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Piayda K, Heilemann JT, Keranov S, Schulz L, Arsalan M, Liebetrau C, Kim WK, Hofmann FJ, Bauer P, Voss S, Troidl C, Sossalla ST, Hamm CW, Nef HM, Dörr O. The role of Matrix Metalloproteinase-2 and Galectin-3 as predictive biomarkers for all-cause mortality in patients undergoing transfemoral transcatheter aortic valve implantation. Biomarkers 2024; 29:205-210. [PMID: 38588595 DOI: 10.1080/1354750x.2024.2341409] [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: 12/28/2023] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Currently available risk scores fail to accurately predict morbidity and mortality in patients with severe symptomatic aortic stenosis who undergo transcatheter aortic valve implantation (TAVI). In this context, biomarkers like matrix metalloproteinase-2 (MMP-2) and Galectin-3 (Gal-3) may provide additional prognostic information. METHODS Patients with severe aortic stenosis undergoing consecutive, elective, transfemoral TAVI were included. Baseline demographic data, functional status, echocardiographic findings, clinical outcomes and biomarker levels were collected and analysed. RESULTS The study cohort consisted of 89 patients (age 80.4 ± 5.1 years, EuroScore II 7.1 ± 5.8%). During a median follow-up period of 526 d, 28 patients (31.4%) died. Among those who died, median baseline MMP-2 (alive: 221.6 [170.4; 263] pg/mL vs. deceased: 272.1 [225; 308.8] pg/mL, p < 0.001) and Gal-3 levels (alive: 19.1 [13.5; 24.6] pg/mL vs. deceased: 25 [17.6; 29.5] pg/mL, p = 0.006) were higher than in survivors. In ROC analysis, MMP-2 reached an acceptable level of discrimination to predict mortality (AUC 0.733, 95% CI [0.62; 0.83], p < 0.001), but the predictive value of Gal-3 was poor (AUC 0.677, 95% CI [0.56; 0.79], p = 0.002). Kaplan-Meier and Cox regression analyses showed that patients with MMP-2 and Gal-3 concentrations above the median at baseline had significantly impaired long-term survival (p = 0.004 and p = 0.02, respectively). CONCLUSIONS In patients with severe aortic stenosis undergoing transfemoral TAVI, MMP-2 and to a lesser extent Gal-3, seem to have additive value in optimizing risk prediction and streamlining decision-making.
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Affiliation(s)
- Kerstin Piayda
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Julian Tim Heilemann
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Stanislav Keranov
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Luisa Schulz
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Mani Arsalan
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
- Department of Cardiothoracic Surgery, Medical Faculty, Goethe-University Frankfurt, Frankfurt, Germany
| | | | - Won-Keun Kim
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
| | - Felix J Hofmann
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Pascal Bauer
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Sandra Voss
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
- Kerckhoff Herzforschungsinstitut, Bad Nauheim, Germany
| | | | - Samuel T Sossalla
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
- Kerckhoff Herzforschungsinstitut, Bad Nauheim, Germany
| | - Christian W Hamm
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
| | - Holger M Nef
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
- Kerckhoff Herzforschungsinstitut, Bad Nauheim, Germany
| | - Oliver Dörr
- Department of Cardiology, Justus-Liebig-University Giessen, Medical Clinic I, Giessen, Germany
- Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
- Kerckhoff Herzforschungsinstitut, Bad Nauheim, Germany
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2
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Munguti C, Ndunda P, Vindhyal MR, Abukar A, Abdel-Jawad M, Fanari Z. Transcarotid versus transthoracic transcatheter aortic valve replacement: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 63:8-13. [PMID: 38320876 DOI: 10.1016/j.carrev.2024.01.015] [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: 06/27/2023] [Revised: 12/27/2023] [Accepted: 01/23/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Transthoracic approaches may be contraindicated in some patients and may be associated with poorer outcomes. Therefore other alternative access routes are increasingly being performed. We conducted a systematic review of the literature on Transcarotid transcatheter aortic valve replacement (TC-TAVR) and meta-analysis comparing outcomes of TC-TAVR and other access routes. METHODS We comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We presented data using risk ratios (95 % confidence intervals) and measured heterogeneity using Higgins' I2. RESULTS Sixteen observational studies on Transcarotid TAVR were included in the analysis; 4 studies compared 180 TC-TAVR patients vs 524 TT-TAVR patients. The mean age and STS score for patients undergoing TC-TAVR were 80 years and 7.6 respectively. For TT-TAVR patients, the mean age and STS score were 79.7 years and 8.7 respectively. TC-TAVR patients had lower 30-day MACE [7.8 % vs 13.7 %; OR 0.54 (95 % CI 0.29-0.99, P = 0.05)] and major or life-threatening bleeding [4.0 % vs 14.2 %; OR 0.25 (95 % CI 0.09-0.67, P = 0.006)]. There was no significant difference in 30-day: mortality [5.0 % vs 8.6 %; OR 0.61 (95 % CI 0.29-1.30, P = 0.20)], stroke or transient ischemic attack [2.8 % vs 4.0 %; OR 0.65 (95 % CI 0.25-1.73, P = 0.39)] and moderate or severe aortic valve regurgitation [5.0 % vs 4.6 %; OR 1.14. (95 % CI 0.52-2.52, P = 0.75)]. There was a trend towards fewer major vascular complications in TC-TAVR [3.0 % vs 7.8 %; OR 0.42 (95 % CI 0.16-1.12, P = 0.08)]. CONCLUSION Compared with transthoracic TAVR, TC-TAVR patients had lower odds of 30-day MACE and life-threatening bleeding and no differences in 30-day mortality, stroke or TIA, aortic valve regurgitation.
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Affiliation(s)
- Cyrus Munguti
- Internal Medicine, University of Kansas School of Medicine - Wichita, KS, United States of America
| | - Paul Ndunda
- Internal Medicine, University of Kansas School of Medicine - Wichita, KS, United States of America
| | - Mohinder R Vindhyal
- Internal Medicine, University of Kansas School of Medicine - Wichita, KS, United States of America
| | - Abdullah Abukar
- Internal Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Mohammed Abdel-Jawad
- Internal Medicine, University of Kansas School of Medicine - Wichita, KS, United States of America; Internal Medicine, Ascension Via Christi St Francis Hospital, Wichita, KS, United States of America
| | - Zaher Fanari
- Internal Medicine/Cardiology, University of California San Francisco, Fresno, CA, United States of America
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Salihu A, Ferlay C, Kirsch M, Shah PB, Skali H, Fournier S, Meier D, Muller O, Hugelshofer S, Skalidis I, Tzimas G, Monney P, Eeckhout E, Arangalage D, Rancati V, Antiochos P, Lu H. Outcomes and Safety of Transcaval Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-analysis. Can J Cardiol 2024:S0828-282X(24)00407-0. [PMID: 38797283 DOI: 10.1016/j.cjca.2024.05.016] [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: 04/23/2024] [Revised: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND The transcaval (TCv) vascular approach is increasingly utilized in transcatheter aortic valve replacement (TAVR), in patients unsuitable for the gold-standard transfemoral approach. We aimed to evaluate the efficacy, safety, and clinical outcomes associated with TCv-TAVR. METHODS A systematic review and meta-analysis was conducted by searching PubMed/MEDLINE, EMBASE and the Cochrane Library for all articles assessing the TCv approach published until December 2023. Outcomes included 30-day and 1-year all-cause mortality (ACM), 30-day rehospitalization, peri-operative and post-operative complications at 30 days. The meta-analysis was registered on the PROSPERO database with the identifier CRD42024501921. RESULTS A total of eight studies with 467 patients were included. TCv-TAVR procedures achieved a success rate of 98.5%. TCv-TAVR was associated with a 30-day ACM rate of 6.4% (95% confidence interval [CI]: 3.9-8.2%), a one-year ACM rate of 14.4% (95% CI: 2.3- 27.6%) and a 30-day rehospitalization rate at of 4.4% (95% CI: 2.2-10.6%). Postoperative stroke or transient ischemic attack, major vascular complications and major or life-threatening bleeding occurred in 3.9%, 8.5% and 10.1% of cases, respectively. Cumulative meta-analyses showed a trend of decreasing rates of vascular complications. CONCLUSIONS The TCv approach in TAVR demonstrated a reassuring efficacy and safety profile, with mortality and post-operative complication rates comparable to those reported for supra-aortic alternative TAVR access routes. The temporal decrease in vascular complications suggests potential improvements in procedural techniques and device technology. These findings further support the TCv approach as a viable option in patients ineligible for the transfemoral access.
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Affiliation(s)
- Adil Salihu
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Clémence Ferlay
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Adult Intensive Care Unit, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Division of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Matthias Kirsch
- Division of Cardiac Surgery, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Pinak B Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 02115 Boston MA, USA
| | - Hicham Skali
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 02115 Boston MA, USA
| | - Stephane Fournier
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - David Meier
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Olivier Muller
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Sarah Hugelshofer
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Ioannis Skalidis
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Georgios Tzimas
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Pierre Monney
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Eric Eeckhout
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Dimitri Arangalage
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Cardiology Department, AP-HP, Bichat Hospital and Université de Paris, Paris, France
| | - Valentina Rancati
- Division of Anesthesiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Panagiotis Antiochos
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Henri Lu
- Division of Cardiology, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 02115 Boston MA, USA.
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4
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Moccetti F, Wolfrum M, Bossard M, Attinger-Toller A, Loretz L, Cuculi F, Toggweiler S. Transfemoral-only transcatheter aortic valve replacement: A single center experience of 400 consecutive patients. Catheter Cardiovasc Interv 2024. [PMID: 38736247 DOI: 10.1002/ccd.31077] [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: 03/05/2024] [Accepted: 04/30/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND In transcatheter aortic valve replacement (TAVR), transfemoral (TF) access offers several advantages over alternative access routes. Advances in sheaths and valve delivery technology have catalyzed the feasibility of TF-TAVR, even in challenging anatomies. AIMS Report procedural characteristics and outcomes of a TAVR program aiming for a 100% TF access rate. METHODS Consecutive patients undergoing TAVR were enrolled in a prospective registry. Equipment used to facilitate TF-access in challenging anatomies included low-profile sheaths, dilatators, peripheral balloons, covered and uncovered self-expanding and balloon-expandable stents, and intravascular lithotripsy (IVL). RESULTS A total of 400 patients with a mean age of 81 ± 6 years (42% female) were analyzed. Minimal iliofemoral artery diameter (MLD) of the main access side was <5 mm in 42 (10.5%), extreme tortuosity was present in 65 (16.3%), and severe calcification in 59 (14.8%). TF-access was successful in 399 (99.8%) patients. A transaxillary access was used in one patient. In multivariable analysis, an MLD < 5 mm was the strongest predictor for vascular complications (11.9% vs. 3.9%, OR: 3.86, 95% CI: 1.38-10.8, p = 0.01). Such patients also had more major/life-threatening bleeding (14.2% vs. 3.1%, p < 0.001) and required more planned and unplanned peripheral interventions to enable TF access (35.8% vs. 3.4%, p < 0.001). CONCLUSION Our study shows that utilization of dedicated sheaths, peripheral balloons, stents, and IVL enables TAVR via TF access in >99% of patients. However, rates of vascular and bleeding complications in patients with narrow iliofemoral arteries (MLD < 5 mm) were high.
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Affiliation(s)
- Federico Moccetti
- Heart Center Lucerne, Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Mathias Wolfrum
- Heart Center Lucerne, Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matthias Bossard
- Heart Center Lucerne, Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Lucca Loretz
- Heart Center Lucerne, Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Florim Cuculi
- Heart Center Lucerne, Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Stefan Toggweiler
- Heart Center Lucerne, Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
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5
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Hussain B, Duhan S, Mahmood A, Al-Alawi L, Aslam MMS, Cuevas C, Alexander T, Ansari MM, Waqar F. Geographical and socioeconomic disparities in post-transcatheter aortic valve replacement pacemaker placement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00153-2. [PMID: 38594158 DOI: 10.1016/j.carrev.2024.04.010] [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: 12/15/2023] [Revised: 03/13/2024] [Accepted: 04/03/2024] [Indexed: 04/11/2024]
Abstract
INTRODUCTION Pacemaker (PPM) implantation is indicated for conduction abnormalities which can develop post-transcatheter aortic valve replacement (TAVR). However, whether post-TAVR PPM risk is associated with the geographical location of the hospital and socioeconomic status of the patient is not well established. Our goal was to explore geographical and socioeconomic disparities in post-TAVR PPM implantation. METHODS A retrospective cohort analysis was conducted using the National Inpatient Sample 2016-2020 with respective ICD-10 codes for TAVR and PPM implantation. A weighted multivariate logistic regression model was used to analyze prognostic outcomes. RESULTS The number of patients hospitalized for undergoing TAVR was 296,740, out of which 28,265 patients had PPM implantation (prevalence 9.5 %). Patients' demographics including sex, ethnicity, household income, and insurance were not associated with risk of post-TAVR PPM except age (OR 1.01, CI 1.07-12.5, p < 0.001). Compared to rural hospitals, urban non-teaching hospitals were associated with a higher risk of post-TAVR PPM (OR 2.09, 1.3-3.43, p = 0.003). Compared to New England hospitals (ME, NH, VT, MA, RI, CT), middle Atlantic hospitals (NY, NJ, PA) were associated with highest post-TAVR PPM risk (OR 1.54, CI 1.2-1.98, p < 0.001), followed by Pacific (AK, WA, OR, CA, HI), mountain (ID, MT, WY, NV, UT, CO, AZ, NM) and east north central US. CONCLUSION Patients' demographics including sex, ethnicity, household income, and insurance were not associated with the risk of post-TAVR PPM except for age. Compared to New England hospitals, Middle Atlantic hospitals were associated with the highest post-TAVR PPM risk followed by Pacific, Mountain, and East North Central US. Prospective studies with data on TAVR wait times, expertise of the interventional staff, and post-TAVR management and discharge planning are required to further explore the observed regional distribution of TAVR outcomes.
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Affiliation(s)
- Bilal Hussain
- Internal Medicine, The Brooklyn Hospital Center, Brooklyn, NY, United States of America.
| | - Sanchit Duhan
- Internal Medicine, Sinai Hospital of Baltimore, Baltimore, MD, United States of America
| | - Ahmed Mahmood
- Cardiology Department, Corpus Christi Medical Center, Corpus Christi, TX, United States of America
| | - Luay Al-Alawi
- Cardiology Department, Corpus Christi Medical Center, Corpus Christi, TX, United States of America
| | | | - Christel Cuevas
- Cardiology Department, Corpus Christi Medical Center, Corpus Christi, TX, United States of America
| | - Thomas Alexander
- Cardiology Department, Corpus Christi Medical Center, Corpus Christi, TX, United States of America
| | - Mohammad M Ansari
- Cardiac Cath Lab and Structural Heart Program, Cardiology Department, Texas Tech University Health Sciences Center, Lubbock, TX, United States of America
| | - Fahad Waqar
- Interventional Cardiology, The Heart Institute - Bon Secours Mercy Health Cincinnati, Cincinnati, OH, United States of America
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6
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Kargoli F, Al Qaraghuli AK, Fang HK, Eng MH. Postsurgical Transcatheter Mitral Valve Replacement. Interv Cardiol Clin 2024; 13:207-216. [PMID: 38432763 DOI: 10.1016/j.iccl.2023.12.002] [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: 03/05/2024]
Abstract
Reintervention is commonly required postsurgical mitral valve replacement (SMVR) or repair due to bioprosthetic valve and annuloplasty ring degeneration. However, redo SMVR is associated with a high risk of morbidity and mortality. Postsurgical transcatheter mitral valve replacement (TMVR) is a safe and less-invasive alternative that has repeatedly been shown to be associated with improved survival and lower rates of complications compared with redo SMVR. Comprehensive patient evaluation and thorough procedural planning are key to successful TMVR.
