Global COVID-19 lockdown highlights humans as both threats and custodians of the environment

The global lockdown to mitigate COVID-19 pandemic health risks has altered human interactions with nature. Here, we report immediate impacts of changes in human activities on wildlife and environmental threats during the early lockdown months of 2020, based on 877 qualitative reports and 332 quantitative assessments from 89 different studies. Hundreds of reports of unusual species observations from around the world suggest that animals quickly responded to the reductions in human presence. However, negative effects of lockdown on conservation also emerged, as confinement resulted in some park officials being unable to perform conservation, restoration and enforcement tasks, resulting in local increases in illegal activities such as hunting. Overall, there is a complex mixture of positive and negative effects of the pandemic lockdown on nature, all of which have the potential to lead to cascading responses which in turn impact wildlife and nature conservation. While the net effect of the lockdown will need to be assessed over years as data becomes available and persistent effects emerge, immediate responses were detected across the world. Thus, initial qualitative and quantitative data arising from this serendipitous global quasi-experimental perturbation highlights the dual role that humans play in threatening and protecting species and ecosystems. Pathways to favorably tilt this delicate balance include reducing impacts and increasing conservation effectiveness.

Clinical and echocardiographic parameters associated with left ventricular recovery after TAVI

Introduction

The relationship between severe Aortic Stenosis (AS) and Left Ventricular (LV) dysfunction is well established. However, there is a paucity of data regarding LV functional recovery after TAVI.

Purpose

To study the clinical and echocardiographic parameters associated with LV functional recovery after TAVI.

Methods

We evaluated all patients who underwent TAVI between 2009–2020 in a tertiary medical center. We included patients with pre-procedural LV Ejection Fraction (LVEF) of 40% and below. All patients had baseline and in-hospital post-procedural echo, and their clinical characteristics were recorded in a designated TAVI registry. LV functional recovery was defined as an absolute increase in at least 10% in LVEF post-procedurally. No LV recovery was defined as an absolute change of up to ±10% in post-procedure LVEF, and LVEF deterioration was defined as an absolute decrease of more than 10% in post-procedural LVEF compared to baseline. Univariate analysis consisting clinical and echocardiographic factors for LV functional recovery was performed, followed by logistic regression adjusting for confounders.

Results

Out of 1,349 consecutive TAVI patients, 100 (7.4%) had LVEF of 40% or less. There were 69 (69%) men with a mean age of 82±8 years, and average BMI of 27±4 kg/m2. Prior coronary artery disease and hypertension were present in 34 (34%) and 21 (21%) of patients, respectively. Out of these 100 patients, 32 (32%) had achieved LV functional recovery and no patient had experienced LVEF deterioration (FIGURE). Mean Left Ventricular End Systolic Diameter (LVESD) was 3.79 and 4.43 in the LV functional recovery and no LV recovery groups, respectively. Mean aortic pressure gradient was higher among patients who had LV functional recovery compared to no LV recovery (45.9 vs. 31.5 mmHg, respectively). Multivariable analysis revealed parameters that were independently associated with LV functional recovery: Coronary artery disease – OR 5.29 (95% CI 1.59–20.44), LVESD – OR 0.87 (95% CI 0.8–0.95) for each 1 mm increment and mean aortic pressure gradient – OR 1.91 (95% CI 1.21–3.28) per each 10 mmHg increment.

Conclusion

In patients with severe AS and LV dysfunction undergoing TAVI, the presence of coronary artery disease, increased aortic pressure gradient and reduced LVESD were associated with early LV functional recovery.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Invasive- versus computed tomography-angiography for the evaluation of coronary artery disease among elderly patients undergoing transcatheter aortic valve implantation

Background

Coronary artery disease (CAD) is common among elderly patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Current guidelines recommend that percutaneous coronary intervention (PCI) of >70% proximal coronary lesions prior to TAVI. The aim of the current study was to evaluate two approaches to CAD diagnosis pre-TAVI.

Methods

We investigated 2,027 patients undergoing TAVI for severe aortic stenosis at two large centers with different pre-procedural CAD assessment: pre-TAVI computed tomography angiography (CTA) with selective invasive angiography according to CTA results (N=831) or mandatory invasive angiography (IA) (N=1,196). Peri-procedural complications were documented according to the VARC-2 criteria. Mortality rates were prospectively documented.

Results

Mean age of the study population was 86±4, of whom 55% were female. Patients in the IA group had significantly higher rates of pre-TAVI PCI compared to the CTA group (32% vs. 17%, p<0.001). Following TAVI, peri-procedural myocardial infarction (MI) rates were significantly lower among the IA group (0.1% vs. 1.5%, p=0.001). However, multivariate binary logistic regression analysis adjusted for age, gender and cardiovascular risk factors failed to show association between centers strategy and peri-procedural MI. Periprocedural bleeding rates were similar between the groups (3.5% vs. 2.9%, p=0.477). Thirty day, and 1-year mortality crude rates were similar between the groups (2.5% vs. 3.4%, p=0.25, and 10.2% vs. 12.0%, p=0.19). Multivariate cox regression adjusted for age, gender and cardiovascular risk factors did not find association between CAD clearance strategy and outcome.

