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Benck KN, Nesbitt K, Dranow E, Glotzbach JP, Tandar A, Pereira SJ. Transcatheter Aortic Valve Replacement Improves Quality of Life and Ventricular Function With Low-Flow/Low-Gradient Aortic Stenosis. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101266. [PMID: 38699658 PMCID: PMC11065317 DOI: 10.1016/j.jscai.2023.101266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Background D2 aortic stenosis (AS) is the highest risk AS subtype with worse operative and mortality outcomes. This study aimed to investigate the quality of life (QoL) and left ventricular ejection fraction (LVEF) in patients with classic (D2 subtype) low-flow/low-gradient AS who underwent transcatheter aortic valve replacement (TAVR). Methods In total, 634 patients with severe AS underwent TAVR at our institution from 2014 to 2020, of whom 76 met criteria for classic D2 AS with reduced LVEF. Echocardiographic and clinical outcomes including mortality, stroke, pacemaker placement (PPM), and readmission at baseline were compared with those at 30 days and 1 year. QoL data were extracted from the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Results The average baseline Society of Thoracic Surgeons risk score for patients with D2 AS was 7.66 ± 6.76. Patients with D2 AS reported improved QoL post-TAVR. The average baseline KCCQ-12 score was 39.5 ± 20, with improvement to 68.9 ± 20.6 at 30 days (P < .01) and 74.9 ± 17.5 at 1 year (P < .01). Mortality was 0% at 30 days and 18.4% at 1 year. The average baseline LVEF was 36.1 ± 9.4. Left ventricular function improved to 43.5 ± 12.9 (P <.001) at 30 days and 46.3 ± 11.2 (P = .03) at 1 year. Complications post-TAVR at 30 days included stroke (1.3%) and PPM (11.8%). Patients with D2 AS exhibited higher baseline conduction defects including atrial fibrillation and higher postoperative PPM than those with other subtypes. Conclusions Patients with D2 AS had significantly improved LVEF and QoL following TAVR at 30 days and 1 year. Postoperative rates of new PPM were higher than other subtypes, while stroke, dialysis, and mortality were lower than expected, supporting the benefit of TAVR in this high-risk group.
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Affiliation(s)
- Kelley N. Benck
- University of Miami Miller School of Medicine, Miami, Florida
| | - Kristin Nesbitt
- University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, Utah
| | - Elizabeth Dranow
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health, Salt Lake City, Utah
| | - Jason P. Glotzbach
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
| | - Anwar Tandar
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah Health, Salt Lake City, Utah
| | - Sara J. Pereira
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah
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Oikonomou G, Apostolos A, Drakopoulou M, Simopoulou C, Karmpalioti M, Toskas P, Stathogiannis K, Xanthopoulou M, Ktenopoulos N, Latsios G, Synetos A, Tsioufis C, Toutouzas K. Long-Term Outcomes of Aortic Stenosis Patients with Different Flow/Gradient Patterns Undergoing Transcatheter Aortic Valve Implantation. J Clin Med 2024; 13:1200. [PMID: 38592019 PMCID: PMC10932005 DOI: 10.3390/jcm13051200] [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: 01/29/2024] [Revised: 02/11/2024] [Accepted: 02/16/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Few data exist on the comparative long-term outcomes of severe aortic stenosis (AS) patients with different flow-gradient patterns undergoing transcatheter aortic valve implantation (TAVI). This study sought to evaluate the impact of the pre-TAVI flow-gradient pattern on long-term clinical outcomes after TAVI and assess changes in the left ventricular ejection fraction (LVEF) of different subtypes of AS patients following TAVI. Methods: Consecutive patients with severe AS undergoing TAVI in our institution were screened and prospectively enrolled. Patients were divided into four subgroups according to pre-TAVI flow/gradient pattern: (i) low flow-low gradient (LF-LG): stroke volume indexed (SVi) ≤ 35 mL/m2 and mean gradient (MG) < 40 mmHg); (ii) normal flow-low gradient (NF-LG): SVi > 35 mL/m2 and MG < 40 mmHg; (iii) low flow-high gradient (LF-HG): Svi 35 mL/m2 and MG ≥ 40 mmHg and (iv) normal flow-high gradient (NF-HG): SVi > 35 mL/m2 and MG ≥ 40 mmHg. Transthoracic echocardiography was repeated at 1-year follow-up. Clinical follow-up was obtained at 12 months, and yearly thereafter until 5-year follow-up was complete for all patients. Results: A total of 272 patients with complete echocardiographic and clinical follow-up were included in our analysis. Their mean age was 80 ± 7 years and the majority of patients (N = 138, 50.8%) were women. 