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Affiliation(s)
- Faraj Kargoli
- Division of Cardiology, University of Arizona, Banner University Medical Center, 1111 East McDowell Road, Phoenix, AZ 85006, USA
| | - Abdullah K Al Qaraghuli
- MedStar Health Research Institute, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA
| | - Hao Kenith Fang
- Division of Cardiothoracic Surgery, Banner University Medical Center, 1111 East McDowell Road, Phoenix, AZ 85006, USA
| | - Marvin H Eng
- Structural Heart Program, University of Arizona, Banner University Medical Center, 755 East McDowell Road, Phoenix, AZ 85006, USA.
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7
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Tsunamoto H, Yamamoto H, Masumoto A, Taniguchi Y, Takahashi N, Onishi T, Takaya T, Kawai H, Hirata KI, Tanaka H. Efficacy of Native T 1 Mapping for Patients With Non-Ischemic Cardiomyopathy and Ventricular Functional Mitral Regurgitation Undergoing Transcatheter Edge-to-Edge Repair. Circ J 2024; 88:519-527. [PMID: 38325820 DOI: 10.1253/circj.cj-23-0777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND We investigated the efficacy of left ventricular (LV) myocardial damage by native T1mapping obtained with cardiac magnetic resonance (CMR) for patients undergoing transcatheter edge-to-edge repair (TEER).Methods and Results: We studied 40 symptomatic non-ischemic heart failure (HF) patients and ventricular functional mitral regurgitation (VFMR) undergoing TEER. LV myocardial damage was defined as the native T1Z-score, which was converted from native T1values obtained with CMR. The primary endpoint was defined as HF rehospitalization or cardiovascular death over 12 months after TEER. Multivariable Cox proportional hazards analysis showed that the native T1Z-score was the only independent parameter associated with cardiovascular events (hazard ratio 3.40; 95% confidential interval 1.51-7.67), and that patients with native T1Z-scores <2.41 experienced significantly fewer cardiovascular events than those with native T1Z-scores ≥2.41 (P=0.001). Moreover, the combination of a native T1Z-score <2.41 and more severe VFMR (effective regurgitant orifice area [EROA] ≥0.30 cm2) was associated with fewer cardiovascular events than a native T1Z-score ≥2.41 and less severe VFMR (EROA <0.30 cm2; P=0.002). CONCLUSIONS Assessment of baseline LV myocardial damage based on native T1Z-scores obtained with CMR without gadolinium-based contrast media is a valuable additional parameter for better management of HF patients and VFMR following TEER.
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Affiliation(s)
- Hiroshi Tsunamoto
- Department of Cardiology, Hyogo Prefectural Harima-Himeji General Medical Center
- Department of Exploratory and Advanced Search in Cardiology, Kobe University Graduate School of Medicine
| | - Hiroyuki Yamamoto
- Department of Cardiology, Hyogo Prefectural Harima-Himeji General Medical Center
| | - Akiko Masumoto
- Department of Cardiology, Hyogo Prefectural Harima-Himeji General Medical Center
| | - Yasuyo Taniguchi
- Department of General Internal Medicine, Hyogo Prefectural Harima-Himeji General Medical Center
| | - Nobuyuki Takahashi
- Department of Cardiology, Hyogo Prefectural Harima-Himeji General Medical Center
| | - Tetsuari Onishi
- Department of Cardiology, Hyogo Prefectural Harima-Himeji General Medical Center
| | - Tomofumi Takaya
- Department of Cardiology, Hyogo Prefectural Harima-Himeji General Medical Center
- Department of Exploratory and Advanced Search in Cardiology, Kobe University Graduate School of Medicine
| | - Hiroya Kawai
- Department of Cardiology, Hyogo Prefectural Harima-Himeji General Medical Center
- Department of Exploratory and Advanced Search in Cardiology, Kobe University Graduate School of Medicine
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
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8
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Fulop P, Valocik G, Barbierik Vachalcova M, Zenuch P, Filipova L. Aortic stenosis and right ventricular dysfunction. Int J Cardiovasc Imaging 2024; 40:299-305. [PMID: 37950827 PMCID: PMC10884046 DOI: 10.1007/s10554-023-02986-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/14/2023] [Indexed: 11/13/2023]
Abstract
At the present time, right ventricular function in patients with aortic stenosis is insufficiently taken into account in the decision-making process of aortic valve replacement. The aim of our study was to evaluate significance of right ventricular dysfunction in patients with severe aortic stenosis by modern 3D echocardiographic methods. This is prospective analysis of 68 patients with severe high and low-gradient aortic stenosis. We evaluated function of left and right ventricle on the basis of 3D reconstruction. Enddiastolic, endsystolic volumes, ejection fraction and stroke volumes of both chambers were assessed. There were more patients with right ventricular dysfunction in low-gradient group (RVEF < 45%) than in the high-gradient group (63.6% vs 39%, p = 0.02). Low-gradient patients had worse right ventricular function than high-gradient patients (RVEF 36% vs 46%, p = 0.02). There wasn't any significant correlation between the right ventricular dysfunction and pulmonary hypertension (r = - 0.25, p = 0.036). There was significant correlation between left and right ejection fraction (r = 0.78, p < 0.0001). Multiple regression analysis revealed that the only predictor of right ventricular function is the left ventricular function. According to our results we can state that right ventricular dysfunction is more common in patients with low-gradient than in high-gradient aortic stenosis and the only predictor of right ventricular dysfunction is left ventricular dysfunction, probably based on ventriculo-ventricular interaction. Pulmonary hypertension in patients with severe AS does not predict right ventricular dysfunction.
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Affiliation(s)
- Pavol Fulop
- 1st Department of Cardiology, Medical Faculty of University Pavol Jozef Safarik, East Slovak Institute of Cardiovascular Diseases, Ondavska 8, 040 11, Kosice, Slovakia
- Department of Internal Medicine, Medical Faculty of University Pavol Jozef Safarik, Hospital Agel Kosice-Saca, Lucna 57, 040 18, Kosice-Saca, Slovakia
| | - Gabriel Valocik
- 1st Department of Cardiology, Medical Faculty of University Pavol Jozef Safarik, East Slovak Institute of Cardiovascular Diseases, Ondavska 8, 040 11, Kosice, Slovakia.
| | - Marianna Barbierik Vachalcova
- 1st Department of Cardiology, Medical Faculty of University Pavol Jozef Safarik, East Slovak Institute of Cardiovascular Diseases, Ondavska 8, 040 11, Kosice, Slovakia
| | - Pavol Zenuch
- 2nd Department of Cardiology, Medical Faculty of University Pavol Jozef Safarik, East Slovak Institute of Cardiovascular Diseases, Kosice, Slovakia
| | - Lenka Filipova
- Department of Internal Medicine, Medical Faculty of University Pavol Jozef Safarik, Hospital Agel Kosice-Saca, Lucna 57, 040 18, Kosice-Saca, Slovakia
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Messé SR, Overbey JR, Thourani VH, Moskowitz AJ, Gelijns AC, Groh MA, Mack MJ, Ailawadi G, Furie KL, Southerland AM, James ML, Moy CS, Gupta L, Voisine P, Perrault LP, Bowdish ME, Gillinov AM, O'Gara PT, Ouzounian M, Whitson BA, Mullen JC, Miller MA, Gammie JS, Pan S, Erus G, Browndyke JN. The impact of perioperative stroke and delirium on outcomes after surgical aortic valve replacement. J Thorac Cardiovasc Surg 2024; 167:624-633.e4. [PMID: 35483981 PMCID: PMC9996687 DOI: 10.1016/j.jtcvs.2022.01.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 12/14/2021] [Accepted: 01/23/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The effects of stroke and delirium on postdischarge cognition and patient-centered health outcomes after surgical aortic valve replacement (SAVR) are not well characterized. Here, we assess the impact of postoperative stroke and delirium on these health outcomes in SAVR patients at 90 days. METHODS Patients (N = 383) undergoing SAVR (41% received concomitant coronary artery bypass graft) enrolled in a randomized trial of embolic protection devices underwent serial neurologic and delirium evaluations at postoperative days 1, 3, and 7 and magnetic resonance imaging at day 7. Outcomes included 90-day functional status, neurocognitive decline from presurgical baseline, and quality of life. RESULTS By postoperative day 7, 25 (6.6%) patients experienced clinical stroke and 103 (28.5%) manifested delirium. During index hospitalization, time to discharge was longer in patients experiencing stroke (hazard ratio, 0.62; 95% confidence interval [CI], 0.42-0.94; P = .02) and patients experiencing delirium (hazard ratio, 0.68; 95% CI, 0.54-0.86; P = .001). At day 90, patients experiencing stroke were more likely to have a modified Rankin score >2 (odds ratio [OR], 5.9; 95% CI, 1.7-20.1; P = .01), depression (OR, 5.3; 95% CI, 1.6-17.3; P = .006), a lower 12-Item Short Form Survey physical health score (adjusted mean difference -3.3 ± 1.9; P = .08), and neurocognitive decline (OR, 7.8; 95% CI, 2.3-26.4; P = .001). Delirium was associated with depression (OR, 2.2; 95% CI, 0.9-5.3; P = .08), lower 12-Item Short Form Survey physical health (adjusted mean difference -2.3 ± 1.1; P = .03), and neurocognitive decline (OR, 2.2; 95% CI, 1.2-4.0; P = .01). CONCLUSIONS Stroke and delirium occur more frequently after SAVR than is commonly recognized, and these events are associated with disability, depression, cognitive decline, and poorer quality of life at 90 days postoperatively. These findings support the need for new interventions to reduce these events and improve patient-centered outcomes.
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Affiliation(s)
- Steven R Messé
- Department of Stroke and Neurocritical Care, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pa
| | - Jessica R Overbey
- International Center for Health Outcomes and Innovation Research (InCHOIR), The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Vinod H Thourani
- Marcus Valve Center, Department of Cardiovascular Surgery, Piedmont Heart Institute, Atlanta, Ga
| | - Alan J Moskowitz
- International Center for Health Outcomes and Innovation Research (InCHOIR), The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Annetine C Gelijns
- International Center for Health Outcomes and Innovation Research (InCHOIR), The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Mark A Groh
- Asheville Heart, Mission Health and Hospitals, Asheville, NC
| | - Michael J Mack
- Cardiovascular Surgery, Baylor Scott & White Health, Plano, Tex
| | - Gorav Ailawadi
- Departments of Cardiac Surgery and Surgery, University of Michigan Health System, Ann Arbor, Mich
| | - Karen L Furie
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI
| | - Andrew M Southerland
- Division of Vascular Neurology, University of Virginia Health System, Charlottesville, Va
| | - Michael L James
- Department of Anesthesiology, Duke University Medical Center, Durham, NC; Department of Neurology, Duke University Medical Center, Durham, NC
| | - Claudia Scala Moy
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Md
| | - Lopa Gupta
- International Center for Health Outcomes and Innovation Research (InCHOIR), The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Pierre Voisine
- Department of Surgery, Institut de Cardiologie et Pneumologie de Québec, Québec, Canada
| | | | - Michael E Bowdish
- Surgery and Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Patrick T O'Gara
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass
| | - Maral Ouzounian
- Division of Cardiac Surgery, Department of Surgery, Peter Munk Cardiac Centre, UHN-Toronto General Hospital, Toronto, Ontario, Canada
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University, Columbus, Ohio
| | - John C Mullen
- Division of Cardiac Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Marissa A Miller
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - James S Gammie
- Department of Cardiac Surgery, Johns Hopkins Heart and Vascular Institute, Baltimore, Md
| | - Stephanie Pan
- International Center for Health Outcomes and Innovation Research (InCHOIR), The Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Guray Erus
- Department of Radiology, Perelman School of Medicine University of Pennsylvania, Philadelphia, Pa
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC
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10
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Elkasaby MH, Khalefa BB, Yassin MNA, Alabdallat YJ, Atia A, Altobaishat O, Omar I, Hussein A. Transcatheter aortic valve implantation versus surgical aortic valve replacement for pure aortic regurgitation: a systematic review and meta-analysis of 33,484 patients. BMC Cardiovasc Disord 2024; 24:65. [PMID: 38262990 PMCID: PMC10804466 DOI: 10.1186/s12872-023-03667-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 12/09/2023] [Indexed: 01/25/2024] Open
Abstract
INTRODUCTION The published studies comparing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in pure aortic regurgitation (AR) are conflicting. We conducted this systematic review and meta-analysis to compare TAVI with SAVR in pure AR. METHODS We searched PubMed, Embase, Web of Science (WOS), Scopus, and the Cochrane Library Central Register of Controlled Trials (CENTRAL) from inception until 23 June 2023. Review Manager was used for statistical analysis. The risk ratio (RR) with a 95% confidence interval (CI) was used to compare dichotomous outcomes. Continuous outcomes were compared using the mean difference (MD) and 95% CI. The inconsistency test (I2) assessed the heterogeneity. We used the Newcastle-Ottawa scale to assess the quality of included studies. We evaluated the strength of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scale. RESULTS We included six studies with 5633 patients in the TAVI group and 27,851 in SAVR. In-hospital mortality was comparable between TAVI and SAVR (RR = 0.89, 95% CI [0.56, 1.42], P = 0.63) (I2 = 86%, P < 0.001). TAVI was favored over SAVR regarding in-hospital stroke (RR = 0.50; 95% CI [0.39, 0.66], P < 0.001) (I2 = 11%, P = 0.34), in-hospital acute kidney injury (RR = 0.56; 95% CI: [0.41, 0.76], P < 0.001) (I2 = 91%, P < 0.001), major bleeding (RR = 0.23; 95% CI: [0.17, 0.32], P < 0.001) (I2 = 78%, P < 0.001), and shorter hospital say (MD = - 4.76 days; 95% CI: [- 5.27, - 4.25], P < 0.001) (I2 = 88%, P < 0.001). In contrast, TAVI was associated with a higher rate of pacemaker implantation (RR = 1.68; 95% CI: [1.50, 1.88], P < 0.001) (I2 = 0% P = 0.83). CONCLUSION TAVI reduces in-hospital stroke and is associated with better safety outcomes than SAVR in patients with pure AR.