Conclusions

In elderly patients, CTA driven approach for CAD evaluation pre-TAVI is a valid strategy with similar outcome as compared to invasive approach. CTA strategy significantly reduces invasive procedures rates without compromising patient's outcome.

Funding Acknowledgement

Type of funding source: None

Procedural and remote outcome among patients undergoing urgent trans-catheter aortic valve implantation

Background

Severe aortic stenosis patients suffer frequent heart failure decompensations events often requiring hospitalization. In extreme situations patients can be found with pulmonary edema and cardiogenic shock, unresponsive to medical treatment. Urgent trans-catheter aortic valve implantation (TAVI) has emerged as a treatment option for these high-risk patients.

Methods

We investigated 3,599 patients undergoing TAVI. Subjects were divided into two groups based on procedure urgency: patients who were electively hospitalized for the procedure (N=3,448) and those who had an urgent TAVI (N=151). Peri-procedural complications were documented according to the VARC-2 criteria. In hospital and 1-year mortality rates were prospectively documented.

Results

Mean age of the study population was 82±7, of whom 52% were female. Peri-procedural complication rates was significantly higher among patients with an urgent indication for TAVI compared to those having an elective procedure: valve malposition 3.6% vs. 0.6% (p-value=0.023), valve migration 3.2% vs. 0.9% (p-value=0.016), post procedure myocardial infarction 3.7% vs. 0.3% (p-value=0.004), and stage 3 acute kidney injury 2.6% vs. 0.5%, (p-value=0.02). Univariate analysis found that patients with urgent indication for TAVI had significantly higher in hospital mortality (5.8% vs. 1.4%, p-value<0.001). similarly, multivariate analysis adjusted for age, gender and cardio-vascular risk factors found that patients with urgent indication had more than 5-folds increased risk of in-hospital mortality (OR 5.94, 95% CI 2.28–15.43, p-value<0.001). Kaplan-Meier's survival analysis showed that patients undergoing urgent TAVI had higher 1-year mortality rates compared to patients undergoing an elective TAVI procedure (p-value log-rank<0.001, Figure). Multivariate analysis found they had more than 2-folds increased risk of mortality at 1-year (HR 2.27, 95% CI 1.53–3.38, p<0.001 compared to those having an elective procedure.

Conclusions

Patients with urgent indication for TAVI have higher in-hospital mortality and higher peri-procedural complication rates. However, if these patients survive the index hospitalization, they enjoy good prognosis.

Kaplan-Meier's survival analysis

Funding Acknowledgement

Type of funding source: None

P3857Validation of the cardiac damage classification and additional effects of albumin levels in a large cohort of patients undergoing transcatheter aortic valve replacement

Background

Risk stratification in patients undergoing transcatheter aortic valve replacement (TAVR) is limited and based on clinical judgment and surgical AVR scoring systems. Recently, extent of cardiac damage using an echocardiographic classification was purposed to assess prognosis of patients undergoing TAVR. We aimed to validate this new scoring system in a real-world cohort and to examine the addition of baseline albumin in risk assessment.

Methods

We investigated 2,608 patients undergoing TAVR. All subjects had an echocardiography test prior to TAVR. Subjects were divided into five groups based on their echocardiography findings: stage 0 – 758 (29%) patients, stage 1 – 769 (30%), stage 2 – 730 (28%), stage 3 – 320 (12%) and stage 4 (1.2%). Patients were further assessed by incorporating baseline albumin.

Results

Mean age of study population was 82±7 years. Kaplan-Meier's survival analysis showed that the cumulative probability of mortality was significantly higher among subjects with increased stage compared to the lower stages (p<0.001). Multivariable analysis demonstrated that each increase in stage was associated with significant increased risk of 1-year mortality (HR 1.37, 95% CI 1.23–1.54, p<0.001). Among patients at increased stage (3–4), incorporation of baseline of albumin identified the highest risk group, such that each 1 decrement in albumin levels was associated with more than triple increase in mortality among patients at stage 3 and 4 (HR 2.77, 95% CI 1.48–5.18, p-value=0.001)[figure]. When added to the scoring risk prediction model, albumin allowed more accurate risk stratification: continuous NRI analysis showed an overall improvement of 11% (95% CI 6%-16%) in the accuracy of classification.

KM according to stage and albumin

Conclusions

Cardiac damage classification is validated in a real-world cohort of patients undergoing TAVR. Incorporation of low baseline albumin may further identify patients at the highest risk group.