Depression and anxiety in elderly patients with severe symptomatic aortic stenosis persistently improves after transcatheter aortic valve replacement (TAVR)

Sleep quality among solid organ transplant recipients during the COVID-19 reopening period in China: the interplay of SARS-CoV-2 infection, mental distress, and physical activity

OBJECTIVES

Given immunosuppression and comorbidities, solid organ transplant (SOT) recipients are more prone to infections during the COVID-19 pandemic. However, little is known about the relationship between SARS-CoV-2 infection and sleep quality in this population. This study aimed to investigate the association between SARS-CoV-2 infection and sleep quality among SOT recipients, examine the moderating roles of anxiety and depression, and explore whether the moderating effects vary with physical activity levels.

METHODS

1121 participants were recruited online in Changsha, China, from February to March 2023. Measurements included sociodemographic and infection-related questionnaire, Pittsburgh Sleep Quality Index, Hospital Anxiety and Depression Scale, and International Physical Activity Questionnaire Short Form.

RESULTS

83.0% of participants were infected during China's reopening period, and the average sleep quality score was 7.88 (SD = 3.59), indicating mild sleep disturbance. Anxiety and depression significantly moderated and strengthened the negative relationship between SARS-CoV-2 infection and sleep quality. Additionally, the moderating effects were significant at moderate-high levels of physical activity but not at low-moderate levels.

CONCLUSIONS

Promoting interventions to alleviate anxiety and depressive symptoms, as well as facilitating a gradual return to general physical activity, is encouraged to mitigate the negative association between SARS-CoV-2 infection and sleep quality among SOT recipients.

Using the Hospital Anxiety and Depression Scale in Patients 80 Years-Old and Older: A Systematic Review

AIMS

To identify and report results from studies of anxiety and depression, as measured by The Hospital Anxiety and Depression Scale (HADS) in patients ≥ 80 years admitted to hospital settings, and to inform nurses, researchers and educators in nursing about these findings.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane, Epistemonikos, Scopus and Web of Science Core Collection of studies published until October 2023.

METHODS

A search strategy was developed with a university librarian. Four independent reviewers screened titles and abstracts based on predefined inclusion criteria. Data were systematically extracted, descriptively analysed, and Critical Appraisal Skills Programme checklists were used to assess studies.

RESULTS

Out of 7076 identified studies, three met the eligibility criteria. Data from 420 participants aged ≥ 80 years were analysed, revealing anxiety prevalence rates between 6% and 18% and mean scores below 4. Depression prevalence rates ranged from 7% to 17%, with a mean score below 4. Most patients with depression were not previously recognised as being depressed.

CONCLUSIONS

Few publications reported on anxiety and/or depression in hospitalised patients aged ≥ 80 years using HADS. A gap in the knowledge base has been identified.

IMPLICATIONS

Anxiety and depression are mental health conditions that can lead to adverse events and strongly affect aging. Increased understanding of the role that these conditions have on hospitalised patients ≥ 80 years is important for nurses when in contact with this patient group.

IMPACT

There is a need for more studies to generate evidence regarding anxiety and depression in an increasingly common and challenging hospital population by building upon evidence that is based on validated instruments such as the Hospital Anxiety and Depression Scale.

REPORTING METHOD

The PRISMA guideline was followed, and the review registered in PROSPERO (Registration number CRD 42022380943).

PATIENT CONTRIBUTION

No patient or public contribution.

TRIAL REGISTRATION

CRD 42022380943.