62 patients (22.8% of the study population) were distributed in the LF-LG group, 98 patients (36%) were LF-HG patients, 95 patients (34.9%) were NF-HG, and 17 patients (6.3%) were NF-LG. There was a greater prevalence of comorbidities among LF-LG AS patients. One-year all-cause mortality differed significantly between the four subgroups of AS patients (log-rank p: 0.022) and was more prevalent among LF-LG patients (25.8%) compared to LF-HG (11.3%), NF-HG (6.3%) and NF-LG patients (18.8%). At 5-year follow-up, global mortality remained persistently higher among LF-LG patients (64.5%) compared to LF-HG (47.9%), NF-HG (42.9%), and NF-LG patients (58.8%) (log-rank p: 0.029). At multivariable Cox hazard regression analysis, baseline SVi (HR: 0.951, 95% C.I.; 0.918-0.984), the presence of at least moderate tricuspid regurgitation at baseline (HR: 3.091, 95% C.I: 1.645-5.809) and at least moderate paravalvular leak (PVL) post-TAVI (HR: 1.456, 95% C.I.: 1.106-1.792) were significant independent predictors of late global mortality. LF-LG patients and LF-HG patients exhibited a significant increase in LVEF at 1-year follow-up. A lower LVEF (p < 0.001) and a lower Svi (p < 0.001) at baseline were associated with LVEF improvement at 1-year. Conclusions: Patients with LF-LG AS have acceptable 1-year outcomes with significant improvement in LVEF at 1-year follow-up, but exhibit exceedingly high 5-year mortality following TAVI. The presence of low transvalvular flow and at least moderate tricuspid regurgitation at baseline and significant paravalvular leak post-TAVI were associated with poorer long-term outcomes in the entire cohort of AS patients. The presence of a low LVEF or a low SVi predicts LVEF improvement at 1-year.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Konstantinos Toutouzas
- First Department of Cardiology, National and Kapodistrian University, “Hippokration” General Hospital of Athens, 11527 Athens, Greece; (G.O.); (A.A.); (M.D.); (C.S.); (M.K.); (P.T.); (K.S.); (M.X.); (N.K.); (G.L.); (A.S.); (C.T.)
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3
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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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Ferruzzi GJ, Silverio A, Giordano A, Corcione N, Bellino M, Attisano T, Baldi C, Morello A, Biondi‐Zoccai G, Citro R, Vecchione C, Galasso G. Prognostic Impact of Mitral Regurgitation Before and After Transcatheter Aortic Valve Replacement in Patients With Severe Low-Flow, Low-Gradient Aortic Stenosis. J Am Heart Assoc 2023; 12:e029553. [PMID: 37646211 PMCID: PMC10547324 DOI: 10.1161/jaha.123.029553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/13/2023] [Indexed: 09/01/2023]
Abstract
Background There is little evidence about the prognostic role of mitral regurgitation (MR) in patients with low-flow, low-gradient aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). The aim of this study was to assess the prevalence and outcome implications of MR severity in patients with low-flow, low-gradient aortic stenosis undergoing TAVR, and to evaluate whether MR improvement after TAVR could influence clinical outcome. Methods and Results This study included consecutive patients with low-flow, low-gradient aortic stenosis undergoing TAVR at 2 Italian high-volume centers. The study population was categorized according to the baseline MR severity and to the presence of MR improvement at discharge. The primary outcome was the composite of all-cause death and hospitalization for worsening heart failure up to 1 year. The study included 268 patients; 57 (21%) patients showed MR >2+. Patients with MR >2+ showed a lower 1-year survival free from the primary outcome (P<0.001), all-cause death (P<0.001), and heart failure hospitalization (P<0.001) compared with patients with MR ≤2+. At multivariable analysis, baseline MR >2+ was an independent predictor of the primary outcome (P<0.001). Among patients with baseline MR >2+, MR improvement was reported in 24 (44%) cases after TAVR. The persistence of MR was associated with a significantly reduced survival free from the primary outcome, all-cause death, and heart failure hospitalization up to 1 year. Conclusions In this study, the presence of moderately severe to severe MR in patients with low-flow, low-gradient aortic stenosis undergoing TAVR portends a worse clinical outcome at 1 year. TAVR may improve MR severity in nearly half of the patients, resulting in a potential outcome benefit after discharge.
