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Burzotta F, Graziani F, Trani C, Aurigemma C, Bruno P, Lombardo A, Liuzzo G, Nesta M, Lanza GA, Romagnoli E, Locorotondo G, Leone AM, Pavone N, Spalletta C, Pelargonio G, Sanna T, Aspromonte N, Cavaliere F, Crea F, Massetti M. Clinical Impact of Heart Team Decisions for Patients With Complex Valvular Heart Disease: A Large, Single-Center Experience. J Am Heart Assoc 2022; 11:e024404. [PMID: 35621200 PMCID: PMC9238748 DOI: 10.1161/jaha.121.024404] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background A multidisciplinary approach might be pivotal for the management of patients with valvular heart disease (VHD), but clinical outcome data are lacking. Methods and Results At our institution, since 2014, internal guidelines recommended heart team consultations for patients with VHD. The clinical/echocardiographic characteristics, treatment recommendations, performed treatment, and early clinical outcomes of consecutive, hospitalized patients with VHD undergoing heart team evaluation were collected. Surgical risk was prospectively assessed by the EuroSCORE II and STS‐PROM. The primary end point of the study was early mortality. A total of 1004 patients with VHD with high clinical complexity (mean age, 75 years; mean EuroSCORE II, 9.4%; mean STS‐PROM, 5.6%; 48% ischemic heart disease; 29% chronic kidney disease, 9% oncologic/hematologic diseases) were enrolled. The heart team recommended an interventional treatment for 807 (80%) patients and conservative management for 197 (20%) patients. Management crossovers occurred in only 5% of patients. The recommended intervention was cardiac surgery for 230 (23%) patients, percutaneous treatment in 516 (51%) patients, and hybrid treatment in 61 (6%) patients. Early mortality occurred in 24 patients (2.4%) and was independently predicted by aortic stenosis, left ventricular ejection fraction, pulmonary artery systolic pressure, and conservative management recommendation. In patients referred to treatment, observed early mortality (1.7%) was significantly lower (P<0.001) than expected on the bases of both the STS‐PROM (5.2%) and EuroSCORE II (9.7%). Conclusions Within the limitations of its single‐center and observational design, the present study suggests that heart team–based management of patients with complex VHD is feasible and allows referral to a wide spectrum of interventions with promising early clinical results.
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Affiliation(s)
- Francesco Burzotta
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia.,Università Cattolica del Sacro Cuore Roma Italia
| | | | - Carlo Trani
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia.,Università Cattolica del Sacro Cuore Roma Italia
| | | | - Piergiorgio Bruno
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia.,Università Cattolica del Sacro Cuore Roma Italia
| | - Antonella Lombardo
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia.,Università Cattolica del Sacro Cuore Roma Italia
| | - Giovanna Liuzzo
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia.,Università Cattolica del Sacro Cuore Roma Italia
| | - Marialisa Nesta
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia
| | - Gaetano Antonio Lanza
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia.,Università Cattolica del Sacro Cuore Roma Italia
| | - Enrico Romagnoli
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia
| | | | | | - Natalia Pavone
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia.,Università Cattolica del Sacro Cuore Roma Italia
| | | | - Gemma Pelargonio
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia.,Università Cattolica del Sacro Cuore Roma Italia
| | - Tommaso Sanna
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia.,Università Cattolica del Sacro Cuore Roma Italia
| | - Nadia Aspromonte
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia.,Università Cattolica del Sacro Cuore Roma Italia
| | - Franco Cavaliere
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia.,Università Cattolica del Sacro Cuore Roma Italia
| | - Filippo Crea
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia.,Università Cattolica del Sacro Cuore Roma Italia
| | - Massimo Massetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS Roma Italia.,Università Cattolica del Sacro Cuore Roma Italia
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2
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Kattih B, Carstens DC, Boeckling F, Rasper T, Pergola G, Dimmeler S, Vasa-Nicotera M, Zeiher AM, Mas-Peiro S. Low Circulating Musclin is Associated With Adverse Prognosis in Patients Undergoing Transcatheter Aortic Valve Implantation at Low-Intermediate Risk. J Am Heart Assoc 2022; 11:e022792. [PMID: 35229655 PMCID: PMC9075297 DOI: 10.1161/jaha.121.022792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Musclin is an activity‐stimulated and cardioprotective myokine that attenuates pathological cardiac remodeling. Musclin deficiency, in turn, results in reduced physical endurance. The aim of this study was to assess the prognostic value of circulating musclin as a novel, putative biomarker to identify patients undergoing transcatheter aortic valve implantation (TAVI) who are at a higher risk of death. Methods and Results In this study, we measured systemic musclin levels in 368 patients undergoing TAVI who were at low to intermediate clinical risk (median EuroSCORE [European System for Cardiac Operative Risk Evaluation] II: 3.5; quartile 1–quartile, 2.2%–5.3%), whereby 209 (56.8%) patients were at low and 159 (43.2%) were at intermediate risk. Median preprocedural musclin levels were 2.7 ng/mL (quartile 1–quartile 3, 1.5–4.6 ng/mL). Musclin levels were dichotomized in low (<2.862 ng/mL, n=199 [54.1%]) or high (≥ 2.862 ng/mL, n=169 [45.9%]) groups using cutoff values determined by classification and regression tree analysis. The primary end point was 1‐year overall survival. Patients with low circulating musclin levels exhibited a significantly higher prevalence of frailty, low albumin values, hypertension, and history of stroke as well as higher N‐terminal pro‐B‐type natriuretic peptide. Low musclin levels significantly predicted risk of death in univariable (hazard ratio, 1.81; 95% CI, 1.00–3.53 [P=0.049]) and multivariable (adjusted hazard ratio, 2.45; 95% CI, 1.06–5.69 [P=0.037]) Cox regression analyses. Additionally, low musclin levels in combination with conventional EuroSCORE II suggested improved risk stratification in patients undergoing TAVI who were at low to intermediate clinical risk into subgroups with reduced 1‐year survival rates by log‐rank test (P for trend=0.003). Conclusions Circulating musclin is an independent predictor of 1‐year overall survival in patients undergoing TAVI. Combined with EuroSCORE II, circulating musclin might help to improve prediction of mortality in patients undergoing TAVI who are at low to intermediate clinical risk.
