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Imamura T, Izumida T, Onoda H, Tanaka S, Ushijima R, Sobajima M, Fukuda N, Ueno H, Kinugawa K. Trajectory of pulmonary congestion during TAVR. Cardiovasc Interv Ther 2024; 39:183-190. [PMID: 38038803 DOI: 10.1007/s12928-023-00971-6] [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: 08/28/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023]
Abstract
Patients with severe aortic stenosis often experience pulmonary congestion due to incremental afterload. The trajectory of pulmonary fluid volume during transcatheter aortic valve replacement (TAVR) remains uncertain. Remote dielectric sensing (ReDS) is a recently introduced device for non-invasive quantification of lung fluid volume without expert techniques. We evaluated the trajectory of ReDS values during TAVR and its prognostic implications. Patients with severe aortic stenosis who underwent ReDS measurements upon admission and at the index discharge after TAVR between 2021 and 2022 were eligible. They were followed up until August 2023. The primary focus was on the trajectory of ReDS values during TAVR, with secondary consideration given to its impact on the composite of death or all-cause readmission after TAVR. A total of 57 patients were included. Median age was 84 years and 24 were male. ReDS value remained unchanged after TAVR, changing from 27% (IQR 24%, 29%) to 26% (IQR 24%, 30%) (p = 0.65). ReDS value did not decrease in 23 (40%) patients. The presence of coronary artery disease and atrial fibrillation were associated with no decrease in ReDS value. This lack of decrease in ReDS value was linked to death or all-cause readmission after TAVR, with an age-adjusted hazard ratio of 3.40 (95% confidence interval 1.01-11.4, p = 0.048). The degree of lung fluid amount did not decrease in 40% of TAVR candidates during the procedure. The lack of decrease in lung fluid amount was associated with mortality and morbidity after TAVR. The next concern is to establish therapeutic strategy for patients with residual pulmonary congestion after TAVR.
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Affiliation(s)
- Teruhiko Imamura
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan.
| | - Toshihide Izumida
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Hiroshi Onoda
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Shuhei Tanaka
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Ryuichi Ushijima
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Mitsuo Sobajima
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Nobuyuki Fukuda
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Hiroshi Ueno
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
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Hakgor A, Dursun A, Kahraman BC, Yazar A, Savur U, Akhundova A, Olgun FE, Arman ME, Boztosun B. Prognostic impact of main pulmonary artery to ascending aorta diameter ratio in patients with severe aortic stenosis underwent transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2024; 103:782-791. [PMID: 38415894 DOI: 10.1002/ccd.31000] [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: 08/24/2023] [Revised: 01/09/2024] [Accepted: 02/19/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Pulmonary hypertension (PH) and right ventricular dysfunction are poor prognostic predictors in patients underwent transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS). AIMS The prognostic impact of the main pulmonary artery/ascending aorta diameter ratio (MPA/AOr), measured simply by computed-tomographic angiography (CTA), was investigated in this patient group. METHODS A total of 374 retrospectively evaluated patients (mean age 78.1 ± 8.4 years, 192 [51.3%] females) who underwent TAVI for severe AS were included. MPA/AOr was measured on preprocedural CTA in all patients and the effect of this measurement on the presence of PH, in-hospital and 2-year-overall long-term mortality was investigated. RESULTS The presence of PH was defined as a systolic pulmonary artery pressure (sPAP) >42 mmHg measured by echocardiography. According to multivariate-logistic-regression analysis, MPA/AOr (adjusted [Adj] odds ratio [OR]: 1.188, confidence interval [CI] 95% [1.002-1.410], p = 0.048), tricuspid annular plane systolic excursion (TAPSE) (adj OR:0.736, CI 95% [0.663-0.816], p < 0.001) and left atrial diameter (adj OR:1.051, CI 95% [1.007-1.098], p = 0.024) were identified as independent predictors of PH. In addition, a statistically significant correlation was found between MPA/AOr and TAPSE (r: -0.283, p < 0.001). Furthermore, MPA/AOr was found to be an independent predictor of both in-hospital (adj OR:1.434, CI 95% [1.093-1.881], p = 0.009) and 2-year long-term (adj OR:1.518, CI 95% [1.243-1.853], p < 0.001) mortality in multivariate analysis including TAPSE, STS score and sPAP. In the 2-year Kaplan-Meier survival probability analysis, an MPA/AOr >0.86 was found to have a hazard ratio of 3.697 (95% CI: 2.341-5.840), with a log-rank p < 0.001. CONCLUSION MPA/AOr, which can be measured simply by CTA, may be useful as an indicator of the presence of PH and poor prognosis in patients planned for TAVI for severe AS.
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Affiliation(s)
- Aykun Hakgor
- Depatment of Cardiology, Medipol Mega University Hospital, Istanbul, Turkey
| | - Atakan Dursun
- Depatment of Cardiology, Medipol Mega University Hospital, Istanbul, Turkey
| | | | - Arzu Yazar
- Depatment of Cardiology, Medipol Mega University Hospital, Istanbul, Turkey
| | - Umeyir Savur
- Depatment of Cardiology, Medipol Mega University Hospital, Istanbul, Turkey
| | - Aysel Akhundova
- Depatment of Cardiology, Medipol Mega University Hospital, Istanbul, Turkey
| | - Fatih Erkam Olgun
- Depatment of Cardiology, Medipol Mega University Hospital, Istanbul, Turkey
| | - Mehmet Emir Arman
- Depatment of Cardiology, Medipol Mega University Hospital, Istanbul, Turkey
- Depatment of Internal Medicine, Ascension St. Vincent Hospital, Indianapolis, Indiana, USA
| | - Bilal Boztosun
- Depatment of Cardiology, Medipol Mega University Hospital, Istanbul, Turkey
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Gao X, Jiang X, Wu Z, Chen N, Gong M, Zhao X, Liu Y, Guo R. Effect of Neutrophil-to-Lymphocyte Ratio on Post-TAVR Mortality and Periprocedural Pulmonary Hypertension. J Interv Cardiol 2024; 2024:4512655. [PMID: 38415185 PMCID: PMC10898951 DOI: 10.1155/2024/4512655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/27/2024] [Accepted: 02/06/2024] [Indexed: 02/29/2024] Open
Abstract
Aims To evaluate the impact of neutrophil-to-lymphocyte ratio (NLR) on periprocedural pulmonary hypertension (PH) and 3-month all-cause mortality in patients with aortic stenosis (AS) who underwent transcatheter aortic valve replacement (TAVR) and to develop a nomogram for predicting the mortality for these patients. Methods and Results 124 patients undergoing TAVR were categorized into three groups according to systolic pulmonary artery pressure (sPAP): Group I (no PH, n = 61) consisted of patients with no pre- and post-TAVR PH; Group II (improved PH, n = 35) consisted of patients with post-TAVR systolic pulmonary artery pressure (sPAP) decreased by more than 10 mmHg compared to pre-TAVR levels; and Group III (persistent PH, n = 28) consisted of patients with post-TAVR sPAP no decrease or less than 10 mmHg, or new-onset PH after the TAVR procedure. The risk of all-cause mortality within 3 months tended to be higher in Group II (11.4%) and Group III (14.3%) compared to Group I (3.3%) (P=0.057). The multinomial logistic regression analysis demonstrated a positive correlation between NLR and both improved PH (OR: 1.182, 95% CI: 1.036-1.350, P=0.013) and persistent PH (OR: 1.181, 95% CI: 1.032-1.352, P=0.016). Kaplan-Meier analysis revealed a significant association between higher NLR and increased 3-month all-cause mortality (16.1% vs. 3.1% in lower NLR group, P=0.021). The multivariable Cox regression analysis confirmed that NLR was an independent predictor for all-cause mortality within 3 months, even after adjusting for clinical confounders. A nomogram incorporating five factors (BNP, heart rate, serum total bilirubin, NLR, and comorbidity with coronary heart disease) was developed. ROC analysis was performed to discriminate the ability of the nomogram, and the AUC was 0.926 (95% CI: 0.850-1.000, P < 0.001). Conclusions Patients with higher baseline NLR were found to be at an increased risk of periprocedural PH and all-cause mortality within 3 months after TAVR.
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Affiliation(s)
- Xin Gao
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaoxiao Jiang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zonglei Wu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Na Chen
- Department of Cardiovascular Ultrasound, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Minghui Gong
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xu Zhao
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yan Liu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ran Guo
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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Emami Meybodi M, Bamarinejad A, Bamarinejad F, Abhari AP, Fakhrolmobasheri M, Khosravi Larijani F, Nasiri S, Shafie D. Prognostic Implication of Preprocedural Pulmonary Hypertension in Patients with Severe Aortic Valve Stenosis Undergoing Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-analysis. Cardiol Rev 2024:00045415-990000000-00200. [PMID: 38285645 DOI: 10.1097/crd.0000000000000583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
Pulmonary hypertension (PH) is a common comorbidity in patients with aortic stenosis (AS) who are candidates for transcatheter aortic valve implantation (TAVI). Herein, we sought to elucidate the prognostic value of preprocedural PH on the early and late mortality after TAVI. The Cochrane Library, Scopus, PubMed, Web of Science, Embase, and ProQuest were screened using a predefined search query. We considered odds ratios (ORs) as the measure of effect. Meta-regression analysis was applied to investigate the potential impact of baseline characteristics on the outcomes. Egger's and Begg's tests were used to assess the publication bias. Thirty-three studies comprising 34 datasets representing 68,435 patients were included in the analysis. Regardless of the definition and severity of PH, pooled data analysis indicated that preprocedural PH was associated with higher cardiac and overall 30-day [OR, 1.45 (1.15-1.82) and OR, 1.75 (1.42-2.17), respectively], and 1-year mortality [OR, 1.63 (1.35-1.96) and OR, 1.59 (1.38-1.82), respectively]. Meta-regression analysis demonstrated that older age, higher New York Heart Association function class, history of hypertension, diabetes, and lower left ventricular ejection fraction were predictors of higher mortality rate following TAVI. Moreover, we found that preprocedural PH is significantly associated with higher in-hospital mortality and 30-day acute kidney injury. Our results demonstrated that preprocedural PH is associated with higher early and late cardiac and overall mortality following TAVI; however, this finding is limited regarding the considerable inconsistency in the definition of PH and PH severity among studies.
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Affiliation(s)
- Mahmood Emami Meybodi
- From the Department of Cardiology, Afshar Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Atefe Bamarinejad
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fateme Bamarinejad
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir Parsa Abhari
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Fakhrolmobasheri
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Shidrokh Nasiri
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Davood Shafie
- Heart Failure Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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Ivanov B, Krasivskyi I, Förster F, Gaisendrees C, Elderia A, Großmann C, Mihaylova M, Djordjevic I, Eghbalzadeh K, Sabashnikov A, Kuhn E, Deppe AC, Rahmanian PB, Mader N, Gerfer S, Wahlers T. Impact of pulmonary hypertension on short-term outcomes in patients undergoing surgical aortic valve replacement for severe aortic valve stenosis. Perfusion 2024:2676591241227883. [PMID: 38213127 DOI: 10.1177/02676591241227883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
OBJECTIVES In patients with left heart disease and severe aortic stenosis (AS), pulmonary hypertension (PH) is a common comorbidity and predictor of poor prognosis. Untreated AS aggravates PH leading to an increased right ventricular afterload and, in line to right ventricular dysfunction. The surgical benefit of aortic valve replacement (AVR) in elderly patients with severe AS and PH could be limited due to the multiple comorbidities and poor outcomes. Therefore, we purposed to investigate the impact of PH on short-term outcomes in patients with moderate to severe AS who underwent surgical AVR in our heart center. METHODS In this study we retrospectively analyzed a cohort of 99 patients with severe secondary post-capillary PH who underwent surgical AVR (AVR + PH group) at our heart center between 2010 and 2021 with a regard to perioperative outcomes. In order to investigate the impact of PH on short-term outcomes, the control group of 99 patients without pulmonary hypertension who underwent surgical AVR (AVR group) at our heart center with similar risk profile was accordingly analyzed regarding pre-, intra- and postoperative data. RESULTS Atrial fibrillation occurred significantly more often (p = .013) in patients who suffered from PH undergoing AVR. In addition, the risk for cardiac surgery (EUROSCORE II) was significantly higher (p < .001) in the above-mentioned group. Likewise, cardiopulmonary bypass time (p = .018), aortic cross-clamp time (p = .008) and average operation time (p = .009) were significantly longer in the AVR + PH group. Furthermore, the in-hospital survival rate was significantly higher (p = .044) in the AVR group compared to the AVR + PH group. Moreover, the dialysis rate was significantly higher (p < .001) postoperatively in patients who suffered PH compared to the patients without PH undergoing AVR. CONCLUSION In our study, patients with severe PH and severe symptomatic AS who underwent surgical aortic valve replacement showed adverse short-term outcomes compared to patients without PH.
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Affiliation(s)
- Borko Ivanov
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
- Department of Cardiothoracic Surgery, Helios Hospital Siegburg, Siegburg, Germany
| | - Ihor Krasivskyi
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Friedrich Förster
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | | | - Ahmed Elderia
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Clara Großmann
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Mariya Mihaylova
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Antje-Christin Deppe
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | | | - Navid Mader
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
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Boxhammer E, Dienhart C, Kletzer J, Ramsauer S, Kopp K, Prinz E, Wintersteller W, Blessberger H, Hammerer M, Steinwender C, Lichtenauer M, Hoppe UC. Elevated systolic pulmonary artery pressure is a substantial predictor of increased mortality after transcatheter aortic valve replacement in males, not in females. Clin Res Cardiol 2024; 113:138-155. [PMID: 37750991 PMCID: PMC10808322 DOI: 10.1007/s00392-023-02307-z] [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: 07/22/2023] [Accepted: 09/05/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND While pulmonary hypertension (PH) in patients with severe aortic valve stenosis (AS) is associated with increased mortality after transcatheter aortic valve replacement (TAVR), there is limited data on gender differences in the effects on long-term survival. OBJECTIVE The aim of this retrospective, multicenter study was to investigate the prognostic impact of pre-interventional PH on survival of TAVR patients with respect to gender. METHODS 303 patients undergoing TAVR underwent echocardiography to detect PH prior to TAVR via measurement of systolic pulmonary artery pressure (sPAP). Different cut-off values were set for the presence of PH. The primary endpoint was all-cause mortality at 1, 3 and 5 years. RESULTS Kaplan-Meier analysis by gender showed that only males exhibited significant increased mortality at elevated sPAP values during the entire follow-up period of 5 years (sPAP ≥ 40 mmHg: p ≤ 0.001 and sPAP ≥ 50 mmHg: p ≤ 0.001 in 1- to 5-year survival), whereas high sPAP values had no effect on survival in females. In Cox regression analysis based on the selected sPAP thresholds, male gender was an independent risk factor for long-term mortality after TAVR in all time courses. CONCLUSION Male gender was an isolated risk factor for premature death after TAVR in patients with echocardiographic evidence of PH and severe AS. This could mean that, the indication for TAVR should be discussed more critically in men with severe AS and an elevated sPAP, while in females, PH should not be an exclusion criterion for TAVR.
