Incidence, predictors, and prognostic significance of impaired functional status early after transcatheter aortic valve replacement

INTRODUCTION AND OBJECTIVES

There are scarce data on the factors associated with impaired functional status after transcatheter aortic valve replacement (TAVR) and its clinical impact. This study aimed to determine the incidence, predictors, and prognostic implications of impaired functional class (NYHA class III-IV) following TAVR.

METHODS

This multicenter study included 3462 transarterial TAVR patients receiving newer generation devices. The patients were compared according to their NYHA class at 1 month of follow-up (NYHA I-II vs NYHA III-IV). A multivariate logistic regression was performed to identify the predictors of 30-day NYHA class III-IV. Patient survival was compared with the Kaplan-Meier method and factors associated with decreased survival were identified with Cox regression analysis.

RESULTS

The mean age of the study population was 80.3±7.3 years, with 47% of women, and a median Society of Thoracic Surgeons score of 3.8% [IQR, 2.5-5.8]. A total of 208 patients (6%) were in NYHA class III-IV 1 month after TAVR. Predictors of 30-day NYHA class III-IV were baseline NYHA class III-IV (OR, 1.76; 95%CI, 1.08-2.89; P=.02), chronic pulmonary obstructive disease (OR, 1.80; 95%CI, 1.13-2.83; P=.01), and post-TAVR severe mitral regurgitation (OR, 2.00; 95%CI, 1.21-3.31; P<.01). Patients in NYHA class III-IV 1 month after TAVR were at higher risk of death (HR, 3.68; 95%CI, 2.39-5.70; P<.01) and heart failure-related hospitalization (HR, 6.00; 95%CI, 3.76-9.60; P<.01) at 1-year follow-up.

CONCLUSIONS

Up to 6% of contemporary TAVR patients exhibited an impaired functional status following TAVR. Worse baseline NYHA class, chronic pulmonary obstructive disease, and severe mitral regurgitation predicted 30-day NYHA class III/IV, and this determined a higher risk of mortality and heart failure hospitalization at 1-year follow-up. Further studies on the prevention and treatment optimization of patients with impaired functional status after TAVR are needed.

Long-term Clinical Outcomes Following Cardiac Stress Testing After Percutaneous Coronary Intervention

BACKGROUND

Cardiac stress testing (CST) is commonly performed after percutaneous coronary intervention (PCI), yet little is known whether such ischemic testing is associated with improved clinical outcomes.

METHODS

We studied patients who underwent their first PCI procedure from October 2008 to December 2016 in Ontario, Canada. Patients who underwent CST from 60 days to 1 year after PCI were compared with those who did not undergo CST. The primary outcome was a composite of cardiovascular death or hospitalisation for myocardial infarction (MI) at 3 years after CST. Inverse probability of treatment weighting was used to adjust for potential differences between the study groups.

RESULTS

Among the 86,150 included patients, 40,988 (47.6%) underwent CST within 60 days to 1 year after PCI. Patients who underwent CST had higher prescription rates of cardiac medications. At 1 year after CST, rates of cardiac catheterisation and coronary revascularisation were more than double those observed in the nontested group (13.4% vs 5.9%, standardised difference [SD] 0.26, for cardiac catheterisation; 6.6% vs 2.7%, SD 0.19, for PCI). The CST group had a significantly lower primary event rate at 3 years compared without CST (3.9% vs 4.5%, hazard ratio 0.87, 95% confidence interval 0.81-0.93).

CONCLUSIONS

This population-based study of PCI patients found a small but significantly lower risk of cardiovascular events among patients who received CST. Further studies are needed to confirm these findings and determine the specific aspects of care that may be associated with the modestly improved outcomes.

Cardiac Death After Transcatheter Aortic Valve Replacement With Contemporary Devices

BACKGROUND

The burden of cardiac death after transcatheter aortic valve replacement (TAVR), particularly from advanced heart failure (HF) and sudden cardiac death (SCD), remains largely unknown.

OBJECTIVES

This study sought to evaluate the incidence and predictors of SCD and HF-related death in TAVR recipients treated with newer-generation devices.

METHODS

This study included a total of 5,421 consecutive patients who underwent TAVR with newer-generation devices using balloon (75.7%) or self-expandable (24.3%) valves.

RESULTS

After a median follow-up of 2 (IQR: 1-3) years, 976 (18.0%) patients had died, 50.8% from cardiovascular causes. Advanced HF and SCD accounted for 11.6% and 7.5% of deaths, respectively. Independent predictors of HF-related death were atrial fibrillation (HR: 2.17; 95% CI: 1.47-3.22; P < 0.001), prior pacemaker (HR: 1.79; 95% CI: 1.10-2.92; P = 0.01), reduced left ventricular ejection fraction (HR: 1.08 per 5% decrease; 95% CI: 1.01-1.14; P = 0.02), transthoracic approach (HR: 2.50; 95% CI: 1.37-4.55; P = 0.003), and new-onset persistent left bundle branch block (HR: 1.85; 95% CI: 1.14-3.02; P = 0.01). Two baseline characteristics (diabetes, HR: 1.81; 95% CI: 1.13-2.89; P = 0.01; and chronic kidney disease, HR: 1.72; 95% CI: 1.02-2.90; P = 0.04) and 3 procedural findings (valve in valve, HR: 2.17; 95% CI: 1.01-4.64; P = 0.04; transarterial nontransfemoral approach, HR: 2.23; 95% CI: 1.23-4.48; P = 0.01; and periprocedural ventricular arrhythmia, HR: 7.19; 95% CI: 2.61-19.76; P < 0.001) were associated with an increased risk of SCD after TAVR.

CONCLUSIONS

Advanced HF and SCD accounted for a fifth of deaths after TAVR in contemporary practice. Potentially treatable factors leading to increased risk of HF deaths and SCD were identified, such as arrhythmia/dyssynchrony factors for HF and valve-in-valve TAVR or periprocedural ventricular arrhythmias for SCD.

Transcatheter aortic valve implantation in patients with extra-small aortic annuli

BACKGROUND

A small aortic annulus (SAA) is a risk factor for prosthesis-patient mismatch (PPM) in patients undergoing surgical or transcatheter aortic valve implantation (TAVI). Data regarding TAVI in patients with extra-SAA is scarce.

AIMS

The aim of this study was to analyse the safety and efficacy of TAVI in patients with extra-SAA.

METHODS

A multicentre registry study including patients with extra-SAA (defined as an aortic annulus area <280 mm² and/or perimeter <60 mm) undergoing TAVI was established. Primary efficacy and safety endpoints were defined as device success and early safety at 30 days, respectively, using the Valve Academic Research Consortium-3 criteria, and were analysed according to valve type: self-expanding (SEV) versus balloon-expandable (BEV).

RESULTS

A total of 150 patients were included, of which 139 (92.7%) were women, and 110 (73.3%) received an SEV. Intraprocedural technical success was 91.3%, with a higher rate in patients receiving an SEV (96.4% vs 77.5% with BEV; p=0.001). Overall, 30-day device success was 81.3%, (85.5% with SEV vs 70.0% with BEV; p=0.032). The primary safety endpoint occurred in 72.0% of patients (with no difference between groups; p=0.118). Severe PPM occurred in 12% (9.0% with SEV and 24.0% with BEV; p=0.039), with no impact on all-cause mortality, cardiovascular mortality, or heart failure readmission at 2-year follow-up.

CONCLUSIONS

TAVI is a safe and feasible treatment in patients with extra-SAA with a high rate of technical success. The use of SEV was associated with a lower rate of intraprocedural complications, higher device success at 30 days and better haemodynamic outcomes compared to BEV.

Incidence, Clinical Characteristics, and Impact of Absent Echocardiographic Signs in Patients With Infective Endocarditis After Transcatheter Aortic Valve Implantation

BACKGROUND

Echocardiography is the primary imaging modality for diagnosis of infective endocarditis (IE) in prosthetic valve endocarditis (PVE) including IE after transcatheter aortic valve implantation (TAVI). This study aimed to evaluate the characteristics and clinical outcomes of patients with absent compared with evident echocardiographic signs of TAVI-IE.

