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Domondon IAA, Jeyakumar D, Raake M, Halaharvi SP, Zafar F, Contreras Vazquez SA, Abarca YA, Goli SR, Rohra D, Shah F, Sikander M, Al-Tawil M. Outcomes of Surgical Versus Transcatheter Aortic Valve Replacement in Obese Patients: A Systematic Review and Meta-Analysis. Cardiol Rev 2024:00045415-990000000-00321. [PMID: 39254505 DOI: 10.1097/crd.0000000000000767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
Transcatheter aortic valve implantation (TAVI) has been increasingly preferred over surgical aortic valve replacement (SAVR) for treating patients with severe aortic stenosis and intermediate to high surgical risk. Recent studies have indicated that obesity may confer protective benefits in cardiac surgery, known as the obesity paradox. We conducted a systematic review and meta-analysis to explore how obesity influences outcomes of TAVI versus SAVR. We searched and reviewed relevant studies comparing TAVI and SAVR in obese patients with aortic stenosis indexed in PubMed, Embase, and Scopus databases. Data from 5 studies with 16,161 patients (TAVI, n = 2951; SAVR, n = 13,210) were included. There was a lower incidence of postprocedural in-hospital mortality [risk ratio (RR), 0.64; 95% confidence interval (CI), 0.41-0.98; P = 0.04], acute kidney injury (RR, 0.53; 95% CI, 0.38-0.73; P = 0.0001), and shorter duration of in-hospital stay (mean difference: -3.35; 95% CI, -4.93 to -1.76; P = 0.0001) in TAVI versus SAVR. There was no significant difference in the risk of postoperative stroke (RR, 0.93; 95% CI, 0.29-3.02; P = 0.91), major bleeding (RR, 0.71; 95% CI, 0.47-1.07; P = 0.10), and myocardial infarction (RR, 0.64; 95% CI, 0.39-1.06; P = 0.08) between TAVI and SAVR. Higher incidences of PPM implantation (RR, 2.0; 95% CI, 1.38-2.90; P = 0.0003) and major vascular complications (RR, 1.51; 95% CI, 1.01-2.27; P = 0.05) were observed with TAVI. In obese patients, TAVI offers similar results as in the general population when compared with SAVR, except for increased vascular complications. An individualized approach can lead to optimal outcomes in this subpopulation.
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Affiliation(s)
- Ileana Anika A Domondon
- From the Emergency Medicine Department, Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom
| | - Deepapriya Jeyakumar
- Internal Medicine Department, Government Sivagangai Medical College, Tamil Nadu Dr. M.G.R Medical University, Sivagangai, India
| | - Mohammed Raake
- Faculty of Medicine, Annamalai University, Chidambaram, Cuddalore, India
| | - Savitri Poornima Halaharvi
- Department of Cardiology, JSS Medical College, Rajiv Gandhi University of Health Sciences, Mysore, India
| | - Fabeha Zafar
- Department of Cardiology, Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Yozahandy A Abarca
- Department of Cardiology, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Mexico City, Mexico
| | - Snehitha Reddy Goli
- Department of Cardiology, College of Medicine, Zhengzhou University, Henan Province, Henan, China
| | - Divya Rohra
- Department of Cardiology, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Farah Shah
- Internal Medicine Department, Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan
| | - Mohammed Sikander
- Department of Cardiology, School of Medicine, University of Texas Rio Grande Valley, TX; and
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Sehgal K, Butala AD, Stub D, Palmer S, Noaman S, Haji K, Htun N, Johnston R, Walton A, Nanayakkara S. Incidence and predictors of vascular complications following transcatheter aortic valve implantation: A comparison of the MANTA and suture-based vascular closure devices. Catheter Cardiovasc Interv 2024. [PMID: 39138822 DOI: 10.1002/ccd.31185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 07/10/2024] [Accepted: 08/05/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Vascular complications post-transcatheter aortic valve implantation (TAVI) are common. Recent data regarding predictors of vascular complications are limited, particularly comparing newer plug-based devices versus traditional suture-based vascular closure devices (VCD). AIM The primary objective was to identify characteristics that predict a higher risk of vascular complications in TAVI patients, as judged by the VARC-3 criteria, specifically comparing risk factors between suture-based vs MANTA device closure. METHODS Retrospective analysis of patients who underwent TAVI between December 2019 and September 2023 was performed. Logistic regression and propensity score matching was performed to ascertain risk factors for vascular complications post-TAVI. RESULTS Of the 1763 patients, there were 106 vascular complications (6%). There was a nonsignificant increased complication rate in MANTA vs suture-based device closure (8.3% vs 5.3%, p = 0.064). Among these, the most common complications were VCD failure (23%), pseudoaneurysm (20%) and arterial dissection (19%). Obesity (p = 0.021), anemia (p = 0.039) and MANTA device use (p = 0.027) were predictors of vascular complications. Within the MANTA cohort, novel oral anticoagulant (NOAC) use was predictive of vascular complications (p = 0.002). Among suture-based devices, obesity (p = 0.037) and anaemia (p = 0.017) were significant predictors. A propensity matched analysis derived 90 pairs of patients matched for age, gender, diabetes, peripheral arterial disease, NOAC use, anemia and obesity, identifying an average treatment effect of 0.039 (p = 0.04) when MANTA device closure was performed. CONCLUSION Vascular complications in TAVI remain common. Identifying predictors such as MANTA device closure, obesity, anemia, and baseline NOAC use will allow for improved risk stratification and appropriate VCD selection in patients undergoing TAVI.
