Temporal trends in outcomes following inpatient transcatheter aortic valve replacement

INTRODUCTION

Despite the growing adoption of transcatheter aortic valve replacement (TAVR), there remains a lack of clinical data evaluating procedural safety and discharge practices.

AIMS

This study aims to investigate if there have been improvements in postoperative clinical outcomes following TAVR.

METHODS

In this large-scale, retrospective cohort study, patients who underwent TAVR as an inpatient were identified from 2016 to 2020 using the National Readmissions Database. The primary outcome was temporal trends in the rates of discharge to home. Secondary endpoints assessed annual discharge survival rates, 30-day readmissions, length of stay, and periprocedural cardiac arrest rates.

RESULTS

Over the 5-year study period, a total of 31,621 inpatient TAVR procedures were identified. Of these, 79.2 % of patients were successfully discharged home with home disposition increasing year-over-year from 74.5 % in 2016 to 85.9 % in 2020 (Odds ratio: 2.01; 95 % CI 1.62-2.48, p < 0.001). The mean annual discharge survival rate was 97.7 % which did not change significantly over the 5-year study period (p = 0.551). From 2016 to 2020, 30-day readmissions decreased from 14.0 % to 10.3 %, respectively (p = 0.028). Perioperative cardiac arrest occurred in 1.8 % (n = 579) of cases with rates remaining unchanged during the study (p = 0.674).

CONCLUSION

Most TAVR patients are successfully discharged alive and home, with decreasing 30-day readmissions observed over recent years. This data suggests potential improvements in preoperative planning, procedural safety, and postoperative care. Despite perioperative cardiac arrest being associated with high mortality, it remains a relatively rare complication of TAVR.

Impact of left ventricular ejection fraction and aortic valve gradient on mortality following transcatheter aortic valve intervention

BACKGROUND

Data regarding the impact of reduced left ventricular ejection fraction (LVEF) and/or reduced mean aortic valve gradient (AVG) on outcomes following transcatheter aortic valve intervention (TAVI) have been conflicting. We sought to assess the relationship between LVEF, AVG, and 1-year mortality in patients undergoing TAVI.

METHODS

We prospectively evaluated 298 consecutive adults undergoing TAVI from 2015 to 2018 at an academic tertiary medical center. Patients were categorized according to LVEF and mean AVG. The primary outcome of interest was all-cause mortality at 1 year.

RESULTS

Of 298 adults undergoing TAVI, 66 (22.1%) had baseline LVEF ≤45% while 232 (77.9%) had baseline LVEF >45%; 173 (58.1%) had baseline AVG < 40mmHg while 125 (41.9%) had baseline AVG ≥ 40mmHg. Rates of 1-year all-cause mortality were significantly higher in patients with LVEF ≤45% (28.8% vs 12.1%, p = 0.001) and those with AVG < 40mmHg (19.7% vs 10.4%, p = 0.031) compared to those with LVEF >45% and AVG ≥ 40mmHg respectively. In multivariable analysis, higher AVG (per mmHg) (OR 0.97, 95% CI 0.94-0.99, p = 0.026) was noted to be independently associated with lower rates of 1-year mortality, while LVEF was not (OR 0.98, 95% CI 0.96-1.01).

CONCLUSIONS

In this prospective, contemporary registry of adults undergoing TAVI, while 1-year unadjusted mortality rates are significantly higher in patients with reduced LVEF and reduced AVG, risk-adjusted mortality at 1 year is only higher in those with reduced AVG - not in those with reduced LVEF.

Diagnosis related group and outcomes following transcatheter aortic valve implantation

BACKGROUND

The association between Medicare Severity-Diagnosis Related Group (DRG) and early and intermediate-term outcomes in patients undergoing transcatheter aortic valve implantation (TAVI) has not been well studied. We aimed to assess the relationship between DRG and 30-day and 1-year mortality in patients undergoing TAVI.

METHODS

The study population included 289 patients with severe symptomatic AS who underwent TAVI from December 2015 to June 2018 at an academic tertiary care medical center. Patients were categorized as DRG 266 or DRG 267, specifying TAVI with or without major complication or comorbidities respectively.

RESULTS

Of the 289 patients, 182 patients (63.0%) were classified under DRG 267 and 107 patients (37.0%) under DRG 266. The DRG 266 group had longer hospital lengths of stay and higher rates of discharge to a skilled nursing facility. While rates of in-hospital and 30-day mortality were similar in both DRG groups, the DRG 266 group had higher 1-year all-cause mortality (26.2% vs 8.8%, P less than .001). In multivariable analysis, serum creatinine (OR 1.42, 95%CI 1.05-1.93) was the only independent predictor of 1-year mortality in the DRG 266 group while atrial fibrillation (OR 3.04, 95%CI 1.03-8.92) was the only independent predictor of mortality in the DRG 267 group.

CONCLUSIONS

In this prospective registry of patients undergoing TAVI, while rates of in-hospital and 30-day mortality were similar in both DRG 266 and 267 groups, the DRG 266 group had higher 1-year all-cause mortality. Distinct predictors of mortality in each DRG group exist.

Predictors of 1-Year Mortality in Men Versus Women Undergoing Transfemoral Transcatheter Aortic Valve Implantation

Although gender-related disparities in intermediate-term outcomes have been reported after transcatheter aortic valve implantation (TAVI), disparate predictors of mortality in men and women who underwent TAVI have not been well studied. This prospective institutional registry study included 297 consecutive patients (153 men, 144 women) who underwent transfemoral TAVI from December 2015 to June 2018 at an academic tertiary medical center. Baseline and clinical characteristics, procedural data, and clinical outcomes at 1 year were recorded. Mortality rates at 1 year were 11.1% and 20.3% in women and men, respectively (p = 0.033). Risk-adjusted mortality was significantly higher in men who underwent TAVI than in women (odds ratio [OR] 2.45, 95% confidence interval [CI] 1.24 to 4.87, p = 0.010). Gender-specific risk-adjusted predictors of 1-year mortality post-TAVI included the presence of atrial fibrillation (OR 4.20, 95% CI 1.31 to 13.46, p = 0.016) and peripheral artery disease (OR 4.64, 95% CI 1.04 to 20.71, p = 0.044) in women and presence of chronic obstructive pulmonary disease (OR 3.14, 95% CI 1.13 to 8.72, p = 0.029), higher serum creatinine (OR 1.57, 95% CI 1.15 to 2.15, p = 0.004), and lower body mass index (OR 0.88, 95% CI 0.80 to 0.97, p = 0.008) in men. In this prospective institutional registry of adults who underwent TAVI, risk-adjusted 1-year mortality is significantly lower in women, and disparate predictors of risk-adjusted 1-year mortality exist in men and women.