Symptoms of Anxiety and Depression in Patients Who Underwent Transcatheter Aortic Valve Implantation: The SAD-TAVI Study

Symptoms of anxiety and/or depression (SAD) commonly co-exist in severe aortic stenosis. In patients who underwent transcatheter aortic valve implantation (TAVI), these symptoms are associated with increased morbidity and mortality. Despite this, mental health remains under-researched in the TAVI literature. Drawing from the largest registry in Australia, we aimed to characterize the prevalence of SAD in TAVI patients. We also aimed to identify patient phenotypes at the highest risk of these symptoms, examine how they evolve after TAVI, and establish factors predictive of improvement and regression in mental health. A total of 1,279 patients who underwent TAVI between 2018 and 2023 included in a multi-center Australian registry were analyzed. The median age was 82 years (interquartile range 77 to 87), 41% were females, and the median Society of Thoracic Surgeons score was 3.9 (2.3 to 5.9). In addition, 353 patients (28%) reported moderate or worse SAD at baseline. Of this group, 260 (74%) had complete resolution in symptoms within 30 days. Body mass index <25 kg/m2 (adjusted odds ratio [aOR] 3.4, p <0.001), vascular site complications (aOR 3.4, p = 0.029), and nonhome discharge (aOR 2.4, p = 0.036) independently predicted the persistence of SAD. Only 72 patients (8%) developed new-onset SAD at 30 days after TAVI. Nonhome discharge (aOR 2.12, p = 0.025) and a composite cardiovascular end point, including stroke, acute myocardial infarction, and heart failure readmission (aOR 2.55, p = 0.028), were independent predictors of new-onset SAD. In conclusion, SAD are common but under-recognized in aortic stenosis. TAVI is highly effective at improving these symptoms, and regular screening for mental health should be considered in the management of all TAVI patients.

The perspectives of older adults related to transcatheter aortic valve replacement: An integrative review

BACKGROUND

Aortic Stenosis (AS) is a common syndrome in older adults wherein the narrowing of the aortic valve impedes blood flow, resulting in advanced heart failure.1 AS is associated with a high mortality rate (50 % at 6 months if left untreated), substantial symptom burden, and reduced quality of life.1-3 Transcatheter aortic valve replacement (TAVR) was approved in 2012 as a less invasive alternative to surgical valve repair, offering a treatment for older frail patients. Although objective outcomes have been widely reported,4 the perspectives of older adults undergoing the TAVR process have never been synthesized.

OBJECTIVES

To contextualize the perspectives and experiences of older adults undergoing TAVR.

METHODS

An integrative review was conducted using Whittemore and Knafl's five-stage methodology.5 Four electronic databases were searched in April 2023. Articles were included if a qualitative methodology was used to assess the perceptions of older adults (>65 years old) undergoing or recovering from TAVR.

RESULTS

Out of 4619 articles screened, 12 articles met the criteria, representing 353 individuals from 10 countries. Relevant themes included the need for an individualized care plan, caregiver and family support, communication and education, persistent psychosocial and physical symptoms, and the unique recovery journey.

CONCLUSION

Older adults with AS undergoing TAVR generally perceive their procedure positively. Improved interdisciplinary and holistic management, open communication, symptom assessment, support, and education is needed.

The Impact of Frailty and Surgical Risk on Health-Related Quality of Life After TAVI

Symptomatic aortic stenosis and frailty reduce health-related quality of life (HrQoL). Transcatheter aortic valve implantation (TAVI) in patients at high to extreme risk has been proven to have a beneficial effect on HrQoL. Currently, TAVI is also considered in patients at intermediate risk. Our meta-analysis investigates whether benefits to HrQoL after TAVI is more pronounced in frail patients and patients at high to extreme vs. intermediate surgical risk. A systematic search of the literature was performed in November 2021 and updated in November 2023 in PUBMED, EMBASE, and the Cochrane Controlled Trials Register. Statistical analysis was performed according to the inverse variance method and the random effects model. A total of 951 studies were assessed, of which 19 studies were included. Meta-analysis showed a mean increase in the Kansas City Cardiomyopathy Questionnaire (KCCQ) score of 29.6 points (6.0, 33.1) in high to extreme risk patients versus 21.0 (20.9, 21.1) in intermediate risk patients (p < 0.00001) and 24.6 points (21.5, 27.8) in frail patients versus 26.8 (20.2, 33.4) in the general TAVI population (p = 0.55). However, qualitative analyses of non-randomized studies showed the opposite results. In conclusion, TAVI improves HrQoL more in high to extreme than intermediate risk patients. Frailty's impact on HrQoL post-TAVI is inconclusive due to varying outcomes in RCTs vs. non-RCTs.