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Affiliation(s)
- Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria.
| | - Christiane Dienhart
- Department of Internal Medicine I, Division of Gastroenterology, Hepathology, Nephrology, Metabolism and Diabetology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Joseph Kletzer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Susanne Ramsauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Kristen Kopp
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Erika Prinz
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Wilfried Wintersteller
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Hermann Blessberger
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, Linz, Austria
| | - Matthias Hammerer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Clemens Steinwender
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, Linz, Austria
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
| | - Uta C Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020, Salzburg, Austria
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Cardaioli F, Nai Fovino L, Fabris T, Masiero G, Arturi F, Trevisanello A, Zuccarelli V, Napodano M, Fraccaro C, Continisio S, Tarantini G. Updated definition of pulmonary hypertension and outcome after transcatheter aortic valve implantation. Heart 2023; 110:27-34. [PMID: 37414524 DOI: 10.1136/heartjnl-2023-322881] [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: 04/26/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVE The European Society of Cardiology guidelines have recently defined new cut-offs for pulmonary hypertension (PH) and pulmonary vasculature resistance (PVR; median pulmonary artery pressure (mPAP) >20 instead of 25 mm Hg and PVR >2 instead of 3 Wood unit). The prognostic value of this updated classification after transcatheter aortic valve implantation (TAVI) is unknown. METHODS 579 consecutive patients treated by TAVI with preprocedural right heart catheterisation evaluation were included. Patients were grouped as: (1) no PH, (2) isolated precapillary/combined (I-PreC/Co) PH and (3) isolated postcapillary PH (I-PoC). All-cause death, cardiovascular death and hospitalisations for heart failure (HF) were evaluated at follow-up. We also analysed the prognostic role of residual postprocedural PH. RESULTS Out of 579 patients, 299 (52%) had PH according to the new criteria compared with 185 (32%) according to the previous ones. Overall median age was 82 years, while 55.3% patients were male. Patients with PH were more frequently diagnosed with chronic obstructive pulmonary disease and atrial fibrillation and were characterised by higher surgical risk as compared with patients without PH.At a median follow-up of 2.9 years, the presence of PH according to previous definition was associated with worse survival (p<0.001) and HF hospitalisation (p=0.002) rates, irrespective of PVR values. With newer cut-offs, PH was associated with worse outcomes only in patients with increased PVR, while no differences were found between patients with PH and normal PVR values and those without PH. Postprocedural mPAP normalisation was observed in 45% of the cases, but it was associated with improved long-term survival only in the I-PoC PH group. CONCLUSIONS New ESC PH cut-offs increased the number of PH diagnoses. The presence of PH, particularly in the setting of increased PVR, identify patients at higher risk for postprocedural mortality and rehospitalisation. Normalisation of PH was associated with better survival only in I-PoC group.
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Affiliation(s)
- Francesco Cardaioli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Luca Nai Fovino
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Tommaso Fabris
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Giulia Masiero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Federico Arturi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Aurora Trevisanello
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Vittorio Zuccarelli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Massimo Napodano
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Saverio Continisio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Università degli Studi di Padova, Padova, Italy
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8
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Turner V, Maret E, Kim JB, Codari M, Hinostroza V, Mastrodicasa D, Watkins AC, Fearon WF, Fischbein MP, Haddad F, Willemink MJ, Fleischmann D. Reduced Pulmonary Artery Distensibility Predicts Persistent Pulmonary Hypertension and 2-Year Mortality in Patients with Severe Aortic Stenosis Undergoing TAVR. Acad Radiol 2023; 30:2825-2833. [PMID: 37147161 DOI: 10.1016/j.acra.2023.03.014] [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: 01/04/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 05/07/2023]
Abstract
RATIONALE AND OBJECTIVES Post-TAVR persistent pulmonary hypertension (PH) is a better predictor of poor outcome than pre-TAVR PH. In this longitudinal study we sought to evaluate whether pulmonary artery (distensibility (DPA) measured on preprocedural ECG-gated CTA is associated with persistent-PH and 2-year mortality after TAVR. MATERIALS AND METHODS Three hundred and thirty-six patients undergoing TAVR between July 2012 and March 2016 were retrospectively included and followed for all-cause mortality until November 2017. All patients underwent retrospectively ECG-gated CTA prior to TAVR. Main pulmonary artery (MPA) area was measured in systole and in diastole. DPA was calculated as: [(area-MPAmax-area-MPAmin)/area-MPAmax]%. ROC analysis was performed to assess the AUC for persistent-PH. Youden Index was used to determine the optimal threshold of DPA for persistent-PH. Two groups were compared based on a DPA threshold of 8% (specificity of 70% for persistent-PH). Kaplan-Meier, Cox proportional-hazard, and logistic regression analyses were performed. The primary clinical endpoint was defined as persistent-PH post-TAVR. The secondary endpoint was defined as all-cause mortality 2 years after TAVR. RESULTS Median follow-up time was 413 (interquartiles 339-757) days. A total of 183 (54%) had persistent-PH and 68 (20%) patients died within 2-years after TAVR. Patients with DPA<8% had significantly more persistent-PH (67% vs 47%, p<0.001) and 2-year deaths (28% vs 15%, p=0.006), compared to patients with DPA>8%. Adjusted multivariable regression analyses showed that DPA<8% was independently associated with persistent-PH (OR 2.10 [95%-CI 1.3-4.5], p=0.007) and 2-year mortality (HR 2.91 [95%-CI 1.5-5.8], p=0.002). Kaplan-Meier analysis showed that 2-year mortality of patients with DPA<8% was significantly higher compared to patients with DPA≥8% (mortality 28% vs 15%; log-rank p=0.003). CONCLUSION DPA on preprocedural CTA is independently associated with persistent-PH and two-year mortality in patients who undergo TAVR.
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Affiliation(s)
- Valery Turner
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304.
| | - Eva Maret
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304; Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
| | - Juyong B Kim
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Marina Codari
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304
| | - Virginia Hinostroza
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304
| | - Domenico Mastrodicasa
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - A Claire Watkins
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - William F Fearon
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael P Fischbein
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Francois Haddad
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Martin J Willemink
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, MC:5659, 453 Quarry Road, Stanford, CA, 94304; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
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9
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Boxhammer E, Paar V, Jirak P, Köller C, Demirel O, Eder S, Reiter C, Kammler J, Kellermair J, Hammerer M, Blessberger H, Steinwender C, Hoppe UC, Lichtenauer M. Main pulmonary artery diameter in combination with cardiovascular biomarkers: new possibilities to identify pulmonary hypertension in patients with severe aortic valve stenosis. Minerva Med 2023; 114:802-814. [PMID: 35822856 DOI: 10.23736/s0026-4806.22.08167-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
BACKGROUND Echocardiography is currently the noninvasive method of choice to screen patients with severe aortic valve stenosis (AS) for pulmonary hypertension (PH) by estimating systolic pulmonary artery pressure (sPAP). However, radiological options are also available by determining the main pulmonary artery (MPA) diameter in the setting of CT angiography. The aim of the present study was to compare cardiovascular biomarkers with the MPA diameter to allow other ways of detecting PH in patients with severe AS. METHODS One hundred ninety-four patients with severe AS undergoing transcatheter aortic valve replacement (TAVR) were included in this study and were divided into two groups based on the CT-angiographically determined MPA diameter. In accordance with ESC guidelines, a cut-off value of 29 mm was determined in this study, with the absence of PH defined by an MPA diameter <29 mm (N79/194) and the presence of PH defined by an MPA diameter ≥29 mm (115/194). Immediately before interventional aortic valve replacement, blood samples were drawn from the subjects and relevant cardiovascular biomarkers such as BNP, cTnI, GDF-15, H-FABP, IGF-BP2 and suPAR were assessed. RESULTS Patients with an MPA diameter ≥29 mm had significantly higher BNP (P=0.004), cTnI (P=0.039) and H-FABP (P=0.015) plasma levels, whereas GDF-15 (P=0.140), IGF-BP2 (P=0.088) and suPAR (P=0.140) showed no significant differences. In addition, cut-off values were calculated to predict an MPA diameter ≥29 mm. Significant results were shown with 1634.00 pg/mL for BNP (P=0.004), with 16.50 pg/mL for cTnI (P=0.039) and with 1.16 ng/mL for H-FABP (P=0.016). In a combined biomarker analysis, the 2-way combination of BNP and IGF-BP2 (AUC 0.671; 95%CI 0.538-0.805; P=0.023) and the 3-way combination of BNP, H-FABP and IGF-BP2 (AUC 0.685; 95%CI 0.551-0.818; P=0.015) showed the best results. Biomarker follow-up at 3 and 12 months after TAVR did not require additional information gain. Regarding 1-year survival, no significant difference could be detected between patients with an MPA diameter<29 mm compared to patients with ≥29 mm (log-rank test: P=0.262). CONCLUSIONS The MPA diameter remains a controversial parameter for the detection of PH in patients with severe AS. Standing on its own, this non-invasive parameter may not be precise enough to detect PH accurately. Combining this parameter with several biomarkers did not provide significant additional information.
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Affiliation(s)
- Elke Boxhammer
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Vera Paar
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Peter Jirak
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Clara Köller
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Ozan Demirel
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Sarah Eder
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Christian Reiter
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University of Linz, Linz, Austria
| | - Jürgen Kammler
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University of Linz, Linz, Austria
| | - Jörg Kellermair
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University of Linz, Linz, Austria
| | - Matthias Hammerer
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Hermann Blessberger
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University of Linz, Linz, Austria
| | - Clemens Steinwender
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University of Linz, Linz, Austria
| | - Uta C Hoppe
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Michael Lichtenauer
- Division of Cardiology, Department of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria -
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10
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Al-Atta A, Farag M, Jeyalan V, Gazzal Asswad A, Thompson A, Irvine T, Edwards R, Das R, Zaman A, Alkhalil M. Low Transvalvular Flow Rate in Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI) Is a Predictor of Mortality: The TFR-TAVI Study. Heart Lung Circ 2023; 32:1489-1499. [PMID: 37993343 DOI: 10.1016/j.hlc.2023.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 07/12/2023] [Accepted: 09/21/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Transvalvular flow rate (TFR) represents a better reflection of transvalvular flow than the stroke volume index (SVi), and has recently emerged as a useful prognostic tool in patients undergoing surgical aortic valve replacement. There is a paucity of data investigating the role of TFR and its relationship with other clinical or echocardiographic factors in patients undergoing transcatheter aortic valve implantation (TAVI). METHOD This was a retrospective single-centre study of 629 consecutive patients who underwent TAVI between March 2009 and September 2020. Pre-TAVI low TFR was defined as <200 c/s. The primary study end point was all-cause mortality. RESULTS Low TFR was observed in 41.8% (263/629) of included patients and was associated with increasing age, low body surface area, hypertension, diabetes, atrial fibrillation, left ventricular (LV) dysfunction, and significant mitral regurgitation. LV function status and severity of aortic valve disease were independent predictors of low TFR. Low TFR was significantly associated with long-term all-cause mortality even after adjustment for other risk factors (adjusted hazard ratio [aHR] 1.44; 95% confidence interval [CI] 1.02-2.03; p=0.038). When data were stratified according to SVi, low TFR was an independent predictor of long-term all-cause mortality in patients with normal SVi (aHR 1.98; 95% CI 1.06-3.69; p=0.032) but not in patients with low SVi (HR 1.23; 95% CI 0.71-2.11; p=0.46; p=0.016 for interaction). CONCLUSIONS Low TFR is common in patients undergoing TAVI and is an independent predictor of all-cause mortality, particularly in patients with normal SVi.
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Affiliation(s)
- Ayman Al-Atta
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - Mohamed Farag
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - Visvech Jeyalan
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | | | | | - Tim Irvine
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - Richard Edwards
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - Rajiv Das
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK
| | - Azfar Zaman
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Mohammed Alkhalil
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.
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11
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Chopra L, Ueyama H, Dalsania A, Prandi FR, Tang G, Khera S, Melarcode-Krishnamoorthy P, Sharma SK, Kini A, Lerakis S. Prognostic Implication of Pulmonary Hypertension in Low-Flow Low-Gradient Aortic Stenosis After Transcatheter Aortic Valve Replacement. Am J Cardiol 2023; 208:6-12. [PMID: 37806187 DOI: 10.1016/j.amjcard.2023.09.054] [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: 07/14/2023] [Revised: 08/29/2023] [Accepted: 09/14/2023] [Indexed: 10/10/2023]
Abstract
Prognostic implications of pulmonary hypertension (PH) in low-flow low-gradient (LG) aortic stenosis (AS) after transcatheter aortic valve replacement (TAVR) remains unexplored. We aimed to investigate the impact of baseline and changes in PH after TAVR. In this single-center retrospective study, we included patients who underwent TAVR for low-flow LG AS. Patients were categorized into 2 groups: baseline pulmonary artery systolic pressure (PASP) <46 mm Hg (no-to-mild PH) and PASP ≥46 mm Hg (moderate-to-severe PH). On the basis of changes in PASP after TAVR, patients were stratified into increased (ΔPASP ≥ + 5 mm Hg), no change (-4 to +4 mm Hg), and decreased (≤ -5 mm Hg) groups. Primary end point was a composite of all-cause mortality and heart failure rehospitalization. In total, 210 patients were included, 148 in the no-to-mild PH group and 62 in the moderate-to-severe PH group. Median follow-up was 13.2 months. The moderate-to-severe PH group was at an increased risk of composite end point (adjusted hazard ratio [HR] 3.5, 95% confidence interval [CI] 1.8 to 6.9), all-cause mortality (HR 2.4, 95% CI 1.1 to 5.6), and heart failure rehospitalization (HR 8.3, 95% CI 2.9 to 23.7). There were no differences in clinical outcomes among those with increased (32%), no change (28%), and decreased (39%) PASP after TAVR. In conclusion, moderate-to-severe PH at baseline is an independent predictor of worse clinical outcomes in patients with low-flow LG AS who undergo TAVR, and this cohort of patients do not seem to derive the benefits of postoperative reduction of PASP.
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Affiliation(s)
- Lakshay Chopra
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hiroki Ueyama
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, New York; Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Ankur Dalsania
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Francesca R Prandi
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gilbert Tang
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sahil Khera
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Samin K Sharma
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Annapoorna Kini
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stamatios Lerakis
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York.