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Affiliation(s)
- Kartik Sehgal
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Anant D Butala
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Cardiology, Cabrini Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Sonny Palmer
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Kawa Haji
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Nay Htun
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Cardiology, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Rozanne Johnston
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Cardiology, Epworth Hospital, Melbourne, Victoria, Australia
| | - Shane Nanayakkara
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
- Department of Cardiology, Cabrini Hospital, Melbourne, Victoria, Australia
- Department of Cardiology, Epworth Hospital, Melbourne, Victoria, Australia
- Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Victoria, Australia
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Seo J, Kharawala A, Borkowski P, Singh N, Akunor H, Nagraj S, Avgerinos DV, Kokkinidis DG. Obesity and Transcatheter Aortic Valve Replacement. J Cardiovasc Dev Dis 2024; 11:169. [PMID: 38921670 PMCID: PMC11203863 DOI: 10.3390/jcdd11060169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 05/20/2024] [Accepted: 05/24/2024] [Indexed: 06/27/2024] Open
Abstract
Amidst an aging population and escalating obesity prevalence, elucidating the impact of obesity on transcatheter aortic valve replacement (TAVR) outcomes becomes paramount. The so-called "obesity paradox"-a term denoting the counterintuitive association of obesity, typically a risk factor for cardiovascular diseases, with improved survival outcomes in TAVR patients relative to their leaner or normal-weight counterparts-merits rigorous examination. This review comprehensively investigates the complex relationship between obesity and the clinical outcomes associated with TAVR, with a specific focus on mortality and periprocedural complications. This study aims to deepen our understanding of obesity's role in TAVR and the underlying mechanisms of the obesity paradox, thereby optimizing management strategies for this patient demographic, tailored to their unique physiological and metabolic profiles.
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Affiliation(s)
- Jiyoung Seo
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY 10461, USA (P.B.)
| | - Amrin Kharawala
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY 10461, USA (P.B.)
| | - Pawel Borkowski
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY 10461, USA (P.B.)
| | - Nikita Singh
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY 10461, USA (P.B.)
| | - Harriet Akunor
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY 10461, USA (P.B.)
| | - Sanjana Nagraj
- Department of Cardiology, Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | | | - Damianos G. Kokkinidis
- Section of Cardiovascular Medicine, Lawrence Memorial Hospital & Northeast Medical Group, Yale New Haven Heath, New London, CT 06614, USA
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Wahadneh OA, Rahman SU, Alziadin N, Maraey A, Raju A, Al-Khalaileh A, Albarakat MM, Aziz S, Dani SS. Inpatient outcomes of transcatheter aortic valve replacement based on class of obesity. Curr Probl Cardiol 2024; 49:102407. [PMID: 38237813 DOI: 10.1016/j.cpcardiol.2024.102407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 01/14/2024] [Indexed: 01/30/2024]
Abstract
Transcatheter aortic valve replacement (TAVR) is a transformative option for severe aortic stenosis, especially in elderly patients. obesity's impact on TAVR outcomes is limited. Using the National Inpatient Sample from 2016 to 2020, We analyzed 217,300 TAVR hospitalizations across BMI groups. No difference in in-hospital mortality was observed, class III obesity experienced longer hospital stays (adjusted β: 0.43 days, P < 0.05), higher costs (adjusted β: $3,126, P < 0.05), increased heart failure exacerbation (adjusted odds ratio [aOR]: 2.68, 95% confidence interval [CI]: [1.03-7.01], p < 0.05), vascular access complications (aOR: 1.29, 95% CI: [1.07-1.52], P < 0.05), and post-operative pulmonary complications (Pneumonia (aOR: 1.42, 95% CI: [1.16-1.74], p < 0.05), acute hypoxic respiratory failure (aOR: 1.99, 95% CI: [1.67-2.36], p < 0.05), and non-invasive ventilation (aOR: 1.62, 95% CI: [1.07-2.44], p < 0.05). Complete heart block and permanent pacemaker requirement were higher in both class II and class III ((aOR: 1.30, 95% CI: [1.11-1.51], P < 0.05), (aOR:1.25, 95% CI: [1.06-1.46], P < 0.05) and ((aOR: 1.18, 95% CI: [1.00-1.40], P < 0.05), (aOR:1.22, 95% CI: [1.02-1.45], P < 0.05)) respectively. Understanding these links is crucial for optimizing TAVR care in obesity, ensuring enhanced outcomes, and procedural safety.
