Using Wearable Devices to Monitor Physical Activity in Patients Undergoing Aortic Valve Replacement: Protocol for a Prospective Observational Study

Background

In last few decades, several tools have been developed to measure physical function objectively; however, their use has not been well established in clinical practice.

Objective

This study aims to describe the preoperative physical function and to assess and compare 6-month postoperative changes in the physical function of patients undergoing treatment for aortic stenosis with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). The study also aims to evaluate the feasibility of wearable devices in assessing physical function in such patients.

Methods

This is a prospective observational study. The enrollment will be conducted 1 month before patients’ SAVR/TAVR. Patients will be provided with the wearable device at baseline (activity tracker device, Garmin vívoactive 3). They will be trained in the use of the device, and they will be requested to wear it on the wrist of their preferred hand until 12 months after SAVR/TAVR. After baseline assessment, they will undergo 4 follow-up assessments at 1, 3, 6, and 12 months after SAVR/TAVR. At baseline and each follow-up, they will undergo a set of standard and validated tests to assess physical function, health-related quality of life, and sleep quality.

Results

The ethics committee of Vicenza in Veneto Region in Italy approved the study (Protocol No. 943; January 4, 2019). As of October 2020, the enrollment of participants is ongoing.

Conclusions

The use of the wearable devices for real-time monitoring of physical activity of patients undergoing aortic valve replacement is a promising opportunity for improving the clinical management and consequently, the health outcomes of such patients.

Trial Registration

Clinicaltrials.gov NCT03843320; https://tinyurl.com/yyareu5y

International Registered Report Identifier (IRRID)

DERR1-10.2196/20072

Changes in cognitive functions and quality of life in patients after transcatheter aortic valve implantation

Introduction

Transcatheter aortic valve implantation (TAVI) has emerged as a therapeutic option for patients with severe aortic stenosis (AS). However, an association between cognitive functions (CF) and health-related quality of life (HRQoL) in TAVI patients is still unclear.

Aim

To assess the long-term changes in CF and HRQoL in elderly patients with AS after TAVI.

Material and methods

A total of 259 patients who underwent cardiological and psychological TAVI qualification were enrolled and divided into the normal (n = 174) and impaired cognition group (n = 85). CF and HRQoL characteristics assessed at baseline and 13 months were compared between groups. The analysis of multiple linear regression was performed to identify the association between HRQoL and CF and to assess the influence of TAVI on HRQoL.

Results

There was no difference in CF between baseline and follow-up. However, an improvement in attention functions and memory skills in the cognitively impaired group was noted at follow-up. In addition, HRQoL scores increased in both groups. An independent predictor associated with HRQoL was global CF (β = –213, p = 0.01), which explained 7% of CF variation. Improvements in all five dimensions of HRQoL, from 4.8% in self-care and up to 33.6% in pain/discomfort, were found. At follow-up, 60% of TAVI patients had improved health, 12% had worse health, 4% showed no change and 24% had a “mixed” change.

Conclusions

TAVI is associated with positive changes in the functioning of elderly patients at long-term follow-up.

Evaluation of YouTube as a reliable source for patient education on aortic valve stenosis

Background

Aortic stenosis (AS) is a prevalent disease in the elderly population and has been a public health concern for decades. YouTube is currently being used for obtaining healthcare related information. We evaluated the quality of information about AS on YouTube for patient education.

Methods

YouTube was queried for the search phrases "aortic valve stenosis", "aortic valve replacement", "transcatheter aortic valve replacement" and "TAVR". Videos were assessed for their reliability and content with two five-point scales. They were categorized into groups according to usefulness and uploader source. All videos were assessed for audience interaction. Videos were viewed and analyzed by 2 independent investigators. Conflicts were resolved by a third investigator.

Results

Search phrases yielded 69,300 videos, among which, 120 videos were evaluated and 85 videos were included in the final analysis. Of the 85 videos, only 45 videos (53%) were found to be useful while 40 videos (47%) were found to be non-useful. The majority (98%) of the useful videos were uploaded by professional sources. Overall, videos uploaded by non-professional sources had higher number of views (23,553 vs. 11,110, P≤0.001) despite of being less useful (14% vs. 67%, P<0.001) when compared to videos uploaded by professional sources.

