEN valve is the only transcatheter heart valve approved by the FDA for commercial use. Moreover, this is only in high-risk inoperable patients. Despite increasing experience with the TAVR procedure, it can be associated with complications, which can be technically challenging, even for an experienced operator. Complications associated with TAVR include vascular complications, valve malpositioning, regurgitation, embolization, coronary compromise, conduction abnormalities, stroke/transient ischemic attack, acute kidney injury, cardiac tamponade, and hemodynamic collapse. A thorough understanding of the procedure is essential for pre-emptive planning for procedural complications and early identification and management of complications are necessary for procedural success. We hereby review our experience of transfemoral TAVR with balloon-expandable valves, offer practical tips to maximize the likelihood of procedural success, describe pre-emptive strategies to prevent peri-procedural complications and bailout measures to manage them, should they occur. © 2018 Wiley Periodicals, Inc.

The Negative Effect of Mean Perfusion Pressure on the Development of Acute Kidney Injury after Transcatheter Aortic Valve Implantation

Objective

To evaluate the predictive value of mean perfusion pressure (mPP) in the development of acute kidney injury (AKIN) after transcatheter aortic valve implantation (TAVI).

Methods

One hundred and forty seven consecutive patients with aortic stenosis (AS) were evaluated for this study and 133 of them were included. Mean arterial pressure (mAP) and central venous pressure (CVP) were used to calculate mPP before TAVI procedure (mPP = mAP-CVP). The occurrence of AKIN was evaluated with AKIN classification according to the Valve Academic Research Consortium-2 recommendations. The patients were divided into two groups according to the receiver operating characteristic (ROC) analysis of their mPP levels (high-risk group and low-risk group).

Results

The AKIN prevalence was 22.6% in this study population. Baseline serum creatinine level, glomerular filtration rate, amount of contrast medium, and the level of mPP were determined as predictive factors for the development of AKIN.

Conclusion

The occurrence of AKIN is associated with increased morbidity and mortality rates in patients with TAVI. In addition to the amount of contrast medium and basal kidney functions, our study showed that lower mPP was strongly associated with development of AKIN after TAVI.

Recovery of Kidney Dysfunction After Transcatheter Aortic Valve Implantation (from the Northern New England Cardiovascular Disease Study Group)

Acute Kidney Recovery (AKR) is a potential benefit of transcatheter aortic valve implantation (TAVI). We determined the incidence and predictors of AKR in a multicenter prospective registry of TAVI. After excluding patients on dialysis or who died within 48 hours postprocedure, we reviewed 1,502 consecutive patients underwent TAVI in Northern New England from 2012 to 2017. Patients were categorized into 3 groups based on the change in postprocedure estimated glomerular filtration rate (eGFR): Acute Kidney Injury (AKI, decrease in eGFR >25%), AKR (increase in eGFR >25%) or no change in kidney function on discharge creatinine following TAVI. We then focused in patients with baseline chronic kidney disease (CKD defined as eGFR ≤60 ml/min; n = 755) and developed multivariate predictor models to determine the clinical and procedural variables associated with AKR. For the TAVI cohort (n = 1,502), the overall incidence of AKR was 17.8%. AKR was threefold higher in patients with eGFR ≤60 ml/min as compared to those with eGFR >60 ml/min (26.6% vs 8.9%, p < 0.001). In the CKD population, hospital complications were similar among patients with no change in renal function and AKR; patients with AKI had a higher rate of hospital mortality, pacemaker implantation, length of hospitalization, and transfusions. Using multivariable logistic regression, moderate to severe lung disease, eGFR < 50 ml/min and previous aortic valve surgery were found to be independent predictors of AKR. Patients with diabetes mellitus, baseline anemia, and Society of thoracic surgeons score >6.1 were less likely to develop AKR. In conclusion, AKR occurred in 1 of 4 of all TAVI patients with baseline CKD and was a more frequent phenomena than AKI. Patients with decreased lung function, previous aortic valve surgery and worse baseline renal function were more likely to demonstrate AKR, whereas patients with diabetes mellitus, baseline anemia, and higher Society of thoracic risk scores were less likely to see improvements in renal function after TAVI.