METHODS

Patients with definite TAVI-IE derived from the Infectious Endocarditis after TAVI International Registry were investigated comparing those with absent and evident echocardiographic signs of IE defined as vegetation, abscess, pseudo-aneurysm, intracardiac fistula, or valvular perforation or aneurysm.

RESULTS

Among 578 patients, 87 (15.1%) and 491 (84.9%) had absent (IE-neg) and evident (IE-pos) echocardiographic signs of IE, respectively. IE-neg were more often treated via a transfemoral access with a self-expanding device and had higher rates of peri-interventional complications (eg, stroke, major vascular complications) during the TAVI procedure (P < .05 for all). IE-neg had higher rates of IE caused by Staphylococcus aureus (33.7% vs 23.2%; P = .038) and enterococci (37.2% vs 23.8%; P = .009) but lower rates of coagulase-negative staphylococci (4.7% vs 20.0%, P = .001). IE-neg was associated with the same dismal prognosis for in-hospital mortality in a multivariate binary regression analysis (odds ratio: 1.51; 95% confidence interval [CI]: .55-4.12) as well as a for 1-year mortality in Cox regression analysis (hazard ratio: 1.10; 95% CI: .67-1.80).

CONCLUSIONS

Even with negative echocardiographic imaging, patients who have undergone TAVI and presenting with positive blood cultures and symptoms of infection are a high-risk patient group having a reasonable suspicion of IE and the need for an early treatment initiation.

Optimal Degree of Balloon-Expandable Transcatheter Valve Oversizing in Patients With Borderline Aortic Annulus Measurements: Insights From a Multicenter Real-World Experience

BACKGROUND

The potential benefit of using larger or smaller transcatheter heart valves (THV) in patients with borderline aortic annulus measurement (BAM) remains uncertain. The objective of this study was to evaluate the clinical outcomes associated with the selection of larger or smaller THV in the context of BAM.

METHODS

This was a multicenter observational study including patients who underwent transcatheter aortic valve replacement with the SAPIEN 3 or SAPIEN 3 Ultra-valve systems (Edwards Lifesciences, Irvine, CA) from April 2014 to June 2021. BAM was defined according to the manufacturer sizing chart and included the following annulus areas: 314 to 346, 400 to 430, 500 to 546 mm². A 1:1 propensity score matching was used to compare outcomes of patients with larger or smaller THV.

RESULTS

From a total of 2467 patients, BAM was identified in 852 patients (34.5%). A larger and smaller THV was selected in 338 (39.7%) and 514 patients (60.3%) patients, respectively. The choice of a larger THV was associated (before and after propensity matching) with a higher risk of new-onset left bundle branch block (HR, 2.25 [95% CI, 1.39-3.65; P=0.001) and permanent pacemaker implantation (HR, 1.86 [95% CI, 1.11-3.09]; P=0.016) without any impact on gradients or the risk of moderate or severe paravalvular regurgitation at discharge (HR, 0.78 [95% CI, 0.41-1.45]; P=0.427). The risk of periprocedural complications such as aortic rupture and tamponade was low (<1%) and similar between groups.

CONCLUSIONS

In patient with BAM, selecting a larger SAPIEN 3/Ultra THV increased the risk of conduction disturbances without any benefit on valve hemodynamics and clinical outcomes.

Coronary Obstruction From TAVR in Native Aortic Stenosis: Development and Validation of Multivariate Prediction Model

BACKGROUND

Transcatheter aortic valve replacement (TAVR)-related coronary artery obstruction prediction remains unsatisfactory despite high mortality and novel preventive therapies.

OBJECTIVES

This study sought to develop a predictive model for TAVR-related coronary obstruction in native aortic stenosis.

METHODS

Preprocedure computed tomography and fluoroscopy images of patients in whom TAVR caused coronary artery obstruction were collected. Central laboratories made measurements, which were compared with unobstructed patients from a single-center database. A multivariate model was developed and validated against a 1:1 propensity-matched subselection of the unobstructed cohort.

RESULTS

Sixty patients with angiographically confirmed coronary obstruction and 1,381 without obstruction were included. In-hospital death was higher in the obstruction cohort (26.7% vs 0.7%; P < 0.001). Annular area and perimeter, coronary height, sinus width, and sinotubular junction height and width were all significantly smaller in the obstructed cohort. Obstruction was most common on the left side (78.3%) and at the level of the coronary artery ostium (92.1%). Coronary artery height and sinus width, but not annulus area, were significant risk factors for obstruction by logistic regression but performed poorly in predicting obstruction. The new multivariate model (coronary obstruction IF cusp height > coronary height, AND virtual valve-to-coronary distance ≤4 mm OR culprit leaflet calcium volume >600 mm3) performed well, with an area under the curve of 0.93 (sensitivity = 0.93, specificity = 0.84) for the left coronary artery and 0.94 (sensitivity = 0.92, specificity = 0.96) for the right.

CONCLUSIONS

A novel computed tomography-based multivariate prediction model that can be implemented routinely in real-world practice predicted coronary artery obstruction from TAVR in native aortic stenosis.

Acetylsalicylic Acid (Aspirin) for Primary Prevention of Cardiovascular Events in Patients with Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Evidence regarding using acetylsalicylic acid (aspirin) for the prevention of cardiovascular (CV) events in patients with diabetes mellitus (DM) is inconsistent. Therefore, we performed a meta-analysis.

METHODS

A literature search was performed (January 1990 to February 2022) and publications meeting the inclusion criteria were reviewed, and a meta-analysis was performed using RevMan software. The primary outcome was a composite of CV death, non-fatal myocardial infarction (MI) and stroke. Secondary outcomes included all-cause mortality, individual components of the primary outcome and major bleeding.

RESULTS

The study cohort comprised 33525 diabetic patients from 9 randomized controlled trials. The primary outcome was significantly lower for aspirin vs. placebo (7.9 vs. 8.6, RR (risk ratio) 0.92, 95% CI (confidence interval) 0.86-0.99). All-cause mortality (10 vs. 10.3%, RR 0.97, 95% CI 0.90-1.03), CV death (4.4 vs. 4.7%, RR 0.93, 95% CI 0.83-1.04), non-fatal MI (4.6 vs. 4.8% RR 0.97, 95% CI 0.83- 1.15) and stroke (3.2 vs. 3.5%, RR 0.89, 95% CI 0.75-1.06) were similar between the two treatment groups. Major bleeding was significantly higher for aspirin compared with placebo (3.4 vs. 2.8%, RR 1.18, 95% CI 1.01-1.39).

CONCLUSION

Aspirin use in patients with DM reduces the composite endpoint of CV death, non-fatal MI and stroke compared with a placebo. However, routine use of aspirin for primary prevention among diabetic patients cannot be advised due to the increased risk of major bleeding. These findings suggest careful risk assessment of individual patients.

Transcatheter versus surgical aortic valve replacement in patients with morbid obesity: a multicentre propensity score-matched analysis

BACKGROUND

Morbidly obese (MO) patients are increasingly undergoing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) for severe aortic stenosis (AS). However, the best therapeutic strategy for these patients remains a matter for debate.

AIMS

Our aim was to compare the periprocedural and mid-term outcomes in MO patients undergoing TAVR versus SAVR.

METHODS

A multicentre retrospective study including consecutive MO patients (body mass index ≥40 kg/m², or ≥35 kg/m² with obesity-related comorbidities) from 18 centres undergoing either TAVR (n=860) or biological SAVR (n=696) for severe AS was performed. Propensity score matching resulted in 362 pairs.

RESULTS

After matching, periprocedural complications, including blood transfusion (14.1% versus 48.1%; p<0.001), stage 2-3 acute kidney injury (3.99% versus 10.1%; p=0.002), hospital-acquired pneumonia (1.7% versus 5.8%; p=0.005) and access site infection (1.5% versus 5.5%; p=0.013), were more common in the SAVR group, as was moderate to severe patient-prosthesis mismatch (PPM; 9.9% versus 39.4%; p<0.001). TAVR patients more frequently required permanent pacemaker implantation (14.4% versus 5.6%; p<0.001) and had higher rates of ≥moderate residual aortic regurgitation (3.3% versus 0%; p=0.001). SAVR was an independent predictor of moderate to severe PPM (hazard ratio [HR] 1.80, 95% confidence interval [CI]: 1.25-2.59; p=0.002), while TAVR was not. In-hospital mortality was not different between groups (3.9% for TAVR versus 6.1% for SAVR; p=0.171). Two-year outcomes (including all-cause and cardiovascular mortality, and readmissions) were similar in both groups (log-rank p>0.05 for all comparisons). Predictors of all-cause 2-year mortality differed between the groups; moderate to severe PPM was a predictor following SAVR (HR 1.78, 95% CI: 1.10-2.88; p=0.018) but not following TAVR (p=0.737).

