Acute kidney injury after transcatheter aortic valve replacement in the elderly: outcomes and risk management

Age, creatinine, and ejection fraction score is a risk factor for acute kidney injury after surgical aortic valve replacement

BACKGROUND

The incidence of acute kidney injury (AKI) increases after surgical aortic valve replacement (SAVR). This study aimed to characterize the risk factors of AKI after SAVR.

METHODS AND RESULTS

We conducted a retrospective registry study based on data from 299 consecutive patients undergoing SAVR. At 48 h after SAVR, 41 patients developed AKI. There was a significantly higher prevalence of older age, higher body mass index (BMI), and diabetes mellitus in the AKI group. Previous use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACEI/ARB) and β-blocker, intake and output volumes within 24 h, mechanical ventilation time, length of intensive care unit and hospital stay, baseline creatinine, baseline, 24 h, and 48 h estimated glomerular filtration rate were strongly associated with the incidence of AKI. BMI >24, history of hypertension, use of ACEI/ARB and β-blocker, and mechanical ventilation time were associated with AKI. Univariate logistic regression indicated that overweight, hypertension, use of ACEI/ARB and β-blocker, and mechanical ventilation time were associated with AKI. Notably, the ACEF score was an independent predictor of AKI. The receiver operating characteristic curve was employed to assess the ACEF score for predicting AKI and the best cutoff was 1.1. After dividing ACEF into quartiles, each one-unit increment in ACEF led to a 2.27-fold risk in the incidence of AKI among patients.

CONCLUSIONS

AKI is a generalizable phenomenon occurring frequently after SAVR. The ACEF score is an independent predictor of AKI among patients undergoing SAVR.

Prognostic Value of the Tricuspid Regurgitation Impact on Outcomes (TRIO) Score in Patients Undergoing Transcatheter Aortic Valve Implantation

Background

Prognosis assessments for transcatheter aortic valve implantation (TAVI) patients remain challenging, particularly as the indications for TAVI expand to lower-risk patients. This study assessed the prognostic value of the tricuspid regurgitation impact on outcomes (TRIO) score in patients after TAVI.

Methods

This single-center study included 530 consecutive patients who underwent TAVI. Patients with a TRIO score >4 were compared to those with a score ≤4. The primary outcome was all-cause mortality, while secondary outcomes included complications defined by the Valve Academic Research Consortium 2 (VARC-2) criteria and major adverse cardiovascular events (MACEs), including mortality, stroke, and heart failure rehospitalization.

Results

Over a mean follow-up period of 22 months, patients with a TRIO score >4 had significantly higher rates of mortality (11.5% vs. 3.1%, p < 0.001) and MACEs (14.9% vs. 3.6%, p < 0.001). Multivariable Cox regression analysis identified a TRIO score >4 as an independent risk factor for all-cause mortality (hazard ratio (HR): 2.41, 95% confidence interval (CI): 1.08-5.37, p = 0.032) and MACEs (HR: 2.78, 95% CI: 1.34-5.75, p = 0.006). Patients with a higher TRIO score also had significantly higher rates of stroke (3.1% vs. 0.5%, p = 0.028), acute kidney injury (10.1% vs. 4.3%, p = 0.011), and MACEs (14.9% vs. 3.6%, p < 0.001) within 30 days after TAVI.

Conclusions

The TRIO score was associated with all-cause mortality and MACEs in patients after a TAVI. The TRIO score could serve as a convenient tool for risk stratification in clinical practice, aiding in identifying high-risk patients.

Incidence of Acute Kidney Injury Post Transcatheter Aortic Valve Implantation (TAVI): A Single-Center Experience

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) has dramatically changed the approach to treating aortic stenosis, particularly for patients unsuitable for surgical aortic valve replacement. Nevertheless, the possibility of quick deterioration of kidney function, known as acute kidney injury (AKI), post operation is considered one of the complications.

OBJECTIVES

The study aimed to determine the incidence of AKI in adults post TAVI.

METHODS

This retrospective cohort study focuses on patients who underwent the TAVI procedure at the King Faisal Cardiac Center at the Ministry of National Guard Health Affairs (MNGHA) in Jeddah, Saudi Arabia, from May 2016 to December 2022. Acute kidney injury post TAVI was defined based on RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) criteria. Chi-square tests and independent sample t-tests were used to compare clinical and demographic characteristics between patients who developed AKI with those who did not, using an alpha of 5%.

RESULTS

The study involved 103 adult patients. Among them, 11 (10.7%) developed AKI post TAVI within seven days of the procedure, while 92 (89.3%) did not. Findings also revealed that patients with hyperlipidemia and a previous history of kidney diseases faced a higher risk of AKI post TAVI. Despite its valuable insights, the study has limitations due to its retrospective nature and small sample size.