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Affiliation(s)
- Omar Al Wahadneh
- Department of Internal Medicine, Carle Foundation Hospital, Urbana, IL, United States.
| | - Saad Ur Rahman
- Department of Internal Medicine, Carle Foundation Hospital, Urbana, IL, United States
| | - Nmair Alziadin
- Department of Internal Medicine, HCA Healthcare/Tufts University School of Medicine: Portsmouth Regional Hospital, Portsmouth, NH, United States
| | - Ahmed Maraey
- Department of Cardiovascular Medicine, University of Toledo, Toledo, OH, United States
| | - Apoorva Raju
- Department of Internal Medicine, Carle Foundation Hospital, Urbana, IL, United States
| | - Ali Al-Khalaileh
- Department of Cardiovascular Medicine, University of Toledo, Toledo, OH, United States
| | - Majd M Albarakat
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Shazia Aziz
- Department of Cardiovascular Medicine, Christiana Care, Newark, DE, United States
| | - Sourbha S Dani
- Cardiovascular Medicine, Lahey Hospital & Medical Center, Burlington, MA, United States
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Khan S, Jagathesan R, Frost OM, Crawford I, Smith S, Gedela S, Fawaz S, Simpson R, Singh A, Karamasis GV, Keeble TR, Davies JR, Kabir A, Aggarwal R, Cook CM. FAcilitating Safe Trans-femoral ACCESS for Transcatheter Aortic Valve Replacement in High Body Mass Index Patients-The FAST-ACCESS Cohort Study. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2024; 8:100232. [PMID: 38283568 PMCID: PMC10818142 DOI: 10.1016/j.shj.2023.100232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 09/11/2023] [Accepted: 09/27/2023] [Indexed: 01/30/2024]
Affiliation(s)
- Sarosh Khan
- Essex Cardiothoracic Centre, Basildon, Essex, UK
- Anglia Ruskin University, Chelmsford, Essex, UK
| | | | | | | | - Sheila Smith
- Essex Cardiothoracic Centre, Basildon, Essex, UK
| | - Swamy Gedela
- Essex Cardiothoracic Centre, Basildon, Essex, UK
| | - Samer Fawaz
- Essex Cardiothoracic Centre, Basildon, Essex, UK
- Anglia Ruskin University, Chelmsford, Essex, UK
| | - Rupert Simpson
- Essex Cardiothoracic Centre, Basildon, Essex, UK
- Anglia Ruskin University, Chelmsford, Essex, UK
| | - Arvind Singh
- Essex Cardiothoracic Centre, Basildon, Essex, UK
| | - Grigoris V. Karamasis
- Essex Cardiothoracic Centre, Basildon, Essex, UK
- Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Thomas R. Keeble
- Essex Cardiothoracic Centre, Basildon, Essex, UK
- Anglia Ruskin University, Chelmsford, Essex, UK
| | | | | | | | - Christopher M. Cook
- Essex Cardiothoracic Centre, Basildon, Essex, UK
- Anglia Ruskin University, Chelmsford, Essex, UK
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6
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Akhtar R, Gul W, Nasir BM, Salman A. Response to "Body Mass Index and Outcomes of Transcatheter Aortic Valve Replacement: A Retrospective Observational Study". Curr Probl Cardiol 2024; 49:102132. [PMID: 37865302 DOI: 10.1016/j.cpcardiol.2023.102132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/14/2023] [Indexed: 10/23/2023]
Affiliation(s)
| | - Wajiha Gul
- Dow University of Health Sciences, Karachi, Pakistan
| | | | - Afia Salman
- Dow University of Health Sciences, Karachi, Pakistan
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Memon S, Goldman S, Rodriguez R, Ramlawi B, Coady PM, Gnall EM. Alternative Application Technique for the MANTA Vascular Closure Device for Percutaneous Large-Bore Arterial Access Closure: The Fluoroscopic DOT Technique. J Endovasc Ther 2023; 30:885-891. [PMID: 35766367 DOI: 10.1177/15266028221105187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Vascular complications are a cause of increased morbidity and mortality when performing percutaneous procedures requiring large-bore arterial access. MANTA vascular closure device (VCD) is currently the only large-bore VCD using an intraluminal foot plate and an extraluminal collagen plug. The traditional depth locator approach might be compromised in; emergent cases without the required measurements, cases of hematoma formation, or other patient, procedure, or operator-specific variables. Furthermore, this technique can be used for postclosure in cases without the required measurement of depth. We describe vascular outcomes using fluoroscopy (fluoroscopic DOT technique) rather than traditional depth locator approach for vascular closure with the MANTA VCD. METHODS Fifty patients who underwent transcatheter aortic valve implantation (TAVI) were retrospectively analyzed using fluoroscopic DOT technique with 18F MANTA VCD between