Clinical Impact of Diabetes Mellitus on Outcomes After Transcatheter Aortic Valve Replacement: Insights From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry

Impact of glycemic control metrics on short- and long-term mortality in transcatheter aortic valve replacement patients: a retrospective cohort study from the MIMIC-IV database

BACKGROUND

Glycemic control is critical for managing transcatheter aortic valve replacement (TAVR) patients, especially those in intensive care units (ICUs). Emerging metrics such as the hemoglobin glycation index (HGI), stress hyperglycemia ratio (SHR), and glycemic variability (GV) offer advanced insights into glucose metabolism. However, their prognostic implications for short- and long-term outcomes post-TAVR remain underexplored.

METHODS

This retrospective cohort study analyzed 3342 ICU-admitted TAVR patients via the MIMIC-IV database. Patients were stratified into tertiles for HGI, SHR, and GV levels. Survival analyses, including Kaplan‒Meier curves, Cox proportional hazards models and restricted cubic splines (RCSs), were used to assess associations between glycemic control metrics and 30-day and 365-day all-cause mortality in these patients. Sensitivity analyses, subgroup assessments, and external validation were also performed to verify the study findings.

RESULTS

During follow-up, 1.6% and 6.9% of patients experienced 30-day and 365-day mortality after TAVR, respectively. In the fully adjusted cox regression model, lower HGI (HR 1.48, 95% CI 1.05-2.09, P = 0.025) and higher SHR (HR 1.63, 95% CI 1.15-2.32, P = 0.006) were most significantly associated with an increased risk of 365-day mortality. Higher SHR was also significantly associated with an increased risk of 30-day mortality in patients (HR 2.92, 95% CI 1.32-6.45, P = 0.008). Both lower (HR 0.59, 95% CI 0.38-0.92, P = 0.019) and higher GV levels (HR 1.43, 95% CI 1.06-1.93, P = 0.020) were associated with the risk of 365-day mortality.

CONCLUSIONS

In critically ill TAVR patients, glycemic control metrics are closely associated with long-term all-cause mortality. The HGI, SHR, and GV provide prognostic insights into clinical outcomes that surpass conventional glucose measurements. These findings highlight the importance of personalized glycemic management strategies in improving TAVR patient outcomes.

Impact of diabetes mellitus on long-term survival after transcatheter mitral valve edge-to-edge repair

Aim

Diabetes mellitus (DM) represents a notable risk factor within surgical and interventional procedures. Data on its influence on survival after Transcatheter Edge-to-Edge Repair (TEER) of Mitral valve Regurgitation (MR) are sparse.

Methods

In a retrospective monocentric assessment after successful treatment of MR using TEER from 06/2010 to 03/2018 patients were stratified for DM. Mortality was analyzed during follow-up using Cox regression analyses.

Results

Of 627 patients (47.0 % females, 88.2 % aged ≥ 70 years, median follow-up 486 days) consecutively included, subjects with DM (N = 174, 27.8 %) had a higher prevalence of comorbidities like obesity (27.3 % vs. 9.2 %, p < 0.001), arterial hypertension (91.4 % vs. 83.7 %, p = 0.013), renal insufficiency (63.8 % vs. 43.9 %, p < 0.001), coronary artery disease (77.0 % vs. 59.8 %, p < 0.001) and peripheral artery disease (14.4 % vs. 8.4 %, p = 0.026). Patients with DM presented with higher median logistic Euroscore I (29.4 % [20.0/43.0] vs. 25.0 % [16.7/36.6], p = 0.001) and more severely reduced systolic function (LVEF 35 % [30/50] vs. 45 % [30/55], p < 0.001). No difference in short- and long-term survival was detected between patients with and without DM (in-hospital mortality 1.7 vs. 2.6 %, p = 0.771; at 30-days 5.0 vs. 6.0 %, p = 0.842, 1-year 28.7 vs. 25.0 %, p = 0.419, 3-years 49.2 vs. 44.1 %, p = 0.554, 5-years 69.0 vs. 68.3 %, p = 0.497). The presence of DM was not attributed as an individual risk factor for elevated mortality (HR 1-year 1.17 [95 % CI 0.80-1.71], p = 0.419; HR long-term 1.13 [95 %CI 0.86-1.49], p = 0.373).

Conclusion

Although linked to a more vulnerable clinical profile and despite being factored in common risk factor models, DM was not associated with an elevated short- and long-term mortality after TEER of MR.

Clinical Impact of Glucose Levels on Patient Outcome after Transcatheter Aortic Valve Replacement

Background

Limited data are available for evaluating the effect of blood glucose on transcatheter aortic valve replacement (TAVR) outcomes in patients with diabetes. We aimed to assess the impact of glucose levels on short-term and long-term adverse outcomes in patients undergoing TAVR.

