Impact of Chronic Kidney Disease on Outcomes in Transcatheter Aortic Valve Implantation

INTRODUCTION

Chronic kidney disease (CKD) is a significant comorbidity in aortic stenosis (AS) patients. We examined the impact of baseline CKD, postoperative acute kidney injury (AKI) and CKD progression on clinical outcomes in patients who underwent transcatheter aortic valve implantation (TAVI).

MATERIALS AND METHODS

Consecutive patients with severe AS who underwent TAVI were classified into CKD stages 1-2 (≥60 mL/min/1.72m²), 3 (30-59 mL/min/1.73m²) and 4-5 (<30 mL/min/1.73m² or dialysis) based on estimated glomerular filtration rate (eGFR). Primary outcome was mortality and secondary outcomes included 1-year echocardiographic data on aortic valve area (AVA), mean pressure gradient (MPG) and aortic regurgitation (AR).

RESULTS

A total of 216 patients were included. Higher eGFR was associated with lower overall mortality (adjusted hazards ratio [AHR] 0.981, 95% confidence interval [CI] 0.968-0.993, P = 0.002). CKD 4-5 were associated with significantly higher mortality from non-cardiovascular causes (P <0.05). Patients with CKD 3-5 had higher incidence of moderate AR than those with CKD 1-2 (P = 0.010); no difference in AVA and MPG was seen. AKI patients had higher mortality (P = 0.008), but the effect was attenuated on multivariate analysis (AHR 1.823, 95% CI 0.977-3.403, P = 0.059). Patients with CKD progression also had significantly higher mortality (AHR 2.969, 95% CI 1.373-6.420, P = 0.006).

CONCLUSION

CKD in severe AS patients undergoing TAVI portends significantly higher mortality and morbidity. Renal disease progression impacts negatively on outcomes and identifies a challenging subgroup of patients for optimal management.

Clinical Updates on the Diagnosis and Management of Chronic Thromboembolic Pulmonary Hypertension

INTRODUCTION

Chronic thromboembolic pulmonary hypertension (CTEPH) is a known sequela after acute pulmonary embolism (PE). It is a debilitating disease, and potentially fatal if left untreated. This review provides a clinically relevant overview of the disease and discusses the usefulness and limitations of the various investigational and treatment options.

METHODS

A PubMed search on articles relevant to PE, pulmonary hypertension, CTEPH, pulmonary endarterectomy, and balloon pulmonary angioplasty were performed. A total of 68 articles were found to be relevant and were reviewed.

RESULTS

CTEPH occurs as a result of non-resolution of thrombotic material, with subsequent fibrosis and scarring of the pulmonary arteries. Risk factors have been identified, but the underlying mechanisms have yet to be fully elucidated. The cardinal symptom of CTEPH is dyspnoea on exertion, but the diagnosis is often challenging due to lack of awareness. The ventilation/perfusion scan is recommended for screening for CTEPH, with other modalities (eg. dual energy computed tomography pulmonary angiography) also being utilised in expert centres. Conventional pulmonary angiography with right heart catheterisation is important in the final diagnosis of CTEPH.

CONCLUSION

Operability assessment by a multidisciplinary team is crucial for the management of CTEPH, as pulmonary endarterectomy (PEA) remains the guideline recommended treatment and has the best chance of cure. For inoperable patients or those with residual disease post-PEA, medical therapy or balloon pulmonary angioplasty are potential treatment options.

Gender Differences in Knowledge, Attitudes and Practices towards Cardiovascular Disease and its Treatment among Asian Patients

Introduction: Knowledge, attitudes and practices (KAP) impact on cardiac disease outcomes, with noted cultural and gender differences. In this Asian cohort, we aimed to analyse the KAP of patients towards cardiac diseases and pertinent factors that influence such behaviour, focusing on gender differences. Materials and Methods: A cross-sectional survey was performed among consecutive outpatients from a cardiac clinic over 2 months in 2014. Results: Of 1406 patients approached, 1000 (71.1%) responded (mean age 57.0 ± 12.7 years, 713 [71.3%] males). There was significant correlation between knowledge and attitude scores (r = 0.224, P <0.001), and knowledge and practice scores (r = 0.114, P <0.001). There was no correlation between attitude and practice scores. Multivariate predictors of higher knowledge scores included female sex, higher education, higher attitude and practice scores and prior coronary artery disease. Multivariate predictors of higher attitude scores included higher education, higher knowledge scores and non-Indian ethnicity. Multivariate predictors of higher practice scores included male sex, Indian ethnicity, older age, higher knowledge score and hypertension. Males had lower knowledge scores (85.8 ± 8.0% vs 88.0 ± 8.2%, P <0.001), lower attitude scores (91.4 ± 9.4% vs 93.2 ± 8.3%, P = 0.005) and higher practice scores (58.4 ± 18.7% vs 55.1 ± 19.3%, P = 0.013) than females. Conclusion: In our Asian cohort, knowledge of cardiovascular health plays a significant role in influencing attitudes and practices. There exists significant gender differences in KAP. Adopting gender-specific strategies for future public health campaigns could address the above gender differences.

The value of weighted views of the acromioclavicular joint. Results of a survey

One hundred twelve practicing members of the American Shoulder and Elbow Surgeons in the United States and Canada were surveyed regarding use of weighted views of the acromioclavicular joint. They were also asked about treatment for hypothetical patients seen in the emergency department or office with grade II or III acromioclavicular separations. One hundred five physicians (94%) responded to the survey. Eighty-five members (81 %) did not recommend obtaining weighted views in the emergency department. Sixty members (57%) did not use weighted views, and the majority commented that weighted views had no influence on their decision-making regarding treatment. Forty-five members (43%) used weighted views, but most did not use the results of this test to determine surgical intervention. Physicians recommending weighted views averaged 21 years of practice, compared with 16 years for those who did not obtain weighted views. Only nine physicians (9%) had changed treatment on the basis of weighted views. The patient's arm dominance, work, or athletic status did not influence most surgeons' decision to perform surgery when weighted views revealed a grade III separation. We found no correlation between obtaining weighted views and performing surgical reconstruction for patients with grade III acromioclavicular separations.