May and August 2021. All patients >18 years of age who qualified for transfemoral TAVI were included. Access was obtained with ultrasound guidance with vessel diameter of at least > 6 mm and free from anterior vessel wall calcification. Patient related factors and primary outcomes of access site bleeding and acute flow-limited limb ischemia requiring intervention were prospectively analyzed. Furthermore, 1 patient who failed hemostasis with suture-mediated VCD had successful hemostasis with fluoroscopic DOT technique as dry postclosure after balloon aortic valvuloplasty. RESULTS In total, 50 patients were analyzed with a mean age of 81 years and majority were male (56%). Majority had comorbidities of hypertension (88%) and hyperlipidemia (94%), 24% had peripheral arterial disease, 38% coronary artery disease, and 58% were former smokers. Importantly, 40% were obese with an average body mass index (BMI) of 29 kg/m2. There were no bleeding or ischemic limb complications post MANTA VCD deployment using the fluoroscopic DOT technique. Furthermore, none of the patients required peripheral intervention from index procedure to 1 month post verified during their 1-month post TAVR follow-up. CONCLUSION Fluoroscopic DOT technique using the MANTA VCD is highly reproducible and allows hemostasis in a predictable manner for procedures requiring large-bore arterial access in the absence of MANTA depth measurement.
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Affiliation(s)
- Sehrish Memon
- Division of Cardiovascular Diseases, Lankenau Medical Center, Lankenau Institute of Medical Research, Wynnewood, PA, USA
| | - Scott Goldman
- Division of Cardiothoracic Surgery, Lankenau Medical Center, Lankenau Institute of Medical Research, Wynnewood, PA, USA
| | - Roberto Rodriguez
- Division of Cardiothoracic Surgery, Lankenau Medical Center, Lankenau Institute of Medical Research, Wynnewood, PA, USA
| | - Basel Ramlawi
- Division of Cardiothoracic Surgery, Lankenau Medical Center, Lankenau Institute of Medical Research, Wynnewood, PA, USA
| | - Paul M Coady
- Division of Cardiovascular Diseases, Lankenau Medical Center, Lankenau Institute of Medical Research, Wynnewood, PA, USA
| | - Eric M Gnall
- Division of Cardiovascular Diseases, Lankenau Medical Center, Lankenau Institute of Medical Research, Wynnewood, PA, USA
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8
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Alharbi A, Shah M, Mhanna M, Rejent K, Safi M, Alsughayer A, Patel N, Assaly R. Body Mass Index and Outcomes of Transcatheter Aortic Valve Replacement: A Retrospective Observational Study. Curr Probl Cardiol 2023; 48:101879. [PMID: 37343774 DOI: 10.1016/j.cpcardiol.2023.101879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/23/2023]
Abstract
The influence of body mass index (BMI) on Transcatheter Aortic Valve Replacement (TAVR) outcomes has been the focus of several previous studies. In this study, we examined the relationship between BMI and various clinical outcomes following TAVR procedures. A comprehensive analysis was conducted using a large cohort of patients who underwent TAVR. In this study, we identified patients who underwent Transcatheter aortic valve replacement (TAVR) in the year 2020. Procedure Classification System (ICD-10-PCS) codes were used to identify TAVR cases. The weighted final study sample included 77319 TAVR hospitalizations. Patients were categorized into 5 groups based on their Body Mass Index (BMI. Our findings revealed that there was no significant difference in in-hospital mortality among different BMI groups when compared to patients with a normal BMI (20 to 24.9). patients with a BMI of 25 or higher demonstrated a statistically significant shorter duration of hospitalization compared to those with a normal BMI. patients with a BMI ranging between 30 and 39.9 exhibited decreased hospitalization costs when compared to patients with a normal BMI. Moreover, our study revealed a decrease in atrial fibrillation, acute heart failure and acute kidney injury complications following TAVR in patients with above-normal BMI. Despite similar in-hospital mortality across BMI groups, having a BMI of 25 or greater is associated with improved immediate outcomes following TAVR. These benefits in overweight and obese patients are consistent with findings described in recent literature. Further studies are warranted to explore the underlying mechanisms and potential implications of these associations, as well as to optimize patient selection and management strategies for TAVR procedures.