The Association between Aortic Valve Stenosis and a Subsequent Diagnosis of Depression in Germany

Background/Objectives: Aortic valve stenosis (AS) represents one of the most common valve diseases in the western world. It often leads to severe symptoms that can lead to a restriction of everyday life and thus to psychological stress. Therefore, we aimed to investigate the association between AS and depression in outpatients in Germany. Methods: The IQVIATM Disease Analyzer database was used to identify 14,681 individuals with non-rheumatic AS (ICD-10: I35.0 or I35.2). They were propensity score matched (1:1) based on age, sex, average yearly consultation frequency during the follow-up, and co-diagnoses to 14,681 patients without AS. Cox regression models were used to analyze the association between aortic stenosis and depression. Results: Within the follow-up period of up to 10 years, depression was diagnosed in 20.6% of AS patients compared to 20.0% in the matched cohort (p = 0.351). In the regression analysis, we were not able to discover an association between AS and a subsequent diagnosis of depression (HR: 1.03; 95% CI: 0.96-1.11). This effect was consistent among different age and sex groups. Conclusions: In the broad population of patients treated outside of hospital settings in Germany, AS was not associated with a higher incidence of depression.

Mental health and transcatheter aortic valve replacement: A scoping systematic review

OBJECTIVE

To systematically review the literature on mental health symptoms before and after transcatheter aortic valve replacement (TAVR) and describe reported clinical associations with these symptoms.

METHODS

Using the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) guidelines, we reviewed studies involving pre- or post-TAVR mental health assessments or psychiatric diagnoses.

RESULTS

Eighteen studies were included. Before TAVR, clinically significant depression and anxiety prevalence is 15-30% and 25-30%, respectively, with only a third of these meeting diagnostic thresholds. These symptoms generally improve over the year post-TAVR. Depression is associated with functional impairment, multimorbidity, and lower physical activity; few associations have been described in relation to anxiety. Inconsistent evidence finds depression associated with post-TAVR mortality. One notable study found persistent depression independently predictive of 12-month mortality, and another found depression and cognition to have additive value in predicting mortality risk.

CONCLUSIONS

Mental health symptoms occur in a significant proportion of the TAVR population. Although symptoms tend to improve, the associations with depression, particularly persistent depression, call for further investigation to examine their associated outcomes. Research is also needed to understand the relationships between mental health conditions and cognition in TAVR-related outcomes.

Anxiety and depression in patients aged 80 years and older following aortic valve therapy. A six-month follow-up study

BACKGROUND

Little is known about mental health following advanced cardiac procedures in the oldest patients.

AIMS

To study changes in anxiety and depression from baseline to one- and six-month follow-up in older patients following transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR).

METHODS

Prospective cohort study of patients ≥ 80 years undergoing elective TAVI or SAVR in a tertiary university hospital. Anxiety and depression were assessed with the Hospital Anxiety and Depression Scale. Differences between TAVI/SAVR were analyzed using Welch's t test or chi-squared. Changes over time and group differences were established with longitudinal models using generalized least squares.

RESULTS

In 143 patients (83.5 ± 2.7 years), 46% (n = 65) received TAVI. Anxiety was identified in 11% of TAVI patients at baseline. One- and six-months later, percentages were 8% and 9%. In SAVR patients, 18% had baseline scores indicating anxiety. One and six-months later, percentages were 11% and 9%. Depression was identified in 15% of TAVI patients. One- and six-months later, percentages were 11% and 17%. At baseline, 11% of SAVR patients had scores indicating depression. One- and six-months after SAVR, percentages were 15% and 12%. Longitudinal analyses showed reductions (P < 0.001) in anxiety from baseline to one-month, and stable scores between one- and six-months for both treatment groups. There was no change over time for depression among treatment groups (P = 0.21).

DISCUSSION AND CONCLUSIONS

SAVR or TAVI in patients ≥ 80 years was associated with anxiety reduction between baseline and follow-up. For depression, there was no evidence of change over time in either treatment group.

