Impella in Acute Myocardial Infarction Complicated by Cardiogenic Shock: History and Current Controversies

In this review, the authors discuss a brief history of the Impella mechanical circulatory support device, a mechanistic role for the device in the context of the underlying pathophysiology of acute myocardial infarction cardiogenic shock (AMI-CS), the current body of literature evaluating its role in AMI-CS, and upcoming efforts to identify a role more clearly for the device in AMI-CS.

Valve-in-valve transcatheter aortic valve implantation versus repeat surgical aortic valve replacement in patients with a failed aortic bioprosthesis

BACKGROUND

Limited data are available regarding clinical outcomes of valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) following the United States Food and Drug Administration approval of ViV TAVI in 2015.

AIMS

The aim of this study was to evaluate in-hospital, 30-day, and 6-month outcomes of ViV TAVI versus repeat surgical aortic valve replacement (SAVR) in patients with a failed aortic bioprosthetic valve.

METHODS

This retrospective cohort study identified patients who underwent ViV TAVI or repeat SAVR utilising the Nationwide Readmission Database from 2016 to 2018. Primary outcomes were all-cause readmission (at 30 days and 6 months) and in-hospital death. Secondary outcomes were in-hospital stroke, pacemaker implantation, 30-day/6-month major adverse cardiac events (MACE), and mortality during readmission. Propensity score-matching (inverse probability of treatment weighting) analyses were implemented.

RESULTS

Out of 6,769 procedures performed, 3,724 (55%) patients underwent ViV TAVI, and 3,045 (45%) underwent repeat SAVR. ViV TAVI was associated with lower in-hospital all-cause mortality (odds ratio [OR] 0.42, 95% confidence interval [CI]: 0.20-0.90, p=0.026) and a higher rate of 30-day (hazard ratio [HR] 1.46, 95% CI: 1.13-1.90, p=0.004) and 6-month all-cause readmission (HR 1.54, 95% CI: 1.14-2.10, p=0.006) compared with repeat SAVR. All secondary outcomes were comparable between the two groups.

CONCLUSIONS

ViV TAVI was associated with lower in-hospital mortality but higher 30-day and 6-month all-cause readmission. However, there was no difference in risk of in-hospital stroke, post-procedure pacemaker implantation, MACE, and mortality during 30-day and 6-month readmission compared with repeat SAVR, suggesting that ViV TAVI can be performed safely in carefully selected patients.

Revascularization or optimal medical therapy for stable ischemic heart disease: A Bayesian meta-analysis of contemporary trials

BACKGROUND

The role of revascularization in patients with stable ischemic heart disease (SIHD) has been controversial, more so in the present era of drug-eluting stents.

AIMS

To examine the absolute risk difference (ARD) between revascularization plus optimal medical therapy (OMT) versus OMT alone among patients with SIHD using Bayesian approach.

METHODS

PubMed/MEDLINE and Cochrane citation indices were utilized to identify randomized controlled trials (RCTs) through March 31, 2020. Among trials comparing initial revascularization plus OMT with initial OMT alone, revascularization arm must have comprised >50% of patients receiving either percutaneous or surgical revascularization, and >50% of patients must have received aspirin and statin as OMT in both arms.

RESULTS

Seven RCTs (12,494) were included in the final analysis. The ARD of all-cause mortality for revascularization with respect to OMT was centred at -0.002 (95% CrI: -0.01; 0.01, Tau: 0.01, 67% probability of ARD of revascularization vs. OMT < 0). The ARD for cardiac mortality was centred at -0.0025 (95%CrI: -0.01; 0.01, Tau: 0.01, 77% probability of ARD of revascularization vs. OMT < 0). The ARD for MI was -0.02 (95% CrI: -0.06; 0.00, Tau: 0.02, 97% probability of ARD for revascularization vs. OMT < 0). There was 96% probability of ARD for unstable angina with revascularization vs. OMT < 0, 4.5% probability of ARD for freedom from angina with revascularization vs. OMT < 0, and 6% probability of ARD for stroke with revascularization vs. OMT < 0.

CONCLUSIONS

Bayesian analysis demonstrated minimal probability of difference in all-cause mortality and cardiac mortality in patients with SIHD who underwent revascularization compared with OMT alone. However, revascularization was associated with lower probability of MI, unstable angina, and increased freedom from angina, but a higher risk of stroke compared with OMT alone.

PROSPERO

The protocol of this systematic review and meta-analysis was registered in PROSPERO [CRD42020160540].

Outcomes of transcatheter aortic valve replacement in patients with cognitive dysfunction

IMPORTANCE

The impact of pre-existing cognitive dysfunction on outcomes after transcatheter aortic valve replacement (TAVR) remains unclear.

OBJECTIVE

To study the association between dementia and post-TAVR outcomes.

DESIGN

Cohort study with propensity-score matching was conducted using the Nationwide Inpatient Sample.

EXPOSURES

History of dementia at the time of undergoing TAVR.

MAIN OUTCOMES

All-cause in-hospital mortality, stroke, bleeding requiring transfusion, acute kidney injury, post-procedural vascular complications, post-procedural pacemaker implantation, length of stay, in-hospital delirium, and discharge disposition in patients with and without dementia undergoing TAVR.

RESULTS

Of 57,805 patients undergoing TAVR, 2910 (5.0%) had a diagnosis of dementia. Propensity-score matching yielded 2895 matched pairs of patients. TAVR was associated with an increased risk of bleeding requiring transfusion (14.7% vs 8.6%, odd ratio (OR) 1.82 [95% confidence interval (CI) 1.26-2.63]; p < 0.01), discharge to a rehabilitation facility (45.8% vs 31.6%, OR 2.27 [95% CI 1.67-3.08]; p < 0.001), in-hospital delirium (7.4% vs 3.6%, OR 2.13 [95% CI 1.26-3.61]; p < 0.01), increased length of stay (6.75 ± 0.07 days vs 6.11 ± 0.06 days, slope = 1.11 [95% CI 1.03-1.19]; p < 0.01), but comparable in-hospital mortality (2.1% vs 2.6%, OR 1.26 [95% CI 0.57-2.79]; p = 0.57] in patients with dementia compared with patients without dementia.

CONCLUSIONS AND RELEVANCE

This study found that patients with dementia undergoing TAVR had a longer hospital stay as well as higher rates of discharge to a rehabilitation facility and in-hospital delirium, which may indicate debility and functional decline during hospitalization; however, in-hospital mortality and other outcomes were comparable between the two groups. TAVR candidates should be subjected to a comprehensive geriatric and cognitive assessment to help risk-stratify them for potential post-procedural functional decline. Prospective studies aimed at standardizing cognitive scoring and evaluating the post-procedural quality of life are needed.