Peripheral artery disease is associated with worse outcomes after TAVR

Introduction

Peripheral arterial disease (PAD) is common in patients undergoing transcatheter aortic valve replacement (TAVR) and presents unique challenges for TAVR arterial access. The impact of TAVR on limb ischemic events in PAD patients undergoing TAVR is unknown.

Purpose

Evaluate patients undergoing TAVR with and without PAD for outcomes involving limb ischemic and systemic cardiovascular events.

Methods

Patients undergoing TAVR were identified in the TriNetX database. The database provides access to electronic medical records (diagnoses and procedures) from approximately 86.5 million patients from 58 healthcare organizations. Patients were stratified by history of PAD. After propensity score matching, 30 day limb ischemic outcomes (peripheral revascularization, acute limb ischemia (ALI), lower extremity amputation), major adverse cardiac events (MACE), and mortality were compared between groups. 1 year outcomes for MACE and mortality were also compared. Event rates calculated using 1 year Kaplan-Meier estimator.

Results

We identified 22,405 patients undergoing TAVR. Of these patients 21.3% had diagnosed PAD. Patients with PAD had significantly increased 30 day peripheral revascularization (2.4% v. 1.2%; adjusted OR (aOR) 2.02, 95% CI 1.47–2.80) and ALI (2.27% v. 0.89%; aOR 2.59 95% CI 1.80–3.70) with a similar rate of amputation (Figure 1). 30 day MACE (13.2% vs. 11.4%; aOR 1.18 95% CI 1.04–1.33) and mortality (2.46% vs. 1.53%; aOR 1.63 1.21–2.19) were also significantly increased with continued significance at 1 year follow up (MACE: 25.8% v. 21.6%; aOR 1.26 95% CI1.15–1.39; Mortality: 9.4% vs. 7.3%; aOR 1.32 95% CI 1.14–1.52) (Figure 2).

Conclusions

In our study, TAVR in PAD patients was associated with increased limb ischemic events as well as increased MACE and mortality at 30 days and 1 year follow up.

Funding Acknowledgement

Type of funding sources: None.

Abstract 82: Post Coronary Angioplasty; Why Did My Patient Die?

Introduction: PCI interventions carry the risk of mortality. Minimizing by appropriate selection of patients, procedural technique, aftercare is critical. Despite advances, mortality risk has not significantly changed. Registries have been developed to assess and report outcomes/quality of care.

Methods: Mortalities identified in the National Cardiovascular Disease Registry [NCDR] database from 2017-2020 @ Stony Brook University Hospital were identified and reviewed. The 2017 mortalities were compared with Vizient [Analytics providing cost/quality/value benchmarking & practice improvement feedback] predictors of mortality (case mix index [CMI]) and NYS PCI database which use different risk adjusters.

Results: There were 79 mortalities over 4 years (average age 79, M:F ratio 2.07 [54/26], 76 died in-house). Cause of death [59 cardiac, 8 neurologic, 4 infection, 1 hemorrhage, 1 pulmonary, 3 unknown; 10 cases attributed to surgery]. Mortality rates remained constant over time. Vizient expected mortality rates show poor correlation with NCDR predictions, which may reflect in part patient selection and unadjusted comorbidity. NCDR correlation with the more restrictive risk adjusted NYS DOH mortality rates is better than for Vizient. NCDR mortality for 2017 was 1.4% [21/1503]; NYS DOH 30 day reported OMR1.76%, EMR 1.36%, RAMR of 1.46% for all [26/1,476] cases and RAMR of 0.95% for non-emergent [1,150] cases.

Conclusions: The NCDR provides a useful tool to benchmark PCI mortality, but unadjusted comorbidity, as demonstrated by mismatches in predicted outcomes] adversely affects observed mortality. Increased attention to patient selection may provide improvements in outcomes, decrease mortality risks, and improve value. Value: Improving patient selection improves NCDR mortality and result in lower costs and better reported outcomes. Patients, Providers and Payers may benefit from the provision of appropriate services and improved outcomes..

Abstract 83: 7 C's In Preventing Stroke Complicating Coronary Angioplasty

Introduction: Despite advances in angioplasty equipment and technique, reducing the incidence of CVA has remained an elusive target. Strokes increase mortality, cost and length of stay, residual disability.

Hypothesis: 1. Monitor and benchmark CVAs, 2. Drill down for predictors, lapses in care, 3. Form a multidisciplinary group to identify failure modes, process controls.

Methods: CVAs complicating coronary PCI from 2017 to present were reviewed.