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12
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Alwan L, Tomii D, Heg D, Okuno T, Lanz J, Praz F, Chong-Nguyen C, Stortecky S, Reineke D, Windecker S, Pilgrim T. Impact of right ventricular-pulmonary arterial coupling on clinical outcomes in patients undergoing transcatheter aortic valve implantation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 56:27-34. [PMID: 37210220 DOI: 10.1016/j.carrev.2023.05.008] [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: 02/14/2023] [Revised: 05/02/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023]
Abstract
AIMS The interplay between pulmonary hypertension (PH) and right ventricular (RV) function is reflected in an index of RV function to pulmonary artery (PA) systolic pressure (PASP). The present study aimed to assess the importance of RV-PA coupling on clinical outcomes after transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS In a prospective TAVI registry, clinical outcomes of TAVI patients with RV dysfunction or PH were stratified according to coupling or uncoupling of tricuspid annular plane systolic excursion (TAPSE) to PASP, and compared to those of patients with normal RV function and absence of PH. The median TAPSE/PASP ratio was used to differentiate uncoupling (>0.39) from coupling (<0.39). Among 404 TAVI patients, 201 patients (49.8 %) had RVD or PH at baseline: 174 patients had RV-PA uncoupling, and 27 had coupling at baseline. RV-PA hemodynamics normalized in 55.6 % of patients with RV-PA coupling and in 28.2 % of patients with RV-PA uncoupling, and deteriorated in 33.3 % of patients with RV-PA coupling and in 17.8 % of patients with no RVD, respectively, at discharge. Patients with RV-PA uncoupling after TAVI showed a trend towards an increased risk of cardiovascular death at 1 year as compared to patients with normal RV-function (HRadjusted 2.06, 95 % CI 0.97-4.37). CONCLUSION After TAVI, RV-PA coupling changed in a significant proportion of patients and is a potentially important metric for risk stratification of TAVI patients with RVD or PH. TWEET: "Patients with right ventricular dysfunction and pulmonary hypertension are at increased risk of death after TAVI. Integrated right ventricular to pulmonary artery hemodynamics change after TAVI in a significant proportion of patients and is instrumental to refine risk stratification." CLINICAL TRIAL REGISTRATION https://www. CLINICALTRIALS gov: NCT01368250.
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Affiliation(s)
- Louhai Alwan
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Daijiro Tomii
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland. https://twitter.com/DaijiroTomii
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - Taishi Okuno
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | | | - Stefan Stortecky
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - David Reineke
- Department of Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland.
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13
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Velidakis N, Khattab E, Gkougkoudi E, Kadoglou NPE. Pulmonary Hypertension in Left Ventricular Valvular Diseases: A Comprehensive Review on Pathophysiology and Prognostic Value. Life (Basel) 2023; 13:1793. [PMID: 37763197 PMCID: PMC10532440 DOI: 10.3390/life13091793] [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: 07/05/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023] Open
Abstract
Left ventricular (LV) valvular diseases, make up one of the most common etiologies for pulmonary hypertension (PH), and it is not well understood how and at which degree it affects prognosis. The aim of the present study was a comprehensive review of the pathophysiologic mechanism of PH in patients with LV valvular diseases and the prognostic value of baseline and post-intervention PH in patients undergoing interventional treatment. The pathophysiology of PH in patients with LV valvular diseases involves gradual elevation of left ventricular filling pressure and left atrial pressure, which are passively transmitted to the pulmonary circulation and raise pulmonary artery systolic pressure (PASP). A long-lasting exposure to elevated PASP progressively leads to initially functional and thereafter irreversible structural changes in the pulmonary vasculature, leading up to high pulmonary vascular resistance. Surgical treatment of severe LV valvular diseases is highly effective in patients without resting PH or those with exercise-induced PH (EIPH) before intervention. In the case of pre-operative PH, successful interventional therapy decreases PASP, but the post-operative cardiac and all-cause mortality remain higher compared to patients without pre-operative PH. Hence, it is of paramount importance to detect patients with severe LV valvulopathies before the development of PH, since they will get greater benefits from early intervention.
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Affiliation(s)
| | | | | | - Nikolaos P. E. Kadoglou
- Medical School, University of Cyprus, Palaios Dromos Lefkosias Lemesou No. 215/62029 Aglantzia, P.O. Box 20537 1678, Nicosia 2024, Cyprus
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14
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Ahmad M, Del Cid Fratti J, Henien M, Pant K, Wattelet MP, Whorf D, Austin BC, Kim M, Barzallo M, Mungee S. Association Between Pulmonary Hypertension and Its Effect on 30-Day Mortality, Readmission, and Cost After Transcatheter Aortic Valve Replacement: A Multicenter Study. Cureus 2023; 15:e40976. [PMID: 37388720 PMCID: PMC10300306 DOI: 10.7759/cureus.40976] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 07/01/2023] Open
Abstract
Background Pulmonary hypertension (PH) is commonly seen in patients with severe aortic stenosis. Transcatheter aortic valve replacement (TAVR) has been shown to improve PH, however, its impact on clinical outcomes and cost remains unclear. Methods We did a multicenter, retrospective analysis of patients undergoing TAVR in our system between December 2012 to November 2020. The initial sample size was 1356. We excluded patients with prior history of heart failure, with a left ventricular ejection fraction of 40% or less, and patients who had active symptoms of heart failure within two weeks of the procedure. Patients were divided into four groups based on their pulmonary pressures, using right ventricular systolic pressure (RVSP) as a surrogate for PH. Groups included patients with normal pulmonary pressures (<35mmHg), mild (35-45mmHg) moderate (46-60mmHg), and severe PH (>60mmHg). Primary outcomes included 30-day mortality and readmission. Secondary outcomes included length of ICU stay and cost of admission. We used Chi-square and T-tests for demographic analysis of categorical continuous variables respectively. Adjusted regression was used for the reliability of correlation between variables. Multivariate analysis was used for final outcomes. Results Final sample size was 474. Average age was 78.9 years (SD: 8.2, 53% Male). Thirty-one percent (n=150) had normal pulmonary pressures, 33% (n=156) had mild PH, 25% (n=122) had moderate and 10% (n=46) had severe PH. Patients with history of hypertension (p-value<0.001), diabetes (p-value<0.001), chronic lung disease (p-value=0.006) and those on supplemental oxygen (p-value=0.046), had significantly higher proportion of patients with moderate and severe PH. We found significantly higher odds of 30-day mortality in patients with severe PH (OR: 6.77, CI: 1.09-41.98: p-value 0.04) compared with normal or mild PH. There was no significant difference in 30-day readmission (p-value=0.859) between the four groups. Cost did not change with severity of PH (Avg: $261,075: p-value=0.810). Patients with severe PH spent a significantly higher number of hours in ICU, compared with the other three groups (Mean: 18.2, p=value <0.001). Conclusions Severe pulmonary hypertension significantly increased the odds of 30-day mortality and ICU stay in TAVR patients. We did not see any significant difference in 30-day readmission and cost of admission, based on PH severity.
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Affiliation(s)
- Mansoor Ahmad
- Cardiology, University of Illinois College at Chicago Peoria, Peoria, USA
| | | | - Mena Henien
- Cardiology, University of Illinois College at Chicago Peoria, Peoria, USA
| | - Kailash Pant
- Cardiology, University of Illinois College at Chicago Peoria, Peoria, USA
| | - Matthew P Wattelet
- Cardiology, University of Illinois College at Chicago Peoria, Peoria, USA
| | - Daniel Whorf
- Cardiology, University of Illinois College at Chicago Peoria, Peoria, USA
| | - Brett C Austin
- Cardiology, University of Illinois College at Chicago Peoria, Peoria, USA
| | - Minchul Kim
- Cardiology, University of Illinois College at Chicago Peoria, Peoria, USA
| | - Marco Barzallo
- Cardiology, University of Illinois College at Chicago Peoria, Peoria, USA
| | - Sudhir Mungee
- Cardiology, University of Illinois College at Chicago Peoria, Peoria, USA
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15
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Trongtorsak A, Thangjui S, Adhikari P, Shrestha B, Kewcharoen J, Navaravong L, Kanjanauthai S, Attanasio S, Saudye HA. Gender Disparities after Transcatheter Aortic Valve Replacement with Newer Generation Transcatheter Heart Valves: A Systematic Review and Meta-Analysis. Med Sci (Basel) 2023; 11:medsci11020033. [PMID: 37218985 DOI: 10.3390/medsci11020033] [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: 02/26/2023] [Revised: 05/04/2023] [Accepted: 05/04/2023] [Indexed: 05/24/2023] Open
Abstract
Previous studies have demonstrated gender disparities in mortality and vascular complications after transcatheter aortic valve replacement (TAVR) with early generation transcatheter heart valves (THVs). It is unclear, however, whether gender-related differences persist with the newer generation THVs. We aim to assess gender disparities after TAVR with newer generation THVs. The MEDLINE and Embase databases were thoroughly searched from inception to April 2023 to identify studies that reported gender-specific outcomes after TAVR with newer generation THVs (Sapien 3, Corevalve Evolut R, and Evolut Pro). The outcomes of interest included 30-day mortality, 1-year mortality, and vascular complications. In total, 5 studies (4 databases) with a total of 47,933 patients (21,073 females and 26,860 males) were included. Ninety-six percent received TAVR via the transfemoral approach. The females had higher 30-day mortality rates (odds ratio (OR) = 1.53, 95% confidence interval (CI) 1.31-1.79, p-value (p) < 0.001) and vascular complications (OR = 1.43, 95% CI 1.23-1.65, p < 0.001). However, one-year mortality was similar between the two groups (OR = 0.78, 95% CI 0.61-1.00, p = 0.28). The female gender continues to be associated with higher 30-day mortality rates and vascular complications after TAVR with newer generation transcatheter heart valves, while there was no difference in 1-year mortality between the genders. More data is needed to explore the causes and whether we can improve TAVR outcomes in females.
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Affiliation(s)
- Angkawipa Trongtorsak
- Ascension Saint Francis Hospital, Internal Medicine Residency Program, Evanston, IL 60202, USA
| | - Sittinun Thangjui
- Bassett Healthcare Network, Internal Medicine Residency Program, New York, NY 13326, USA
| | - Pabitra Adhikari
- Ascension Saint Francis Hospital, Internal Medicine Residency Program, Evanston, IL 60202, USA
| | - Biraj Shrestha
- Reading Hospital-Tower Health, Internal Medicine Residency Program, West Reading, PA 19611, USA
| | - Jakrin Kewcharoen
- Division of Cardiovascular Medicine, Loma Linda University Health, Loma Linda, CA 92350, USA
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, School of Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Somsupha Kanjanauthai
- Division of Cardiovascular Medicine, University of Southern California, Los Angeles, CA 90007, USA
| | - Steve Attanasio
- Rush University Medical Center, Division of Cardiovascular Medicine, Chicago, IL 60612, USA
| | - Hammad A Saudye
- Ascension Saint Francis Hospital, Division of Cardiovascular Medicine, Evanston, IL 60202, USA
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16
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Angellotti D, Manzo R, Castiello DS, Immobile Molaro M, Mariani A, Iapicca C, Nappa D, Simonetti F, Avvedimento M, Leone A, Canonico ME, Spaccarotella CAM, Franzone A, Ilardi F, Esposito G, Piccolo R. Echocardiographic Evaluation after Transcatheter Aortic Valve Implantation: A Comprehensive Review. Life (Basel) 2023; 13:1079. [PMID: 37240724 PMCID: PMC10221682 DOI: 10.3390/life13051079] [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: 03/06/2023] [Revised: 04/19/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is an increasingly popular treatment option for patients with severe aortic stenosis. Recent advancements in technology and imaging tools have significantly contributed to the success of TAVI procedures. Echocardiography plays a pivotal role in the evaluation of TAVI patients, both before and after the procedure. This review aims to provide an overview of the most recent technical advancements in echocardiography and their use in the follow-up of TAVI patients. In particular, the focus will be on the examination of the influence of TAVI on left and right ventricular function, which is frequently accompanied by other structural and functional alterations. Echocardiography has proven to be key also in detecting valve deterioration during extended follow-up. This review will provide valuable insights into the technical advancements in echocardiography and their role in the follow-up of TAVI patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
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Ugwu JK, Kandah DR, Ndulue JK, Ebiem OP, Ugwu-Erugo JN, Hamilton R, Osei K, Taskesen T, Shivapour DM, Chawla A, Marcus RH. Comparative Outcomes of TAVR in Mixed Aortic Valve Disease and Aortic Stenosis: A Meta-analysis. Cardiol Ther 2023; 12:143-157. [PMID: 36567395 PMCID: PMC9986165 DOI: 10.1007/s40119-022-00293-3] [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: 10/04/2022] [Accepted: 11/28/2022] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Transcatheter aortic valve replacement (TAVR) has become a suitable alternative to surgical aortic valve replacement (SAVR) for the treatment of symptomatic severe aortic stenosis (AS). A high proportion of patients with AS have mixed aortic valve disease (MAVD) with mild or more concurrent aortic regurgitation (AR). Differential outcomes of TAVR among patients with AS and MAVD have not been well characterized. We compared 1-year mortalities following TAVR among patients with MAVD and AS. METHODS We conducted a meta-analysis of studies published in PubMed/Medline. The primary outcome was 1-year all-cause mortality following TAVR among patients with MAVD vs. AS. Secondary endpoints were: (1) incidence of AR within 30 days following TAVR (post TAVR AR); and (2) 1-year all-cause mortality within each group stratified according to severity of post TAVR AR. RESULTS Nine studies involving 9505 participants were included in the analysis. At 1 year following TAVR, mortality was lower in MAVD than in AS; HR 0.89, 95% CI 0.81-0.98. The mortality advantage increased when pre-TAVR AR was moderate or more; HR 0.84, 95% CI 0.72-0.99. The mortality advantage was attenuated after correction for publication bias. There was a higher risk of post TAVR AR in the MAVD group; OR 1.51, 95% CI 1.20-1.90 but the impact on mortality of moderate vs. mild post TAVR AR was greater among patients with AS than in patients with MAVD HR 1.67 95% CI 0.89-3.14 vs. 0.93 95% CI 0.47-1.85. CONCLUSIONS Patients with MAVD have similar or improved survival 1 year after TAVR compared to those with AS.