Methods and Results

Data from severe aortic stenosis (AS) patients who underwent TAVR from 2010 to 2022 were collected retrospectively. In total, 615 patients were enrolled in the study: Among the total patient population, 43% had diabetes mellitus (DM), with a mean hemoglobin A1c (HbA1c) level of 7.4 ± 2.5. Within this cohort, 33% were classified as having uncontrolled diabetes, while 17% were considered well-controlled. Diabetic patients were younger (80.7 ± 6.8 vs. 82.0 ± 6.8 years, p = 0.001) and had more cardiovascular risk factors. No significant differences were found in outcomes between the two groups during the twelve-year follow-up. A multivariable logistic regression analysis was conducted on 270 DM patients to examine the impact of blood glucose levels and HbA1c on outcomes such as arrhythmia, stroke, and acute kidney injury (AKI). For arrhythmia, the odds ratio for HbA1c and blood glucose were 1.1039 (p = 0.23), and 0.998 (p = 0.76), indicating no significant associations. In stroke cases, HbA1c had an odds ratio of 1.194 (p = 0.36), while an odds ratio of 1.020 (p = 0.013) for blood glucose indicated a significant association. Notably, for AKI, the odds ratio for HbA1c was 2.304 (p = 0.02), indicating a significant link between higher HbA1c levels and increased AKI risk, with blood glucose levels trending toward significance (odds ratio = 1.0137, p = 0.061).

Conclusions

Diabetic status is a predictor of short-term outcomes following TAVR. Thus, these screening parameters should be included in risk assessment tools for TAVR candidates.

Diabetes is associated with a higher incidence of short-term mortality risk and readmission in patients who undergo surgical but not transcatheter aortic valve replacement

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is increasingly used for aortic valve replacement instead of surgical aortic valve replacement (sAVR). We aimed to examine the impact of diabetes on 30-day mortality, 30-day readmission and compare outcomes between TAVR and sAVR.

METHODS

Data were extracted from the Nationwide Readmissions Database from 2012 to 2017. The primary outcome was 30-day mortality, and the secondary outcome was 30-day readmission.

RESULTS

The study included 110 135 patients who underwent aortic valve replacement. Of these, 59 466 (54.0%) were hospitalised for TAVR, and 50 669 (46.0%) underwent sAVR. Diabetes was present in 36.4% of TAVR patients and 29.1% of sAVR patients. In TAVR patients, the adjusted risk of 30-day readmission and mortality was similar regardless of diabetes status (aHR=0.94 (0.86-1.03); 0.97 (0.84-1.12); respectively). However, sAVR patients with diabetes had a higher adjusted risk of 30-day mortality (aHR=1.13 (1.01-1.25)) but not readmission (aHR=0.92 (0.84-1.01)). When comparing outcomes between TAVR and sAVR in patients with diabetes, TAVR patients were older and had a higher prevalence of chronic kidney disease (CKD). Nevertheless, 30-day readmission and mortality were lower in patients who underwent TAVR (aHR=0.59 (0.53-0.67), aHR=0.29 (0.25-0.34), respectively) compared with sAVR. Coronary artery disease was the most significant predictor of readmission in patients with diabetes. CKD increased the risk of mortality by almost twofold in both techniques.

CONCLUSION

Diabetes increases the risk of short-term mortality in sAVR but not TAVR. Moreover, the incidence of 30-day mortality and readmission is lower in TAVR compared with TAVR among patients with diabetes.

Aortic Stenosis, Heart Failure, and Aortic Valve Replacement

Importance

Heart failure (HF) and aortic stenosis (AS) frequently coexist, presenting a complex clinical challenge due to their intertwined pathophysiology and associated high morbidity and mortality. Despite numerous advancements in transcatheter and surgical aortic valve replacement (AVR), HF decompensation remains the leading cause of cardiac rehospitalization and a major predictor of mortality in patients with AS, before or after AVR. This review aims to provide a comprehensive analysis of the interplay between AS and HF, delving into myocardial changes caused by stenotic insult, the impact of AVR on these changes, and the prevalence and contributing elements of HF before and after AVR.

Observations

The prevalence of HF remains high before and after AVR, particularly among patients with left ventricular dysfunction. Increased afterload from AS causes cardiac remodeling, which is initially benign but over time these changes become maladaptive, contributing to HF and increased mortality. The progression of HF is influenced by the degree of reverse cardiac remodeling, which can be affected by comorbid conditions, the hemodynamic performance of the valve prosthesis, and vascular stiffness. Several blood and imaging biomarkers offer insights into underlying AS pathophysiology, serving as mortality predictors and predicting HF in this patient population.