Results: There were 32 CVAs [5 hemorrhagic; 27 thrombotic] occurring in 6410 PCI by 18 operators [0.5%] & 9 deaths [0.28] CVA pts were high acuity: 2 [0.06] post Cardiac arrest, 11 [.34] STEMIs, 8 [.25] Non-STEMIs, 12 [.38] ACS. Age > 65 years in 22 [0.69]. Comorbidity: CVA/TIA/Carotid disease 8 [0.25], PAD 6 [0.19], CKD 4/5 in 3 [0.09], Atrial fib 4 [0.13], LVEF < 35% 12 [0.38]. Ventricular support for cardiogenic shock in 5 [0.16]. Access changed from femoral to radial with 7 CVA [0.22] associated with radial, 22 [0.69] with femoral, and 3 [0.09] with both. Anticoagulation: heparin alone 5 [0.16] and bivalirudin ± heparin in 27 [0.84]. Most interventions utilized bivalirudin. PCI with Heparin & Aspiration thrombectomy, in 5 [0.16] had a higher thrombotic CVA risk. Multidisciplinary review concerns included: 1. pt factors [bleeding/clotting history, current meds and side effects, risk factors for CVA/TIA {e.g. STEMI/non-STEMI, cardiogenic shock, atrial fibrillation, age, carotid disease}, 2. Equipment {e.g. access sheath size and length, catheter preshaped/shaped/multiple, wire [e.g. straight, curved tip, shapeable, hydrophilic, exchange], thrombectomy, angioplasty [balloon, rotoblator, stent], 3. Personnel [experience, volume, trainees], 4. Process [Anticoagulation {timing, heparin,/bivalirudin, dose, monitoring}, Cleaning hands/wires/bowl, Catheter exchanges, Case Duration. Patient monitoring, Brain attack protocol activation and response.

Conclusions: The multidisciplinary group formulated a7 C’s Chain of prevention to lessen the risk of CVA: Continuous monitoring , Contributing factor identification, Consensus development of best practices, Cleanliness , Compulsive attention to detail / technique, Communication , Controversies in Care [notably DOACs].

Mechanical aspiration thrombectomy using the penumbra CAT RX system for patients presenting with acute coronary syndrome

Patient undergoing PCI can have distal embolization and microvascular obstruction despite normalization of epicardial blood flow. Aspiration thrombectomy has been studied previously to reduce infarct size, but prior methods of aspiration thrombectomy were associated with increased risk of stroke and is currently recommended as a bailout strategy. Penumbra CAT RX has been recently approved for aspiration thrombectomy, we evaluated the catheter's use in an academic cardiac catheterization lab. Patients undergoing cardiac catherization at an academic medical center who had deployment of the Penumbra CAT RX from 2017 through 2020 were included in the case series. TIMI flow pre and post procedure were determined by individual operator. Endpoints included 30-day cardiovascular death and post-procedural stroke. The Penumbra CAT RX catheter was used in a total of 34 patients, with 71% STEMI, 23% NSTEMI, 3% UA, and 3% new onset heart failure. TIMI 3 flow was achieved in 88% of cases. There were no cases of 30-day cardiovascular death or post procedural stroke. Aspiration thrombectomy continues to have clinical benefit in modern cardiac catherization laboratories with use in select cases. The Penumbra CAT RX appears to be safe and highly effective at thrombus removal in the acute setting without increased stroke risk as seen with manual aspiration thrombectomy.

A stepwise approach utilizing a double helix wire technique, snare capture and a switch from a transfemoral to transradial approach to remove an entrapped balloon

During an attempted PCI utilizing a femoral approach, a balloon became entrapped in the Left Circumflex Artery. Initial retrieval efforts including pulling the balloon and inflating a second balloon over the entrapment failed, the balloon fractured, and the distal end of the balloon apparatus migrated out of the guide catheter. We utilized a stepwise approach with a double helix wiring technique, snares and a change from a transfemoral to transradial approach to successfully retrieve the foreign bodies. This case highlights the importance of utilizing multiple techniques in series and understanding anatomical influences on equipment retrieval when single techniques and approaches fail.

Balloon Aortic Valvuloplasty With Same-Setting Complex Percutaneous Coronary Intervention in the TAVR Era: A Case Series

BACKGROUND

The use of balloon aortic valvuloplasty (BAV) prior to same-setting complex percutaneous coronary intervention (PCI) in patients with severe aortic stenosis (AS) and concomitant severe coronary artery disease (CAD) has not been well studied in the era of transcatheter aortic valve replacement (TAVR).

METHODS

We reviewed 379 BAVs performed between January 2016 and April 2020 at an academic tertiary-care medical center. Overall, 327 BAVs were performed in the setting of TAVR. Of the remaining 52 BAVs, 20 were performed immediately prior to same-setting complex PCI. We examined the baseline and procedural data, and clinical outcomes of these cases.

RESULTS

Mean patient age was 81 ± 9 years and 70% were men. Chronic kidney disease (40%), diabetes mellitus (35%), and atrial fibrillation (35%) were the most prevalent comorbidities. Rotational atherectomy was performed in 75% of cases and Impella device was utilized in 15%. PCI of distal left main coronary artery and proximal left anterior descending coronary artery was performed in 30% and 80% of cases, respectively. Mean contrast volume was 149 ± 61 mL, fluoroscopy time was 37 ± 20 minutes, total skin dose was 2821 ± 1931 mGy, and total area dose was 18651 ± 12090 μGy/m². Rate of in-hospital complications was low, with a 0% mortality and stroke rate. Eighty percent of patients were referred for TAVR; 70% went on to undergo successful TAVR and 10% deferred TAVR due to improvement in symptoms.

CONCLUSIONS

BAV with same-setting complex PCI is safe and feasible in patients with severe AS and severe CAD awaiting TAVR.

Giant Cell, Giant Problems: A Case of Giant Cell Myocarditis Complicated by Cardiogenic Shock and Refractory Ventricular Tachycardia Managed With a Mechanical Circulatory Support Device

This report reviews the management of a case of Giant Cell Myocarditis (GCM) that presented with cardiogenic shock. This case highlights the importance of a multi-disciplinary approach to the care of these patients including the use of a mechanical circulatory support (MCS) device.

Sex-Related Differences in Early- and Long-Term Mortality After Transcatheter and Surgical Aortic Valve Replacement: A Systematic Review and Meta-Analysis

BACKGROUND

Observational data suggest that early- and long-term outcomes of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) differ significantly between men and women, but have demonstrated conflicting results. This study sought to examine early- and long-term mortality with TAVR and SAVR in women versus men.