CONCLUSIONS

SAVR and TAVR offer similar mid-term outcomes in MO patients with severe AS, however, TAVR offers some advantages in terms of periprocedural morbidity.

Sex Differences in Infective Endocarditis After Transcatheter Aortic Valve Replacement

BACKGROUND

Outcomes after transcatheter aortic valve replacement (TAVR) and infectious diseases may vary according to sex.

METHODS

This multicenter study aimed to determine the sex differences in clinical characteristics, management, and outcomes of infective endocarditis (IE) after TAVR. A total of 579 patients (217 women, 37.5%) were included retrospectively from the Infectious Endocarditis after TAVR International Registry who had the diagnosis of definite IE following TAVR.

RESULTS

Women were older (80±8 vs. 78±8 years, p=0.001) and exhibited a lower comorbidity burden. Clinical characteristics and microbiological profile were similar between men and women, but culture-negative IE was more frequent in women (9.9% vs. 4.3%, p=0.009). A high proportion of patients had a clinical indication for surgery (54.4% in both groups, p=0.99), but a surgical intervention was performed in a minority of patients (women: 15.2%, men: 20.3%, p=0.13). The mortality rate at index IE hospitalization was similar in both groups (women: 35.4%, men: 31.7%, p=0.373), but women exhibited a higher mortality rate at 2-year follow-up (63% vs. 52.1%, p=0.021). Female sex remained an independent risk factor for cumulative mortality in the multivariable analysis (HR_adj: 1.28, 95% CI: 1.02-1.62, p=0.035). After adjustment for in-hospital events, surgery was not associated with better outcomes in women.

CONCLUSIONS

There were no significant sex-related differences in the clinical characteristics and management of IE after TAVR. However, female sex was associated with increased two-years mortality risk.

Mitral Valve Infective Endocarditis after Trans-Catheter Aortic Valve Implantation

Scarce data exist on mitral valve (MV) infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). This multicenter study included a total of 579 patients with a diagnosis of definite IE after TAVI from the IE after TAVI International Registry and aimed to evaluate the incidence, characteristics, management, and outcomes of MV-IE after TAVI. A total of 86 patients (14.9%) had MV-IE. These patients were compared with 284 patients (49.1%) with involvement of the transcatheter heart valve (THV) only. Two factors were found to be associated with MV-IE: the use of self-expanding valves (adjusted odds ratio 2.49, 95% confidence interval [CI] 1.23 to 5.07, p = 0.012), and the presence of an aortic regurgitation ≥2 at discharge (adjusted odds ratio 3.33; 95% CI 1.43 to 7.73, p <0.01). There were no differences in IE timing and causative microorganisms between groups, but surgical management was significantly lower in patients with MV-IE (6.0%, vs 21.6% in patients with THV-IE, p = 0.001). All-cause mortality rates at 2-year follow-up were high and similar between patients with MV-IE (51.4%, 95% CI 39.8 to 64.1) and patients with THV-IE (51.5%, 95% CI 45.4 to 58.0) (log-rank p = 0.295). The factors independently associated with increased mortality risk in patients with MV-IE were the occurrence of heart failure (adjusted p <0.001) and septic shock (adjusted p <0.01) during the index hospitalization. One of 6 IE episodes after TAVI is localized on the MV. The implantation of a self-expanding THV and the presence of an aortic regurgitation ≥2 at discharge were associated with MV-IE. Patients with MV-IE were rarely operated on and had a poor prognosis at 2-year follow-up.

Very early infective endocarditis after transcatheter aortic valve replacement

BACKGROUND

Scarce data exist about early infective endocarditis (IE) after trans-catheter aortic valve replacement (TAVR).

OBJECTIVE

The objective was to evaluate the characteristics, management, and outcomes of very early (VE) IE (≤ 30 days) after TAVR.

METHODS

This multicenter study included a total of 579 patients from the Infectious Endocarditis after TAVR International Registry who had the diagnosis of definite IE following TAVR.

RESULTS

Ninety-one patients (15.7%) had VE-IE. Factors associated with VE-IE (vs. delayed IE (D-IE)) were female gender (p = 0.047), the use of self-expanding valves (p < 0.001), stroke (p = 0.019), and sepsis (p < 0.001) after TAVR. Staphylococcus aureus was the main pathogen among VE-IE patients (35.2% vs. 22.7% in the D-IE group, p = 0.012), and 31.2% of Staphylococcus aureus infections in the VE-IE group were methicillin-resistant (vs. 14.3% in the D-IE group, p = 0.001). The second-most common germ was enterococci (34.1% vs. 24.4% in D-IE cases, p = 0.05). VE-IE was associated with very high in-hospital (44%) and 1-year (54%) mortality rates. Acute renal failure following TAVR (p = 0.001) and the presence of a non-enterococci pathogen (p < 0.001) were associated with an increased risk of death.

CONCLUSION

A significant proportion of IE episodes following TAVR occurs within a few weeks following the procedure and are associated with dismal outcomes. Some baseline and TAVR procedural factors were associated with VE-IE, and Staphylococcus aureus and enterococci were the main causative pathogens. These results may help to select the more appropriate antibiotic prophylaxis in TAVR procedures and guide the initial antibiotic therapy in those cases with a clinical suspicion of IE. Very early infective endocarditis after trans-catheter aortic valve replacement. VE-IE indicates very early infective endocarditis (≤30 days post TAVR). D-IE indicates delayed infective endocarditis.

Surgical Treatment of Patients With Infective Endocarditis After Transcatheter Aortic Valve Implantation

BACKGROUND

The optimal treatment of patients developing infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is uncertain.

OBJECTIVES

The goal of this study was to investigate the clinical characteristics and outcomes of patients with TAVI-IE treated with cardiac surgery and antibiotics (IE-CS) compared with patients treated with antibiotics alone (IE-AB).

METHODS

Crude and inverse probability of treatment weighting analyses were applied for the treatment effect of cardiac surgery vs medical therapy on 1-year all-cause mortality in patients with definite TAVI-IE. The study used data from the Infectious Endocarditis after TAVI International Registry.

RESULTS

Among 584 patients, 111 patients (19%) were treated with IE-CS and 473 patients (81%) with IE-AB. Compared with IE-AB, IE-CS was not associated with a lower in-hospital mortality (HR_unadj: 0.85; 95% CI: 0.58-1.25) and 1-year all-cause mortality (HR_unadj: 0.88; 95% CI: 0.64-1.22) in the crude cohort. After adjusting for selection and immortal time bias, IE-CS compared with IE-AB was also not associated with lower mortality rates for in-hospital mortality (HR_adj: 0.92; 95% CI: 0.80-1.05) and 1-year all-cause mortality (HR_adj: 0.95; 95% CI: 0.84-1.07). Results remained similar when patients with and without TAVI prosthesis involvement were analyzed separately. Predictors for in-hospital and 1-year all-cause mortality included logistic EuroSCORE I, Staphylococcus aureus, acute renal failure, persistent bacteremia, and septic shock.

CONCLUSIONS

In this registry, the majority of patients with TAVI-IE were treated with antibiotics alone. Cardiac surgery was not associated with an improved all-cause in-hospital or 1-year mortality. The high mortality of patients with TAVI-IE was strongly linked to patients' characteristics, pathogen, and IE-related complications.