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Affiliation(s)
- Mohamed Hamouda Elkasaby
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
- Medical Research Group of Egypt (MRGE), Cairo, Egypt.
| | - Basma Badrawy Khalefa
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Mazen Negmeldin Aly Yassin
- Faculty of Medicine, Helwan University, Cairo, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Yasmeen Jamal Alabdallat
- Faculty of Medicine, Hashemite University, Zarqa, Jordan
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Ahmed Atia
- Faculty of Medicine, Cairo University, Cairo, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Obieda Altobaishat
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Islam Omar
- Faculty of Pharmacy, South Valley University, Qena, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Amany Hussein
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
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11
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Zinoviev R, Hasan RK, Gammie JS, Resar JR, Czarny MJ. Economic Burden of Inpatient Care for Mitral Regurgitation in Maryland. J Am Heart Assoc 2024; 13:e029875. [PMID: 38214264 PMCID: PMC10926798 DOI: 10.1161/jaha.123.029875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 10/16/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Mitral regurgitation (MR) is the most common valvular disease in the United States and increases the risk of death and hospitalization. The economic burden of MR in the United States is not known. METHODS AND RESULTS We analyzed inpatient hospitalization data from the 1 221 173 Maryland residents who had any in-state admissions from October 1, 2015, to September 30, 2019. We assessed the total charges for patients without MR and for patients with MR who underwent medical management, transcatheter mitral valve repair or replacement, or surgical mitral valve repair or replacement. During the study period, 26 076 inpatients had a diagnosis of MR. Compared with patients without MR, these patients had more comorbidities and higher inpatient mortality. Patients with medically managed MR incurred average total charges of $23 575 per year; MR was associated with $10 559 more in charges per year and an incremental 3.1 more inpatient days per year as compared with patients without MR. Both surgical mitral valve repair or replacement and transcatheter mitral valve repair or replacement were associated with higher charges as compared with medical management during the year of intervention ($47 943 for surgical mitral valve repair or replacement and $63 108 for transcatheter mitral valve repair or replacement). Annual charges for both groups were significantly lower as compared with medical management in the second and third years postintervention. CONCLUSIONS MR is associated with higher mortality and inpatient charges. Patients who undergo surgical or transcatheter intervention incur lower charges compared with medically managed MR patients in the years after the procedure.
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Affiliation(s)
| | - Rani K. Hasan
- Division of Cardiology, Johns Hopkins University School of MedicineBaltimoreMD
| | - James S. Gammie
- Division of Cardiac SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| | - Jon R. Resar
- Division of Cardiology, Johns Hopkins University School of MedicineBaltimoreMD
| | - Matthew J. Czarny
- Division of Cardiology, Johns Hopkins University School of MedicineBaltimoreMD
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12
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Saad M, Elhakim A, Rusch R, Berndt R, Panholzer B, Lutter G, Frank D. Trans-Brachial TAVI in a Patient with Aortic Isthmus Stenosis: A Case Report. J Clin Med 2024; 13:308. [PMID: 38256442 PMCID: PMC10816714 DOI: 10.3390/jcm13020308] [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: 12/02/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND TAVI indications expand not only to low-risk patients but also to patients with a more complex anatomy and comorbidities. Transfemoral retrograde access is recognized as the first preferred approach according to the current guidelines. However, this approach is not suitable in up to 10-15% of patients, for whom an alternative non-femoral access route is required. CASE PRESENTATION An 83-year-old male patient with known aortic isthmus stenosis presented with severe symptomatic aortic stenosis. Computed tomography revealed a subtotal isthmus stenosis, directly after left subclavian artery origin, with many collaterals extending toward the axillary and subclavian arteries. Duplex ultrasound verified the proximal diameter of the left brachial artery to be 5.5 mm. A successful surgical cutdown trans-brachial TAVI with an Evolut prosthetic valve with a size of 29 mm was performed. On the fourth postoperative day, the patient was discharged, and the three-month follow-up was uneventful. CONCLUSION In patients with aortic isthmus stenosis, the brachial artery could be a feasible alternative, as a less invasive access site, which can be determined after careful assessment of the vessel diameter. More data are required to evaluate the safety and efficacy of this access route and to achieve more technical improvements to increase operator familiarity with it.
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Affiliation(s)
- Mohammed Saad
- Cardiology Department, Schleswig-Holstein University Hospital-Kiel, Arnold-Heller-Street 3, 24105 Kiel, Germany; (A.E.); (D.F.)
| | - Abdelrahman Elhakim
- Cardiology Department, Schleswig-Holstein University Hospital-Kiel, Arnold-Heller-Street 3, 24105 Kiel, Germany; (A.E.); (D.F.)
| | - Rene Rusch
- Vascular Surgery Department, Schleswig-Holstein University Hospital-Kiel, Arnold-Heller-Street 3, 24105 Kiel, Germany; (R.R.); (R.B.)
| | - Rouven Berndt
- Vascular Surgery Department, Schleswig-Holstein University Hospital-Kiel, Arnold-Heller-Street 3, 24105 Kiel, Germany; (R.R.); (R.B.)
| | - Bernd Panholzer
- Cardiothoracic Surgery Department, Schleswig-Holstein University Hospital-Kiel, Arnold-Heller-Street 3, 24105 Kiel, Germany; (B.P.); (G.L.)
| | - Georg Lutter
- Cardiothoracic Surgery Department, Schleswig-Holstein University Hospital-Kiel, Arnold-Heller-Street 3, 24105 Kiel, Germany; (B.P.); (G.L.)
| | - Derk Frank
- Cardiology Department, Schleswig-Holstein University Hospital-Kiel, Arnold-Heller-Street 3, 24105 Kiel, Germany; (A.E.); (D.F.)
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13
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Schaefer A, Bhadra OD, Conradi L, Westermann D, Kellner C, De Backer O, Bajoras V, Sondergaard L, Qureshi WT, Kakouros N, Aldrugh S, Amat-Santos I, Kaneko T, Harloff M, Teles R, Nolasco T, Neves JP, Abecasis M, Werner N, Lauterbach M, Sacha J, Krawczyk K, Trani C, Romagnoli E, Mangieri A, Condello F, Regueiro A, Brugaletta S, Biancari F, Niemelä M, Giannini F, Toselli M, Ruggiero R, Buono A, Maffeo D, Bruno F, Conrotto F, D'Ascenzo F, Savontaus M, Pykäri J, Ielasi A, Tespili M, Cimmino M, Albanese M, Biondi-Zoccai G, Corcione N, Morello A, Giordano A. Procedural success in transaxillary transcatheter aortic valve implantation according to type of transcatheter heart valve: results from the multicenter TAXI registry. Clin Res Cardiol 2024; 113:48-57. [PMID: 37138103 DOI: 10.1007/s00392-023-02216-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/25/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Transaxillary (TAx) transcatheter aortic valve implantation (TAVI) is a preferred alternative access in patients ineligible for transfemoral TAVI. AIMS This study used the Trans-AXillary Intervention (TAXI) registry to compare procedural success according to different types of transcatheter heart valves (THV). METHODS For the TAXI registry anonymized data of patients treated with TAx-TAVI were collected from 18 centers. Acute procedural, early and 1-month clinical outcomes were adjudicated in accordance with standardized VARC-3 definitions. RESULTS From 432 patients, 368 patients (85.3%, SE group) received self-expanding (SE) THV and 64 patients (14.8%, BE group) received balloon-expandable (BE) THV. Imaging revealed lower axillary artery diameters in the SE group (max/min diameter in mm: 8.4/6.6 vs 9.4/6.8 mm; p < 0.001/p = 0.04) but a higher proportion of axillary tortuosity in BE group (62/368, 23.6% vs 26/64, 42.6%; p = 0.004) with steeper aorta-left ventricle (LV) inflow (55° vs 51°; p = 0.002) and left ventricular outflow tract (LVOT)-LV inflow angles (40.0° vs 24.5°; 0.002). TAx-TAVI was more often conducted by right sided axillary artery in the BE group (33/368, 9.0% vs 17/64, 26.6%; p < 0.001). Device success was higher in the SE group (317/368, 86.1% vs 44/64, 68.8%, p = 0.0015). In logistic regression analysis, BE THV were a risk factor for vascular complications and axillary stent implantation. CONCLUSIONS Both, SE and BE THV can be safely used in TAx-TAVI. However, SE THV were more often used and were associated with a higher rate of device success. While SE THV were associated with lower rates of vascular complications, BE THV were more often used in cases with challenging anatomical circumstances.
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Affiliation(s)
- Andreas Schaefer
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany.
| | - Oliver D Bhadra
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Caroline Kellner
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Ole De Backer
- The Heart Center-Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Vilhelmas Bajoras
- The Heart Center-Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Department of Interventional Cardiology, Division of Cardiology and Vascular Diseases, Vilnius University, Hospital Santaros Clinics, Vilnius, Lithuania
| | - Lars Sondergaard
- The Heart Center-Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Waqas T Qureshi
- Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA, USA
| | - Nikolaos Kakouros
- Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA, USA
| | - Summer Aldrugh
- Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA, USA
| | - Ignacio Amat-Santos
- Cardiology Department, CIBERCV, Hospital Clinico Universitario de Valladolid, Valladolid, Spain
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Morgan Harloff
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rui Teles
- Cardiothoracic Surgery Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
| | - Tiago Nolasco
- Cardiothoracic Surgery Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
| | - Jose Pedro Neves
- Cardiothoracic Surgery Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
| | - Miguel Abecasis
- Cardiothoracic Surgery Department, Hospital de Santa Cruz, Carnaxide, Lisbon, Portugal
| | - Nikos Werner
- Department of Medicine 3, Barmherzige Brüder Hospital, Trier, Germany
| | | | - Jerzy Sacha
- Department of Cardiology, Institute of Medical Sciences, University Hospital, University of Opole, Opole, Poland
| | - Krzysztof Krawczyk
- Department of Cardiology, Institute of Medical Sciences, University Hospital, University of Opole, Opole, Poland
| | - Carlo Trani
- Institute of Cardiology, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Enrico Romagnoli
- Institute of Cardiology, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Antonio Mangieri
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Francesco Condello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Ander Regueiro
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Salvatore Brugaletta
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Fausto Biancari
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Matti Niemelä
- Department of Internal Medicine, Oulu University Hospital, Oulu, Finland
| | - Francesco Giannini
- Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy
| | - Marco Toselli
- Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy
| | - Rossella Ruggiero
- Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy
| | - Andrea Buono
- Interventional Cardiology Unit, Cardiovascular Department, Fondazione Poliambulanza Institute, Brescia, Italy
| | - Diego Maffeo
- Interventional Cardiology Unit, Cardiovascular Department, Fondazione Poliambulanza Institute, Brescia, Italy
| | - Francesco Bruno
- Department of Medical Science, Division of Cardiology, Città Della Salute e della Scienza, Turin, Italy
| | - Federico Conrotto
- Department of Medical Science, Division of Cardiology, Città Della Salute e della Scienza, Turin, Italy
| | - Fabrizio D'Ascenzo
- Department of Medical Science, Division of Cardiology, Città Della Salute e della Scienza, Turin, Italy
| | - Mikko Savontaus
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Jouni Pykäri
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | | | - Maurizio Tespili
- Clinical and Interventional Cardiology Unit, Istituto Clinico Sant'Ambrogio, Gruppo Ospedaliero San Donato, Milan, Italy
| | - Michele Cimmino
- Interventional Cardiology Unit, Santa Lucia Clinic, S. Giuseppe Vesuviano, Naples, Italy
| | - Michele Albanese
- Interventional Cardiology Unit, Santa Lucia Clinic, S. Giuseppe Vesuviano, Naples, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- Mediterranea Cardiocentro, Naples, Italy
| | - Nicola Corcione
- Interventional Cardiology Unit, Pineta Grande Hospital, Castel Volturno, Italy
| | - Alberto Morello
- Interventional Cardiology Unit, Pineta Grande Hospital, Castel Volturno, Italy
| | - Arturo Giordano
- Interventional Cardiology Unit, Pineta Grande Hospital, Castel Volturno, Italy
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14
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Gheyath B, Chau E, Latif S, Smith TW. The Interventional Imager: How Do We Train the Next Interventional Imagers? Interv Cardiol Clin 2024; 13:29-38. [PMID: 37980065 DOI: 10.1016/j.iccl.2023.08.007] [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: 11/20/2023]
Abstract
With the increase in structural heart procedural volume, interventional imagers are required. Multiple imaging modalities exist to guide these procedures. With comprehensive understanding of pathology, anatomy, and procedures, an advanced imager plays an important role in the heart team. Imaging training is part of general cardiology fellowship. Current structures do not provide adequate procedural time to fill the role. Interested graduates pursue advanced training by either focusing on echocardiography and procedural imaging or multidetector computed tomography and cardiac magnetic resonance. This yields individuals with different expertise.
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Affiliation(s)
- Bashaer Gheyath
- Department of Imaging, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Taper, A238, Los Angeles, CA 90048, USA. https://twitter.com/bgheyath
| | - Edward Chau
- Division of Cardiovascular Medicine, University of California Davis Medical Center, 4680 Y Street, Suite 2820, Sacramento, CA 95817, USA
| | - Syed Latif
- Heart and Vascular Institute, Sutter Medical Center, Sacramento, CA, USA
| | - Thomas W Smith
- Division of Cardiovascular Medicine, University of California Davis Medical Center, 4680 Y Street, Suite 2820, Sacramento, CA 95817, USA.
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15
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Katsaros O, Apostolos A, Ktenopoulos N, Koliastasis L, Kachrimanidis I, Drakopoulou M, Korovesis T, Karanasos A, Tsalamandris S, Latsios G, Synetos A, Tsioufis K, Toutouzas K. Transcatheter Aortic Valve Implantation Access Sites: Same Goals, Distinct Aspects, Various Merits and Demerits. J Cardiovasc Dev Dis 2023; 11:4. [PMID: 38248874 PMCID: PMC10817029 DOI: 10.3390/jcdd11010004] [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: 11/14/2023] [Revised: 12/03/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has been established as a safe and efficacious treatment for patients with severe symptomatic aortic stenosis (AS). Despite being initially developed and indicated for high-surgical-risk patients, it is now offered to low-risk populations based on the results of large randomized controlled trials. The most common access sites in the vast majority of patients undergoing TAVI are the common femoral arteries; however, 10-20% of the patients treated with TAVI require an alternative access route, mainly due to peripheral atherosclerotic disease or complex anatomy. Hence, to achieve successful delivery and implantation of the valve, several arterial approaches have been studied, including transcarotid (TCr), axillary/subclavian (A/Sc), transapical (TAp), transaortic (TAo), suprasternal-brachiocephalic (S-B), and transcaval (TCv). This review aims to concisely summarize the most recent literature data and current guidelines as well as evaluate the various access routes for TAVI, focusing on the indications, the various special patient groups, and the advantages and disadvantages of each technique, as well as their adverse events.
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Affiliation(s)
- Odysseas Katsaros
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (A.A.); (N.K.); (L.K.); (I.K.); (M.D.); (T.K.); (A.K.); (G.L.); (A.S.); (K.T.)
| | - Anastasios Apostolos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (A.A.); (N.K.); (L.K.); (I.K.); (M.D.); (T.K.); (A.K.); (G.L.); (A.S.); (K.T.)
| | - Nikolaos Ktenopoulos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (A.A.); (N.K.); (L.K.); (I.K.); (M.D.); (T.K.); (A.K.); (G.L.); (A.S.); (K.T.)
| | - Leonidas Koliastasis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (A.A.); (N.K.); (L.K.); (I.K.); (M.D.); (T.K.); (A.K.); (G.L.); (A.S.); (K.T.)
