Impact of Pre-procedural Cerebrovascular Events on Clinical Outcomes After Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is an increasingly common treatment of symptomatic severe aortic valve stenosis (AS). Thus, it is reasonable to carefully investigate the impact of individual clinical factors on outcomes after TAVI.

OBJECTIVES

We aimed to investigate the impact of the previous cerebro-vascular events (CVEs) on outcomes of patients with severe AS undergoing TAVI.

METHODS

A total of 148 consecutive patients scheduled for TAVI were included and stratified as with and without a history of CVEs (stroke or transient ischemic attack). Frailty features were also assessed. The primary endpoint was a 12-month all-cause mortality.

RESULTS

Seventeen (11.5%) patients had a history of CVEs (the CVE group). At 30 days and 12 months, all-cause mortality was higher in the CVE group [30-day: 5 (29.4%) vs. 7 (5.3%); p=0.005; 12-month: 9 (52.9%) vs. 13 (9.9%); p=0.001]. Similarly, at the longest available follow-up, mortality was higher in the CVE group [10 (58.8%) vs. 23 (17.6%); p=0.001]. Similar rates of other complications after TAVI were noted, apart from inhospital acute kidney injury (AKI) grade 3 [3 (17.6%) vs. 5 (3.8%); p=0.049] and blood transfusions [9 (52.9%) vs. 35 (26.7%); p=0.026]. Results of 5MWT and Katz index assessment indicated a greater level of frailty in the CVE group. There were no differences in subsequent events including CVEs, bleeding, myocardial infarction, and new-onset of atrial fibrillation (AF) at 12 months between the groups.

CONCLUSION

We showed that a history of CVEs in patients with severe AS undergoing TAVI is associated with a higher long-term mortality.

The obesity paradox in patients undergoing transcatheter aortic valve implantation: is there any effect of body mass index on survival?

BACKGROUND

Conflicting results have been presented regarding the influence of body mass index (BMI) on outcomes among patients undergoing transcatheter aortic valve implantation (TAVI).

AIMS

To investigate the impact of BMI on clinical outcomes after TAVI.

METHODS

A total of 148 consecutive patients were categorised using baseline BMI according to the World Health Organization criteria. Baseline patient characteristics, frailty, and procedural and clinical outcomes including 30-day and 12-month all-cause mortality were compared between the BMI categories. Patients were followed up for a median of 460.0 (182.0-1042.0) days.

RESULTS

Obesity was diagnosed in 37 (25.2%) patients, 73 (49.7%) patients were overweight, and 37 (25.2%) had normal weight. Prevalence of lower frailty as assessed by five-metre walk test was confirmed in obese patients as compared to other groups. A trend towards a lower rate of in-hospital bleeding complications (18 [48.6%] vs. 21 [28.8%] vs. 9 [24.3%] in normal-weight, overweight, and obese patients, respectively; p = 0.06) and less frequent blood transfusions (18 [48.6%] vs. 17 [23.3%) vs. 8 [21.6%]; p = 0.016) was observed in overweight and obese groups. The rate of grade 3 acute kidney injury was lowest in the overweight group (4 [10.8%] vs. 1 [1.4%] vs. 3 [8.1%]; p = 0.05). There was no difference between the groups in terms of 30-day all-cause mortality (p = 0.15). However, 12-month all-cause mortality was lowest in obese pa-tients (12 [32.4%] vs. 10 [13.7%] vs. 2 [5.4%]; p = 0.004). Increase in BMI was independently associated with lower all-cause mortality (hazard ratio [95% confidence interval] per 1 kg/m2 increase: 0.91 [0.845-0.98]; p = 0.018).

CONCLUSIONS

Increased BMI was independently associated with survival benefit after TAVI.

Impact of chronic obstructive pulmonary disease and frailty on long-term outcomes and quality of life after transcatheter aortic valve implantation

BACKGROUND

Association between chronic obstructive pulmonary disease (COPD) and long-term mortality as well as the quality of life (QoL) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) is still unclear.

AIM

We sought to evaluate the impact of COPD on mortality and QoL of patients with AS undergoing TAVI.

METHODS

A total of 148 consecutive patients who underwent TAVI were enrolled and stratified by history of COPD.