Association of Depression and Cognitive Dysfunction With Patient-Centered Outcomes After Transcatheter Aortic Valve Replacement

BACKGROUND

Depression and cognitive dysfunction (CD) are not routinely screened for in patients before transcatheter aortic valve replacement (TAVR) and their association with postprocedural outcomes is poorly understood. The objectives of this study are to determine the prevalence of depression and CD in patients with aortic stenosis undergoing TAVR and evaluate their association with mortality and quality of life.

METHODS

We analyzed a prospective, multicenter TAVR registry that systematically screened patients for preexisting depression and CD with the Patient Health Questionnaire-2 and Mini-Cog, respectively. The associations with mortality were assessed with Cox proportional hazard models and quality of life (Kansas City Cardiomyopathy Questionnaire and EuroQol visual analogue scale) were evaluated using multivariable ordinal regression models.

RESULTS

A total of 884 patients were included; median follow-up was 2.88 years (interquartile range=1.2-3.7). At baseline, depression was observed in 19.6% and CD in 31.8%. In separate models, after adjustment, depression (HR, 1.45 [95% CI, 1.13-1.86]; P<0.01) and CD (HR, 1.27 [95% CI, 1.02-1.59]; P=0.04) were each associated with increased mortality. Combining depression and CD into a single model, mortality was greatest among those with both depression and CD (n=62; HR, 2.06 [CI, 1.44-2.96]; P<0.01). After adjustment, depression was associated with 6.6 (0.3-13.6) points lower on the Kansas City Cardiomyopathy Questionnaire 1-year post-TAVR and 6.7 (0.5-12.7) points lower on the EuroQol visual analogue scale. CD was only associated with lower EuroQol visual analogue scale.

CONCLUSIONS

Depression and CD are common in patients that undergo TAVR and are associated with increased mortality and worse quality of life. Depression may be a modifiable therapeutic target to improve outcomes after TAVR.

Examining the relationship between depression and medication adherence among elderlies suffering from cardiovascular disease referring to the clinics affiliated with Kermanshah University of Medical Sciences: A cross-sectional study

Background

In recent years, around 30% of all mortalities worldwide has been related to cardiovascular disease (CVD). The most important predictor solution of cardiovascular events is enhancing medication adherence. Meanwhile, the main reason behind development of physical disorders among the elderly is depression. In this regard, the present research was performed to determine the relationship between depression and medication adherence among the elderly suffering from CVD.

Methods

A cross-sectional study was done via an analytical approach on 188 elderlies fulfilling the inclusion criteria. The participants were chosen through convenience nonrandomized sampling from March to July 2022. The data were collected through demographic and healthcare information form plus Madanloo chronic disease medication adherence and geriatric depression scale. The analysis of the data was done by SPSS 26 plus Stata 14.2.

Results

The mean depression score was 5.6(4.3) and the mean score of medication adherence in the elderlies was 168.03(23.85). The prevalence of depression was higher in women than in men (p = 0.015), and the elderlies differing from heart failure reported the minimum extent of medication adherence. The findings obtained from analysis of variance showed that age, level of education, and monthly level of income were among the effective demographic factors in the extent of depression and medication adherence (p < 0.05). Meanwhile, 26% of changes in medication adherence can be attributed to depression. Further, the results of the multiple linear regression model reported that depression, age, and polypharmacy are among the predictors of medication adherence.

Discussion and Conclusion

A weak to moderate relationship existed between depression and medication adherence among these elderlies. Given the growing elderly population, the importance of depression, and lack of medication adherence in incidence of CVD events, it is recommended to train the healthcare team to monitor the elderly regarding depression symptoms.

Quality of life in patients with transcatheter aortic valve implantation: an analysis from the INTERVENT project

Background

Transcatheter aortic valve implantation (TAVI) is a standard treatment for patients with aortic valve stenosis due to its very low mortality and complication rates. However, survival and physical integrity are not the only important factors. Quality of life (QoL) improvement is a crucial part in the evaluation of therapy success.