CONCLUSIONS

The study emphasizes the importance of identifying patients with hyperlipidemia and pre-existing kidney conditions and closely monitoring renal function. While some preventive methods did not significantly impact AKI occurrences, further research is needed to refine preventive strategies.

Association between hospital racial composition and aortic valve replacement outcomes: A national inpatients sample database analysis

BACKGROUND

Racial and ethnic disparities exist in the outcomes following surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI). However, it is unclear whether hospital racial composition contributes to these racial disparities.

METHODS

We analyzed the National Inpatient Sample (NIS) database from 2015 to 2019 to identify patients with aortic stenosis (AS) who received SAVR and TAVI. The Racial/Ethnic Diversity Index (RDI) was used to assess hospital racial composition as the proportion of nonwhite patients to total hospital admissions. Hospitals were categorized into RDI quintiles. Textbook outcome (TO) was defined as no in-hospital mortality, no postoperative complications and no prolonged length of stay (LOS). Multivariable mixed generalized linear models were conducted to assess the association between RDI and post-SAVR and post-TAVI outcomes. Moreover, quantile regression was used to assess the additional cost and length of stay associated with the RDI quintile.

RESULTS

The study included 82,502 SAVR or TAVI performed across 3285 hospitals, with 47.4% isolated SAVR and 52.5% isolated TAVI. After adjustment, quintiles 4 and 5 demonstrated significantly lower odds of TO than the lowest RDI quintile in both the SAVR cohort (quintile 4, 0.79 [95% CI, 0.73-0.85]; quintile 5, 0.79 [95% CI, 0.73-0.86]) and TAVI cohort (quintile 4, 0.88 [95% CI, 0.82-0.95]; quintile 5, 0.80 [95% CI, 0.74-0.86]). Despite non-observable differences in in-hospital mortality across all RDI quintiles, the rate of AKI and blood transfusion increased with increasing RDI for both cohorts. Further, Higher RDI quintiles were associated with increased costs and longer LOS. From 2015 to 2019, post-TAVI outcomes improved across all RDI quintiles.

CONCLUSIONS

Hospitals with a higher RDI experienced lower TO achievements, increased AKI, and blood transfusion, along with extended LOS and higher costs. Importantly, post-TAVI outcomes improved from 2015 to 2019 across all RDI groups.

Inpatient outcomes of transcatheter aortic valve replacement based on class of obesity

Transcatheter aortic valve replacement (TAVR) is a transformative option for severe aortic stenosis, especially in elderly patients. obesity's impact on TAVR outcomes is limited. Using the National Inpatient Sample from 2016 to 2020, We analyzed 217,300 TAVR hospitalizations across BMI groups. No difference in in-hospital mortality was observed, class III obesity experienced longer hospital stays (adjusted β: 0.43 days, P < 0.05), higher costs (adjusted β: $3,126, P < 0.05), increased heart failure exacerbation (adjusted odds ratio [aOR]: 2.68, 95% confidence interval [CI]: [1.03-7.01], p < 0.05), vascular access complications (aOR: 1.29, 95% CI: [1.07-1.52], P < 0.05), and post-operative pulmonary complications (Pneumonia (aOR: 1.42, 95% CI: [1.16-1.74], p < 0.05), acute hypoxic respiratory failure (aOR: 1.99, 95% CI: [1.67-2.36], p < 0.05), and non-invasive ventilation (aOR: 1.62, 95% CI: [1.07-2.44], p < 0.05). Complete heart block and permanent pacemaker requirement were higher in both class II and class III ((aOR: 1.30, 95% CI: [1.11-1.51], P < 0.05), (aOR:1.25, 95% CI: [1.06-1.46], P < 0.05) and ((aOR: 1.18, 95% CI: [1.00-1.40], P < 0.05), (aOR:1.22, 95% CI: [1.02-1.45], P < 0.05)) respectively. Understanding these links is crucial for optimizing TAVR care in obesity, ensuring enhanced outcomes, and procedural safety.

Transcatheter aortic valve replacement in patients with chronic kidney disease: a multi-centre retrospective study

Background

Chronic kidney disease (CKD) is a common comorbid condition in patients undergoing transcatheter aortic valve replacement (TAVR). Reported outcome studies on the association of baseline CKD and mortality is currently limited.

Objectives

To determine the prevalence of chronic kidney disease in patients undergoing TAVR and analyse their overall procedural outcomes.