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Affiliation(s)
| | - Angelo Silverio
- Department of Medicine, Surgery and DentistryUniversity of SalernoBaronissi (Salerno)Italy
| | - Arturo Giordano
- Interventional Cardiology UnitPineta Grande HospitalCasertaItaly
| | - Nicola Corcione
- Interventional Cardiology UnitPineta Grande HospitalCasertaItaly
| | - Michele Bellino
- Department of Medicine, Surgery and DentistryUniversity of SalernoBaronissi (Salerno)Italy
| | - Tiziana Attisano
- Interventional Cardiology UnitUniversity Hospital San Giovanni di Dio e Ruggi d'AragonaSalernoItaly
| | - Cesare Baldi
- Interventional Cardiology UnitUniversity Hospital San Giovanni di Dio e Ruggi d'AragonaSalernoItaly
| | - Alberto Morello
- Interventional Cardiology UnitPineta Grande HospitalCasertaItaly
| | - Giuseppe Biondi‐Zoccai
- Department of Medical‐Surgical Sciences and BiotechnologiesSapienza University of RomeLatinaItaly
- Mediterranea CardiocentroNaplesItaly
| | - Rodolfo Citro
- Cardiovascular and Thoracic DepartmentUniversity Hospital San Giovanni di Dio e Ruggi d’AragonaSalernoItaly
- Vascular Pathophysiology Unit, IRCCS NeuromedIserniaItaly
| | - Carmine Vecchione
- Department of Medicine, Surgery and DentistryUniversity of SalernoBaronissi (Salerno)Italy
- Vascular Pathophysiology Unit, IRCCS NeuromedIserniaItaly
| | - Gennaro Galasso
- Department of Medicine, Surgery and DentistryUniversity of SalernoBaronissi (Salerno)Italy
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5
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Sato K, Seo Y, Ishizu T, Albakaa NK, Izumo M, Okada A, Izumi C, Inami S, Takeda Y, Onishi T, Izumi Y, Kumagai A, Fukuda T, Takahashi N, Kitai T, Iwano H, Sugawara S, Akasaka K, Harada K, Masaoka Y, Kusunose K, Tanabe K, Sakamoto T, Takamura T, Ieda M. Cardiac Reversibility and Survival After Transcatheter Aortic Valve Implantation in Patients With Low-Gradient Aortic Stenosis. J Am Heart Assoc 2023; 12:e029717. [PMID: 37581389 PMCID: PMC10492952 DOI: 10.1161/jaha.123.029717] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/11/2023] [Indexed: 08/16/2023]
Abstract
Background Prognostic implications of transcatheter aortic valve implantation (TAVI) in low-gradient (LG) aortic stenosis (AS) remain controversial. The authors hypothesized that differences in cardiac functional recovery may solve this ongoing controversy. The aim was to evaluate clinical outcomes and the response of left ventricular (LV) function following TAVI in patients with LG AS. Methods and Results This multicenter retrospective study included 1742 patients with severe AS undergoing TAVI between January 2015 and March 2019. Patients were subdivided into low-flow (LF) LG, normal-flow (NF) LG, LF high-gradient, and NF high-gradient AS groups according to the mean gradient of the aortic valve (LG <40 mm Hg) and LV stroke volume index (LF <35 mL/m2). Outcomes and changes in echocardiographic parameters after TAVI were compared between the groups. A total of 227 patients (13%) had reduced ejection fraction, and 486 patients (28%) had LG AS (LF-LG 143 [8%]; NF-LG 343 [20%]). During a median follow-up period of 747 days, 301 patients experienced a composite end point of cardiovascular death and rehospitalization for cardiovascular events, which was higher in the LF-LG and NF-LG groups than in the high-gradient groups. LG AS was independently associated with the primary outcome (hazard ratio, 1.69; P<0.001). Among 1239 patients with follow-up echocardiography, LG AS showed less improvement in the LV mass index and LV end-diastolic volume compared with high-gradient AS after 1 year, while LV recovery was similar between the LF AS and NF AS groups. Conclusions LG AS was associated with poorer outcomes and LV recovery, regardless of flow status after TAVI. Careful evaluation of AS severity may be required in LG AS to provide TAVI within the appropriate time and advanced care afterward.