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Affiliation(s)
- Badder Kattih
- Department of Medicine, Cardiology Goethe University Hospital Frankfurt Germany.,German Centre for Cardiovascular ResearchPartner Site Frankfurt Rhine-Main Berlin Germany.,Institute for Cardiovascular Regeneration Goethe University Frankfurt am Main Germany
| | - Daniel C Carstens
- Department of Medicine, Cardiology Goethe University Hospital Frankfurt Germany.,Institute for Cardiovascular Regeneration Goethe University Frankfurt am Main Germany
| | - Felicitas Boeckling
- Department of Medicine, Cardiology Goethe University Hospital Frankfurt Germany.,German Centre for Cardiovascular ResearchPartner Site Frankfurt Rhine-Main Berlin Germany.,Institute for Cardiovascular Regeneration Goethe University Frankfurt am Main Germany
| | - Tina Rasper
- Department of Medicine, Cardiology Goethe University Hospital Frankfurt Germany
| | - Graziella Pergola
- Department of Medicine, Cardiology Goethe University Hospital Frankfurt Germany.,German Centre for Cardiovascular ResearchPartner Site Frankfurt Rhine-Main Berlin Germany
| | - Stefanie Dimmeler
- German Centre for Cardiovascular ResearchPartner Site Frankfurt Rhine-Main Berlin Germany.,Institute for Cardiovascular Regeneration Goethe University Frankfurt am Main Germany
| | - Mariuca Vasa-Nicotera
- Department of Medicine, Cardiology Goethe University Hospital Frankfurt Germany.,German Centre for Cardiovascular ResearchPartner Site Frankfurt Rhine-Main Berlin Germany
| | - Andreas M Zeiher
- Department of Medicine, Cardiology Goethe University Hospital Frankfurt Germany.,German Centre for Cardiovascular ResearchPartner Site Frankfurt Rhine-Main Berlin Germany
| | - Silvia Mas-Peiro
- Department of Medicine, Cardiology Goethe University Hospital Frankfurt Germany.,German Centre for Cardiovascular ResearchPartner Site Frankfurt Rhine-Main Berlin Germany
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3
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Jonik S, Marchel M, Pędzich-Placha E, Huczek Z, Kochman J, Ścisło P, Czub P, Wilimski R, Hendzel P, Opolski G, Grabowski M, Mazurek T. Heart Team for Optimal Management of Patients with Severe Aortic Stenosis-Long-Term Outcomes and Quality of Life from Tertiary Cardiovascular Care Center. J Clin Med 2021; 10:jcm10225408. [PMID: 34830690 PMCID: PMC8623928 DOI: 10.3390/jcm10225408] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 11/16/2022] Open
Abstract
Background: This retrospective study was proposed to investigate outcomes of patients with severe aortic stenosis (AS) after implementation of various treatment strategies following dedicated Heart Team (HT) decisions. Methods: Primary and secondary endpoints and quality of life during a median follow-up of 866 days of patients with severe AS qualified after HT discussion to: optimal medical treatment (OMT) alone, OMT and transcather aortic valve replacement (TAVR) or OMT and surgical aortic valve replacement (SAVR) were evaluated. As the primary endpoint composite of all-cause mortality, non-fatal disabling strokes and non-fatal rehospitalizations for AS were considered, while other clinical outcomes were determined as secondary endpoints. Results: From 2016 to 2019, 176 HT meetings were held, and a total of 482 participants with severe AS and completely implemented HT decisions (OMT, TAVR and SAVR for 79, 318 and 85, respectively) were included in the final analysis. SAVR and TAVR were found to be superior to OMT for primary and all secondary endpoints (p < 0.05). Comparing interventional strategies only, TAVR was associated with reduced risk of acute kidney injury, new onset of atrial fibrillation and major bleeding, while the superiority of SAVR for major vascular complications and need for permanent pacemaker implantation was observed (p < 0.05). The quality of life assessed at the end of follow-up was significantly better for patients who underwent TAVR or SAVR than in OMT-group (p < 0.05). Conclusions: We demonstrated that after careful implementation of HT decisions interventional strategies compared to OMT only provide superior outcomes and quality of life for patients with AS.