Canadian Multicenter Chronic Total Occlusion Registry: Ten-Year Follow-Up Results of Chronic Total Occlusion Revascularization

BACKGROUND

Chronic total occlusions (CTO) occur in nearly 20% of coronary angiograms. CTO revascularization, either by percutaneous coronary intervention (PCI) or coronary artery bypass grafting surgery (CABG), is infrequently performed, approximately one-third of cases. Long-term outcomes are unknown. The objective of the study was to determine whether early CTO revascularization of patients, either by CABG or PCI, was associated with improved clinical outcomes.

METHODS

One thousand six hundred twenty-four patients from the Canadian CTO registry were followed for at least 9.75 years. Revascularization was performed according to routine clinical practice. Patients were grouped according to CTO revascularization status (PCI or CABG of CTO vessel, CTO revasc) or no CTO revasc (medical therapy only, or PCI/CABG of non-CTO vessels only), within 3 months of initial angiogram. Patients were followed for mortality, revascularization procedures (PCI and CABG), and hospitalizations for acute coronary syndromes and heart failure.

RESULTS

Early CTO revasc was performed in 28.2% of patients (17.5% CABG, 10.7% PCI). The CTO revasc group was younger, with more males and generally fewer comorbidities. There was a significantly lower mortality probability at 10 years in the CTO revascularization group (22.7% [95% CI, 19.0%-26.9%]) compared with the no CTO revasc group (36.6% [95% CI, 33.8%-39.5%]). At 10 years, revascularization rates (14.0% versus 22.8%) and acute coronary syndrome hospitalization rates (10.0% versus 16.6%) were significantly lower in the CTO revasc group. Baseline-adjusted analysis showed CTO revasc was associated with significantly lower all-cause mortality (hazard ratio, 0.67 [95% CI, 0.54-0.84]). In both landmark and time varying analyses, association with lower mortality was particularly robust for CTO revascularization by CABG (hazard ratio 0.56 and 0.60, respectively), with a marginally significant result for PCI in the time varying analysis (hazard ratio 0.711 [95% CI, 0.51-0.998]).

CONCLUSIONS

Early CTO revascularization was associated with significantly lower all-cause mortality, revascularization rates, and hospitalization for acute coronary syndrome at 10 years, and mainly driven by outcomes in patients with CABG.

Perivalvular Extension of Infective Endocarditis after Transcatheter Aortic Valve Replacement

BACKGROUND

Infective endocarditis (IE) following transcatheter aortic valve replacement (TAVR) has been associated with a dismal prognosis. However, scarce data exist on IE perivalvular extension (PEE) in such patients.

METHODS

This multicenter study included a total of 579 patients who had the diagnosis of definite IE at a median of 171 (53-421) days following TAVR. PEE was defined as the presence of an intracardiac abscess, pseudoaneurysm or fistula confirmed by transthoracic/transophageal echocardiography, computed tomography or peri-operative findings.

RESULTS

A total of 105 patients (18.1%) were diagnosed with PEE (perivalvular abscess, pseudoaneurysm, fistula, or a combination in 87, 7, 7, and 4 patients, respectively). A history of chronic kidney disease (ORadj: 2.08; 95% CI: [1.27-3.41], p=0.003) and IE secondary to coagulase-negative staphylococci (ORadj: 2.71; 95% CI: [1.57-4.69], p<0.001) was associated with an increased risk of PEE. Surgery was performed at index IE episode in 34 patients (32.4%) with PEE (vs. 15.2% in patients without PEE, p<0.001). In-hospital and 2-year mortality rates among PEE-IE patients were 36.5% and 69.4%, respectively. Factors independently associated with an increased mortality risk were the occurrence of other complications (stroke post-TAVR, acute renal failure, septic shock) and the lack of surgery at index IE hospitalization (padj<0.05 for all).

CONCLUSION

PEE occurred in about one fifth of IE post-TAVR patients, with the presence of coagulase-negative staphylococci and chronic kidney disease determining an increased risk. Patients with PEE-IE exhibited very high early and late mortality rates, and surgery during IE hospitalization seemed to be associated with better outcomes.

Infective Endocarditis Caused by Staphylococcus Aureus after Transcatheter Aortic Valve Replacement

BACKGROUND

Staphylococcus aureus (S aureus) has been extensively studied as causative microorganism of surgical prosthetic-valve infective endocarditis (IE). However, scarce evidence exists on S aureus IE after transcatheter aortic valve replacement (TAVR).

METHODS

Data was obtained from the Infectious Endocarditis after TAVR International Registry including patients with definite IE following TAVR from 59 centers in 11 countries. Patients were divided into two groups according to microbiological etiology (non-S aureus-IE, non-SA-IE vs. S aureus-IE, SA-IE).

RESULTS

SA-IE was identified in 141 out of 573 (24.6%) patients, methicillin-sensitive S aureus in most cases (115/141, 81.6%). SEV were more common than BEV in patients with early SA-IE. Major bleeding and sepsis complicating TAVR, neurological symptoms or systemic embolism at admission and IE with cardiac device involvement other than the TAVR prosthesis were associated with SA-IE (p<0.05 for all). Among IE post-TAVR patients, the likelihood of SA-IE increased from 19% in the absence of those risk factors to 84.6% if ≥3 risk factors were present. In-hospital (47.8% vs. 26.9%, p<0.001) and 2-year mortality (71.5% vs. 49.6%, p<0.001) rates were higher among SA-IE (vs. non-SA-IE) patients. Surgery at the time of index SA-IE was associated with a lower mortality rate at follow-up (HR_adj: 0.46, 95% CI: 0.22-0.96, p=0.038).

CONCLUSIONS

SA-IE represented ∼ 25% of IE cases after TAVR and was associated with a very high in-hospital and late mortality. The presence of some features determined a higher likelihood of SA-IE and could help to orientate early antibiotic regimen selection. Surgery at index SA-IE was associated with improved outcomes, and its role should be evaluated in future studies.

Predictors of Left Ventricular Outflow Tract Obstruction After Transcatheter Mitral Valve Replacement in Severe Mitral Annular Calcification: An Analysis of the Transcatheter Mitral Valve Replacement in Mitral Annular Calcification Global Registry

[Figure: see text].

Impact of Morbid Obesity and Obesity Phenotype on Outcomes After Transcatheter Aortic Valve Replacement

Background There is a paucity of outcome data on patients who are morbidly obese (MO) undergoing transcatheter aortic valve replacement. We aimed to determine their periprocedural and midterm outcomes and investigate the impact of obesity phenotype. Methods and Results Consecutive patients who are MO (body mass index, ≥40 kg/m², or ≥35 kg/m² with obesity-related comorbidities; n=910) with severe aortic stenosis who underwent transcatheter aortic valve replacement in 18 tertiary hospitals were compared with a nonobese cohort (body mass index, 18.5-29.9 kg/m², n=2264). Propensity-score matching resulted in 770 pairs. Pre-transcatheter aortic valve replacement computed tomography scans were centrally analyzed to assess adipose tissue distribution; epicardial, abdominal visceral and subcutaneous fat. Major vascular complications were more common (6.6% versus 4.3%; P=0.043) and device success was less frequent (84.4% versus 88.1%; P=0.038) in the MO group. Freedom from all-cause and cardiovascular mortality were similar at 2 years (79.4 versus 80.6%, P=0.731; and 88.7 versus 87.4%, P=0.699; MO and nonobese, respectively). Multivariable analysis identified baseline glomerular filtration rate and nontransfemoral access as independent predictors of 2-year mortality in the MO group. An adverse MO phenotype with an abdominal visceral adipose tissue:subcutaneous adipose tissue ratio ≥1 (VAT:SAT) was associated with increased 2-year all-cause (hazard ratio [HR], 3.06; 95% CI, 1.20-7.77; P=0.019) and cardiovascular (hazard ratio, 4.11; 95% CI, 1.06-15.90; P=0.041) mortality, and readmissions (HR, 1.81; 95% CI, 1.07-3.07; P=0.027). After multivariable analysis, a (VAT:SAT) ratio ≥1 remained a strong predictor of 2-year mortality (hazard ratio, 2.78; P=0.035). Conclusions Transcatheter aortic valve replacement in patients who are MO has similar short- and midterm outcomes to nonobese patients, despite higher major vascular complications and lower device success. An abdominal VAT:SAT ratio ≥1 identifies an obesity phenotype at higher risk of adverse clinical outcomes.