Methods

This retrospective observational study was conducted at 43 publicly funded hospitals in Hong Kong. Severe aortic stenosis patients undergoing TAVR between the years 2010 and 2019 were enroled in the study. Two groups were identified according to the presence of baseline chronic kidney disease.

Results

A total of 499 patients (228, 58.6% men) were enroled in the study. Baseline hypertension was more prevalent in patients with CKD (82.8%; P=0.003). As for primary end-points, mortality rates of CKD patients were significantly higher compared to non-CKD patients (10% vs. 4.1%; P=0.04%). Gout and hypertension were found to be significantly associated with CRF. Patients with gout were nearly six times more likely to have CRF than those without gout (odds ratio = 5.96, 95% CI = 3.12-11.29, P<0.001). Patients with hypertension had three times the likelihood of having CRF compared to those without hypertension (odds ratio=2.83, 95% CI=1.45-6.08, P=0.004).

Conclusion

In patients with severe aortic stenosis undergoing TAVR, baseline CKD significantly contributes to mortality outcomes at long-term follow up.

Cardiovascular Outcomes of Transcatheter Aortic Valve Implantation in Patients With Chronic Kidney Disease in Octogenarian Population

Limited data are available regarding in-hospital outcomes of transcatheter aortic valve implantation (TAVI) in the octogenarian population with chronic kidney disease (CKD). We sought to study the cardiovascular outcomes of TAVI in CKD hospitalization with different stages at the national cohort registry. We used the National Inpatient Sample database to compare TAVI CKD low-grade (LG) (stage I to IIIa, b) versus TAVI CKD high-grade (HG) (stage IV to V) in octogenarians. Outcomes such as inpatient mortality, cardiogenic shock, new permanent pacemaker implantation, acute kidney injury), sudden cardiac arrest, mechanical circulatory support, major bleeding, transfusion, and resource utilization were compared between the 2 cohorts. A total of 74,766 octogenarian patients (TAVI CKD-HG n = 12,220; TAVI CKD-LG n = 62,545) were included in our study. On matched analysis, TAVI CKD-HG had higher odds of in-hospital mortality (adjusted odds ratio [aOR] 2.18, 95% confidence interval [CI] 1.0-2.5, p <0.0001), cardiogenic shock (aOR 1.22, 95% CI 1.07 to 1.39, p = 0.0019), permanent pacemaker implantation (aOR 1.14, 95% CI 1.06 to 1.23, p = 0.0006), acute kidney injury (aOR 1.19, 95% CI 1.13 to 1.27, p <0.0001), sudden cardiac arrest (aOR 1.32, 95% CI 1.09 to 1.61, p = 0.004), major bleeding (aOR 1.1, 95% CI 1.006 to 1.22, p <0.0368) and higher rates of blood transfusion (aOR 1.62, 95% CI 1.5 to 1.75, p <0.0001) when compared with the TAVI CKD-LG cohort. However, there was no statistically significant difference in the odds of cerebrovascular accident and mechanical circulatory support use between the 2 groups.

Impact of Acute Kidney Injury After Transcatheter Aortic Valve Replacement: A Nationwide Study

BACKGROUND

In patients undergoing transcatheter aortic valve replacement (TAVR), the impact of acute kidney injury (AKI) on the prognosis and especially on future kidney function has been sparsely examined, and data from large cohorts are warranted.

METHODS AND RESULTS

With Danish nationwide registries, we identified all patients undergoing TAVR from 2014 to 2021 with no previous dialysis treatment. According to 2 plasma creatinine samples, we identified those suffering a postprocedural AKI within 21 days after TAVR. With 1 year of follow-up, we compared the associated rates of dialysis treatment and death between patients with and without an AKI using multivariable Cox analysis. Finally, according to the lowest recorded creatinine sample, we assessed the kidney function among AKI survivors between 90 and 180 days after the index date. We identified 4091 TAVRs: 193 (4.7%) with AKI (55.4% men; median age, 82 years) and 3898 (95.3%) without AKI (57.0% men; median age, 81 years). Compared with those without AKI, patients with AKI showed increased associated 1-year rates of dialysis treatment (hazard ratio [HR], 7.20 [95% CI, 4.10-12.66]) and death (HR, 2.39 [95% CI, 1.59-3.58]). After 6 months, 74% of AKI survivors had complete kidney recovery, 14.7% had incomplete kidney recovery, 6.3% failed to recover, and 5.1% were on dialysis treatment.

CONCLUSIONS

We identified that AKI after TAVR was associated with an increased rate of future dialysis treatment and all-cause death. Among survivors, 74% had complete kidney recovery within 6 months.