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Affiliation(s)
- Justin K Ugwu
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America.
| | - Daniel R Kandah
- Internal Medicine Residency, MercyOne Des Moines Medical Center, Des Moines, IA, United States of America
| | - Jideofor K Ndulue
- Providence Medical Group, Chehalis Family Medicine, Chehalis, WA, United States of America
| | - Okechukwu P Ebiem
- Department of Hospital Medicine, Miami Valley Hospital, Dayton, OH, United States of America
| | | | - Russell Hamilton
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America
| | - Kofi Osei
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America
| | - Tuncay Taskesen
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America
| | - Daniel M Shivapour
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America
| | - Atul Chawla
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America
| | - Richard H Marcus
- Department of Cardiovascular Medicine, MercyOne Des Moines Medical Center, 1111 6Th Ave, Des Moines, IA, 50314, United States of America
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Dahiya G, Kyvernitakis A, Elhamdani A, Begg A, Doyle M, Elsayed M, Bailey S, Raina A, Kanwar M, Biederman RWW, Benza RL. Prognostic role of pulmonary hemodynamics before transcatheter aortic valve replacement among patients with severe aortic stenosis. J Heart Lung Transplant 2023; 42:275-282. [PMID: 36437170 DOI: 10.1016/j.healun.2022.10.001] [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: 03/21/2022] [Revised: 08/17/2022] [Accepted: 10/02/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) frequently co-exists in patients with severe aortic stenosis (AS). In this study, we sought to identify the implications of invasive pulmonary hemodynamics on major adverse cardiac events (MACE), biventricular function and NYHA functional class after transcatheter aortic valve replacement (TAVR). METHODS Invasive hemodynamics via right heart catheterization (RHC) were performed pre-TAVR. Patients were stratified per mean PA pressure (mPAP), diastolic pulmonary gradient (DPG) and pulmonary vascular resistance (PVR), and followed at 1-month and 1-year intervals up to 6 years. MACE outcomes included cardiovascular death and heart failure hospitalizations post-TAVR. RESULTS Among 215 patients, Kaplan-Meir estimates demonstrated an increased 1-year risk of MACE from 8% among those without pre-TAVR PH to 27% among patients with pre-existing PH. Specifically, the MACE risk was 32% among PH patients with PVR ≥ 3WU (p = .04) and 53% among PH patients with DPG ≥ 7 mm Hg (p < .01). On univariate Cox regression, RV stroke work index (RVSWI) (HR,1.02; p = .02), and pulmonary hemodynamic index (PHI) (HR,1.27; p = .047) were identified as additional predictors of MACE post-TAVR. On multivariable Cox regression analysis, SvO2 (HR, 0.95; p = .01) and PVR (HR, 1.2; p = .04) were demonstrated as predictive of MACE post-TAVR. A significant improvement in LVEF (2-Factor ANOVA, p < .01) and RV fractional area change (RVFAC%) (p < .01) was noted as assessed at baseline, 1-month and 1-year follow up post-TAVR. There was a significant interaction between pre-TAVR PH status and time post procedure with respect to NYHA functional class (p = .03), that is, the manner and degree of change in NYHA class over time depended on pre-TAVR PH status. CONCLUSIONS Defining invasive pulmonary hemodynamics, such as mPAP, PVR, and DPG among patients with severe AS undergoing TAVR has significant prognostic implications. Routine risk stratification by utilizing invasive hemodynamics can better identify patients who will have functional improvement and improved outcomes post-TAVR.
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Affiliation(s)
- Garima Dahiya
- Division of Cardiovascular Disease, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Andreas Kyvernitakis
- Division of Cardiovascular Disease, Department of Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Adee Elhamdani
- Department of Internal Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Andrew Begg
- Department of Internal Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Mark Doyle
- Division of Cardiovascular Disease, Department of Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Mahmoud Elsayed
- Division of Cardiovascular Disease, Department of Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Stephen Bailey
- Department of Thoracic and Cardiovascular Surgery, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Amresh Raina
- Division of Cardiovascular Disease, Department of Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Manreet Kanwar
- Division of Cardiovascular Disease, Department of Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Robert W W Biederman
- Division of Cardiovascular Disease, Department of Medicine, Allegheny Health Network Education Consortium, Pittsburgh, Pennsylvania
| | - Raymond L Benza
- Division of Cardiovascular Medicine and Pulmonary Hypertension, Department of Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio.
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Kletzer J, Hecht S, Ramsauer S, Scharinger B, Kaufmann R, Kammler J, Kellermair J, Akbari K, Blessberger H, Steinwender C, Hergan K, Hoppe UC, Lichtenauer M, Boxhammer E. A Story of PA/BSA and Biomarkers to Diagnose Pulmonary Hypertension in Patients with Severe Aortic Valve Stenosis-The Rise of IGF-BP2 and GDF-15. J Cardiovasc Dev Dis 2023; 10:jcdd10010022. [PMID: 36661917 PMCID: PMC9864369 DOI: 10.3390/jcdd10010022] [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: 12/13/2022] [Revised: 12/30/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023] Open
Abstract
(1) Background: Currently, echocardiography is the primary non-invasive diagnostic method used to screen patients with severe aortic valve stenosis (AS) for pulmonary hypertension (PH) by estimating systolic pulmonary artery pressure (sPAP). Other radiological methods have been a focus of research in the past couple of years, as it was shown that by determining the pulmonary artery (PA) diameter, prognostic statements concerning overall mortality could be made in these patients. This study compared established and novel cardiovascular biomarkers with the PA/BSA value to detect PH in patients with severe AS. (2) Methods: The study cohort comprised 188 patients with severe AS undergoing transcatheter aortic valve replacement (TAVR), who were then divided into two groups based on PA/BSA values obtained through CT-angiography. The presence of PH was defined as a PA/BSA ≥ 16.6 mm/m2 (n = 81), and absence as a PA/BSA < 16.6 mm/m2 (n = 107). Blood samples were taken before TAVR to assess cardiovascular biomarkers used in this study, namely brain natriuretic peptide (BNP), cardiac troponin I (cTnI), high-sensitive troponin (hsTN), soluble suppression of tumorigenesis-2 (sST2), growth/differentiation factor 15 (GDF-15), heart-type fatty acid-binding protein (H-FABP), insulin-like growth factor binding protein 2 (IGF-BP2), and soluble urokinase-type plasminogen activator receptor (suPAR). (3) Results: Patients with a PA/BSA ≥ 16.6 mm/m2 showed significantly higher levels of BNP (p = <0.001), GDF-15 (p = 0.040), and H-FABP (p = 0.007). The other investigated cardiovascular biomarkers did not significantly differ between the two groups. To predict a PA/BSA ≥ 16.6 mm/m2, cut-off values for the biomarkers were calculated. Here, GDF-15 (p = 0.029; cut-off 1172.0 pg/mL) and BNP (p < 0.001; cut-off 2194.0 pg/mL) showed significant results. Consequently, analyses of combined biomarkers were performed, which yielded IGF-BP2 + BNP (AUC = 0.721; 95%CI = 0.585−0.857; p = 0.004) as the best result of the two-way analyses and GDF-15 + IGF-BP2 + BNP (AUC = 0.727; 95%CI = 0.590−0.864; p = 0.004) as the best result of the three-way analyses. No significant difference regarding the 1-year survival between patients with PA/BSA < 16.6 mm/m2 and patients with PA/BSA ≥ 16.6 mm/m2 was found (log-rank test: p = 0.452). (4) Conclusions: Although PA/BSA aims to reduce the bias of the PA value caused by different body compositions and sizes, it is still a controversial parameter for diagnosing PH. Combining the parameter with different cardiovascular biomarkers did not lead to a significant increase in the diagnostic precision for detecting PH in patients with severe AS.
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Affiliation(s)
- Joseph Kletzer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Stefan Hecht
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Susanne Ramsauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Bernhard Scharinger
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Reinhard Kaufmann
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Jürgen Kammler
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Jörg Kellermair
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Kaveh Akbari
- Department of Radiology, Johannes Kepler University Hospital Linz, 4020 Linz, Austria
| | - Hermann Blessberger
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Clemens Steinwender
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Klaus Hergan
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
- Correspondence:
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Bäz L, Möbius-Winkler S, Diab M, Kräplin T, Westphal JG, Ibrahim K, Schulze PC, Franz M. Prognostic relevance of mitral and tricuspid regurgitation after transcatheter aortic valve implantation: Impact of follow-up time point for decision-making. Front Cardiovasc Med 2023; 10:990373. [PMID: 36873389 PMCID: PMC9977804 DOI: 10.3389/fcvm.2023.990373] [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: 07/09/2022] [Accepted: 01/24/2023] [Indexed: 02/18/2023] Open
Abstract
Background In patients with aortic stenosis treated by transcatheter aortic valve implantation (TAVI), mitral and tricuspid regurgitation (MR and TR) at baseline and after TAVI are likely to be of prognostic relevance, and questions such as whether and when treatment further improves prognosis in these patients arise. Aims Against that background, the purpose of this study was to analyze a variety of clinical characteristics including MR and TR with respect to their potential value as predictors of 2-year mortality after TAVI. Methods A cohort of 445 typical TAVI patients was available for the study and clinical characteristics were evaluated baseline, 6 to 8 weeks as well as 6 months after TAVI. Results In 39% of the patients relevant (moderate or severe) MR and in 32% of the patients relevant (moderate or severe) TR could be detected at baseline. The rates were 27% for MR (p = 0.001, compared to baseline) and 35% for TR (p = n.s., compared to baseline) at the 6- to 8-week follow-up. After 6 months, relevant MR was observable in 28% (p = 0.036, compared to baseline) and relevant TR in 34% (p = n.s., compared to baseline) of the patients. As predictors of 2-year mortality, a multivariate analysis identified the following parameters for the different time points: sex, age, AS entity, atrial fibrillation, renal function, relevant TR, systolic pulmonary artery pressure (PAPsys), and 6-min walk distance at baseline; clinical frailty scale and PAPsys 6-8 weeks after TAVI and BNP and relevant MR 6 months after TAVI. There was a significantly worse 2-year survival in patients with relevant TR at baseline (68.4% vs. 82.6%, p < 0.001; whole population, n = 445) and in patients with relevant MR at 6 months (87.9% vs. 95.2%, p = 0.042; landmark analysis: n = 235). Conclusion This real-life study demonstrated the prognostic relevance of repeated evaluation of MR and TR before and after TAVI. Choosing the right time point for treatment is a remaining clinical challenge, which should be further addressed in randomized trials.
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Affiliation(s)
- Laura Bäz
- Department of Internal Medicine I, University Hospital Jena, Jena, Germany.,Research Program "Else Kröner-Forschungskolleg AntiAge", Jena University Hospital, Jena, Germany
| | | | - Mahmoud Diab
- Department of Cardiothoracic Surgery, University Hospital Jena, Jena, Germany
| | | | - Julian G Westphal
- Department of Internal Medicine I, University Hospital Jena, Jena, Germany
| | - Karim Ibrahim
- Department of Internal Medicine I, Klinikum Chemnitz, Chemnitz, Germany
| | | | - Marcus Franz
- Department of Internal Medicine I, University Hospital Jena, Jena, Germany
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21
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Muacevic A, Adler JR, Jamil A, Csendes D, Gutlapalli SD, Prakash K, Swarnakari KM, Bai M, Manoharan MP, Raja R, Khan S. Outcomes of Preprocedural Pulmonary Hypertension on All-Cause and Cardiac Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation: A Systematic Review. Cureus 2023; 15:e34300. [PMID: 36860229 PMCID: PMC9969809 DOI: 10.7759/cureus.34300] [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: 11/27/2022] [Accepted: 01/27/2023] [Indexed: 01/30/2023] Open
Abstract
Patients with symptomatic aortic stenosis (AS) commonly have an associated finding of pulmonary hypertension (PH), and it has been previously shown to have increased morbidity and mortality following surgical aortic valve repair (SAVR) as well as transcatheter aortic valve implantation (TAVI). There are no guidelines stating the cut-off point for PH at which the patient can safely undergo TAVI with benefits outweighing the risks. This is partly due to the lack of uniformity in the PH definition used in various studies. This systematic review sought to study the effect of preprocedural pulmonary hypertension on early and late all-cause and cardiac mortality in patients undergoing TAVI. We performed a systematic review of studies comparing patients with AS undergoing TAVI having PH. The review was undertaken as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were identified from PubMed, Pubmed Central (PMC), Cochrane, and Medline on January 10, 2022, for literature published until January 10, 2022. MeSH strategy was used on PubMed to search the literature, and filters were applied to search only Observational Studies, randomized controlled trials (RCT), and meta-analysis. A total of 170 unique articles were identified and screened. Of the 33 full-text articles that were reviewed, 18 articles, including duplicates, were excluded. Fifteen articles fulfilled the selection criteria and were included in this review. The study design included two meta-analyses, one randomized control trial, one prospective cohort study, and 11 retrospective cohort studies. The studies involved a total of approximately 30,000 patients. The observational studies in our review were of good to fair quality, the RCT had a low to moderate bias, and the meta-analysis was of moderate quality. Baseline PH and persistence of PH post-TAVI are strongly associated with all-cause and cardiac mortality. Few studies have shown that a decrease in post-TAVI PH carries mortality benefits. Therefore, efforts should be made to identify mechanisms of persistent PH post-TAVI and whether interventions to reduce PH pre-TAVI will have any clinical implications or not by conducting RCT.
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22
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Miyamoto J, Ohno Y, Kamioka N, Ikari Y, Otsuka T, Tada N, Naganuma T, Yamawaki M, Yamanaka F, Shirai S, Mizutani K, Tabata M, Ueno H, Takagi K, Watanabe Y, Yamamoto M, Hayashida K. Impact of Periprocedural Pulmonary Hypertension on Outcomes After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2022; 80:1601-1613. [DOI: 10.1016/j.jacc.2022.08.757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/02/2022] [Accepted: 08/10/2022] [Indexed: 11/05/2022]
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23
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Généreux P. Pulmonary Hypertension and Aortic Stenosis. J Am Coll Cardiol 2022; 80:1614-1616. [DOI: 10.1016/j.jacc.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 01/07/2023]
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24
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Boxhammer E, Scharinger B, Kaufmann R, Brandtner H, Schmidbauer L, Kammler J, Kellermair J, Reiter C, Akbari K, Hammerer M, Blessberger H, Steinwender C, Hergan K, Hoppe UC, Lichtenauer M, Hecht S. Comparability between Computed Tomography Morphological Vascular Parameters and Echocardiography for the Assessment of Pulmonary Hypertension in Patients with Severe Aortic Valve Stenosis-Results of a Multi-Center Study. Diagnostics (Basel) 2022; 12:diagnostics12102363. [PMID: 36292052 PMCID: PMC9600691 DOI: 10.3390/diagnostics12102363] [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: 09/15/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Computed tomography (CT) of the aorta and cardiac vessels, which is performed in patients with severe aortic valve stenosis (AS) before transcatheter aortic valve replacement (TAVR), offers the possibility of non-invasive detection of pulmonary hypertension (PH), for example, by determining the diameter of the main pulmonary artery (PA), the right pulmonary artery (RPA) or the left pulmonary artery (LPA). An improvement of the significance of these radiological parameters is often achieved by indexing to the body surface area (BSA). The aim of this study was to compare different echocardiographic systolic pulmonary artery pressure (sPAP) values with radiological data in order to define potential clinical cut-off values for the presence or absence of PH. Methods: A total of 138 patients with severe AS undergoing TAVR underwent pre-interventional transthoracic echocardiography with determination of sPAP values and performance of CT angiography (CTA) of the aorta and femoral arteries. Radiologically, the PA, RPA, LPA, and ascending aorta (AA) diameters were obtained. Vascular diameters were not only indexed to BSA but also ratios were created with AA diameter (for example PA/AA-ratio). From these CT-derived vascular parameters, AUROC curves were obtained regarding the prediction of different sPAP values (sPAP 40−45−50 mmHg) and finally correlation analyses were calculated. Results: The best AUROC and correlation analyses were generally obtained at an sPAP ≥ 40 mmHg. When considering diameters alone, the PA diameter was superior to the RPA and LPA. Indexing to BSA generally increased the diagnostic quality of the parameters, and finally, in a synopsis of all results, PA/BSA had the best AUC 0.741 (95% CI 0.646−0. 836; p < 0.001; YI 0.39; sensitivity 0.87; specificity 0.52) and Spearman’s correlation coefficient (r = 0.408; p < 0.001) at an sPAP of ≥40 mmHg. Conclusions: Features related to pulmonary hypertension are fast and easily measurable on pre-TAVR CT and offer great potential regarding non-invasive detection of pulmonary hypertension in patients with severe AS and can support the echocardiographic diagnosis. In this study, the diameter of the main pulmonary artery with the additionally determined ratios were superior to the values of the right and left pulmonary artery. Additional indexing to body surface area and thus further individualization of the parameters with respect to height and weight can further improve the diagnostic quality.
