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Reindl M, Lechner I, Holzknecht M, Tiller C, Fink P, Oberhollenzer F, von der Emde S, Pamminger M, Troger F, Kremser C, Laßnig E, Danninger K, Binder RK, Ulmer H, Brenner C, Klug G, Bauer A, Metzler B, Mayr A, Reinstadler SJ. Cardiac Magnetic Resonance Imaging Versus Computed Tomography to Guide Transcatheter Aortic Valve Replacement: A Randomized, Open-Label, Noninferiority Trial. Circulation 2023; 148:1220-1230. [PMID: 37634187 DOI: 10.1161/circulationaha.123.066498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Computed tomography (CT) is recommended for guiding transcatheter aortic valve replacement (TAVR). However, a sizable proportion of TAVR candidates have chronic kidney disease, in whom the use of iodinated contrast media is a limitation. Cardiac magnetic resonance imaging (CMR) is a promising alternative, but randomized data comparing the effectiveness of CMR-guided versus CT-guided TAVR are lacking. METHODS An investigator-initiated, prospective, randomized, open-label, noninferiority trial was conducted at 2 Austrian heart centers. Patients evaluated for TAVR according to the inclusion criteria (severe symptomatic aortic stenosis) and exclusion criteria (contraindication to CMR, CT, or TAVR, a life expectancy <1 year, or chronic kidney disease level 4 or 5) were randomized (1:1) to undergo CMR or CT guiding. The primary outcome was defined according to the Valve Academic Research Consortium-2 definition of implantation success at discharge, including absence of procedural mortality, correct positioning of a single prosthetic valve, and proper prosthetic valve performance. Noninferiority was assessed using a hybrid modified intention-to-treat/per-protocol approach on the basis of an absolute risk difference margin of 9%. RESULTS Between September 11, 2017, and December 16, 2022, 380 candidates for TAVR were randomized to CMR-guided (191 patients) or CT-guided (189 patients) TAVR planning. Of these, 138 patients (72.3%) in the CMR-guided group and 129 patients (68.3%) in the CT-guided group eventually underwent TAVR (modified intention-to-treat cohort). Of these 267, 19 patients had protocol deviations, resulting in a per-protocol cohort of 248 patients (121 CMR-guided, 127 CT-guided). In the modified intention-to-treat cohort, implantation success was achieved in 129 patients (93.5%) in the CMR group and in 117 patients (90.7%) in the CT group (between-group difference, 2.8% [90% CI, -2.7% to 8.2%]; P<0.01 for noninferiority). In the per-protocol cohort (n=248), the between-group difference was 2.0% (90% CI, -3.8% to 7.8%; P<0.01 for noninferiority). CONCLUSIONS CMR-guided TAVR was noninferior to CT-guided TAVR in terms of device implantation success. CMR can therefore be considered as an alternative for TAVR planning. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03831087.
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Affiliation(s)
- Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Priscilla Fink
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Fritz Oberhollenzer
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Sebastian von der Emde
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Mathias Pamminger
- University Clinic of Radiology (M.P., F.T., C.K., A.M.), Medical University of Innsbruck, Austria
| | - Felix Troger
- University Clinic of Radiology (M.P., F.T., C.K., A.M.), Medical University of Innsbruck, Austria
| | - Christian Kremser
- University Clinic of Radiology (M.P., F.T., C.K., A.M.), Medical University of Innsbruck, Austria
| | - Elisabeth Laßnig
- Department of Cardiology and Intensive Care (E.L., K.D., R.K.B.), University Teaching Hospital Klinikum Wels-Grieskrichen, Wels, Austria
| | - Kathrin Danninger
- Department of Cardiology and Intensive Care (E.L., K.D., R.K.B.), University Teaching Hospital Klinikum Wels-Grieskrichen, Wels, Austria
| | - Ronald K Binder
- Department of Cardiology and Intensive Care (E.L., K.D., R.K.B.), University Teaching Hospital Klinikum Wels-Grieskrichen, Wels, Austria
| | - Hanno Ulmer
- Institute of Medical Statistics and Informatics (H.U.), Medical University of Innsbruck, Austria
| | - Christoph Brenner
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
| | - Agnes Mayr