Comparative Analysis of TAVR (Transcatheter Aortic Valve Replacement) and Surgical Valve Replacement for Low-Risk Patients

"Aortic stenosis" (AS) refers to a cardiac condition in which the aortic valve narrows, creating an obstruction that hinders the flow of blood from the left ventricle to the aorta. This contraction of the arteries influences normal blood circulation, leading to elevated pressure within the left ventricle and potentially culminating in heart failure. The management of AS typically involves two primary treatments, i.e. "surgical aortic valve replacement" (SAVR) and "transcatheter aortic valve replacement" (TAVR). In both cases, the goal is to replace a dysfunctional aortic valve with a functional substitute. Presently, TAVR has gained much preference over SAVR in clinical practice. However, there is a dearth of comprehensive research directly comparing the real-world outcomes of TAVR and SAVR. In recent years, TAVR has emerged as an attractive alternative to SAVR, yet studies that provide a detailed comparison of their real-world solutions are limited. This review article assesses the mortality of patients who underwent TAVR vis-a-vis patients who underwent SAVR.

Comparisons of different new-generation transcatheter aortic valve implantation devices for patients with severe aortic stenosis: a systematic review and network meta-analysis

BACKGROUND

Whether there are differences among the new-generation transcatheter aortic valve implantation (TAVI) devices for patients with aortic stenosis remains unclear. The aim of the study was to compare the efficiency and safety of different new-generation TAVI devices for patients with aortic stenosis.

MATERIALS AND METHODS

A comprehensive search of PubMed, Embase and Web of Science from their inception to 1 February 2022. Randomized clinical trials and observational studies that compared two or more different TAVI devices were enroled. Pairwise meta-analysis and frequentist network meta-analysis were conducted to pool the outcome estimates of interest.

RESULTS

A total of 79 studies were finally included. According to the surface under the cumulative ranking, the top two ranked valves for lower rates of events were as follows: direct flow medical (DFM) (4.6%) and Lotus (48.8%) for lower rate of device success; Sapien 3 (16.8%) and DFM (19.7%) for lower mortality; DFM (8.6%) and Sapien 3 (25.5%) for lower rates of stroke; Evolut (27.6%) and DFM (35.8%) for lower rates of major and life-threatening bleeding; Portico (22.6%) and Sapien 3 (41.9%) for lower rates of acute kidney injury; Acurate (8.6%) and DFM (13.2%) for lower rates of permanent pacemaker implantation; Lotus (0.3%) and Sapien 3 (22.7%) for lower rates of paravalvular leak; Evolut (1.4%) and Portico (29.1%) for lower rates of mean aortic valve gradients.

CONCLUSIONS

The findings of the present study suggested that the device success rates were comparable among these new-generation valves except for DFM. After excluding DFM, Sapien 3 might be the best effective for decreased mortality and stroke; Lotus might be the best effective for decreased paravalvular leak; Evolut might be the best effective for decreased major and life-threatening bleeding and mean aortic valve gradients; Acurate and Portico might be the best effective for decreased permanent pacemaker implantation and acute kidney injury, respectively.

Does the Type of Chronic Heart Failure Impact In-Hospital Outcomes for Aortic Valve Replacement Procedures?

BACKGROUND

This study assessed in-hospital outcomes of patients with chronic systolic, diastolic, or mixed heart failure (HF) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR).

METHODS

The Nationwide Inpatient Sample database was used to identify patients with aortic stenosis and chronic HF who underwent TAVR or SAVR between 2012 and 2015. Propensity score matching and multivariate logistic regression were used to determine outcome risk.

RESULTS

A cohort of 9,879 patients with systolic (27.2%), diastolic (52.2%), and mixed (20.6%) chronic HF were included. No statistically significant differences in hospital mortality were noted. Overall, patients with diastolic HF had the shortest hospital stays and lowest costs. Compared with patients with diastolic HF, the risk of acute myocardial infarction (TAVR odds ratio [OR], 1.95; 95% CI, 1.20-3.19; P = .008; SAVR OR, 1.38; 95% CI, 0.98-1.95; P = .067) and cardiogenic shock (TAVR OR, 2.15; 95% CI, 1.43-3.23; P < .001; SAVR OR, 1.89; 95% CI, 1.42-2.53; P ≤ .001) was higher in patients with systolic HF, whereas the risk of permanent pacemaker implantation (TAVR OR, 0.58; 95% CI, 0.45-0.76; P < .001; SAVR OR, 0.58; 95% CI, 0.40-0.84; P = .004) was lower following aortic valve procedures. In TAVR, the risk of acute deep vein thrombosis and kidney injury was higher, although not statistically significant, in patients with systolic HF than in those with diastolic HF.