- Department of Cardiology, University of Brussels, CHU Saint-Pierre, 1000 Brussels, Belgium
| | - Ioannis Kachrimanidis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (A.A.); (N.K.); (L.K.); (I.K.); (M.D.); (T.K.); (A.K.); (G.L.); (A.S.); (K.T.)
| | - Maria Drakopoulou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (A.A.); (N.K.); (L.K.); (I.K.); (M.D.); (T.K.); (A.K.); (G.L.); (A.S.); (K.T.)
| | - Theofanis Korovesis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (A.A.); (N.K.); (L.K.); (I.K.); (M.D.); (T.K.); (A.K.); (G.L.); (A.S.); (K.T.)
| | - Antonios Karanasos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (A.A.); (N.K.); (L.K.); (I.K.); (M.D.); (T.K.); (A.K.); (G.L.); (A.S.); (K.T.)
| | - Sotirios Tsalamandris
- Department of Cardiology, Hippokration General Hospital of Athens, 11527 Athens, Greece;
| | - George Latsios
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (A.A.); (N.K.); (L.K.); (I.K.); (M.D.); (T.K.); (A.K.); (G.L.); (A.S.); (K.T.)
| | - Andreas Synetos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (A.A.); (N.K.); (L.K.); (I.K.); (M.D.); (T.K.); (A.K.); (G.L.); (A.S.); (K.T.)
| | - Konstantinos Tsioufis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (A.A.); (N.K.); (L.K.); (I.K.); (M.D.); (T.K.); (A.K.); (G.L.); (A.S.); (K.T.)
| | - Konstantinos Toutouzas
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration General Hospital of Athens, 11527 Athens, Greece; (A.A.); (N.K.); (L.K.); (I.K.); (M.D.); (T.K.); (A.K.); (G.L.); (A.S.); (K.T.)
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Gohmann RF, Schug A, Pawelka K, Seitz P, Majunke N, El Hadi H, Heiser L, Renatus K, Desch S, Leontyev S, Noack T, Kiefer P, Krieghoff C, Lücke C, Ebel S, Borger MA, Thiele H, Panknin C, Abdel-Wahab M, Horn M, Gutberlet M. Interrater variability of ML-based CT-FFR during TAVR-planning: influence of image quality and coronary artery calcifications. Front Cardiovasc Med 2023; 10:1301619. [PMID: 38188259 PMCID: PMC10768187 DOI: 10.3389/fcvm.2023.1301619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/13/2023] [Indexed: 01/09/2024] Open
Abstract
Objective To compare machine learning (ML)-based CT-derived fractional flow reserve (CT-FFR) in patients before transcatheter aortic valve replacement (TAVR) by observers with differing training and to assess influencing factors. Background Coronary computed tomography angiography (cCTA) can effectively exclude CAD, e.g. prior to TAVR, but remains limited by its specificity. CT-FFR may mitigate this limitation also in patients prior to TAVR. While a high reliability of CT-FFR is presumed, little is known about the reproducibility of ML-based CT-FFR. Methods Consecutive patients with obstructive CAD on cCTA were evaluated with ML-based CT-FFR by two observers. Categorization into hemodynamically significant CAD was compared against invasive coronary angiography. The influence of image quality and coronary artery calcium score (CAC) was examined. Results CT-FFR was successfully performed on 214/272 examinations by both observers. The median difference of CT-FFR between both observers was -0.05(-0.12-0.02) (p < 0.001). Differences showed an inverse correlation to the absolute CT-FFR values. Categorization into CAD was different in 37/214 examinations, resulting in net recategorization of Δ13 (13/214) examinations and a difference in accuracy of Δ6.1%. On patient level, correlation of absolute and categorized values was substantial (0.567 and 0.570, p < 0.001). Categorization into CAD showed no correlation to image quality or CAC (p > 0.13). Conclusion Differences between CT-FFR values increased in values below the cut-off, having little clinical impact. Categorization into CAD differed in several patients, but ultimately only had a moderate influence on diagnostic accuracy. This was independent of image quality or CAC.
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Affiliation(s)
- Robin F. Gohmann
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
- Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Adrian Schug
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
- Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Konrad Pawelka
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
- Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Patrick Seitz
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
| | - Nicolas Majunke
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Hamza El Hadi
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Linda Heiser
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
| | - Katharina Renatus
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
- Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Steffen Desch
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Sergey Leontyev
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Thilo Noack
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Philipp Kiefer
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | | | | | - Sebastian Ebel
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
- Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Michael A. Borger
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
- Helios Health Institute, Leipzig, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
- Helios Health Institute, Leipzig, Germany
| | | | - Mohamed Abdel-Wahab
- Department of Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Matthias Horn
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Leipzig, Germany
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
- Medical Faculty, University of Leipzig, Leipzig, Germany
- Helios Health Institute, Leipzig, Germany
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Barrett CD, Nickel A, Rosenberg MA, Ream K, Tzou WS, Aleong R, Tumolo A, Garg L, Zipse M, West JJ, Varosy P, Sandhu A. PRIME score for prediction of permanent pacemaker implantation after transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2023; 102:1357-1363. [PMID: 37735946 DOI: 10.1002/ccd.30845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/02/2023] [Accepted: 09/10/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVES We sought to produce a simple scoring system that can be applied at clinical visits before transcatheter aortic valve replacement (TAVR) to stratify the risk of permanent pacemaker (PPM) after the procedure. BACKGROUND Atrioventricular block is a known complication of TAVR. Current models for predicting the risk of PPM after TAVR are not designed to be applied clinically to assist with preprocedural planning. METHODS Patients undergoing TAVR at the University of Colorado were split into a training cohort for the development of a predictive model, and a testing cohort for model validation. Stepwise and binary logistic regressions were performed on the training cohort to produce a predictive model. Beta coefficients from the binary logistic regression were used to create a simple scoring system for predicting the need for PPM implantation. Scores were then applied to the validation cohort to assess predictive accuracy. RESULTS Patients undergoing TAVR from 2013 to 2019 were analyzed: with 483 included in the training cohort and 123 included in the validation cohort. The need for a pacemaker was associated with five preprocedure variables in the training cohort: PR interval > 200 ms, Right bundle branch block, valve-In-valve procedure, prior Myocardial infarction, and self-Expandable valve. The PRIME score was developed using these clinical features, and was highly accurate for predicting PPM in both the training and model validation cohorts (area under the curve 0.804 and 0.830 in the model training and validation cohorts, respectively). CONCLUSIONS The PRIME score is a simple and accurate preprocedural tool for predicting the need for PPM implantation after TAVR.
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Affiliation(s)
| | - Andrew Nickel
- University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | | | - Karen Ream
- Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
| | - Wendy S Tzou
- Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
| | - Ryan Aleong
- Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
| | - Alexis Tumolo
- Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
| | - Lohit Garg
- Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
| | - Matthew Zipse
- Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
| | - John J West
- Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
- Denver Health Medical Center, Denver, Colorado, USA
| | - Paul Varosy
- Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - Amneet Sandhu
- Anschutz Medical Campus, University of Colorado, Aurora, Colorado, USA
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
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18
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Srinivasan S, Novelli A, Callas P, Gupta T, Straight F, Dauerman HL. Cardiac catheterization, coronary intervention, and wait times for transcatheter aortic valve replacement. Coron Artery Dis 2023; 34:475-482. [PMID: 37799044 DOI: 10.1097/mca.0000000000001275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
OBJECTIVES Prolonged wait times for transcatheter aortic valve replacement (TAVR) are associated with increased morbidity and mortality. The incidence and predictors of short TAVR wait times (STWT: defined as ≤ 30 days from referral to TAVR procedure) have not been defined. This study examined the impact of clinical characteristics, demographics, and pre-TAVR cardiac catheterization on wait times for TAVR. METHODS This was a retrospective observational analysis of 831 patients with severe aortic stenosis undergoing TAVR from 2019 to mid-2022 at the University of Vermont Medical Center. Demographics, timing of treatment [stratified by COVID-19 onset (1 March 2020)], TAVR center travel distance, baseline clinical factors, and process-related variables were analyzed to determine univariate STWT predictors (P < 0.10). Multivariable analysis was performed to determine independent STWT predictors. RESULTS Approximately 50% of TAVR patients in this study achieved a STWT. The proportion of patients with STWT was higher (54.7% vs. 45.2%; P = 0.008) after the onset of COVID-19 pandemic. STWT was not related to travel distance (P = 0.61). Patients with left ventricular ejection fraction (LVEF) > 60% were less likely to achieve STWT compared to patients with LVEF < 40% (OR 0.45, P = 0.003). Patients who required catheterization or percutaneous coronary intervention (PCI) before TAVR were significantly less likely to achieve STWT (OR 0.65, P = 0.01). CONCLUSION TAVR wait times were not affected by the COVID-19 pandemic or single rural TAVR center travel distance. Sicker patients were more likely to achieve STWT while catheterization/PCI before TAVR was associated with longer wait times.
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Affiliation(s)
| | - Alexandra Novelli
- Department of Medicine, University of Vermont Larner College of Medicine
| | - Peter Callas
- Division of Cardiology, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Tanush Gupta
- Department of Medicine, University of Vermont Larner College of Medicine
- Division of Cardiology, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Faye Straight
- Division of Cardiology, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Harold L Dauerman
- Department of Medicine, University of Vermont Larner College of Medicine
- Division of Cardiology, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
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Fath AR, Aglan A, Khurana A, Abuasbeh J, Eldaly AS, Mantha Y, Abraham B, Olagunju A, Prasad A. Transcatheter Aortic Valve Replacement: Variations in Use, Charges, and Geography in the United States. Am J Cardiol 2023; 205:363-368. [PMID: 37647820 DOI: 10.1016/j.amjcard.2023.07.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/21/2023] [Accepted: 07/30/2023] [Indexed: 09/01/2023]
Abstract
The use of transcatheter aortic valve replacement (TAVR) in the United States has been increasing but with variability. We used a 100% sample of Medicare beneficiaries (MBs), from the Centers for Medicare and Medicaid Services database, who underwent TAVR by cardiologists between 2015 and 2019. We stratified data by geographic region, rural/urban areas, and provider's gender. We examined the average number of TAVRs performed per 100,000 MBs, the average number of TAVRs performed per individual cardiologist, and the average submitted charge (ASC) per procedure. The number of TAVR per 100,000 MBs was significantly variable among regions in all years (all P≤0.028), except in 2015 (P=0.103), with the highest rates being in the Northeast and the lowest being in the West. The number of TAVRs per cardiologist was significantly different among regions only in 2019 (P=0.04), with the Northeast showing the highest numbers and the South showing the lowest. The ASC was also significantly variable among regions in all years (all P≤0.01). The highest ASC was in the Midwest for all years, whereas the lowest was in the West in 2015 to 2016 and in the South in 2017 to 2019. In all years, the number of TAVRs per cardiologist was higher in urban areas than in rural areas (all P<0.05); however, rural cardiologists had higher ASCs (all P<0.05). The number of TAVR procedures per cardiologist was not significantly different between male and female cardiologists (all P>0.1). Female cardiologists had a significantly higher ASC only in 2015 (P=0.034). In conclusion, there are variations in TAVR use and charges for MBs according to geographic, urban, and rural regions and the performing cardiologist's gender.
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Affiliation(s)
- Ayman R Fath
- Department of Cardiovascular Diseases, University of Texas Health Science Center, San Antonio, Texas
| | - Amro Aglan
- Department of Internal Medicine, Beth Israel Lahey Health, Boston, Massachusetts
| | - Aditya Khurana
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Jumanah Abuasbeh
- Department of Public Health, University of Arizona, Phoenix, Arizona
| | | | - Yogamaya Mantha
- Department of Cardiovascular Diseases, University of Texas Health Science Center, San Antonio, Texas
| | - Bishoy Abraham
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, Arizona
| | | | - Anand Prasad
- Department of Cardiovascular Diseases, University of Texas Health Science Center, San Antonio, Texas.
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20
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Ahmed A, Mathew DM, Mathew SM, Awad AK, Varghese KS, Khaja S, Vega E, Pandey R, Thomas JJ, Mathew CS, Ahmed S, George J, Awad AK, Fusco PJ. General Anesthesia Versus Local Anesthesia in Patients Undergoing Transcatheter Aortic Valve Replacement: An Updated Meta-Analysis and Systematic Review. J Cardiothorac Vasc Anesth 2023; 37:1358-1367. [PMID: 37120319 DOI: 10.1053/j.jvca.2023.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/07/2023] [Accepted: 03/06/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVES For patients with aortic stenosis, transcatheter aortic valve replacement (TAVR) offers a less invasive treatment modality than conventional surgical valve replacement. Although the surgery is performed traditionally under general anesthesia (GA), recent studies have described success with TAVR using local anesthesia (LA) and/or conscious sedation. The study authors performed a pairwise meta-analysis to compare the clinical outcomes of TAVR based on operative anesthesia management. DESIGN A random effects pairwise meta-analysis via the Mantel-Haenszel method. SETTING Not applicable, as this is a meta-analysis. PARTICIPANTS No individual patient data were used. INTERVENTIONS Not applicable, as this is a meta-analysis. MEASUREMENTS AND MAIN RESULTS The authors comprehensively searched the PubMed, Embase, and Cochrane databases to identify studies comparing TAVR performed using LA or GA. Outcomes were pooled as risk ratios (RR) or standard mean differences (SMD) and their 95% CIs. The authors' pooled analysis included 14,388 patients from 40 studies (7,754 LA; 6,634 GA). Compared to GA TAVR, LA TAVR was associated with significantly lower rates of 30-day mortality (RR 0.69; p < 0.01) and stroke (RR 0.78; p = 0.02). Additionally, LA TAVR patients had lower rates of 30-day major and/or life-threatening bleeding (RR 0.64; p = 0.01), 30-day major vascular complications (RR 0.76; p = 0.02), and long-term mortality (RR 0.75; p = 0.009). No significant difference was seen between the 2 groups for a 30-day paravalvular leak (RR 0.88, p = 0.12). CONCLUSIONS Transcatheter aortic valve replacement performed using LA is associated with lower rates of adverse clinical outcomes, including 30-day mortality and stroke. No difference was seen between the 2 groups for a 30-day paravalvular leak. These results support the use of minimally invasive forms of TAVR without GA.
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Affiliation(s)
- Adham Ahmed
- City University of New York School of Medicine, New York, NY.
| | - Dave M Mathew
- City University of New York School of Medicine, New York, NY
| | - Serena M Mathew
- City University of New York School of Medicine, New York, NY
| | - Ahmed K Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Sofia Khaja
- City University of New York School of Medicine, New York, NY
| | - Eamon Vega
- City University of New York School of Medicine, New York, NY
| | - Roshan Pandey
- City University of New York School of Medicine, New York, NY
| | | | | | - Sarah Ahmed
- City University of New York School of Medicine, New York, NY
| | - Jerrin George
- University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - Ayman K Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Peter J Fusco
- City University of New York School of Medicine, New York, NY
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21
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Gherasie FA, Achim A. TAVR Interventions and Coronary Access: How to Prevent Coronary Occlusion. Life (Basel) 2023; 13:1605. [PMID: 37511980 PMCID: PMC10381891 DOI: 10.3390/life13071605] [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: 06/19/2023] [Revised: 07/06/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
Due to technological advancements during the past 20 years, transcatheter aortic valve replacements (TAVRs) have significantly improved the treatment of symptomatic and severe aortic stenosis, significantly improving patient outcomes. The continuous evolution of transcatheter valve models, refined imaging planning for enhanced accuracy, and the growing expertise of technicians have collectively contributed to increased safety and procedural success over time. These notable advancements have expanded the scope of TAVR to include patients with lower risk profiles as it has consistently demonstrated more favorable outcomes than surgical aortic valve replacement (SAVR). As the field progresses, coronary angiography is anticipated to become increasingly prevalent among patients who have previously undergone TAVR, particularly in younger cohorts. It is worth noting that aortic stenosis is often associated with coronary artery disease. While the task of re-accessing coronary artery access following TAVR is challenging, it is generally feasible. In the context of valve-in-valve procedures, several crucial factors must be carefully considered to optimize coronary re-access. To obtain successful coronary re-access, it is essential to align the prosthesis with the native coronary ostia. As part of preventive measures, strategies have been developed to safeguard against coronary obstruction during TAVR. One such approach involves placing wires and non-deployed coronary balloons or scaffolds inside an at-risk coronary artery, a procedure known as chimney stenting. Additionally, the bioprosthetic or native aortic scallops intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure offers an effective and safer alternative to prevent coronary artery obstructions. The key objective of our study was to evaluate the techniques and procedures employed to achieve commissural alignment in TAVR, as well as to assess the efficacy and measure the impact on coronary re-access in valve-in-valve procedures.
