The relationship between chronic obstructive pulmonary disease and transcatheter aortic valve implantation-A systematic review and meta-analysis

Incidence, predictors, and prognostic significance of impaired functional status early after transcatheter aortic valve replacement

INTRODUCTION AND OBJECTIVES

There are scarce data on the factors associated with impaired functional status after transcatheter aortic valve replacement (TAVR) and its clinical impact. This study aimed to determine the incidence, predictors, and prognostic implications of impaired functional class (NYHA class III-IV) following TAVR.

METHODS

This multicenter study included 3462 transarterial TAVR patients receiving newer generation devices. The patients were compared according to their NYHA class at 1 month of follow-up (NYHA I-II vs NYHA III-IV). A multivariate logistic regression was performed to identify the predictors of 30-day NYHA class III-IV. Patient survival was compared with the Kaplan-Meier method and factors associated with decreased survival were identified with Cox regression analysis.

RESULTS

The mean age of the study population was 80.3±7.3 years, with 47% of women, and a median Society of Thoracic Surgeons score of 3.8% [IQR, 2.5-5.8]. A total of 208 patients (6%) were in NYHA class III-IV 1 month after TAVR. Predictors of 30-day NYHA class III-IV were baseline NYHA class III-IV (OR, 1.76; 95%CI, 1.08-2.89; P=.02), chronic pulmonary obstructive disease (OR, 1.80; 95%CI, 1.13-2.83; P=.01), and post-TAVR severe mitral regurgitation (OR, 2.00; 95%CI, 1.21-3.31; P<.01). Patients in NYHA class III-IV 1 month after TAVR were at higher risk of death (HR, 3.68; 95%CI, 2.39-5.70; P<.01) and heart failure-related hospitalization (HR, 6.00; 95%CI, 3.76-9.60; P<.01) at 1-year follow-up.

CONCLUSIONS

Up to 6% of contemporary TAVR patients exhibited an impaired functional status following TAVR. Worse baseline NYHA class, chronic pulmonary obstructive disease, and severe mitral regurgitation predicted 30-day NYHA class III/IV, and this determined a higher risk of mortality and heart failure hospitalization at 1-year follow-up. Further studies on the prevention and treatment optimization of patients with impaired functional status after TAVR are needed.

Comorbidity clusters and in-hospital outcomes in patients admitted with acute myocardial infarction in the USA: A national population-based study

BACKGROUND

The prevalence of multimorbidity in patients with acute myocardial infarction (AMI) is increasing. It is unclear whether comorbidities cluster into distinct phenogroups and whether are associated with clinical trajectories.

METHODS

Survey-weighted analysis of the United States Nationwide Inpatient Sample (NIS) for patients admitted with a primary diagnosis of AMI in 2018. In-hospital outcomes included mortality, stroke, bleeding, and coronary revascularisation. Latent class analysis of 21 chronic conditions was used to identify comorbidity classes. Multivariable logistic and linear regressions were fitted for associations between comorbidity classes and outcomes.

RESULTS

Among 416,655 AMI admissions included in the analysis, mean (±SD) age was 67 (±13) years, 38% were females, and 76% White ethnicity. Overall, hypertension, coronary heart disease (CHD), dyslipidaemia, and diabetes were common comorbidities, but each of the identified five classes (C) included ≥1 predominant comorbidities defining distinct phenogroups: cancer/coagulopathy/liver disease class (C1); least burdened (C2); CHD/dyslipidaemia (largest/referent group, (C3)); pulmonary/valvular/peripheral vascular disease (C4); diabetes/kidney disease/heart failure class (C5). Odds ratio (95% confidence interval [CI]) for mortality ranged between 2.11 (1.89-2.37) in C2 to 5.57 (4.99-6.21) in C1. For major bleeding, OR for C1 was 4.48 (3.78; 5.31); for acute stroke, ORs ranged between 0.75 (0.60; 0.94) in C2 to 2.76 (2.27; 3.35) in C1; for coronary revascularization, ORs ranged between 0.34 (0.32; 0.36) in C1 to 1.41 (1.30; 1.53) in C4.

CONCLUSIONS

We identified distinct comorbidity phenogroups that predicted in-hospital outcomes in patients admitted with AMI. Some conditions overlapped across classes, driven by the high comorbidity burden. Our findings demonstrate the predictive value and potential clinical utility of identifying patients with AMI with specific comorbidity clustering.

In-Hospital and One-Year Outcomes of Transcatheter Aortic Valve Replacement in Patients Requiring Supplemental Home Oxygen Use

Background

There have been limited reports with inconsistent results on the impact of long-term use of oxygen therapry (LTOT) in patients treated with transcatheter aortic valve replacement (TAVR).

