Transcatheter aortic valve replacement for advanced valvular disease in active SLE and APS

Long-Term Outcomes After Transcatheter Aortic Valve Implantation in Patients With Chronic Inflammatory Disease

BACKGROUND

Chronic inflammatory disease (CID) accelerates atherosclerosis and the development of aortic stenosis. Data on long-term outcomes after transcatheter aortic valve implantation (TAVI) in those patients are missing. The aim of this study was to investigate the clinical long-term outcomes of patients with and without autoimmune-related CID undergoing TAVI for the treatment of severe aortic stenosis.

METHODS AND RESULTS

From a prospective registry, consecutive patients with TAVI were included. Baseline clinic and imaging data (echocardiographic and computed tomography) were analyzed. Long-term (up to 5 years) clinical and echocardiographic outcomes were studied. Of 1000 consecutive patients (mean age 81±6 years, 46% female), 107 (11%) had CID; the most frequent entities included polymyalgia rheumatica (31%) and rheumatoid arthritis (28%). Patients with CID were predominantly female (60% versus 44%, P=0.002) and more often had pulmonary disorders (21% versus 13%, P=0.046) and atrial fibrillation (32% versus 20%, P=0.003). The presence of CID was associated with a higher rate of postinterventional infection (5% versus 1%, P=0.007) and further emerged as a risk factor for rehospitalization for bleeding or infection (hazard ratio, 1.93 and 1.62, respectively). Premature valve degeneration, endocarditis, and all-cause mortality were not increased among patients with CID.

CONCLUSIONS

This real-world analysis found that patients with CID undergoing TAVI were associated with a higher risk of postinterventional infectious complications and rehospitalization due to infection. However, valve durability and survival seem not to differ between patients with TAVI with versus without CID.

Autoimmune connective tissue diseases and aortic valve replacement outcomes: a population-based study

Aims

Patients with autoimmune connective tissue diseases (CTDs) have a high burden of valvular heart disease and are often thought of as high surgical risk patients.

Methods and results

Patients undergoing aortic valve replacement (AVR) were identified in the Nationwide Readmissions Database between January 2012 and December 2018. Patients with a history of systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, mixed C, Sjögren syndrome, polymyositis, and dermatomyositis were included in the CTD cohort. Patients undergoing coronary artery bypass grafting concomitantly with AVR were excluded. A total of 569 600 hospitalizations were included, of which16 531 (2.9%) had CTD. CTD patients were more likely to be females, with higher rates of heart failure, pulmonary hypertension, and more likely to be insured by Medicare. CTD patients had lower mortality than non-CTD patients [odds ratio (OR) 0.66; 95% confidence interval (CI): 0.59–0.74] and stroke [OR 0.87; 95% (CI): 0.79–0.97]. CTD patients undergoing SAVR had lower mortality [OR 0.69; 95% (CI): 0.60–0.80] and stroke [OR 0.86; 95% (CI): 0.75–0.98). CTD patients undergoing TAVR had lower mortality outcomes [OR 0.67; 95% (CI): 0.56–0.80]; however, they had comparable stroke outcomes [OR 0.97; 95% (CI): 0.83–1.13, P = 0.69].

Conclusions

Outcomes for patients with CTD requiring AVR are not inferior to their non-CTD counterparts. A comprehensive heart team selection of patients undergoing AVR approaches should place CTD history under consideration; however, pre-existing CTD should not be prohibitive of AVR interventions.

Potential risk of perioperative thromboembolism in patients with antiphospholipid syndrome who undergo transcatheter aortic valve implantation: A case series

Antiphospholipid syndrome (APS) is an autoimmune disease characterized by a positive serum antiphospholipid antibody status. Patients with APS usually have an underlying hypercoagulable state, which can increase the risk of perioperative thromboembolism. We describe three patients with APS who underwent transcatheter aortic valve implantation for symptomatic severe aortic stenosis. Of them, two had complicated cerebrovascular events, and the other had no complications. Careful antithrombotic management is essential to minimize the risk of thromboembolism and bleeding in patients with APS.

Cardiac manifestations of rheumatic diseases

Autoimmune rheumatic diseases are inflammatory disorders that can involve multiple organs, including the heart. The high risk of cardiovascular pathology in these patients is not only due to traditional cardiovascular risk factors, but also to chronic inflammation and autoimmunity. All cardiac structures may be affected during the course of systemic autoimmune diseases (valves, the conduction system, the myocardium, endocardium and pericardium, and coronary arteries), and the cardiac complications have a variety of clinical manifestations. As these are all associated with an unfavourable prognosis, it is essential to detect subclinical cardiac involvement in asymptomatic systemic autoimmune disease patients and begin adequate management and treatment early. In this review, we examine the multiple cardiovascular manifestations in patients with rheumatological disorders and available management strategies.

Association of Autoimmune Connective Tissue Disease and Outcomes in Patients Undergoing Transcatheter Aortic Valve Implantation

Patients with autoimmune connective tissue disease (CTD) are at higher risk for developing aortic valve pathology, but the safety and value of transcatheter aortic valve implantation (TAVI) in this population has not been investigated. This study evaluated mortality, complication, and readmission rates along with length of stay and total costs after TAVI in patients with CTD. We retrospectively reviewed 47,216 patients who underwent TAVI from the National Readmissions Database between January 2011 and September 2015. Patients with systemic lupus erythematosus, scleroderma, rheumatoid arthritis, and other autoimmune CTD comprised the cohort. The primary outcome was mortality at index hospitalization. The 2,557 CTD patients (5.4%) had a higher Elixhauser co-morbidity index (7.1 vs 6.1, p <0.001) than non-CTD patients. CTD and non-CTD patients had similar mortality (2.8 vs 4.1%, p = 0.052), 30-day readmission (19.3 vs 17.0%, p = 0.077), length of stay (8.2 vs 8.3 days, p = 0.615), and total adjusted costs ($57,202 vs $58,309, p = 0.196), respectively. However, CTD patients were more frequently readmitted for postoperative infection (9.4 vs 5.6%, p = 0.042) and septicemia (8.2 vs 4.5%, p = 0.019). After multivariable adjustment, CTD patients faced lower mortality at index hospitalization (odds ratio [OR] 0.56 [0.38 to 0.82], p = 0.003) but were more frequently readmitted for septicemia (OR = 1.95 [1.10 to 3.45], p = 0.023) and postoperative infection (OR = 3.10 [1.01 to 9.52], p = 0.048) relative to non-CTD patients. In conclusion, CTD is not a risk factor for in-hospital mortality but is an independent risk factor for infectious complications post-TAVI.

Cardiac manifestations of systemic lupus erythematosus

The heart is one of the most frequently affected organs in SLE. Any part of the heart can be affected, including the pericardium, myocardium, coronary arteries, valves, and the conduction system. In addition to pericarditis and myocarditis, a high incidence of CAD has become increasingly recognized as a cause of mortality, especially in older adult patients and those with long-standing SLE. Many unanswered questions remain in terms of understanding the pathogenesis of cardiac manifestations of SLE. It is not currently possible to predict the patients who are at greatest risk for the various types of cardiac involvement. However, with the rapid advancement of basic science and translational research approaches, it is now becoming easier to identify specific mutations associated with SLE. A better understanding of these genetic factors may eventually allow clinicians to categorize and predict the patients who are at risk for specific cardiac manifestations of SLE.