Conclusions and Relevance

HF development in AS is multifactorial and its link to left ventricular dysfunction is a complex process. Delineating the determinants of HF admissions in AS is crucial for identifying individuals at high risk. Identifying the early signs of left ventricular decompensation by using surrogate markers may be the key, even before left ventricular function becomes impaired. Translating multimodality imaging techniques and biomarkers into routine clinical practice for evaluating cardiac damage and integrating these markers with patient and procedural factors that affect HF before and after AVR can facilitate timely intervention, minimizing the likelihood of HF progression and influencing future guidelines.

Aortic Stenosis and the Evolution of Cardiac Damage after Transcatheter Aortic Valve Replacement

Background/Objectives: Severe aortic stenosis (AS) is the most frequent valvular heart disease. Models for stratifying cardiac damage associated with aortic stenosis have been developed to predict outcomes following valve replacement. However, evidence regarding morphological and functional evolution, as well as potential changes in the degree of cardiac damage, is limited. We aim to provide information on the evolution of cardiac morphology and the function of patients undergoing transcatheter aortic valve replacement (TAVR) who have been classified using a cardiac damage staging system. Methods: In total, 496 patients were included in the analysis, and were classified into four stages based on the extent of cardiac damage as follows: Stage 0, no cardiac damage: left ventricle global longitudinal strain (LV-GLS) < -17%; right ventricular-arterial coupling (RVAc) ≥ 0.35), and absence of significant mitral regurgitation (MR). Stage 1, left-sided subclinical damage: LV-GLS ≥ -17%. Stage 2, left-sided damage: significant MR. Stage 3, right-sided damage: RVAc < 0.35. Results: The mean age was 82.1 ± 5.9 years, and 53.0% were female. In total, 24.5% of patients met the criteria for Stage 0, and Stage 1 included 42.8% of patients, Stage 2 included 16.5%, and Stage 3 comprised 16.2% of patients. Mortality was 8.4% for stage 0, 17.4% for stage 1, 25.6% for stage 2, and 28.6% for stage 3 patients (p = 0.004). Diabetes mellitus (DM) (p = 0.047) and chronic kidney disease (CKD) (p = 0.024) were the only clinical predictors of no change or worsening in the stage of cardiac damage. Regarding echocardiographic variables, concomitant tricuspid, and mitral regurgitation, ≥ 2 were both significantly associated with no change or worsening, also (p < 0.001). Conclusions: Cardiac damage that is secondary to severe aortic stenosis has morphological and functional repercussions that, even after valve replacement, persist and might worsen the prognosis.

Haemodynamic and metabolic phenotyping of patients with aortic stenosis and preserved ejection fraction: A specific phenotype of heart failure with preserved ejection fraction?

AIMS

Degenerative aortic valve stenosis with preserved ejection fraction (ASpEF) and heart failure with preserved ejection fraction (HFpEF) display intriguing similarities. This study aimed to provide a non-invasive, comparative analysis of ASpEF versus HFpEF at rest and during exercise.

METHODS AND RESULTS

We prospectively enrolled 148 patients with HFpEF and 150 patients with degenerative moderate-to-severe ASpEF, together with 66 age- and sex-matched healthy controls. All subjects received a comprehensive evaluation at rest and 351/364 (96%) performed a combined cardiopulmonary exercise stress echocardiography test. Patients with ASpEF eligible for transcatheter aortic valve replacement (n = 125) also performed cardiac computed tomography (CT). HFpEF and ASpEF patients showed similar demographic distribution and biohumoral profiles. Most patients with ASpEF (134/150, 89%) had severe high-gradient aortic stenosis; 6/150 (4%) had normal-flow, low-gradient ASpEF, while 10/150 (7%) had low-flow, low-gradient ASpEF. Both patient groups displayed significantly lower peak oxygen consumption (VO2 ), peak cardiac output, and peak arteriovenous oxygen difference compared to controls (all p < 0.01). ASpEF patients showed several extravalvular abnormalities at rest and during exercise, similar to HFpEF (all p < 0.01 vs. controls). Epicardial adipose tissue (EAT) thickness was significantly greater in ASpEF than HFpEF and was inversely correlated with peak VO2 in all groups. In ASpEF, EAT was directly related to echocardiography-derived disease severity and CT-derived aortic valve calcium burden.

CONCLUSION

Functional capacity is similarly impaired in ASpEF and HFpEF due to both peripheral and central components. Further investigation is warranted to determine whether extravalvular alterations may affect disease progression and prognosis in ASpEF even after valve intervention, which could support the concept of ASpEF as a specific sub-phenotype of HFpEF.