Methods

We compared in-hospital and intermediate TAVR outcomes in 150 patients requiring LTOT (home O₂ cohort) with 2,313 non-home O₂ patients.

Results

Home O₂ patients were younger, and had more comorbidities including chronic obstructive pulmonary disease (COPD), diabetes, carotid artery disease, lower forced expiratory volume (FEV₁) (50.3±21.1% vs. 75.0±24.7%, P < 0.001), and lower diffusion capacity (DLCO, 48.6±19.2% vs. 74.6±22.4%, P < 0.001). These differences represented higher baseline Society of Thoracic Surgeons (STS) risk score (15.5±10.2% vs. 9.3±7.0%, P < 0.001) and lower pre-procedure Kansas City Cardiomyopathy Questionnaire (KCCQ-12) scores (32.5 ± 22.2 vs. 49.1 ± 25.4, P < 0.001). The home O₂ cohort required higher use of alternative TAVR vascular access (24.0% vs. 12.8%, P = 0.002) and general anesthesia (51.3% vs. 36.0%, P < 0.001). Compared to non-home O₂ patients, home O₂ patients showed increased in-hospital mortality (5.3% vs. 1.6%, P = 0.001), procedural cardiac arrest (4.7% vs. 1.0%, P < 0.001), and postoperative atrial fibrillation (4.0% vs. 1.5%, P = 0.013). At 1-year follow-up, the home O₂ cohort had a higher all-cause mortality (17.3% vs. 7.5%, P < 0.001) and lower KCCQ-12 scores (69.5 ± 23.8 vs. 82.1 ± 19.4, P < 0.001). Kaplan-Meir analysis revealed a lower survival rate in the home O₂ cohort with an overall mean (95% confidence interval (CI)) survival time of 6.2 (5.9 - 6.5) years (P < 0.001).

Conclusion

Home O₂ patients represent a high-risk TAVR cohort with increased in-hospital morbidity and mortality, less improvement in 1-year KCCQ-12, and increased mortality at intermediate follow-up.

Association Between Chronic Obstructive Pulmonary Disease and All-Cause Mortality After Aortic Valve Replacement for Aortic Stenosis

Chronic obstructive pulmonary disease (COPD) and aortic stenosis (AS) are the most common diseases in which age plays a major role in the increase of their prevalence and when they co-exist, the outcomes prognosis worsens significantly. The aim of the present study was to evaluate the association between pulmonary functional parameters and all-cause mortality after aortic valve replacement (transcatheter or surgical). A total of 400 patients with severe AS and preoperative pulmonary functional test were retrospectively analyzed. Echocardiography and pulmonary functional parameters before aortic valve replacement were collected. COPD severity was defined according to criteria from the Society of Thoracic Surgeons. COPD was present in 128 patients (32%) with severe AS. Patients without COPD had smaller left ventricular (LV) mass and LV end-systolic volume and better LV function than the group with COPD. During a median follow-up of 32 months, 92 patients (23%) died. The survival rates were significantly lower in patients with moderate and severe COPD (log-rank p = 0.003). In the multivariable Cox regression analysis, any grade of COPD was associated with an approximately 2-fold increased risk of all-cause mortality (hazard ratio 1.933; 95% confidence interval 1.166 to 3.204; p = 0.011 for mild COPD and hazard ratio 2.028; 95% confidence interval 1.154 to 3.564; p = 0.014 for moderate or severe COPD). In addition to other clinical factors, any grade of COPD was associated with 2-fold increased risk of all-cause mortality.

Modifiable risk factors for permanent pacemaker after transcatheter aortic valve implantation: CONDUCT registry

OBJECTIVE

The onset of new conduction abnormalities requiring permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) is still a relevant adverse event. The main objective of this registry was to identify modifiable procedural risk factors for an improved outcome (lower rate of PPI) after TAVI in patients at high risk of PPI.

METHODS

Patients from four European centres receiving a balloon-expandable TAVI (Edwards SAPIEN 3/3 Ultra) and considered at high risk of PPI (pre-existing conduction disturbance, heavily calcified left ventricular outflow tract or short membranous septum) were prospectively enrolled into registry.

RESULTS

A total of 300 patients were included: 42 (14.0%) required PPI after TAVI and 258 (86.0%) did not. Patients with PPI had a longer intensive care unit plus intermediate care stay (65.7 vs 16.3 hours, p<0.001), general ward care stay (6.9 vs 5.3 days, p=0.004) and later discharge (8.6 vs 5.0 days, p<0.001). Of the baseline variables, only pre-existing right bundle branch block at baseline (OR 6.8, 95% CI 2.5 to 18.1) was significantly associated with PPI in the multivariable analysis. Among procedure-related variables, oversizing had the highest impact on the rate of PPI: higher than manufacturer-recommended sizing, mean area oversizing as well as the use of the 29 mm valve (OR 3.4, 95% CI 1.4 to 8.5, p=0.008) all were significantly associated with PPI. Rates were higher with the SAPIEN 3 (16.1%) vs SAPIEN 3 Ultra (8.5%), although not statistically significant but potentially associated with valve sizing. Implantation depth and postdelivery balloon dilatation also tended to affect PPI rates but without a statistical significance.