Stroke Complicating Infective Endocarditis After Transcatheter Aortic Valve Replacement

BACKGROUND

Stroke is one of the most common and potentially disabling complications of infective endocarditis (IE). However, scarce data exist about stroke complicating IE after transcatheter aortic valve replacement (TAVR).

OBJECTIVES

The purpose of this study was to determine the incidence, risk factors, clinical characteristics, management, and outcomes of patients with definite IE after TAVR complicated by stroke during index IE hospitalization.

METHODS

Data from the Infectious Endocarditis after TAVR International Registry (including 569 patients who developed definite IE following TAVR from 59 centers in 11 countries) was analyzed. Patients were divided into two groups according to stroke occurrence during IE admission (stroke [S-IE] vs. no stroke [NS-IE]).

RESULTS

A total of 57 (10%) patients had a stroke during IE hospitalization, with no differences in causative microorganism between groups. S-IE patients exhibited higher rates of acute renal failure, systemic embolization, and persistent bacteremia (p < 0.05 for all). Previous stroke before IE, residual aortic regurgitation ≥moderate after TAVR, balloon-expandable valves, IE within 30 days after TAVR, and vegetation size >8 mm were associated with a higher risk of stroke during the index IE hospitalization (p < 0.05 for all). Stroke rate in patients with no risk factors was 3.1% and increased up to 60% in the presence of >3 risk factors. S-IE patients had higher rates of in-hospital mortality (54.4% vs. 28.7%; p < 0.001) and overall mortality at 1 year (66.3% vs. 45.6%; p < 0.001). Surgical treatment was not associated with improved outcomes in S-IE patients (in-hospital mortality: 46.2% in surgical vs. 58.1% in no surgical treatment; p = 0.47).

CONCLUSIONS

Stroke occurred in 1 of 10 patients with IE post-TAVR. A history of stroke, short time between TAVR and IE, vegetation size, valve prosthesis type, and residual aortic regurgitation determined an increased risk. The occurrence of stroke was associated with increased in-hospital and 1-year mortality rates, and surgical treatment failed to improve clinical outcomes.

Effect of Clopidogrel and Aspirin vs Aspirin Alone on Migraine Headaches After Transcatheter Atrial Septal Defect Closure: One-Year Results of the CANOA Randomized Clinical Trial

Importance

Adding clopidogrel to aspirin for 3 months after transcatheter atrial septal defect (ASD) closure results in a lower incidence of new-onset migraine attacks. However, the outcomes at 6- to 12-month follow-up (after clopidogrel cessation at 3 months) remain largely unknown.

Objective

To assess the incidence of migraine attacks at 6- and 12-month follow-up after transcatheter ASD closure.

Design, Setting, and Participants

This prespecified analysis of a randomized, double-blind clinical trial included patients with no prior history of migraine undergoing ASD closure from 6 university hospitals in Canada from December 2008 to November 2014. Patients were followed up at 3, 6, and 12 months, and a migraine headache questionnaire was administered at each time. Analysis began June 2019.

Interventions

Patients were randomized (1:1) to receive dual antiplatelet therapy (aspirin plus clopidogrel; n = 84) vs single antiplatelet therapy (aspirin plus placebo; n = 87) for 3 months following transcatheter ASD closure. After 3 months, only single antiplatelet therapy (aspirin) was pursued.

Main Outcomes and Measures

Incidence and severity of migraine attacks at 6- and 12-month follow-up.

Results

The mean (SD) age of the study population was 38 (12) years, with 106 women (62%). A total of 27 patients (15.8%) had new-onset migraine attacks within the 3 months following ASD closure (8 of 84 [9.5%] vs 19 of 87 [21.8%] in the initial clopidogrel and placebo groups, respectively; P = .03). After cessation of clopidogrel and aspirin monotherapy, the percentage of patients with migraine attacks decreased over time, with 8 (4.7%) and 4 patients (2.3%) continuing to have migraine attacks at 6 and 12 months, respectively (vs 3 months: P < .001). The severity of migraine attacks progressively decreased over time; no moderate or severe attacks occurred at 6 and 12 months (vs 3 months: P < .001). There were no differences between groups in the rate of migraine attacks at 6 months (initial clopidogrel group: 2 of 84 [2.4%]; initial placebo group: 6 of 87 [6.9%]; P = .28) and 12 months (initial clopidogrel group: 3 of 84 [3.6%]; initial placebo group: 1 of 87 [1.1%]; P = .36) after ASD closure. Only 2 patients (1.2%; 1 patient per group) presented with new-onset migraine attacks after 3 months.

Conclusions and Relevance

New-onset migraine attacks after ASD closure improved or resolved spontaneously within 6 to 12 months in most patients. No significant rebound effect was observed after clopidogrel cessation at 3 months. These results demonstrate a low rate of migraine events beyond 3 months following transcatheter ASD closure and support the early discontinuation of clopidogrel therapy if administered.

Trial Registration

ClinicalTrials.gov Identifier: NCT00799045.

Upstream anticoagulation for patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: Insights from the TOTAL trial

OBJECTIVES

To assess the relationship between preprocedural anticoagulation use and clinical and angiographic outcomes.

BACKGROUND

For patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), the optimal timing of anticoagulant administration remains uncertain.

METHODS

Patients enrolled in the TOTAL trial were stratified based on whether or not they had received any parenteral anticoagulant prior to randomization and PCI. Baseline and procedural characteristics were compared. For one-year clinical outcomes, Cox proportional modeling adjusted on a propensity score was used to analyze differences between groups. Angiographic endpoints were analyzed by logistic regression models adjusted for propensity scores.

RESULTS

In the trial, 10,064 patients were enrolled and underwent PCI. Preprocedural anticoagulation was used in 6,381 patients (63%).The most common anticoagulant was intravenous unfractionated heparin (5,188, 81%). Patients who received preprocedural anticoagulation had higher rates of TIMI-2-3 or TIMI-3 flow and lower grades of thrombus prior to PCI. Pretreatment with anticoagulation was associated with lower use of bailout thrombectomy, GP IIb/IIIa inhibitors, and intra-aortic balloon pump. After adjustment, preprocedural anticoagulation was associated with lower rates of CABG and minor bleeding at 1 year but there were no significant differences in death, stroke, recurrent MI, cardiogenic shock, or congestive heart failure.

CONCLUSIONS

Preprocedural anticoagulation is associated with improved flow and reduced thrombus in the IRA prior to PCI, less bailout thrombectomy during PCI but no difference in death, recurrent infarction, or heart failure at 1 year.

Characteristics and usefulness of unintended premature ventricular contraction during invasive assessment of aortic stenosis

BACKGROUND

Postextrasystolic potentiation (PESP)-associated augmentation in left ventricular-aorta pressure gradient (LVAoG) observed after incidental premature ventricular contraction (PVC) during resting echocardiography is similar to dobutamine stress echocardiography (DSE)-associated augmentation in LVAoG in patients with low-flow, low-gradient (LF-LG) aortic stenosis (AS). What is not known is whether a similar relationship exists when unintended PVC causes PESP during cardiac catheterization in patients with AS.

METHODS

We retrospectively reviewed all catheterizations performed for patients with at least moderate AS who had LVAoG assessment. Univariate and multivariate analyses were conducted to determine the predictors of pre- and post-PVC mean LVAoG ≥ 40 mmHg.

RESULTS

Between September 2015 to September 2017, of 140 individuals undergoing cardiac catheterization, 34 met study criteria. Mean pre-PVC gradient was 38.9 ± 22.8 mmHg. All patients exhibited PESP-associated augmentation of LVAoG by an average of 28 ± 12%. In multivariate analysis, the only significant predictor of post-PVC mean LVAoG ≥ 40 mmHg was preserved LV function (OR 6.81; 95% CI 1.41-32.82, p = 0.02). Inability to generate ≥ 40 mmHg of mean LVAoG post-PVC had 100% specificity for nonsevere AS in our observational cohort.

CONCLUSIONS

Unintended but interpretable PVCs occurred in one in four patients with AS undergoing cardiac catheterization with measurable hemodynamics. All of our patients with PVCs, regardless of underlying LVEF, exhibited PESP-associated augmentation of LVAoG. Our exploratory analysis suggests that inability to generate ≥40 mmHg of mean LVAoG post-PVC is highly specific for nonsevere AS.