Systemic proinflammatory-profibrotic response in aortic stenosis patients with diabetes and its relationship with myocardial remodeling and clinical outcome

BACKGROUND

Previous studies have mainly focused more on how diabetes affects the valve than the myocardium in aortic stenosis (AS). In the pressure-overloaded heart, myocardial fibrosis is an important driver of the progression from compensated hypertrophy to heart failure. Using comprehensive noninvasive imaging and plasma proteomics, we investigated whether and how diabetes aggravates the remodeling of the myocardium and its relation with prognosis in AS patients.

METHODS

Severe AS patients were enrolled in two prospective cohorts for imaging and biomarker analysis. The imaging cohort (n = 253) underwent echocardiography and cardiac magnetic resonance, and the biomarker cohort (n = 100) blood sampling with multiplex proximity extension assay for 92 proteomic biomarkers. The composite outcome of hospitalization for heart failure admissions and death was assessed in the imaging cohort.

RESULTS

Diabetic patients were older (70.4 ± 6.8 versus 66.7 ± 10.1 years) with more advanced ventricular diastolic dysfunction and increased replacement and diffuse interstitial fibrosis (late gadolinium enhancement % 0.3 [0.0-1.6] versus 0.0 [0.0-0.5], p = 0.009; extracellular volume fraction % 27.9 [25.7-30.1] versus 26.7 [24.9-28.5], p = 0.025) in the imaging cohort. Plasma proteomics analysis of the biomarker cohort revealed that 9 proteins (E-selectin, interleukin-1 receptor type 1, interleukin-1 receptor type 2, galectin-4, intercellular adhesion molecule 2, integrin beta-2, galectin-3, growth differentiation factor 15, and cathepsin D) were significantly elevated and that pathways related to inflammatory response and extracellular matrix components were enriched in diabetic AS patients. During follow-up (median 6.3 years), there were 53 unexpected heart failure admissions or death in the imaging cohort. Diabetes was a significant predictor of heart failure and death, independent of clinical covariates and aortic valve replacement (HR 1.88, 95% CI 1.06-3.31, p = 0.030).

CONCLUSIONS

Plasma proteomic analyses indicate that diabetes potentiates the systemic proinflammatory-profibrotic milieu in AS patients. These systemic biological changes underlie the increase of myocardial fibrosis, diastolic dysfunction, and worse clinical outcomes in severe AS patients with concomitant diabetes.

Diabetes mellitus in transfemoral transcatheter aortic valve implantation: a propensity matched analysis

BACKGROUND

Diabetes Mellitus (DM) affects a third of patients with symptomatic severe aortic valve stenosis undergoing transcatheter aortic valve implantation (TAVI). DM is a well-known risk factor for cardiac surgery, but its prognostic impact in TAVI patients remains controversial. This study aimed to evaluate outcomes in diabetic patients undergoing TAVI.

METHODS

This multicentre registry includes data of > 12,000 patients undergoing transfemoral TAVI. We assessed baseline patient characteristics and clinical outcomes in patients with DM and without DM. Clinical outcomes were defined by the second valve academic research consortium. Propensity score matching was applied to minimize potential confounding.

RESULTS

Of the 11,440 patients included, 31% (n = 3550) had DM and 69% (n = 7890) did not have DM. Diabetic patients were younger but had an overall worse cardiovascular risk profile than non-diabetic patients. All-cause mortality rates were comparable at 30 days (4.5% vs. 4.9%, RR 0.9, 95%CI 0.8-1.1, p = 0.43) and at one year (17.5% vs. 17.4%, RR 1.0, 95%CI 0.9-1.1, p = 0.86) in the unmatched population. Propensity score matching obtained 3281 patient-pairs. Also in the matched population, mortality rates were comparable at 30 days (4.7% vs. 4.3%, RR 1.1, 95%CI 0.9-1.4, p = 0.38) and one year (17.3% vs. 16.2%, RR 1.1, 95%CI 0.9-1.2, p = 0.37). Other clinical outcomes including stroke, major bleeding, myocardial infarction and permanent pacemaker implantation, were comparable between patients with DM and without DM. Insulin treated diabetics (n = 314) showed a trend to higher mortality compared with non-insulin treated diabetics (n = 701, Hazard Ratio 1.5, 95%CI 0.9-2.3, p = 0.08). EuroSCORE II was the most accurate risk score and underestimated 30-day mortality with an observed-expected ratio of 1.15 in DM patients, STS-PROM overestimated actual mortality with a ratio of 0.77 and Logistic EuroSCORE with 0.35.

CONCLUSION

DM was not associated with mortality during the first year after TAVI. DM patients undergoing TAVI had low rates of mortality and other adverse clinical outcomes, comparable to non-DM TAVI patients. Our results underscore the safety of TAVI treatment in DM patients.

TRIAL REGISTRATION

The study is registered at clinicaltrials.gov (NCT03588247).

