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Yocum D, Elashoff B, Verta P, Armock G, Yergler J. Patient reported outcomes do not correlate to functional knee recovery and range of motion in total knee arthroplasty. J Orthop 2023; 43:36-40. [PMID: 37564705 PMCID: PMC10409997 DOI: 10.1016/j.jor.2023.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 08/12/2023] Open
Abstract
Background Many total knee arthroplasty (TKA) patients exhibit continued pain and limited function following surgery. Determining TKA outcomes is typically reliant on post-operative evaluations and completing patient-reported outcomes (PROMs). Due to low compliance rates, it is essential to identify new strategies for monitoring patients. The purpose of this analysis was to assess the correlations between gait kinematics, PROMs, and knee range of motion (ROM). Methods 130 patients (75 female) received Persona IQ TKA (Zimmer Biomet, Warsaw, IN, USA) which includes a stem extension with embedded accelerometer and gyroscope. PROM scores were compared at baseline and 6 weeks post-TKA using a paired t-test. Gait kinematics were recorded daily via the Persona IQ stem extension. Pearson's correlation coefficients were derived between PROMs and average gait kinematics. Results Knee Injury and Osteoarthritis Outcome Score (KOOS Jr.) and Veterans RAND 12 (VR-12) physical scores improved following surgery (p ≤ 0.001, p = 0.003, respectively). Weak statistically significant correlations were found between PROMS and gait kinematics. Conclusion Weak correlations between PROMs and gait kinematics indicate patient perception of improvement and objectively measured functional status may not be interchangeable. Further, compliance with Persona IQ data reached 95.4-97.7% (depending on the parameter) at 6 weeks following surgery, a 20% higher compliance rate over PROMs. Daily functional measurements provide insight into the patient's progression and may be useful in detecting poor outcomes.
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Affiliation(s)
- Derek Yocum
- South Bend Orthopaedics, 53880 Carmichael Dr., South Bend, IN, 46635, USA
| | | | - Patrick Verta
- Canary Medical, 2710 Loker Ave W, Carlsbad, CA, 92010, USA
| | - Gary Armock
- South Bend Orthopaedics, 53880 Carmichael Dr., South Bend, IN, 46635, USA
| | - Jeffrey Yergler
- South Bend Orthopaedics, 53880 Carmichael Dr., South Bend, IN, 46635, USA
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2
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Barker CM, Cork DP, McCullough PA, Mehta HS, Van Houten J, Gunnarsson C, Ryan M, Irish W, Mollenkopf S, Verta P. Comparison of Survival in Patients With Clinically Significant Tricuspid Regurgitation With and Without Heart Failure (From the Optum Integrated File). Am J Cardiol 2021; 144:125-130. [PMID: 33385352 DOI: 10.1016/j.amjcard.2020.12.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 11/19/2022]
Abstract
This study aimed to quantify survival rates for patients with tricuspid regurgitation (TR) using real-world data. Several clinical conditions are associated with TR, including heart failure (HF), other valve disease (OVD), right-sided heart disease (RSHD), and others that impact mortality. Optum data from January 1, 2007, through December 31, 2018 included patients age ≥18 years with TR and 12 months of continuous health plan enrollment before TR. Exclusion criteria were end-stage renal disease or known/primary organ pathology. Cohorts were created hierarchically: (1) TR with HF; (2) TR with OVD (no HF); (3) TR with RSHD only (no OVD or HF); (4) TR only. Survival was estimated using a Cox hazard model with an interaction term for TR severity and adjusted for patient demographics and Elixhauser co-morbidities. A total of 33,686 met study inclusion (1) TR with HF (26.6%); (2) TR with OVD (36.7%); (3) TR with RSHD only (17.1%); (4) TR only (19.6%). TR patients (regardless of severity) with HF, OVD or RSHD had an increased risk of mortality compared with patients with TR alone. TR severity was also significantly associated (hazard ratio = 1.33; p = 0.0002) with an increased risk of all-cause mortality. In conclusion, TR severity is significantly associated with an increased risk of all-cause mortality, independent of associated conditions including HF, OVD, or RSHD. In patients with severe TR, the mortality risk is most pronounced for patients who had RSHD without HF or OVD before their TR diagnosis.
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Affiliation(s)
- Colin M Barker
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Peter A McCullough
- Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Hirsch S Mehta
- San Diego Cardiac Center, SHARP Healthcare, San Diego, California
| | | | | | | | - William Irish
- Brody School of Medicine, Greenville, North Carolina
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3
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Messika-Zeitoun D, Candolfi P, Dreyfus J, Burwash IG, Iung B, Philippon JF, Toussaint JM, Verta P, Feldman TE, Obadia JF, Vahanian A, Mesana T, Enriquez-Sarano M. Management and Outcome of Patients Admitted With Tricuspid Regurgitation in France. Can J Cardiol 2020; 37:1078-1085. [PMID: 33358751 DOI: 10.1016/j.cjca.2020.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Growing evidence shows a major outcome impact and undertreatment of tricuspid regurgitation (TR), but large and comprehensive contemporary reports of management and outcome at the nationwide level are lacking. METHODS We gathered all consecutive patients admitted with a diagnosis of likely functional TR in 2014-2015 in France from the Programme de Médicalisation des Systèmes d'Information national database and collected rate of surgery, in-hospital mortality, 1-year mortality, or heart failure (HF) readmission rates. RESULTS In 2014-2015, 17,676 consecutive patients (75 ± 14 years of age, 51% female) were admitted with a TR diagnosis. Charlson index was ≥ 2 in 56% of the population and 46% presented with HF. TR was associated with prior cardiac surgery, ischemic/dilated cardiomyopathy, or mitral regurgitation in 73% of patients. Only 10% of TR patients overall and 67% of those undergoing mitral valve surgery received a tricuspid valve intervention. Among the 13,654 (77%) conservatively managed patients, in-hospital mortality, 1-year mortality, and 1-year mortality or HF readmission rates were 5.1%, 17.8%, and 41%, respectively, overall, and 5.3%,17.2%, and 37%, respectively, among those with no underlying medical conditions (8-fold higher than predicted for age and gender). CONCLUSIONS This nationwide cohort of patients admitted with TR included elderly patients with frequent comorbidities/underlying cardiac diseases. In patients conservatively managed, mortality and morbidity were considerably high over a short time span. Despite this poor prognosis, only 10% of patients underwent a tricuspid valve intervention. These nationwide data showing a considerable risk and potential underuse of treatment highlight the critical need to develop strategies to improve the management and outcomes of TR patients.