CONCLUSION

These outcomes suggest that chronic HF types do not incur statistically significant hospital mortality risk in patients undergoing TAVR or SAVR.

Zero to Hero? Reducing the Rate of Acute Kidney Injury in Transcatheter Aortic Valve Replacement: The Low Contrast Approach

Background: Acute kidney injury (AKI) after transcatheter aortic valve replacement (TAVR) increases hospital stay, morbidity, and mortality, and the amount of contrast used during the procedure has been linked to the occurrence of AKI. Reducing the amount of contrast used during TAVR is hypothesized to decrease AKI without compromising outcomes. Methods: We conducted a single-institution retrospective analysis of patients who underwent TAVR from 2017 to 2019. Patients receiving ≤20 mL of contrast were labeled as group I, and patients receiving >20 mL of contrast were labeled as group II. Primary endpoints were 30-day mortality, AKI, and early aortic regurgitation. Results: A total of 594 patients met the inclusion and exclusion criteria, with 429 patients (72.2%) included in group I and 165 patients (27.8%) included in group II. Two hundred eighteen patients (50.8%) from group I and 41 patients (24.8%) from group II had preoperative chronic kidney disease stage III or IV. The mean contrast volume was 8.5 ± 6 mL for group I and 33 ± 16 mL for group II (P<0.001). In group I, 13 patients (3.0%) developed AKI, and 6 (1.4%) required hemodialysis. In group II, 9 (5.5%) patients developed AKI, and 1 (0.6%) required hemodialysis. The differences between the 2 groups for AKI and hemodialysis were not statistically significant. Overall, 579 patients (97.5%) had less than moderate aortic regurgitation in the postoperative echocardiogram. Conclusion: Low contrast TAVR is safe and effective and can reduce the incidence of AKI when compared to the standard contrast dose without affecting outcomes such as death and aortic regurgitation.

Effect of TAVR Approach and Other Baseline Factors on the Incidence of Acute Kidney Injury: A Systematic Review and Meta-Analysis

Background

Acute kidney injury (AKI) is a well-known complication following a transcatheter aortic valve replacement (TAVR) and is associated with higher morbidity and mortality.

Objective

We aim to compare the risk of developing AKI after transfemoral (TF), transapical (TA), and transaortic (TAo) approaches following TAVR.

Methods

We searched Medline and EMBASE databases from January 2009 to January 2021. We included studies that evaluated the risk of AKI based on different TAVR approaches. After extracting each study's data, we calculated the risk ratio and 95% confidence intervals using RevMan software 5.4. Publication bias was assessed by the forest plot.

Results

Thirty-six (36) studies, consisting of 70,406 patients undergoing TAVR were included. Thirty-five studies compared TF to TA, and only seven investigations compared TF to TAo. AKI was documented in 4,857 out of 50,395 (9.6%) patients that underwent TF TAVR compared to 3,155 out of 19,721 (16%) patients who underwent TA-TAVR, with a risk ratio of 0.49 (95% CI, 0.36–0.66; p < 0.00001). Likewise, 273 patients developed AKI out of the 1,840 patients (14.8%) that underwent TF-TAVR in contrast to 67 patients out of the 421 patients (15.9%) that underwent TAo-TAVR, with a risk ratio of 0.51 (95% CI, 0.27–0.98; p = 0.04). There was no significant risk when we compared TA to TAo approaches, with a risk ratio of 0.89 (95% CI, 0.29–2.75; p = 0.84).

Conclusion

The risk of post-TAVR AKI is significantly lower in patients who underwent TF-TAVR than those who underwent TA-TAVR or TAo-TAVR.

Managing complications after transcatheter aortic valve implantation

INTRODUCTION

Although transcatheter aortic valve implantation (TAVI) has become a streamlined and standardized procedure, different complications still remain and need the operators to be properly trained about their management.

AREAS COVERED

This review article aims at offering a practical overview of the most impactful TAVI complications, analyzing, and discussing the potential risk factors, and focusing on the available strategies for their management.

EXPERT OPINION

Complications following TAVI have been decreasing thanks to technical advancements and operators experience. The thorough knowledge of potential complications and their prevention played a key role in the decreasing of complications rates. Pre-procedural, computed tomography angiography assessment of patient's anatomical characteristics, allows to properly choose and tailor the best strategy for managing complications in most of cases. Nevertheless, further research is required to shed lights about the optimal strategies to adopt for managing TAVI complications.