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Affiliation(s)
| | - Momin Shah
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Mohammed Mhanna
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, IA
| | - Kassidy Rejent
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Mohammad Safi
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Anas Alsughayer
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Neha Patel
- Department of Internal Medicine, University of Toledo, Toledo, OH
| | - Ragheb Assaly
- Department of Internal Medicine, University of Toledo, Toledo, OH; Department of Internal Medicine, Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH
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Huang B, Yan H, Li Y, Zhou Q, Abudoureyimu A, Cao G, Jiang H. Transcatheter Aortic Valve Replacement in Elderly Patients: Opportunities and Challenges. J Cardiovasc Dev Dis 2023; 10:279. [PMID: 37504535 PMCID: PMC10380827 DOI: 10.3390/jcdd10070279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023] Open
Abstract
Over the past two decades, the rapid evolution of transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe aortic stenosis (AS) in the elderly. The prevalence of comorbidities in elderly AS patients presents a considerable challenge to the effectiveness and prognosis of patients after TAVR. In this article, we aim to summarize some of the clinical aspects of the current use of TAVR in elderly patients and attempt to highlight the challenges and issues that need further consideration.
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Affiliation(s)
- Bing Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Hui Yan
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Yunyao Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Qiping Zhou
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Ayipali Abudoureyimu
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Guiqiu Cao
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
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Tscharre M, Wittmann F, Kitzmantl D, Schlöglhofer T, Cichra P, Lee S, Eichelberger B, Wadowski PP, Laufer G, Wiedemann D, Panzer S, Zimpfer D, Gremmel T. Impact of ABO Blood Group on Thromboembolic and Bleeding Complications in Patients with Left Ventricular Assist Devices. Thromb Haemost 2023; 123:336-346. [PMID: 36402132 DOI: 10.1055/a-1983-0676] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND The ABO blood group system is linked to hemostasis via its relationship with von Willebrand factor (VWF) and factor VIII (FVIII). In the current study, we investigated the association of the ABO system with clinical outcomes as well as VWF and platelet function in patients with left ventricular assist devices (LVADs). METHODS Bleeding and thromboembolic complications were assessed in 111 patients during 1 year after LVAD implantation. In 67 LVAD patients, VWF antigen, VWF activity, VWF ristocetin cofactor, VWF collagen-binding, and FVIII activity were assessed. Platelet surface P-selectin and activated glycoprotein IIb/IIIa were determined by flow cytometry, and soluble P-selectin was measured with an enzyme-linked immunoassay. Platelet aggregation was assessed by light transmission and impedance aggregometry. RESULTS Thirty-six patients (32.4%) experienced a bleeding and 22 patients (19.8%) a thromboembolic event. In univariate analyses, patients with blood group O had numerically more bleeding complications and less thromboembolic events as compared to patients with blood group non-O (both p ≥ 0.05). After multivariable adjustment, blood group O was significantly associated with a higher risk of bleeding (hazard ratio 2.42 [95% confidence interval 1.03-5.70], p = 0.044) but not linked to thromboembolic complications. CONCLUSION Patients with blood group O had significantly lower levels of VWF and FVIII (all p < 0.05), whereas P-selectin expression in response to thrombin-receptor activating peptide and soluble P-selectin were higher as compared to patients with blood group non-O (both p < 0.05). LVAD patients with blood group O are at an increased bleeding risk, potentially due to lower VWF and FVIII levels.