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Affiliation(s)
| | | | | | - Ian G Burwash
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Bernard Iung
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; INSERM U1148, Bichat Hospital, Paris, France; Faculté de Médecine Paris-Diderot, University Paris VII, Paris, France
| | - Jean-François Philippon
- Département d'épidémiologie et de biostatistiques, Ecole des hautes études en santé publique, Paris, France
| | | | | | | | - Jean-Francois Obadia
- Hôpital Cardiovasculaire Louis Pradel, Chirurgie Cardio-Vasculaire et Transplantation Cardiaque, Hospices Civils de Lyon and Claude Bernard University, Lyon, France
| | - Alec Vahanian
- INSERM U1148, Bichat Hospital, Paris, France; Faculté de Médecine Paris-Diderot, University Paris VII, Paris, France
| | - Thierry Mesana
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Maurice Enriquez-Sarano
- Division of Cardiovascular Disease, Mayo Clinic and Mayo Medical School, Rochester, Minnesota, USA
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Barker CM, Cork DP, McCullough PA, Mehta HS, Houten JV, Gunnarsson C, Mollenkopf S, Verta P. Healthcare utilization in clinically significant tricuspid regurgitation patients with and without heart failure. J Comp Eff Res 2020; 10:29-37. [PMID: 33174767 DOI: 10.2217/cer-2020-0198] [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] [Indexed: 11/21/2022] Open
Abstract
Aim: This study evaluated how the presence of right-sided heart disease (RSHD), other valve disease (OVD) and heart failure (HF) impacts healthcare utilization in patients with tricuspid valve disease (tricuspid regurgitation [TR]). Materials & methods: Of the 33,686 patients with TR: 6618 (19.6%) had TR-only; 8952 (26.6%) had TR with HF; 12,367 (36.7%) had TR with OVD but no HF; and 5749 (17.1%) had TR with RSHD only. Results: The presence of RSHD, OVD or HF in patients with TR was independently associated with increased annualized hospitalizations, hospital days and costs relative to patients with TR alone. Conclusion: All three co-morbidities were associated with increased healthcare utilization, with HF showing the greatest impact across all measures.
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Affiliation(s)
- Colin M Barker
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Peter A McCullough
- Baylor University Medical Center, Baylor Heart & Vascular Institute, Baylor Jack & Jane Hamilton Heart & Vascular Hospital, Dallas, TX, USA
| | - Hirsch S Mehta
- San Diego Cardiac Center, SHARP Advanced Heart Failure, San Diego, CA, USA
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Janssen E, Murphy S, Mancilla M, Mollenkopf S, Verta P, Feldman T, Davidson C, Eleid M, Kipperman R, Smith R, Lim S, Zahr F, Gray W, Greenbaum A, Leon M, Kodali S. TCT CONNECT-494 Importance of Symptom and Activity Improvement for Patients With Tricuspid Regurgitation (TR). J Am Coll Cardiol 2020. [DOI: 10.1016/j.jacc.2020.09.523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Messika‐Zeitoun D, Candolfi P, Vahanian A, Chan V, Burwash IG, Philippon J, Toussaint J, Verta P, Feldman TE, Iung B, Glineur D, Mesana T, Enriquez‐Sarano M. Dismal Outcomes and High Societal Burden of Mitral Valve Regurgitation in France in the Recent Era: A Nationwide Perspective. J Am Heart Assoc 2020; 9:e016086. [PMID: 32696692 PMCID: PMC7792268 DOI: 10.1161/jaha.120.016086] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 06/15/2020] [Indexed: 01/24/2023]
Abstract
Background Although US recent data suggest that mitral regurgitation (MR) is severely undertreated and carries a poor outcome, population-based views on outcome and management are limited. We aimed to define the current treatment standards, clinical outcomes, and costs related to MR at the nationwide level. Methods and Results In total, 107 412 patients with MR were admitted in France in 2014 to 2015. Within 1 year, 8% were operated and 92% were conservatively managed and constituted our study population (68% primary MR and 32% secondary MR). The mean age was 77±15 years; most patients presented with comorbidities. In-hospital and 1-year mortality rates were 4.1% and 14.3%, respectively. Readmissions were common (63% at least once and 37% readmitted ≥2 times). Rates of 1-year mortality or all-cause readmission and 1-year mortality or heart failure readmission were 67% and 34%, respectively, and increased with age, Charlson index, heart failure at admission, and secondary MR etiology; however, the event rate remained notably high in the primary MR subset (64% and 28%, respectively). The mean costs of hospital admissions and of readmissions were 5345±6432 and 10 080±10 847 euros, respectively. Conclusions At the nationwide level, MR was a common reason for admission and affected an elderly population with frequent comorbidities. Less than 10% of patients underwent a valve intervention. All subsets of patients who were conservatively managed incurred high mortality and readmissions rates, and MR represented a major societal burden with an extrapolated annual cost of 350 to 550 million euros (390-615 million US dollars). New strategies to improve the management and outcomes of patients with both primary and secondary MR are critical and warranted.
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Affiliation(s)
| | | | - Alec Vahanian
- Department of CardiologyAssistance Publique – Hôpitaux de ParisBichat HospitalParisFrance
- INSERM U1148Bichat HospitalParisFrance
- University Paris VIIFaculté de Médecine Paris‐DiderotParisFrance
| | - Vincent Chan
- University of Ottawa Heart InstituteOttawaCanada
| | | | - Jean‐François Philippon
- Ecole des hautes études en santé publiqueDépartement d’épidémiologie et de biostatistiquesParisFrance
| | | | | | | | - Bernard Iung
- Department of CardiologyAssistance Publique – Hôpitaux de ParisBichat HospitalParisFrance
- INSERM U1148Bichat HospitalParisFrance
- University Paris VIIFaculté de Médecine Paris‐DiderotParisFrance
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Cork DP, McCullough PA, Mehta HS, Barker CM, Gunnarsson C, Ryan MP, Baker ER, Van Houten J, Mollenkopf S, Verta P. Impact of mitral regurgitation on cardiovascular hospitalization and death in newly diagnosed heart failure patients. ESC Heart Fail 2020; 7:1502-1509. [PMID: 32469120 PMCID: PMC7373926 DOI: 10.1002/ehf2.12653] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 01/15/2020] [Accepted: 02/04/2020] [Indexed: 01/14/2023] Open
Abstract
AIMS Heart failure (HF) carries a poor prognosis, and the impact of concomitant mitral regurgitation (MR) is not well understood. This analysis aimed to estimate the incremental effect of MR in patients newly diagnosed with HF. METHODS AND RESULTS Data from the IBM® MarketScan® Research Databases were analysed. Included patients had at least one inpatient or two outpatient HF claims. A 6 month post-period after HF index was used to capture MR diagnosis and severity. HF patients were separated into three cohorts: without MR (no MR), not clinically significant MR (nsMR), and significant MR (sMR). Time-to-event analyses were modelled to estimate the clinical burden of disease. The primary outcome was a composite endpoint of death or cardiovascular (CV)-related admission. Secondary outcomes were death and CV hospitalization alone. All models controlled for baseline demographics and co-morbidities. Patients with sMR were at significantly higher risk of either death or CV admission compared with patients with no MR [hazard ratio (HR) 1.26; 95% confidence interval (CI) 1.15-1.39]. When evaluating death alone, patients with sMR had significantly higher risk of death (HR 1.24; 95% CI 1.08-1.43) compared with patients with no MR. When evaluating CV admission alone, patients with MR were at higher risk of hospital admission vs. patients with no MR, and the magnitude was dependent upon the MR severity: sMR (HR 1.55; 95% CI 1.38-1.74) and nsMR (HR 1.23; 95% CI 1.08-1.40). CONCLUSIONS Evidence of MR in retrospective claims significantly increases the clinical burden of incident HF patients. Time to death and CV hospitalizations are increased when MR is clinically significant.