Hemodynamic Performance of Two Current-Generation Transcatheter Heart Valve Prostheses in Severely Calcified Aortic Valve Stenosis

BACKGROUND

Treatment of severely calcified aortic valve stenosis is associated with a higher rate of paravalvular leakage (PVL) and permanent pacemaker implantation (PPI). We hypothesized that the self-expanding transcatheter heart valve (THV) prostheses Evolut Pro (EPro) is comparable to the balloon-expandable Sapien 3 (S3) regarding hemodynamics, PPI, and clinical outcome in these patients.

METHODS

From 2014 to 2019, all patients with very severe calcification of the aortic valve who received an EPro or an S3 THV were included. Propensity score matching was utilized to create two groups of 170 patients.

RESULTS

At discharge, there was significant difference in transvalvular gradients (EPro vs. S3) (dPmean 8.1 vs. 11.1 mmHg, p ≤ 0.001) and indexed effective orifice area (EOAi) (1.1 vs. 0.9, p ≤ 0.001), as well as predicted EOAi (1 vs. 0.9, p ≤ 0.001). Moderate patient prosthesis mismatch (PPM) was significantly lower in the EPro group (17.7% vs. 38%, p ≤ 0.001), as well as severe PPM (2.9% vs. 8.8%, p = 0.03). PPI and the PVL rate as well as stroke, bleeding, vascular complication, and 30-day mortality were comparable.

CONCLUSIONS

In patients with severely calcified aortic valves, both THVs performed similarly in terms of 30-day mortality, PPI rate, and PVL occurrence. However, patient prothesis mismatch was observed more often in the S3 group, which might be due to the intra-annular design.

Impact of anemia on short-term outcomes after TAVR: A subgroup analysis from the BRAVO-3 randomized trial

OBJECTIVES

To determine the prognostic impact of anemia in patients randomized to bivalirudin or unfractionated heparin (UFH) during transcatheter aortic valve replacement (TAVR).

BACKGROUND

Whether the periprocedural use of bivalirudin as compared with UFH in anemic patients undergoing TAVR has an impact on outcomes remains unknown.

METHODS

The BRAVO-3 trial compared the use of bivalirudin versus UFH in 802 high risk patients undergoing transfemoral TAVR for severe symptomatic aortic stenosis. Patients were stratified according to the presence (defined as hemoglobin levels <13 g/dl in men and <12 g/dl in women) or absence of anemia. The primary outcomes were net adverse cardiac events (NACE; a composite of all-cause mortality, myocardial infarction, stroke, or bleeding) and major bleeding (Bleeding Academic Research Consortium ≥3b) at 30 days.

RESULTS

Among 798 patients with available baseline hemoglobin levels, 427 (54%) were anemic of whom 221 (52%) received bivalirudin. There were no significant differences in NACE and major bleeding at 30 days between patients with and without anemia, irrespective of the type of anticoagulant used (p_interaction  = 0.71 for NACE, p_interaction  = 1.0 for major bleeding). However, anemic patients had a higher risk of major vascular complications (adjusted OR 2.43, 95% CI 1.42-4.16, p = 0.001), and acute kidney injury (adjusted OR 1.74, 95% CI 1.16-2.59, p = 0.007) compared to non-anemic patients at 30 days.

CONCLUSIONS

Anemia was not associated with a higher risk of NACE or major bleeding at 30 days after TAVR without modification of the treatment effects of periprocedural anticoagulation with bivalirudin versus UFH.

Association between time-related changes in routine blood morphological parameters and renal function after transcatheter aortic valve implantation - a preliminary study

Introduction

Transcatheter aortic valve implantation (TAVI) although minimally invasive is still accompanied by changes in blood morphological parameters, some of them linked to unfavorable outcomes.

Aim

To find any association between changes in blood morphology reflecting an inflammatory response and acute kidney injury (AKI).

Material and methods

This study involved 176 consecutive transfemoral TAVI patients with a mean age of 78.4 ±7.0 years. Serum creatinine concentration (CREA) and blood morphology were analyzed in the blood samples taken before the procedure, then approximately 1, 24, 48 and 72 hours after the procedure, and lastly at the time of discharge. Post-procedural maximal or minimal values (max/min) and max/min-to-bs ratio of the laboratory parameters were also calculated.

Results

Leucocyte (WBC) and neutrophil (NEUT) counts increased significantly after the procedure whereas lymphocyte (LYMPH) counts declined markedly, reaching the highest or lowest values 24 hours after the procedure. A significant increase in neutrophil-to-lymphocyte ratio (NLR) was observed. Platelet count (PLT) dropped to a minimum at 72 hours after TAVI but at discharge did not return to the admission level. TAVI was associated with a marked increase in CREA with a peak at 48 hours after the procedure (135.7 ±75.9 μM/l). Patients with AKI (n = 65; 36.9%) presented more pronounced variations in relative changes in counts of all blood morphological parameters. A positive moderate (r = 0.412) correlation between maximal NLR and relative CREA changes was noted.