Conclusions

There is a potential to increase public awareness about aortic valve stenosis and the available treatment options by utilizing YouTube. Professional societies are encouraged to provide more useful material that can deliver comprehensive and reliable information in an entertaining and intuitive manner to the public.

Functional capacity and health-related quality of life outcomes post transcatheter aortic valve replacement: a systematic review and meta-analysis

Background

transcatheter aortic valve replacement (TAVR) provides prognostic benefit for high surgical-risk patients with severe aortic stenosis (AS), yet the impact to patient outcomes is far less understood.

Method

we performed a systematic review and meta-analysis to evaluate functional capacity and health-related quality of life (HRQoL) outcomes for patients up to 12 months post TAVR. A total of 20 eligible publications, comprising randomised-controlled trials, observational studies and a registry study were identified from electronic databases, including MEDLINE, EMBASE, Cochrane Library and others (inception to February 2017).

Results

the total sample was 2,775 with a mean age of 81.8 ± 2.1 years, more than half (52%) were female and high surgical risk 9.6 ± 4.3% mean STS (Society of Thoracic Surgeons risk model). Post TAVR, patients had significant improvement in functional capacity of >40 m in the 6-minute walk test (6MWT) (95% confidence interval (CI) 9.69-73.28) and a clinically meaningful increase in ability to perform daily physical-based tasks (Duke Activity Status Index (DASI), mean difference (MD) increase 5.42 points, 95% CI 3.16-7.68). HRQoL improved consistently following TAVR regardless of measure used. Significant increases occurred in the physical component summary scores (PCS) of the short form (SF) health surveys (MD increase 10.45 (SF36) and 10.14 (SF12) points).

Conclusion

functional capacity and HRQoL improved substantially following TAVR, despite evolving patient selection criteria, thus TAVR continues to provide a directly beneficial option for severe AS patients.

Assessment of quality of life in patients after surgical and transcatheter aortic valve replacement

OBJECTIVES

Transcatheter aortic valve implantation (TAVI) and minimally invasive aortic valve replacement (mini-thoracotomy, mini-sternotomy, MIAVR) have become an appealing alternative to conventional surgical (SAVR) treatment of severe aortic stenosis (AS) in high-risk patients.

BACKGROUND

Aim of the study was to evaluate the quality of life (QoL) in patients with AS and treated with transfemoral TAVI, SAVR, mini-thoracotomy and mini-sternotomy.

METHODS

One hundred and seventy-three patients with symptomatic AS were enrolled in 2011-2013. TAVI group consisted of 39 patients (22.5%), mini-sternotomy was performed in 44 patients (25.5%), mini-thoracotomy in 50 (29%), and AVR in 40 patients (23%). QoL was assessed perioperatively, 12 and 24 months after aortic valve replacement (AVR) by Minnesota Living with Heart Failure Questionnaire (MLHFQ) and EQ-5D-3L.

RESULTS

Median follow-up was 583.5 (IQR: 298-736) days. Improvement of health status after procedure in comparison with pre-operative period was significantly more often reported after TAVI in perioperative period (90.3%; P = 0.004) and 12 months after procedure (100%, P = 0.02). Global MLHFQ, physical and emotional dimension score at 30-day from AVR presented significant improvement after TAVI in comparison with surgical methods (respectively: 8.3(±8.6), P = 0.003; 4.1(±5.9), P = 0.01; 1.5(±2.6), P = 0.005). Total MLHFQ score was significantly lower (better outcome) in TAVI patients 1 year after procedure (4.8(±6.8), P = 0.004), no differences in somatic and emotional component were found. No differences were found in MLHFQ score 24 months after AVR. Data from EQ-D5-3L questionnaire demonstrated significant improvement of QoL at 30-day follow-up after TAVI in comparison with surgical methods (1.2(±1.7), P = 0.0008).