CONCLUSION

Valve oversizing is a strong procedure-related risk factor for PPI following TAVI. The clinical impact of the valve type (SAPIEN 3), implantation depth, and postdelivery balloon dilatation did not reach significance and may reflect already refined procedures in the participating centres, giving attention to these avoidable risk factors.

TRIAL REGISTRATION NUMBER

NCT03497611.

Conscious sedation versus general anesthesia for transcatheter aortic valve implantation in patients with severe chronic obstructive pulmonary disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is considered a major risk factor for postoperative complications after transcatheter aortic valve implantation (TAVI). To date, there is no clear consensus on the best anesthesia management for these patients. We aimed to investigate the effects of types of anesthesia on clinical outcomes in patients with severe COPD undergoing TAVI.

METHODS

This is a single-center, retrospective study comparing conscious sedation (CS) versus general anesthesia (GA) in 72 patients with severe COPD who underwent TAVI. The primary endpoints were 30-day all-cause mortality and postoperative pulmonary complications.

RESULTS

The main outcome of interest of this study was that the frequency of pulmonary complications was statistically higher in the GA group (21.4% vs 3.3%, p = 0.038). These differences are most likely attributed to the GA because of prolonged mechanical ventilation, and longer ICU stay (2 (1.2-3) vs 2.5 (2-4) days, p = 0.029) associated with an increased risk of nosocomial infections. There were no significant differences in procedure complications and 30-day mortality between the two groups (GA; 19% vs CS; 13.3%, p = 0.521). One-year survival rates, compared by Kaplan-Meier analysis, were similar between groups (log-rank p = 0.733).

CONCLUSION

In aortic stenosis patients with severe COPD undergoing TAVI, the use of GA compared with CS was associated with higher incidences of respiratory-related complications, and longer ICU length of stay. CS is a safe and viable option for these patients and should be considered the favored approach.

Clinical outcomes of patients with hepatic insufficiency undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis

Background

Transcatheter aortic valve implantation (TAVI) is currently a common treatment in high-risk aortic stenosis patients, but the impact of hepatic insufficiency on prognosis after TAVI is debatable and whether TAVI is superior to surgical aortic valve replacement (SAVR) in patients with hepatic insufficiency is uncertain.

Objective

To investigate the effect of abnormal liver function on the outcome and safety after TAVI and whether TAVI is superior to SAVR in patients with hepatic insufficiency.

Methods

PubMed, Embase, the Cochrane Library and Web of Science were systematically searched from inception up to 26 November 2021. Studies were eligible if mortality and complications after TAVI in patients with and without hepatic insufficiency, or mortality and complications for TAVI versus SAVR in patients with hepatic insufficiency were reported. The Newcastle–Ottawa scale (NOS) was used to evaluate the quality of each study. This meta-analysis was registered with PROSPERO (CRD42021253423) and was carried out by using RevMan 5.3 and Stata 14.0.

Results

This meta-analysis of 21 studies assessed a total of 222,694 patients. Hepatic insufficiency was associated with higher short-term (in-hospital or 30-day) mortality [OR = 1.62, 95% CI (1.18 to 2.21), P = 0.003] and 1–2 years mortality [HR = 1.64, 95% CI (1.42 to 1.89), P < 0.00001] after TAVI. Between TAVI and SAVR in patients with hepatic insufficiency, there was a statistically significant difference in in-hospital mortality [OR = 0.46, 95% CI (0.27 to 0.81), P = 0.007], the occurrence rate of blood transfusions [OR = 0.29, 95% CI (0.22 to 0.38), P < 0.00001] and the occurrence rate of acute kidney injury [OR = 0.55, 95% CI (0.33 to 0.91), P = 0.02].

Conclusions

TAVI patients with hepatic insufficiency may have negative impact both on short-term (in-hospital or 30-day) and 1–2-years mortality. For patients with hepatic insufficiency, TAVI could be a better option than SAVR.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02510-2.