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Affiliation(s)
- Kimi Sato
- Department of Cardiology, Faculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Yoshihiro Seo
- Department of CardiologyNagoya City University Graduate School of Medical SciencesNagoyaJapan
| | - Tomoko Ishizu
- Department of Cardiology, Faculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Noor K. Albakaa
- Department of Cardiology, Faculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Masaki Izumo
- Division of CardiologySt. Marianna Medical University HospitalKawasakiJapan
| | - Atsushi Okada
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Chisato Izumi
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Shu Inami
- Department of Cardiovascular MedicineDokkyo Medical UniversityMibuJapan
| | - Yasuharu Takeda
- Department of Cardiovascular MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Toshinari Onishi
- Department of Cardiovascular MedicineSakai City Hospital OrganizationSakaiJapan
| | - Yuki Izumi
- Department of CardiologySakakibara Heart InstituteTokyoJapan
| | - Akiko Kumagai
- Division of Cardiology, Department of Internal MedicineIwate Medical UniversityIwateJapan
| | - Tomoko Fukuda
- Department of Cardiology and Clinical Examination, Faculty of MedicineOita UniversityOitaJapan
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of MedicineOita UniversityOitaJapan
| | - Takeshi Kitai
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterOsakaJapan
- Department of Cardiovascular MedicineKobe City Medical Center General HospitalKobeJapan
| | - Hiroyuki Iwano
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of MedicineHokkaido UniversitySapporoJapan
- Division of CardiologyTeine Keijinkai HospitalSapporoJapan
| | - Shigeo Sugawara
- Department of CardiologyNihonkai General HospitalYamagataJapan
| | - Kazumi Akasaka
- Medical Laboratory and Blood CenterAsahikawa Medical University HospitalAsahikawaJapan
| | - Kenji Harada
- Division of Cardiovascular Medicine, Department of Internal MedicineJichi Medical UniversityTochigiJapan
| | - Yoshiko Masaoka
- Department of CardiologyHiroshima City Hiroshima Citizens HospitalHiroshimaJapan
| | - Kenya Kusunose
- Department of Cardiovascular MedicineTokushima University HospitalTokushimaJapan
| | - Kazuaki Tanabe
- Division of CardiologyShimane University Faculty of MedicineIzumoJapan
| | - Takahiro Sakamoto
- Division of CardiologyShimane University Faculty of MedicineIzumoJapan
| | | | - Masaki Ieda
- Department of Cardiology, Faculty of MedicineUniversity of TsukubaTsukubaJapan
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6
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Rahman F, Mehta HH, Resar JR, Hasan RK, Marconi W, Aziz H, Czarny MJ. Outcomes among patients undergoing transcatheter aortic valve replacement with very low baseline gradients. Front Cardiovasc Med 2023; 10:1194360. [PMID: 37600049 PMCID: PMC10436597 DOI: 10.3389/fcvm.2023.1194360] [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: 03/27/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Background While there is evidence that patients with low-flow, low-gradient aortic stenosis (AS) benefit from transcatheter aortic valve replacement (TAVR), data are lacking regarding outcomes of patients with a very low gradient (VLG). Methods In this retrospective, single-center study of patients with severe AS who underwent TAVR, three groups were defined using baseline mean aortic valve gradient: VLG (≤25 mmHg), low gradient (LG, 26-39 mmHg), and high gradient (HG, ≥40 mmHg). The primary outcome was the composite of Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 of <45, decrease in KCCQ-12 of ≥10 compared with baseline, or death at 1 year. Results One-thousand six patients were included: 571 HG, 353 LG, and 82 VLG. The median age was 82.1 years [interquartile range (IQR) 76.3-86.9]; VLG patients had more baseline comorbidities compared with the other groups. The primary outcome was highest at 1 year in the VLG group (VLG, 46.7%; LG, 29.9%; HG, 23.1%; p = 0.002), with no difference between groups after adjustment for baseline characteristics. At baseline, <30% of VLG patients had an excellent or good (50-100) KCCQ-12, whereas more than 75% and 50% had an excellent or good KCCQ-12 at 30-day and 1-year follow-up, respectively. Conclusion Although patients with VLG undergoing TAVR have a higher rate of poor outcomes at 1 year compared with patients with LG and HG severe AS, this difference is largely attributable to baseline comorbidities. Patients with severe AS undergoing TAVR have significant improvement in health status outcomes regardless of resting mean gradient.