Transcatheter aortic valve replacement in patients with paradoxical low-flow, low-gradient aortic stenosis: Incidence and predictors of treatment futility

BACKGROUND

Few and controversial data exist on the outcomes of patients with paradoxical low-flow, low-gradient aortic stenosis (PLFLG-AS) following transcatheter aortic valve replacement (TAVR). This study aims to better characterize clinical outcomes and predictors of treatment futility in PLFLG-AS patients undergoing TAVR.

METHODS

In this multicenter study, 318 patients with PLFLG-AS undergoing TAVR were categorized according to treatment futility, defined as all-cause mortality, poor functional status (NYHA class III-IV) or deterioration in functional class at 1-year follow-up. Clinical outcomes and the factors associated with treatment futility were assessed.

RESULTS

The mean age of the patients was 81.0 ± 8.3 years and 50.3% were women. At 1-year follow-up, 17.6% died and 12.9% had heart failure hospitalization. Residual impaired functional capacity (NYHA ≥ II) was present in 54.4% of patients who were alive at 1-year, and 9.8% remained in NYHA III/IV. The primary endpoint was observed in 103 (32.4%) patients, of which 54% died and 46% had a poor or worsening functional class. Factors independently associated with treatment futility were the presence of atrial fibrillation (AF) (OR:1.79, 95%CI, 1.04-3.10), chronic obstructive pulmonary disease (COPD) (OR:2.66, 95%CI, 1.50-4.74) and a lower SVi (OR per each decrease in 10 ml/m²:1.89, 95%CI, 1.06-3.45). The risk of treatment futility of patients with AF, COPD and a SVi < 30 ml/m² was 66.38% (95%CI, 54.29%-78.48%).

CONCLUSION

Close to one-third of patients with PLFLG-AS failed to derive a benefit from TAVR. The presence of AF, COPD and a low SVi were predictors of treatment futility. Being able to identify patients less likely to improve after the procedure may help to guide management and improve outcomes in patients with PLFLG-AS.

Outcomes From Transcatheter Aortic Valve Replacement in Patients With Low-Flow, Low-Gradient Aortic Stenosis and Left Ventricular Ejection Fraction Less Than 30%: A Substudy From the TOPAS-TAVI Registry

Importance

In low-flow, low-gradient aortic stenosis (LFLG AS), the severity of left ventricular dysfunction remains a key factor in the evaluation of aortic valve replacement.

Objective

To evaluate the clinical outcomes and changes in left ventricular ejection fraction (LVEF) after transcatheter aortic valve replacement (TAVR) in patients with LFLG AS and severe left ventricular dysfunction.

Design, Setting, and Participants

This multicenter registry is a substudy of the True or Pseudo-Severe Aortic Stenosis-TAVI registry that included patients with classic LFLG AS, defined as a mean transvalvular gradient less than 35 mm Hg, an effective orifice area less than 1.0 cm2, and an LVEF of 40% or less. Patients were divided in groups with very low (<30%) LVEF and low (30%-40%) LVEF. Dobutamine stress echocardiography (DSE) was performed before TAVR in a subset with very low LVEF, and presence of contractile reserve was defined as an increase of 20% or more in stroke volume. Clinical outcomes were assessed at 1 and 12 months and yearly thereafter, and echocardiography was performed at 1-year follow-up. Retrospective data were collected from 2007 to 2013 and prospective data from January 2013 to March 2018. Data were analyzed from March to October 2018.

Exposures

Transcatheter aortic valve replacement in patients with LFLG AS.

Main Outcomes and Measures

Changes in LVEF over time; periprocedural and late mortality.

Results

A total of 293 patients were included, including 128 (43.7%) with very low LVEF and 165 with low LVEF (56.3%). Their mean (SD) age was 80 (7) years, and most (214 [73.0%]) were men. The mean (SD) LVEF in the very low LVEF group was 22% (5%), compared with 37% (7%) in the low LVEF group (P < .001). There were no differences between groups in rates of periprocedural mortality and late mortality (median [interquartile range], 23 [6-38] months). Patients with very low LVEF displayed a greater increase in LVEF at the 1-year follow-up examination (mean absolute increase, 11.9% [95% CI, 8.8%-15.1%]), than the low LVEF group (3.6% [95% CI, 1.1%-6.1%]; P < .001). In 92 patients with very low LVEF who had preprocedural DSE, results showed a lack of contractile reserve in 45 (49%), but this had no effect on clinical outcomes or changes in LVEF over time.

Conclusions and Relevance

In patients with LFLG AS and severe left ventricular dysfunction, TAVR was associated with similar clinical outcomes as in counterparts with milder left ventricular dysfunction. The TAVR procedure was associated with a significant increase in LVEF, irrespective of contractile reserve. These results support TAVR for LFLG AS, irrespective of the severity of left ventricular dysfunction and DSE results.

Distal transradial access for cardiac catheterization: A systematic scoping review

OBJECTIVE

Systematically review the literature for cardiac catheterization and coronary angiography via distal transradial access (dTRA) and its outcomes.

BACKGROUND

dTRA, via anatomical snuffbox, may have several advantages over conventional transradial access (cTRA) for percutaneous cardiac procedures, including easier left-sided access for aorto-coronary grafts, future proximal radial artery preservation, and patient and operator comfort. However, its procedural characteristics and safety profile remain unclear.

METHODS

Ovid MEDLINE and EMBASE were searched from inception to September 2018. Two authors independently performed two-stage selection and data extraction. Reports assessing the dTRA approach for cardiac intervention in adults reporting any outcomes were eligible. Descriptive summary statistics were calculated from pooled data.

RESULTS

A total of 19 publications comprising 4,212 participants undergoing dTRA were included. Mean age was 63.8 years, and 23.0% were female. dTRA was primarily undertaken for assessment of stable coronary artery disease (87.6%), with 41.7% for diagnostic procedures and 46.9% undergoing percutaneous coronary intervention. The overall success rate for undertaking the dTRA approach was 95.4% (69-100%). Complications occurred in 2.4% of cases, of which the leading complications were bleeding/hematoma (18.2%). Complication rates did not significantly differ between dTRA and cTRA. The occurrence of radial artery occlusion in patients undergoing dTRA was low (1.7%).

CONCLUSIONS

Observational data demonstrate that dTRA is a safe and feasible method for percutaneous cardiac procedures, with high rates of procedural success and low rates of complication. As data comparing dTRA with cTRA remain limited, future high-quality randomized comparative studies are required.

Frailty and Outcomes After Myocardial Infarction: Insights From the CONCORDANCE Registry

Background

Little is known about the prognostic implications of frailty, a state of susceptibility to stressors and poor recovery to homeostasis in older people, after myocardial infarction (MI).

Methods and Results

We studied 3944 MI patients aged ≥65 years treated at 41 Australian hospitals from 2009 to 2016 in the CONCORDANCE (Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events) registry. Frailty index (FI) was determined using the health deficit accumulation method. All‐cause and cardiac‐specific mortality at 6 months were compared between frail (FI >0.25) and nonfrail (FI ≤0.25) patients. Among 1275 patients with ST‐segment–elevation MI (STEMI), 192 (15%) were frail, and among 2669 non‐STEMI (NSTEMI) patients, 902 (34%) were frail. Compared with nonfrail counterparts, frail STEMI patients received 30% less reperfusion therapy and 22% less revascularization during index hospitalization; frail NSTEMI patients received 30% less diagnostic angiography and 39% less revascularization. Unadjusted 6‐month all‐cause mortality (STEMI: 13% versus 3%; NSTEMI: 13% versus 4%) and cardiac‐specific mortality (STEMI: 6% versus 1.4%, NSTEMI: 3.2% versus 1.2%) were higher among frail patients. After adjustment for known prognosticators, FI was significantly associated with higher 6‐month all‐cause (STEMI: odds ratio: 1.74 per 0.1 FI [95% confidence interval, 1.37–2.22], P<0.001; NSTEMI: odds ratio: 1.62 per 0.1 FI [95% confidence interval, 1.40–1.87], P<0.001) but not cardiac‐specific mortality (STEMI: P=0.99; NSTEMI: P=0.93).