Futility in Transcatheter Aortic Valve Implantation: A Search for Clarity

Although transcatheter aortic valve implantation (TAVI) has revolutionised the landscape of treatment for aortic stenosis, there exists a cohort of patients where TAVI is deemed futile. Among the pivotal high-risk trials, one-third to half of patients either died or received no symptomatic benefit from the procedure at 1 year. Futility of TAVI results in the unnecessary exposure of risk for patients and inefficient resource utilisation for healthcare services. Several cardiac and extra-cardiac conditions and frailty increase the risk of mortality despite TAVI. Among the survivors, these comorbidities can inhibit improvements in symptoms and quality of life. However, certain conditions are reversible with TAVI (e.g. functional mitral regurgitation), attenuating the risk and improving outcomes. Quantification of disease severity, identification of reversible factors and a systematic evaluation of frailty can substantially improve risk stratification and outcomes. This review examines the contribution of pre-existing comorbidities towards futility in TAVI and suggests a systematic approach to guide patient evaluation.

Predictors and clinical outcomes of poor symptomatic improvement after transcatheter aortic valve replacement

Objective

Transcatheter aortic valve replacement (TAVR) improves clinical symptoms in most patients with severe aortic stenosis (AS). However, some patients do not benefit from the symptom-reducing effects of TAVR. We assessed the predictors and clinical outcomes of poor symptomatic improvement (SI) after TAVR.

Methods

A total of 1749 patients with severe symptomatic AS undergoing transfemoral TAVR were evaluated using the Japanese multicentre TAVR registry. Poor SI was defined as readmission for heart failure (HF) within 1 year after TAVR or New York Heart Association (NYHA) class ≥3 after 1 year. A logistic regression model was used to identify predictors of poor SI. One-year landmark analysis after TAVR was used to evaluate the association between poor SI and clinical outcomes.

Results

Among the overall population (mean age, 84.5 years; female, 71.3%; mean STS score, 6.3%), 6.6% were categorised as having poor SI. Atrial fibrillation, chronic obstructive pulmonary disease, Clinical Frailty Scale ≥4, chronic kidney disease and moderate to severe mitral regurgitation were independent predictors of poor SI. One-year landmark analysis demonstrated that poor SI had a higher incidence of all-cause death and readmission for HF compared with SI (p<0.001). Poor SI with preprocedural NYHA class 2 had a worse outcome than SI with preprocedural NYHA class ≥3.

Conclusions

Poor SI was associated with worse outcomes 1 year after the procedure. It had a greater impact on clinical outcomes than baseline symptoms. TAVR may be challenging for patients with many predictors of poor SI.

Trial registration number

This registry, associated with the University Hospital Medical Information Network Clinical Trials Registry, was accepted by the International Committee of Medical Journal Editors (UMIN-ID: 000020423).

Transcatheter versus surgical aortic valve replacement in patients with chronic obstructive pulmonary disease

Although a number of studies compared mortality after transcatheter aortic valve implantation (TAVI) with that after surgical aortic replacement (SAVR) in patients with chronic obstructive pulmonary disease (COPD), no meta-analysis of them has been conducted to date. To determine whether TAVI or SAVR is associated with better postprocedural survival in patients with COPD, a meta-analysis of all studies currently available was performed. Design. To identify all comparative studies of TAVI with SAVR in patients with COPD, PubMed and Web of Science were searched through January 2020. Studies meeting the following criteria were included in the present meta-analysis: the design was an observational comparative study or a randomized controlled trial; the study population was patients with COPD; patients were assigned to TAVI versus SAVR; and outcomes included all-cause mortality. Adjusted (if unavailable, unadjusted) odds or hazard ratios with their confidence intervals (CIs) of mortality for TAVI versus SAVR were extracted from each study. Study-specific estimates were combined in the random-effects model. Results. Six eligible studies with a total of 4771 patients with COPD were identified and included in the present meta-analysis. The meta-analysis indicated significantly lower early (in-hospital or 30-day) mortality after TAVI than after SAVR (odds ratio, 0.69; 95% CI, 0.53-0.90; p = .006) but no significant difference in midterm (1-year to 5-year) mortality between TAVI and SAVR (hazard ratio, 1.07; 95% CI, 0.79-1.44; p = .68). Conclusions. In patients with COPD, TAVI was associated with reduced early mortality, while midterm mortality appeared similar, as compared with SAVR.

Short- and medium-term survival after TAVI: Clinical predictors and the role of the FRANCE-2 score

Aim

The aim of this study was to explore the value of the FRANCE-2 score in associating with clinical outcome in the medium and short-term after TAVI and to compare its relative merits with other risk score models.

Methods

187 consecutive patients undergoing TAVI in a single UK centre were retrospectively studied. The FRANCE-2, logistic EuroSCORE, EuroSCORE II, German AV and STS/ACC TVT risk scores were calculated retrospectively and c-statistics associating with mortality were applied. Survival outcomes were compared between different risk groups according to the FRANCE-2 scores.