A Risk Model for 1-Year Mortality After Transcatheter Aortic Valve Replacement From the J-TVT Registry

Background

Although transcatheter aortic valve replacement (TAVR) has demonstrated favorable outcomes in randomized studies, there remains a sizable group of patients in whom TAVR may be futile. Characterizing the survival rate in a wide array of patients undergoing TAVR can help develop effective strategies for improving the allocation of medial resources.

Objectives

The aim of this study was to develop a risk model to estimate 1-year mortality after TAVR from a representative nationwide registry in Japan.

Methods

The J-TVT (Japan Transcatheter Valve Therapies) registry contains complete data, including 1-year outcomes, on patients undergoing TAVR in Japan. A total of 17,655 patients underwent TAVR between 2013 and 2018. They were randomly divided into 2 groups in a 7:3 ratio to form a derivation cohort of 12,316 patients and a validation cohort of 5,339 patients. A risk model was constructed for 1-year mortality in the derivation cohort, and its discrimination and calibration were assessed in the validation cohort.

Results

The mean age of all registered patients was 84.4 years, and 68.8% were women. The mean body size area was 1.43 m2, and the mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 7.3%. The estimated 1-year survival was 91.8%; 202 and 1,316 deaths were observed at 30 days and 1 year, respectively; The estimated C index for the developed model was 0.733 (95% CI: 0.709-0.757) in the validation cohort, with good calibration.

Conclusions

A prediction model for 1-year survival following TAVR derived from a national clinical database performed well and should aid physicians managing TAVR patients.

Diabetes mellitus and cardiovascular mortality across the spectrum of aortic stenosis

OBJECTIVE

Current data regarding the impact of diabetes mellitus (DM) on cardiovascular mortality in patients with aortic stenosis (AS) are restricted to severe AS or aortic valve replacement (AVR) trials. We aimed to investigate cardiovascular mortality according to DM across the entire spectrum of outpatients with AS.

METHODS

Between May 2016 and December 2017, patients with mild (peak aortic velocity=2.5-2.9 m/s), moderate (3-3.9 m/s) and severe (≥4 m/s) AS graded by echocardiography were included during outpatient cardiology visits in the Nord-Pas-de-Calais region in France and followed-up for modes of death between May 2018 and August 2020.

RESULTS

Among 2703 patients, 820 (30.3%) had DM, mean age was 76±10.8 years with 46.6% of women and a relatively high prevalence of underlying cardiovascular diseases. There were 200 cardiovascular deaths prior to AVR during the 2.1 years (IQR 1.4-2.7) follow-up period. In adjusted analyses, DM was significantly associated with cardiovascular mortality (HR=1.40, 95% CI 1.04 to 1.89; p=0.029). In mild or moderate AS, the cardiovascular mortality of patients with diabetes was similar to that of patients without diabetes. In severe AS, DM was associated with higher cardiovascular mortality (HR=2.65, 95% CI 1.50 to 4.68; p=0.001). This was almost exclusively related to a higher risk of death from heart failure (HR=2.61, 95% CI 1.15 to 5.92; p=0.022) and sudden death (HR=3.33, 95% CI 1.28 to 8.67; p=0.014).

CONCLUSION

The effect of DM on cardiovascular mortality varied across AS severity. Despite no association between DM and outcomes in patients with mild/moderate AS, DM was strongly associated with death from heart failure and sudden death in patients with severe AS.

Trends and Outcomes of Aortic Valve Replacement in Patients With Diabetes in the US

Aims

We aimed to assess the trend and outcome of aortic valve replacement in patients with diabetes.

Background

Diabetes is associated with higher cardiovascular events.

Methods

Data from the National Inpatient Sample was analyzed between 2012 and 2017. We compared hospitalizations and in-hospital cardiovascular outcomes in patients with diabetes to those without diabetes, hospitalized for aortic valve replacement.

Results

In diabetes patients undergoing TAVR, the mean age of participants decreased from 79.6 ± 8 to 67.8 ± 8, hospitalizations increased from 0.97 to 7.68/100,000 US adults (p &lt; 0.002 for both). There was a significant temporal decrease in mortality, acute renal failure (ARF), and stroke. Compared to non-diabetic patients, those with diabetes had a higher risk of stroke, ARF, and pacemaker requirement [adjusted OR = 1.174 (1.03–1.34), 1.294 (1.24–1.35), 1.153 (1.11–1.20), respectively], but a similar adjusted mortality risk. In diabetes patients undergoing sAVR, the mean age of participants decreased from 70.4 ± 10 to 68 ± 9 (p &lt; 0.001), hospitalizations dropped from 7.72 to 6.63/100,000 US adults (p = 0.025), so did mortality, bleeding, and ARF. When compared to non-diabetes patients, those with diabetes were older and had a higher adjusted risk of mortality, stroke, and ARF [adjusted OR= 1.115 (1.06–1.17), 1.140 (1.05–1.23), 1.217 (1.18–1.26); respectively].