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Affiliation(s)
| | - Alexandru Achim
- Department of Cardiology, Medizinische Universitätsklinik, Kantonsspital Baselland, Rheinstrasse 26, 4410 Liestal, Switzerland
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22
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Al-Kassou B, Al-Shaikh H, Aksoy A, Shamekhi J, Zietzer A, Sugiura A, Veulemans V, Adam M, Grube E, Bakhtiary F, Zimmer S, Kelm M, Baldus S, Nickenig G, Sedaghat A. Impact of transradial versus transfemoral access for preprocedural coronary angiography on TAVR-associated complications. IJC HEART & VASCULATURE 2023; 46:101205. [PMID: 37122629 PMCID: PMC10130599 DOI: 10.1016/j.ijcha.2023.101205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/28/2023] [Accepted: 04/04/2023] [Indexed: 05/02/2023]
Abstract
Background Vascular injury and bleeding complications remain frequent after transcatheter aortic valve replacement (TAVR). Whether the access-site of preprocedural coronary angiography (CAG) affects TAVR-related complications is not known. The aim of this study was to evaluate the impact of transradial (TRA) versus transfemoral access (TFA) for preprocedural CAG on outcomes in patients undergoing subsequent TAVR. Methods The study cohort included 1002 patients undergoing transfemoral TAVR, of whom 39.4% (395/1002) had undergone radial and 60.6% (607/1002) femoral access for pre-TAVR CAG. The primary endpoint was a composite of 30-day mortality and major vascular complications after TAVR. Key secondary endpoints included VARC-3-defined complications. Results The primary endpoint occurred less frequently in patients with prior TRA (3.3%) as compared to patients with prior TFA (6.3%, p = 0.04), which was mainly driven by significantly lower rates of major vascular complications (0.8% vs 2.5%, p = 0.05). Moreover, incidences of periprocedural access-related vascular injury and unplanned endovascular interventions were lower in TRA patients (13.2% vs 18.0%, p = 0.05). The rate of major bleeding tended to be lower in the TRA (1.5%) as compared to the TFA group (3.5%) but was not significantly different (p = 0.07). Moreover, the rate of life-threatening bleeding was comparable between both groups (0.5% vs 0.8%, p = 0.71). Conclusion Transradial access for preprocedural CAG was associated with significantly lower rates of vascular complications following subsequent TAVR as compared to transfemoral access. However, despite the tendency to lower major bleedings with transradial access, no significant association was detectable between the access-site of coronary angiography and TAVR-related bleeding complications.
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Affiliation(s)
- Baravan Al-Kassou
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Hasanin Al-Shaikh
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Adem Aksoy
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Jasmin Shamekhi
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Andreas Zietzer
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Atsushi Sugiura
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Verena Veulemans
- Division of Cardiology, University Hospital of Duesseldorf, Germany
- CARID, Cardiovascular Research Institute Duesseldorf, Germany
| | - Matti Adam
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Eberhard Grube
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Farhad Bakhtiary
- Heart Center, Department of Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Malte Kelm
- CARID, Cardiovascular Research Institute Duesseldorf, Germany
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Stephan Baldus
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Georg Nickenig
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Alexander Sedaghat
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
- RheinAhrCardio, Praxis für Kardiologie, Bad Neuenahr-Ahrweiler, Germany
- Corresponding author.
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23
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Hosseini M, Lahr BD, Greason KL, Arghami A, Gulati R, Eleid MF, Crestanello JA. Obesity and vascular complication in percutaneous transfemoral transcatheter aortic valve insertion. Catheter Cardiovasc Interv 2023; 101:1221-1228. [PMID: 37036273 DOI: 10.1002/ccd.30658] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 02/01/2023] [Accepted: 03/19/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Obesity has been associated with an increased risk of vascular complication during percutaneous coronary intervention, but there are no data on the risk of vascular complication during percutaneous transfemoral transcatheter aortic valve insertion (TAVI). OBJECTIVES We hypothesized there would be a similar increased risk associated with TAVI. METHODS We reviewed the records of 1176 patients who received percutaneous transfemoral transcatheter aortic valve insertion from September 2015 to September 2020. All patients received 1) preoperative computed tomoraphy angiography assessment of the abdomen and pelvis to delineate iliofemoral artery anatomy, 2) ultrasound-guided percutaneous femoral arterial access, and 3) pre-closure of the delivery sheath femoral access site. Vascular complication was recorded based on definitions set forth by Valve Academic Research Consortium 3. RESULTS The median age of patients was 81 years, and 60% were men. The median body mass index (BMI) was 29 kg/m2 (range, 11-67), and 91 (8%) patients had a value ≥40 kg/m2 (i.e., morbid obesity). Delivery sheath size was 14-French in 859 (73%) patients, 16-French in 311 (26%), and 18-French in 6 (1%). Vascular complication occurred in 53 (5%) patients, including 39 (7%) among the first half of procedures and 14 (2%) among the second half (p < 0.001). When stratified by obesity status (BMI < or ≥30 kg/m2 , p < 0.001), the complication rate was 4% in nonobese patients and 5% in obese patients. Multivariable analysis showed no overall association between risk of vascular complication and BMI categories (p = 0.583)BMI continuous values (p = 0.529), or sheath size (p = 0.217). CONCLUSIONS Obesity is not associated with a vascular complication during percutaneous transfemoral transcatheter aortic valve insertion. The operation should not be denied in obese patients.
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Affiliation(s)
- Motahar Hosseini
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian D Lahr
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Haramati A, Latib A, Lazarus MS. Post-procedural structural heart CT imaging: TAVR, TMVR, and other interventions. Clin Imaging 2023; 101:86-95. [PMID: 37311399 DOI: 10.1016/j.clinimag.2023.05.012] [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: 03/20/2023] [Revised: 05/16/2023] [Accepted: 05/25/2023] [Indexed: 06/15/2023]
Abstract
Transcatheter valve replacement has experienced substantial growth in the past decade and this technique can now be used for any of the four heart valves. Transcatheter aortic valve replacement (TAVR) has overtaken surgical aortic valve replacement. Transcatheter mitral valve replacement (TMVR) is often performed in pre-existing valves or after prior valve repair, although numerous devices are undergoing trials for replacement of native valves. Transcatheter tricuspid valve replacement (TTVR) is similarly under active development. Lastly, transcatheter pulmonic valve replacement (TPVR) is most often used for revision treatment of congenital heart disease. Given the growth of these techniques, radiologists are increasingly called upon to interpret post-procedural imaging for these patients, particularly with CT. These cases will often arise unexpectedly and require detailed knowledge of potential post-procedural appearances. We review both normal and abnormal post-procedural findings on CT. Certain complications-device migration or embolization, paravalvular leak, or leaflet thrombosis-can occur after replacement of any valve. Other complications are specific to each type of valve, including coronary artery occlusion after TAVR, coronary artery compression after TPVR, or left ventricular outflow tract obstruction after TMVR. Finally, we review access-related complications, which are of particular concern due to the requirement of large-bore catheters for these procedures.
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Affiliation(s)
- Adina Haramati
- Department of Radiology, New York-Presbyterian/Weill Cornell Medicine, 525 East 68(th) Street, New York, NY 10065, United States of America
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210(th) Street, Bronx, NY 10467, United States of America
| | - Matthew S Lazarus
- Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210(th) Street, Bronx, NY 10467, United States of America.
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Junquera L, Kalavrouziotis D, Dumont E, Rodés-Cabau J, Mohammadi S. Paradigm shifts in alternative access for transcatheter aortic valve replacement: An update. J Thorac Cardiovasc Surg 2023; 165:1359-1370.e2. [PMID: 34052017 DOI: 10.1016/j.jtcvs.2021.04.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Lucía Junquera
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Dimitri Kalavrouziotis
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Eric Dumont
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Siamak Mohammadi
- Department of Cardiac Surgery, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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Hadaya J, Sanaiha Y, Cho NY, Danielsen B, Carey J, Shemin RJ, Benharash P. Regional Variation in the Use and Outcomes of Transcatheter Aortic Valve Replacement in California. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 47:55-61. [PMID: 36055940 DOI: 10.1016/j.carrev.2022.08.033] [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: 08/20/2022] [Accepted: 08/23/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) has been widely adopted for management of aortic stenosis. The purpose of this study was to examine regional access to and outcomes following TAVR in California. METHODS Patients undergoing TAVR or isolated surgical aortic valve replacement (SAVR) from 2008 to 2019 in California were identified in the Office of Statewide Health Planning and Development database. California was divided into seven regions: Northern California, San Francisco Bay Area, Central California, Los Angeles, Inland Empire, Orange, and San Diego. Regional TAVR volumes were normalized to Medicare beneficiaries or isolated SAVR volume. Outcomes included risk-adjusted 30-day mortality and major adverse cardiovascular and cerebral events (MACCE). Trends were studied using non-parametric tests, and regional outcomes using logistic regression. RESULTS TAVR volume increased annually since 2011, with 7148 cases performed in California in 2019. After normalization, variation in utilization of TAVR was evident, with the least performed in Central California. TAVR to SAVR ratios in 2019 were greatest in Northern California, Los Angeles, and San Diego, and least in the Inland Empire. After risk adjustment, there were no significant regional differences in 30-day mortality, but lower 30-day MACCE in the San Francisco Bay Area. CONCLUSIONS Regional differences in TAVR utilization exist, with limited access in Central California and the Inland Empire, but risk-adjusted outcomes are similar. Efforts to reach underserved areas through existing program expansion or regional referrals may distribute transcatheter technology more equitably across California.
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Affiliation(s)
- Joseph Hadaya
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States of America
| | - Yas Sanaiha
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States of America
| | - Nam Yong Cho
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States of America
| | - Beate Danielsen
- Health Information Solutions, Rocklin, CA, United States of America
| | - Joseph Carey
- Division of Cardiothoracic Surgery, Department of Surgery, University of California Irvine Medical Center, United States of America
| | - Richard J Shemin
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States of America
| | - Peyman Benharash
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, United States of America.
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Franke B, Schlief A, Walczak L, Sündermann S, Unbehaun A, Kempfert J, Solowjowa N, Kühne T, Goubergrits L. Comparison of hemodynamics in biological surgical aortic valve replacement and transcatheter aortic valve implantation: An in-silico study. Artif Organs 2023; 47:352-360. [PMID: 36114598 DOI: 10.1111/aor.14405] [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: 05/05/2022] [Revised: 08/03/2022] [Accepted: 08/30/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES In aortic valve replacement (AVR), the treatment strategy as well as the model and size of the implanted prosthesis have a major impact on the postoperative hemodynamics and thus on the clinical outcome. Preinterventional prediction of the hemodynamics could support the treatment decision. Therefore, we performed paired virtual treatment with transcatheter AVR (TAVI) and biological surgical AVR (SAVR) and compared hemodynamic outcomes using numerical simulations. METHODS 10 patients with severe aortic stenosis (AS) undergoing TAVI were virtually treated with both biological SAVR and TAVI to compare post-interventional hemodynamics using numerical simulations of peak-systolic flow. Virtual treatment procedure was done using an in-house developed tool based on position-based dynamics methodology, which was applied to the patient's anatomy including LVOT, aortic root and aorta. Geometries were automatically segmented from dynamic CT-scans and patient-specific flow rates were calculated by volumetric analysis of the left ventricle. Hemodynamics were assessed using the STAR CCM+ software by solving the RANS equations. RESULTS Virtual treatment with TAVI resulted in realistic hemodynamics comparable to echocardiographic measurements (median difference in transvalvular pressure gradient [TPG]: -0.33 mm Hg). Virtual TAVI and SAVR showed similar hemodynamic functions with a mean TPG with standard deviation of 8.45 ± 4.60 mm Hg in TAVI and 6.66 ± 3.79 mm Hg in SAVR (p = 0.03) while max. Wall shear stress being 12.6 ± 4.59 vs. 10.2 ± 4.42 Pa (p = 0.001). CONCLUSIONS Using the presented method for virtual treatment of AS, we were able to reliably predict post-interventional hemodynamics. TAVI and SAVR show similar hemodynamics in a pairwise comparison.
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Affiliation(s)
- Benedikt Franke
- Institute of Computer-assisted Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Adriano Schlief
- Institute of Computer-assisted Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Lars Walczak
- Institute of Computer-assisted Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Fraunhofer MEVIS, Bremen, Germany
| | - Simon Sündermann
- Department of Cardiology and Angiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Axel Unbehaun
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Natalia Solowjowa
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Titus Kühne
- Institute of Computer-assisted Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Leonid Goubergrits
- Institute of Computer-assisted Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Einstein Center Digital Future, Berlin, Germany
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De Lucia R, Giannini C, Parollo M, Barletta V, Costa G, Giannotti Santoro M, Primerano C, Angelillis M, De Carlo M, Zucchelli G, Bongiorni MG, Petronio AS. Non-continuous mobile electrocardiogram monitoring for post-transcatheter aortic valve replacement delayed conduction disorders put to the test. Europace 2023; 25:1116-1125. [PMID: 36691737 PMCID: PMC10062351 DOI: 10.1093/europace/euac285] [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: 08/11/2022] [Accepted: 12/28/2022] [Indexed: 01/25/2023] Open
Abstract
AIMS Permanent pacemaker implantation (PPM-I) remains nowadays the most important drawback of transcatheter aortic valve replacement (TAVR) procedure and the optimal strategy of delayed conduction disturbances (CDs) in these patients is unclear. The study aimed to validate an ambulatory electrocardiogram (ECG) monitoring through a 30 s spot ambulatory digital mobile ECG (AeECG), by using KardiaMobile-6L device in a 30-day period after TAVR procedure. METHODS AND RESULTS Between March 2021 and February 2022, we consecutively enrolled all patients undergoing TAVR procedure, except pacemaker (PM) carriers. At discharge, all patients were provided of a KardiaMobile-6L device and a spot digital ECG (eECG) recording 1 month schedule. Clinical and follow-up data were collected, and eECG schedule compliance and recording quality were explored. Among 151 patients without pre-existing PM, 23 were excluded for pre-discharge PPM-I, 18 failed the KardiaMobile-6L training phase, and 10 refused the device. Delayed CDs with a Class I/IIa indication for PPM-I occurred in eight patients (median 6 days). Delayed PPM-I vs. non-delayed PPM-I patients were more likely to have longer PR and QRS intervals at discharge. PR interval at discharge was the only independent predictor for delayed PPM-I at multivariate analysis. The overall eECG schedule compliance was 96.5%. None clinical adverse events CDs related were documented using this new AeECG monitoring modality. CONCLUSION A strategy of 30 s spot AeECG is safe and efficacious in delayed CDs monitoring after TAVR procedure with a very high eECG schedule level of compliance.
