European Society of Cardiology Council for Cardiology Practice worldwide survey of transcatheter aortic valve implantation beliefs and practices

Background Transcatheter aortic valve implantation (TAVI) continues to gain popularity in the management of patients with severe aortic stenosis (SAS). Distribution of resources to maximise appropriate use remains a priority. Design & methods To determine the current perceptions and behaviours regarding SAS patient management, an 18-point multiple-choice questionnaire was distributed to European Society of Cardiology (ESC) Council for Cardiology Practice (CCP) e-journal and/or electronic newsletter subscribers. Respondents to all questions were considered. Sub-analyses based on respondent age, practice setting and geographical location were performed. Results Of 1245 full respondents, 41.5% were aged ≥ 51 years, 22.7% were aged 41-50 years and 35.8% were aged ≤ 40 years. The majority were located in Europe (77.5%), followed by Asia/Oceania (11.6%), America (7.6%) and Africa (3.4%). In-hospital and out-of-hospital cardiologists accounted for 57.4% of and 28.5% of the sample, respectively, with the remainder being general practitioners/other. The majority of respondents (70.1%) claimed to diagnose between one and five cases of SAS per month. Free access to TAVI was reported by 41.2%, being less common for those aged ≤ 40 years (32.7%; p < 0.001), those located in Asia/Oceania, America and Africa (20.1%, 18.1% and 2.4%, respectively; p < 0.01 in each case) and in-hospital compared to out-of-hospital cardiologists (35.7% vs. 54.5%, respectively; p < 0.001). The most common reason for not referring a patient for an aortic valve intervention was assessment that the patient was high risk/non-operable (55.5%), followed by short life expectancy (30.5%). The most common reason for referring a patient for TAVI over surgical replacement was surgical risk score (56.9%). The most commonly perceived main complication of TAVI was stroke (28.9%), while the most frequently selected main benefit was improvement in quality of life (37.2%). A high proportion (82.5%) of respondents believed that TAVI is/may become a viable option for lower-risk SAS patients in future. Conclusion The population of potential TAVI is significant worldwide, with key barriers to referral being access limitations and poor physician education. Strategies to minimise these factors are paramount.

Association between serum calcium, serum phosphate and aortic stenosis with implications for prevention

Background

Aortic stenosis is the most common cause of valvular heart disease with no means of prevention. Lowering serum levels of calcium or phosphate are potential preventive strategies but observational studies on the associations with aortic stenosis are inconsistent.

Design and methods

A case–control study was conducted in 132 individuals undergoing echocardiography (63 with aortic stenosis and 69 without) and the results combined with three other comparable studies (914 individuals overall) to provide a summary odds ratio of aortic stenosis for a 0.1 mmol/L increase (approximately one standard deviation) in calcium and phosphate respectively. The relationship between calcium and phosphate and the severity of aortic stenosis, according to peak trans-aortic velocity, was also examined in the case–control study using linear regression.

Results

Both calcium and phosphate were positively associated with aortic stenosis. The summary odds ratio for a 0.1 mmol/L increase in calcium was 1.79 (95% confidence interval 1.07–2.99), p = 0.027 and for phosphate it was 1.47 (1.08–2.01), p = 0.015. Peak trans-aortic velocity increased with phosphate levels, 9% (4%–14%) per 0.1 mmol/L, p = 0.001, but not with calcium, p = 0.089.

Conclusions

If the associations are causal and reversible, these results indicate that a small reduction in calcium or phosphate levels, within the physiological rage, would translate into a clinically significant reduction in the risk of aortic stenosis. Randomised trials of calcium and phosphate lowering therapies in aortic stenosis are needed.

Cognitive Outcomes After Transcatheter Aortic Valve Implantation: A Metaanalysis

OBJECTIVES

To quantitatively summarize changes in cognitive performance in individuals with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI).

DESIGN

Metaanalysis.

PARTICIPANTS

Individuals undergoing TAVI (N = 1,065 (48.5% male) from 18 studies, average age ≥80).

MEASUREMENTS

The MEDLINE, EMBASE, and Cochrane Central databases were searched for original peer-reviewed reports assessing cognitive performance using standardized cognitive tests before and after TAVI. Data were extracted for cognitive scores before TAVI; perioperatively (within 7 days after TAVI); 1, 3, and 6 months after TAVI, and 12 to 34 months after TAVI (over the long term). Standardized mean differences (SMDs) were generated using random-effects models for changes in cognition at each time point. Metaregression analyses were conducted to assess the association between population and procedural characteristics and cognitive outcomes. Risk of bias was assessed.

RESULTS

There were no significant changes from baseline in perioperative cognitive performance (SMD = 0.05, 95% confidence interval (CI) = -0.08-0.18; z = 0.75, P = .46), although overall cognitive performance had improved significantly 1 month after TAVI (SMD = -0.33, 95% CI = -0.50 to -0.16; z = 3.83, P < .001). There were no differences in cognitive performance 3 and 6 months after TAVI or over the long term. Cognitive outcomes were not associated with any covariates in regression analyses.

CONCLUSION

Cognitive performance is preserved after TAVI, suggesting TAVI is not detrimental to cognition.