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Affiliation(s)
- Szymon Jonik
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Michał Marchel
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
- Correspondence: ; Tel.: +48-22-599-19-58; Fax: +48-22-599-19-57
| | - Ewa Pędzich-Placha
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Zenon Huczek
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Janusz Kochman
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Piotr Ścisło
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Paweł Czub
- Department of Cardiac Surgery, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (P.C.); (R.W.); (P.H.)
| | - Radosław Wilimski
- Department of Cardiac Surgery, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (P.C.); (R.W.); (P.H.)
| | - Piotr Hendzel
- Department of Cardiac Surgery, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (P.C.); (R.W.); (P.H.)
| | - Grzegorz Opolski
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
| | - Tomasz Mazurek
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 01-267 Warsaw, Poland; (S.J.); (E.P.-P.); (Z.H.); (J.K.); (P.Ś.); (G.O.); (M.G.); (T.M.)
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4
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Marcus G, Qiu F, Manoragavan R, Ko DT, Elbaz-Greener G, Chung JCY, Sud M, Farkouh ME, Madan M, Fremes SE, Wijeysundera HC. Temporal Trends and Drivers of Heart Team Utilization in Transcatheter Aortic Valve Replacement: A Population-Based Study in Ontario, Canada. J Am Heart Assoc 2021; 10:e020741. [PMID: 34155897 PMCID: PMC8403321 DOI: 10.1161/jaha.120.020741] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The multidisciplinary Heart Team (HT) is recommended for management decisions for transcatheter aortic valve replacement (TAVR) candidates, and during TAVR procedures. Empiric evidence to support these recommendations is limited. We aimed to explore temporal trends, drivers, and outcomes associated with HT utilization. Methods and Results TAVR candidates were identified in Ontario, Canada, from April 1, 2012 to March 31, 2019. The HT was defined as having a billing code for both a cardiologist and cardiac surgeon during the referral period. The procedural team was defined as a billing code during the TAVR procedure. Hierarchical logistical models were used to determine the drivers of HT. Median odds ratios were calculated to quantify the degree of variation among hospitals. Of 10 412 patients referred for TAVR consideration, 5489 (52.7%) patients underwent a HT during the referral period, with substantial range between hospitals (median odds ratio of 1.78). Utilization of a HT for TAVR referrals declined from 69.9% to 41.1% over the years of the study. Patient characteristics such as older age, frailty and dementia, and hospital characteristics including TAVR program size, were found associated with lower HT utilization. In TAVR procedures, the procedural team included both cardiologists and cardiac surgeons in 94.9% of cases, with minimal variation over time or between hospitals. Conclusions There has been substantial decline in HT utilization for TAVR candidates over time. In addition, maturity of TAVR programs was associated with lower HT utilization.
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Affiliation(s)
- Gil Marcus
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | | | - Ragavie Manoragavan
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | - Dennis T Ko
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,ICES Toronto Ontario Canada.,Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
| | - Gabby Elbaz-Greener
- Department of Cardiology Hadassah Medical Center Jerusalem Israel.,Faculty of Medicine Hebrew University of Jerusalem Israel
| | - Jennifer C Y Chung
- Division of Cardiovascular Surgery Department of Surgery Peter Munk Cardiac Centre University Health NetworkUniversity of Toronto Ontario Canada
| | - Maneesh Sud
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,ICES Toronto Ontario Canada.,Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre University of Toronto Canada
| | - Mina Madan
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | - Stephen E Fremes
- Schulich Heart Program Division of Cardiac Surgery Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | - Harindra C Wijeysundera
- Schulich Heart Program Division of Cardiology Sunnybrook Health Sciences Centre University of Toronto Ontario Canada.,ICES Toronto Ontario Canada.,Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
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5
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Tirado-Conte G, Espejo-Paeres C, Nombela-Franco L, Jimenez-Quevedo P, Cobiella J, Vivas D, de Agustín JA, McInerney A, Pozo E, Salinas P, Nuñez-Gil I, Gonzalo N, Villagran E, de Hoyos A, Mejia-Renteria H, Macaya F, Carnero M, Vilacosta I, Fernández-Ortiz A, Escaned J, Maroto L, Macaya C. Performance of the heart team approach in daily clinical practice in high-risk patients with aortic stenosis. J Card Surg 2020; 36:31-39. [PMID: 33085128 DOI: 10.1111/jocs.15116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/27/2020] [Accepted: 09/29/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The heart team (HT) approach plays a key role in selecting the optimal treatment strategy for patients with aortic stenosis (AS). However, little is known about the HT decision process and its impact on outcomes. The aim of this study was to identify the factors associated with the HT decision and evaluate clinical outcomes according to the treatment choice. METHODS The study included a total of 286 consecutive patients with AS referred for discussion in the weekly HT meeting in a cardiovascular institute over 2 years. Patients were stratified according to the selected therapeutic approach: medical treatment (MT), surgical (SAVR), or transcatheter (TAVR) aortic valve replacement. Baseline characteristics involved in making a therapeutic choice were identified and a decision-making tree was built using classification and regression tree methodology. RESULTS Based on HT discussion, 53 patients were assigned to SAVR, 210 to TAVR, and 23 to MT. Older patients (≥88 years old) were mainly assigned to TAVR or MT according to the logistic EuroSCORE (<or≥28, respectively). While among younger patients (<88 years), significant mitral regurgitation (≥grade III), frailty, Society of Thoracic Surgeons score, and estimated glomerular filtration rate were the most relevant factors influencing treatment allocation. One-year all-cause mortality was 16.6% in the invasive groups (TAVR = 17.2%, SAVR = 14.0%) and 68.7% in the MT arm. CONCLUSION The HT decision was determined by well-recognized risk factors that were used to define a treatment decision algorithm. Future studies with younger and lower-risk patients may identify new contributory factors that may alter the selection process and treatment choice.