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Affiliation(s)
- Maximilian Tscharre
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria.,Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Franziska Wittmann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniela Kitzmantl
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas Schlöglhofer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Philip Cichra
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Silvia Lee
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Beate Eichelberger
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Patricia P Wadowski
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Simon Panzer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Gremmel
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, Mistelbach, Austria.,Institute of Cardiovascular Pharmacotherapy and Interventional Cardiology, Karl Landsteiner Society, St. Pölten, Austria
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Memon S, Gnall EM. Post-closure with MANTA fluoroscopic DOT technique for emergent percutaneous mechanical circulatory support and 'bail-out' for large bore arterial hemostasis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 51:45-51. [PMID: 36740550 DOI: 10.1016/j.carrev.2023.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/17/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Large bore arterial hemostasis for emergent MCS initiation in cardiogenic shock and during failures of suture mediated vascular closure devices (VCD) necessitates dry/post-closure technique for successful closure. Use of the alternative MANTA fluoroscopic DOT technique, without depth finder, as post closure and as 'bail-out' in this high-risk patient population is described. METHODS All patients who underwent emergent percutaneous transfemoral MCS initiation, without use of upfront sutured-mediated pro-glide VCDs, and procedures where proglide-perclose technique (PPT) failed to achieve hemostasis were post-closed with the alternative MANTA fluoroscopic DOT technique (without depth finder) as primary method or as 'bail-out'. Patient related factors, cardiovascular co-morbidities, clinical indication, distribution of 14F versus 18F MANTA, and types of procedures obtained. Primary outcomes of access site related acute flow-limiting limb ischemia or bleeding requiring intervention analyzed. RESULTS 27 patients met inclusion criteria; mean age 64 years, majority male 19 (70 %), more than half obese (56 %) with mean BMI 31.06 kg/m2. 22 (81 %) had emergent MCS initiation and 5 (19 %) PPT hemostasis failures. Types of percutaneous MCS support included; 11 (44 %) Impella CP, 2 (7 %) 15F arterial ECMO, 6 (22 %) 17F arterial ECMO, 4 (15 %) 19F ECMO. All achieved hemostasis utilizing alternative MANTA fluoroscopic DOT technique without vascular complications of bleeding or acute ischemic limb. CONCLUSION The alternative MANTA fluoroscopic DOT technique (without depth finder) can be successfully applied as post-closure for emergent MCS support delayed hemostasis and as bail-out for per-close suture mediated VCD failures for large bore arterial hemostasis.
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Affiliation(s)
- Sehrish Memon
- Division of Cardiovascular and Structural Heart Disease, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, PA, United States of America
| | - Eric M Gnall
- Division of Cardiovascular and Structural Heart Disease, Lankenau Medical Center and Lankenau Institute of Medical Research, Wynnewood, PA, United States of America.
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12
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Gupta R, Mahmoudi E, Behnoush AH, Khalaji A, Malik AH, Sood A, Bandyopadhyay D, Zaid S, Goel A, Sreenivasan J, Patel C, Vyas AV, Lavie CJ, Patel NC. Effect of BMI on patients undergoing transcatheter aortic valve implantation: A systematic review and meta-analysis. Prog Cardiovasc Dis 2023:S0033-0620(22)00158-X. [PMID: 36657654 DOI: 10.1016/j.pcad.2022.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 12/26/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND The relationship of body mass index (BMI) and an "obesity paradox" with cardiovascular risk prediction is controversial. This systematic review and meta-analysis aims to compare the associations of different BMI ranges on transcatheter aortic valve implantation (TAVI) outcomes. METHODS International databases, including PubMed, the Web of Science, and the Cochrane Library, were systematically searched for observational and randomized controlled trial studies investigating TAVI outcomes in any of the four BMI categories: underweight, normal weight, overweight, and obese with one of the predefined outcomes. Primary outcomes were in-hospital, 30-day, and long-term all-cause mortality. Random-effects meta-analysis was performed to calculate the odds ratio (OR) or standardized mean differences (SMD) with 95% confidence interval (CI) for each paired comparison between two of the BMI categories. RESULTS A total of 38 studies were included in our analysis, investigating 99,829 patients undergoing TAVI. There was a trend toward higher comorbidities such as hypertension, diabetes, and dyslipidemia in overweight patients and individuals with obesity. Compared with normal-weight, patients with obesity had a lower rate of 30-day mortality (OR 0.42, 95% CI 0.25-0.72, p < 0.01), paravalvular aortic regurgitation (OR 0.63, 95% CI 0.44-0.91, p = 0.01), 1-year mortality (OR 0.48, 95% CI 0.24-0.96, p = 0.04), and long-term mortality (OR 0.69, 95% CI 0.51-0.94, p = 0.02). However, acute kidney injury (OR 1.16, 95% CI 1.04-1.30, p = 0.01) and permanent pacemaker implantation (OR 1.25, 95% CI 1.05-1.50, p = 0.01) odds were higher in patients with obesity. Noteworthy, major vascular complications were significantly higher in underweight patients in comparison with normal weight cases (OR 1.62, 95% CI 1.07-2.46, p = 0.02). In terms of left ventricular ejection fraction (LVEF), patients with obesity had higher post-operative LVEF compared to normal-weight individuals (SMD 0.12, 95% CI 0.02-0.22, p = 0.02). CONCLUSION Our results suggest the presence of the "obesity paradox" in TAVI outcomes with higher BMI ranges being associated with lower short- and long-term mortality. BMI can be utilized for risk prediction of patients undergoing TAVI.