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Affiliation(s)
| | - Peter A McCullough
- Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Baylor University Medical Center, Dallas, TX, USA
| | - Hirsch S Mehta
- San Diego Cardiac Center, SHARP Memorial Hospital, San Diego, CA, USA
| | - Colin M Barker
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Michael P Ryan
- CTI Clinical Trial and Consulting Services, Covington, KY, USA
| | - Erin R Baker
- CTI Clinical Trial and Consulting Services, Covington, KY, USA
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8
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Messika‐Zeitoun D, Verta P, Gregson J, Pocock SJ, Boero I, Feldman TE, Abraham WT, Lindenfeld J, Bax J, Leon M, Enriquez‐Sarano M. Impact of tricuspid regurgitation on survival in patients with heart failure: a large electronic health record patient‐level database analysis. Eur J Heart Fail 2020; 22:1803-1813. [DOI: 10.1002/ejhf.1830] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/06/2020] [Indexed: 01/09/2023] Open
Affiliation(s)
| | | | - John Gregson
- Department of Medical Statistics London School of Hygiene and Tropical Medicine London UK
| | - Stuart J. Pocock
- Department of Medical Statistics London School of Hygiene and Tropical Medicine London UK
| | | | | | - William T. Abraham
- Department of Medicine, Physiology, and Cell Biology, Division of Cardiovascular Medicine, and the Davis Heart and Lung Research Institute Ohio State University Columbus OH USA
| | - JoAnn Lindenfeld
- Department of Heart Failure and Transplantation Vanderbilt Heart and Vascular Institute Nashville TN USA
| | - Jeroen Bax
- Department of Cardiology Leiden University Medical Centre Leiden The Netherlands
| | - Martin Leon
- Cardiovascular Research Foundation New York NY USA
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Cork DP, McCullough PA, Mehta HS, Barker CM, Van Houten J, Gunnarsson C, Ryan MP, Baker ER, Mollenkopf S, Verta P. The economic impact of clinically significant tricuspid regurgitation in a large, administrative claims database. J Med Econ 2020; 23:521-528. [PMID: 31952454 DOI: 10.1080/13696998.2020.1718681] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Indexed: 10/25/2022]
Abstract
Aim: This study aimed to quantify the healthcare burden of clinically significant tricuspid regurgitation (TR) in patients with and without heart failure (HF).Materials and Methods: Data were from the IBM MarketScan Research Databases from October 2011 to September 2016. Eligible patients met the following inclusion criteria: age ≥18 with a TR diagnosis, 12 months pre (baseline), and 6 months post (landmark) medical enrollment. The landmark period was used to categorize TR severity, defined as a record of pulmonary hypertension with ascites, lower extremity edema or hepatic insufficiency, or tricuspid valve surgery. Cohorts were defined based on TR etiology and severity: (1) no HF and no clinically significant TR; (2) HF with no clinically significant TR; (3) no HF with clinically significant TR; and (4) HF with clinically significant TR. Outcomes of interest were all-cause hospitalizations, hospital days, and expenditures. Multivariable models were fit for each of the annualized outcomes and adjusted for patient demographics, comorbidities, and other concomitant valve diseases.Results: There were 92,994 patients eligible for analysis. Patients with no HF and no clinically significant TR had the annualized healthcare burden of 0.20 all-cause hospitalizations (approximately one inpatient hospitalization every 5 years), 1.07 hospital days, and $17,478 in expenditures. The presence of clinically significant TR, alone or with HF, significantly increased healthcare utilization and expenditures. For patients with no HF with clinically significant TR, the annualized economic burden increased to 0.41 all-cause hospitalizations, 3.13 hospital days, and $29,985 in expenditures. For patients with HF and clinically significant TR, the annualized economic burden was even greater with 0.59 all-cause hospitalizations, 4.31 hospital days, and $42,255 in expenditures.Conclusion: The presence of clinically significant TR is associated with an increase in healthcare utilization and expenditures, irrespective of the presence of HF.
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Affiliation(s)
| | - Peter A McCullough
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, TX, USA
| | - Hirsch S Mehta
- San Diego Cardiac Center, SHARP Memorial Hospital, San Diego, CA, USA
| | - Colin M Barker
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - Michael P Ryan
- CTI Clinical Trial and Consulting Services, Covington, KY, USA
| | - Erin R Baker
- CTI Clinical Trial and Consulting Services, Covington, KY, USA
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Mehta H, McCullough P, Cork DP, Barker C, Van Houten J, Gunnarsson C, Mollenkopf S, Verta P. MEDICAL THERAPY IN PATIENTS WITH FUNCTIONAL MITRAL REGURGITATION: ARE PATIENTS OPTIMIZED IN THE REAL WORLD? J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31949-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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McCullough PA, Mehta HS, Barker CM, Cork DP, Gunnarsson C, Ryan MP, Baker ER, Van Houten J, Mollenkopf S, Verta P. The Economic Impact of Mitral Regurgitation on Patients With Medically Managed Heart Failure. Am J Cardiol 2019; 124:1226-1231. [PMID: 31470974 DOI: 10.1016/j.amjcard.2019.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 11/27/2022]
Abstract
The objective of this study was to quantify the financial healthcare burden of mitral regurgitation (MR) on medically managed heart failure (HF) patients. Data from the Truven Health MarketScan Commercial Claims and Medicare Supplemental Databases were analyzed. Included patients had a minimum of 1 inpatient or 2 outpatient claims for HF with a 6-month preperiod (baseline). A 6-month postperiod (landmark) after HF index was used to capture MR diagnosis and severity. Following the landmark period, patients had to have 12 months of continuous medical and prescription drug plan enrollment with at least 2 records of HF medication refills. A therapeutic intensity score was calculated based on HF medication usage. Medically managed HF patients were separated into 3 cohorts: without MR (no MR), insignificant MR (iMR), and significant MR (sMR). Healthcare utilization and all-cause expenditures were modeled to quantify the burden of MR. All models controlled for baseline demographics, co-morbid conditions, and HF therapeutic intensity. Medically managed incident HF patients with sMR had significantly more hospital days (1.91 vs 1.72 days; p = 0.0096) and annual expenditures ($23,988 vs $21,530; p < 0.0001) compared with no MR patients. No differences were identified when comparing iMR and no MR. When evaluating HF admissions, sMR patients had an estimated 50% greater HF admissions rate (0.036 vs 0.024; p < 0.0001) compared with no MR patients. Additionally, HF admits for iMR were 23% more than those with no MR (0.029 vs 0.024; p = 0.0064). In conclusion, evidence of MR in retrospective claims significantly increases the healthcare impact of medically managed HF patients. Both utilization and financial burden is more pronounced when MR is clinically significant.
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12
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Verta P, McCullough P, Barker C, Cork D, Mehta H, Gunnarsson C, Ryan M, Baker E, Mollenkopf S, Van Houten J. TCT-432 The Economic Impact of Clinically Significant Tricuspid Regurgitation. J Am Coll Cardiol 2019. [DOI: 10.1016/j.jacc.2019.08.525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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13
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Mehta HS, Houten JV, Verta P, Gunnarsson C, Mollenkopf S, Cork DP. Twelve-month healthcare utilization and expenditures in Medicare fee-for-service patients with clinically significant mitral regurgitation. J Comp Eff Res 2019; 8:1089-1098. [DOI: 10.2217/cer-2019-0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study sought to quantify the healthcare burden of Medicare patients with clinically significant mitral regurgitation (sMR). Materials & methods: Proxy definitions were used for sMR, including MR surgery, atrial fibrillation, pulmonary hypertension or >2 echocardiograms. Results: In this study, 11,173 patients had significant degenerative MR (sDMR); 25,402 had significant functional MR (sFMR); and 12,232 had significant uncharacterized MR (sUMR). Patients with sFMR (18,880) were more likely to be hospitalized and present to the emergency department compared with patients with sDMR (9,795) or sUMR (10,587). Annual healthcare expenditures for sMR patients were: US$29,328 for sFMR; US$17,112 for sUMR; and US$12,870 for sDMR. Conclusion: Novel therapeutic interventions merit further evaluation to reduce the substantial healthcare burden of sMR in the Medicare population.