RESULTS

Of 148 patients enrolled, 19 (12.8%) patients had a history of COPD. Patients with COPD were high-risk patients with higher prevalence of incomplete revascularization and frailty features. At follow-up of 15.8 months, all-cause mortality in patients with COPD was over four times higher than in patients without COPD [17.8% vs. 52.6%; p = 0.002-age/gender-adjusted OR (95% CI) 4.73 (1.69-13.24)]. On the other hand, in Cox regression model, the only independent predictors of all-cause death at long-term follow-up were: incomplete coronary revascularization [HR (95% CI) 5.45 (2.38-12.52); p = 0.001], estimated glomerular filtration rate [per 1 ml/min/1.73 m² increase: 0.96 (0.94-0.98); p = 0.001], and previous stroke/transient ischemic attack [2.86 (1.17-7.00); p = 0.021]. Also, the difference in mortality between patients with and without COPD was not significant after adjustment for the most of frailty indices. Importantly, groups were comparable in terms of QoL at baseline and 12 months.

CONCLUSION

COPD may pose an important factor affecting long-term outcomes of patients with severe AS undergoing TAVI. However, its effects might be partially related to coexisting comorbidities and frailty.

Impact of previous cardiac surgery with sternotomy on clinical outcomes and quality of life after transcatheter aortic valve implantation for severe aortic stenosis

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has evolved as an effective treatment in patients with symptomatic severe aortic stenosis (AS) and increased operative risk. Data on the influence of previous sternotomy on the risk of TAVI are limited.

AIM

We sought to investigate the effect of previous cardiac surgery with sternotomy on clinical outcomes and quality of life (QoL) after TAVI.

METHODS

The study included 148 consecutive patients with symptomatic severe AS, who underwent TAVI. Baseline charac-teristics, procedural and long-term clinical outcomes, and QoL assessment with the EQ-5D-3L questionnaire were compared between patients with and without previous sternotomy.

RESULTS

Patients with previous sternotomy (23.0% of the population) were younger and more often male, had higher rate of previous myocardial infarction (MI; 26 [22.8%] vs. 22 [64.7%], p = 0.001), and lower median left ventricular ejection frac-tion (60.0% [50.0-65.0] vs. 50.0% [42.0-60.0], p = 0.004). Periprocedural risk measured with the Logistic Euroscore and the Society of Thoracic Surgeons scale was comparable in both groups. There were no differences in 30-day and 12-month all-cause mortality between the groups with and without sternotomy (10 [8.8%] vs. 2 [5.9%], p = 0.7; odds ratio [OR] adjusted for age/sex/previous MI, 0.56, 95% confidence interval [CI] 0.10-3.29; for 12-month mortality adjusted OR 0.19, 95% CI 0.04-0.99). At the longest available follow-up, mortality was higher in patients without sternotomy (30 [26.3%] vs. 3 [8.8%], p = 0.03; adjusted OR 0.10, 95% CI 0.02-0.42). Similar rates of other complications after TAVI were noted. No differences in the EQ-5D-3L questionnaire at baseline and 12-month follow-up were confirmed.

CONCLUSIONS

TAVI seems to be a safe and effective technique for the treatment of severe AS in patients with previous cardiac surgery.

Incidence of Postoperative Delirium and Its Impact on Outcomes After Transcatheter Aortic Valve Implantation

There are limited data on the occurrence of postoperative delirium after transcatheter aortic valve implantation (TAVI). We sought to investigate the incidence of delirium after TAVI and its impact on clinical outcomes. A total of 148 consecutive patients who underwent TAVI were enrolled. Of these patients, 141 patients survived hospital stay. The incidence of delirium was assessed in these patients for the first 4 days after the index procedure. The patients were divided into 2 groups based on the presence of delirium. Baseline characteristics, procedural and long-term outcomes, and frailty and quality-of-life indexes were compared among the groups. Of the 141 patients analyzed, 29 patients developed delirium. The transapical access was more common in patients with delirium (51.7% vs 8.9%, p <0.001). A greater median contrast volume load in the delirium group was noted (75 vs 100 ml, p = 0.001). Significantly more patients with delirium were considered as frail before TAVI. Thirty-day and 12-month all-cause mortality rates were higher in the delirium group (0.0% vs 17.2%, p <0.001; and 3.6% vs 37.9%, p <0.001, respectively). Differences in mortality were significant even after adjustment for baseline characteristics. The quality of life at 12 months, assessed by the 3-level version of the EuroQol 5-dimensional questionnaire, was similar in both groups. Despite a relatively minimally invasive character of TAVI as compared with surgery, some patients experience delirium after TAVI. Importantly, the occurrence of delirium after TAVI may help to identify patients with worse short- and long-term outcomes.