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Affiliation(s)
- Faisal Rahman
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Hetal H. Mehta
- Division of Cardiology, Doylestown Health, Doylestown, PA, United States
| | - Jon R. Resar
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Rani K. Hasan
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Wendy Marconi
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Hamza Aziz
- Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Matthew J. Czarny
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
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7
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Wagener M, Reuthebuch O, Heg D, Tüller D, Ferrari E, Grünenfelder J, Huber C, Moarof I, Muller O, Nietlispach F, Noble S, Roffi M, Taramasso M, Templin C, Toggweiler S, Wenaweser P, Windecker S, Stortecky S, Jeger R. Clinical Outcomes in High-Gradient, Classical Low-Flow, Low-Gradient, and Paradoxical Low-Flow, Low-Gradient Aortic Stenosis After Transcatheter Aortic Valve Implantation: A Report From the SwissTAVI Registry. J Am Heart Assoc 2023:e029489. [PMID: 37301760 DOI: 10.1161/jaha.123.029489] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/05/2023] [Indexed: 06/12/2023]
Abstract
Background In view of the rising global burden of severe symptomatic aortic stenosis, its early recognition and treatment is key. Although patients with classical low-flow, low-gradient (C-LFLG) aortic stenosis have higher rates of death after transcatheter aortic valve implantation (TAVI) when compared with patients with high-gradient (HG) aortic stenosis, there is conflicting evidence on the death rate in patients with severe paradoxical low-flow, low-gradient (P-LFLG) aortic stenosis. Therefore, we aimed to compare outcomes in real-world patients with severe HG, C-LFLG, and P-LFLG aortic stenosis undergoing TAVI. Methods and Results Clinical outcomes up to 5 years were addressed in the 3 groups of patients enrolled in the prospective, national, multicenter SwissTAVI registry. A total of 8914 patients undergoing TAVI at 15 heart valve centers in Switzerland were analyzed for the purpose of this study. We observed a significant difference in time to death at 1 year after TAVI, with the lowest observed in HG (8.8%) aortic stenosis, followed by P-LFLG (11.5%; hazard ratio [HR], 1.35 [95% CI, 1.16-1.56]; P<0.001) and C-LFLG (19.8%; HR, 1.93 [95% CI, 1.64-2.26]; P<0.001) aortic stenosis. Cardiovascular death showed similar differences between the groups. At 5 years, the all-cause death rate was 44.4% in HG, 52.1% in P-LFLG (HR, 1.35 [95% CI, 1.23-1.48]; P<0.001), and 62.8% in C-LFLG aortic stenosis (HR, 1.7 [95% CI, 1.54-1.88]; P<0.001). Conclusions Up to 5 years after TAVI, patients with P-LFLG have higher death rates than patients with HG aortic stenosis but lower death rates than patients with C-LFLG aortic stenosis.
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Affiliation(s)
- Max Wagener
- University Hospital Basel, University of Basel Switzerland
- University Hospital Galway, University of Galway Ireland
| | | | - Dik Heg
- CTU Bern, University of Bern Switzerland
| | | | | | | | - Christoph Huber
- University Hospital Geneva, University of Geneva Switzerland
| | | | - Olivier Muller
- University Hospital Lausanne, University of Lausanne Switzerland
| | - Fabian Nietlispach
- Cardiovascular Center Zürich, Hirslanden Klinik Im Park Zürich Switzerland
| | - Stéphane Noble
- University Hospital Geneva, University of Geneva Switzerland
| | - Marco Roffi
- University Hospital Geneva, University of Geneva Switzerland
| | | | | | | | | | - Stephan Windecker
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Stefan Stortecky
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Raban Jeger
- University Hospital Basel, University of Basel Switzerland
- Triemli Hospital Zürich Zürich Switzerland
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8
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Patel KP, Vandermolen S, Cooper J, Pugliese F, Ozkor M, Kennon S, Mathur A, Khanji MY, Mullen MJ, Baumbach A, Awad WI. Comparing Outcomes Between Surgical and Transcatheter Aortic Valve Replacement in Classical Low-Flow Low-Gradient Aortic Stenosis. Am J Cardiol 2023; 192:206-211. [PMID: 36842338 DOI: 10.1016/j.amjcard.2023.01.020] [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] [Received: 10/30/2022] [Revised: 12/29/2022] [Accepted: 01/13/2023] [Indexed: 02/27/2023]
Abstract
Patients with classic low-flow low-gradient (cLFLG) aortic stenosis (AS) have a poor prognosis but still benefit from aortic valve replacement. There is a paucity of evidence to guide the choice between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). This study compared procedural and midterm outcomes in patients with cLFLG AS between TAVR and SAVR. Patients with cLFLG AS, defined as an aortic valve area ≤1 cm2, mean gradient <40 mm Hg, and left ventricular ejection fraction <50%, were selected from a single center between 2015 and 2020. Inverse probability weighting and regression were used to adjust for differences in baseline characteristics, the nonrandom assignment of treatment modalities, and procedural differences. The primary end point was all-cause mortality. A total of 322 patients (220 TAVR and 102 SAVR) were included. At a follow-up of 4.4 ± 1.5 years, the adjusted hazard ratio (HR) for mortality after inverse probability weighting with SAVR was 0.66, 95% confidence interval (CI) 0.31 to 1.35; p = 0.24. Worse renal function at baseline (per 10 ml/min/m2 increase HR 0.92, 95% CI 0.84 to 1.00, p = 0.04) and multiple valve interventions (HR 5.39, 95% CI 2.62 to 11.12, p <0.001) independently predicted mortality. There was no difference in stroke and permanent pacemaker implantation, but the rates of renal replacement therapy were higher among the SAVR cohort: 13.7% versus 0%; p <0.001. In conclusion, among patients with cLFLG AS, there was no difference in midterm mortality between TAVR and SAVR, supporting the use of either treatment. However, in patients with poor renal function or at risk of renal failure, TAVR may be the preferred option.