Conclusions

TAVI is associated with significant changes in blood morphological parameters that reflect an inflammatory response. They are more pronounced among subjects with post-procedural AKI.

An Analysis of the Predictors of Major Bleeding After Transcatheter Aortic Valve Transplantation Using the National Inpatient Sample (2015-2018)

Background Transcatheter aortic valve replacement (TAVR) is now a common procedure to treat and improve quality of life, clinical outcomes, and self-sufficiency in high-risk patients with aortic stenosis, and its use has been expanding rapidly in younger and low-risk populations. The aim of this study was to evaluate the outcomes, trends, and predictors of major bleeding in patients undergoing TAVR. Methodology We utilized the National Inpatient Sample (NIS) data from the year 2015 to 2018. International Classification of Disease 10 codes were utilized to extract data. Baseline characteristics were compared using Pearson's chi-square test for categorical variables and independent samples t-test for continuous variables. A multivariable logistic regression model was used to evaluate the predictors of major bleeding. Propensity matching was done for adjusted analysis to compare outcomes in TAVR with and without major bleeding. The outcomes of interest in this study were (1) predictors of major bleeding after TAVR; (2) in-hospital mortality; and (3) resource utilization in terms of cost and length of stay. Results A total of 34,752 weighted hospitalizations for TAVR were included in the analysis. Of the patients undergoing the procedure, 2,294 (6.6%) had a major bleed while 32,458 (93.3%) did not. At baseline, patients with coagulopathy (odds ratio [OR]: 2.03; 95% confidence interval [CI]: 1.82-2.27), congestive heart failure (OR: 1.26; 95% CI: 1.13-1.40), chronic obstructive pulmonary disease (OR: 1.41; 95% CI: 1.29-1.55), liver disease (OR: 1.96; 95% CI: 1.61-2.39), peripheral vascular disease (OR: 1.29; 95% CI: 1.17-1.43), cerebrovascular disease (OR: 1.22; 95% CI: 1.07-1.38), end-stage renal disease (ESRD) (OR: 2.17; 95% CI: 1.82-2.59), and coronary artery disease (OR: 1.17; 95% Cl: 1.06-1.30) had higher adjusted rates of odds of major bleeding. Patients who had major bleeding had a higher median cost of stay (US$60,326 vs. US$45490) and length of stay (seven vs. three days). Conclusions Mortality is higher in patients with major bleeding, and at baseline, coagulopathy and ESRD are significant predictors of a major bleed in patients undergoing TAVR.

Mildly Increased Renin Expression in the Absence of Kidney Injury in the Murine Transverse Aortic Constriction Model

Cardiorenal syndrome type 2 is characterized by kidney failure as a consequence of heart failure that affects >50% of heart failure patients. Murine transverse aortic constriction (TAC) is a heart failure model, where pressure overload is induced on the heart without any systemic hypertension or its consequences. Whether renal function is altered in this model is debated, and if so, at which time post-TAC renal dysfunction starts to contribute to worsening of cardiac function. We therefore studied the effects of progressive heart failure development on kidney function in the absence of chronically elevated systemic blood pressure and renal perfusion pressure. C57BL/6J mice (N = 129) were exposed to TAC using a minimally invasive technique and followed from 3 to 70 days post-TAC. Cardiac function was determined with 3D ultrasound and showed a gradual decrease in stroke volume over time. Renal renin expression and plasma renin concentration increased with progressive heart failure, suggesting hypoperfusion of the kidney. In addition, plasma urea concentration, a surrogate marker for renal dysfunction, was increased post-TAC. However, no structural abnormalities in the kidney, nor albuminuria were present at any time-point post-TAC. Progressive heart failure is associated with increased renin expression, but only mildly affected renal function without inducing structural injury. In combination, these data suggest that heart failure alone does not contribute to kidney dysfunction in mice.

Acute Kidney Injury in Transcatheter Aortic Valve Replacement

Introduction

Transcatheter aortic valve replacement (TAVR) has been established as a standard of care for patients with severe aortic stenosis. We aim to study the predictors of acute kidney injury (AKI) after TAVR from a contemporary analysis using the National Inpatient Sample (NIS) database.

Methods

We performed a national analysis using the NIS database to evaluate predictors of acute kidney injury (AKI) after TAVR. Our study period was from 2015 to 2018, and we identified TAVR patients in all procedure fields. Patients aged less than 18 years were excluded from the study.