METHODS

Electronic search was performed until February 2018 for studies reporting sex-specific mortality following TAVR or isolated SAVR. Data were pooled using random-effects models. Outcomes included rates of early mortality (in hospital or 30 days) and long term (1 year or longer).

RESULTS

With 35 studies, a total of 80,928 patients were included in our systematic review and meta-analysis, including 40,861 men and 40,067 women. Pooled analyses suggested considerable sex-related differences in longterm mortality following TAVR and SAVR. Following SAVR, women had higher long-term mortality (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.16-1.56; P<.001) and a trend toward higher early mortality (OR, 1.69; 95% CI, 0.97-2.97; P=.07) compared to men. Following TAVR, women had lower long-term mortality (OR, 0.78; 95% CI, 0.71-0.86; P<.001) and no difference in early mortality (OR, 1.09; 95% CI, 0.96-1.23; P=.17) compared to men.

CONCLUSIONS

In this systematic review and meta-analysis, women had higher long-term mortality and a trend toward higher early mortality compared to men following SAVR. Following TAVR, women had lower long-term mortality and no difference in early mortality compared with men.

TAVR in a 65-Year-Old Man With a Bicuspid Aortic Valve With Extremely Large Annulus and Severe Left Ventricular Dysfunction

This case illustrates that transfemoral transcatheter aortic valve replacement is safe and feasible in patients with bicuspid aortic stenosis with extremely large annulus and concomitant severe left ventricular dysfunction.

Abstract 347: Can Radiation Exposure in the Catheterization Lab be Controlled With an Increasing Frequency of Complex and High Risk Procedures?

Background: Radiation [stochastic and deterministic] exposes patients and providers that must be balanced against the benefits achieved. Data derived from high exposure events has resulted in a goal of ALARA [as low as reasonably achievable] with concerns at 50 mSv [single event], 100 mSV [proximate exposures], 400 mSv [lifetime exposure]. Cath lab patients may receive high radiation as a consequence of high risk/ complex procedures, obesity, prior PCI/CABG and lesion complexity [ESRD, calcified, CTO], structural disease, supported interventions. Initiatives to reduce radiation exposure include: procedure staging, collimation, mapping, decrease fluoro frame rates and cine run number/length.

Procedure: Radiation of patients with invasive procedures in 2018 and 2019 with high exposure stochastic risk [Dose Area Product ≥20,000 μGy* m 2 ( 200 Gy*cm 2 ) or Skin Dose deterministic risk > 5 Gray were analyzed for associations and compared. Effective dose [0.23 mSy/Gy*m 2 ] provides a lifetime risk of fatal cancer related to radiation.

Results: Interventional volume increased from 1431 to 1547 PCI. The number and frequency of high DAP exposures decreased [237 to 161] and for 10 of 11 high volume operators; there was no decrease in high Skin Dose cases [83 versus 119]. Associations with high DAP rates: Surgical turndowns [14/161; 9%], high risk/complex procedures (e.g. rotablator [42/161; 26.1%], CTOs [27/161; 16.8%]), Obesity [100/161; 62%; Morbid Obesity 31/161; 19%]. Single vessel PCI patients comprised 41/161; 25.5% of high exposures with 10/41 [24% having a prior CABG]. Single event Dose Area Products were as high as 167,235 μGy* m 2 [effective dose 368 mSv; lifetime risk of fatal cancer 0.92%]; repeat procedures [up to 5 returns/ year with cumulative doses 10/161 in the 100-200 mSv range [1:200 -1:400 lifetime fatal cancer risk]. 36 of the 161 patients were ≤ 60 years old. Despite Skin Doses as high as 14 Gray no skin sequelae occurred. Operators varied in the frequency of high radiation procedures [highest volume 56/268; 21%; all others 105/1547; 8%], influenced by patient selection and procedure, but also by technical variables [e.g. fluoro verus cine, frame rate, collimation].

Conclusions: Despite efforts, radiation exposure remains a concern, aggravated by the need for increasingly high risk, structural heart, and supported interventional procedures. Opportunities for improvement include: lab upgrade to improve imaging in progress, increase staging [CABG , multivessel PCI patients], limit runs/ frame rates, increase mapping, optimize collimation. Lifetime fatal cancer risk is higher in younger than older patients with similar exposures due to both the latency period for cancer development and the likelihood of repeat radiation exposure. Efforts are underway to limit and track the cumulative radiation exposure of patients.

Abstract 348: Using the NCDR Cath/pci Registry to Identify Opportunities and to Maintain and Improve Cardiovascular Care

Background: The NCDR Cath/PCI Registry provides standardized capture of cardiovascular and anatomic risk factors and national benchmarking of outcomes to identify quality concerns and opportunities for improvement in the quality of care by practitioner and hospital. A rolling 4 quarter analysis is provided to participants that include measures of performance, quality, appropriate use.

Procedure: Two performance measures [in-hospital PCI mortality and D2B] and two quality measures [in-hospital bleeding/ transfusion post PCI and contrast nephropathy] and were selected for intensive review and process improvement. The rolling 4 quarters ending in 2018 Q3 are compared to the 209Q3 results. Drill down analysis of event contributory factors was performed in a joint practice setting to identify opportunities for improvement.

Results: In hospital risk adjusted PCI mortality improved over the assessed period from 3.4 Q3208 to 1.4 Q32019 [1.27 for the 3 rd quarter of 2019]. above the 75 th percentile. Stony Brook D2B times were maintained in the desired range of < 60 minutes [58 min in 2018Q3 and 59 min in 2019Q3]. Efforts to improve field First Medical Contacts [EMS] to facilitate D2B times by field transmission and ED review of field ECG with activation of the D2B Cath team demonstrate FMC-2B times of 92.2 minutes in 2018 and 83.1 minutes in 2019; achieving and maintaining the desired range of < 90 minutes. Transport times from external hospitals were extremely variable, dependent on intake process, transport availability and distance. Rate of bleeding and transfusion post PCI were <10% outliers at 7.82% and 3.42% for 2018Q3. Both have improved but remain challenges at < 10 th percentile at 4.25% bleeding and 2.25% transfusion rate for 2019Q3. Interestingly radial operators also remain outliers, with preprocedure severe anemia, active bleeding, inappropriate transfusion thresholds have been identified as contributory concerns. Acute kidney injury [presumptive contrast nephropathy] improved from 9.57% in 2018Q3 to 6.16% [50 th percentile] 2019Q3. More aggressive hydration with the “Poseidon trial” protocol improved post procedure CIN, which is often aggravated by hypotension, aggressive diuresis, ACEI/ARB/AA medications in patients with volume overload and heart failure.

