Sex difference in the prognostic role of body composition parameters in Taiwanese patients undergoing transcatheter aortic valve implantation

Associations between body mass index and all-cause mortality: A systematic review and meta-analysis

Fasting insulin and c-reactive protein confound the association between mortality and body mass index. An increase in fat mass may mediate the associations between hyperinsulinemia, hyperinflammation, and mortality. The objective of this study was to describe the "average" associations between body mass index and the risk of mortality and to explore how adjusting for fasting insulin and markers of inflammation might modify the association of BMI with mortality. MEDLINE and EMBASE were searched for studies published in 2020. Studies with adult participants where BMI and vital status was assessed were included. BMI was required to be categorized into groups or parametrized as non-first order polynomials or splines. All-cause mortality was regressed against mean BMI squared within seven broad clinical populations. Study was modeled as a random intercept. β coefficients and 95% confidence intervals are reported along with estimates of mortality risk by BMIs of 20, 30, and 40 kg/m2 . Bubble plots with regression lines are drawn, showing the associations between mortality and BMI. Splines results were summarized. There were 154 included studies with 6,685,979 participants. Only five (3.2%) studies adjusted for a marker of inflammation, and no studies adjusted for fasting insulin. There were significant associations between higher BMIs and lower mortality risk in cardiovascular (unadjusted β -0.829 [95% CI -1.313, -0.345] and adjusted β -0.746 [95% CI -1.471, -0.021]), Covid-19 (unadjusted β -0.333 [95% CI -0.650, -0.015]), critically ill (adjusted β -0.550 [95% CI -1.091, -0.010]), and surgical (unadjusted β -0.415 [95% CI -0.824, -0.006]) populations. The associations for general, cancer, and non-communicable disease populations were not significant. Heterogeneity was very large (I2  ≥ 97%). The role of obesity as a driver of excess mortality should be critically re-examined, in parallel with increased efforts to determine the harms of hyperinsulinemia and chronic inflammation.

Influence of Gender on Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-Analysis

Background

To assess whether there are differences in common postoperative complications and survival between men and women after transcatheter aortic valve implantation.

Methods

We searched the Cochrane Library, PubMed, Embase, and the Web of Science from January 2000 to August 2022. Gender-related articles reporting complications and mortality after transcatheter aortic valve implantation were identified. The primary outcomes were the thirty-day mortality, one-year mortality and perivalvular leakage. The secondary outcomes were conversion to open heart surgery during operation, ejection fraction after operation, reintervention and other common postoperative complications. Data were pooled using the risk ratio or standardized mean difference with 95% confidence interval. Subgroup analysis, meta-regression, sensitivity analysis, egger's test and begg's test were performed. The original study protocol was registered prospectively with PROSPERO (CRD42021245858).

Results

There were 24 studies, a total of 92,499 patients, enrolled in our systematic review and meta-analysis, including 43,948 men and 48,551 women. Comprehensive analysis showed significant differences in gender in postoperative complications and survival after transcatheter aortic valve implantation. Men had a significantly higher risk of perivalvular leakage (risk ratio (RR) = 1.42; 95% CI: 1.15 to 1.75; p = 0.001; I 2 = 68%), but lower risk in bleeding (RR = 0.69; 95% CI: 0.61 to 0.79; p < 0.00001; I 2 = 82%), vascular complications (RR = 0.56; 95% CI: 0.52 to 0.61; p < 0.00001; I 2 = 48%), and stroke (RR = 0.86; 95% CI: 0.80 to 0.93; p < 0.00001; I 2 = 12%). The thirty-day mortality of men is slightly lower than that of women (RR = 0.87; 95% CI: 0.81 to 0.93; p = 0.0001; I 2 = 47%), the difference in one-year mortality was also significant (RR = 1.20; 95% CI: 1.08 to 1.33; p = 0.0008; I 2 = 59%). Univariate meta-regression analyses showed that pulmonary hypertension is the major source of heterogeneity in bleeding.

Conclusions

Men after transcatheter aortic valve implantation have a lower risk of related postoperative complications, but a higher risk of paravalvular leak and no advantage in medium-term survival.

Age-dependent differences in the prognostic relevance of body composition-related variables in type A aortic dissection patients

Background

The current research is allocated to appraise the association between the parameters of body composition and findings in type A aortic dissection (TAAD) cases in diverse age groups.

Methods

Data from consecutive TAAD patients undergoing implantation of modified triple-branched stent-graft from January 2017 and December 2019 were prospectively collected and analyzed. A regression model of Cox proportional hazard was employed to assess correlations among body composition-related variables (body mass index [BMI], lean body mass [LBM], body surface area [BSA], and LBM index) as well as cumulative mortality.

Results

Overall, 258 patients (53.9 ± 11.1 years old; 72.9% male) were separated into young (n = 110) and elderly (n = 148) age groups based upon whether they were younger or older than 50 years of age. Of these patients, 247 survivors were included in subsequent analyses over an average 26.8 ± 11.6 month follow-up duration. Multivariate analyses in the elderly group instead of young group indicated that increased BMI (p = 0.042), BMI ≤ 18.5 kg/m² (p = 0.025), and lower LBM index values (p = 0.019) were significant predictors of increased total all-cause cumulative mortality. BMI was considerably positively correlated with estimated all-cause cumulative mortality in elderly but not young TAAD cases.