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Affiliation(s)
- Gabriela Tirado-Conte
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Carolina Espejo-Paeres
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Luis Nombela-Franco
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Pilar Jimenez-Quevedo
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Javier Cobiella
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - David Vivas
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Jose Alberto de Agustín
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Angela McInerney
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Eduardo Pozo
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Pablo Salinas
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Ivan Nuñez-Gil
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Nieves Gonzalo
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Enrique Villagran
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Alfonso de Hoyos
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Hernán Mejia-Renteria
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Fernando Macaya
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Manuel Carnero
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Isidre Vilacosta
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Antonio Fernández-Ortiz
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Javier Escaned
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Luis Maroto
- Department of Cardiac Surgery, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Carlos Macaya
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
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6
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Role of comprehensive geriatric assessment in low surgical risk older patients with aortic stenosis. Aging Clin Exp Res 2020; 32:381-388. [PMID: 31148097 DOI: 10.1007/s40520-019-01228-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 05/18/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Among elderly with severe aortic stenosis (AS), Comprehensive Geriatric Assessment (CGA) originally contributed to address to transcatheter aortic valve implantation (TAVI) patients not suitable to surgical aortic valve replacement(SAVR). Nevertheless, TAVI has recently been proposed also in lower surgical risk patients. AIMS To evaluate predictors of TAVI procedure and clinical outcomes among these patients. METHODS For each patient ≥ 65 years with severe AS referring to our Cardiac Surgery Division, CGA was performed, including functional and cognitive status, comorbidity burden, frailty, nutritional status, gait speed, hand-grip strength and number of medications. Surgical risk was evaluated according to the Society of Thoracic Surgeons (STS) score (low-risk < 4%). Post-procedural outcomes (30-day survival and post-procedural complications) were obtained by medical records and a one-year follow-up assessed survival, and functional and cognitive performance. RESULTS Among 154 subjects (mean age 82.9 years), 52 were at low-risk according to STS score. 32 patients were addressed to TAVI, 20 to SAVR. Variables significantly associated with TAVI-approach were lower gait speed (p 0.030) and higher number of medications (p 0.015). Short and long-term outcomes did not differ between groups. DISCUSSION Among CGA variables, gait speed and number of medications were associated with the decision to perform TAVI instead of SAVR, even in patients at low surgical risk. 30-day and one-year survival and one-year functional and cognitive decline were similar between groups, despite a relevant prevalence of frailty in the TAVI group. CONCLUSIONS We suggest that gait speed and number of medications should be considered in selecting appropriate candidates to TAVI among low surgical risk patients.
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7
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van Beek-Peeters JJAM, van Noort EHM, Faes MC, de Vos AJBM, van Geldorp MWA, Minkman MMN, van der Meer NJM. Shared decision making in older patients with symptomatic severe aortic stenosis: a systematic review. Heart 2020; 106:647-655. [PMID: 32001621 DOI: 10.1136/heartjnl-2019-316055] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/24/2019] [Accepted: 12/19/2019] [Indexed: 12/18/2022] Open
Abstract
This review provides an overview of the status of shared decision making (SDM) in older patients regarding treatment of symptomatic severe aortic stenosis (SSAS). The databases Embase, Medline Ovid, Cinahl and Cochrane Dare were searched for relevant studies from January 2002 to May 2018 regarding perspectives of professionals, patients and caregivers; aspects of decision making; type of decision making; application of the six domains of SDM; barriers to and facilitators of SDM. The systematic search yielded 1842 articles, 15 studies were included. Experiences of professionals and informal caregivers with SDM were scarcely found. Patient refusal was a frequently reported result of decision making, but often no insight was given into the decision process. Most studies investigated the 'decision' and 'option' domains of SDM, yet no study took all six domains into account. Problem analysis, personalised treatment aims, use of decision aids and integrating patient goals in decisions lacked in all studies. Barriers to and facilitators of SDM were 'individualised formal and informal information support' and 'patients' opportunity to use their own knowledge about their health condition and preferences for SDM'. In conclusion, SDM is not yet common practice in the decision making process of older patients with SSAS. Moreover, the six domains of SDM are not often applied in this process. More knowledge is needed about the implementation of SDM in the context of SSAS treatment and how to involve patients, professionals and informal caregivers.