Conclusions: The NCDR Cath/PCI is a valuable resource for benchmarking performance, outcomes and appropriateness on an ongoing basis. Continuing feedback has allowed us to document and sustain improvement and to evaluate the effect of interventions implemented to improve the quality of care. Analysis also demonstrated that individual operators were not identified as significant outliers for the analyzed variables suggesting that systemic process improvement should be pursued.

Impact of Severity of Chronic Kidney Disease on Management and Outcomes Following Transcatheter Aortic Valve Replacement With Newer-Generation Transcatheter Valves

BACKGROUND

The association between chronic kidney disease (CKD) and outcomes following transcatheter aortic valve replacement (TAVR) in the setting of newer-generation transcatheter heart valves (THVs) is not well known. Accordingly, we sought to assess the impact of CKD severity on outcomes in adults undergoing TAVR with newer-generation THVs.

METHODS

The study population included 298 consecutive patients who underwent TAVR with a newer-generation THV (Sapien 3 [Edwards Lifesciences] or CoreValve Evolut R or Evolut Pro [Medtronic]) from December 2015 to June 2018 at an academic tertiary medical center. Patients were classified into three groups: group I, defined as creatinine clearance (CrCl) ≥60 mL/ min (n = 133); group II, defined as CrCl ≥30 mL/min and <60 mL/min (n = 128); and group III, defined as CrCl <30 mL/min (n = 37).

RESULTS

Median length of stay was longer in groups II and III (2.0 days in group I vs 3.0 days in group II vs 4.0 days in group III; P<.01). While rates of 30-day readmission were significantly higher in groups II and III compared with group I (14.5% in group I vs 26.6% in group II vs 37.1% in group III; P<.01), rates of in-hospital and 30-day mortality and disabling stroke were similar. In multivariable analysis, CKD was independently associated with higher 30-day readmission rates (group II: odds ratio, 2.10; 95% confidence interval 1.02-4.32; group III: odds ratio, 3.52; 95% confidence interval, 1.40-8.87; group I: referent).

CONCLUSIONS

In this prospective study of adults undergoing TAVR with newer-generation THVs, moderate and severe CKD was associated with a nearly 2-fold and 3-fold higher risk of 30-day readmission, respectively.

Transcatheter Tricuspid Valve-in-Valve Replacement Via Right Internal Jugular Vein Access in a 39-Year-Old Woman

Transcatheter tricuspid valve-in-valve replacement via right internal jugular is safe and feasible for failed bioprosthetic valve implantation. Challenging aspects include stiff wire advancement into the pulmonary artery for rail establishment and multiple push-pull manipulations for balloon and valve advancement.

Gender Disparities in Management and Outcomes Following Transcatheter Aortic Valve Implantation With Newer Generation Transcatheter Valves

The impact of gender on management and early outcomes after transcatheter aortic valve implantation (TAVI) in the setting of newer generation transcatheter heart valves (THVs) is not well known. We evaluated gender-specific differences on clinical management and in-hospital outcomes in adults who underwent TAVI with newer generation THVs. The study population included 298 consecutive patients who underwent TAVI and received a newer generation THV (Sapien 3 [Edwards Lifesciences, Irvine, California] or Corevalve Evolut R or Evolut Pro [Medtronic, Minneapolis, Minnesota]) from December 2015 to June 2018 at an academic tertiary medical center. Of the 298 patients, 154 (52%) were men and 144 (48%) were women. Compared with men, women were older, had lower serum creatinine, higher left ventricular ejection fraction, and lower rates of multiple co-morbidities, including previous coronary artery bypass graft surgery, previous myocardial infarction, and atrial fibrillation. Women were noted to have smaller aortic annular area and perimeter and underwent implantation of smaller THVs than men. At the time of discharge, women were more frequently prescribed a P2Y12 inhibitor (primarily clopidogrel) and less frequently prescribed oral anticoagulation (namely warfarin). Hospital length of stay and in-hospital rates of mortality, disabling stroke, and pacemaker were similar in men and women. In conclusion, in this observational prospective study of adults who underwent TAVI with newer generation THVs, while gender-related disparities in clinical presentation and procedural management were observed, no significant difference in clinical outcomes were noted in men and women. Further studies examining gender-related differences in procedural and postprocedural care after TAVI in the contemporary era are warranted to better understand and optimize clinical outcomes in both men and women.

Abstract 143: Spoke and Hub or Moat and Castle, Evolving Referral Patterns

Objective: Stony Brook University Renaissance Medical School and University Hospital [UH] is a tertiary care hospital in Sufflolk County, NY, an area covering 912 square miles [86 miles in length and maximum width of 26 miles] and serving a population of 1.5 million. UH coordinates STEMI calls of the 94 voluntary ambulance services covering the county. The county geography has made coverage for emergent interventional procedures challenging. UH, until relatively recently had one of two cath labs (now 7) and the only CT surgical program (now 3) in the county. Independent cath labs (and 2 CTS programs) have been set up at Community hospitals to provide 7 x 24 interventional service, changes that may modify the traditional "Hub with Spokes" referral pattern for STEMI. Opposing this centrifugal force has been the increasing consolidation of health care hospital networks. We examined the effects of these changes on STEMI referrals and overall volume at UH and a Cath capable community hospital between 2014- 2017.

Procedure: We examined the effects of changes in emergency cath lab availability on STEMI referrals and overall volume at UH and a Cath capable community hospital [BMH] between 2014- 2017.