Methods

Patients with TAVI were questioned about their QoL before, one month and one year after the intervention as part of the INTERVENT registry trial at Mainz University Medical Center. Three different questionnaires were included in the data collection (Katz ADL, EQ-5D-5l, PHQ-D).

Results

We included 285 TAVI patients in the analysis (mean age 79.8 years, 59.4% male, mean EuroSCORE II 3.8%). 30-day mortality was 3.6%, complications of any kind occurred in 18.9% of the patients. Main finding was a significant increase in the general state of health measured on the visual analog scale by an average of 4.53 (± 23.58) points (BL to 1-month follow-up, p = 0.009) and by 5.19 (± 23.64) points (BL to 12-month follow-up, p = 0.016). There was also an improvement of depression symptoms, which was reflected in a decrease in the total value of the PHQ-D by 1.67 (± 4.75) points (BL to 12-month follow-up, p = 0.001). The evaluation of the EQ-5D-5l showed a significant improvement in mobility after one month (M = -0.41 (± 1.31), p < 0.001. Regarding the independence of the patients, no significant difference could be found. Apart from that, patients with risk factors, comorbidities or complications also benefited from the intervention despite their poor starting position.

Conclusion

We could show an early benefit of QoL in TAVI patients with significant improvement in the subjective state of health and a decrease in symptoms of depression. These findings were consistent over 1 year of follow up.

The Trajectory of Nutritional Status and Physical Activity before and after Transcatheter Aortic Valve Implantation

It is suggested that older patients waiting for an elective surgical procedure have a poor nutritional status and low physical activity level. It is unknown if this hypothesis is true and if these conditions improve after a medical procedure. We aimed to determine the trajectory of both conditions before and after transcatheter aortic valve implantation (TAVI). Included patients (n = 112, age 81 ± 5 years, 58% male) received three home visits (preprocedural, one and six months postprocedural). Nutritional status was determined with the mini nutritional assessment—short form (MNA-SF) and physical activity using an ankle-worn monitor (Stepwatch). The median MNA-SF score was 13 (11−14), and 27% of the patients were at risk of malnutrition before the procedure. Physical activity was 6273 ± 3007 steps/day, and 69% of the patients did not meet the physical activity guidelines (>7100 steps/day). We observed that nutritional status and physical activity did not significantly change after the procedure (β 0.02 [95% CI −0.03, 0.07] points/months on the MNA-SF and β 16 [95% CI −47, 79] steps/month, respectively). To conclude, many preprocedural TAVI patients should improve their nutritional status or activity level. Both conditions do not improve naturally after a cardiac procedure.

Peri-procedural code status for transcatheter aortic valve replacement: Absence of program policies and standard practices

BACKGROUND

Little is known about policies and practices for patients undergoing Transcatheter Aortic Valve Replacement (TAVR) who have a documented preference for Do Not Resuscitate (DNR) status at time of referral. We investigated how practices across TAVR programs align with goals of care for patients presenting with DNR status.

METHODS

Between June and September 2019, we conducted semi-structured interviews with TAVR coordinators from 52/73 invited programs (71%) in Washington and California (TAVR volume > 100/year:34%; 50-99:36%; 1-50:30%); 2 programs reported no TAVR in 2018. TAVR coordinators described peri-procedural code status policies and practices and how they accommodate patients' goals of care. We used data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry, stratified by programs' DNR practice, to examine differences in program size, patient characteristics and risk status, and outcomes.

RESULTS

Nearly all TAVR programs (48/50: 96%) addressed peri-procedural code status, yet only 26% had established policies. Temporarily rescinding DNR status until after TAVR was the norm (78%), yet time frames for reinstatement varied (38% <48 h post-TAVR; 44% 48 h-to-discharge; 18% >30 days post-discharge). For patients with fluctuating code status, no routine practices for discharge documentation were well-described. No clinically substantial differences by code status practice were noted in Society of Thoracic Surgeons Predicted Risk of Mortality risk score, peri-procedural or in-hospital cardiac arrest, or hospice disposition. Six programs maintaining DNR status recognized TAVR as a palliative procedure. Among programs categorically reversing patients' DNR status, the rationale for differing lengths of time to reinstatement reflect divergent views on accountability and reporting requirements.