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Affiliation(s)
- Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
- Correspondence: (E.B.); (S.H.)
| | - Bernhard Scharinger
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Reinhard Kaufmann
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Herwig Brandtner
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Lukas Schmidbauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Jürgen Kammler
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Jörg Kellermair
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Christian Reiter
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Kaveh Akbari
- Department of Radiology, Johannes Kepler University Hospital Linz, 4020 Linz, Austria
| | - Matthias Hammerer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Hermann Blessberger
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Clemens Steinwender
- Department of Cardiology, Kepler University Hospital, Medical Faculty of the Johannes Kepler University Linz, 4020 Linz, Austria
| | - Klaus Hergan
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Müllner Hauptstraße 48, 5020 Salzburg, Austria
| | - Stefan Hecht
- Department of Radiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
- Correspondence: (E.B.); (S.H.)
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25
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Iliuta L, Rac-Albu M, Rac-Albu ME, Andronesi A. Impact of Pulmonary Hypertension on Mortality after Surgery for Aortic Stenosis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1231. [PMID: 36143909 PMCID: PMC9502966 DOI: 10.3390/medicina58091231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 11/23/2022]
Abstract
Background and Objectives: The prognosis of patients with aortic stenosis (AS) adding pulmonary hypertension (PHT) is worse than in those with normal pulmonary artery pressure (PAP), and there are few results reported for the association between PHT and adverse outcomes of AS. We aimed to determine the predictive factors for the development of PHT in patients with surgical AS and to identify those factors that may predict the surgical prognosis. We aimed to identify the independent predictors for PHT regression at 2 years after surgery. Additionally, we tried to evaluate the involvement of PHT as an additional perioperative risk factor in patients with AS undergoing surgical aortic valve replacement (AVR). Materials and Methods: We carried out a two-year prospective study on 340 patients with AS undergoing surgical AVR. Results: The independent predictors for the occurrence of PHT in patients with surgical AS were: age > 75 years (RR = 6, p = 0.001), a restrictive left ventricle diastolic filling pattern (LVDFP) (RR = 9, p = 0.001) and associated moderate mitral regurgitation (MR) (RR = 9, p = 0.0001). The presence of severe PHT increased by 7.6 times the early postoperative risk of death, regardless of the presence of other parameters. The independent predictors for early postoperative mortality were: severe PHT, restrictive left ventricle diastolic pattern, age > 75 years, interventricular septum (IVS) thickness >18 mm and the presence of comorbidities. Conclusions: The presence of a severe PHT in patients with AS undergoing surgical AVR is associated with an early postoperative increased mortality rate. The mean PAP is a more reliable parameter for prognosis appreciation than the LV systolic function.
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Affiliation(s)
- Luminita Iliuta
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Cardioclass Clinic for Cardiovascular Disease, 031125 Bucharest, Romania
| | - Marius Rac-Albu
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Cardioclass Clinic for Cardiovascular Disease, 031125 Bucharest, Romania
| | - Madalina-Elena Rac-Albu
- Department of Medical Informatics and Biostatistics, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Andreea Andronesi
- Nephrology Department, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Nephrology Department, Fundeni Clinical Institute, 022328 Bucharest, Romania
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26
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The Evolution of Pulmonary Hypertension and Its Prognostic Implications Post-TAVI-Single Center Experience. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091182. [PMID: 36143859 PMCID: PMC9501961 DOI: 10.3390/medicina58091182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Since the first transcatheter aortic valve implantation (TAVI) procedure was performed in 2002, advances in technology and refinement of the method have led to its widespread use in patients with severe aortic stenosis (AS) and high surgical risk. We aim to identify the impact of TAVI on the clinical and functional status of patients with severe AS at the one-month follow-up and to identify potential predictors associated with the evolution of pulmonary hypertension (PH) in this category of patients. Materials and Methods: We conducted a prospective study which included 86 patients diagnosed with severe AS undergoing TAVI treatment. We analyzed demographics, clinical and echocardiographic parameters associated with AS and PH both at enrolment and at the 30-day follow-up. Results: In our study, the decrease of EUROSCORE II score (p < 0.001), improvement of angina (p < 0.001) and fatigue (p < 0.001) as clinical benefits as well as a reduction in NYHA functional class in patients with heart failure (p < 0.001) are prognostic predictors with statistical value. Regression of left ventricular hypertrophy (p = 0.001), increase in the left ventricle ejection fraction (p = 0.007) and improvement of diastolic dysfunction (p < 0.001) are echocardiographic parameters with a prognostic role in patients with severe AS undergoing TAVI. The pulmonary artery acceleration time (PAAT) (p < 0.001), tricuspid annular plane systolic excursion (TAPSE) (p = 0.020), pulmonary arterial systolic pressure (PASP) (p < 0.001) and the TAPSE/PASP ratio (p < 0.001) are statistically significant echocardiographic parameters in our study that assess both PH and its associated prognosis in patients undergoing TAVI. Conclusions: PAAT, TAPSE, PASP and the TAPSE/PASP ratio are independent predictors that allow the assessment of PH and its prognostic implications post-TAVI.
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Adamopoulos D, Pagoulatou S, Rovas G, Bikia V, Müller H, Giannakopoulos G, Mauler-Wittwer S, Licker MJ, Stergiopulos N, Lador F, Noble S. Prognostic Implications of the Novel Pulmonary Hypertension Definition in Patients with Aortic Stenosis after Transcatheter Valve Replacement. J Clin Med 2022; 11:jcm11154279. [PMID: 35893367 PMCID: PMC9332728 DOI: 10.3390/jcm11154279] [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: 05/16/2022] [Revised: 07/08/2022] [Accepted: 07/15/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction: Pulmonary hypertension (PH), traditionally defined as a mean pulmonary artery pressure (PAP) ≥ 25 mmHg, is associated with poor outcomes in patients undergoing a transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS). Recently, a novel definition for PH has been proposed, placing the cut-off value of mean PAP at 20 mmHg, and introducing pulmonary vascular resistance as an exclusive indicator for the pre-capillary involvement. In light of the novel criteria, whether PH still preserves its prognostic significance remains unknown. Methods: The study population consisted of 380 patients with AS, who underwent a right heart catheterization before TAVR. The cohort was divided according to the presence of PH (n = 174, 45.7%) or not. Patients with PH were further divided into the following groups: (1) Pre-capillary PH ((Pre-capPH), n = 46, 12.1%); (2) Isolated post-capillary PH ((IpcPH), n = 78, 20.5%); (3) Combined pre and post-capillary PH ((CpcPH), n = 82, 21.6%). The primary endpoint was all-cause mortality at 1 year. Results: A total of 246 patients (64.7%) exhibited mean PAP > 20 mmHg. Overall, the presence of PH was associated with higher 1-year mortality rates (hazard ratio (HR) 2.8, 95% CI: 1.4−5.8, p = 0.004). Compared to patients with no PH, Pre-capPH and CpcPH (but not IpcPH) were related to higher 1-year mortality (HR 2.7, 95% CI: 1.0−7.2, p = 0.041 and HR 3.9, 95% CI: 1.8−8.5, p = 0.001, respectively). This remained significant even after the adjustment for baseline comorbidities. Conclusions: Pre-interventional PH according to the novel hemodynamic criteria, is linked with poor outcomes in patients undergoing TAVR for severe AS. However, this is mainly driven by patients with mean PAP ≥ 25 mmHg. Patients with a pre-capillary PH component as defined by increased PVR present an even worse prognosis as compared to patients with isolated post-capillary or no PH who present comparable 1-year mortality rates.
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Affiliation(s)
- Dionysios Adamopoulos
- Faculty of Medicine, Department of Medicine, Geneva University, 1206 Geneva, Switzerland; (M.-J.L.); (F.L.); (S.N.)
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
- Correspondence:
| | - Stamatia Pagoulatou
- Laboratory of Hemodynamics and Cardiovascular Technology, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; (S.P.); (G.R.); (V.B.); (N.S.)
| | - Georgios Rovas
- Laboratory of Hemodynamics and Cardiovascular Technology, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; (S.P.); (G.R.); (V.B.); (N.S.)
| | - Vasiliki Bikia
- Laboratory of Hemodynamics and Cardiovascular Technology, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; (S.P.); (G.R.); (V.B.); (N.S.)
| | - Hajo Müller
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
| | - Georgios Giannakopoulos
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
| | - Sarah Mauler-Wittwer
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
| | - Marc-Joseph Licker
- Faculty of Medicine, Department of Medicine, Geneva University, 1206 Geneva, Switzerland; (M.-J.L.); (F.L.); (S.N.)
- Department of Acute Medicine, Division of Anaesthesiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
| | - Nikolaos Stergiopulos
- Laboratory of Hemodynamics and Cardiovascular Technology, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; (S.P.); (G.R.); (V.B.); (N.S.)
| | - Frédéric Lador
- Faculty of Medicine, Department of Medicine, Geneva University, 1206 Geneva, Switzerland; (M.-J.L.); (F.L.); (S.N.)
- Department of Internal Medicine, Division of Pneumology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
- Pulmonary Hypertension Program, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
| | - Stéphane Noble
- Faculty of Medicine, Department of Medicine, Geneva University, 1206 Geneva, Switzerland; (M.-J.L.); (F.L.); (S.N.)
- Department of Internal Medicine, Division of Cardiology, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland; (H.M.); (G.G.); (S.M.-W.)
- Pulmonary Hypertension Program, Hôpitaux Universitaires de Genève (HUG), 1205 Geneva, Switzerland
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Alman K, Sadd CJ, Ravel A, Raza F, Chybowski A, Runo JR. Prevalence of Aortic Stenosis and TAVR outcomes in Patients with Systemic Sclerosis associated Pulmonary Hypertension. Pulm Circ 2022; 12:e12118. [PMID: 36034401 PMCID: PMC9400580 DOI: 10.1002/pul2.12118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 05/15/2022] [Accepted: 07/07/2022] [Indexed: 11/20/2022] Open
Abstract
There is little known about performing transcatheter aortic valve replacement (TAVR) in patients with group 1 pulmonary arterial hypertension (PAH) on advanced pulmonary vasodilator therapy. Retrospective cohort study among 90 patients with systemic sclerosis‐associated pulmonary arterial hypertension and systemic sclerosis‐associated pulmonary hypertension (SSc‐PAH/PH) evaluated at a tertiary PH center. The SSc‐PAH/PH cohort was stratified by the presence or absence of aortic stenosis (AS) to identify differences in baseline characteristics, hemodynamics, and long‐term outcomes. Of the 90 SSc‐PAH/PH patients, 13 patients were diagnosed with AS at PH diagnosis and another 6 patients developed AS during the study period. The period prevalence of AS was 21.1% (19/90, 95% confidence interval: 13.2%–30.1%) of which 94.7% was mild (18/19) at diagnosis with mean age at AS diagnosis of 66.3 + 2.2 years. Among AS patients, 31.6% (6/19) progressed to severe AS, five of which underwent TAVR (median age: 70 years) while on advanced PAH therapy. One of the five TAVR patients developed worsening pulmonary hypertension post‐TAVR. The 5‐year survival rate for all AS patients from diagnosis date was 37.2%. There was a high prevalence of AS in this cohort of SSc‐PAH/PH patients, with mean age of onset younger than patients with nonbicuspid aortic valve stenosis. This is the largest series of SSc‐PAH/PH patients on advanced pulmonary vasodilator therapy who underwent TAVR with acceptable early outcomes.
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Affiliation(s)
- Kirsten Alman
- Department of Medicine, School of Medicine and Public Health University of Wisconsin‐Madison Madison WI USA
| | - Corey J Sadd
- Department of Medicine, School of Medicine and Public Health University of Wisconsin‐Madison Madison WI USA
| | - Amish Ravel
- Department of Cardiology, School of Medicine and Public Health University of Wisconsin‐Madison Madison WI USA
| | - Farhan Raza
- Department of Cardiology, School of Medicine and Public Health University of Wisconsin‐Madison Madison WI USA
| | - Amy Chybowski
- Department of Pulmonary and Critical Care Medicine, School of Medicine and Public Health University of Wisconsin‐Madison Madison WI USA
| | - James R Runo
- Department of Pulmonary and Critical Care Medicine, School of Medicine and Public Health University of Wisconsin‐Madison Madison WI USA
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Sudo M, Shamekhi J, Sedaghat A, Aksoy A, Zietzer A, Tanaka T, Wilde N, Weber M, Sinning JM, Grube E, Veulemans V, Adam M, Kelm M, Baldus S, Nickenig G, Zimmer S, Tiyerili V, Al-Kassou B. Predictive value of the Fibrosis-4 index in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. Clin Res Cardiol 2022; 111:1367-1376. [DOI: 10.1007/s00392-022-02055-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022]
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30
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Boxhammer E, Berezin AE, Paar V, Bacher N, Topf A, Pavlov S, Hoppe UC, Lichtenauer M. Severe Aortic Valve Stenosis and Pulmonary Hypertension: A Systematic Review of Non-Invasive Ways of Risk Stratification, Especially in Patients Undergoing Transcatheter Aortic Valve Replacement. J Pers Med 2022; 12:jpm12040603. [PMID: 35455719 PMCID: PMC9026430 DOI: 10.3390/jpm12040603] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 02/01/2023] Open
Abstract
Patients with severe aortic valve stenosis and concomitant pulmonary hypertension show a significantly reduced survival prognosis. Right heart catheterization as a preoperative diagnostic tool to determine pulmonary hypertension has been largely abandoned in recent years in favor of echocardiographic criteria. Clinically, determination of echocardiographically estimated systolic pulmonary artery pressure falls far short of invasive right heart catheterization data in terms of accuracy. The aim of the present systematic review was to highlight noninvasive possibilities for the detection of pulmonary hypertension in patients with severe aortic valve stenosis, with a special focus on cardiovascular biomarkers. A total of 525 publications regarding echocardiography, cardiovascular imaging and biomarkers related to severe aortic valve stenosis and pulmonary hypertension were analyzed in a systematic database analysis using PubMed Central®. Finally, 39 publications were included in the following review. It was shown that the current scientific data situation, especially regarding cardiovascular biomarkers as non-invasive diagnostic tools for the determination of pulmonary hypertension in severe aortic valve stenosis patients, is poor. Thus, there is a great scientific potential to combine different biomarkers (biomarker scores) in a non-invasive way to determine the presence or absence of PH.
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Affiliation(s)
- Elke Boxhammer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Alexander E. Berezin
- Internal Medicine Department, State Medical University of Zaporozhye, 69035 Zaporozhye, Ukraine;
| | - Vera Paar
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Nina Bacher
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Albert Topf
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Sergii Pavlov
- Department of Clinical Laboratory Diagnostics, State Medical University of Zaporozhye, 69035 Zaporozhye, Ukraine;
| | - Uta C. Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria; (E.B.); (V.P.); (N.B.); (A.T.); (U.C.H.)