Results: In 2014 of 167 STEMI calls 76 [45.5%] were referred to UH and 49 [29.3%] BMH. 2015 had 209 calls, 109 [52.2%] were referred to UH and 53 [25.4%] BMH. 2016 had 205 calls, 89 [43.4%] referred to UH and 53 [25.9%] BMH. 2017 had 247 calls, 101 [40.9%] referred to UH and 47 [19.0%] BMH. Ambulance company patterns of referral remained relatively stable despite an increase in local hospital availability. 34 ambulance companies brought patients to UH and 17 to BMH in 2014; 28 brought pts to UH and 19 to BMH in 2017. Ambulance companies continued to serve multiple hospitals throughout the monitored period. Total volume at UH remained little effected by changing practice guidelines or referral patterns: 2014: 2194 cath and 1329 PCI [total 3523]; 2015: 2371 cath and 1502 PCI [total 3873]; 2016: 2336 cath and 1578 PCI [total 3914]; 2017: 2367 cath and 1516 PCI [total 3883]. At UH, private [reflecting community hospital referrals] and staff physician utilization of the Cath lab also remained relatively unchanged in the studied period.

Conclusions: Increased availability of 24 x 7 cath lab availability has resulted in a modest relative decline in referrals, more pronounced at the community hospital. Despite this, overall volume and therefore demand remains preserved. The increasing development of hospital networks and hospital based emergency ambulance services has not yet had a major impact on services, changing our "Hub with Spokes" to a "Castle and Moat", but will continue to be closely observed.

Abstract 142: Feel the Burn, PCI Advances Increase Radiation Exposure of Patients

Objective: Interventional cardiology success in revascularization and structural heart has an unseen cost. Complex, prolonged cases increase exposure of patients (Pts) and staff to ionizing radiation. The increased radiation has direct deterministic effects (air kerma; skin dose) and stochastic effects (air kerma x area product). Fluoro time is also monitored. Individual MD and overall lab perfomance exposure guidelines for the laboratory have been set [peak Skin dose < 5 Gray, Air kerma x Area product (DAP) < 200 Gray*cm 2 , fluoro time < 60 min).

Procedure: Exposure for cath pts was tracked. MD, pt, anatomic, procedural variables associated with high exposures were identified and specific interventions to minimize radiation exposure identified.

Results: Over a year period 17.2% of cases [237/1375] received high skin [6.0%; 83/1375] or DAP radiation [17.2%; 237/1375]. No pt sequelae were identified on follow-up for doses as high as 13.251 Gray, 775 Gy*cm2, fluoro time 119.9 min. Fluoro time was not a useful measure; it did not correlate with either skin dose or DAP, reflecting variable use of fluoro compared to cine, pt BMI, differing fluoro rates (ranging from 4 fps to 15 fps). Frequency of high radiation exposure by MD (with over 50 cases/year) ranged from 4.5% - 28.3% of interventions [Skin dose 1.1%-15.4% and DAP 4.5%-28.3%]. Pt risk factors included: morbid obesity, multivessel/multilesion interventions, lesion complexity [particularly calcified lesions and CTOs], complex structural heart procedures. MD factors included: highly angled views, # of cine runs [8.9% (122/1375) > 40 runs, 3.7% (51/1375) > 50 runs, 0.8% 14/1375) > 75 runs], staged procedures versus multivessel/ multilesion procedures, trainee staffing. Default radiation exposure settings of Xray equipment are now set at lower levels acceptable for imaging (MD can modify). MD feedback and interventions to decrease radiation exposure are ongoing, targeting: MD continued case awareness of displayed radiation dose with appropriate staging, use of lowest visually acceptable fluoro rates, shortening and minimizing cine runs where possible, store/map reference images, vary imaging angle and decrease where possible steep angulations, optimal collimation. The MDs who have adopted these practices have the lowest pt exposure rates [skin dose 1.4-5.1%, DAP 4.5-8.6% guideline tracked]. Opportunities for improvement are evident in current practice but also include improved tracking of pt medical treatment related exposure, upgrades in Xray equipment.

Conclusions: Advances in equipment and MD experience have been offset by the increasing disease complexity of attempted interventions [including CTOs]. Pt factors and MD practice both contribute to optimal radiation safety [ALARA]. MD practice is a key modifiable variable to promote radiation safety, affecting exposure of pts and staff.

Bivalirudin versus heparin in patients undergoing percutaneous peripheral interventions: A systematic review and meta-analysis

Background

Bivalirudin may be an effective alternative anticoagulant to heparin for use in percutaneous peripheral interventions. We aimed to compare the safety and efficacy of bivalirudin versus heparin as the procedural anticoagulant agent in patients undergoing percutaneous peripheral intervention.

Methods

For this meta-analysis and systematic review, we conducted a search in PubMed, Medline, Embase, and Cochrane for all the clinical studies in which bivalirudin was compared to heparin as the procedural anticoagulant in percutaneous peripheral interventions. Outcomes studied included all-cause mortality, all-bleeding, major and minor bleeding, and access site complications.

Results

Eleven studies were included in the analysis, totaling 20,137 patients. There was a significant difference favoring bivalirudin over heparin for all-cause mortality (risk ratio 0.58, 95% CI 0.39–0.87), all-bleeding (risk ratio 0.62, 95% CI 0.50–0.78), major bleeding (risk ratio 0.61, 95% CI 0.39–0.96), minor bleeding (risk ratio 0.66, 95% CI 0.47–0.92), and access site complications (risk ratio 0.66, 95% CI 0.51–0.84). There was no significant difference in peri-procedural need for blood transfusions (risk ratio 0.79, 95% CI 0.57–1.08), myocardial infarction (risk ratio 0.87, 95% CI 0.59–1.28), stroke (risk ratio 0.77, 95% CI 0.59–1.01), intracranial bleeding (risk ratio 0.77, 95% CI 0.29–2.02), or amputations (OR 0.75, 95% CI 0.53–1.05).