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Affiliation(s)
- Rahul Gupta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA.
| | - Elham Mahmoudi
- Universal Scientific Education and Research Network, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Behnoush
- Universal Scientific Education and Research Network, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirmohammad Khalaji
- Universal Scientific Education and Research Network, Tehran University of Medical Sciences, Tehran, Iran
| | - Aaqib H Malik
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Aayushi Sood
- Department of Internal Medicine, The Wright Center for Graduate Medical Education, Scranton, PA, USA
| | - Dhrubajyoti Bandyopadhyay
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Syed Zaid
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Institute, Houston, TX, USA
| | - Akshay Goel
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Institute, Houston, TX, USA
| | - Jayakumar Sreenivasan
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Chirdeep Patel
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Apurva V Vyas
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Nainesh C Patel
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
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13
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Yao Y, He J, Xiong T, Chen F, Ou Y, Li Y, Liu Q, Zhu Z, Zhang Y, Yang H, Liang Y, Wei X, Li X, Peng Y, Wei J, He S, Li Q, Chen Y, Meng W, Chen G, Zhou W, Zheng M, Zhou X, Chen M, Feng Y. Prognostic value of the dynamic hepatorenal function on intermediate-term mortality in TAVI patients with survival to discharge. Clin Cardiol 2022; 46:84-91. [PMID: 36448412 PMCID: PMC9849429 DOI: 10.1002/clc.23940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Renal and liver dysfunctions are risk factors for mortality in patients with severe aortic stenosis (AS). Transcatheter aortic valve implantation (TAVI) has the potential to break the vicious cycle between AS and hepatorenal dysfunction by relieving aortic valve obstruction. HYPOTHESIS A part of patients can derive hepatorenal function improvement from TAVI, and this noncardiac benefit improves the intermediate-term outcomes. METHODS We developed this retrospective cohort study in 439 consecutive patients undergoing TAVI and described the dynamic hepatorenal function assessed by model for end-stage liver disease model for end-stage liver disease (MELD)-XI score in subgroups. The endpoint was 2-year all-cause mortality. RESULTS Receiver-operating characteristic analysis showed that the baseline MELD-XI score of 10.71 was the cutoff point. A high MELD-XI score (>10.71) at baseline was an independent predictor of the 2-year mortality hazard ratio (HR: 2.65 [1.29-5.47], p = .008). After TAVI, patients with irreversible high MELD-XI scores had a higher risk of 2-year mortality than patients who improved from high to low MELD-XI scores (HR: 2.50 [1.06-5.91], p = .03). Factors associated with reversible MELD-XI scores improvement were low baseline MELD-XI scores (≤12.00, odds ratio [OR]: 2.02 [1.04-3.94], p = .04), high aortic valve peak velocity (≥5 m/s, OR: 2.17 [1.11-4.24], p = .02), and low body mass index (≤25 kg/m2 , OR: 2.73 [1.25-5.98], p = .01). CONCLUSION High MELD-XI score at baseline is an independent predictor for 2-year mortality. Patients with hepatorenal function improvement after TAVI have better outcomes. For patients with irreversible hepatorenal dysfunction after TAVI, further optimization of the subsequent treatment after TAVI is needed to improve the outcomes.
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Affiliation(s)
- Yijun Yao
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Jingjing He
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Tianyuan Xiong
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Fei Chen
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Yuanweixiang Ou
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Yiming Li
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Qi Liu
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Zhongkai Zhu
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Yi Zhang
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Haoran Yang
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Yujia Liang
- Department of Cardiology, Section of Cardiac UltrasoundWest China Hospital, Sichuan UniversityChengduChina
| | - Xin Wei
- Department of Cardiology, Section of Cardiac UltrasoundWest China Hospital, Sichuan UniversityChengduChina
| | - Xi Li
- Department of Cardiology, Section of Cardiac UltrasoundWest China Hospital, Sichuan UniversityChengduChina
| | - Yong Peng
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Jiafu Wei
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Sen He
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Qiao Li
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Yong Chen
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Wei Meng
- Department of Cardiac Surgery, West China HospitalSichuan UniversityChengduChina
| | - Guo Chen
- Department of Anesthesiology, West China HospitalSichuan UniversityChengduChina
| | - Wenxia Zhou
- Department of Cardiology, Section of Cardiac UltrasoundWest China Hospital, Sichuan UniversityChengduChina
| | - Mingxia Zheng
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Xuan Zhou
- Department of Radiology, West China HospitalSichuan UniversityChengduChina
| | - Mao Chen
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
| | - Yuan Feng
- Department of Cardiology, West China HospitalSichuan UniversityChengduChina
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14
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Kalogeropoulos AS, Redwood SR, Allen CJ, Hurrell H, Chehab O, Rajani R, Prendergast B, Patterson T. A 20-year journey in transcatheter aortic valve implantation: Evolution to current eminence. Front Cardiovasc Med 2022; 9:971762. [PMID: 36479570 PMCID: PMC9719928 DOI: 10.3389/fcvm.2022.971762] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/31/2022] [Indexed: 07/26/2023] Open
Abstract
Since the first groundbreaking procedure in 2002, transcatheter aortic valve implantation (TAVI) has revolutionized the management of aortic stenosis (AS). Through striking developments in pertinent equipment and techniques, TAVI has now become the leading therapeutic strategy for aortic valve replacement in patients with severe symptomatic AS. The procedure streamlining from routine use of conscious sedation to a single arterial access approach, the newly adapted implantation techniques, and the introduction of novel technologies such as intravascular lithotripsy and the refinement of valve-bioprosthesis devices along with the accumulating experience have resulted in a dramatic reduction of complications and have improved associated outcomes that are now considered comparable or even superior to surgical aortic valve replacement (SAVR). These advances have opened the road to the use of TAVI in younger and lower-risk patients and up-to-date data from landmark studies have now established the outstanding efficacy and safety of TAVI in patients with low-surgical risk impelling the most recent ESC guidelines to propose TAVI, as the main therapeutic strategy for patients with AS aged 75 years or older. In this article, we aim to summarize the most recent advances and the current clinical aspects involving the use of TAVI, and we also attempt to highlight impending concerns that need to be further addressed.