Conclusion

The recent temporal trend of aortic valve replacement in patients with diabetes shows a significant increase in TAVR coupled with a decrease in sAVR. Mortality and other cardiovascular outcomes decreased in both techniques. sAVR, but not TAVR, was associated with higher in-hospital mortality risk.

Propitious temporal changes in clinical outcomes after transcatheter compared to surgical aortic valve replacement; a meta-analysis of over 65,000 patients

Background

The treatment of symptomatic severe aortic stenosis (AS) has rapidly evolved over the past decade, in both transcatheter (TAVR) and surgical aortic valve replacement (SAVR), resulting in reported improved clinical outcomes. Operator experience and technical improvements have improved outcomes especially for patients undergoing TAVR. We sought to determine and compare 1-year outcomes using a contemporary meta-analysis.

Method

We searched the Medline (MESH), Cochrane and Google scholar databases using keywords “AS”, “atrial fibrillation” (AFib) and “stroke”. We performed a meta-analysis to compare TAVR with SAVR populations for post-procedural stroke, all-cause and cardiovascular mortality at 1-year.

Results

A total of 23 studies met criteria for analysis with total population of 66,857 patients, of which 61,913 had TAVR and 4944 had SAVR. Temporal trends demonstrated overall improvement in outcome for both, TAVR and SAVR groups through the decade. Outcomes, in terms of stroke (3.1% vs. 5%), all-cause (12.4% vs. 10.3%) and cardiovascular mortality (7.2% vs. 6.2%) were similar at 1-year, in TAVR versus SAVR, respectively.

Conclusion

Despite overall gradual improvement in both TAVR and SAVR outcomes over the decade, there is a statistical overlap in confidence intervals for all-cause, cardiovascular mortality and postprocedural stroke at 1-year. While 23 individual studies demonstrate considerable advantages of each technique in certain cohorts, integrating over 65,000 pts with our stratified surgical analysis suggests that TAVR is comparable to SAVR for low and intermediate risk population while superior to SAVR only in the highest-risk population for short and intermediate term outcomes. This has substantial socio-economic implications as we contemplate expanding our TAVR indications to low/intermediate risk populations.

Diabetes Mellitus and Its Implications in Aortic Stenosis Patients

Aortic stenosis (AS) and diabetes mellitus (DM) are both progressive diseases that if left untreated, result in significant morbidity and mortality. Several studies revealed that the prevalence of DM is substantially higher in patients with AS and, thus, the progression from mild to severe AS is greater in those patients with DM. DM and common comorbidities associated with both diseases, DM and AS, increase patient management complexity and make aortic valve replacement the only effective treatment. For that reason, a better understanding of the pathogenesis underlying both these diseases and the relationships between them is necessary to design more appropriate preventive and therapeutic approaches. In this review, we provided an overview of the main aspects of the relationship between AS and DM, including common comorbidities and risk factors. We also discuss the established treatments/therapies in patients with AS and DM.

Preoperative heart failure worsens outcome after aortic valve replacement irrespective of left ventricular ejection fraction

BACKGROUND

Left ventricular ejection fraction (LVEF) affects outcome of valve replacement (AVR) in aortic stenosis (AS). The study aim was to investigate the prognostic importance of concomitant cardiovascular disease in relation to preoperative LVEF.

METHODS AND RESULTS

All adult patients undergoing AVR due to AS 2008-2014 in a national register for heart diseases were included. All-cause mortality and hospitalization for heart failure during follow-up after AVR, stratified by preserved or reduced LVEF (=50%), was derived from national patient registers and analyzed by Cox regression.During the study period 10,406 patients, median age 73 years, a median follow-up of 35 months were identified. Preserved LVEF was present in 7,512 (72.2%). Among them 647 (8.6%) had a history of heart failure (HF) and 1,099 (14.6%) atrial fibrillation (AF) before intervention. Preoperative HF was associated with higher mortality irrespective of preserved or reduced LVEF: Hazard Ratio (HR) 1.64 (95% C.I. 1.35 -1.99) and 1.58 (95% C.I. 1.30 -1.92). Prior AF was associated with a higher risk of mortality in patients with preserved but not in those with reduced LVEF: HR 1.62 (95% C.I. 1.36 -1.92) and 1.05 (95% C.I. 0.86 -1.28). Irrespective of LVEF preoperative HF and AF were associated with an increased risk of postoperative heart failure hospitalization.