- University Clinic of Radiology (M.P., F.T., C.K., A.M.), Medical University of Innsbruck, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology (M.R., I.L., M.H., C.T., P.F., F.O., S.v.d.E., C.B., G.K., A.B., B.M., S.J.R.), Medical University of Innsbruck, Austria
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Hasun M, Dörler J, Alber HF, Bauer A, Berger R, Christ G, Frick M, Hoppe UC, Huber K, Lamm G, Laßnig E, von Lewinski D, Rab A, Roithinger FX, Schuchlenz H, Siostrzonek P, Sipötz J, Stefenelli T, Steinwender C, Edlinger M, Weidinger F. Improved in-hospital outcome for radial access in a large contemporary cohort of primary percutaneous coronary intervention. Cardiovasc Diagn Ther 2021; 11:726-735. [PMID: 34295699 DOI: 10.21037/cdt-20-977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/28/2021] [Indexed: 11/06/2022]
Abstract
Background Randomised controlled trials have shown diverse results for radial access in patients undergoing primary percutaneous coronary intervention (PPCI). Moreover, it is questionable whether radial access improves outcome in patients with cardiogenic shock undergoing PPCI. We aimed to investigate the outcome according to access site in patients with or without cardiogenic shock, in daily clinical practice. Methods For the present analysis we included 9,980 patients undergoing PPCI between 2012 and 2018, registered in the multi-centre, nationwide registry on PCI for myocardial infarction (MI). In-hospital mortality, major adverse cardiovascular events (MACE), and net adverse clinical events (NACE) until discharge were compared between 4,498 patients with radial (45%) and 5,482 patients with femoral (55%) access. Results Radial compared to femoral access was associated with lower in-hospital mortality (3.5% vs. 7.7%; P<0.01). Multivariable logistic regression analysis confirmed reduced in-hospital mortality [odds ratio (OR) 0.57, 95% confidence interval (CI): 0.43 to 0.75]. Furthermore, MACE (OR 0.60, 95% CI: 0.47 to 0.78) as well as NACE (OR 0.59, 95% CI: 0.46 to 0.75) occurred less frequently in patients with radial access. Interaction analysis with cardiogenic shock showed an effect modification, resulting in lower mortality in PCI via radial access in patients without, but no difference in those with cardiogenic shock (OR 1.78, 95% CI: 1.07 to 2.96). Conclusions Radial access for patients with acute MI undergoing PPCI is associated with improved survival in a large contemporary cohort of daily practice. However, this beneficial effect is restricted to hemodynamically stable patients.
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Affiliation(s)
- Matthias Hasun
- 2nd Medical Department with Cardiology and Intensive Care Medicine, KA Rudolfstiftung, Vienna, Austria
| | - Jakob Dörler
- Department of Internal Medicine III, Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
| | - Hannes F Alber
- Department of Internal Medicine and Cardiology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Axel Bauer
- Department of Internal Medicine III, Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
| | - Rudolf Berger
- Department of Internal Medicine I, Cardiology and Nephrology, Krankenhaus der Barmherzigen Brüder Eisenstadt, Eisenstadt, Austria
| | - Günter Christ
- 5th Medical Department with Cardiology, Sozialmedizinisches Zentrum Süd - Kaiser Franz Josef Hospital, Vienna, Austria
| | - Matthias Frick
- 1st Department of Internal Medicine, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Uta C Hoppe
- Department of Internal Medicine II, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Kurt Huber
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Medicine, Wilhelminenspital, and Medical School, Sigmund Freud University, Vienna, Austria
| | - Gudrun Lamm
- Department of Internal Medicine III, Universitätsklinikum St. Pölten, St. Pölten, Austria
| | - Elisabeth Laßnig
- Department of Internal Medicine II, Cardiology and Intensive Care Medicine, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Dirk von Lewinski
- Department of Internal Medicine, Cardiology, Medical University Graz, Graz, Austria
| | - Anna Rab
- Department for Internal Medicine, Landeskrankenhaus Villach, Villach, Austria
| | - Franz X Roithinger
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Herwig Schuchlenz