Conclusion

Our meta-analysis suggests that bivalirudin use for percutaneous peripheral interventions is associated with lower all-cause mortality, bleeding, and access site complications as compared to heparin. Further large randomized trials are needed to confirm the current results.

Abstract 180: Some Like it Hot; Radiation Safety in the Catheterization Lab

Objective: Ionizing radiation is an unseen and often unappreciated safety concern for patients and cath lab staff. Radiation exposure has both deterministic and stochastic effects, with patient risk estimated by peak Skin Dose and Air kerma Area product. In our lab exposure guidelines have been set for radiation safety (fluoro time < 60 min, 4,000 mGray and 20,000 cGray cm 2 ). A prior audit of practice 2011-2013 found that 17.1% (758/4,439) of patients undergoing interventional procedures exceeded these limits. Safer radiation practices were implemented including: intra procedure operator feedback, decrease in cine frame rate and run length, promote mapping and less angled views. However changing patient characteristics (increased obesity, prior CABG) and an increase in structural procedures warrant reexamination of practice.

Procedure: The frequency of guideline excessive radiation exposure for cardiac cath lab patients was tracked over a 12 month period from 11/2016-11/2017. The frequency of radiation exposure exceeding our guidelines was tracked overall and by operator (16), and by specific intervention.

Results: Over the one year period 10.2% of interventions [174/1,702] received excessive skin or total body radiation. Rates exceeding guidelines by operator ranged from 4% to 26% with operators performing structural or peripheral procedures having the highest patient radiation exposures. Structural procedures resulted in exposures as high as 123 min fluoro time, TAD of 226,385 cGray cm2, 11,129 mGray skin dose [patient had post procedure skin damage]. Factors associated with high radiation exposures included: increasing obesity, prior surgical revascularization, coronary anomalies, multivessel procedure or high complexity procedure, difficulties in imaging requiring highly angled or multiple views, procedural complications. Interventions associated with limiting exposure included: limiting fellow participation, decrease in frame rate, interim stills with limited cine runs. The default settings of X-Ray equipment have been modified to encourage safe and appropriate use of radiation in the cardiac catheterization lab (however, physician overide of settings is still possible).

Conclusions: The changes made in imaging equipment and procedures 5 years ago have been largely sustained and have resulted in less frequent radiation outliers. Patient factors (e.g. obesity, prior CABG) complex and multivessel interventions, structural and vascular procedures are potentially frequently associated with excess radiation. Changing default settings and implementing radiation safety practices, including staging where appropriate, can significantly decrease radiation exposure to patients and staff. Cumulative and target organ specific patient doses of radiation should be tracked and more readily accessible in the patient’s medical record.

Abstract 243: Contrast Induced Nephropathy; Out of Sight, Out of Mind

Objectives: Same day cardiac interventions are increasing; concerns that are not immediately apparent may be neglected. We sought to determine if pts at higher risk of contrast nephropathy are identified, appropriately treated and followed.

Background: Contrast induced nephropathy [CIN] impacts on mortality risk; ranging from transient renal impairment with full recovery, to cumulative impairment, to renal failure and the need for permanent dialysis. Preprocedural modifiable [hydration status, contrast reexposure <72 hrs, nephrotoxic medications], partially modifiable [hypotension & heart failure], and non-modifiable [baseline renal function [eGFR<60], age >75 yrs] risk factors influence risk. Procedural factors [contrast volume, hypotension, IABP patients] increase risk. CIN risk is decreased by optimizing risk factors and hydration, minimizing contrast. Post procedure the Mehran CIN predictor is calculated and a 48 hr post IP or 7 day OP creatinine is obtained to identify CIN.

Procedure: From 2016-17 pts undergoing interventional procedures exceeding the lab standard for radiation exposure were selected for review as representing a cohort likely to have increased contrast exposure.

Results: There were 3,996 procedures [2,436 diagnostic, 1,560 interventions] performed in the reviewed period. Of 56 outlier pts, 11 were treated for structural heart disease and 45 underwent coronary angioplasty. Pre procedure risk factors included: age >75 [19/56], DM [19/56], HF [25/56], CKD 3 [12/55; 1 pt on HD]. Opportunities for decreasing contrast: LV gram 7/45, prior contrast exposure within 72 hrs 5/45, multivessel intervention 15/45. Few [7/45] of the pts received periprocedural hydration as recommended by the EHR power plan [cited reason heart failure 25/45]. Contrast use was as high as 475 cc; use of biplane imaging was infrequent. The Mehran CIN risk score was low in 13/55 [7.5% CIN/0.04% HD], intermediate in 36/55 [14.0% CIN/ 0.12 HD], high in 7/55 [26.1-57.3% CIN/ 1.09-12.6% HD]. Pre procedure creatinine was not available in 1 pt and volume of contrast administered undocumented in another pt. 48 hr creatinine was documented in 33/56 pts; 10 of the 33 pts developed post procedure CIN.

Conclusions: Shortened hospitalizations decrease the awareness of and preventive treatment for CIN. A multidisciplinary team has identified multiple opportunities for practice improvement: provider education, review of the EHR power plan [for modification of pre and intraprocedural risk factors, implementation of correctly dosed fluid repletion with renal consultation for high risk patients, appropriate follow-up of creatinine], Preprocedural calculation and intraprocedural monitoring to achieve low risk contrast volume [(ml)/eGFR <3.7}, interventional report embedding CIN risk score, EHR tracking and audit to ensure implementation with appropriate feedback as necessary.

Outcomes of ≤6-month versus 12-month dual antiplatelet therapy after drug-eluting stent implantation: A meta-analysis and meta-regression

BACKGROUND

The benefit of ≤6-month compared with 12-month dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) placement remains controversial. We performed a meta-analysis and meta-regression of ≤6-month versus 12-month DAPT in patients undergoing PCI with DES placement.