CONCLUSIONS

TAVI improves QoL in perioperative and 12 months observation in comparison with mini-thoracotomy, mini-sternotomy and SAVR. Improvement in QoL was obtained in both generic and disease specific questionnaires. © 2016 Wiley Periodicals, Inc.

Health-related quality of life after transcatheter or surgical aortic valve replacement in high-risk patients with severe aortic stenosis: an updated review of literature

Recent trials have highlighted the comparable mortality benefits and durability of the results for patients with severe aortic stenosis (AS) and high surgical risk managed with either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (AVR). Various national guidelines and international regulatory bodies have approved TAVR, thereby leading to potential wide usage and dissemination of this technique worldwide. Quality-of-life outcomes, in spite of being an important measure of success and acceptability of the procedure, have not been publicized as extensively. For high risk patients with severe AS, implementation of TAVR has resulted in comparable survival, but different and novel adverse events compared with AVR. We present an updated review focusing on the quality-of-life outcomes and issues with this new and important procedural approach.

Novel approaches for prevention of stroke related to transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has emerged as a therapeutical option in patients with aortic stenosis. The methodology has evolved rapidly throughout the last decade. Nowadays, peri-procedural circulatory support, surgical vascular access, general anesthesia and mechanical ventilation are mainly reserved for selected patients. However, numerous challenges need to be addressed in order to further improved outcome of this distinct cohort: patient selection in general, vascular access strategies, long-term valve performance and paravalvular leakage. Another key issue is the risk of cerebrovascular events related to TAVI. In this article, the authors review the current literature on the risk of cerebrovascular events, the underlying mechanisms, the diagnostic read-outs of cerebral injury and their prognostic value, and ultimately discuss conceivable concepts for prevention of stroke associated with TAVI.

Feasibility of sheathless transfemoral aortic valve implantation in patients with small access vessel diameters

OBJECTIVES

We intended to show feasibility of sheathless transfemoral aortic valve implantation in patients with small access vessel diameters.

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has emerged as a valid treatment option in patients with aortic valve stenosis who are poor candidates for surgical aortic valve replacement. Few patients, who cannot undergo transfemoral or transsubclavian aortic valve implantation due to small access vessel diameters, are not suitable for transapical or direct aortic valve implantation, either.

METHODS

In more than 700 transcatheter aortic valve implantations since 2008 we identified 17 patients who had to be excluded from transfemoral valve implantation due to vessel diameters <6 mm and who were no candidates for transapical or direct aortic implantation. We performed CoreValve™ implantations in these patients without the required 18F sheath to cross the vessels despite their small size (4.6-5.9 mm).

RESULTS

Sixteen sheathless implantations were successful. In all 17 patients, bleeding during the procedure due to the smaller delivery catheter was minimal. Sixteen patients had a successful access site closure at the end of the procedure.

CONCLUSIONS

Sheathless implantation of a self-expanding aortic valve can be safely considered in selected patients with access vessel diameters below 6 mm, if transapical or direct aortic implantation is not suitable.

Beyond adding years to life: health-related quality-of-life and functional outcomes in patients with severe aortic valve stenosis at high surgical risk undergoing transcatheter aortic valve replacement

Aortic valve stenosis (AVS) is the most frequent acquired valvular heart disease in western industrialized countries and its prevalence considerably increases with age. Once becoming symptomatic severe AVS has a very poor prognosis. Progressive and rapid symptom deterioration leads to an impairment of functional status and compromised healthrelated quality-of-life (HrQoL) simultaneously. Until recently, surgical aortic valve replacement (SAVR) has been the only effective treatment option for improving symptoms and prolonging survival. Transcatheter aortic valve replacement (TAVR) emerged as an alternative treatment modality for those patients with severe symptomatic AVS in whom the risk for SAVR is considered prohibitive or too high. TAVR has gained clinical acceptance with almost startling rapidity and has even quickly become the standard of care for the treatment of appropriately selected individuals with inoperable AVS during recent years. Typically, patients currently referred for and treated by TAVR are elderly with a concomitant variable spectrum of multiple comorbidities, disabilities and limited life expectancy. Beyond mortality and morbidity, the assessment of HrQoL is of paramount importance not only to guide patient-centered clinical decision-making but also to judge this new treatment modality. As per current evidence, TAVR significantly improves HrQoL in high-surgical risk patients with severe AVS with sustained effects up to two years when compared with optimal medical care and demonstrates comparable benefits relative to SAVR.