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Affiliation(s)
- Kush P Patel
- Barts Heart Center, West Smithfield, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Sebastian Vandermolen
- Barts Heart Center, West Smithfield, London, United Kingdom; National Institute for Heart Research Barts Biomedical Research Center and Center for Advanced Cardiovascular Imaging, William Harvey Research Institute, Queen Mary University of London, United Kingdom
| | - Jackie Cooper
- Barts Heart Center, West Smithfield, London, United Kingdom; National Institute for Heart Research Barts Biomedical Research Center and Center for Advanced Cardiovascular Imaging, William Harvey Research Institute, Queen Mary University of London, United Kingdom
| | - Francesca Pugliese
- Barts Heart Center, West Smithfield, London, United Kingdom; National Institute for Heart Research Barts Biomedical Research Center and Center for Advanced Cardiovascular Imaging, William Harvey Research Institute, Queen Mary University of London, United Kingdom
| | - Mick Ozkor
- Barts Heart Center, West Smithfield, London, United Kingdom
| | - Simon Kennon
- Barts Heart Center, West Smithfield, London, United Kingdom
| | - Anthony Mathur
- Barts Heart Center, West Smithfield, London, United Kingdom; Center for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom
| | - Mohammed Y Khanji
- Barts Heart Center, West Smithfield, London, United Kingdom; National Institute for Heart Research Barts Biomedical Research Center and Center for Advanced Cardiovascular Imaging, William Harvey Research Institute, Queen Mary University of London, United Kingdom
| | - Michael J Mullen
- Barts Heart Center, West Smithfield, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Andreas Baumbach
- Barts Heart Center, West Smithfield, London, United Kingdom; Center for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom
| | - Wael I Awad
- Barts Heart Center, West Smithfield, London, United Kingdom; Center for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, United Kingdom.
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9
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Lee G, Chikwe J, Milojevic M, Wijeysundera HC, Biondi-Zoccai G, Flather M, Gaudino MFL, Fremes SE, Tam DY. ESC/EACTS vs. ACC/AHA guidelines for the management of severe aortic stenosis. Eur Heart J 2023; 44:796-812. [PMID: 36632841 DOI: 10.1093/eurheartj/ehac803] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 11/08/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023] Open
Abstract
Aortic stenosis (AS) is a serious and complex condition, for which optimal management continues to evolve rapidly. An understanding of current clinical practice guidelines is critical to effective patient care and shared decision-making. This state of the art review of the 2021 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines and 2020 American College of Cardiology/American Heart Association Guidelines compares their recommendations for AS based on the evidence to date. The European and American guidelines were generally congruent with the exception of three key distinctions. First, the European guidelines recommend intervening at a left ventricular ejection fraction of 55%, compared with 60% over serial imaging by the American guidelines for asymptomatic patients. Second, the European guidelines recommend a threshold of ≥65 years for surgical bioprosthesis, whereas the American guidelines employ multiple age categories, providing latitude for patient factors and preferences. Third, the guidelines endorse different age cut-offs for transcatheter vs. surgical aortic valve replacement, despite limited evidence. This review also discusses trends indicating a decreasing proportion of mechanical valve replacements. Finally, the review identifies gaps in the literature for areas including transcatheter aortic valve implantation in asymptomatic patients, the appropriateness of Ross procedures, concomitant coronary revascularization with aortic valve replacement, and bicuspid AS. To summarize, this state of the art review compares the latest European and American guidelines on the management of AS to highlight three areas of divergence: timing of intervention, valve selection, and surgical vs. transcatheter aortic valve replacement criteria.