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Affiliation(s)
- Hirsch S Mehta
- San Diego Cardiac Center, SHARP Memorial Hospital, San Diego, CA, USA
| | | | | | | | | | - David P Cork
- San Diego Cardiac Center, SHARP Memorial Hospital, San Diego, CA, USA
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Messika-Zeitoun D, Vahanian A, Verta P, Maisano F. Perspective on the treatment of functional mitral regurgitation using the Cardioband System. Eur Heart J 2019; 40:3196-3197. [DOI: 10.1093/eurheartj/ehz613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Alec Vahanian
- Department of Cardiology, Assistance Publique–Hôpitaux de Paris (AP-HP), Bichat Hospital, Paris, France
| | | | - Francesco Maisano
- University Heart Center, University Hospital Zürich, Zürich, Switzerland
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15
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McCullough PA, Mehta HS, Cork DP, Barker CM, Gunnarsson C, Mollenkopf S, Van Houten J, Verta P. The healthcare burden of disease progression in medicare patients with functional mitral regurgitation. J Med Econ 2019; 22:909-916. [PMID: 31104524 DOI: 10.1080/13696998.2019.1621325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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] [Indexed: 10/26/2022]
Abstract
Objective: This retrospective database analysis estimated the incremental effect that disease progression from non-clinically significant functional mitral regurgitation (nsFMR) to clinically significant FMR (sFMR) has on clinical outcomes and costs. Methods: Medicare Fee for Service beneficiaries with nsFMR were examined, defined as those with a heart failure diagnosis prior to MR. Patients were classified as ischemic if there was a history of: CAD, AMI, PCI, or CABG. The primary outcome was time to sFMR, defined as pulmonary hypertension, atrial fibrillation, mitral valve surgery, serial echocardiography, or death, using a Cox hazard regression model. Annualized hospitalizations, inpatient hospital days, and healthcare expenditures were also modeled. Results: Patients with IHD had higher risk (Hazard Ratio = 1.22 [1.14-1.30]) for disease progression compared to patients without. The progression cohort had significantly more annual inpatient hospitalizations (non-IHD = 1.32; IHD = 1.40) than the non-progression cohort (non-IHD = 0.36; IHD = 0.34), and significantly more annual inpatient hospital days (non-IHD = 13.07; IHD = 13.52) than the non-progression cohort (non-IHD = 2.29; with IHD = 2.08). The progression cohort had over 3.5-times higher costs vs the non-progression cohort, independent of IHD (non-IHD = $12,798 vs $46,784; IHD = $12,582 vs $49,348). Conclusion: Treating FMR patients earlier in their clinical trajectory may prevent disease progression and reduce high rates of healthcare utilization and expenditures.
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Affiliation(s)
- Peter A McCullough
- a Baylor Heart and Vascular Hospital, Baylor Heart and Vascular Institute, Baylor University Medical Center , Dallas , TX , USA
| | - Hirsch S Mehta
- b SHARP Memorial Hospital, San Diego Cardiac Center , San Diego , CA , USA
| | - David P Cork
- b SHARP Memorial Hospital, San Diego Cardiac Center , San Diego , CA , USA
| | - Colin M Barker
- c Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center , Nashville , TN , USA
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Psotka MA, Fiuzat M, Carson PE, Kao DP, Cerkvenik J, Schaber DE, Verta P, Kazmierski RT, Shinnar M, Stockbridge N, Unger EF, Zuckerman B, Butler J, Felker GM, Konstam MA, Lindenfeld J, Solomon SD, Teerlink JR, O'Connor CM, Abraham WT. Design of a "Lean" Case Report Form for Heart Failure Therapeutic Development. JACC Heart Fail 2019; 7:913-921. [PMID: 31401097 DOI: 10.1016/j.jchf.2019.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 01/11/2023]
Abstract
The development of treatments for heart failure (HF) is challenged by burdensome clinical trials. Reducing the need for extensive data collection and increasing opportunities for data compatibility between trials may improve efficiency and reduce resource burden. The Heart Failure Collaboratory (HFC) multi-stakeholder consortium sought to create a lean case report form (CRF) for use in HF clinical trials evaluating cardiac devices. The HFC convened patients, clinicians, clinical researchers, the U.S. Food and Drug Administration (FDA), payers, industry partners, and statisticians to create a consensus core CRF. Eight recent clinical trial CRFs for the treatment of HF from 6 industry partners were analyzed. All CRF elements were systematically reviewed. Those elements deemed critical for data collection in HF clinical trials were used to construct the final, harmonized CRF. The original CRFs included 176 distinct data items covering demographics, vital signs, physical examination, medical history, laboratory and imaging testing, device therapy, medications, functional and quality of life assessment, and outcome events. The resulting, minimally inclusive CRF device contains 75 baseline data items and 6 events, with separate modular additions that can be used depending on the additional detail required for a particular intervention. The consensus electronic form is now freely available for use in clinical trials. Creation of a core CRF is important to improve clinical trial efficiency in HF device development in the United States. This living document intends to reduce clinical trial administrative burden, increase evidence integrity, and improve comparability of clinical data between trials.