Conclusions

Frail patients receive lower rates of invasive cardiac care during MI hospitalization. Increased frailty was independently associated with increased postdischarge all‐cause mortality but not cardiac‐specific mortality. These findings inform identification of frailty during MI hospitalization as a potential opportunity to address competing risks for mortality in this high‐risk population.

Long-Term Outcomes After Transcatheter Aortic Valve-in-Valve Replacement

BACKGROUND

Data on long-term outcomes after valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) are scarce. The objective of this study was to determine the long-term clinical outcomes and structural valve degeneration (SVD) over time in patients undergoing ViV-TAVR.

METHODS AND RESULTS

Consecutive patients undergoing ViV-TAVR in 9 centers between 2009 and 2015 were included. Patients were followed yearly, and clinical and echocardiography data were collected prospectively. SVD was defined as subclinical (increase >10 mm Hg in mean transvalvular gradient+decrease >0.3 cm² in valve area or new-onset mild or moderate aortic regurgitation) and clinically relevant (increase >20 mm Hg in mean transvalvular gradient+decrease >0.6 cm² in valve area or new-onset moderate-to-severe aortic regurgitation). A total of 116 patients (mean age, 76±11 years; 64.7% male; mean Society of Thoracic Surgeons score, 8.0±5.1%) were included. Balloon- and self-expandable valves were used in 47.9% and 52.1% of patients, respectively, and 30-day mortality was 6.9%. At a median follow-up of 3 years (range, 2-7 years), 30 patients (25.9%) had died, 20 of them (17.2%) from cardiovascular causes. Average mean transvalvular gradients remained stable up to 5-year follow-up ( P=0.92), but clinically relevant SVD occurred in 3/99 patients (3.0%), and 15/99 patients (15.1%) had subclinical SVD. One patient with SVD had redo ViV-TAVR.

CONCLUSIONS

About one-fourth of ViV-TAVR recipients had died after a median follow-up of 3 years. Overall valve hemodynamics remained stable over time and clinically relevant SVD was infrequent, but 1 out of 10 patients exhibited some degree of SVD.

SGLT2 inhibitors and the changing landscape for treatment of diabetes

Type 2 diabetes mellitus has become an epidemic with rapidly increasing prevalence worldwide. While strict glycemic control has been shown to reduce the risk of diabetic microvascular complications, its role in preventing cardiovascular disease has been less clear. Indeed, anti-hyperglycemic therapies have historically been neutral for cardiovascular benefit. However, recent cardiovascular outcome trials utilizing sodium glucose transporter 2 inhibitors across a broad spectrum of cardiovascular disease patients have demonstrated significant mortality benefit resulting in a paradigm shift in the approach towards patients with heart disease and diabetes mellitus.

Information on Cardiovascular Disease in the Digital Era: Results From a Cross-Sectional Patient Survey

Public health strategies to reduce cardiovascular disease (CVD) rely on the effective dissemination of evidence-based information to at-risk populations. An improved understanding of the information sources patients use can facilitate content development and promote awareness of effective interventions for CVD prevention, monitoring, and management. We therefore sought to determine the contemporary patterns of CVD information source usage via a prospective, cross-sectional survey study of CVD information sources in a primary care centre in Ontario, Canada. Primary source(s) used for CVD information were defined as: traditional media (television or print media), Internet-based sources, or community resources (community agencies and health care providers). Of 4682 consecutively screened patients aged > 18 years 3189 (68%) participated in the survey. The mean age of the survey respondents was 37 ± 14 years and 54.4% were female. Traditional media (71%) were used more frequently than Internet-based sources (45%) or community health services (23%). Only 20% of respondents identified health care providers as the source of information for CVD. Compared with respondents aged ≥ 55 years, the adjusted odds of Internet-based source use were significantly higher among younger age groups, whereas the adjusted odds of print media and health services usage was lowest among ages 25-34 years. Although traditional print and electronic media remain the primary resource for CVD-related information, younger individuals increasingly rely on Internet-based sources. These findings have important implications for public health policy and resource allocation, highlighting the importance of maintaining traditional media presence in addition to the development of high-quality Internet-based sources of CVD information.

Treatment of Drug-Eluting Stent In-Stent Restenosis With Drug-Eluting Balloons: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the efficacy of drug-coated balloon (DEB) for the treatment of drug-eluting stent (DES) in-stent restenosis (ISR).

METHODS

A comprehensive literature search was performed. The primary outcome was the composite of death, myocardial infarction (MI), and target-lesion revascularization (TLR) at longest available follow-up (range, 12-36 months). Outcomes for DEB vs balloon angioplasty (BA) and DEB vs DES were analyzed separately using a random-effect Mantel-Haenszel model, as per an a priori protocol.

RESULTS

The study cohort comprised 1526 patients (746 DEB, 537 DES, 243 BA). DEB was associated with lower composite outcome compared with BA alone (19% vs 47%; risk ratio [RR], 0.31; 95% confidence interval [CI], 0.11-0.84; P=.02), driven primarily by lower TLR (17% vs 34%; RR, 0.66; 95% CI, 0.46-0.95; P=.03), with no difference in death or MI. There was no difference in the composite outcome between DEB and DES (20% vs 17%; RR, 1.2; 95% CI, 0.82-1.74; P=.35); DEB was associated with higher TLR (17.4% vs 11.3%; RR, 1.48; 95% CI, 1.08-2.03; P=.01), but lower all-cause mortality (2.2% vs 5.7%; RR, 0.43; 95% CI, 0.22-0.82; P=.01), with no difference in MI or stent thrombosis.

CONCLUSIONS

DEB was associated with a lower TLR rate than BA alone, but associated with a higher TLR rate than implantation of another DES. However, additional DES use was associated with an increase in mortality, a finding that requires further investigation.

Long-term pharmacodynamic effects of Ticagrelor versus Clopidogrel in fibrinolytic-treated STEMI patients undergoing early PCI

The long-term pharmacodynamic effects of Ticagrelor versus Clopidogrel in patients undergoing early percutaneous coronary intervention (PCI) after fibrinolytic therapy is unknown. From May 2014 to August 2016, 212 patients undergoing PCI within 24 h of Tenecteplase (TNK), Aspirin, and Clopidogrel for ST-elevated myocardial infarction (STEMI) were randomized at four Canadian sites to receive additional Clopidogrel or Ticagrelor initiated prior to PCI. The platelet reactivity units (PRU) were measured with the VerifyNow Assay before study drug administration (baseline), at 4 and 24 h post PCI, and follow-up appointment. A mixed-model analysis with time as the repeated measure and drug as the between-subjects factor was calculated using 2 separate 1 × 4 ANOVAs, with students t-tests used to compare drugs within each time point. Complete clinical follow-up data (median 115.0 days; IQR 80.3-168.8) was available in 50 patients (23.6%) randomized to either Clopidogrel (n = 23) or Ticagrelor (n = 27). Analyses revealed significant decreases in PRU from baseline to 4 h (261.4 vs. 71.7; Mdiff = - 189.7; p < 0.001) to 24 h (71.7 vs. 27.7; Mdiff = - 44.0; p < 0.001) to end of follow-up (27.7 vs.17.9; Mdiff = - 9.9. p = 0.016) for those randomized to Ticagrelor and significant decreases in PRU only from baseline to 4 h (271.3 vs. 200.8; Mdiff = - 70.5, p = < 0.001) in patients receiving Clopidogrel, and a significantly greater proportion of patients with adequate platelet inhibition (PRU < 208) on long-term follow-up (Clopidogrel, 82.6% vs. Ticagrelor, 100.0%; p = 0.038). Our results demonstrate that in patients undergoing PCI within 24 h of fibrinolysis for STEMI, Ticagrelor provides prolonged platelet inhibition compared with Clopidogrel.