Clinical effects of acute kidney injury after transcatheter aortic valve implantation: a systematic review and meta-analysis

Several observational studies have shown that postoperative acute kidney injury (AKI) may significantly worsen the prognosis of a transcatheter aortic valve implantation (TAVI). The purpose of this systematic review and meta-analysis is to evaluate the recent evidence on the impact of AKI on clinical outcomes following TAVI. A comprehensive search in PubMed, Embase and the Cochrane Library was performed for relevant studies by two independent investigators. We pooled the odds ratio (OR) from individual studies, and performed heterogeneity, quality assessment and publication bias analysis. Forty-three eligible studies comprising 544,112 patients were included. Postoperative AKI not only significantly increased the risk for short-term and long-term all-cause mortality (OR 6.25, 95% CI 5.72-6.83, P < 0.00001; OR 3.49, 95% CI 2.78-4.40, P < 0.00001, respectively), but also increased the risk for early myocardial infarction (OR 3.98, 95% CI 1.90-8.31, P = 0.0002), major and life-threatening bleeding (OR 1.51, 95% CI 1.12-2.03, P = 0.007; OR 2.35, 95% CI 1.80-3.06, P < 0.00001, respectively), major vascular complications (OR 1.69, 95% CI 1.30-2.18, P < 0.0001), need for blood transfusion (OR 2.15, 95% CI 1.89-2.46, P < 0.00001) renal replacement therapy (OR 22.36, 95% CI 11.88-42.12, P = 0.0002) and cerebrovascular accidents (OR 1.92, 95% CI 1.23-2.98, P = 0.004). Acute kidney injury following TAVI is associated with increased postoperative mortality and morbidity. Future efforts are required to determine whether early prevention of post-procedural AKI after TAVI impacts upon clinical outcomes.

Outcomes After Massive Transfusion in Trauma Patients: Variability Among Trauma Centers

BACKGROUND

Exsanguinating trauma patients often require massive blood transfusion (defined as transfusion of 10 or more pRBC units within first 24 h). The aim of our study is to assess the outcomes of trauma patients receiving massive transfusion at different levels of trauma centers.

METHODS

Two-y (2013-2014) retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program. We included all adult trauma patients who received massive transfusion (MT) of blood. Outcome measures were mortality, hospital length of stay, intensive care unit-free and ventilator-free days, blood products received, and complications.

RESULTS

We analyzed a total of 416,957 patients, of which 2776 met the inclusion criteria and included in the study. Mean age was 40.6 ± 20 y, 78.3% were males and 33.1% of the injuries were penetrating. Median injury severity score [IQR] was 29 [18-40], median [IQR] Glasgow Coma Scale 10[4-15]. Mean packed red blood cells transfusion in the first 24 h was 20 ± 13 units and mean plasma transfusion was 13 ± 11 units. Overall in-hospital mortality was 43.5%. Receiving MT in level I trauma center was independently associated with lower rates of mortality (odds ratio [OR]: 0.75 [0.46-0.96], P < 0.001). Higher injury severity score (OR: 1.020 [1.010-1.030], P < 0.001) and increased units of packed red blood cells transfused (OR: 1.067 [1.041-1.093], P < 0.001) were independently associated with increased mortality. However, there was no association between teaching status, age, gender, emergency department vitals, and units of plasma transfused.

CONCLUSIONS

Hemorrhage continues to remain one of the most common cause of death after trauma. Almost half of the patients who received massive transfusion died. Patients who receive massive blood transfusion in a level I trauma centers have improved survival compared with level II trauma centers.

Antiplatelet therapy in valvular and structural heart disease interventions

Transcatheter interventions for valvular and structural heart diseases are rapidly expanding due to greater operators' experience and development of new generation devices associated with increased procedural safety. They represent the standard strategy for patients with prohibitive risk for open surgery. These procedures are associated with a significant occurrence of both thrombotic and bleeding complications, thus in this setting, even more than in other percutaneous procedures, the balance between thrombotic and bleeding risk is critical. This review describes the current data available on the antithrombotic management of patients undergoing transcatheter aortic valve implantation (TAVI), percutaneous mitral valve repair with the MitraClip system, percutaneous left atrial appendage occlusion and percutaneous patent foramen ovale (PFO)/atrial septal defects (ASD) closure.

Bedside risk score for prediction of acute kidney injury after transcatheter aortic valve replacement

Background

Acute kidney injury (AKI) is a common post-transcatheter aortic valve replacement (TAVR) complication associated with a poor prognosis. We sought to create a risk calculator using information that would be available during the work-up period.

Methods

Data were obtained from a multicentre TAVR registry (n=1993) with cases from 1 January 2012 to 31 December 2015. We used logistic regression to create a risk calculator to predict AKI as defined by the Valve Academic Research Consortium Guidelines. We internally validated our risk calculator using bootstrapping, and evaluated model discrimination and calibration.

Results

A simple risk score was derived with six variables, including New York Heart Association functional classification class 4, non-femoral access site, valve-in-valve procedure, haemoglobin, creatinine clearance and weight in kilograms. The score was able to predict the absolute risk of AKI from 1% to 72%. The model showed good discrimination with c-statistic 0.713, with good agreement between predicted and observed AKI rates across quintiles of risk.

Conclusions

This is the first risk calculator to assess post-TAVR risk of AKI. We found that information known pre-procedurally can be used to predict AKI. This may allow for more informed decision-making as well as identifying high-risk patients.