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Affiliation(s)
| | - Mona Fiuzat
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Peter E Carson
- Department of Cardiology, Washington Veterans Affairs Medical Center, Washington, DC
| | - David P Kao
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | | | | | | | | | - Meir Shinnar
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | | | - Ellis F Unger
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Bram Zuckerman
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi
| | - G Michael Felker
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Marvin A Konstam
- CardioVascular Center of Tufts Medical Center, Boston, Massachusetts
| | - JoAnn Lindenfeld
- Heart Failure and Transplantation Section, Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, California
| | | | - William T Abraham
- Departments of Medicine, Physiology, and Cell Biology, Division of Cardiovascular Medicine, Davis Heart and Lung Research Institute, Ohio State University, Columbus, Ohio
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Cork DP, Mehta H, Barker C, Verta P, Gunnarsson C, Ryan MP, Baker ER, Mollenkopf S, Van Houten J, McCullough P. THE ECONOMIC IMPACT OF MITRAL REGURGITATION ON MEDICALLY MANAGED INCIDENT HEART FAILURE PATIENTS. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31737-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Messika-Zeitoun D, Nickenig G, Latib A, Kuck KH, Baldus S, Schueler R, La Canna G, Agricola E, Kreidel F, Huntgeburth M, Zuber M, Verta P, Grayburn P, Vahanian A, Maisano F. Transcatheter mitral valve repair for functional mitral regurgitation using the Cardioband system: 1 year outcomes. Eur Heart J 2018; 40:466-472. [DOI: 10.1093/eurheartj/ehy424] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 07/03/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- David Messika-Zeitoun
- Department of Cardiology, Assistance Publique – Hôpitaux de Paris (AP-HP), Bichat Hospital, Paris, France
- INSERM U1148, Bichat Hospital, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Georg Nickenig
- Department of Cardiology, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Azeem Latib
- Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy
| | - Karl-Heinz Kuck
- Department of Cardiology, Asklepios Klinik St. Georg Hospital, Hamburg, Germany
| | - Stephan Baldus
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Robert Schueler
- Department of Cardiology, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Giovanni La Canna
- Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy
| | - Felix Kreidel
- Department of Cardiology, Asklepios Klinik St. Georg Hospital, Hamburg, Germany
| | - Michael Huntgeburth
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Michel Zuber
- Valve Clinic, University Heart Center, University Hospital Zürich, Zürich, Switzerland
| | | | - Paul Grayburn
- Department of Cardiology, Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Alec Vahanian
- Department of Cardiology, Assistance Publique – Hôpitaux de Paris (AP-HP), Bichat Hospital, Paris, France
- INSERM U1148, Bichat Hospital, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Francesco Maisano
- Valve Clinic, University Heart Center, University Hospital Zürich, Zürich, Switzerland
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Cork D, Kottenmeier E, Mollenkopf S, Gunnarsson C, Verta P, Mehta H. Abstract 112: 12-Month Healthcare Utilization and Expenditures in Medicare Advantage Patients With Mitral Regurgitation From the Medical Outcomes Research for Effectiveness and Economics Registry. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.11.suppl_1.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Mitral Regurgitation (MR) is associated with significant health care costs. This study aims to quantify the financial healthcare burden of Medicare Advantage (MA) patients across all MR patients from the Medical Outcomes Research for Effectiveness and Economics (MORE2) Registry.
Methods:
MA patients with a minimum of 1 inpatient or 2 outpatient claims for MR from 2008-2014 were reviewed. The index date was defined as a first inpatient claim or second outpatient claim. A 6-month pre-period (baseline) and 6-month post (washout) after index was used to define baseline etiology and severity. Three MR cohorts were defined: (1) Functional MR (FMR) was defined by the presence of heart failure during washout; (2) Degenerative MR (DMR) was defined by presence of chordal rupture or the absence of both heart failure and ischemia; and (3) Uncharacterized MR (UMR) was defined by patients otherwise not meeting the criteria for FMR or DMR. sMR was defined by a history of MR surgery, a diagnosis of atrial fibrillation or pulmonary hypertension, chordal rupture (DMR only), or record of two or more echocardiograms (per clinical guidelines) during washout. Demographics, comorbidities, healthcare utilization, and all-cause expenditures were summarized.
Results:
Of the 164,682 MA patients with MR who met inclusion criteria, 70,452 (43%) had FMR, 51,399 (31%) had DMR, and 42,831 (26%) had UMR. Average age (SD) was similar across cohorts: 74 (7.95), 72 (8.46), and 74 (7.45) years for FMR, DMR, and UMR, respectively. Proportion of severe patients and Charlson Comorbidity Index (CCI) indicates that the FMR cohort was “sicker” as compared to the others: FMR (41,325 [59% of 70,452]; CCI 4.56), DMR (16,169 [32% of 51,399]; CCI 1.67), and UMR (16,131 [38% of 42,831]; CCI 2.80). 2,079 patients (1.26% of total 164,682) received mitral valve surgery at index or washout with the highest occurrence in FMR patients (1,663), followed by UMR (327) and DMR (89). When comparing across the MR cohorts, the FMR cohort had higher rates of hospital admission, but length of stay was similar between cohorts (FMR [19.9%, 4-days], DMR [9.4%, 4-days], and UMR [13.6%, 3-days]). FMR had the highest annual all-cause healthcare costs (SD) ($22,569, [$59,876]), followed by UMR ($14,735 [$32,070]) and DMR ($10,485 [$23,934]).
Conclusions:
MR in the Medicare Advantage population is associated with a substantial health care burden, with FMR patients having the highest cost and utilization patterns. This population should, therefore, have access to innovative treatment options that relieve symptoms and reduce economic burden.
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Cork DP, Kottenmeier E, Verta P, Mollenkopf S, Green T, Mehta H. 12-MONTH PROGRESSION TO SEVERITY IN NON-CLINICALLY SIGNIFICANT FUNCTIONAL MITRAL REGURGITATION [NSFMR] PATIENTS WITH AND WITHOUT ISCHEMIA IN MEDICARE FEE-FOR-SERVICE PATIENTS. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31801-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abraham WT, Aggarwal S, Prabhu SD, Cecere R, Pamboukian SV, Bank AJ, Sun B, Pae WE, Hayward CS, McCarthy PM, Peters WS, Verta P, Slaughter MS. Ambulatory extra-aortic counterpulsation in patients with moderate to severe chronic heart failure. JACC Heart Fail 2015; 2:526-33. [PMID: 25301151 DOI: 10.1016/j.jchf.2014.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/14/2014] [Accepted: 04/15/2014] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The study sought to assess feasibility, safety, and potential efficacy of a novel implantable extra-aortic counterpulsation system (C-Pulse) in functional class III and ambulatory functional class IV heart failure (HF) patients. BACKGROUND 30% to 40% of HF patients suffer from poor functional status and quality of life (QoL) but are not in need of end-stage treatments. We undertook a multicenter single-arm study to assess the C-Pulse System in such patients. METHODS New York Heart Association (NYHA) functional class III or ambulatory functional class IV HF patients were eligible. Safety was assessed continuously through 12 months. Efficacy measurements included changes from baseline to 6 and 12 months in NYHA functional class, Minnesota Living with Heart Failure (MLWHF) and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, 6-min walk distance (6MWD), and exercise peak oxygen consumption (pVO2; 6 months only). RESULTS Twelve men and 8 women (56.7 ± 7 years, 34 to 71 years of age) with ischemic (n = 7) or nonischemic (n = 13) cardiomyopathy were implanted. There was no 30-day mortality and no neurological events or myocardial infarctions through 12 months. At 6 months, there were 3 deaths (1 device-related). One-year survival was 85%. At 6 months, C-Pulse produced improvements in NYHA functional class (3.1 ± 0.3 to 1.9 ± 0.7, p = 0.0005), MLWHF (63.6 ± 19.9 to 40.2 ± 23.2, p = 0.0005), and KCCQ scores (43.6 ± 21.1 to 65.6 ± 21.5, p = 0.0002), but not 6MWD (275.5 ± 64.0 to 296.4 ± 104.9, p = NS) or pVO2 (14.5 ± 3.6 to 13.1 ± 4.4, p = NS). Improvements continued at 12 months, with 6MWD change becoming statistically significant (336.5 ± 91.8, p = 0.0425). CONCLUSIONS Use of C-Pulse in this population is feasible, appears safe, and improves functional status and QoL. A prospective, multicenter, randomized controlled trial is underway. (C-Pulse IDE Feasability Study-A Heart Assist System; NCT00815880).