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Affiliation(s)
- Grace Lee
- Temerty Faculty of Medicine, 1 King's College Circle, Toronto, ON M5S1A8, Canada
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 San Vicente Blvd a3600, Los Angeles, CA 90048, USA
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Heroja Milana Tepića 1, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, M4N 3M5, University of Toronto, Toronto, ON, Canada
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185 Roma RM, Italy.,Mediterranea Cardiocentro, Via Orazio, 2, 80122 Napoli, NA, Italy
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 1300 York Ave, NY New York, USA
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto, 200 Elizabeth St., Toronto, ON M5G 2C4, Canada
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10
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Transcatheter Aortic Valve Replacement Outcomes in End-Stage Renal Disease Patients on Hemodialysis Requiring Midodrine. STRUCTURAL HEART 2023. [DOI: 10.1016/j.shj.2023.100163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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11
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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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12
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Fraccaro C, Tarantini G, Rosato S, Baglio G, Biancari F, Barbanti M, Tamburino C, Bedogni F, Ranucci M, Ussia GP, Seccareccia F, D'Errigo P. Early and mid-term outcome of patients with low-flow-low-gradient aortic stenosis treated with newer-generation transcatheter aortic valves. Front Cardiovasc Med 2022; 9:991729. [PMID: 36277797 PMCID: PMC9583539 DOI: 10.3389/fcvm.2022.991729] [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: 07/11/2022] [Accepted: 09/09/2022] [Indexed: 11/13/2022] Open
Abstract
Patients with non-paradoxical low-flow-low-gradient (LFLG) aortic stenosis (AS) are at increased surgical risk, and thus, they may particularly benefit from transcatheter aortic valve replacement (TAVR). However, data on this issue are still limited and based on the results with older-generation transcatheter heart valves (THVs). The aim of this study was to investigate early and mid-term outcome of TAVR with newer-generation THVs in the setting of LFLG AS. Data for the present analysis were gathered from the OBSERVANT II dataset, a national Italian observational, prospective, multicenter cohort study that enrolled 2,989 consecutive AS patients who underwent TAVR at 30 Italian centers between December 2016 and September 2018, using newer-generation THVs. Overall, 420 patients with LVEF ≤50% and mean aortic gradient <40 mmHg were included in this analysis. The primary outcomes were 1-year all-cause mortality and a combined endpoint including all-cause mortality and hospital readmission due to congestive heart failure (CHF) at 1 year. A risk-adjusted analysis was performed to compare the outcome of LFLG AS patients treated with TAVR (n = 389) with those who underwent surgical aortic valve replacement (SAVR, n = 401) from the OBSERVANT I study. Patients with LFLG AS undergoing TAVR were old (mean age, 80.8 ± 6.7 years) and with increased operative risk (mean EuroSCORE II, 11.5 ± 10.2%). VARC-3 device success was 83.3% with 7.6% of moderate/severe paravalvular leak. Thirty-day mortality was 3.1%. One-year all-cause mortality was 17.4%, and the composite endpoint was 34.8%. Chronic obstructive pulmonary disease (HR 1.78) and EuroSCORE II (HR 1.02) were independent predictors of 1-year mortality, while diabetes (HR 1.53) and class NYHA IV (HR 2.38) were independent predictors of 1-year mortality or CHF. Compared with LFLG AS treated with SAVR, TAVR patients had a higher rate of major vascular complications and permanent pacemaker, while SAVR patients underwent more frequently to blood transfusion, cardiogenic shock, AKI, and MI. However, 30-day and 1-year outcomes were similar between groups. Patients with non-paradoxical LFLG AS treated by TAVR were older and with higher surgical risk compared with SAVR patients. Notwithstanding, TAVR was safe and effective with a similar outcome to SAVR at both early and mid-term.
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Affiliation(s)
- Chiara Fraccaro
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy,*Correspondence: Giuseppe Tarantini
| | - Stefano Rosato
- Centro Nazionale per la Salute Globale, National Center for Global Health, Istituto Superiore di Sanità Italiana, Roma, Italy
| | - Giovanni Baglio
- Italian National Agency for Regional Healthcare Services, Rome, Italy
| | - Fausto Biancari
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy,Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Marco Barbanti
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico—San Marco”, University of Catania, Catania, Italy
| | - Corrado Tamburino
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico—San Marco”, University of Catania, Catania, Italy
| | - Francesco Bedogni
- Interventional Cardiology Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, Milan, Italy
| | - Gian Paolo Ussia
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | - Fulvia Seccareccia
- Centro Nazionale per la Salute Globale, National Center for Global Health, Istituto Superiore di Sanità Italiana, Roma, Italy
| | - Paola D'Errigo