CONCLUSION

In patients planned for AVR, a history of HF or AF, irrespective of LVEF, worsens the postoperative prognosis. HF and AF can be seen as markers of myocardial fibrosis not necessarily discovered by LVEF and the merely use of it, besides symptoms, for timing of AVR seems suboptimal.

Procedural Characteristics and Late Outcomes of Percutaneous Coronary Intervention in the Workup Pre-TAVR

OBJECTIVES

This study sought to determine, in patients undergoing percutaneous coronary intervention (PCI) during the work-up pre-transcatheter aortic valve replacement (TAVR): 1) the clinical and peri-procedural PCI characteristics; 2) the long-term outcomes; and 3) the clinical events in those patients with complex coronary features.

BACKGROUND

A PCI is performed in about 25% of TAVR candidates, but procedural features and late outcomes of pre-TAVR PCI remain largely unknown.

METHODS

Multicenter study including 1197 consecutive patients who had PCI in the work-up pre-TAVR. A total of 1,705 lesions (1.5 ± 0.7 lesions per patient) were included. Death, stroke, myocardial infarction, and major adverse cardiovascular and cerebrovascular events (MACCE) were recorded, as well as target lesion failure (TLF) and target vessel failure (TVF).

RESULTS

One-half of patients exhibited a multivessel disease and the mean SYNTAX (SYNergy between PCI with TAXUS and Cardiac Surgery) score was 12.1 ± 9.1. The lesions were of B2/C type, calcified, bifurcation, and ostial in 49.9%, 45.8%, 21.4%, and 19.3% of cases, respectively. After a median follow-up of 2 (interquartile range: 1 to 3) years, a total of 444 (37.1%) patients presented an MACCE. Forty patients exhibited TVF (3.3%), with TLF identified in 32 (2.7%) patients. By multivariable analysis, previous peripheral artery disease (p < 0.001), chronic obstructive pulmonary disease (p = 0.002), atrial fibrillation (p = 0.003), diabetes mellitus (p = 0.012), and incomplete revascularization (p = 0.014) determined an increased risk of MACCE. In patients with unprotected left main or SYNTAX score >32 (n = 128), TLF, TVF, and MACCE rates were 3.9%, 6.3%, and 35.9%, respectively (p = 0.378; p = 0.065, and p = 0.847, respectively, vs. the rest of the population).

CONCLUSIONS

Patients undergoing PCI in the work-up pre-TAVR frequently exhibited complex coronary lesions and multivessel disease. PCI was successful in most cases, and TLF and TVF rates at 2-year follow-up were low, also among patients with high-risk coronary features. However, overall MACCE occurred in about one-third of patients, with incomplete revascularization determining an increased risk. These results should inform future studies to better determine the optimal revascularization strategy pre-TAVR.

Comparative Outcomes of Transapical Versus Transfemoral Access for Transcatheter Aortic Valve Replacement in Diabetics

INTRODUCTION

The outcomes of transfemoral (TF) compared with transapical (TA) access for transcatheter aortic valve replacement (TAVR) in diabetics are unknown.

METHODS

We queried the NIS database (2011-2014) to identify diabetics who underwent TAVR. We performed a propensity matching analysis comparing TF-TAVR versus TA-TAVR.

RESULTS

The analysis included 14.555 diabetics who underwent TAVR. After matching, in-hospital mortality was not different between TF-TAVR and TA-TAVR. (3.5 vs. 4.4%, p = 0.11). TF-TAVR was associated with lower rates of cardiogenic shock (2.7 vs. 4.7%, p = 0.02), use of mechanical circulatory support (2.0 vs. 2.9%, p = 0.03), acute renal failure (17.8 vs. 26.5%, p < 0.001), major bleeding (35.8 vs. 40.7%, p < 0.001) and respiratory complications (1.1 vs. 4.4%, p < 0.001) compared with TA-TAVR. However, TF-TAVR was associated with a higher rate of vascular complications (2.9 vs. 0.9%, p < 0.001), cardiac tamponade (0.5 vs. 0.0%, p < 0.001), complete heart block (10.8 vs. 7.7%, p < 0.001) and pacemaker insertion (11.8 vs. 8.3%, p < 0.001). There was no difference between both groups in acute stroke (1.8 vs. 2.2%, p = 0.39), hemodialysis (2.0 vs. 2.2%, p = 0.71), and ventricular arrhythmias (4.9 vs. 4.2%, p = 0.19). Notably, TF-TAVR was associated with higher mortality, acute stroke, AKI, hemodialysis, PCI, and respiratory complications in complicated diabetics compared with non-complicated diabetics.

CONCLUSIONS

This observational analysis showed no difference in-hospital mortality between TF-TAVR and TA-TAVR among diabetic patients. Studies exploring the optimal access for TAVR among diabetics are recommended.