Effect of diabetes mellitus on clinical outcomes and quality of life after transcatheter aortic valve implantation for severe aortic valve stenosis

BACKGROUND

Diabetes mellitus (DM) is considered a marker of poor prognosis after cardiac surgery. We sought to investigate the effect of DM on clinical outcomes and quality of life (QoL) after transcatheter aortic valve implantation (TAVI).

METHODS

A total of 148 consecutive patients with symptomatic, severe aortic stenosis who underwent TAVI were included. Baseline characteristics, procedural and long-term clinical outcomes, and the results of frailty and QoL assessment with EQ-5D-3L questionnaire were compared between patients with and without DM.

RESULTS

DM was present in 48 of 148 (32.4%) patients. No differences in periprocedural risk (Logistic Euroscore and Society of Thoracic Surgeons (STS) scale) between groups were observed. There were no differences in 30-day and 12-month all-cause mortality between groups [DM(-) vs. DM(+): 7 (7.0%) vs. 5 (10.4%), p = 0.53 and 12 (12.0%) vs. 10 (20.8%), p = 0.16, respectively]. No influence of DM presence on the risk of death was confirmed after adjustment for age and gender (for 30-day mortality, age/gender-adjusted OR 1.55, 95%CI 0.47-5.17; for 12-month mortality, age/gender-adjusted OR 2.05, 95%CI 0.79-5.32). Similarly, at the longest available follow-up, mortality did not differ between groups [14 (29.2%) vs. 19 (19.0%), p = 0.16; age/gender-adjusted OR 1.81, 95%CI 0.80-4.08]. Similar rates of other complications after TAVI were noted. Frailty measured with the 5-meter walking test was more frequently reported in patients with DM [11 (22.9%) vs. 10 (10.0%), p = 0.035]. No differences in QoL parameters at baseline and 12 months were noted.

CONCLUSIONS

Patients with DM undergoing TAVI demonstrated similar mortality, complication rates, and QoL outcomes compared to patients without DM.

Prognostic value of tricuspid regurgitation velocity and probability of pulmonary hypertension in patients undergoing transcatheter aortic valve implantation

Pulmonary hypertension (PH) is associated with adverse clinical outcomes after transcatheter aortic valve implantation (TAVI). We sought to investigate the effects of tricuspid regurgitant velocity (TRV) and echocardiographic probability of PH on clinical outcomes of patients undergoing TAVI. A total of 148 consecutive patients undergoing TAVI were included and stratified as having "low" (TRV ≤2.8 m/s), "intermediate" (TRV 2.9-3.4 m/s), and "high" (TRV >3.4 m/s) probability of PH. Only the patients from the "high" probability group were considered as patients with PH. All-cause mortality, complications rate and quality of life (QoL) were assessed according to VARC-2 recommendations. Of 148 patients, 65 (43.9%) were considered as patients with PH. These presented with higher NYHA class at baseline (p = 0.027) and had more frequently a history of previous stroke/transient ischemic attack (p = 0.019). A difference in all-cause mortality was noted at 12 months [PH (-) vs. PH (+): 9.6 vs. 21.5%; p = 0.043]; however, it was no longer significant after adjustment for age and gender (OR 2.39, 95% CI 0.91-6.24; p = 0.08). Unadjusted and adjusted rates of all-cause death at maximal follow-up of 13.3 (6.0-31.1) months were higher in patients with PH. However, the presence of PH was not identified as an independent predictor of all-cause mortality at follow-up. No difference in other complications rates and QoL were noted. The presence of TRV >3.4 m/s indicating "high" probability of PH may predict impaired clinical outcomes after TAVI. No impact of PH on QoL outcomes was confirmed.

Impact of frailty on mortality after transcatheter aortic valve implantation

BACKGROUND

We sought to investigate the relation between frailty indices and 12-month mortality after transcatheter aortic valve implantation (TAVI).

METHODS

We included 101 consecutive patients with severe aortic stenosis who have undergone TAVI. Frailty indices according to Valve Academic Research Consortium-2 recommendations (5-m walk test [5MWT] and hand grip strength) as well as other available scales of frailty (Katz index, Elderly Mobility Scale [EMS], Canadian Study of Health and Aging [CSHA] scale, Identification of Seniors at Risk [ISAR] scale) were assessed at baseline. The primary endpoint was 12-month all-cause mortality.