- Correspondence:
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31
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Patel KP, Treibel TA, Scully PR, Fertleman M, Searle S, Davis D, Moon JC, Mullen MJ. Futility in Transcatheter Aortic Valve Implantation: A Search for Clarity. Interv Cardiol 2022; 17:e01. [PMID: 35111240 PMCID: PMC8790725 DOI: 10.15420/icr.2021.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/05/2021] [Indexed: 12/12/2022] Open
Abstract
Although transcatheter aortic valve implantation (TAVI) has revolutionised the landscape of treatment for aortic stenosis, there exists a cohort of patients where TAVI is deemed futile. Among the pivotal high-risk trials, one-third to half of patients either died or received no symptomatic benefit from the procedure at 1 year. Futility of TAVI results in the unnecessary exposure of risk for patients and inefficient resource utilisation for healthcare services. Several cardiac and extra-cardiac conditions and frailty increase the risk of mortality despite TAVI. Among the survivors, these comorbidities can inhibit improvements in symptoms and quality of life. However, certain conditions are reversible with TAVI (e.g. functional mitral regurgitation), attenuating the risk and improving outcomes. Quantification of disease severity, identification of reversible factors and a systematic evaluation of frailty can substantially improve risk stratification and outcomes. This review examines the contribution of pre-existing comorbidities towards futility in TAVI and suggests a systematic approach to guide patient evaluation.
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Affiliation(s)
- Kush P Patel
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
| | - Thomas A Treibel
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
| | - Paul R Scully
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
| | - Michael Fertleman
- Cutrale Perioperative and Ageing Group, Department of Bioengineering, Imperial College London London, UK
| | - Samuel Searle
- MRC Unit for Lifelong Health and Ageing, University College London London, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, University College London London, UK
| | - James C Moon
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
| | - Michael J Mullen
- Institute of Cardiovascular Sciences, University College London London, UK.,Barts Heart Centre, St Bartholomew's Hospital London, UK
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Sudo M, Sugiura A, Treiling L, Al-Kassou B, Shamekhi J, Kütting D, Wilde N, Weber M, Zimmer S, Nickenig G, Sedaghat A. Baseline PA/BSA ratio in patients undergoing transcatheter aortic valve replacement - A novel CT-based marker for the prediction of pulmonary hypertension and outcome. Int J Cardiol 2021; 348:26-32. [PMID: 34923001 DOI: 10.1016/j.ijcard.2021.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/16/2021] [Accepted: 12/13/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pulmonary hypertension (pH) has a prognostic impact on patients undergoing transcatheter aortic valve replacement (TAVR). Pulmonary artery (PA) dilatation assessed by multidetector computed tomography (MDCT) has the potential to predict PH. The aim of the study was to evaluate the clinical parameters associated with PA dilatation and to investigate its prognostic relevance in patients undergoing TAVR. METHODS In 770 patients undergoing TAVR between February 2016 and July 2019, PA diameter was measured by MDCT before TAVR. Additionally, PA diameter divided by ascending aorta diameter or body surface area (BSA) was calculated. RESULTS Of all the CT-derived parameters compared with a receiver operating characteristic curve, the value for PA/BSA with a median of 1.68 (IQR 1.47, 1.91) cm/m2 showed the greatest area-under-the-curve (0.75) for predicting PH at baseline. Based on this median, patients were assigned to a small PA/BSA (n = 386) or a large PA/BSA (n = 384) group. Hereby, a large PA/BSA was independently associated with PH at baseline (OR:8.39 [5.36-13.14], p < 0.001) and after TAVR (OR:1.73 [1.18-2.53], p = 0.005). A large PA/BSA was associated with a significantly higher cumulative two-year all-cause mortality compared to small PA/BSA (30.0% vs. 13.7%, p < 0.001), which was supported in the multivariable model (HR:1.87; 95%CI, 1.12-3.04; p = 0.017). CONCLUSION Patients with a large PA/BSA on MDCT are more likely to have PH at baseline and after TAVR. Large PA/BSA is associated with an increased risk of mortality and could provide additional information for risk stratification in patients undergoing TAVR.
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Affiliation(s)
- Mitsumasa Sudo
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany; Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Atsushi Sugiura
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Louisa Treiling
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Baravan Al-Kassou
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Jasmin Shamekhi
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Daniel Kütting
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Nihal Wilde
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Alexander Sedaghat
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Bonn, Germany.
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Impact of Pulmonary Artery Dilatation on Clinical Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2021; 14:2560-2569. [PMID: 34774478 DOI: 10.1016/j.jcin.2021.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/04/2021] [Accepted: 08/10/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the clinical impact of computed tomography (CT)-derived pulmonary artery dilatation (PAD) in patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND Several studies have reported an association between pulmonary hypertension and cardiovascular events, but the prognostic value of PAD in patients undergoing TAVR remains unclear. METHODS The preprocedural computed tomographic studies of patients who underwent TAVR at Cedars-Sinai Medical Center between November 2013 and December 2017 were analyzed. Patients were divided into 2 groups according to the presence of PAD assessed on CT (pulmonary artery [PA] diameter ≥29 mm). The primary endpoint was all-cause mortality at 2 years. RESULTS A total of 895 patients were included (mean age 81.3 ± 8.5 years), with a mean Society of Thoracic Surgeons score of 4.8%. The median PA diameter was 28.0 mm, and PAD was observed in 369 patients (41.2%). Compared with the no-PAD group, the PAD group had higher Society of Thoracic Surgeons scores and higher rates of atrial fibrillation, chronic kidney disease, and chronic obstructive pulmonary disease. The PAD group had higher 2-year all-cause mortality than the no-PAD group (28.9% vs 12.8%; P < 0.001), and PAD was independently associated with mortality (adjusted HR: 2.21; 95% CI: 1.44-3.39; P < 0.001). Furthermore, PAD had strong prognostic power in the subgroup analysis, stratified according to PA pressure (>36 mm Hg). CONCLUSIONS CT-derived PAD is a significant prognostic factor in patients undergoing TAVR.
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Cignoni CB, Vuu SKM, Liu H, Clark JM, Watson CD, Ferber LR, Richards WT, Ang DN. Increased Mortality in Hip Fracture Patients With Aortic Stenosis and Pulmonary Hypertension Compared to Aortic Stenosis Alone. Am Surg 2021:31348211054525. [PMID: 34841906 DOI: 10.1177/00031348211054525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Hip fractures are one of the most common traumatic injuries in the United States, secondary to an aging population. Multiple comorbidities are found in patients who present to trauma centers (TCs) with isolated hip fractures (IHFs) including significant cardiac disease. Aortic stenosis (AS) among these patients has been recently shown to increase mortality. However, factors leading to death from AS are unknown. We hypothesize that pulmonary hypertension (PH) is a significant mechanism of death among IHF patients with AS. METHODS This is a multicenter retrospective cohort study examining IHF patients treated at Level I and II TCs within a large hospital system from 2015 to 2019. Patients who had IHFs and AS were compared to those who had IHFs, AS, and PH. Multivariable logistic regression was used to risk adjust by age, race, insurance status, and comorbidities. The primary outcome was inpatient mortality. The secondary outcomes were hospital-acquired complications. RESULTS A total of 1388 IHF patients with AS were included in the study. Eleven percent of these patients also had PH. The crude mortality rate was higher if IHF patients had both AS and PH compared to IHF with AS alone (9% vs 3.7%, P-value .003). After risk adjustment, a higher risk of mortality was still significant (aOR 2.56 [95% CI 1.28, 5.11]). In addition, IHF patients with both AS and PH had higher complication rates; the exposure group had higher percentage of pulmonary embolism (1.4% vs .2%, adjusted P-value .03), new-onset congestive heart failure (4.1% vs 1%, adjusted P-value .01), and sepsis/septicemia (3.5% vs 1.4%, adjusted P-value .05). CONCLUSION In patients with IHFs, PH and AS increase the likelihood of inpatient mortality by 2.5 times compared to AS alone. Pulmonary hypertension among IHF patients with AS is an important risk factor to identify in the preoperative period. Early identification may lead to better perioperative management and counseling of patients at higher risk of complications.
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Affiliation(s)
- Christian B Cignoni
- University of Central Florida College of Medicine - General Surgery Residency, Ocala, FL, USA
| | - Steven K M Vuu
- University of Central Florida College of Medicine - General Surgery Residency, Ocala, FL, USA
| | - Huazhi Liu
- University of Central Florida College of Medicine - General Surgery Residency, Ocala, FL, USA
| | - Jason M Clark
- University of Central Florida College of Medicine - General Surgery Residency, Ocala, FL, USA.,Department of Surgery, University of South Florida, Tampa, FL, USA.,Department of Trauma, Ocala Regional Medical Center, Ocala, FL, USA
| | - Carrie D Watson
- University of Central Florida College of Medicine - General Surgery Residency, Ocala, FL, USA.,Department of Surgery, University of South Florida, Tampa, FL, USA.,Department of Trauma, Ocala Regional Medical Center, Ocala, FL, USA
| | - Laurence R Ferber
- University of Central Florida College of Medicine - General Surgery Residency, Ocala, FL, USA.,Department of Surgery, University of South Florida, Tampa, FL, USA.,Department of Trauma, Ocala Regional Medical Center, Ocala, FL, USA
| | - Winston T Richards
- University of Central Florida College of Medicine - General Surgery Residency, Ocala, FL, USA.,Department of Surgery, University of South Florida, Tampa, FL, USA.,Department of Trauma, Ocala Regional Medical Center, Ocala, FL, USA
| | - Darwin N Ang
- University of Central Florida College of Medicine - General Surgery Residency, Ocala, FL, USA.,Department of Surgery, University of South Florida, Tampa, FL, USA.,Department of Trauma, Ocala Regional Medical Center, Ocala, FL, USA
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35
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Right ventricular dysfunction by computed tomography associates with outcomes in severe aortic stenosis patients undergoing transcatheter aortic valve replacement. J Cardiovasc Comput Tomogr 2021; 16:158-165. [PMID: 34794909 DOI: 10.1016/j.jcct.2021.11.005] [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: 09/20/2021] [Revised: 11/03/2021] [Accepted: 11/10/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although cardiac computed tomography angiography (CCTA) assessment of right ventricular dysfunction (RVD) is feasible, the incremental prognostic value remains uncertain in patients undergoing transcatheter aortic valve replacement (TAVR) evaluation. This study sought to determine the incremental clinical utility of RVD identification by CCTA while accounting for clinical and echocardiographic parameters. METHODS Patients who underwent multiphasic ECG-gated functional CCTA using dual-source system for routine TAVR planning were evaluated. Biphasic contrast protocol injection allowed for biventricular contrast enhancement. CCTA-based RVD was defined as right ventricular ejection fraction (RVEF) < 50%. The association of CCTA-RVD with all-cause mortality and the composite outcome of death or heart failure hospitalization after TAVR was evaluated and examined for its incremental utility beyond clinical risk assessment and echocardiographic parameters. RESULTS A total of 502 patients were included (median [IQR] age, 82 [77 to 87] years; 56% men) with a median follow-up of 22 [16 to 32] months. Importantly, 126 (25%) patients were identified as having RVD by CCTA that was not identified by echocardiography. CCTA-defined RVD predicted death and the composite outcome in both univariate analyses (HR for mortality, 2.15; 95% CI, 1.44-3.22; p < 0.001; HR for composite outcome, 2.11; 95% CI, 1.48-3.01; p < 0.001) and in multivariate models that included clinical risk factors and echocardiographic findings (HR for mortality, 1.74; 95% CI, 1.11-2.74; p = 0.02; HR for composite outcome, 1.63; 95% CI, 1.09-2.44; p = 0.02). CONCLUSIONS Functional CCTA assessment pre-TAVR correctly identified 25% of patients with RVD that was not evident on 2D echocardiography. The presence of RVD on CCTA independently associates with clinical outcomes post-TAVR.
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Imamura T, Narang N, Sobajima M, Tanaka S, Ushijima R, Fukuda N, Ueno H, Kinugawa K. Decoupling Between Pulmonary Artery Diastolic and Wedge Pressure Following Transcatheter Aortic Valve Replacement. Circ J 2021; 86:383-390. [PMID: 34602582 DOI: 10.1253/circj.cj-21-0573] [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] [Indexed: 11/09/2022]
Abstract
BACKGROUND Coexistent pulmonary hypertension with severe aortic stenosis confers a greater risk of mortality for patients undergoing transcatheter aortic valve replacement (TAVR). In this patient population, the impact of significant decoupling between pulmonary artery diastolic and pulmonary capillary wedge, as it relates to clinical risk, remained uncertain.Methods and Results:Patients with severe aortic stenosis who underwent TAVR and completed pre-procedural and post-procedural invasive hemodynamic assessments with right heart catheterization were retrospectively assessed. The impact of post-TAVR decoupling, defined as a pressure difference ≥3 mmHg, on 2-year all-cause mortality or risk of heart failure admission was analyzed. Among 77 included patients (median age 86 years, 23 men), 16 had post-TAVR decoupling. The existence of post-TAVR decoupling was associated with a higher cumulative incidence of the primary endpoint (44% vs. 7%, P=0.001), with an adjusted hazard ratio of 5.87 (95% confidence interval 1.58-21.9, P=0.008). CONCLUSIONS A greater risk of worse outcomes in those with post-TAVR decoupling was observed. A therapeutic strategy for post-TAVR decoupling and its clinical implication need to be created and investigated in the future.
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Affiliation(s)
| | - Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center
| | - Mitsuo Sobajima
- Second Department of Internal Medicine, University of Toyama
| | - Shuhei Tanaka
- Second Department of Internal Medicine, University of Toyama
| | | | - Nobuyuki Fukuda
- Second Department of Internal Medicine, University of Toyama
| | - Hiroshi Ueno
- Second Department of Internal Medicine, University of Toyama
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Extent of Cardiac Damage and Mortality in Patients Undergoing Transcatheter Aortic Valve Implantation. J Clin Med 2021; 10:jcm10194563. [PMID: 34640580 PMCID: PMC8509290 DOI: 10.3390/jcm10194563] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 09/23/2021] [Accepted: 09/29/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Aims: We sought to assess the impact of the extent of cardiac damage on survival among real-world patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). (2) Methods: A staging classification was applied to 262 patients from the EffecTAVI Registry at baseline and re-assessed within 30-days after TAVI. The primary endpoint of the study was all-cause mortality at 1-year. Secondary endpoints included cerebrovascular accident, myocardial infarction, permanent pacemaker implantation, endocarditis, and re-hospitalization for all causes. (3) Results: At baseline, 23 (8.7%) patients were in Stage 0/1 (no cardiac damage/left ventricular damage), 106 (40.4%) in Stage 2 (left atrial or mitral valve damage), 59 (22.5%) in Stage 3 (pulmonary vasculature or tricuspid valve damage) and 74 (28.3%) in Stage 4 (right ventricular damage). At 30-days after TAVI, a lower prevalence of advanced stages of cardiac damage than baseline, mainly driven by a significant improvement in left ventricular diastolic parameters and right ventricular function, was reported. At 1-year, a stepwise increase in mortality rates was observed according to staging at baseline: 4.3% in Stage 0/1, 6.6% in Stage 2, 18.6% in Stage 3 and 21.6% in Stage 4 (p = 0.08). No differences were found in secondary endpoints. (4) Conclusions: TAVI has an early beneficial impact on the left ventricular diastolic and right ventricular function. However, the extent of cardiac damage at baseline significantly affects the risk of mortality at 1-year after the procedure.