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

Objective

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

Methods

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

Results

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

Conclusion

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

The association of diabetes mellitus treated with oral antidiabetic drugs and insulin with mortality after transcatheter valve implantation: a 3-year follow-up of the TAVIK registry

BACKGROUND

Diabetes mellitus (DM) on insulin is a patient-related factor in the assessment of surgical risk based on the EuroSCORE II and, as such, it confers additional risk on outcomes after transcatheter aortic valve implantation (TAVI). The aim of this study was to investigate the effect of diabetes mellitus treated with insulin and oral antidiabetic drugs on clinical outcomes after TAVI.

METHODS

This study is an analysis of 2000 patients who underwent TAVI between 2008 and 2015. Patients were stratified post hoc into the following categories: without diabetes (n = 1337), with diabetes treated with oral antidiabetic drugs (OAD; n = 387) and with diabetes treated using insulin (n = 276).

RESULTS

There was no significant difference in device success (89.5% vs 89.4% vs 88.8%, adjusted odds ratio (adjOR) 1.10 [95% confidence interval (CI) 0.64-1.91]) and VARC-2-defined major complications among the three groups of patients (without DM, OAD, and insulin, respectively). Minor but not major or disabling strokes (adjOR 2.19; 95% CI 1.11-4.3) and overall renal complications (but not stage 2/3 alone) (adjOR 1.46; 95% CI 1.18-1.81) were more common in patients with diabetes than in those without diabetes. Insulin-treated patients had a significantly lower survival rate than that of patients with orally treated diabetes and of those without diabetes at 1 year (75.7% vs. 84.5% vs 84.7%, pairwise p < 0.01) and 3 years (56.9% vs. 65.9% vs. 67.9%, adj. p < 0.05) after TAVI. However, insulin-treated diabetes was not identified as an independent risk factor for higher mortality in the first (HR 1.29; 95% CI 0.97-1.72, p = 0.084) and 3rd years (HR 1.21; 95% CI 0.98-1.49; p = 0.079) after multivariable adjustment.

CONCLUSIONS

Although insulin-dependent DM is an established component of surgical risk assessment, it was not identified as an independent factor associated with reduced survival in TAVI. DM treated with oral antidiabetic drugs or insulin may have less role in decision making of treatment in TAVI candidates.

Type 2 diabetes mellitus increases long-term mortality risk after isolated surgical aortic valve replacement

BACKGROUND

Diabetes mellitus (DM) adversely affects morbidity and mortality for major atherosclerosis-related cardiovascular diseases and is associated with increased risk for the development of aortic stenosis. Clinical data regarding the impact of DM on outcomes of patients undergoing aortic valve replacement (AVR) have revealed inconsistent results. The aim of the current study was to investigate and compare the impact of type 2 DM on short-, intermediate- and long-term mortality between DM and non-DM patients who undergo isolated AVR.

METHODS

We performed an observational study in a large tertiary medical center over a 14-year period (2004-2018), which included all patients who had undergone isolated AVR surgery for the first time. Of the 1053 study patients, 346 patients (33%) had type 2 DM (DM group) and were compared with non-DM (non-DM group) patients (67%). Short-term (in-hospital), intermediate (1- and 3-years), and late (5- and 10-years) mortality were evaluated. Mean follow-up of was 69 ± 43 months.

RESULTS

Short-term (in-hospital) mortality was similar between the DM compared with the non-DM group: 3.5% and 2.5% (p = 0.517). Intermediate-term mortality (1- and 3-year) was higher in the DM group compared with the non-DM group, but did not reach statistical significance: 8.1% vs. 5.7% (p = 0.169) and 12.1% vs. 8.3% (p = 0.064) respectively. Long-term (5- and 10-year) mortality was significantly higher in the DM group, compared to the non-DM group: 19.4% vs. 12.9% (p = 0.007) and 30.3% vs. 23.5% (p = 0.020) respectively. Among the 346 DM patients, 55 (16%) were treated with insulin and 291 (84%) with oral antiglycemic medication only. Overall in-hospital mortality among insulin-treated DM patients was 7.3% compared with 2.7% among non insulin-treated DM patients (p = 0.201). Long-term mortality was higher in the subgroup of insulin-treated DM patients compared with the subgroup of non-insulin treated DM patients with an overall mortality rate of 36.4% vs. 29.2% (p = 0.039). Furthermore, predictors for late mortality included DM (HR 1.39 CI 1.03-1.86, p = 0.031) and insulin treatment (HR 1.76 CI 1.05-2.94, p = 0.033), as demonstrated after adjustment for confounders by multivariable analysis.

CONCLUSIONS

Type 2 DM is an independent predictor for long-term mortality after isolated AVR surgery.