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Affiliation(s)
| | | | - Miriam C Faes
- Department of Geriatrics, Amphia Hospital, Breda, The Netherlands
| | | | | | - Mirella M N Minkman
- TIAS, School for Business and Society, Tilburg University, Tilburg, The Netherlands.,Vilans, Centre of Expertise for Long-term Care, Utrecht, The Netherlands
| | - Nardo J M van der Meer
- TIAS, School for Business and Society, Tilburg University, Tilburg, The Netherlands.,Department of Anesthesiology, Amphia Hospital, Breda, The Netherlands
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8
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Lareyre F, Mialhe C, Bourlon F, Habib Y, Dommerc C, Raffort J. Diabetes mellitus is not associated with worse vascular outcome following percutaneous transfemoral transcatheter aortic valve implantation. Acta Cardiol 2019; 74:480-486. [PMID: 30642229 DOI: 10.1080/00015385.2018.1522074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background: Transcatheter aortic valve implantation (TAVI) is an alternative to open surgical aortic valve replacement and the impact of diabetes on vascular outcomes is worth of investigation. The aim of our study was to determine if diabetic patients had distinct pre-operative characteristics compared to non-diabetics and to evaluate the impact of the disease on vascular outcomes.Methods: Four hundred consecutive patients who underwent TAVI with percutaneous transfemoral access were retrospectively included. Vascular outcomes were classified according to the Valve Academic Research Consortium 2 classification.Results: Seventy-eight (19.5%) patients were diabetics. Compared to non-diabetics, diabetic patients were younger and had significantly higher body mass index (29.7+/- 0.7 kg/m2 vs 26.8+/- 0.3, p < .0001), higher proportion of associated dyslipidemia (34.6% vs 11.5%, p < .0001) and arterial hypertension (60% vs 38.2%, p = .0009). Anatomical characteristics of the vascular access and procedural characteristics did not differ among the groups. No significant difference was observed in the incidence of major and minor vascular complications and 30-day post-operative mortality between diabetic and non-diabetic patients (2.6% vs 1.9%, p = .6916).Conclusion: Diabetes is not associated with worse vascular outcome following TAVI suggesting that the vascular access can be managed safely in these patients.
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Affiliation(s)
- Fabien Lareyre
- Cardiovascular Surgery Unit, Cardio Thoracic Centre of Monaco, Monaco
- Université Côte d’Azur, Nice, France
| | - Claude Mialhe
- Cardiovascular Surgery Unit, Cardio Thoracic Centre of Monaco, Monaco
| | - François Bourlon
- Cardiovascular Surgery Unit, Cardio Thoracic Centre of Monaco, Monaco
| | - Yacoub Habib
- Cardiovascular Surgery Unit, Cardio Thoracic Centre of Monaco, Monaco
| | - Carine Dommerc
- Cardiovascular Surgery Unit, Cardio Thoracic Centre of Monaco, Monaco
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Rea CW, Wang TKM, Ruygrok PN, Sidhu K, Ramanathan T, Nand P, Stewart JT, Webster MWI. Characteristics and Outcomes of Patients With Severe Aortic Stenosis Discussed by the Multidisciplinary "Heart Team" According to Treatment Allocation. Heart Lung Circ 2019; 29:368-373. [PMID: 30948328 DOI: 10.1016/j.hlc.2019.02.192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 10/30/2018] [Accepted: 02/26/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) is an alternative and effective contemporary intervention to surgical aortic valve replacement (SAVR) for patients with severe aortic valve disease at increased surgical risk. Guidelines recommend a multidisciplinary "Heart Team" (MHT) review of patients considered for a TAVI procedure, but this has been little studied. We reviewed the characteristics, treatments and outcomes of such patients reviewed by the MHT at our centre. METHODS Data on consecutive patients with severe aortic valve stenosis discussed by the Auckland City Hospital MHT from June 2011 to August 2016 were obtained from clinical records. Patient characteristics, treatment and outcomes were analysed using standard statistical methods. RESULTS Over the 5-year period 243 patients (mean age 80.2 ± 8.0 years, 60% male) were presented at the MHT meeting. TAVI was recommended for 200, SAVR for 26 and medical therapy for 17 patients, with no significant difference in mean age (80.2 ± 8.3, 80.4 ± 6.1, 80.4 ± 7.3 years, respectively) or EuroSCORE II (6.5 ± 4.7%, 5.3 ± 3.6%, 6.7 ± 4.3%, respectively). Over time, there was an increase in the number of patients discussed and treated, with no change in their mean age, but the mean EuroSCORE II significantly decreased (TAVI p = 0.026, SAVR p = 0.004). Survival after TAVI and SAVR was similar to that of the age-matched general population, but superior to medical therapy p = 0.002 (93% (n = 162), 84% (n = 21) and 73% (n = 18) at one year and 85% (n = 149), 84% (n = 21) and 54% (n = 13) at 2 years, respectively). CONCLUSIONS An increasing number of patients were discussed at the MHT meeting with the majority undergoing TAVI, with a similar age and EuroSCORE II to those allocated SAVR or medical therapy. Survival following TAVI and SAVR was superior to medical therapy and similar to the age-matched general population. These findings suggest that the MHT process is robust, consistent and appropriately allocating a limited treatment resource.
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Affiliation(s)
- Conor W Rea
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Tom Kai Ming Wang
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Peter N Ruygrok
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand.
| | - Karishma Sidhu
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | | | - Parma Nand
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - James T Stewart
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Mark W I Webster
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
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Patel A, Mahendran K, Collins M, Abdelaziz M, Khogali S, Luckraz H. Incidental abnormal CT scan findings during transcatheter aortic valve implantation assessment: incidence and implications. Open Heart 2018; 5:e000855. [PMID: 30228909 PMCID: PMC6135460 DOI: 10.1136/openhrt-2018-000855] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/05/2018] [Accepted: 07/24/2018] [Indexed: 11/07/2022] Open
Abstract
Objectives The aim of this retrospective series is to describe the prevalence and clinical significance of the incidental findings found during pre–transcatheter aortic valve implantation (TAVI) work-up and to ascertain the clinical course of such patients. Methods Consecutive patients undergoing TAVI from 2013 to 2015 where a TAVI CT assessment was performed (n=138) were included in the study. All incidental findings that were not expected from the patient’s history were discussed at the TAVI multidisciplinary meeting in order to ascertain the clinical significance of said findings and whether they would alter the proposed course of treatment. Mortality data were determined by careful retrospective case note and follow-up appointment analysis. Results Seventy-eight patients (57%) were found to have incidental findings on pre-TAVI CT scan. The majority of patients had benign pathology with high incidence in particular of diverticular disease, pleural effusions, gallstones, hiatus hernia and degenerative spinal disease. Vascular pathology such as superior mesenteric, renal and iliac artery stenoses and abdominal aortic aneurysm was detected in seven patients. In terms of long-term mortality data, we found no significant difference between those with incidental findings and those without (p=0.48). Survival as assessed by Kaplan-Meier analysis showed no significant difference between those with and without incidental abnormal CT scan findings (p=0.98). Conclusions Incidental findings with potential for malignancy are common in an elderly, comorbid population. Ultimately, clinical correlation and prognosis must be swiftly ascertained in order to streamline the patients down the appropriate management pathway while avoiding unnecessary delay for treatment of their aortic stenosis.