RESULTS

Twelve-month all-cause mortality was 17.8%. According to 5MWT, 17.8% were frail; hand grip test: 6.9%; Katz index: 17.8%; EMS: 7.9%; CSHA scale: 16.9%; and ISAR scale: 52.5%. Associations between frailty indices and 12-month all-cause mortality after TAVI were significant in Cox regression analysis (frail vs not frail, presented as hazard ratio[95%CI] adjusted for logistic EuroSCORE): for 5MWT, 72.38 (15.95-328.44); for EMS, 23.39 (6.89-79.34); for CSHA scale, 53.97 (14.67-198.53); for Katz index, 21.69 (6.89-68.25); for hand grip strength, 51.54 (12.98-204.74); and for ISAR scale, 15.94 (2.10-120.74). Similarly, such relationship was confirmed when 5MWT, EMS, and CSHA were used as continuous variables (hazard ratio [95%CI] adjusted for logistic EuroSCORE: for 5MWT per 1-second increase, 2.55 [1.94-3.37]; for EMS per 1-point decrease, 2.90 (1.99-4.21); and for CSHA per 1-point increase, 3.13 [2.17-4.53]).

CONCLUSIONS

Our study confirmed a strong predictive ability of most of the proposed frailty indices for 12-month mortality after TAVI. For patients scheduled for TAVI, the use of frailty indices, which are easy and quick to assess on clinical basis but with strong performance, for example, 5MWT, EMS, or hand grip test, may be advocated.

Long-Term Mortality and Quality of Life After Transcatheter Aortic Valve Insertion in Very Elderly Patients

BACKGROUND

We sought to compare long-term mortality and quality of life (QoL) in very elderly (≥80 years) patients undergoing transcatheter aortic valve implantation (TAVI) in comparison with younger patients (<80 years).

METHODS

A total of 101 patients treated with TAVI were divided into two groups according to age: <80 years (n = 42; 41.6%) and ≥80 years (n = 59; 58.4%). The baseline characteristics, including procedural outcomes as well as frailty and QoL assessment were compared between age groups.

RESULTS

Very elderly patients (≥80 years) were more frequently female, with a higher estimated risk of death based on STS score. Other baseline characteristics, including frailty indices, were comparable between groups. No difference in complication rate between age groups was observed. At 12 months, mortality rates were comparable for patients <80 years vs ≥80 years (16.7% vs 18.6%, respectively; P=.99). An improvement in QoL after 12 months as assessed by EQ-5D-3L was confirmed for both age groups, but with more pronounced beneficial effect of TAVI in younger patients.

CONCLUSION

The results of our single-center study showed that older age does not seem to be associated with impaired clinical outcomes after TAVI. However, benefit of TAVI in terms of long-term QoL improvement may be less apparent in very elderly patients.

Impact of Coronary Artery Disease Burden on 12-Month Mortality of Patients After Transcatheter Aortic Valve Implantation

OBJECTIVES

The aim of the study was to compare 12-month mortality rate of patients with and without complete coronary revascularization before transcatheter aortic valve implantation (TAVI).

BACKGROUND

There are limited data on the impact of coronary artery disease burden in patients with severe aortic stenosis undergoing TAVI.

METHODS

One hundred and one consecutive patients undergoing TAVI were enrolled. Of them 16 (15.8%) had an incomplete coronary revascularization. The primary endpoint was 12-month all-cause mortality.

RESULTS

Twelve-month all-cause mortality was higher in patients with incomplete coronary revascularization than in patients with complete coronary revascularization or without significant lesions (75.0% vs 7.1%; P < 0.001). Importantly, incomplete coronary revascularization was an independent predictor of higher mortality rate after 12 months (hazard ratio (HR) for incomplete coronary revascularization 10.86, 95% CI 3.72-31.73; P < 0.001; HR for a history of stroke/TIA 3.93, 95% confidence interval (CI) 1.39-11.07; P < 0.001; HR for blood transfusion 2.84 95% CI (1.06-7.63); P = 0.039). In 9 of 16 (56.3%) patients, incomplete revascularization was related to the presence of chronic total occlusions (CTO). Patients with CTO had an increased mortality rate after 12 months (55.6% vs 14.1%; P = 0.008) as compared to patients without the CTO.

CONCLUSIONS

Incomplete coronary revascularization and a history of stroke or TIA may be independent predictors of all-cause mortality in patients undergoing TAVI. However, further studies are recommended to confirm the results, especially in terms of the impact of CTO presence on long-term mortality after TAVI.