Results

Of the 187 patients, 57.2% were male and their mean age was 80.9 ± 6.9 years. The c-index of FRANCE-2 score for predicting 30-day mortality was 0.793 (p = 0.009), for 1-year mortality 0.679 (p = 0.016) and for 2-year mortality was 0.613 (p = 0.088). The mean survival time for patients with a high FRANCE-2 score (18.6 months) was significantly less than for patients with low and moderate scores (p = 0.0004). The logistic EuroSCORE and EuroSCORE II were poorly associated with 30-day and 1-year mortality. STS/ACC TVT score was best predictive of 1-year mortality and German AV score was moderately predictive of 30-day mortality.

Conclusions

The FRANCE-2 risk score is associated with differential short- and medium-term survival in patients undergoing TAVI. The presence of a high FRANCE-2 score (>5) is associated with poor survival. The FRANCE-2 scoring system could be considered as a useful additional tool by the Heart multidisciplinary team (MDT) in identifying patients who are likely to have limited survival benefit although this requires further prospective evaluation.

Elevated high-sensitivity troponin T levels at 1-year follow-up are associated with increased long-term mortality after TAVR

Background

Elevated pre-procedural high-sensitivity troponin T (hs-TnT) levels predict adverse outcomes in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). It is unknown whether elevated troponin levels still provide prognostic information during follow-up after successful TAVR. We evaluated the long-term implications of elevated hs-TnT levels found at 1-year post-TAVR.

Methods and results

The study included 349 patients who underwent TAVR for severe AS from 2010–2019 and for whom 1-year hs-TnT levels were available. Any required percutaneous coronary interventions were performed > 1 week before TAVR. The primary endpoint was survival time starting at 1-year post-TAVR. Optimal hs-TnT cutoff for stratifying risk, identified by ROC analysis, was 39.4 pg/mL. 292 patients had hs-TnT < 39.4 pg/mL (median 18.3 pg/mL) and 57 had hs-TnT ≥ 39.4 pg/mL (median 51.2 pg/mL). The high hs-TnT group had a higher median N-terminal pro-B-type natriuretic peptide (NT-proBNP) level, greater left ventricular (LV) mass, higher prevalence of severe diastolic dysfunction, LV ejection fraction < 35%, severe renal dysfunction, and more men compared with the low hs-TnT group. All-cause mortality during follow-up after TAVR was significantly higher among patients who had hs-TnT ≥ 39.4 pg/mL compared with those who did not (mortality rate at 2 years post-TAVR: 12.3% vs. 4.1%, p = 0.010). Multivariate analysis identified 1-year hs-TnT ≥ 39.4 pg/mL (hazard ratio 2.93, 95% CI 1.91–4.49, p < 0.001), NT-proBNP level > 300 pg/mL, male sex, an eGFR < 60 mL/min/1.73 m² and chronic obstructive pulmonary disease as independent risk factors for long-term mortality after TAVR.

Conclusions

Elevated hs-TnT concentrations at 1-year after TAVR were associated with a higher long-term mortality.

Graphic abstract

Effects of COPD on in-hospital outcomes of transcatheter aortic valve implantation: Results from the National Inpatient Sample database

Background

Comorbid chronic obstructive pulmonary disease (COPD) increases morbidity and mortality among aortic valve replacement patients undergoing conventional surgery. The impact of COPD in patients undergoing less invasive transcatheter aortic valve insertion (TAVI) is unclear.

Hypothesis

This study evaluates the in‐hospital outcomes of TAVI in patients with and without COPD.

Methods

This population‐based, retrospective study of 8466 TAVI patients (29.87% with COPD) evaluates the effects of COPD on short‐term clinical outcomes (in‐hospital mortality, length of hospital stay, and postoperative complications) using data from the National Inpatient Sample database from 2011 to 2014. Logistic regression analysis was used to determine factors associated with in‐hospital mortality and postoperative complications. Linear regression analysis was used to identify factors associated with length of hospital stay.

Results

COPD is significantly associated with increased risk of respiratory complications and pneumonia after TAVI (aOR = 1.43, 95% CI: 1.24‐1.64; P < .001) but not in‐hospital mortality, length of hospital stay, or non‐respiratory postoperative complications as compared to non‐COPD patients. Concomitant COPD is significantly associated with increased risk of respiratory complications or pneumonia after TAVI but may still be the best treatment option for some patients.

Conclusions

Patients with comorbid COPD who receive TAVI have greater risk of developing postoperative respiratory complications and pneumonia. Vigilance for specific respiratory complications is highly warranted when treating this subgroup. Treatment decisions must be individualized.