- Department of Internal Medicine, Cardiology and Intensive Care Medicine, Landeskrankenhaus Graz West, Graz, Austria
| | - Peter Siostrzonek
- Department of Internal Medicine II - Cardiology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Johann Sipötz
- 2nd Department of Internal Medicine, Hanusch Hospital, Vienna, Austria
| | - Thomas Stefenelli
- Department of Internal Medicine I, Sozialmedizinisches Zentrum Ost - Donauspital, Vienna, Austria
| | - Clemens Steinwender
- Department of Internal Medicine I, Cardiology and Internal Intensive Medicine, Kepler Universitätsklinikum, Linz, Austria
| | - Michael Edlinger
- Department of Medical Statistics, Informatics, and Health Economics, Medical University Innsbruck, Innsbruck, Austria.,Department of Development and Regeneration, KU Leuven, Belgium
| | - Franz Weidinger
- 2nd Medical Department with Cardiology and Intensive Care Medicine, KA Rudolfstiftung, Vienna, Austria
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Reinstadler SJ, Reindl M, Lechner I, Holzknecht M, Tiller C, Roithinger FX, Frick M, Hoppe UC, Jirak P, Berger R, Delle-Karth G, Laßnig E, Klug G, Bauer A, Binder R, Metzler B. Effect of the COVID-19 Pandemic on Treatment Delays in Patients with ST-Segment Elevation Myocardial Infarction. J Clin Med 2020; 9:E2183. [PMID: 32664309 PMCID: PMC7408681 DOI: 10.3390/jcm9072183] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/17/2020] [Accepted: 07/02/2020] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 19 (COVID-19) and its associated restrictions could affect ischemic times in patients with ST-segment elevation myocardial infarction (STEMI). The objective of this study was to investigate the influence of the COVID-19 outbreak on ischemic times in consecutive all-comer STEMI patients. We included consecutive STEMI patients (n = 163, median age: 61 years, 27% women) who were referred to seven tertiary care hospitals across Austria for primary percutaneous coronary intervention between 24 February 2020 (calendar week 9) and 5 April 2020 (calendar week 14). The number of patients, total ischemic times and door-to-balloon times in temporal relation to COVID-19-related restrictions and infection rates were analyzed. While rates of STEMI admissions decreased (calendar week 9/10 (n = 69, 42%); calendar week 11/12 (n = 51, 31%); calendar week 13/14 (n = 43, 26%)), total ischemic times increased from 164 (interquartile range (IQR): 107-281) min (calendar week 9/10) to 237 (IQR: 141-560) min (calendar week 11/12) and to 275 (IQR: 170-590) min (calendar week 13/14) (p = 0.006). Door-to-balloon times were constant (p = 0.60). There was a significant difference in post-interventional Thrombolysis in myocardial infarction (TIMI) flow grade 3 in patients treated during calendar week 9/10 (97%), 11/12 (84%) and 13/14 (81%; p = 0.02). Rates of in-hospital death and re-infarction were similar between groups (p = 0.48). Results were comparable when dichotomizing data on 10 March and 16 March 2020, when official restrictions were executed. In this cohort of all-comer STEMI patients, we observed a 1.7-fold increase in ischemic time during the outbreak of COVID-19 in Austria. Patient-related factors likely explain most of this increase. Counteractive steps are needed to prevent further cardiac collateral damage during the ongoing COVID-19 pandemic.
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Affiliation(s)
- Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | | | - Matthias Frick
- Department of Cardiology, Academic Teaching Hospital Feldkirch, A-6800 Feldkirch, Austria
| | - Uta C Hoppe
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, A-5020 Salzburg, Austria
| | - Peter Jirak
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, A-5020 Salzburg, Austria
| | - Rudolf Berger
- Department of Cardiology and Internal Medicine, Hospital of St. John of God, A-7000 Eisenstadt, Austria
| | - Georg Delle-Karth
- Department of Cardiology, Vienna North Hospital, A-1210 Vienna, Austria
| | - Elisabeth Laßnig
- Department of Cardiology and Intensive Care, Klinikum Wels, A-4600 Wels, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Ronald Binder
- Department of Cardiology and Intensive Care, Klinikum Wels, A-4600 Wels, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
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