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Affiliation(s)
- William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio.
| | | | - Sumanth D Prabhu
- Division of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky
| | - Renzo Cecere
- Division of Cardiothoracic Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | | | - Alan J Bank
- United Heart and Vascular Clinic, St. Paul, Minnesota
| | - Benjamin Sun
- Minneapolis Heart Institute, Minneapolis, Minnesota
| | - Walter E Pae
- Division of Cardiothoracic Surgery, Pennsylvania State University, Hershey, Pennsylvania
| | | | - Patrick M McCarthy
- Division of Cardiothoracic Surgery, Northwestern University, Chicago, Illinois
| | | | | | - Mark S Slaughter
- Thoracic and Cardiovascular Surgery Division, University of Louisville, Louisville, Kentucky
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Abraham WT, Aggarwal S, Prabhu SD, Cecere R, Pamboukian SV, Bank AJ, Sun B, Pae WE, Hayward CS, McCarthy PM, Peters WS, Verta P, Slaughter MS. Reply: Upgrade ambulatory extra-aortic counterpulsation to full-support LVAD. JACC Heart Fail 2015; 3:343-4. [PMID: 25858795 DOI: 10.1016/j.jchf.2014.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 12/23/2014] [Indexed: 11/16/2022]
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Gray WA, Verta P. The impact of regulatory approval and Medicare coverage on outcomes of carotid stenting. Catheter Cardiovasc Interv 2013; 83:1158-66. [DOI: 10.1002/ccd.25283] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 11/02/2013] [Accepted: 11/05/2013] [Indexed: 11/07/2022]
Affiliation(s)
- William A. Gray
- Center for Interventional Vascular Therapy; Columbia University; New York New York
| | - Patrick Verta
- Clinical and medical affairs consultant; Orange California
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Stilp E, Baird C, Gray WA, Schneider PA, Simonton CA, Verta P, Mena-Hurtado CI. An evidence-based review of the impact of periprocedural myocardial infarction in carotid revascularization. Catheter Cardiovasc Interv 2013; 82:709-14. [PMID: 23765902 DOI: 10.1002/ccd.25056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 05/13/2013] [Accepted: 06/01/2013] [Indexed: 11/06/2022]
Abstract
Landmark trials comparing carotid endarterectomy (CEA) with medical therapy in patients with symptomatic or asymptomatic atherosclerotic stenosis of extracranial carotid arteries have favored carotid revascularization. Carotid artery stenting (CAS) has emerged as a minimally invasive option for revascularization of carotid artery stenoses and has been shown to be noninferior to CEA, regardless of patient symptom status. Debate continues regarding the importance of periprocedural myocardial infarction (PMI) as an endpoint in carotid revascularization trials. Recent randomized comparisons of CEA and CAS pre-specify PMI as an endpoint. Understanding PMI in CEA and CAS, the need for routine biomarker assessment surrounding both revascularization strategies, the effect of PMI on long-term morbidity and mortality, and the groups most at risk for PMI are of critical importance when choosing a carotid revascularization strategy for symptomatic and asymptomatic patients, since decreasing the incidence of PMI will make revascularization safer. This review examines available data regarding the relevance of PMI in vascular and carotid-specific outcomes.
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Affiliation(s)
- Erik Stilp
- Department of Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
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Jaff MR, Bates M, Sullivan T, Popma J, Gao X, Zaugg M, Verta P. Significant reduction in systolic blood pressure following renal artery stenting in patients with uncontrolled hypertension: results from the HERCULES trial. Catheter Cardiovasc Interv 2012; 80:343-50. [PMID: 22511402 DOI: 10.1002/ccd.24449] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 04/12/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Atherosclerotic renal artery stenosis (ARAS) causes hypertension (HTN) and threatens renal function (RF). The HERCULES Trial is a prospective, multicenter trial of renal stenting in patients with uncontrolled HTN and ARAS evaluating the safety and effectiveness of the RX Herculink Elite Renal Stent System (Abbott Vascular, Santa Clara, CA). METHODS A total of 202 patients (241 total lesions; 78 bilateral lesions) were enrolled between August 2007 and October 2009. The primary endpoint was 9-month binary restenosis determined by duplex ultrasound and/or angiography. Secondary endpoints included changes in blood pressure, antihypertensive medications, and RF between baseline and 9 months. Brain natriuretic peptide (BNP) was measured at baseline, 24 hr and 30 days postprocedure. RESULTS Mean systolic blood pressure (SBP) at baseline was 162 mm Hg. Nearly 70% of patients were receiving three or more antihypertensive medications (mean 3.4 medications per patient). Baseline serum creatinine was 1.2 ± 0.4 and 61.5% of subjects had estimated glomerular filtration <60. The restenosis rate was 10.5% at 9 months. The study device, procedure, and clinical success rates were 96.0, 99.2, and 98.0%, respectively. Freedom from major adverse events was 94.8%. At 9 months, the mean SBP significantly decreased (mean 145, paired t test P < 0.0001) after stenting with no change in medications. There was no correlation between SBP reduction and baseline BNP or BNP reduction. CONCLUSIONS HERCULES demonstrates clinically and statistically significant SBP reduction in patients with uncontrolled HTN, low in-stent restenosis, and complication rates. This study highlights that when appropriate patients are selected for renal artery stenting, impressive reductions in blood pressure may be anticipated. Although the magnitude of absolute reduction in SBP was related to baseline SBP, elevated baseline BNP levels were not predictive of reduction in SBP. Further studies for predictors of clinical response following percutaneous renal revascularization are needed.
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Affiliation(s)
- Michael R Jaff
- The Vascular Center, Massachusetts General Hospital, Boston, Massachusetts, USA.
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Matsumura JS, Gray W, Chaturvedi S, Yamanouchi D, Peng L, Verta P. Results of carotid artery stenting with distal embolic protection with improved systems: Protected Carotid Artery Stenting in Patients at High Risk for Carotid Endarterectomy (PROTECT) trial. J Vasc Surg 2012; 55:968-976.e5. [DOI: 10.1016/j.jvs.2011.10.120] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 09/21/2011] [Accepted: 10/17/2011] [Indexed: 10/14/2022]
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Lammer J, Bosiers M, Zeller T, Schillinger M, Boone E, Zaugg MJ, Verta P, Peng L, Gao X, Schwartz LB. First clinical trial of nitinol self-expanding everolimus-eluting stent implantation for peripheral arterial occlusive disease. J Vasc Surg 2011; 54:394-401. [DOI: 10.1016/j.jvs.2011.01.047] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 01/18/2011] [Accepted: 01/18/2011] [Indexed: 11/30/2022]
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Gray WA, Rosenfield KA, Jaff MR, Chaturvedi S, Peng L, Verta P. Influence of Site and Operator Characteristics on Carotid Artery Stent Outcomes. JACC Cardiovasc Interv 2011; 4:235-46. [DOI: 10.1016/j.jcin.2010.10.009] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Revised: 10/08/2010] [Accepted: 10/15/2010] [Indexed: 11/16/2022]
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Matsumura JS, Gray W, Chaturvedi S, Gao X, Cheng J, Verta P. CAPTURE 2 risk-adjusted stroke outcome benchmarks for carotid artery stenting with distal embolic protection. J Vasc Surg 2010; 52:576-83, 583.e1-583.e2. [DOI: 10.1016/j.jvs.2010.03.064] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 03/19/2010] [Accepted: 03/25/2010] [Indexed: 11/15/2022]
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Chaturvedi S, Matsumura JS, Gray W, Xu C, Verta P. Carotid artery stenting in octogenarians: periprocedural stroke risk predictor analysis from the multicenter Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events (CAPTURE 2) clinical trial. Stroke 2010; 41:757-64. [PMID: 20185789 DOI: 10.1161/strokeaha.109.569426] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events (CAPTURE 2) is an ongoing prospective, nonrandomized, multicenter clinical trial enrolling patients undergoing carotid artery stenting. The aim of this analysis is to identify risk predictors for periprocedural stroke in patients > or = 80 years old. METHODS Symptomatic patients with > or = 50% stenosis and asymptomatic patients with > or = 80% stenosis were enrolled. Patients' neurological status was assessed by an independent neurologist before as well as 24 hours and 30 days postprocedure. All strokes and suspected strokes were adjudicated by an independent committee. Logistic regression analysis was conducted to identify baseline demographic, lesion, procedural, or comorbidity parameters associated with outcomes in patients > or = 80 years of age. RESULTS As of January 10, 2009, 5297 patients underwent carotid artery stenting in 186 US CAPTURE 2 clinical centers and 1166 were > or = 80 years old. Octogenarians were similar to nonoctogenarians in terms of gender and symptomatic status but had fewer of certain risk factors (prior myocardial infarction or carotid endarterectomy, diabetes, smoking history) and more cardiac arrhythmia and renal insufficiency. For the overall cohort, death/stroke rate was 3.3%; stroke rate was 2.7% (0.8% major, 1.9% minor). Death/stroke rates were significantly higher for octogenarians than nonoctogenarians (4.5% versus 3.0%) as were stroke rates (3.8% versus 2.4%). Symptomatic status, embolic protection device dwell time, and lesion length were risk predictors for periprocedural stroke in octogenarians. CONCLUSIONS Patients > or = 80 years old have higher periprocedural event rates than nonoctogenarians. Age, symptomatic status, and lesion length should be considered when identifying appropriate candidates for the procedure.