Conclusion

Briefly, these results suggest that BMI and LBM indices are only significant predictors of TAAD patient all-cause mortality in elderly patient cohorts, whereas they do not offer significant prognostic value for younger patients. As such, these age differences must be taken into consideration when conducting stratified risk assessments based upon TAAD patient body composition characteristics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01742-1.

Does "obesity paradox" apply for patients undergoing transcatheter aortic valve replacement?

BACKGROUND

Data is controversial regarding the existence of an "obesity paradox" in patients undergoing Transcatheter Aortic Valve Replacement (TAVR). We sought to investigate the prognostic value of the body mass index (BMI) on outcomes following TAVR.

METHODS

This is an observational, single-center study involving all patients who underwent TAVR from 2009 to 2019. BMI was calculated in all patients before TAVR. The cohort was subdivided into four groups: underweight (<20 kg/m²), normal weight (≥20 to <25 kg/m²), overweight (≥25 to <30 kg/m²) and obese (≥30 kg/m²). The main endpoint was all-cause 30-day and one-year mortality.

RESULTS

A total of 412 patients (mean age 79.6 ± 7.8 years, mean STS score 5.3 ± 3.6) were included. Patients were grouped as follows: underweight (n = 35, 8.5%), normal weight (n = 121, 29.4%), overweight (n = 140, 34%) and obese (n = 116, 28.1%). Obese patients were younger, included more females and had lower STS score than the rest of the cohort whereas underweight patients were older, had higher STS score, more chronic kidney disease, more left ventricular dysfunction and more often underwent non-transfemoral TAVR. BMI predicted 30-day survival (AUC:0.692 [95%CI 0.522-0.862]; p = 0.030) with an optimal cut-off of 24.4 (sensitivity = 66.6%, specificity = 63.6%). On multivariate analysis, higher BMI trended toward lower 30-day mortality (HR = 0.87 [95%CI 0.75-1.01]; p = 0.071). Thirty-day mortality was higher in the underweight group (8.3%) in comparison with other BMI subgroups (normal weight 2.5%, overweight 1.4%, obese 0.9%; p = 0.045). However, no significant difference was found after adjustment of confounders (all p = NS). BMI did not predict one-year mortality. No significant difference in one-year survival was observed between the four BMI subgroups (log rank p = 0.925).

CONCLUSION

BMI could represent an interesting prognostic tool for short-term mortality in patients undergoing TAVR. BMI < 20 kg/m² was associated with higher 30-day mortality. Symptoms improved similarly in obese patients compared to lower BMI patients. For 30-day survivors, no evidence of the existence of an obesity paradox was observed in this cohort.

Baseline, procedural and outcome features of patients undergoing transcatheter aortic valve implantation according to different body mass index categories

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has become first-line treatment for severe aortic valve stenosis in patients with moderate, high or prohibitive surgical risk. However, access site complications may occur more frequently in extreme body mass index (BMI) categories. The aim of this study was to describe the features and outcomes of patients undergoing TAVI in a comprehensive Italian prospective clinical registry, focusing on BMI classes.

METHODS

A national prospective database was queried for baseline, procedural, and outcome details of patients undergoing TAVI according to established BMI categories: underweight (BMI <18.5 kg/m²), normal weight (BMI 18.5-24.9 kg/m²), overweight (BMI 25.0-29.9 kg/m²), and obese (BMI≥30 kg/m²). Short- and long-term outcomes, including major adverse events (MAE), i.e. the composite of death, stroke, myocardial infarction, major vascular complication, major bleeding, or renal failure, were appraised with bivariate and multivariable analyses.

RESULTS

A total of 3075 subjects were included, 64 (2.1%) were underweight, 1319 (42.9%) were normal weight, 1152 (37.4%) were overweight, and 540 (17.6%) were obese. Several baseline differences were evident, including gender, diabetes mellitus, renal function, chronic obstructive pulmonary disease, surgical scores, and left ventricular ejection fraction (LVEF) (all P<0.05). Several procedural differences were also evident, including percutaneous approach, predilation, prosthesis type and size (all P<0.05), with postprocedural aortic regurgitation >2+ significantly more common in underweight patients (P<0.05). Nonetheless, unadjusted analysis for one-month outcomes showed similar rates for fatal and non-fatal outcomes, including MAE (all P>0.05), with the notable exception of permanent pacemaker implantation, which was more common in higher BMI classes (P=0.010) Unadjusted analysis for long-term events showed an increased rate of death in underweight patients (P=0.024). Multivariable adjusted analysis confirmed the increased risk of permanent pacemaker implantation in obese patients (P=0.015 when comparing obese vs. normal weight subjects), but disproved differences in long-term mortality and other outcomes (P>0.05 for all comparisons).

CONCLUSIONS

Irrespective of BMI class, TAVI is associated with favorable outcomes in surgical high-risk risk patients, with the notable exclusion of permanent pacemaker implantation, which is significantly more common in obese subjects.