Along with a provision of a detailed overview of the current literature regarding functional and HrQoL outcomes in patients undergoing TAVR, this review article addresses specific considerations of the HrQoL aspect in the elderly patient and finally outlines the implications of HrQoL outcomes for medico-economic deliberations.

Development of a risk score for outcome after transcatheter aortic valve implantation

AIMS

Transcatheter aortic valve implantation (TAVI) is an increasingly common procedure in elderly and multimorbid patients with aortic stenosis. We aimed at developing a pre-procedural risk evaluation scheme beyond current surgical risk scores.

METHODS

We developed a risk algorithm for 1-year mortality in two cohorts consisting of 845 patients undergoing routine TAVI procedures by commercially available devices, mean age 80.9 ± 6.5, 51 % women. Clinical variables were determined at baseline. Multivariable Cox regression related clinical data to mortality (n = 207 deaths).

RESULTS

To account for variability related to age and sex and by enrolment site we forced age, sex, and cohort into the score model. Body mass index, estimated glomerular filtration rate, hemoglobin, pulmonary hypertension, mean transvalvular gradient and left ventricular ejection fraction at baseline were most strongly associated with mortality and entered the risk prediction algorithm [C-statistic 0.66, 95 % confidence interval (CI) 0.61-0.70, calibration χ (2)-statistic = 6.51; P = 0.69]. Net reclassification improvement compared to existing surgical risk predication schemes was positive. The score showed reasonable model fit and calibration in external validation in 333 patients, N = 55 deaths (C-statistic 0.60, 95 % CI 0.52-0.68; calibration χ (2)-statistic = 16.2; P = 0.06). Additional measurement of B-type natriuretic peptide and troponin I did not improve the C-statistic. Frailty increased the C-statistic to 0.71, 95 % CI 0.65-0.76.

CONCLUSIONS

We present a new risk evaluation tool derived and validated in routine TAVI cohorts that predicts 1-year mortality. Biomarkers only marginally improved risk prediction. Frailty increased the discriminatory ability of the score and needs to be considered. Risk algorithms specific for TAVI may help to guide decision-making when patients are evaluated for TAVI.

Functional status and quality of life after transcatheter aortic valve replacement: a systematic review

BACKGROUND

The functional and quality-of-life benefits of transcatheter aortic valve replacement (TAVR) have not been established.

PURPOSE

To evaluate the changes in functional status and quality of life after TAVR.

DATA SOURCES

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 1 January 2002 to 30 September 2013.

STUDY SELECTION

Studies of TAVR that reported the New York Heart Association (NYHA) class, Short Form-12/36 Health Survey physical and mental component summary (points), or other measures of functional status.

DATA EXTRACTION

Two reviewers independently extracted the mean change (follow-up minus baseline) in primary outcomes. Because of substantial heterogeneity, data were not pooled; the range of mean change was summarized.

DATA SYNTHESIS

We identified 60 observational studies (56 pre–post comparison and 4 head-to-head comparative studies) and 2 randomized, controlled trials (11 205 patients). Most studies showed a clinically important decrease in NYHA class at 6 to 11 months (range, -0.8 to -2.1 classes) and 12 to 23 months (range, -0.8 to -2.1 classes). The improvement in the Short Form-12/36 Health Survey physical component score was clinically important over 12 months (range, 4.9 to 26.9 points), and the change in mental component score was smaller (range, 1.0 to 8.9 points).Clinically important improvements were seen in other disease-specific measures but were less consistently seen in general health measures.

LIMITATIONS

Comparative evidence is limited by few head-to-head studies. Survivor bias may have overestimated the benefits.

CONCLUSION

Transcatheter aortic valve replacement provides clinically important benefits in physical function and disease-specific measures of quality of life but modest benefits in psychological and general health measures. More comparative studies on functional status and quality of life are needed for informed treatment decision making.