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Affiliation(s)
- Andreas S. Kalogeropoulos
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
- Department of Cardiology, MITERA General Hospital, Hygeia Healthcare Group, Athens, Greece
| | - Simon R. Redwood
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Christopher J. Allen
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Harriet Hurrell
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Omar Chehab
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Ronak Rajani
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
- School of Bioengineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Bernard Prendergast
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Tiffany Patterson
- St. Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom
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15
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Seo J, Li W, Safiriyu I, Kharawala A, Nagraj S, Tahir A, Doundoulakis I, Koliastasis L, Rios S, Palaiodimos L, Kokkinidis DG. A Meta-Analysis on the Impact of High BMI in Patients Undergoing Transcatheter Aortic Valve Replacement. J Cardiovasc Dev Dis 2022; 9:386. [PMID: 36354785 PMCID: PMC9695436 DOI: 10.3390/jcdd9110386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/22/2022] [Accepted: 11/01/2022] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND A paradoxical association of obesity with lower risk of transcatheter aortic valve replacement (TAVR) outcomes has been reported. We aimed to systematically review the literature and compare TAVR-related morbidity and mortality among individuals with overweight or obesity and their peers with normal body mass index (BMI). METHODS PubMed and Embase databases were systematically searched for studies reporting TAVR outcomes in different BMI groups. Separate meta-analyses were conducted for studies reporting hazard ratios (HR) and odds ratios/relative risks. Short- and mid-/long-term outcomes were examined. RESULTS 26 studies with a total of 74,163 patients were included in our study. Overweight was associated with lower risk of short-term mortality (HR: 0.77; 95% CI: 0.60-0.98) and mid-/long-term mortality (HR: 0.79; 95% CI: 0.70-0.89). Obesity was associated with lower risk for mid-/long-term mortality (HR: 0.79; 95% CI: 0.73-0.86), but no difference was observed in short-term mortality, although a trend was noted (HR: 0.87l 95% CI: 0.74-1.01). Individuals with obesity demonstrated an association with higher odds of major vascular complications (OR: 1.33; 95% CI: 1.05-1.68). Both overweight (OR: 1.16; 95% CI: 1.03-1.30) and obesity (OR: 1.26; 95% CI: 1.06-1.50) were associated with higher likelihood for receiving permanent pacemakers after TAVR. CONCLUSION Individuals with overweight and obesity were associated with lower mortality risk compared to those with normal BMI but with higher likelihood of major vascular complications and permanent pacemaker implantation after TAVR.
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Affiliation(s)
- Jiyoung Seo
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, The Bronx, NY 10461, USA
| | - Weijia Li
- AdventHealth Orlando, Orlando, FL 32803, USA
| | - Israel Safiriyu
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, The Bronx, NY 10461, USA
| | - Amrin Kharawala
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, The Bronx, NY 10461, USA
| | - Sanjana Nagraj
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, The Bronx, NY 10461, USA
| | - Arooj Tahir
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, The Bronx, NY 10461, USA
| | - Ioannis Doundoulakis
- Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, 10679 Athens, Greece
| | - Leonidas Koliastasis
- Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, 10679 Athens, Greece
| | - Saul Rios
- Montefiore Einstein Center for Heart & Vascular Care, Albert Einstein College of Medicine, Montefiore Medical Center, The Bronx, NY 10467, USA
| | - Leonidas Palaiodimos
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, The Bronx, NY 10461, USA
| | - Damianos G. Kokkinidis
- Section of Cardiovascular Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT 06510, USA
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