Transcatheter aortic valve implantation-related futility: prevalence, predictors, and clinical risk model

Futility denotes failure to achieve the projected outcome. We investigated the prevalence, predictors, and clinical risk model of transcatheter aortic valve implantation (TAVI)-related futility. We included 464 consecutive patients undergoing TAVI from 2010 to 2017. Futility was defined as death and/or hospitalization for heart failure (HFH) within 1 year after TAVI. Of 464 patients (mean age: 84.4 years), 69% were females (EuroSCOREII: 6.3%; Society of Thoracic Surgeons [STS] score: 6.9%). Forty-six patients (9.9%) experienced TAVI-related futility, and 36 of 46 patients (69.6%) died within 1 year due to cardiac (37.5%) and non-cardiac (62.5%) causes. Previous HFH (hazard ratio [HR], 2.20; 95% confidence interval [CI]: 1.13-4.35, p = 0.020), chronic obstructive pulmonary disease (COPD) (HR, 3.39; 95% CI: 1.12-8.42, p = 0.033), and moderate/severe mitral or tricuspid regurgitation (HR, 2.98; 95% CI: 1.32-6.27, p = 0.010) were independent predictors of futility. With 1 point assigned to each predictor (total 0 point, futility low-risk; total 1 point, futility intermediate-risk; total 2-3 points, futility high-risk), the futility risk model clearly stratified individual futility risk into three groups (the freedom from futility at 1 year: 96.2%, 82.1%, and 67.9% each). Our futility risk model presented better discrimination than EuroSCOREII, and STS score (c-statistic: 0.73 vs. 0.68 vs. 0.67). Medical futility was recognized in 9.9% of patients undergoing TAVI. Previous HFH, COPD, and concomitant atrioventricular regurgitation were associated with futility. The risk model derived from three predictors showed good performance in predicting futility risk.

Is the Newly Defined R2CHA2DS2-Vasc Score a Predictor for Late Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement?

Objective

To assess the performance of the modified R₂CHA₂DS₂-VASc score for predicting mid-to-long-term mortality (> 30 days) in patients undergoing transcatheter aortic valve replacement (TAVR).

Methods

Data of 78 patients who underwent TAVR were retrospectively reviewed. R₂CHA₂DS₂-VASc score was compared with the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II or ES II) and the transcatheter valve therapytranscatheter aortic valve replacement (TVT-TAVR) risk score.

Results

The mean follow-up period was 17.4±9.9 months (maximum 37 months). Early mortality (first 30 days) was observed in 10 (12.8%) patients, whereas mid-to-long-term mortality (> 30 days) was observed in 26 (33.3%) patients. Non-survivors had higher values of R₂CHA₂DS₂-VASc, ES II, and TAVR scores than survivors (P<0.001, P<0.001, and P=0.001, respectively). Analysis of Pearson’s correlation revealed that R₂CHA₂DS₂-VASc score was moderately correlated with ES II and TAVR scores (r=0.51, P<0.001; r=0.44, P=0.001, respectively). Pairwise comparisons of R₂CHA₂DS₂-VASc (area under the curve [AUC]: 0.870, 95% confidence interval [CI]: 0.776-0.964; P<0.001), ES II (AUC: 0.801, 95% CI: 0.703-0.899; P<0.001), and TAVR scores (AUC: 0.730, 95% CI: 0.610-852; P=0.002) showed similar accuracy for predicting mortality. R₂CHA₂DS₂-VASc score is an independent predictor of mortality in multivariable Cox regression analysis. A cutoff value of six for R₂CHA₂DS₂-VASc score showed a sensitivity of 74% and a specificity of 89% for predicting mid-to-long-term mortality.

Conclusion

R₂CHA₂DS₂-VASc score, easily calculated from clinical parameters, is associated with prediction of mid-to-longterm mortality in patients undergoing TAVR.

Meta-Analysis and Meta-Regression of Transcatheter Aortic Valve Implantation for Pure Native Aortic Regurgitation

AIM

To assess outcomes of transcatheter aortic valve implantation (TAVI) for pure native aortic regurgitation (AR) and to evaluate whether 30-day all-cause mortality is modulated by patient characteristics, we performed a meta-analysis and meta-regression of currently available studies.

METHOD

Studies enrolling ≥20 patients undergoing TAVI for AR were considered for inclusion. Study-specific estimates (incidence rates of outcomes) were combined using one-group meta-analysis in a random-effects model. Subgroup meta-analysis of studies exclusively using early-generation devices (EGD) and new-generation devices (NGD) and stepwise random-effects multivariate meta-regression were also performed.