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Affiliation(s)
- Seemant Chaturvedi
- Department of Neurology and Stroke Program, Wayne State University, Detroit, MI 48201, USA.
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Gray WA, Chaturvedi S, Verta P. Thirty-Day Outcomes for Carotid Artery Stenting in 6320 Patients From 2 Prospective, Multicenter, High-Surgical-Risk Registries. Circ Cardiovasc Interv 2009; 2:159-66. [PMID: 20031712 DOI: 10.1161/circinterventions.108.823013] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The American Heart Association has established guidelines for acceptable 30-day death and stroke rates for patients with severe carotid disease undergoing standard-risk carotid endarterectomy: <3% for asymptomatic lesions and <6% for symptomatic lesions. To date, carotid artery stenting has not demonstrated these outcomes in multicenter, prospective assessments of high-surgical-risk patients.
Methods and Results—
Data from 2 prospective, multicenter (280 US sites, 672 operators), postmarket surveillance studies in high-surgical-risk patients were analyzed: 2145 patients from the Emboshield and Xact Post Approval Carotid Stent Trial (EX) and 4175 patients from the Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events (C2). Both studies had pre- and postprocedure neurological evaluation and independent adjudication of neurological events. The overall 30-day death and stroke rate was 4.1% (95% CI, 3.3% to 5.0%) for EX and 3.4% (95% CI, 2.9% to 4.0%) for C2. In the population comparable with American Heart Association guidelines (<80 years), the combined 30-day death and stroke rate was 5.3% (95% CI, 3.6% to 7.4%) for symptomatic patients and 2.9% (95% CI, 2.4% to 3.4%) for asymptomatic patients, independent of unfavorable risk factors (anatomic or physiologic); in patients ≥80 years, this rate was 10.5% (95% CI, 6.3% to 16.0%) and 4.4% (95% CI, 3.3% to 5.7%), respectively. In subjects with anatomic features unfavorable for surgery, the 30-day death and stroke rates were 1.7% (95% CI, 0.0% to 8.9%) and 2.7% (95% CI, 1.3% to 4.9%) for symptomatic and asymptomatic cohorts, respectively, independent of age.
Conclusions—
Outcomes for carotid artery stenting in nonoctogenarian high-surgical-risk patients have improved since the pivotal Food and Drug Administration approval trials, and have achieved American Heart Association standards in both symptomatic and asymptomatic lesions.
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Affiliation(s)
- William A. Gray
- From the Center for Interventional Vascular Therapy (W.A.G.), Columbia University, New York, NY; Department of Neurology and Stroke Program (S.C.), Wayne State University, Detroit, Mich; and Abbott Vascular (P.V.), Endovascular Global Clinical Science, Santa Clara, Calif
| | - Seemant Chaturvedi
- From the Center for Interventional Vascular Therapy (W.A.G.), Columbia University, New York, NY; Department of Neurology and Stroke Program (S.C.), Wayne State University, Detroit, Mich; and Abbott Vascular (P.V.), Endovascular Global Clinical Science, Santa Clara, Calif
| | - Patrick Verta
- From the Center for Interventional Vascular Therapy (W.A.G.), Columbia University, New York, NY; Department of Neurology and Stroke Program (S.C.), Wayne State University, Detroit, Mich; and Abbott Vascular (P.V.), Endovascular Global Clinical Science, Santa Clara, Calif
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Fairman R, Gray WA, Scicli AP, Wilburn O, Verta P, Atkinson R, Yadav JS, Wholey M, Hopkins LN, Raabe R, Barnwell S, Green R. The CAPTURE Registry. Ann Surg 2007; 246:551-6; discussion 556-8. [PMID: 17893491 DOI: 10.1097/sla.0b013e3181567a39] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although previous reports of carotid stenting with embolic protection (CAS) have focused on clinical outcomes of death, stroke and myocardial infarction, there are few data available characterizing the strokes that occur during CAS, thus limiting understanding of potential mechanisms. This report examines the timing, location, severity, and type of strokes occurring with CAS in the Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Unanticipated or Rare Events (CAPTURE) study. METHODS The CAPTURE is a prospective, multicenter registry conducted to assess outcomes of CAS in the postapproval setting after device approval. A neurologist examined the patients before the procedure, at 24 hours and 30 days post-procedure. The primary end point was a composite of death, any stroke, or myocardial infarction within 30 days post-procedure. Strokes and all neurologic events suspected to be strokes were adjudicated by an independent Clinical Events Adjudication Committee using prespecified definitions. Source documents of all patients with strokes in this cohort were reviewed. RESULTS The 30-day results were available for 3500 patients. The 30-day primary end point event rate of death, stroke, and myocardial infarction was 6.3% (95% confidence interval: 5.5%-7.1%), and the rate of major stroke and death was 2.9% (95% confidence interval: 2.4 to 3.5). 4.8% of patients experienced a stroke (3.9% ipsilateral and 0.9% nonipsilateral, 2% major). A majority of stroke symptoms (57.7%) were noted post-procedure and pre-discharge, whereas 22.3% were noted during the procedure and 20% postdischarge. A similar timing distribution regardless of preprocedural symptomatic status was found.Overall, 41% (69 of 170) of all strokes were major. The incidence of major strokes was statistically significantly greater among symptomatic compared with asymptomatic patients, 4.6% (22 of 482) and 1.6% (47 of 3018), respectively. There were more minor than major strokes in asymptomatic patients (63% vs. 37%; P=0.10), whereas stroke severity was equally distributed in symptomatic patients. Among the ipsilateral strokes, almost half (44%) were major, whereas only one-quarter (26%) of the nonipsilateral strokes were major.Overall, 23% of the major strokes were hemorrhagic and 94% of these strokes were noted on the ipsilateral side. There was a tendency toward more major hemorrhagic strokes in symptomatic than in asymptomatic patients (36% vs. 17%; P=0.07). Fifty-four percent of the strokes post-procedure and pre-discharge were major, whereas 27% of the strokes postdischarge were major. Furthermore, 65% of hemorrhagic strokes were noted post-procedure and pre-discharge, 30% postdischarge. CONCLUSIONS Strokes related to CAS seem to become clinically apparent after the procedure but before discharge in the majority of events. Nevertheless, a significant minority of stroke symptoms follows discharge from the hospital, typically after 24 hours. Timing of stroke after CAS seems to be similar to timing of stroke after carotid endarterectomy. Moreover, nearly 1 in 5 strokes occur in a nonipsilateral distribution, with the exception of intraprocedural events, which were all ipsilateral to the stent being implanted. Hemorrhagic stroke seemed to be more prevalent in the strokes occurring in the post-procedure period. These descriptors of stroke severity, location, and timing may provide insight in to the mechanistic causes of adverse neurologic outcomes in CAS.