Evolution of Procedural and Clinical Outcomes After Balloon-Expanding Transcatheter Aortic Valve Implantation In Canada (from the Early Canadian Experience and SOURCE XT Registries)

Transcatheter aortic valve implantation (TAVI) has evolved globally, yet its evolution and performance across the Canadian landscape have yet to be formally assessed. Patients captured within the early Canadian TAVI experience with a balloon-expanding valve (n = 339; 2005 to 2009) and those enrolled in the Canadian SOURCE XT registry (n = 415; 2012 to 2015) were systematically compared with respect to baseline clinical, echocardiographic, and procedural characteristics. Valve-related and clinical outcomes were compared across the 2 time periods according to standardized definitions. Notable baseline between-group differences were noted across time, with Society of Thoracic Surgeons Predicted Risk of Mortality score being lower in the SOURCE XT cohort compared with the earlier Canadian cohort (7.4 ± 6.6% vs 9.8 ± 6.4%, p <0.001). The SOURCE XT cohort underwent TAVI through the transfemoral approach more frequently than their earlier Canadian counterparts (75% vs 48%), at the expense of transapical access, with major access site vascular complications (2.7% vs 13%), and ≥mild residual aortic regurgitation (39% vs 69%) being significantly less frequent (p <0.001 for all). At 30-days, there were no significant differences in rates of stroke (1.9% vs 2.4%) or new pacemakers (5.8% vs 5.0%); however, 30-day and 1-year mortality rates were significantly lower in the SOURCE XT cohort (3.6% vs 10.4%; 13.0% vs 24.2%, respectively, p<0.001 for both). In conclusion, TAVIs evolution in Canada with a balloon-expanding valve coincided with more optimized patient selection and increasing use of transfemoral access, which along with increasing operator experience, contributed to improved procedural and longer term clinical outcomes.

Population-Based Study on Patterns of Cardiac Stress Testing After Percutaneous Coronary Intervention

BACKGROUND

The appropriate use criteria considers cardiac stress testing within 2 years after percutaneous coronary intervention (PCI) to be rarely appropriate, unless prompted by symptoms or change in clinical status. Little is known about the patterns of cardiac stress testing after PCI in the single-payer Canadian healthcare system, where mechanisms for reimbursement are different from the United States.

METHODS AND RESULTS

Frequency and timing of cardiac stress testing within 2 years of PCI performed between April 2004 and March 2013 in Ontario, Canada, was determined from linked provincial databases. Subsequent rates of coronary angiography and revascularization after stress testing were ascertained. Of the 112 691 patients with PCI, 67 442 (59.8%) underwent at least 1 stress test, with 38 267 (34.0%) undergoing repeat stress testing (ie, >1 stress test) within 2 years. Patients who underwent stress testing were younger, had less medical comorbidities, were more likely to reside in urban areas, and had higher incomes. Spikes in incidence of repeat stress testing were observed at 3 to 4 months, 6 to 7 months, and 12 to 13 months after the prior stress test. Of those tested, only 5.9% underwent subsequent coronary angiography, and only 3.1% underwent repeat revascularization within 60 days of stress testing.

CONCLUSIONS

More than half of all patients undergo cardiac stress testing within 2 years of PCI, with one third undergoing repeat stress tests. Only 1 of 30 tested patients underwent repeat revascularization. These findings reinforce the appropriate use criteria recommendations against routine stress testing after PCI. Further work is needed to aid with the selection of patients most likely to benefit from stress testing after PCI.

Bedside risk score for prediction of acute kidney injury after transcatheter aortic valve replacement

Background

Acute kidney injury (AKI) is a common post-transcatheter aortic valve replacement (TAVR) complication associated with a poor prognosis. We sought to create a risk calculator using information that would be available during the work-up period.

Methods

Data were obtained from a multicentre TAVR registry (n=1993) with cases from 1 January 2012 to 31 December 2015. We used logistic regression to create a risk calculator to predict AKI as defined by the Valve Academic Research Consortium Guidelines. We internally validated our risk calculator using bootstrapping, and evaluated model discrimination and calibration.

Results

A simple risk score was derived with six variables, including New York Heart Association functional classification class 4, non-femoral access site, valve-in-valve procedure, haemoglobin, creatinine clearance and weight in kilograms. The score was able to predict the absolute risk of AKI from 1% to 72%. The model showed good discrimination with c-statistic 0.713, with good agreement between predicted and observed AKI rates across quintiles of risk.

Conclusions

This is the first risk calculator to assess post-TAVR risk of AKI. We found that information known pre-procedurally can be used to predict AKI. This may allow for more informed decision-making as well as identifying high-risk patients.

Clinical Outcomes and Prognosis Markers of Patients With Liver Disease Undergoing Transcatheter Aortic Valve Replacement

Background—

Chronic liver disease is a known risk factor for perioperative morbidity and mortality in patients undergoing cardiac surgery. Very little data exist about such patients treated with transcatheter aortic valve replacement (TAVR). Our objective was to evaluate early and late clinical outcomes in a large cohort of patients with liver disease undergoing TAVR and to determine predictive factors of mortality among these patients.

Methods and Results—

This multicenter study collected data from 114 patients with chronic liver disease who underwent TAVR in 12 institutions. Perioperative and long-term outcomes were compared with a cohort of 1118 patients without liver disease after a propensity score–matching analysis (114 matched pairs). In-hospital mortality and vascular and bleeding complications were similar between matched groups. Acute kidney injury was more common in liver disease group (30.8% versus 13.5%; P =0.010). Although cardiovascular mortality was similar between groups (9.4% versus 6.5%; P =0.433) at 2-year follow-up, noncardiac mortality was higher in the liver group (26.4% versus 14.8%; P =0.034). Lower glomerular filtration rate (hazard ratio, 1.10, for each decrease of 5 mL/min in estimated glomerular filtration rate; 95% confidence interval, 1.03–1.17; P =0.005) and Child-Pugh class B or C (hazard ratio, 3.11; 95% confidence interval, 1.47–6.56; P =0.003) were the predictors of mortality in patients with chronic liver disease, with a mortality rate of 83.2% at 2-year follow-up in patients with both factors (estimated glomerular filtration rate <60 mL/min and Child-Pugh B or C).

Conclusions—

These findings suggested that TAVR is a feasible treatment for severe aortic stenosis in patients with early-stage liver disease or as bridge therapy before a curative treatment of the hepatic condition. Patients with Child-Pugh class B-C, especially in combination with renal impairment, had a very low survival rate, and TAVR should be carefully considered to avoid a futile treatment. These results may contribute to improve the clinical decision-making process and management in patients with liver disease.

Impact of anticoagulation therapy on valve haemodynamic deterioration following transcatheter aortic valve replacement

Objective

To evaluate the changes in transvalvular gradients and the incidence of valve haemodynamic deterioration (VHD) following transcatheter aortic valve replacement (TAVR), according to use of anticoagulation therapy.

Methods and results

This multicentre study included 2466 patients (46% men; mean age 81±7 years) who underwent TAVR with echocardiography performed at 12-month follow-up. Anticoagulation therapy was used in 707 patients (28.7%) following TAVR (AC group). A total of 663 patients received vitamin K antagonists, and 44 patients received direct oral anticoagulants. A propensity score matching analysis was performed to adjust for intergroup (AC vs non-AC post-TAVR) differences. A total of 622 patients per group were included in the propensity-matched analysis. VHD was defined as a ≥10 mm Hg increase in the mean transprosthetic gradient at follow-up (vs hospital discharge). The mean clinical follow-up was 29±18 months. The mean transvalvular gradient significantly increased at follow-up in the non-AC group within the global cohort (P=0.003), whereas it remained stable over time in the AC group (P=0.323). The incidence of VHD was significantly lower in the AC group (0.6%) compared with the non-AC group (3.7%, P<0.001), and these significant differences remained within the propensity-matched populations (0.6% vs 3.9% in the AC and non-AC groups, respectively, P<0.001). The occurrence of VHD did not associate with an increased risk of all-cause death (P=0.468), cardiovascular death (P=0.539) or stroke (P=0.170) at follow-up.

Conclusions

The lack of anticoagulation therapy post-TAVR was associated with significant increments in transvalvular gradients and a greater risk of VHD. VHD was subclinical in most cases and did not associate with major adverse clinical events. Future randomised trials are needed to determine if systematic anticoagulation therapy post-TAVR would reduce the incidence of VHD.