RESULTS

The search identified 11 eligible studies including a total of 911 patients undergoing TAVI for AR. Pooled analysis demonstrated an incidence of device success of 80.4% (NGD 90.2%, EGD 67.2%; p < 0.001), moderate or higher paravalvular aortic regurgitation (PAR) of 7.4% (NGD 3.4%, EGD 17.3%; p < 0.001), 30-day all-cause mortality of 9.5% (NGD 6.1%, EGD 14.7%; p < 0.001), mid-term (4 mo - 1 yr) all-cause mortality of 18.8% (NGD 11.8%, EGD 32.2%; p < 0.001), life-threatening/major bleeding complications (BC) 5.7% (NGD 3.5%, EGD 12.4%; p = 0.015), and major vascular complications (MVC) of 3.9% (NGD 3.0%, EGD 6.2%; p = 0.041). All coefficients in the multivariate meta-regression adjusting simultaneously for the proportion of diabetes mellitus, chronic obstructive pulmonary disease, peripheral arterial disease, concomitant moderate or higher mitral regurgitation, and mean left ventricular ejection fraction (with significant coefficients in the univariate meta-regression) were not statistically significant.

CONCLUSIONS

Thirty (30)-day all-cause mortality after TAVI for AR was high (9.5%) with a high incidence of moderate or higher PAR (7.4%). Compared with EGD, NGD was associated with significantly higher device success rates and significantly lower rates of second-valve deployment, moderate or higher PAR, 30-day/mid-term all-cause mortality, serious BC, and MVC.

Impact of concurrent tricuspid regurgitation on mortality after transcatheter aortic-valve implantation

OBJECTIVES

To determine whether concomitant tricuspid regurgitation (TR) is associated with increased mortality in patients with severe aortic stenosis (AS) undergoing transcatheter aortic-valve implantation (TAVI), we performed a meta-analysis of currently available studies.

METHODS

MEDLINE and EMBASE were searched through May 2018. We included comparative or cohort studies enrolling patients with AS undergoing TAVI and reporting early (in-hospital or 30-day) and late (including early) all-cause mortality in patients stratified by baseline TR grade. An odds ratio (OR) of early mortality and a hazard ratio (HR) of late mortality with its 95% CI for significant versus non-significant (typically, ≥moderate versus <moderate) TR was extracted. Study-specific estimates were combined in the random-effects model.

RESULTS

Our search identified 12 eligible studies enrolling a total of 41,485 TAVI patients. The meta-analysis for early mortality combining 3 ORs demonstrated a significant 1.80-fold increase in mortality with significant TR (OR, 1.80; 95% CI, 1.01 to 3.19; P = 0.05). The primary meta-analysis for midterm (6-month to 30-month) mortality combining all the 12 HRs/ORs indicated a significant 1.96-fold increase in mortality (HR/OR, 1.96; 95% CI, 1.35 to 2.85; P = 0.0004). The secondary meta-analysis for midterm mortality combining 7 homogeneous HRs (adjusted HRs for ≥moderate versus <moderate TR) showed a significant 2.25-fold increase in mortality (HR, 2.25; 95% CI, 1.20-4.24; P = 0.01).

CONCLUSIONS

Concurrent significant (typically, ≥moderate) TR is associated with an approximately two-fold increase in both early and midterm all-cause mortality in patients with AS undergoing TAVI.

Guideline-defined futility or patient-reported outcomes to assess treatment success after TAVI: what to use? Results from a prospective cohort study with long-term follow-up

Objective

Transcatheter aortic valve implantation (TAVI) provides a significant symptom relief and mortality reduction in most patients; however, a substantial group of patients does not experience the same beneficial results according to physician-determined outcomes.

Methods

Single-centre prospective design; the population comprises all consecutive patients undergoing TAVI in 2012-2017. TAVI futility was defined as the combined endpoint of either no symptomatic improvement or mortality at 1 year. We actively gathered telephone follow-up using a predefined questionnaire.

Results

Guideline defined TAVI futility was present in 212/741 patients. Multivariate regression showed lower albumin and non-transfemoral approach to be predictive for futility. In addition to these, chronic obstructive pulmonary disease, lower estimated glomerular filtration rate, atrial fibrillation, low-flow-low-gradient aortic stenosis and lower Body Mass Index were predictive for 1-year mortality. Patients who showed symptomatic benefit estimated the percentage in which their symptoms were remedied higher than patients who did not (80% vs 60%, p<0.001). Guideline-defined TAVI futility occurs frequently, contrasting with patient-reported outcome measures (PROMs). The vast majority in both groups would again choose for TAVI treatment.

Conclusion

Lower albumin and non-transfemoral access route were predictors for guideline-defined TAVI futility, defined as mortality within 1 year or no objective symptomatic improvement in New York Heart Association class. Futility according to this definition occurred frequently in this study, contrasting with much more positive PROMs. The majority of patients would undergo a TAVI again, underlining the patients' experienced value of TAVI and putting the definition of TAVI futility further on debate. In the near future, less-strict criteria for TAVI futility, that is, using a shorter warranted life expectancy and incorporating patients' perceived outcomes, should be used.

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.