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Affiliation(s)
- Raffaele De Lucia
- Second Division of Cardiology, CardioThoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Cristina Giannini
- Cardiac Catheterization Division, CardioThoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Matteo Parollo
- Second Division of Cardiology, CardioThoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Valentina Barletta
- Second Division of Cardiology, CardioThoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Giulia Costa
- Cardiac Catheterization Division, CardioThoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Mario Giannotti Santoro
- Second Division of Cardiology, CardioThoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Chiara Primerano
- Cardiac Catheterization Division, CardioThoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Marco Angelillis
- Cardiac Catheterization Division, CardioThoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Marco De Carlo
- Cardiac Catheterization Division, CardioThoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Giulio Zucchelli
- Second Division of Cardiology, CardioThoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Maria Grazia Bongiorni
- Second Division of Cardiology, CardioThoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Anna Sonia Petronio
- Cardiac Catheterization Division, CardioThoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Tomala O, Zamvar V, Bing R, Pessotto R, Cruden N. Comparison of outcomes of trans-subclavian versus trans-apical approaches in transcatheter aortic valve implantation. J Cardiothorac Surg 2022; 17:180. [PMID: 35927712 PMCID: PMC9354363 DOI: 10.1186/s13019-022-01929-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 08/01/2022] [Indexed: 11/12/2022] Open
Abstract
Background Many patients are unsuitable for conventional femoral transcatheter aortic valve implantation (TAVI) but there is limited evidence as to which alternative approach has the best outcomes. We compared clinical outcomes in patients undergoing trans-subclavian (TS) or trans-apical (TA) TAVI. Methods This was a national retrospective observational study of patients undergoing surgical TAVI in Scotland between January 2013 and March 2020. The pre-operative patient characteristics, intraoperative details and post-operative outcomes were compared between TS and TA cohorts using data from the National Institute of Cardiovascular Outcomes Research (NICOR) registry. Results Among 1055 patients who underwent TAVI, TS or TA access was used in 50 (4.7%) and 90 (8.5%) patients respectively. Self-expanding Medtronic Evolut R valves were used in 84% of TS procedures, while balloon-expandable Edwards SAPIEN valves were used in all TA procedures. The TS group had a lower mean logistic EuroSCORE than the TA group (27.31 ± 19.44% vs 34.92 ± 19.61% p = 0.029). The TS approach was associated with a higher incidence of moderate postprocedural aortic regurgitation (12.5% vs 2.4%, p = 0.025). There was no significant difference in 30-day, 1-year or overall all-cause mortality. Conclusions Both trans-subclavian and trans-apical access are viable approaches for patients requiring non-transfemoral TAVI. Differences in peri-procedural indices reflect the disparate patient populations and factors governing prosthesis choice, and short- and long-term mortality was similar.
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Affiliation(s)
- Olaf Tomala
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Vipin Zamvar
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK.
| | - Rong Bing
- Department of Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Renzo Pessotto
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Nick Cruden
- Department of Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
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Boissonnet CP, Wisner JN, Giorgi MA, Carosella L, Brescacin Castillejo C, Pissinis J, Guetta JN. Temporal Trends in Self-Expandable Transcatheter Aortic Valve Replacement in South America: A Systematic Review and Meta-Analysis. Value Health Reg Issues 2022; 30:148-160. [DOI: 10.1016/j.vhri.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 11/24/2021] [Accepted: 01/11/2022] [Indexed: 11/29/2022]
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Transcatheter Mitral Valve Replacement in High-Surgical Risk Patients: A Single-Center Experience and Outcome. J Interv Cardiol 2022; 2022:6587036. [PMID: 35847236 PMCID: PMC9242753 DOI: 10.1155/2022/6587036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 05/23/2022] [Accepted: 05/31/2022] [Indexed: 11/28/2022] Open
Abstract
Background Re-operative mitral valve (MV) replacement is a high-risk procedure, therefore, transcatheter MV replacement (TMVR) is a promising therapeutic option. Aim In this study, we aimed to evaluate the feasibility and safety of TMVR in patients with high surgical risk with degenerated mitral bioprostheses (TMViV), failed surgical rings (TMViR), and mitral annular calcification (TMViMAC). Methods This is a retrospective cohort study that enrolled patients with high surgical risk who underwent TMVR from February 2017 to September 2020. The TMVR procedure was performed using Edwards SAPIEN-3 valves through the transseptal approach. Results Sixty-four patients aged 62.7 ± 16.1 years with an STS score of 9.2 ± 3.7% underwent TMVR [35 (55%) TMViV, 16 (25%) TMViR, and 13 (20%) TMViMAC]. Mitral stenosis was more frequent in TMViV, mitral regurgitation was more frequent in TMViR, and combined mitral stenosis and regurgitation were more frequent in TMViMAC (P < 0.05). The MV gradient was 14.3 ± 5.3 mmHg and the MV area was 1.5±0.6 cm2. The 29 mm valve was frequently used in TMViV and TMViMAC, while the 23 mm valve was frequently used in TMViR (P=0.003∗). The procedural and fluoroscopy times were 58.7 ± 8.9 and 41.1 ± 8.2 minutes, respectively. Technical success was reported in 62 (98.4%) patients; 1 TMViR patient experienced valve embolization and salvage surgery, and 1 TMViMAC patient experienced slight valve malposition. At 3 months, 2 (3.1%) patients showed valve thrombosis (treated with anticoagulation), and 1 (1.6%) patient developed a paravalvular leak (underwent surgical MV replacement). At 6 months, 3 (4.7%) patients showed valve degeneration (underwent surgical MV replacement). Throughout follow-up, no patient exhibited mortality. Conclusions TMVR is a feasible and safe approach in patients with high surgical risk. TMViV and TMViR are reasonable as the first treatment approaches, and TMViMAC seems encouraging.
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Evolving Indications of Transcatheter Aortic Valve Replacement—Where Are We Now, and Where Are We Going. J Clin Med 2022; 11:jcm11113090. [PMID: 35683476 PMCID: PMC9180932 DOI: 10.3390/jcm11113090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/04/2022] [Accepted: 05/27/2022] [Indexed: 01/14/2023] Open
Abstract
Indications for transcatheter aortic valve replacement (TAVR) have steadily increased over the last decade since the first trials including inoperable or very high risk patients. Thus, TAVR is now the most common treatment of aortic valve stenosis in elderly patients (vs. surgical aortic valve replacement -SAVR-). In this review, we summarize the current indications of TAVR and explore future directions in which TAVR indications can expand.
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Structural Heart Valve Disease in the Era of Change and Innovation: The Crosstalk between Medical Sciences and Engineering. Bioengineering (Basel) 2022; 9:bioengineering9060230. [PMID: 35735473 PMCID: PMC9220173 DOI: 10.3390/bioengineering9060230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 05/18/2022] [Indexed: 11/29/2022] Open
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Amponsah DK, Crousillat DR, Elmariah S. Racial and Ethnic Disparities in the Treatment of Aortic Stenosis: Current Challenges and Future Strategies for Achieving Equity in Care. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022. [DOI: 10.1007/s11936-022-00963-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Stastny L, Krapf C, Dumfarth J, Gasser S, Bauer A, Friedrich G, Metzler B, Feuchtner G, Mayr A, Grimm M, Bonaros N. Minireview: Transaortic Transcatheter Aortic Valve Implantation: Is There Still an Indication? Front Cardiovasc Med 2022; 9:798154. [PMID: 35310977 PMCID: PMC8931192 DOI: 10.3389/fcvm.2022.798154] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
Transaortic (TAo) transcatheter aortic valve implantation has become a valid alternative access route in patients with unsuitable femoral arteries. The current literature does not allow to clearly favor one of the alternative access routes. Every approach has its specific advantages. Transaortic (TAo) access is of particular importance in the case of calcifications of the supra-aortic branches and the aortic arch, as under these circumstances other alternative access routes, such as transaxillary or transcarotid, are not feasible. The purpose of this minireview is to give an overview and update on TAo transcatheter aortic valve implantation focusing on indication, technical aspects, and recent clinical data.
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Affiliation(s)
- Lukas Stastny
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Christoph Krapf
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Julia Dumfarth
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
- *Correspondence: Julia Dumfarth
| | - Simone Gasser
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Axel Bauer
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Guy Friedrich
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bernhard Metzler
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gudrun Feuchtner
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Agnes Mayr
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
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Kaneko T, Vemulapalli S, Kohsaka S, Shimamura K, Stebbins A, Kumamaru H, Nelson AJ, Kosinski A, Maeda K, Bavaria JE, Saito S, Reardon MJ, Kuratani T, Popma JJ, Inohara T, Thourani VH, Carroll JD, Shimizu H, Takayama M, Leon MB, Mack MJ, Sawa Y. Practice Patterns and Outcomes of Transcatheter Aortic Valve Replacement in the United States and Japan: A Report From Joint Data Harmonization Initiative of STS/ACC TVT and J-TVT. J Am Heart Assoc 2022; 11:e023848. [PMID: 35243902 PMCID: PMC9075277 DOI: 10.1161/jaha.121.023848] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background The practice pattern and outcome of medical devices following their regulatory approval may differ by country. The aim of this study is to compare postapproval national clinical registry data on transcatheter aortic valve replacement between the United States and Japan on patient characteristics, periprocedural outcomes, and the variability of outcomes as a part of a partnership program (Harmonization‐by‐Doing) between the 2 countries. Methods and Results The patient‐level data were extracted from the US Society of Thoracic Surgeons /American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) and the J‐TVT (Japanese Transcatheter Valvular Therapy) registry, respectively, to analyze transcatheter aortic valve replacement outcomes between 2013 and 2019. Data entry for these registries was mandated by the federal regulators, and the majority of variable definitions were harmonized to allow direct data comparison. A total of 244 722 transcatheter aortic valve replacements from 646 institutions in the United States and 26 673 transcatheter aortic valve replacements from 171 institutions in Japan were analyzed. Median volume per site was 65 (interquartile range, 45–97) in the United States and 28 (interquartile range, 19–41) in Japan. Overall, patients in J‐TVT were older (United States: mean‐age, 80.1±8.7 versus Japan: 84.4±5.2; P<0.001), were more frequently women (45.9% versus 68.1%; P<0.001), and had higher median Society of Thoracic Surgeons Predicted Risk of Mortality (5.27% versus 6.20%; P<0.001) than patients in the United States. Japan had lower unadjusted 30‐day mortality (1.3% versus 3.2%; P<0.001) and composite outcomes of death, stroke, and bleeding (17.5 versus 22.5%; P<0.001) but had higher conversion to open surgery (0.94% versus 0.56%; P<0.001). Conclusions This collaborative analysis between the United States and Japan demonstrated the feasibility of international comparison using the national registries coded under mutual variable definitions. Both countries obtained excellent outcomes, although the Japanese had lower 30‐day mortality and major morbidity. Harmonization‐by‐Doing is one of the key steps needed to build global‐level learning to improve patient outcomes.
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Affiliation(s)
- Tsuyoshi Kaneko
- Division of Cardiac Surgery Brigham and Women's Hospital Boston MA
| | | | - Shun Kohsaka
- Department of Cardiology Keio University School of Medicine Tokyo Japan
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery Osaka University Hospital Osaka Japan
| | | | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment Graduate School of Medicine Faculty of Medicine The University of Tokyo Japan
| | | | | | - Koichi Maeda
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Suita City Japan
| | - Joseph E Bavaria
- Division of Cardiac Surgery University of Pennsylvania Philadelphia PA
| | - Shigeru Saito
- Division of Cardiology Shonan Kamakura Hospital Kamakura Japan
| | | | - Toru Kuratani
- Department of Cardiovascular Surgery Osaka University Hospital Osaka Japan
| | | | - Taku Inohara
- Duke Clinical Research Institute Durham NC.,Department of Cardiology Keio University School of Medicine Tokyo Japan
| | - Vinod H Thourani
- Department of Cardiac Surgery Piedmont Heart Institute Atlanta GA
| | | | - Hideyuki Shimizu
- Department of Cardiovascular Surgery Keio University School of Medicine Tokyo Japan
| | | | - Martin B Leon
- Division of Cardiology Columbia University Irving Medical CenterNew York-Presbyterian Hospital New York NY
| | - Michael J Mack
- Cardiovascular Service line Baylor Scott & White HealthBaylor Scott & White Research Institute Dallas TX
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery Osaka University Hospital Osaka Japan
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Gohmann RF, Seitz P, Pawelka K, Majunke N, Schug A, Heiser L, Renatus K, Desch S, Lauten P, Holzhey D, Noack T, Wilde J, Kiefer P, Krieghoff C, Lücke C, Ebel S, Gottschling S, Borger MA, Thiele H, Panknin C, Abdel-Wahab M, Horn M, Gutberlet M. Combined Coronary CT-Angiography and TAVI Planning: Utility of CT-FFR in Patients with Morphologically Ruled-Out Obstructive Coronary Artery Disease. J Clin Med 2022; 11:jcm11051331. [PMID: 35268422 PMCID: PMC8910873 DOI: 10.3390/jcm11051331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Coronary artery disease (CAD) is a frequent comorbidity in patients undergoing transcatheter aortic valve implantation (TAVI). If significant CAD can be excluded on coronary CT-angiography (cCTA), invasive coronary angiography (ICA) may be avoided. However, a high plaque burden may make the exclusion of CAD challenging, particularly for less experienced readers. The objective was to analyze the ability of machine learning (ML)-based CT-derived fractional flow reserve (CT-FFR) to correctly categorize cCTA studies without obstructive CAD acquired during pre-TAVI evaluation and to correlate recategorization to image quality and coronary artery calcium score (CAC). Methods: In total, 116 patients without significant stenosis (≥50% diameter) on cCTA as part of pre-TAVI CT were included. Patients were examined with an electrocardiogram-gated CT scan of the heart and high-pitch scan of the torso. Patients were re-evaluated with ML-based CT-FFR (threshold = 0.80). The standard of reference was ICA. Image quality was assessed quantitatively and qualitatively. Results: ML-based CT-FFR was successfully performed in 94.0% (109/116) of patients, including 436 vessels. With CT-FFR, 76/109 patients and 126/436 vessels were falsely categorized as having significant CAD. With CT-FFR 2/2 patients but no vessels initially falsely classified by cCTA were correctly recategorized as having significant CAD. Reclassification occurred predominantly in distal segments. Virtually no correlation was found between image quality or CAC. Conclusions: Unselectively applied, CT-FFR may vastly increase the number of false positive ratings of CAD compared to morphological scoring. Recategorization was virtually independently from image quality or CAC and occurred predominantly in distal segments. It is unclear whether or not the reduced CT-FFR represent true pressure ratios and potentially signifies pathophysiology in patients with severe aortic stenosis.