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Affiliation(s)
- Akshay Patel
- Department of Cardiothoracic Surgery, Heart and Lung Centre, New Cross Hospital, Wolverhampton, UK
| | - Kajan Mahendran
- Department of Cardiothoracic Surgery, Heart and Lung Centre, New Cross Hospital, Wolverhampton, UK
| | - Michael Collins
- Department of Radiology, Heart and Lung Centre, New Cross Hospital, Wolverhampton, UK
| | - Mahmoud Abdelaziz
- Department of Cardiothoracic Surgery, Heart and Lung Centre, New Cross Hospital, Wolverhampton, UK
| | - Saib Khogali
- Department of Cardiology, Heart and Lung Centre, New Cross Hospital, Wolverhampton, UK
| | - Heyman Luckraz
- Department of Cardiothoracic Surgery, Heart Centre, American Hospital Dubai, Dubai, United Arab Emirates
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Vale NC, Campante Teles R, Madeira S, Brito J, Sousa Almeida M, Nolasco T, Abecasis J, Rodrigues G, Carmo J, Furstenau M, Ribeiras R, Neves JP, Mendes M. Post-procedural N-terminal pro-brain natriuretic peptide predicts one-year mortality after transcatheter aortic valve implantation. Rev Port Cardiol 2018; 37:67-73. [DOI: 10.1016/j.repc.2017.06.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 04/12/2017] [Accepted: 06/29/2017] [Indexed: 11/26/2022] Open
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Vale NC, Campante Teles R, Madeira S, Brito J, Sousa Almeida M, Nolasco T, Abecasis J, Rodrigues G, Carmo J, Furstenau M, Ribeiras R, Neves JP, Mendes M. Post-procedural N-terminal pro-brain natriuretic peptide predicts one-year mortality after transcatheter aortic valve implantation. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2018.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Lareyre F, Raffort J, Dommerc C, Habib Y, Bourlon F, Mialhe C. A 7-Year Single-Center Experience of Transfemoral TAVI: Evolution of Surgical Activity and Impact on Vascular Outcome. Angiology 2017; 69:532-539. [DOI: 10.1177/0003319717737665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) has become a well-established alternative to open surgery to treat aortic stenosis. We describe our 7-year TAVI experience using transfemoral access and identity changes in surgical activity and evaluate its impact on postoperative vascular outcomes. Consecutive patients (N = 340) who underwent TAVI with percutaneous transfemoral access were retrospectively included and divided into 4 quartiles according to the date of intervention. Vascular outcomes were classified according to the Valve Academic Research Consortium 2 classification. The number of patients who underwent transfemoral TAVI increased over time and their clinical characteristics evolved, with a lower Society of Thoracic Surgeons score and less comorbidities. The material used evolved and TAVI could be performed despite higher iliac calcification and tortuosity scores. With experience, the procedural time, the postoperative length of stay at hospital, and the 30-day postoperative mortality significantly decreased. No significant change was observed for vascular outcome, except for minor hematoma. We witnessed an increase in transfemoral TAVI procedure, with changes in clinical and procedural characteristics associated with an improvement in postoperative outcomes.