METHODS

We conducted electronic database searches of randomized controlled trials (RCTs) comparing DAPT durations after DES placement. For studies with longer follow-up, outcomes at 12 months were identified. Odds ratios and 95% confidence intervals were computed with the Mantel-Haenszel method. Fixed-effect models were used; if heterogeneity (I) > 40 was identified, effects were obtained with random models.

RESULTS

Nine RCTs were included with total n = 19,224 patients. No significant differences were observed between ≤6-month compared with 12-month DAPT in all-cause mortality (OR 0.87; 95% confidence interval (CI): 0.69-1.11), cardiovascular (CV) mortality (OR 0.89; 95% CI: 0.66-1.21), non-CV mortality (OR 0.85; 95% 0.58-1.24), myocardial infarction (OR 1.10; 95% CI: 0.89-1.37), stroke (OR 0.97; 95% CI: 0.67-1.42), stent thrombosis (ST) (OR 1.37; 95% CI: 0.89-2.10), and target vessel revascularization (OR 0.95; 95% CI: 0.77-1.18). No significant difference in major bleeding (OR 0.72; 95% CI: 0.49-1.05) was observed, though the all-bleeding event rate was significantly lower in the ≤6-month DAPT group (OR 0.76; 95% CI: 0.59-0.96). In the meta-regression analysis, a significant association between bleeding events and non-CV mortality with 12-month DAPT was found, as well as between ST and mortality in addition to MI with ≤6-month DAPT.

CONCLUSION

DAPT for ≤6 months is associated with similar mortality and ischemic outcomes but less bleeding events compared with 12-month DAPT after PCI with DES.

Coronary artery spasm: Is ST-elevation key for diagnosis?

Coronary vasospasm is uncommon during pregnancy and the postpartum period. We present a very rare case of an acute coronary vasospasm in a 36-year-old woman who was two weeks postpartum. The coronary arteriograms showed a coronary vasospasm in the distal left anterior descending and circumflex coronary arteries. Electrocardiogram (ECG) presentation was atypical, with T-wave inversions in leads I, aVL, and V2 to V6. To our knowledge, this is the first case with a well-documented coronary artery vasospasm in a postpartum woman without the classic ST elevation on ECG. Management should follow the usual principles of care for acute coronary vasospasm.

Dedicated two-stent technique in complex bifurcation percutaneous coronary intervention with use of everolimus-eluting stents: the EES-bifurcation study

OBJECTIVES

To compare the outcomes of initial one-stent (1S) versus dedicated two-stent (2S) strategies in complex bifurcation percutaneous coronary intervention (PCI) using everolimus-eluting stents (EES).

BACKGROUND

PCI of true bifurcation lesions is technically challenging and historically associated with reduced procedural success and increased restenosis. Prior studies comparing initial one-stent (1S) versus dedicated two-stent (2S) strategies using first-generation drug-eluting stents have shown no reduction in ischemic events and more complications with a 2S strategy.

METHODS

We performed a retrospective study of 319 consecutive patients undergoing PCI at a single referral center with EES for true bifurcation lesions, defined by involvement of both the main vessel (MV) and side branch (SB). Baseline, procedural characteristics, quantitative coronary angiography and clinical outcomes in-hospital and at one year were compared for patients undergoing 1S (n=175) and 2S (n=144) strategies.

RESULTS

Baseline characteristics were well-matched. 2S strategy was associated with greater SB acute gain (0.65±0.41 mm vs. 1.11±0.47 mm, p<0.0001). In-hospital serious adverse events were similar (9% with 2S vs. 8% with 1S, p=0.58). At one year, patients treated by 2S strategy had non-significantly lower rates of target vessel revascularization (5.8% vs. 7.4%, p=0.31), myocardial infarction (7.8% vs. 12.2%, p=0.31) and major adverse cardiovascular events (16.6% vs. 21.8%, p=0.21).

CONCLUSION

In this study of patients undergoing PCI for true coronary bifurcation lesions using EES, 2S strategy was associated with superior SB angiographic outcomes without excess complications or ischemic events at one year.

High platelet reactivity on clopidogrel therapy correlates with increased coronary atherosclerosis and calcification: a volumetric intravascular ultrasound study

OBJECTIVES

This study sought to evaluate the relationship between platelet reactivity and atherosclerotic burden in patients undergoing percutaneous coronary intervention (PCI) with pre-intervention volumetric intravascular ultrasound (IVUS) imaging.

BACKGROUND

Atherosclerosis progresses by the pathologic sequence of subclinical plaque rupture, thrombosis, and healing. In this setting, increased platelet reactivity may lead to more extensive arterial thrombosis at the time of plaque rupture, leading to a more rapid progression of the disease. Alternatively, abnormal vessel wall biology with advanced atherosclerosis is known to enhance platelet reactivity. Therefore, it is possible that by either mechanism, increased platelet reactivity may be associated with greater atherosclerotic burden.

METHODS

This study included patients who underwent PCI with pre-intervention IVUS imaging and platelet reactivity functional assay (P2Y(12) reaction units) performed >16 h after PCI, after the stabilization of clopidogrel therapy (administered before PCI). Platelet reactivity >230 P2Y(12) reaction units defined high on-treatment platelet reactivity (HPR).

RESULTS

Among 335 patients (mean age 65.0 years, 71% men), there were 109 patients with HPR (32.5%) and 226 without HPR (67.5%), with HPR being associated with diabetes and chronic renal insufficiency. By IVUS analysis, patients with HPR had significantly greater target lesion calcium lengths, calcium arcs, and calcium indexes. Furthermore, patients with HPR tended to have longer lesions and greater volumetric dimensions, indicating higher plaque volume, larger total vessel volume, and also greater luminal volume, despite similar plaque burden. By multivariate analysis controlling for baseline clinical variables, HPR was the single consistent predictor of all IVUS parameters examined, including plaque volume, calcium length, and calcium arc.

CONCLUSIONS

Increased platelet reactivity on clopidogrel treatment, defined as >230 P2Y(12) reaction units, is associated with greater coronary artery atherosclerotic disease burden and plaque calcification.