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Affiliation(s)
- Ronald Fairman
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Gray WA, Yadav JS, Verta P, Scicli A, Fairman R, Wholey M, Hopkins LN, Atkinson R, Raabe R, Barnwell S, Green R. The CAPTURE registry: results of carotid stenting with embolic protection in the post approval setting. Catheter Cardiovasc Interv 2007; 69:341-8. [PMID: 17171654 DOI: 10.1002/ccd.21050] [Citation(s) in RCA: 155] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pivotal study data examining carotid stenting with embolic protection as a less invasive alternative to endarterectomy for high surgical risk patients have been acquired under controlled conditions with highly selected physicians and hospitals. This report examines outcomes of carotid stenting post-approval after diffusion of this technology to a broader cross-section of physicians and hospitals. METHODS The Carotid Acculink/Accunet Post-Approval Trial to Uncover Unanticipated or Rare Events (CAPTURE) is a prospective, multi-center registry to assess two important aspects of the post-IDE experience: the safety of carotid stenting by physicians with varying levels of experience as a measure of the adequacy of physician training, and the identification of rare/unexpected device-related complications. The primary endpoint was a composite of death, any stroke, or myocardial infarction within 30 days post-procedure. RESULTS 3,500 patients were enrolled by 353 physicians at 144 sites. The 30-day primary endpoint event rate was 6.3% (95% CI: 5.5-7.1%) and did not differ among the three operator experience levels (5.3%, 6.0%, and 7.4%; P = 0.31) from most to least experienced, respectively. There were no differences in outcomes among physician specialties when adjusted for case mix. There were no unanticipated device related adverse events. CONCLUSIONS The results of the CAPTURE study compare favorably to those achieved in the predicate pivotal investigations, and suggest that the post-approval transfer of this new therapy to the community practice setting via carotid stent training programs is effective in preparing physicians with varying experience levels and specialty training backgrounds.
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Affiliation(s)
- William A Gray
- Center for Interventional Vascular Therapies, Columbia University, 161 Fort Washington Avenue 5th Floor, New York, NY 10032, USA.
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Gray WA, Yadav JS, Verta P, Scicli A, Fairman R, Wholey M, Hopkins LN, Atkinson R, Raabe R, Barnwell S, Green R. The CAPTURE registry: Predictors of outcomes in carotid artery stenting with embolic protection for high surgical risk patients in the early post-approval setting. Catheter Cardiovasc Interv 2007; 70:1025-33. [DOI: 10.1002/ccd.21359] [Citation(s) in RCA: 172] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Gray WA, Hopkins LN, Yadav S, Davis T, Wholey M, Atkinson R, Cremonesi A, Fairman R, Walker G, Verta P, Popma J, Virmani R, Cohen DJ. Protected carotid stenting in high-surgical-risk patients: The ARCHeR results. J Vasc Surg 2006; 44:258-68. [PMID: 16890850 DOI: 10.1016/j.jvs.2006.03.044] [Citation(s) in RCA: 335] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Accepted: 03/30/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Carotid endarterectomy is the standard of care for most patients with severe extracranial carotid bifurcation disease. However, its safety and efficacy in patients with significant surgical risk are unclear. The ARCHeR (ACCULINK for Revascularization of Carotids in High-Risk patients) trial was performed to determine whether carotid artery stenting with embolic protection is a safe and effective alternative to endarterectomy in high-surgical-risk patients. METHODS The ARCHeR trial is a series of three sequential, multicenter, nonrandomized, prospective studies. Forty-eight sites enrolled 581 high-surgical-risk patients between May 2000 and September 2003. Patients with severe carotid artery stenosis (angiographically defined, symptomatic > or =50%, or asymptomatic > or =80%) had an ACCULINK nitinol stent implanted. The ACCUNET filter embolic protection system was added to the procedure in the final 2 studies (422 patients). The primary efficacy end point was a composite of periprocedural (< or =30 days) death, stroke, and myocardial infarction, plus ipsilateral stroke between days 31 and 365. RESULTS The 30-day rate of death/stroke/myocardial infarction was 8.3% (95% confidence interval [CI], 6.2%-10.8%), and that of stroke/death was 6.9% (95% CI, 5.0%-9.3%). Most (23/32) strokes were minor, of which more than half (12/23) returned to baseline National Institutes of Health Stroke Scale scores within 30 days. The 30-day major/fatal stroke rate was 1.5% (95% CI, 0.7%-2.9%). No hemorrhagic strokes were observed in the study. Ipsilateral cerebrovascular accident occurred in 1.3% between 30 days and 1 year, thus giving a primary composite end point of 30-day death/stroke/myocardial infarction plus ipsilateral stroke at 1 year of 9.6% (95% CI, 7.2%-12.0%), which is below the 14.4% historical control comparator. Target lesion revascularization at 12 months and 2 years was 2.2% and 2.9%, respectively. CONCLUSIONS The ARCHeR results demonstrate that extracranial carotid artery stenting with embolic filter protection is not inferior to historical results of endarterectomy and suggest that carotid artery stenting is a safe, durable, and effective alternative in high-surgical-risk patients.
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Affiliation(s)
- William A Gray
- Columbia University Medical Center, New York, NY 10032, USA.
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Becquemin JP, Benhaiem-Sigaux N, Verta P, Leandri J, Loisance D. Arterial healing in rabbits following carbon dioxide laser endarterectomy. Ann Vasc Surg 1986; 1:55-9. [PMID: 3504690 DOI: 10.1016/s0890-5096(06)60703-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
CO2 laser open endarterectomy of small atherosclerotic vessels appears feasible. Under the conditions described, the endarterectomized arterial wall is not smooth but the thrombogenicity of the laser-treated surface is low, and the endothelial healing rapid. These advantages are to be weighed against the consequence of thermal injury, in particular, the late development of aneurysms. Before human clinical trials are made, further experimental studies are required to determine the best type of laser and optimal wave length to limit thermal injury.
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Affiliation(s)
- J P Becquemin
- Département d'Histocytologie, Hôpital Henri Mondor, Créteil, France
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