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Turner VL, Jubran A, Kim JB, Maret E, Moneghetti KJ, Haddad F, Amsallem M, Codari M, Hinostroza V, Mastrodicasa D, Sailer AM, Kobayashi Y, Nishi T, Yeung AC, Watkins AC, Lee AM, Miller DC, Fischbein MP, Fearon WF, Willemink MJ, Fleischmann D. CTA pulmonary artery enlargement in patients with severe aortic stenosis: Prognostic impact after TAVR. J Cardiovasc Comput Tomogr 2021; 15:431-440. [PMID: 33795188 PMCID: PMC10017114 DOI: 10.1016/j.jcct.2021.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/09/2021] [Accepted: 03/13/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Identifying high-risk patients who will not derive substantial survival benefit from TAVR remains challenging. Pulmonary hypertension is a known predictor of poor outcome in patients undergoing TAVR and correlates strongly with pulmonary artery (PA) enlargement on CTA. We sought to evaluate whether PA enlargement, measured on pre-procedural computed tomography angiography (CTA), is associated with 1-year mortality in patients undergoing TAVR. METHODS We retrospectively included 402 patients undergoing TAVR between July 2012 and March 2016. Clinical parameters, including Society of Thoracic Surgeons (STS) score and right ventricular systolic pressure (RVSP) estimated by transthoracic echocardiography were reviewed. PA dimensions were measured on pre-procedural CTAs. Association between PA enlargement and 1-year mortality was analyzed. Kaplan-Meier and Cox proportional hazards regression analyses were performed. RESULTS The median follow-up time was 433 (interquartiles 339-797) days. A total of 56/402 (14%) patients died within 1 year after TAVR. Main PA area (area-MPA) was independently associated with 1-year mortality (hazard ratio per standard deviation equal to 2.04 [95%-confidence interval (CI) 1.48-2.76], p < 0.001). Area under the curve (95%-CI) of the clinical multivariable model including STS-score and RVSP increased slightly from 0.67 (0.59-0.75) to 0.72 (0.72-0.89), p = 0.346 by adding area-MPA. Although the AUC increased, differences were not significant (p = 0.346). Kaplan-Meier analysis showed that mortality was significantly higher in patients with a pre-procedural non-indexed area-MPA of ≥7.40 cm2 compared to patients with a smaller area-MPA (mortality 23% vs. 9%; p < 0.001). CONCLUSIONS Enlargement of MPA on pre-procedural CTA is independently associated with 1-year mortality after TAVR.
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Affiliation(s)
- Valery L Turner
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Ayman Jubran
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Juyong Brian Kim
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Eva Maret
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Department of Clinical Physiology, Karolinska University Hospital, Karolinska Institute, Stockholm.
| | - Kegan J Moneghetti
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Marina Codari
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Virginia Hinostroza
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Domenico Mastrodicasa
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Anna M Sailer
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Takeshi Nishi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Alan C Yeung
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Amelia C Watkins
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - Anson M Lee
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - D Craig Miller
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - Michael P Fischbein
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - William F Fearon
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
| | - Martin J Willemink
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - Dominik Fleischmann
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
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Imamura T, Ueno H, Sobajima M, Kinugawa K, Watanabe Y, Yashima F, Tada N, Naganuma T, Yamawaki M, Yamanaka F, Shirai S, Mizutani K, Tabata M, Takagi K, Yamamoto M, Hayashida K. Risk assessment in patients with left ventricular systolic dysfunction following transcatheter aortic valve replacement. J Card Surg 2021; 36:3673-3678. [PMID: 34254368 DOI: 10.1111/jocs.15822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mortality following transcatheter aortic valve replacement (TAVR) in patients with post-procedural left ventricular systolic dysfunction remains high. We investigated clinical variables associating with worse clinical outcomes following TAVR in patients with systolic dysfunction. METHODS We retrospectively investigated 2588 patients with severe aortic stenosis who received TAVR and were enrolled in the optimized transcatheter valvular intervention (OCEAN-TAVI) multicenter registry (UMIN000020423). The association between the clinical variables following TAVR and 2-year cardiovascular mortality was investigated among those with post-TAVR left ventricular ejection fraction less than 50%. RESULTS A total of 298 patients (median 85 years old, 131 men) were included. The presence of moderate or greater tricuspid regurgitation following TAVR was independently associated with 2-year mortality (adjusted hazard ratio 3.41, 95% confidence interval 1.15-10.1), and significantly discriminated 2-year cardiovascular mortality (30% vs. 12%, p = 0.001). No patients with any improvement in tricuspid regurgitation had cardiovascular death. CONCLUSION Following TAVR, the existence of significant tricuspid regurgitation was associated with cardiovascular mortality in patients with heart failure with reduced ejection fraction.
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Affiliation(s)
- Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Hiroshi Ueno
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Mitsuo Sobajima
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Fumiaki Yashima
- Department of Cardiology, Saiseikai Utsunomiya Hospital, Tochigi, Japan.,Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Norio Tada
- Department of Cardiology, Sendai Kosei Hospital, Sendai, Japan
| | - Toru Naganuma
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | - Masahiro Yamawaki
- Department of Cardiology, Saiseikai Yokohama City Eastern Hospital, Yokohama, Japan
| | - Futoshi Yamanaka
- Department of Cardiology, Shonan Kamakura General Hospital, Kanagawa, Japan.,Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shinichi Shirai
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | | | - Minoru Tabata
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu-Ichikawa Medical Center, Chiba, Japan
| | - Kensuke Takagi
- Department of Cardiology, Ogaki Municipal Hospital, Gifu, Japan
| | | | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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Panagides V, Alperi A, Mesnier J, Philippon F, Bernier M, Rodes-Cabau J. Heart failure following transcatheter aortic valve replacement. Expert Rev Cardiovasc Ther 2021; 19:695-709. [PMID: 34227916 DOI: 10.1080/14779072.2021.1949987] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Over the past decade, the number of transcatheter aortic valve replacement (TAVR) procedures has increased exponentially. Despite major improvements in both device and successes, the rate of hospital readmission after TAVR remains high, with heart failure (HF) decompensation being one of the most important causes.Areas covered: This review provides an overview of the current status of HF following TAVR, including details about its incidence, clinical impact, contributing factors, and current and future treatment perspectives.Expert opinion: HF decompensation has been identified as the most common cause of rehospitalization following TAVR, and it has been associated with a negative prognosis. Multiple preexisting factors including low flow status, cardiac amyloidosis, myocardial fibrosis, multivalvular disease, pulmonary hypertension, coronary artery disease, and atrial fibrillation have been associated with an increased risk of HF events. Also, multiple post-procedural factors like the occurrence of significant paravalvular leaks, severe prosthesis-patient mismatch, and conduction disturbances have also contributed to increase this risk . Thus, reducing HF events in TAVR recipients would require a multifactorial and multidisciplinary effort including the optimization of the medical treatment and close follow-up and treatment of residual or concomitant valvular disease and conduction disturbance issues. Future studies in this challenging group of patients are warranted.
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Affiliation(s)
- Vassili Panagides
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Alberto Alperi
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Jules Mesnier
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Francois Philippon
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Mathieu Bernier
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodes-Cabau
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
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Amanullah MR, Pio SM, Ng ACT, Sin KYK, Marsan NA, Ding ZP, Leon MB, Généreux P, Delgado V, Ewe SH, Bax JJ. Prognostic Implications of Associated Cardiac Abnormalities Detected on Echocardiography in Patients With Moderate Aortic Stenosis. JACC Cardiovasc Imaging 2021; 14:1724-1737. [PMID: 34023268 DOI: 10.1016/j.jcmg.2021.04.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/03/2021] [Accepted: 04/01/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES This study aimed to evaluate the prevalence and prognostic value of the extent of extra-aortic valvular cardiac abnormalities in a large multicenter registry of patients with moderate AS. BACKGROUND The prognostic significance of a new classification system that incorporates the extent of cardiac injury (beyond the aortic valve) has been proposed in patients with severe aortic stenosis (AS). Whether this can be applied to patients with moderate AS is unclear. METHODS Based on the echocardiographic findings at the time of diagnosis of moderate AS (aortic valve area between 1.0 and 1.5 cm2 and dimensionless velocity index ratio of ≥0.25), a total of 1,245 patients were included and analyzed retrospectively. They were recategorized into 5 groups according to the extent of extra-aortic valvular cardiac abnormalities: none (Group 0), involving the left ventricle (Group 1), the left atrial or mitral valve (Group 2), the pulmonary artery vasculature or tricuspid valve (Group 3), or the right ventricle (Group 4). Patients were followed for all-cause mortality and combined endpoint (all-cause mortality, stroke, heart failure, or myocardial infarction). RESULTS The distribution of patients according to the proposed classification was 13.1%, 26.8%, 42.6%, 10.6%, and 6.9% in Groups 0, 1, 2, 3, and 4, respectively. During a median follow-up of 4.3 (2.4 to 6.9) years, 564 (45.3%) patients died. There was a significant higher mortality rates with increasing extent of extra-aortic valvular cardiac abnormalities (log-rank p < 0.001). On multivariate analysis, the presence of extra-aortic valvular cardiac abnormalities remained independently associated with all-cause mortality and combined outcome, adjusted for aortic valve replacement as a time-dependent covariable. In particular, Group 2 and above were independently associated with all-cause mortality. CONCLUSIONS In patients with moderate AS, the presence of extra-aortic valvular cardiac abnormalities is associated with poor outcome.
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Affiliation(s)
| | | | - Arnold C T Ng
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Australia
| | - Kenny Y K Sin
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Zee Pin Ding
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Martin B Leon
- Department of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - See Hooi Ewe
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands.
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Abstract
Aortic stenosis is the most common valvular disease requiring valve replacement. Valve replacement therapies have undergone progressive evolution since the 1960s. Over the last 20 years, transcatheter aortic valve replacement has radically transformed the care of aortic stenosis, such that it is now the treatment of choice for many, particularly elderly, patients. This review provides an overview of the pathophysiology, presentation, diagnosis, indications for intervention, and current therapeutic options for aortic stenosis.
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Affiliation(s)
- Marko T Boskovski
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Thomas G Gleason
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
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Weber J, Bond K, Flanagan J, Passick M, Petillo F, Pollack S, Robinson N, Petrossian G, Cao JJ, Barasch E. The Prognostic Value of Left Atrial Global Longitudinal Strain and Left Atrial Phasic Volumes in Patients Undergoing Transcatheter Valve Implantation for Severe Aortic Stenosis. Cardiology 2021; 146:489-500. [PMID: 33752215 DOI: 10.1159/000514665] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/24/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The changes and the prognostic implications of left atrial (LA) volumes (LAV), LA function, and vascular load in patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) are less known. METHODS We enrolled 150 symptomatic patients (mean age 82 ± 8 years, 58% female, and pre-TAVI aortic valve area 0.40 ± 0.19 cm/m2) with severe AS who underwent 2D transthoracic echocardiography and 2D speckle tracking echocardiography at average 21 ± 35 days before and 171 ± 217 days after TAVI. The end point was a composite of new onset of atrial fibrillation, hospitalization for heart failure and all-cause death (major adverse cardiac events [MACE]). RESULTS After TAVI, indexed maximal LA volume and minimum volume of the LA decreased by 2.1 ± 10 mL/m2 and 1.6 ± 7 mL/m2 (p = 0.032 and p = 0.011, respectively), LA function index increased by 6.8 ± 11 units (p < 0.001), and LA stiffness decreased by 0.38 ± 2.0 (p = 0.05). No other changes in the LA phasic volumes, emptying fractions, and vascular load were noted. Post-TAVI, both left atrial and ventricular global peak longitudinal strain improved by about 6% (p = 0.01 and 0.02, respectively). MACE was reached by 37 (25%) patients after a median follow-up period of 172 days (interquartile range, 20-727). In multivariable models, MACE was associated with both pre- and post-TAVI LA global peak longitudinal strain (hazard ratio [HR] 0.75, CI 0.59-0.97; and HR 0.77, CI 0.60-1.00, per 5 percentage point units, respectively), pre-TAVI LV global endocardial longitudinal strain (HR 1.37, CI 1.02-1.83 per 5 percentage point units), and with most of the LA phasic volumes. CONCLUSION Within 6 months after TAVI, there is reverse LA remodeling and an improvement in LA reservoir function. Pre- and post-TAVI indices of LA function and volume remain independently associated with MACE. Larger studies enrolling a greater diversity of patients may provide sufficient evidence for the utilization of these imaging biomarkers in clinical practice.
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Affiliation(s)
- Jonathan Weber
- Departments of Research and Cardiac Imaging, St. Francis Hospital, The Heart Center, Roslyn, New York, USA
| | - Kristine Bond
- Departments of Research and Cardiac Imaging, St. Francis Hospital, The Heart Center, Roslyn, New York, USA
| | - Joseph Flanagan
- Departments of Research and Cardiac Imaging, St. Francis Hospital, The Heart Center, Roslyn, New York, USA
| | - Michael Passick
- Departments of Research and Cardiac Imaging, St. Francis Hospital, The Heart Center, Roslyn, New York, USA
| | - Florentina Petillo
- Departments of Research and Cardiac Imaging, St. Francis Hospital, The Heart Center, Roslyn, New York, USA
| | - Simcha Pollack
- Departments of Research and Cardiac Imaging, St. Francis Hospital, The Heart Center, Roslyn, New York, USA
| | - Newell Robinson
- Departments of Research and Cardiac Imaging, St. Francis Hospital, The Heart Center, Roslyn, New York, USA
| | - George Petrossian
- Departments of Research and Cardiac Imaging, St. Francis Hospital, The Heart Center, Roslyn, New York, USA
| | - J Jane Cao
- Departments of Research and Cardiac Imaging, St. Francis Hospital, The Heart Center, Roslyn, New York, USA.,Health Sciences Center, Stony Brook University, Stony Brook, New York, USA
| | - Eddy Barasch
- Departments of Research and Cardiac Imaging, St. Francis Hospital, The Heart Center, Roslyn, New York, USA, .,Health Sciences Center, Stony Brook University, Stony Brook, New York, USA,
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Chaturvedi A, Baran TM, Ambrosini R, Krishnamoorthy V. Improving CT assessment for pulmonary hypertension in patients with severe aortic stenosis, correlation with right heart catheterization. Clin Imaging 2021; 77:122-129. [PMID: 33676129 DOI: 10.1016/j.clinimag.2021.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/27/2020] [Accepted: 01/28/2021] [Indexed: 01/25/2023]
Abstract
PURPOSE To identify CT parameters useful for assessment of pulmonary hypertension (PH) in patients with severe aortic stenosis (AS). MATERIALS AND METHODS Retrospective study of 165 patients who had undergone right heart catheterization (RHC), and CTA of the thorax for preoperative aortic valve replacement (TAVR) planning. These were divided into groups based on mean pulmonary artery (PA) pressure (mPAP) of 25 mm Hg on RHC (85 cases and 80 controls). Diameters of main pulmonary artery diameter (MPAD), left pulmonary artery (LPA), right pulmonary artery (RPA), and maximal long axis and short axis diameters of the right atrium (RA) and ventricle (RV) were measured on the axial plane. Univariate and multivariate statistical analysis was utilized to identify metrics predictive of PH. RESULTS MPAD, LPA, and RPA were higher in subjects with mPAP >25 mm Hg (p < 0.0001 for all). Thresholds of 30.5 mm for MPAD (68.4% sensitivity, 82.7% specificity), and 27.5 mm for LPA and RPA (LPA: 51.9% sensitivity, 78.8% specificity; RPA: 62.0% sensitivity, 78.8% specificity) provided the best discrimination of elevated mPAP. Compared to literature values for MPAD (28.9 mm in men and 26.9 mm in women), these thresholds provide lower sensitivity but greatly increased specificity. Inclusion of RA enlargement to MPAD increased specificity to 98.5%, while inclusion of RV enlargement increased specificity to 100%. CONCLUSION Threshold to identify PH in patients with AS using PA enlargement is higher than previously reported range for normal. Inclusion of RA and RV enlargement improves the ability of CT to more accurately identify PH in patients with AS.