Transcatheter aortic valve implantation in patients with a reduced left ventricular ejection fraction: a single-centre experience in 2000 patients (TAVIK Registry)

BACKGROUND

Previous studies into the effect of a reduced left ventricular ejection fraction (EF) on the short- and long-term prognosis of patients undergoing transcatheter aortic valve implantation (TAVI) have reported conflicting findings. We analysed data from the Karlsruhe TAVI registry with the aim of addressing this question.

METHODS AND RESULTS

Patients with aortic stenosis undergoing TAVI were divided into sub-groups according to EF: severely reduced (<30%; n = 109), reduced (≥30 and ≤40%; n = 201), and mid-range/preserved (>40%; n = 1690). VARC complications at 30 days for the population with severely reduced EF did not differ in comparison to the patients with mid-range/preserved EF. Patients with severely reduced EF had a significantly lower survival at 48 h (91.7 vs. 99.0%; p < 0.001), at 30 days (84.4 vs. 95.8%; p < 0.001) and at 1 year (66.1 vs. 85.0%, p < 0.001) compared to those with mid-range/preserved EF. The risk of death increased with age, peripheral arterial disease, poor self-care and chronic renal failure in patients with severely reduced EF.

CONCLUSIONS

Mortality post-TAVI was higher for patients with a reduced EF, although the excess comorbidity burden likely contributed to this. A reduced EF should not be considered a contraindication for TAVI per se, but the additional presence of comorbidity indicates increased risk for these patients.

Diabetes mellitus is associated with increased acute kidney injury and 1-year mortality after transcatheter aortic valve replacement: A meta-analysis

BACKGROUND

Diabetes mellitus (DM) is associated with adverse outcomes after surgical aortic valve replacement. However, there are conflicting data on the impact of DM on outcomes of transcatheter aortic valve replacement (TAVR).

HYPOTHESIS

DM is associated with poor outcomes after different cardiac procedures. Therefore, DM can also be associated with poor outcomes after TAVR.

METHODS

We searched PubMed and Cochrane Central Register of Controlled Trials for studies that evaluated outcomes after TAVR and stratified at least 1 of the studied endpoints by DM status. The primary endpoint was all-cause mortality at 1 year. Secondary endpoints were early (up to 30 days) mortality, acute kidney injury (AKI), cerebrovascular accident (CVA), major bleeding, and major vascular complications. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using random effects models.

RESULTS

We included 64 studies with a total of 38 686 patients. DM was associated with significantly higher 1-year mortality (OR: 1.14, 95% CI: 1.04-1.26, P = 0.008) and periprocedural AKI (OR: 1.28, 95% CI: 1.08-1.52, P = 0.004). On the other hand, there were no significant differences between diabetics and nondiabetics in early mortality, CVAs, major bleeding, or major vascular complications.

CONCLUSIONS

DM is associated with increased 1-year mortality and periprocedural AKI in patients undergoing TAVR. The results of this study suggest that DM is a predictor of adverse outcomes in patients undergoing TAVR.

A systematic review and meta-analysis-does chronic obstructive pulmonary disease predispose to bronchopleural fistula formation in patients undergoing lung cancer surgery?

BACKGROUND

we conducted this systematic meta-analysis to determine the association between chronic obstructive pulmonary disease (COPD) and risk of bronchopleural fistula (BPF) in patients undergoing lung cancer surgery.

METHODS

Literature retrieval was performed in PubMed, Embase and the Web of Science to identify the full-text articles that met our eligibility criteria. Odds ratio (OR) with 95% confidence interval (CI) served as the summarized statistics. Q-test and I(2)-statistic were used to evaluate the level of heterogeneity. Sensitivity analysis was performed to further examine the stability of pooled OR. Publication bias was detected by both Begg's test and Egger's test.

RESULTS

Eight retrospective observational studies were included into this meta-analysis. The overall summarized OR was 2.03 (95% CI: 1.44-2.86; P<0.001), revealing that COPD was significantly associated with the risk of BPF after lung cancer surgery. In subgroup analysis, the relationship between COPD and BPF occurrence remained statistically prominent in the subgroups stratified by statistical analysis (univariate analysis, OR: 1.91; 95% CI: 1.35-2.69; P<0.001; multivariate analysis, OR: 3.18; 95% CI: 1.95-5.19; P<0.001), operative modes (pneumonectomy, OR: 2.11; 95% CI: 1.15-3.87; P=0.016) and in non-Asian populations (OR: 2.36; 95% CI: 1.18-4.73; P=0.016). No significant impact of COPD on BPF risk was observed in Asian patients (OR: 1.48; 95% CI: 0.85-2.57; P=0.16). No significant heterogeneity or publication bias was discovered across the included studies.

CONCLUSIONS

Our meta-analysis indicates that COPD can significantly predispose to BPF formation in patients undergoing lung cancer surgery. Because some limitations still exist in this meta-analysis, our findings should be further verified and modified in the future.