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Affiliation(s)
- Fabien Lareyre
- Cardiovascular Surgery Unit, Cardiothoracic Centre of Monaco, Monaco
- University of Côte d’Azur, INSERM, CNRS, IRCAN, Nice, France
| | | | - Carine Dommerc
- Cardiovascular Surgery Unit, Cardiothoracic Centre of Monaco, Monaco
| | - Yacoub Habib
- Cardiovascular Surgery Unit, Cardiothoracic Centre of Monaco, Monaco
| | - François Bourlon
- Cardiovascular Surgery Unit, Cardiothoracic Centre of Monaco, Monaco
| | - Claude Mialhe
- Cardiovascular Surgery Unit, Cardiothoracic Centre of Monaco, Monaco
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Kaier K, von Kampen F, Baumbach H, von Zur Mühlen C, Hehn P, Vach W, Zehender M, Bode C, Reinöhl J. Two-year post-discharge costs of care among patients treated with transcatheter or surgical aortic valve replacement in Germany. BMC Health Serv Res 2017; 17:473. [PMID: 28693565 PMCID: PMC5504607 DOI: 10.1186/s12913-017-2432-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/04/2017] [Indexed: 11/17/2022] Open
Abstract
Background This study presents data on post-discharge costs of care among patients treated with transcatheter or surgical aortic valve replacement over a two year period. Methods Based on a prospective clinical trial, post-discharge utilization of health services and status of assistance were collected for 151 elderly patients via 2250 monthly telephone interviews, valued using standardized unit costs and analysed using two-part regression models. Results At month 1 post-discharge, total costs of care are substantially elevated (monthly mean: €3506.7) and then remain relatively stable over the following 23 months (monthly mean: €622.3). As expected, the majority of these costs are related to in-hospital care (~98% in month 1 post-discharge and ~72% in months 2–24). Patients that died during follow-up were associated with substantially higher cost estimates of in-hospital care than those surviving the two-year study period, while patients’ age and other patient characteristics were of minor relevance. Estimated costs of outpatient care are lower at month 1 than during the rest of the study period, and not affected by the event of death during follow-up. The estimated costs of nursing care are, in contrast, much higher in year 2 than in year 1 and differ substantially by gender and type of procedure as well as by patients’ age. Overall, these monthly cost estimates add up to €10,352 for the first and €7467.6 for the second year post-discharge. Conclusions Substantial cost increases at month 1 post-discharge and in case of death during follow-up are the main findings of the study, which should be taken into account in future economic evaluations on the topic. Application of standardized unit costs in combination with monthly patient interviews allows for a far more precise estimate of the variability in post-discharge health service utilization in this group of patients than the ones given in previous studies. Trial registration German Clinical Trial Register Nr. DRKS00000797. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2432-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Klaus Kaier
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg im Breisgau, Germany. .,Department of Cardiology, Heart Center Freiburg University, Freiburg im Breisgau, Germany. .,Clinical Epidemiology, Center for Medical Biometry and Medical Informatics, Medical Center - University of Freiburg, Stefan-Meier-Str. 26, D-79104, Freiburg, Germany.
| | - Frederike von Kampen
- Department of Cardiology, Heart Center Freiburg University, Freiburg im Breisgau, Germany
| | - Hardy Baumbach
- Department of Cardiovascular Surgery, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | | | - Philip Hehn
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg im Breisgau, Germany
| | - Werner Vach
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg im Breisgau, Germany
| | - Manfred Zehender
- Department of Cardiology, Heart Center Freiburg University, Freiburg im Breisgau, Germany
| | - Christoph Bode
- Department of Cardiology, Heart Center Freiburg University, Freiburg im Breisgau, Germany
| | - Jochen Reinöhl
- Department of Cardiology, Heart Center Freiburg University, Freiburg im Breisgau, Germany
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Geriatric assessment to objectify the multidisciplinary heart team decision for treatment of elderly patients with severe, symptomatic aortic valve stenosis. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Learning Curves Among All Patients Undergoing Transcatheter Aortic Valve Implantation in Germany: A Retrospective Observational Study. Int J Cardiol 2017; 235:17-21. [PMID: 28274581 DOI: 10.1016/j.ijcard.2017.02.138] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 02/23/2017] [Accepted: 02/27/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) is a rapidly evolving technique for therapy of aortic stenosis. Previous studies report learning curves with respect to in-hospital mortality and clinical complications. We aim to determine whether observed improvements of in-hospital outcomes after TAVI are the result of improvements in procedures or due to a change in the patient population, and whether improvements differ between the transfemoral (TF) and the transapical (TA) approach. METHODS Data was analyzed using risk-adjusted regression analyses in order to track the development of clinical outcomes of all isolated TAVI procedures performed in Germany from 2008 to 2013 (N=32.436) in all German hospitals performing TAVI. Measurements include in-hospital mortality, stroke, bleeding, and mechanical ventilation. RESULTS Unadjusted mortality rates decrease over time for both TA-TAVI and TF-TAVI. Reductions in mortality were smaller for TA-TAVI than for TF-TAVI. These trends could also be observed for risk-adjusted (standardized) mortality rates, indicating that time trends and differences between TA-TAVI (around 7% in 2013) and TF-TAVI (around 4% in 2013) cannot be explained by changes in the risk factor composition of the patient populations. Bleeding complications decreased for both access routes. Both unadjusted and standardized bleeding rates were substantially higher for TA-TAVI. In addition, TA-TAVI procedures were associated with an increased likelihood of requiring >48h of mechanical ventilation. CONCLUSIONS Observed improvements in TAVI-related in-hospital mortality are not due to a change in patient population. The results indicate the superiority of a TF-first approach.
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Kennon S, Archbold A. Expert Opinion: Guidelines for the Management of Patients with Aortic Stenosis Undergoing Non-cardiac Surgery: Out of Date and Overly Prescriptive. Interv Cardiol 2017; 12:133-136. [PMID: 29588742 DOI: 10.15420/icr.2017:20:2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Patients with severe aortic stenosis who require non-cardiac surgery present a difficult clinical problem. The most recent clinical practice guidelines from the American College of Cardiology/American Heart Association and the European Society of Cardiology for the perioperative cardiovascular assessment and management of patients undergoing noncardiac surgery were both published in 2014. These guidelines are reviewed in the light of recently published randomised controlled trial data regarding the efficacy of transcatheter aortic valve implantation to treat aortic stenosis.