Results

We report data of 173,760 TAVR patients, of which 20,045 (11.5%) had AKI and 153,715 (88.4%) did not. There were three principal findings of our study. First, mortality was higher in patients with AKI compared to patients who did not have AKI (8% vs. 0.8%; p<0.01). Second, patients with chronic kidney disease, weight loss, liver disease, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, metastatic cancer, and peripheral vascular disease had higher adjusted odds of AKI. Third, length of stay and cost of stay were significantly higher in patients who had AKI during the index admission. 

Conclusion

Patients with AKI had higher in-hospital mortality. We also report that at baseline, chronic kidney disease, weight loss, liver disease, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, metastatic cancer, and peripheral vascular disease were important predictors of AKI in patients after TAVR. Length of stay and cost of stay were higher with AKI, which result in higher burden on the health care system due to increased resource utilization.

Critical Limb Ischemia in a Young Patient With a Mechanical Aortic Valve Leading to Bilateral Above-Knee Amputation

This case reports a 24-year-old female with prior aortic insufficiency who underwent a mechanical aortic valve replacement with subsequent transient ischemic attacks and documented subtherapeutic international normalized ratio (INR). She presented with pain and bilateral lower extremity pulselessness. Workup showed a supratherapeutic INR, no thrombus on echocardiogram, and computed tomography angiography demonstrating no flow in the bilateral common femoral arteries. Patient failed repeated thrombectomies and had a bilateral above-knee amputation. The patient was suspected to have acute on chronic emboli from the mechanical aortic valve and further testing did not elucidate contributory causes of her critical limb ischemia. We believe this is the first documented case of bilateral lower extremity ischemia due to mechanical valve complications.

Predicting Acute Kidney Injury: A Machine Learning Approach Using Electronic Health Records

Acute kidney injury (AKI) is a common complication in hospitalized patients and can result in increased hospital stay, health-related costs, mortality and morbidity. A number of recent studies have shown that AKI is predictable and avoidable if early risk factors can be identified by analyzing Electronic Health Records (EHRs). In this study, we employ machine learning techniques to identify older patients who have a risk of readmission with AKI to the hospital or emergency department within 90 days after discharge. One million patients’ records are included in this study who visited the hospital or emergency department in Ontario between 2014 and 2016. The predictor variables include patient demographics, comorbid conditions, medications and diagnosis codes. We developed 31 prediction models based on different combinations of two sampling techniques, three ensemble methods, and eight classifiers. These models were evaluated through 10-fold cross-validation and compared based on the AUROC metric. The performances of these models were consistent, and the AUROC ranged between 0.61 and 0.88 for predicting AKI among 31 prediction models. In general, the performances of ensemble-based methods were higher than the cost-sensitive logistic regression. We also validated features that are most relevant in predicting AKI with a healthcare expert to improve the performance and reliability of the models. This study predicts the risk of AKI for a patient after being discharged, which provides healthcare providers enough time to intervene before the onset of AKI.

Transcatheter and Surgical Aortic Valve Replacement Outcomes for Patients with Chronic Heart Failure

OBJECTIVES

To determine in-hospital outcomes and assess high-risk groups among chronic heart failure (CHF) patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR).

DESIGN

A retrospective analysis of the Nationwide Inpatient Sample database from January 2012 to September 2015 was performed.

SETTING

Hospitals across the United States that offer TAVRs or SAVRs.

PARTICIPANTS

Adults with a diagnosis of CHF and AS.

INTERVENTIONS

The patients underwent either TAVR or SAVR.

MEASUREMENTS AND MAIN RESULTS

Totals of 5,871 and 4,008 CHF patients underwent TAVR and SAVR, respectively. TAVR patients were significantly older, more were female, and had a higher comorbidity burden. No significant differences in in-hospital mortality were noted between TAVR and SAVR. However, mean length of stay was significantly longer by 3.5 days in the SAVR group, as was the mean total cost. With the exception of complete heart block, permanent pacemaker implantation, and vascular complications, the majority of postoperative events were higher among the SAVR group. Multivariate regression analysis identified postoperative cardiac, respiratory and renal complications as significant predictors of in-hospital mortality for both groups. Additionally, age ≥75 years and vascular complications were significant predictors of mortality for patients undergoing TAVR.

CONCLUSIONS

Among CHF patients with symptomatic AS, TAVR had similar in-hospital mortality rate compared with SAVR despite higher comorbidity burden. TAVR patients are at a lower risk of cardiovascular, respiratory, and renal complications and might lead to reduced length of hospital stay and cost. Hence, TAVR may be a safer option in this population.