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Affiliation(s)
- Abhishek Chaturvedi
- Imaging Science, University of Rochester Medical Center, Rochester, NY, USA.
| | - Timothy M Baran
- Imaging Science, University of Rochester Medical Center, Rochester, NY, USA
| | - Robert Ambrosini
- Imaging Science, University of Rochester Medical Center, Rochester, NY, USA
| | - Vijay Krishnamoorthy
- Department of Medicine: Cardiology, University of Rochester Medical Center, Rochester, NY, USA
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Perry TE, George SA, Lee B, Wahr J, Randle D, Sigurðsson G. A guide for pre-procedural imaging for transcatheter aortic valve replacement patients. Perioper Med (Lond) 2020; 9:36. [PMID: 33292498 PMCID: PMC7690031 DOI: 10.1186/s13741-020-00165-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 10/30/2020] [Indexed: 12/17/2022] Open
Abstract
Safe and accurate pre-procedural assessment of cardiovascular anatomy, physiology, and pathophysiology prior to TAVR procedures can mean the difference between success and catastrophic failure. It is imperative that clinical care team members share a basic understanding of the preprocedural imaging technologies available for optimizing the care of TAVR patients. Herein, we review current imaging technology for assessing the anatomy, physiology, and pathophysiology of the aortic valvular complex, ventricular function, and peripheral vasculature, including echocardiography, cardiac catheterization, cardiac computed tomography, and cardiac magnetic resonance prior to a TAVR procedure. The authorship includes cardiac-trained anesthesiologists, anesthesiologists with expertise in pre-procedural cardiac assessment and optimization, and interventional cardiologists with expertise in cardiovascular imaging prior to TAVRs. Improving the understanding of all team members will undoubtedly translate into safer, more coordinated patient care.
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Affiliation(s)
- Tjörvi E. Perry
- Department of Anesthesia, Division of Cardiothoracic Anesthesia, University of Minnesota, 420 Delaware St SE, MMC 294, Minneapolis, MN 55455 USA
| | - Stephen A. George
- Department of Cardiology, Regions Hospital Heart Center, 640 Jackson Street, Saint Paul, MN 55101 USA
| | - Belinda Lee
- Department of Anesthesia, Division of Cardiothoracic Anesthesia, University of Minnesota, 420 Delaware St SE, MMC 294, Minneapolis, MN 55455 USA
| | - Joyce Wahr
- Department of Anesthesia, Preoperative Assessment Center, University of Minnesota, 420 Delaware St SE, MMC 294, Minneapolis, MN 55455 USA
| | - Darrell Randle
- Department of Anesthesia, Preoperative Assessment Center, University of Minnesota, 420 Delaware St SE, MMC 294, Minneapolis, MN 55455 USA
| | - Garðar Sigurðsson
- Department of Cardiology, University of Minnesota, 420 Delaware St. SE, MMC 207, Minneapolis, MN 55455 USA
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46
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Meiburg R, Huberts W, Rutten MCM, van de Vosse FN. Uncertainty in model-based treatment decision support: Applied to aortic valve stenosis. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2020; 36:e3388. [PMID: 32691507 PMCID: PMC7583387 DOI: 10.1002/cnm.3388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 06/02/2020] [Accepted: 07/15/2020] [Indexed: 06/11/2023]
Abstract
Patient outcome in trans-aortic valve implantation (TAVI) therapy partly relies on a patient's haemodynamic properties that cannot be determined from current diagnostic methods alone. In this study, we predict changes in haemodynamic parameters (as a part of patient outcome) after valve replacement treatment in aortic stenosis patients. A framework to incorporate uncertainty in patient-specific model predictions for decision support is presented. A 0D lumped parameter model including the left ventricle, a stenotic valve and systemic circulatory system has been developed, based on models published earlier. The unscented Kalman filter (UKF) is used to optimize model input parameters to fit measured data pre-intervention. After optimization, the valve treatment is simulated by significantly reducing valve resistance. Uncertain model parameters are then propagated using a polynomial chaos expansion approach. To test the proposed framework, three in silico test cases are developed with clinically feasible measurements. Quality and availability of simulated measured patient data are decreased in each case. The UKF approach is compared to a Monte Carlo Markov Chain (MCMC) approach, a well-known approach in modelling predictions with uncertainty. Both methods show increased confidence intervals as measurement quality decreases. By considering three in silico test-cases we were able to show that the proposed framework is able to incorporate optimization uncertainty in model predictions and is faster and the MCMC approach, although it is more sensitive to noise in flow measurements. To conclude, this work shows that the proposed framework is ready to be applied to real patient data.
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Affiliation(s)
- Roel Meiburg
- Department of Biomedical EngineeringEindhoven University of TechnologyEindhoventhe Netherlands
| | - Wouter Huberts
- Department of Biomedical EngineeringEindhoven University of TechnologyEindhoventhe Netherlands
- School for Cardiovascular DiseaseMaastricht UniversityMaastrichtthe Netherlands
| | - Marcel C. M. Rutten
- Department of Biomedical EngineeringEindhoven University of TechnologyEindhoventhe Netherlands
| | - Frans N. van de Vosse
- Department of Biomedical EngineeringEindhoven University of TechnologyEindhoventhe Netherlands
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47
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Sultan I, Fukui M, Bianco V, Brown JA, Kliner DE, Hickey G, Thoma FW, Lee JS, Schindler JT, Kilic A, Gleason TG, Cavalcante JL. Impact of Combined Pre and Postcapillary Pulmonary Hypertension on Survival after Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 131:60-66. [PMID: 32713655 DOI: 10.1016/j.amjcard.2020.06.037] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 11/27/2022]
Abstract
We aimed to evaluate the association between pulmonary hypertension (PH) hemodynamic classification and all-cause mortality in patients with symptomatic severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). PH is common and associated with post-TAVI outcomes in patients with severe AS. Although PH in these patients is primarily driven by elevated left-sided pressures (postcapillary PH), some patients develop increased pulmonary vascular resistance (PVR) configuring the combined pre- and postcapillary PH (CpcPH). We analyzed severe AS patients with mean pulmonary artery pressure (mPAP) measured by right heart catheterization (RHC) before TAVI between 2011 and 2017. PH hemodynamic classification was defined as: No PH (mPAP < 25 mm Hg); precapillary PH (mPAP ≥ 25 mm Hg, pulmonary capillary wedge pressure (PCWP) ≤15 mm Hg); isolated postcapillary PH (IpcPH; mPAP ≥ 25 mm Hg, PCWP > 15 mm Hg, PVR ≤ 3 Wood units (WU); CpcPH (mPAP ≥ 25 mm Hg, PCWP > 15 mm Hg, PVR > 3 WU). Kaplan-Meier and Cox regression analyses were used to test the association of PH hemodynamic classification with post-TAVI all-cause mortality. We examined 561 patients (mean age 82 ± 8 years, 51% men, mean LVEF 54 ± 14%). The prevalence of no PH was 201 (36%); precapillary PH, 59 (10%); IpcPH, 189 (34%); and CpcPH, 112 (20%). During a median follow-up of 30 months, 240 all-cause deaths occurred. Patients with CpcPH had higher mortality than those with no-PH even after adjustment for baseline characteristics (Hazard ratio 1.56, 95% confidence interval 1.06 to 2.29, p = 0.025). There was no survival difference among patients with non-PH, precapillary PH and IpcPH. In conclusion, for patients with symptomatic severe AS treated with TAVI, CcpPH is independently associated with long-term all-cause mortality despite successful TAVI.
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48
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Omar S, Aneni E, Escolar E, Mihos CG, Xydas S, LaPietra A, Beohar N, Arenas IA. Tricuspid regurgitation and in-hospital outcomes after transcatheter aortic valve replacement in high-risk patients. J Thorac Dis 2020; 12:2963-2970. [PMID: 32642209 PMCID: PMC7330359 DOI: 10.21037/jtd.2020.02.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The prognostic impact of tricuspid regurgitation (TR) following transcatheter aortic valve replacement (TAVR) is uncertain, and the management of patients with severe aortic stenosis and significant TR undergoing TAVR is unclear. Methods Retrospective study investigating the role of TR severity on hospital outcomes in high risk patients with severe aortic stenosis undergoing TAVR. Results A total of 174 participants were included in the present study. The median age was 84 years and 48% were women. The median (IR) STS score was 7.3 (4.7-13.6). The pre-procedural mean (SD) aortic valve area (AVA) was 0.69 (0.2) cm2 and the average (SD) peak and mean gradients were 71 [23]/42 [15] mmHg. Pre TAVR, 28.7% of patients had significant (moderate or severe) TR. Significant TR pre-TAVR increased the risk of in-hospital cardiovascular (CV) and all-cause and mortality [adjusted relative risk (RR) (95% CI): 14.67 (1.35-159.51) and 5.09 (1.14-22.72), respectively], and those with severe TR post-TAVR had longer hospital stay [median (IR): 9.9 (2.9-17.0) days]. No improvement or worsened TR (greater than mild) post-TAVR was associated with higher CV and all-cause mortality [adjusted RR (95% CI): 21.5 (1.81-255.96) and 8.19 (1.67-40.29), respectively]. Right ventricular systolic pressure (RVSP) was independently associated with TR severity pre and post TAVR. Conclusions Significant TR was common among patients undergoing high risk TAVR, and is associated with increased in hospital mortality and longer hospital stay. Patients with elevated RVSP and persistent moderate or severe TR after TAVR are at higher risk of in hospital death.
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Affiliation(s)
- Sabry Omar
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach FL, USA
| | - Ehimen Aneni
- Department of Internal Medicine, Mount Sinai Medical Center, Miami Beach FL, USA
| | - Esteban Escolar
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach FL, USA
| | - Christos G Mihos
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Steve Xydas
- Columbia University Division of Cardiac Surgery, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Angelo LaPietra
- Columbia University Division of Cardiac Surgery, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Nirat Beohar
- Cardiac Catheterization Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Ivan A Arenas
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
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Wessler BS, Weintraub AR, Udelson JE, Kent DM. Can Clinical Predictive Models Identify Patients Who Should Not Receive TAVR? A Systematic Review. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2020; 4:295-299. [PMID: 32905421 DOI: 10.1080/24748706.2020.1782549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background One third of high- and prohibitive-risk TAVR patients remain severely symptomatic or die 1 year after treatment. There is interest in identifying individuals for whom this procedure is futile and should not be offered. Methods We performed a systematic review of the highest reported stratum of risk in TAVR clinical predictive models (CPMs). We explore whether currently available predictive models can identify patients for whom TAVR is futile, based on a quantitative futility definition and the observed and predicted outcomes for patients in the highest stratum of risk. Results 17 TAVR CPMs representing 69,191 treated patients were published from 2013 to 2018. When reported, the median number of patients in the highest stratum of risk was 569 (range 1 to 1759). Observed mortality for this risk stratum ranged from 9% at 30 days to 59% at 1 year after TAVR. Statistical confidence in these observed event rates was low. The highest predicted event rates ranged from 11.0% for in-hospital mortality to 75.1% for the composite of mortality or high symptom burden 1 year after TAVR. Conclusion No high-risk TAVR group in currently available TAVR CPMs had an appropriate event rate and adequate statistical power to meet a quantitative definition of futility.
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Affiliation(s)
- Benjamin S Wessler
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center.,Predictive Analytics and Comparative Effectiveness (PACE) Center, Tufts Medical Center
| | - Andrew R Weintraub
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center
| | - James E Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Tufts Medical Center
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50
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Alushi B, Vathie K, Thiele H, Lauten A. Transcatheter therapies for severe tricuspid regurgitation. Quo vadis? Herz 2020; 46:234-241. [PMID: 32468139 DOI: 10.1007/s00059-020-04941-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 04/13/2020] [Accepted: 05/04/2020] [Indexed: 11/25/2022]
Abstract
Moderate-to-severe tricuspid regurgitation (TR) is common and is associated with a poor prognosis. To date, most patients are undertreated; therefore, transcatheter options could be clinically impactful in those who are denied surgery. Several transcatheter solutions have been developed that address the problem via leaflet enhancement, annuloplasty, or heterotopic implantation of self-expandable or balloon-expandable valves in the caval veins. A comprehensive patient evaluation, based on multimodality imaging techniques for a better understanding of the valvular pathology and TR mechanism, remains paramount for an appropriate device selection. To date, several trials have shown the feasibility and safety of a multitude of devices in this setting, but data from randomized clinical trials regarding clinical benefit based on hard endpoints are still lacking. Although the optimal patient profile and timing of intervention remain under investigation, data from available studies indicate that an earlier treatment referral, before onset of irreversible right ventricular remodeling, could be beneficial. This review discusses the present landscape and future implications of transcatheter therapies for severe TR.
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Affiliation(s)
- Brunilda Alushi
- Department of General and Interventional Cardiology, Helios Klinikum Erfurt, Nordhäuser Str. 74, 99089, Erfurt, Germany.
- Department of Cardiology, Campus Benjamin Franklin, Charité Medical University Berlin, Berlin, Germany.
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany.
| | - Kourosh Vathie
- Department of General and Interventional Cardiology, Helios Klinikum Erfurt, Nordhäuser Str. 74, 99089, Erfurt, Germany
| | - Holger Thiele
- Department of Cardiology, Heart Center Leipzig at University Leipzig and Leipzig Heart Institute, Leipzig, Germany
| | - Alexander Lauten
- Department of General and Interventional Cardiology, Helios Klinikum Erfurt, Nordhäuser Str. 74, 99089, Erfurt, Germany
- Department of Cardiology, Campus Benjamin Franklin, Charité Medical University Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
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