CONCLUSIONS

Marked heterogeneity exists in management of peri-procedural code status across TAVR programs, including timeframe for reestablishing DNR status post-procedure. These findings call for standardization of DNR decisions at specific care points (before/during/after TAVR) to ensure consistent alignment with patients' health-related goals and values.

Comparison of the levels of depression and anxiety in elderly aortic stenosis patients treated with surgical or transcatheter aortic valve replacement

Objective

Currently, only a few studies have been conducted on the mental status recovery in elderly aortic stenosis (AS) patients after treatment. How transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) differentially impinge on the mental status of elderly AS patients is completely unknown. The present prospective study aims to investigate this question by comparing the post-treatment levels of depression and anxiety, quality of life and frailty.

Methods

A total of 120 elderly patients (age above 70) with symptomatic AS were included, where 78 of them were treated with TAVR and 42 of them were treated with SAVR. Levels of depression and anxiety, quality of life and frailty were assessed by the Chinese version of Hospital Anxiety and Depression Scale (HADS), World Health Organization Quality of Life Instrument-Older Adults Module (WHOQOL-OLD) and clinical frailty scale, respectively. Scores were recorded and compared at admission, 1 month, 4 months and 8 months after treatment.

Results

Before treatment, both patient groups had similar baseline characteristics and all mental parameters. During the follow-up period, patients in the TAVR group demonstrated significant improvement in all assessed mental parameters to certain extent compared to the SAVR group. Specifically, frailty was significantly improved in the TAVR-treated patients at all three follow-up time points. Levels of depression and anxiety were significantly improved 8 months after treatment, although the remaining patient number is limited. Quality of life was only significantly improved 1 month after treatment.

Conclusion

TAVR may provide a better mental recovery outcome in elderly AS patients.

Anxiety and Depression Prevalence and Risk Factors Among Patients With Cardiovascular Diseases in Post-COVID-19 China

Objective: Data are limited on the psychological disorders of patients with cardiovascular disease during the post-COVID-19 period, although mental health status is associated with morbidity and mortality. We aimed to investigate the prevalence of anxiety and depression and risk factors among patients with cardiovascular disease in the post-pandemic period.

Method: A cross-sectional survey was conducted through opportunistic and snowball sampling in southeast China from 10 October to 24 November. Anxiety and depression were assessed on the hospital anxiety and depression scale (HADS).

Results: A total of 435 patients with hypertension (48.05%), atrial fibrillation (17.24%), coronary artery disease (14.48%), heart failure (9.89%) and other heart diseases (10.34%) completed the survey. Interestingly, most patients reported monthly income comparable to (90.11%) or even greater than (8.51%) pre-pandemic income. The occurrence of anxiety and depression was 11.72 and 9.20%, respectively. Marital status and treatment interruption during the pandemic were independent risk factors for both anxiety and depression. Moreover, current monthly income and access to telemedicine during the pandemic were independent risk factors for anxiety.

Conclusion: Patients with cardiovascular disease may experience anxiety and depression not only because of disease complications but also because of the effects of the pandemic. In facing the global challenge posed by the coronavirus, efforts should be made to improve patients' psychological well-being in the management of populations with cardiovascular disease.

Delayed Improvement of Depression and Anxiety after Transcatheter Aortic Valve Implantation (TAVI) in Stages of Extended Extra-Valvular Cardiac Damage