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Affiliation(s)
- Robin Fabian Gohmann
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
- Correspondence: ; Tel.: +49-341-865-255-024
| | - Patrick Seitz
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
| | - Konrad Pawelka
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
| | - Nicolas Majunke
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (N.M.); (S.D.); (P.L.); (J.W.); (H.T.); (M.A.-W.)
| | - Adrian Schug
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
| | - Linda Heiser
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
| | - Katharina Renatus
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
| | - Steffen Desch
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (N.M.); (S.D.); (P.L.); (J.W.); (H.T.); (M.A.-W.)
| | - Philipp Lauten
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (N.M.); (S.D.); (P.L.); (J.W.); (H.T.); (M.A.-W.)
| | - David Holzhey
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (D.H.); (T.N.); (P.K.); (M.A.B.)
| | - Thilo Noack
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (D.H.); (T.N.); (P.K.); (M.A.B.)
| | - Johannes Wilde
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (N.M.); (S.D.); (P.L.); (J.W.); (H.T.); (M.A.-W.)
| | - Philipp Kiefer
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (D.H.); (T.N.); (P.K.); (M.A.B.)
| | - Christian Krieghoff
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
| | - Christian Lücke
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
| | - Sebastian Ebel
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
| | - Sebastian Gottschling
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
| | - Michael A. Borger
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (D.H.); (T.N.); (P.K.); (M.A.B.)
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (N.M.); (S.D.); (P.L.); (J.W.); (H.T.); (M.A.-W.)
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany
| | | | - Mohamed Abdel-Wahab
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (N.M.); (S.D.); (P.L.); (J.W.); (H.T.); (M.A.-W.)
| | - Matthias Horn
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Härtelstr. 16-18, 04107 Leipzig, Germany;
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany; (P.S.); (K.P.); (A.S.); (L.H.); (K.R.); (C.K.); (C.L.); (S.E.); (S.G.); (M.G.)
- Medical Faculty, University of Leipzig, Liebigstr. 27, 04103 Leipzig, Germany
- Leipzig Heart Institute, Russenstr. 69a, 04289 Leipzig, Germany
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Simpson TF, Kheiri B, Chadderdon S, Song HK, Lantz G, Cigarroa J, Zahr F, Golwala H. TAVR operator volumes, trends, and geographic variations amongst Medicare beneficiaries in the United States. Catheter Cardiovasc Interv 2022; 99:1181-1185. [PMID: 35188321 DOI: 10.1002/ccd.30134] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/10/2022] [Accepted: 01/26/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To evaluate transcatheter aortic valve replacement (TAVR) operator procedural volumes, and describe temporal and geographic trends. BACKGROUND TAVR is the standard of care for most patients with severe symptomatic aortic stenosis. Despite an association between operator procedural volume and outcomes, nationwide TAVR operator volumes have been incompletely described. METHODS We queried the National Medicare Provider Utilization and Payment Database for transfemoral TAVRs from 2014 to 2018. Annual operator volume, state and regional volumes, and longitudinal trends were extracted and analyzed using descriptive statistics. RESULTS In 2018, the mean annual operator volume was 23.6 TAVRs. The highest 1% of operators by volume performed 7.6% of total TAVR procedures in the United States, while 35.7% of operators performed 10 or fewer TAVRs per year. From 2014 to 2018, there was a 53.9% annualized increase in TAVRs, and the mean annual volume per operator grew from 12.5 to 23.6. There was more than five-fold variability in the density of operators (range 0.35-1.79 operators per 100,000 population) and mean operator volume by state (range 14.2-52.4 TAVRs per operator). CONCLUSIONS In this nationally representative study of operators performing transfemoral TAVRs among Medicare patients, we found the mean annual volume of TAVR in 2018 to be 23.6 and has increased since 2014. There was considerable variability in operator density and procedural volumes, with a significant proportion of operators performing 10 or fewer TAVRs per year. Ambiguity remains in regard to the optimal balance of procedural requirements to sustain high efficacy outcomes and ensure critical access to TAVR therapies.
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Affiliation(s)
- Timothy F Simpson
- Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Babikir Kheiri
- Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Scott Chadderdon
- Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Howard K Song
- Division of Cardiothoracic Surgery, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Gurion Lantz
- Division of Cardiothoracic Surgery, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Joaquin Cigarroa
- Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Firas Zahr
- Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Harsh Golwala
- Division of Cardiovascular Medicine, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
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Kakuta T, Fukushima S, Kawamoto N, Kainuma S, Tadokoro N, Ikuta A, Minami K, Kanzaki H, Amaki M, Okada A, Irie Y, Takagi K, Izumi C, Fujita T. Transaortic Transcatheter Aortic Valve Replacement in Patients From a Single Institution ― Feasibility, Safety, and Midterm Outcomes ―. Circ J 2022; 86:393-401. [DOI: 10.1253/circj.cj-21-0877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takashi Kakuta
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center
| | - Satsuki Fukushima
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center
| | - Naonori Kawamoto
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center
| | - Satoshi Kainuma
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center
| | - Naoki Tadokoro
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center
| | - Ayumi Ikuta
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center
| | - Kimito Minami
- Surgical Intensive Care, National Cerebral and Cardiovascular Research Center
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Research Center
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Research Center
| | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Research Center
| | - Yuki Irie
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Research Center
| | - Kensuke Takagi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Research Center
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Research Center
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Research Center
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Brescia AA, Watt TMF, Murray SL, Rosenbloom LM, Kleeman KC, Allgeyer H, Eid J, Romano MA, Bolling SF. Rheumatic mitral valve repair or replacement in the valve-in-valve era. J Thorac Cardiovasc Surg 2022; 163:591-602.e1. [PMID: 32620398 PMCID: PMC7655552 DOI: 10.1016/j.jtcvs.2020.04.118] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 03/31/2020] [Accepted: 04/15/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE For degenerative mitral disease, repair is superior to replacement; however, the best operative strategy for rheumatic mitral disease remains unclear. We evaluated the association between decision-making in choosing repair versus replacement and outcomes across 2 decades of rheumatic mitral surgery. METHODS Patients undergoing isolated, first-time rheumatic mitral surgery were identified. Era 1 (1997-2008) and Era 2 (2009-2018) were distinguished by intraoperative assessment of anterior leaflet mobility/calcification (Era 2) in deciding between mitral repair versus replacement. Primary outcome was a composite of death, reoperation, and severe valve dysfunction. RESULTS Among 180 patients, age was 59 ± 14 years, and ejection fraction was 58% ± 10%. A higher proportion in Era 1 (n = 56) compared with Era 2 (n = 124) had preoperative atrial fibrillation (68% vs 46%; P = .006); the groups were otherwise similar. Primary indication was mitral stenosis in 69% (124 out of 180; pure = 35, mixed = 89) and did not differ by era (P = .67). During Era 1, 70% (39 out of 56) underwent repair, compared with 33% (41 out of 124) during Era 2 (P < .001). Freedom from death, reoperation, or severe valve dysfunction at 5 years was higher in Era 2 (72% ± 9%) than Era 1 (54% ± 13%; P = .04). Five-year survival was higher in Era 2 than Era 1, but did not differ between repair versus replacement. Five-year cumulative incidence of reoperation with death as a competing risk did not differ by era, but was higher after repair than replacement. CONCLUSIONS Careful assessment of anterior leaflet mobility/calcification to determine mitral repair or replacement was associated with improved outcomes. This decision-making strategy may alter the threshold for rheumatic mitral replacement in the current valve-in-valve era.
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Affiliation(s)
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- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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41
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Augoustides JG. Protecting the Central Nervous System During Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Mack M, Carroll JD, Thourani V, Vemulapalli S, Squiers J, Manandhar P, Deeb GM, Batchelor W, Herrmann HC, Cohen DJ, Hanzel G, Gleason T, Kirtane A, Desai N, Guibone K, Hardy K, Michaels J, DiMaio JM, Christensen B, Fitzgerald S, Krohn C, Brindis RG, Masoudi F, Bavaria J. Transcatheter Mitral Valve Therapy in the United States: A Report From the STS-ACC TVT Registry. J Am Coll Cardiol 2021; 78:2326-2353. [PMID: 34711430 DOI: 10.1016/j.jacc.2021.07.058] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 07/15/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
Data for nearly all patients undergoing transcatheter edge-to-edge repair (TEER) and transcatheter mitral valve replacement (TMVR) with an approved device in the United States is captured in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. All data submitted for TEER or TMVR between 2014 and March 31, 2020, are reported. A total of 37,475 patients underwent a mitral transcatheter procedure, including 33,878 TEER and 3,597 TMVR. Annual procedure volumes for TEER have increased from 1,152 per year in 2014 to 10,460 per year in 2019 at 403 sites and for TMVR from 84 per year to 1,120 per year at 301 centers. Mortality rates have decreased for TEER at 30 days (5.6%-4.1%) and 1 year (27.4%-22.0%). Early off-label use data on TMVR in mitral valve-in-valve therapy led to approval by the U.S. Food and Drug Administration in 2017, and the 2019 30-day mortality rate was 3.9%. Overall improvements in outcomes over the last 6 years are apparent. (STS/ACC TVT Registry Mitral Module; NCT02245763).
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Affiliation(s)
- Michael Mack
- Baylor Scott & White Health, Dallas, Texas, USA.
| | - John D Carroll
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Vinod Thourani
- Department of Surgery, Piedmont Hospital, Atlanta, Georgia, USA
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University Health Care System, Durham, North Carolina, USA
| | | | | | - G Michael Deeb
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Howard C Herrmann
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA; St Francis Hospital, Roslyn, New York, USA
| | | | | | - Ajay Kirtane
- Cardiovascular Research Foundation, New York, New York, USA; Department of Medicine, Columbia University, New York, New York, USA
| | - Nimesh Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kim Guibone
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Karen Hardy
- CommonSpirit Health, Lexington, Kentucky, USA
| | | | | | | | | | - Carole Krohn
- The Society of Thoracic Surgeons, Chicago, Illinois, USA
| | - Ralph G Brindis
- Philip R. Lee Institute for Health Policy Studies, University of California-San Francisco, San Francisco, California, USA
| | | | - Joseph Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Amgai B, Patel N, Chakraborty S, Bandyopadhyay D, Hajra A, Koirala S, Ghosh RK, Aronow WS, Lavie CJ, Fonarow GC, Abbott JD, Kapadia S. 30-day readmission following urgent and elective transcatheter aortic valve replacement: A Nationwide Readmission Database analysis. Catheter Cardiovasc Interv 2021; 98:E1026-E1032. [PMID: 34410035 DOI: 10.1002/ccd.29918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 06/20/2021] [Accepted: 08/05/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is being increasingly used for decompensated severe symptomatic aortic stenosis. Data on urgent and elective TAVR readmission is scarce in the literature. Here, we have performed a retrospective cohort study with the Nationwide Readmission Database of 2016 to identify the rate of 30-day all-cause readmission, common causes of readmission, and distribution of morbidity in index admission and readmission after urgent and elective TAVR. METHODS We used International Classification of Diseases, Tenth Revision codes (02R.F38H, 02R.F38Z, 02R.F48Z) for identification of all TAVR procedures done in 2016 in patients >18 years old. We found 8379 patients who underwent urgent TAVR and 32,006 patients who underwent elective TAVR in 2016. RESULT The mean age of patients undergoing urgent TAVR was 79 ± 9.97 years with 44.6% women. The mean age of patients undergoing elective TAVR was 80.7 ± 8.25 years with 46.2% women. We found the 30-day all-cause readmission rate of 15.5% and 9.5% in patients undergoing urgent and elective TAVR, respectively (p < 0.001). The cardiac cause was the predominant cause of readmission in both groups (43.77% vs. 42.11%, p = 0.57), followed by pulmonary cause, gastrointestinal (GI) cause, and renal cause. Among cardiac causes, congestive heart failure (CHF) was predominant cause of readmission and was similar in both groups (18.73 in urgent TAVR vs. 15.73 in elective TAVR, p = 0.12). CONCLUSION We found that the all-cause 30-day readmission rate was higher in patients who had undergone urgent TAVR. Further studies are needed to better understand this difference.
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Affiliation(s)
| | | | | | | | - Adrija Hajra
- Jacobi Medical Center/Albert Einstein College of Medicine, New York, New York, USA
| | - Soniya Koirala
- Institute of Medicine Tribhuvan University, Kathmandu, Nepal
| | - Raktim K Ghosh
- MedStar Heart and Vascular Institute, Union Memorial Hospital, Baltimore, Maryland, USA
| | - Wilbert S Aronow
- Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the University of Queensland School of Medicine, New Orleans, Louisiana, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, California, USA
| | | | - Samir Kapadia
- Cleveland Clinic, Heart and Vascular Institute, Cleveland, Ohio, USA
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Mori M, Gupta A, Wang Y, Vahl T, Nazif T, Kirtane AJ, George I, Yong CM, Onuma O, Kodali S, Geirsson A, Leon MB, Krumholz HM. Trends in Transcatheter and Surgical Aortic Valve Replacement Among Older Adults in the United States. J Am Coll Cardiol 2021; 78:2161-2172. [PMID: 34823659 DOI: 10.1016/j.jacc.2021.09.855] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/25/2021] [Accepted: 09/07/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recent trends, including survival beyond 30 days, in aortic valve replacement (AVR) following the expansion of indications for transcatheter aortic valve replacement (TAVR) are not well-understood. OBJECTIVES The authors sought to characterize the trends in characteristics and outcomes of patients undergoing AVR. METHODS The authors analyzed Medicare beneficiaries who underwent TAVR and SAVR in 2012 to 2019. They evaluated case volume, demographics, comorbidities, 1-year mortality, and discharge disposition. Cox proportional hazard models were used to assess the annual change in outcomes. RESULTS Per 100,000 beneficiary-years, AVR increased from 107 to 156, TAVR increased from 19 to 101, whereas SAVR declined from 88 to 54. The median [interquartile range] age remained similar from 77 [71-83] years to 78 [72-84] years for overall AVR, decreased from 84 [79-88] years to 81 [75-86] years for TAVR, and decreased from 76 [71-81] years to 72 [68-77] years for SAVR. For all AVR patients, the prevalence of comorbidities remained relatively stable. The 1-year mortality for all AVR decreased from 11.9% to 9.4%. Annual change in the adjusted odds of 1-year mortality was 0.93 (95% CI: 0.92-0.94) for TAVR and 0.98 (95% CI: 0.97-0.99) for SAVR, and 0.94 (95% CI: 0.93-0.95) for all AVR. Patients discharged to home after AVR increased from 24.2% to 54.7%, primarily driven by increasing home discharge after TAVR. CONCLUSIONS The advent of TAVR has led to about a 60% increase in overall AVR in older adults. Improving outcomes in AVR as a whole following the advent of TAVR with increased access is a reassuring trend.
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Affiliation(s)
- Makoto Mori
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Aakriti Gupta
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA; Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Yun Wang
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA; Richard and Susan Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Torsten Vahl
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Tamim Nazif
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Ajay J Kirtane
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Isaac George
- Division of Cardiac, Thoracic and Vascular Surgery, New York Presbyterian Hospital-Columbia University Irving Medical Center, New York, New York, USA
| | - Celina M Yong
- Department of Medicine (Cardiovascular Medicine), Stanford University School of Medicine, Stanford, California, USA; Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | - Oyere Onuma
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Susheel Kodali
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Martin B Leon
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA; Section of Cardiology, Yale School of Medicine, New Haven, Connecticut, USA; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA.
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Allana SS, Alkhouli M, Alli O, Coylewright M, Horne A, Ijioma N, Kadavath S, Pineda AM, Sanchez C, Schreiber TL, Shah AP, Smith C, Suradi H, Sylvia KE, Young M, Krishnan SK. Identifying opportunities to advance health equity in interventional cardiology: Structural heart disease. Catheter Cardiovasc Interv 2021; 99:1165-1171. [PMID: 34837459 DOI: 10.1002/ccd.30021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/12/2021] [Accepted: 11/04/2021] [Indexed: 11/10/2022]
Abstract
Health care practices are influenced by variety of factors. These factors that include social determinants, race and ethnicity, and gender not only affect access to health care but can also affect quality of care and patient outcomes. These are a source of health care disparities. This article acknowledges that these disparities exist in getting optimal care in structural heart disease, reviews the literature and proposes steps that can help reduce these disparities on personal and committee levels.