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Affiliation(s)
- Simon Kennon
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
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18
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Kaier K, Gutmann A, Baumbach H, von Zur Mühlen C, Hehn P, Vach W, Beyersdorf F, Zehender M, Bode C, Reinöhl J. Quality of life among elderly patients undergoing transcatheter or surgical aortic valve replacement- a model-based longitudinal data analysis. Health Qual Life Outcomes 2016; 14:109. [PMID: 27456092 PMCID: PMC4960709 DOI: 10.1186/s12955-016-0512-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 07/17/2016] [Indexed: 11/10/2022] Open
Abstract
Background Quality of life (QoL) measurements reported in observational studies are often biased, since patients who failed to improve are more likely to be unable to respond due to death or impairment. In order to observe the development of QoL in patients close to death, we analyzed a set of monthly QoL measurements for a cohort of elderly patients treated for aortic valve stenosis (AS) with special consideration of the effect of distance to death. Methods QoL in 169 elderly patients (age ≥ 75 years), treated either with transcatheter aortic valve replacement (TAVR; n = 92), surgical aortic-valve replacement (n = 70), or drug-based therapy (n = 7), was evaluated using the standardized EQ-5D questionnaire. Over a two-year period, patients were consulted using monthly telephone interviews or outpatient visits, leading to a total of 2463 time points at which QoL values, New York Heart Association (NYHA) Functional Classification and their status of assistance were assessed. Furthermore, post-procedural clinical events and complications were monitored. Linear and ordered logistic regression analyses with random intercept were carried out, taking into account overall trends and distance to death. Results QoL measures decreased slightly over time, were temporarily impaired at month 1 after the initial episode of hospitalization and decreased substantially at the end of life with a measurable effect starting at the sixth from last follow-up (month) before death. Many clinical complications (bleeding complications, stroke, acute kidney injury) showed an impairment of QoL measurements, but the inclusion of lagged variables demonstrated medium term (three months) QoL impairments for access site bleeding only. All other complications are associated with event-related impairments that decreased dramatically at the second and third follow-up interviews (month) after event. Conclusions Distance to death shows clear effects on QoL and should be taken into account when analyzing QoL measures in the elderly patients treated for aortic valve stenosis. Trial registration German Clinical Trial Register Nr. DRKS00000797
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Affiliation(s)
- Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Stefan-Meier-Str. 26, D-79104, Freiburg, Germany. .,Department of Cardiology, Heart Center Freiburg University, Freiburg, Germany.
| | - Anja Gutmann
- Department of Cardiology, Heart Center Freiburg University, Freiburg, Germany
| | - Hardy Baumbach
- Department of Cardiovascular Surgery, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | | | - Philip Hehn
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Stefan-Meier-Str. 26, D-79104, Freiburg, Germany
| | - Werner Vach
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Stefan-Meier-Str. 26, D-79104, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Manfred Zehender
- Department of Cardiology, Heart Center Freiburg University, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology, Heart Center Freiburg University, Freiburg, Germany
| | - Jochen Reinöhl
- Department of Cardiology, Heart Center Freiburg University, Freiburg, Germany
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Stachon P, Kaier K, Milde S, Pache G, Sorg S, Siepe M, von zur Mühlen C, Zirlik A, Beyersdorf F, Langer M, Zehender M, Bode C, Reinöhl J. Two-year survival of patients screened for transcatheter aortic valve replacement with potentially malignant incidental findings in initial body computed tomography. Eur Heart J Cardiovasc Imaging 2015; 16:731-7. [PMID: 25759083 PMCID: PMC4463004 DOI: 10.1093/ehjci/jev055] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 02/18/2015] [Indexed: 12/21/2022] Open
Abstract
Aims Recently, transcatheter aortic valve replacement (TAVR) has evolved as the standard treatment in patients with inoperable aortic valve stenosis. According to TAVR guidelines, body computed tomography (CT) is recommended for pre-procedural planning. Due to the advanced age of these patients, multiple radiological potentially malignant incidental findings (pmIFs) appear in this cohort. It is unknown how pmIFs influence the decision by the heart team to intervene and the mortality. Methods and results We evaluated in a retrospective single-centre observational study 414 participants screened for TAVR with dual-source CT between October 2010 and December 2012. pmIFs are common and appeared in 18.7% of all patients screened for TAVR. The decision to intervene by TAVR or surgical aortic valve replacement (SAVR) was made by an interdisciplinary heart team and the role of pmIF in decision-making and time to treatment with TAVR or SAVR was analysed, retrospectively. The appearance of a pmIF vs. no pmIF did not significantly influence therapeutic decisions [odds ratio (OR) 1.14; P = 0.835] or time to treatment (91 ± 152 vs. 61 ± 109 days, respectively). Several findings, which are highly suspicious for malignancy, were less likely associated with invasive treatment (OR 0.207; P = 0.046). Patient survival was evaluated for at least 2 years until January 2014. Two-year survival of patients after TAVR or SAVR, treated according to the heart team decision, was ∼75% and independent from the presence of a non-severe (P = 0.923) or severe (P = 0.823) pmIF. Conclusion The study indicates that frequently occurring radiologic pmIF did not influence 2-year survival after a decision to intervene was made by an interdisciplinary heart team.
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Affiliation(s)
- Peter Stachon
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Klaus Kaier
- Center for Medical Biometry and Medical Informatics, Medical Center, University of Freiburg, Freiburg, Germany
| | - Simone Milde
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Gregor Pache
- Department of Radiology, Center for Diagnostic and Therapeutic Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Stefan Sorg
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Constantin von zur Mühlen
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Andreas Zirlik
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Mathias Langer
- Department of Radiology, Center for Diagnostic and Therapeutic Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Jochen Reinöhl
- Department of Cardiology and Angiology I, University Heart Center Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
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