Background: Depression and anxiety are frequently occurring and likely to be linked to the severity of cardiac diseases like aortic stenosis (AS). This seems to be of interest since a staging classification of extra-valvular cardiac damage in AS has been introduced and shown to be of prognostic relevance. Objective: The current study aimed to investigate the frequency of depression and anxiety in association to staging and their dynamics after transcatheter aortic valve implantation (TAVI). Methods: A total number of 224 AS patients undergoing TAVI were classified according to the 2017 staging classification into stage 0 to 4 and further dichotomized into group A (stage 0 to 2) and B (stage 3 and 4). Using the Hospital Anxiety and Depression Scale (HADS-D), patients were assigned to depressive versus non-depressive or anxious versus non-anxious per staging group respectively, and analyzed at baseline, 6 weeks, 6 months and 12 months after TAVI. Results: After dichotomization, 158 patients (70.5%) were assigned to group A and 66 patients (29.5%) to group B. The part showing pathologic values for depression was 25.4% (57/224 patients) in the entire collective, 26.6% (42/158 patients) in group A and 22.7% (15/66 patients) in group B (p = n.s.). The proportion showing pathologic values for anxiety was 26.8% (60/224 patients) in the entire collective and did not differ between group A (24.7%, 39/158 patients) and B (31.8%, 21/66 patients) (p = n.s.). In patients revealing pathologic values for depression or anxiety prior to TAVI, there were significant and stable improvements over time observable already in short-term (6 weeks) follow-up in group A, and likewise, but later, in long-term (6/12 months) follow-up in group B. Conclusions: Although of proven prognostic relevance, higher stages of extra-valvular cardiac damage are not associated with higher rates of pre-existing depression or anxiety. The TAVI procedure resulted in a persisting reduction of depression and anxiety in patients showing pathologic values at baseline. Notably, these improvements are timely delayed in higher stages.

Antithrombotic therapy in patients undergoing transcatheter aortic valve replacement: the complexity of the elderly

Along with epidemiologic transitions of the global population, the burden of aortic stenosis (AS) is rapidly increasing and transcatheter aortic valve replacement (TAVR) has quickly spread; indeed, it is nowadays also employed in treating patients with AS at intermediate operative risk. Nonetheless, the less invasive interventional strategy still carries relevant issues concerning post-procedural optimal antithrombotic strategy, given the current indications provided by guidelines are not completely supported by evidence-based data. Geriatric patients suffer from high bleeding and thromboembolic risks, whose balance is particularly subtle due to the presence of concomitant conditions, such as atrial fibrillation and chronic kidney disease, that make the post-TAVR antithrombotic management particularly insidious. This scenario is further complicated by the lack of specific evidence regarding the 'real-life' complex conditions typical of the geriatric syndromes, thus, the management of such a heterogeneous population, ranging from healthy ageing to frailty, is far from being defined. The aim of the present review is to summarize the critical points and the most updated evidence regarding the post-TAVR antithrombotic approach in the geriatric population, with a specific focus on the most frequent clinical settings.

Heart and brain interactions : Pathophysiology and management of cardio-psycho-neurological disorders

Cardiovascular diseases (CVD) and mental health disorders (MHD; e.g. depression, anxiety and cognitive dysfunction) are highly prevalent and are associated with significant morbidity and mortality and impaired quality of life. Currently, possible interactions between pathophysiological mechanisms in MHD and CVD are rarely considered during the diagnostic work-up, prognostic assessment and treatment planning in patients with CVD, and research addressing bidirectional disease mechanisms in a systematic fashion is scarce. Besides some overarching pathogenetic principles shared by CVD and MHD, there are specific syndromes in which pre-existing neurological or psychiatric illness predisposes and contributes to CVD development (as in Takotsubo syndrome), or in which the distorted interplay between innate immune and central nervous systems and/or pre-existing CVD leads to secondary MHD and brain damage (as in peripartum cardiomyopathy or atrial fibrillation). Clinical manifestations and phenotypes of cardio-psycho-neurological diseases depend on the individual somatic, psychosocial, and genetic risk profile as well as on personal resilience, and differ in many respects between men and women. In this article, we provide arguments on why, in such conditions, multidisciplinary collaborations should be established to allow for more comprehensive understanding of the pathophysiology as well as appropriate and targeted diagnosis and treatment. In addition, we summarize current knowledge on the complex interactions between the cardiovascular and central nervous systems in Takotsubo syndrome and peripartum cardiomyopathy, and on the neurological and psychiatric complications of atrial fibrillation.