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Affiliation(s)
- Salman S Allana
- Division of Cardiology, Department of Medicine, Froedtert Hospital and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mohamad Alkhouli
- Department of Cardiology, West Virginia University, Morgantown, West Virginia, USA
| | - Olueseun Alli
- Novant Heart and Vascular Institute, Charlotte, North Carolina, USA
| | - Megan Coylewright
- Department of Cardiology, University of Tennessee at Chattanooga, Chattanooga, Tennessee, USA
| | - Aaron Horne
- Division of Cardiology, Department of Medicine, Palestine Regional Medical Center, Palestine, Texas, USA
| | - Nkechi Ijioma
- Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sabeeda Kadavath
- Department of of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andres M Pineda
- Department of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Carlos Sanchez
- Heart and Vascular Service Line, OhioHealth - Riverside Methodist Hospital, Columbus, Ohio, USA
| | - Theodore L Schreiber
- Department of Cardiology, Ascension St. John Hospital Warren Family Physicians, Warren, Michigan, USA
| | - Atman P Shah
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Conrad Smith
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Hussam Suradi
- Division of Cardiovascular Medicine, Department of Medicine, Rush University Medical Center/Rush Medical College, Chicago, Illinois, USA
| | - Kristyn E Sylvia
- The Society for Cardiovascular Angiography and Interventions, Washington, District of Columbia, USA
| | - Michael Young
- Division of Cardiology, Department of Medicine, Darthmouth-Hitchcock Health System, Lebanon, New Hampshire, USA
| | - Sandeep K Krishnan
- Director of Structural Heart Program, Heart and Vascular Institute, King's Daughters Medical Center, Ashland, Kentucky, USA
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Affiliation(s)
- Pedro H M C de Melo
- Departamento de Cardiologia Intervencionista - Hospital Sírio Libanês, São Paulo, SP - Brasil
| | - Rodrigo Modolo
- Departamento de Clínica Médica - Divisão de Cardiologia - Faculdade de Ciências Médicas - Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
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Nguyen V, Willner N, Eltchaninoff H, Burwash IG, Michel M, Durand E, Gilard M, Dindorf C, Iung B, Cribier A, Vahanian A, Chevreul K, Messika-Zeitoun D. Trends in aortic valve replacement for aortic stenosis: a French nationwide study. Eur Heart J 2021; 43:666-679. [PMID: 36282793 DOI: 10.1093/eurheartj/ehab773] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/20/2021] [Accepted: 10/25/2021] [Indexed: 12/29/2022] Open
Abstract
AIMS Transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement (SAVR) has profoundly changed the management of patients with aortic valve stenosis (AS). Large unbiased nationwide data regarding TAVR implementation, impact on SAVR and their respective outcomes are scarce. METHODS AND RESULTS Based on a French administrative hospital-discharge database, we collected data on all consecutive aortic valve replacements (AVRs) performed in France for AS between 2007 and 2019 [106 253 isolated SAVR (49%), 46 514 combined SAVR (21%), and 65 651 TAVR (30%)]. The number of AVR linearly increased between 2007 and 2019 (from 10 892 to 23 109, P for trend < 0.0001) due to a marked increase in TAVR (from 253 to 13 030, P for trend < 0.0001), while SAVR increased up to 2013 and then declined (10 892 in 2007, 12 699 in 2013, and 10 079 in 2019). The Charlson index decreased linearly for TAVR, but in two steps for SAVR (2011 and 2017). In-hospital mortality rates of both SAVR and TAVR declined (both P for trend < 0.0001) and were similar or lower for TAVR than for isolated SAVR in patients 75 years or above in the last 3 years (2017-19). Complication rates of TAVR also declined but permanent pacemaker rates remained high and length of stay substantial (16.7% and median 6 days, respectively, in 2017-19). CONCLUSION The number of AVR has doubled in a decade and TAVR has become the dominant form of AVR in 2018. The improvement in patient profiles seems to have anticipated the demonstrated benefit of TAVR in intermediate and low-risk patients. In patients 75 years or older, TAVR should be considered as the first option. We also highlight two important areas for improvement, the high permanent pacemaker rates, and the long length of stay even in the contemporary era. Our results may have major implications for clinical practice and policymakers.
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Affiliation(s)
- Virginia Nguyen
- Cardiology Department, Centre Cardiologique du Nord, Saint-Denis, France
| | - Nadav Willner
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Helene Eltchaninoff
- Department of Cardiology, Normandie University, UNIROUEN, U1096, CHU Rouen, Rouen, F-76000 France
| | - Ian G Burwash
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Morgane Michel
- Université de Paris, Paris, France.,URC Eco Ile de France, AP-HP, Hôtel Dieu, Paris, France.,INSERM, ECEVE, U1123, Paris, France
| | - Eric Durand
- Department of Cardiology, Normandie University, UNIROUEN, U1096, CHU Rouen, Rouen, F-76000 France
| | - Martine Gilard
- Department of Cardiology, Brest University Hospital, Brest, France
| | - Christel Dindorf
- Department of Cardiology, Normandie University, UNIROUEN, U1096, CHU Rouen, Rouen, F-76000 France.,Université de Paris, Paris, France.,URC Eco Ile de France, AP-HP, Hôtel Dieu, Paris, France
| | - Bernard Iung
- Université de Paris, Paris, France.,Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat Hospital, Paris, France.,INSERM U1148, Bichat Hospital, Paris, France
| | - Alain Cribier
- Department of Cardiology, Normandie University, UNIROUEN, U1096, CHU Rouen, Rouen, F-76000 France
| | - Alec Vahanian
- Université de Paris, Paris, France.,INSERM U1148, Bichat Hospital, Paris, France
| | - Karine Chevreul
- Université de Paris, Paris, France.,URC Eco Ile de France, AP-HP, Hôtel Dieu, Paris, France.,INSERM, ECEVE, U1123, Paris, France
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Gohmann RF, Pawelka K, Seitz P, Majunke N, Heiser L, Renatus K, Desch S, Lauten P, Holzhey D, Noack T, Wilde J, Kiefer P, Krieghoff C, Lücke C, Gottschling S, Ebel S, Borger MA, Thiele H, Panknin C, Horn M, Abdel-Wahab M, Gutberlet M. Combined Coronary CT-Angiography and TAVR Planning for Ruling Out Significant Coronary Artery Disease: Added Value of Machine-Learning-Based CT-FFR. JACC Cardiovasc Imaging 2021; 15:476-486. [PMID: 34801449 DOI: 10.1016/j.jcmg.2021.09.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 09/07/2021] [Accepted: 09/10/2021] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To analyze the ability of machine-learning (ML)-based computed tomography (CT)-derived fractional flow reserve (CT-FFR) to further improve the diagnostic performance of coronary CT angiography (cCTA) for ruling out significant coronary artery disease (CAD) during pre-transcatheter aortic valve replacement (TAVR) evaluation in patients with a high pre-test probability for CAD. BACKGROUND CAD is a frequent comorbidity in patients undergoing TAVR. Current guidelines recommend its assessment before TAVR. If significant CAD can be excluded on cCTA, invasive coronary angiography (ICA) may be avoided. Although cCTA is a very sensitive test, it is limited by relatively low specificity and positive predictive value, particularly in high-risk patients. METHODS Overall, 460 patients (79.6 ± 7.4 years) undergoing pre-TAVR CT were included and examined with an electrocardiogram-gated CT scan of the heart and high-pitch scan of the vascular access route. Images were evaluated for significant CAD. Patients routinely underwent ICA (388/460), which was omitted at the discretion of the local Heart Team if CAD could be effectively ruled out on cCTA (72/460). CT examinations in which CAD could not be ruled out (CAD+) (n = 272) underwent additional ML-based CT-FFR. RESULTS ML-based CT-FFR was successfully performed in 79.4% (216/272) of all CAD+ patients and correctly reclassified 17 patients as CAD negative. CT-FFR was not feasible in 20.6% because of reduced image quality (37/56) or anatomic variants (19/56). Sensitivity, specificity, positive predictive value, and negative predictive value were 94.9%, 52.0%, 52.2%, and 94.9%, respectively. The additional evaluation with ML-based CT-FFR increased accuracy by Δ+3.4% (CAD+: Δ+6.0%) and raised the total number of examinations negative for CAD to 43.9% (202/460). CONCLUSIONS ML-based CT-FFR may further improve the diagnostic performance of cCTA by correctly reclassifying a considerable proportion of patients with morphological signs of obstructive CAD on cCTA during pre-TAVR evaluation. Thereby, CT-FFR has the potential to further reduce the need for ICA in this challenging elderly group of patients before TAVR.
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Affiliation(s)
- Robin F Gohmann
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany; Medical Faculty, University of Leipzig, Leipzig, Germany.
| | - Konrad Pawelka
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany; Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Patrick Seitz
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
| | - Nicolas Majunke
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Linda Heiser
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
| | - Katharina Renatus
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany; Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Steffen Desch
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Philipp Lauten
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - David Holzhey
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Thilo Noack
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Johannes Wilde
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Philipp Kiefer
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Christian Krieghoff
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
| | - Christian Lücke
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
| | - Sebastian Gottschling
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany
| | - Sebastian Ebel
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany; Medical Faculty, University of Leipzig, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Leipzig, Germany; Leipzig Heart Institute, Leipzig, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany; Leipzig Heart Institute, Leipzig, Germany
| | | | - Matthias Horn
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, Leipzig, Germany
| | - Mohamed Abdel-Wahab
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig, Leipzig, Germany; Medical Faculty, University of Leipzig, Leipzig, Germany; Leipzig Heart Institute, Leipzig, Germany
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Thompson MP, Hou H, Brescia AA, Pagani FD, Sukul D, McCullough JS, Likosky DS. Center Variability in Medicare Claims-Based Publicly Reported Transcatheter Aortic Valve Replacement Outcome Measures. J Am Heart Assoc 2021; 10:e021629. [PMID: 34689581 PMCID: PMC8751838 DOI: 10.1161/jaha.121.021629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Public reporting of transcatheter aortic valve replacement (TAVR) claims–based outcome measures is used to identify high‐ and low‐performing centers. Whether claims‐based TAVR outcomes can reliably be used for center‐level comparisons is unknown. In this study, we sought to evaluate center variability in claims‐based TAVR outcomes used in public reporting. Methods and Results The study sample included 119 554 Medicare beneficiaries undergoing TAVR between January 2014 and October 2018 based on procedure codes in 100% Medicare inpatient claims. Multivariable hierarchical logistic regression was used to estimate center‐specific adjusted rates and reliability (R) of 30‐day mortality, discharge not to home/self‐care, 30‐day stroke, and 30‐day readmission. Reliability was defined as the ratio of between‐hospital variation to the sum of the between‐ and within‐hospital variation. The median (interquartile range [IQR]) center‐level adjusted outcome rates were 3.1% (2.9%–3.4%) for 30‐day mortality, 41.4% (31.3%–53.4%) for discharge not to home, 2.5% (2.3%–2.7%) for 30‐day stroke, and 14.9% (14.4%–15.5%) for 30‐day readmission. Median reliability was highest for the discharge not to home measure (R=0.95; IQR, 0.94–0.97), followed by the 30‐day stroke (R=0.92; IQR, 0.87–0.94), 30‐day mortality (R=0.86; IQR, 0.81–0.91), and 30‐day readmission measures (R=0.42; IQR, 0.35–0.51). Across outcomes, there was an inverse relationship between center volume and measure reliability. Conclusions Claims‐based TAVR outcome measures for mortality, discharge not to home, and stroke were reliable measures for center‐level comparisons, but readmission measures were unreliable. Stakeholders should consider these findings when evaluating claims‐based measures to compare center‐level TAVR performance.
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Affiliation(s)
- Michael P Thompson
- Department of Cardiac Surgery Michigan Medicine Ann Arbor MI.,Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Hechuan Hou
- Department of Cardiac Surgery Michigan Medicine Ann Arbor MI
| | - Alexander A Brescia
- Department of Cardiac Surgery Michigan Medicine Ann Arbor MI.,Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Francis D Pagani
- Department of Cardiac Surgery Michigan Medicine Ann Arbor MI.,Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Devraj Sukul
- Division of Cardiovascular Medicine Department of General Internal Medicine Michigan Medicine Ann Arbor MI
| | - Jeffrey S McCullough
- Department of Health Management and Policy School of Public Health University of Michigan Ann Arbor MI
| | - Donald S Likosky
- Department of Cardiac Surgery Michigan Medicine Ann Arbor MI.,Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
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50
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Xuan Y, Dvir D, Wisneski AD, Wang Z, Ye J, Guccione JM, Ge L, Tseng EE. Impact of Transcatheter Aortic Valve Size on Leaflet Stresses: Implications for Durability and Optimal Grey Zone Sizing. ACTA ACUST UNITED AC 2021; 6:64-71. [PMID: 34708162 DOI: 10.4244/aij-d-19-00005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Aims As indications for transcatheter aortic valve replacement (TAVR) continue to expand towards younger and lower-risk patients, durability becomes an increasingly important question. Durability decreases as leaflet stresses increase, but the impact of transcatheter heart valve (THV) size on stress is unknown. Patient annulus sizes can fall within "grey zones" between 2 TAVR sizes. Our aim was to examine the impact of balloon-expandable THV size on leaflet stresses. Methods and Results SapienXT 23mm, 26mm, and 29mm sizes (Edwards Lifesciences, Inc) underwent micro-computed tomography scanning to create THV computational models then loaded to systemic pressure using finite element software. THV leaflet maximum principal stresses were 1.69MPa (23mm), 1.70MPa (26mm), and 2.12MPa (29mm) at mean arterial pressure. For intermediate annulus sizes, undersizing the larger THV yielded lower leaflet stresses than oversizing the smaller THV. Conclusions Increasing THV size yielded greater leaflet maximum principal stresses, which could suggest a relationship between THV size and long-term durability.. For annulus "grey zones" sizes, undersizing the larger THV resulted in lower leaflet stresses than oversizing the smaller THV. These results may influence optimal device sizing, as THV durability remains an important, unanswered question.
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Affiliation(s)
- Yue Xuan
- Department of Surgery, University of California San Francisco and San Francisco VA Medical Centers, San Francisco, CA
| | - Danny Dvir
- Division of Cardiology, University of Washington, Seattle, WA
| | - Andrew D Wisneski
- Department of Surgery, University of California San Francisco and San Francisco VA Medical Centers, San Francisco, CA
| | - Zhongjie Wang
- Department of Surgery, University of California San Francisco and San Francisco VA Medical Centers, San Francisco, CA
| | - Jian Ye
- Division of Cardiovascular Surgery, St. Paul's Hospital and Vancouver General Hospital, Vancouver, BC, Canada
| | - Julius M Guccione
- Department of Surgery, University of California San Francisco and San Francisco VA Medical Centers, San Francisco, CA
| | - Liang Ge
- Department of Surgery, University of California San Francisco and San Francisco VA Medical Centers, San Francisco, CA
| | - Elaine E Tseng
- Department of Surgery, University of California San Francisco and San Francisco VA Medical Centers, San Francisco, CA
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