- Centro Nazionale per la Salute Globale, National Center for Global Health, Istituto Superiore di Sanità Italiana, Roma, Italy
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13
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Gennari M, Mastroiacovo G, Trabattoni P, Roberto M, Bonomi A, Bartorelli AL, Olivares P, Tamborini G, Muratori M, Pepi M, Polvani G, Agrifoglio M. The prognostic value of left ventricular dimensions at the time of transcatheter aortic valve replacement: A propensity‐matched analysis. J Card Surg 2022; 37:1887-1893. [DOI: 10.1111/jocs.16381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/17/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Marco Gennari
- Department of Cardiovascular Surgery IRCCS Centro Cardiologico Monzino Milan Italy
| | - Giorgio Mastroiacovo
- Department of Cardiovascular Surgery IRCCS Centro Cardiologico Monzino Milan Italy
| | - Piero Trabattoni
- Department of Cardiovascular Surgery IRCCS Centro Cardiologico Monzino Milan Italy
| | - Maurizio Roberto
- Department of Cardiovascular Surgery IRCCS Centro Cardiologico Monzino Milan Italy
| | - Alice Bonomi
- Department of Statistics IRCCS Centro Cardiologico Monzino Milan Italy
| | - Antonio L. Bartorelli
- Department of Biomedical and Clinical Sciences “Luigi Sacco” University of Milan Milan Italy
| | - Paolo Olivares
- Department of Interventional Cardiology IRCCS Centro Cardiologico Monzino Milan Italy
| | - Gloria Tamborini
- Department of Echocardiography IRCCS Centro Cardiologico Monzino Milan Italy
| | - Manuela Muratori
- Department of Echocardiography IRCCS Centro Cardiologico Monzino Milan Italy
| | - Mauro Pepi
- Department of Cardiac Imaging, IRCCS Centro Cardiologico Monzino Clinical Area Manager Milan Italy
| | - Gianluca Polvani
- Department of Cardiovascular Surgery IRCCS Centro Cardiologico Monzino Milan Italy
- Department of Surgical and Dental Biomedical Sciences University of Milan Milan Italy
| | - Marco Agrifoglio
- Department of Cardiovascular Surgery IRCCS Centro Cardiologico Monzino Milan Italy
- Department of Surgical and Dental Biomedical Sciences University of Milan Milan Italy
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14
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Ludwig S, Goßling A, Seiffert M, Westermann D, Sinning JM, Sugiura A, Adam M, Mauri V, Frank D, Seoudy H, Rudolph T, Potratz M, Conradi L, Schofer N. Risk prediction in patients with low-flow, low-gradient aortic stenosis and reduced ejection fraction undergoing TAVI. Open Heart 2022; 9:openhrt-2021-001912. [PMID: 34987075 PMCID: PMC8734034 DOI: 10.1136/openhrt-2021-001912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/06/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Patients with low-flow, low-gradient aortic stenosis (LFLG AS) and reduced left ventricular ejection fraction (LVEF) are known to suffer from poor prognosis after transcatheter aortic valve implantation (TAVI). This study aimed to develop a simple score system for risk prediction in this vulnerable subset of patients. METHODS All patients with LFLG AS with reduced EF and sufficient CT data for aortic valve calcification (AVC) quantification, who underwent TAVI at five German centres, were retrospectively included. The Risk prEdiction in patients with Low Ejection Fraction low gradient aortic stenosis undergoing TAVI (RELiEF TAVI) score was developed based on multivariable Cox regression for all-cause mortality. RESULTS Among all included patients (n=718), RELiEF TAVI score variables were defined as independent predictors of mortality: male sex (HR 1.34 (1.06, 1.68), p=0.013), underweight (HR 3.10 (1.50, 6.40), p=0.0022), chronic obstructive pulmonary disease (HR 1.55 (1.21, 1.99), p=0.001), pulmonary hypertension (HR 1.51 (1.17, 1.94), p=0.0015), atrial fibrillation (HR 1.28 (1.03, 1.60), p=0.028), stroke volume index (HR 0.96 (0.95, 0.98), p<0.001), non-transfemoral access (HR 1.36 (1.05, 1.76), p=0.021) and low AVC density (HR 1.44 (1.15, 1.79), p=0.0012). A score system was developed ranging from 0 to 12 points (risk of 1-year mortality: 13%-99%). Kaplan-Meier analysis for low (0-1 points), moderate (2-4 points) and high RELiEF TAVI score (>4 points) demonstrated rates of 18.0%, 29.0% and 46.1% (p<0.001) for all-cause mortality and 23.8%, 35.9% and 53.4% (p<0.001) for the combined endpoint of all-cause mortality or heart failure rehospitalisation after 1 year, respectively. CONCLUSIONS The RELiEF TAVI score is based on simple clinical, echocardiographic and CT parameters and might serve as a helpful tool for risk prediction in patients with LFLG AS and reduced LVEF scheduled for TAVI.
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Affiliation(s)
- Sebastian Ludwig
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany .,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Luebeck, Germany
| | - Alina Goßling
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Moritz Seiffert
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Luebeck, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Luebeck, Germany
| | - Jan-Malte Sinning
- Department of Cardiology, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Atsushi Sugiura
- Department of Cardiology, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Matti Adam
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Victor Mauri
- Department of Cardiology, Heart Center, University of Cologne, Cologne, Germany
| | - Derk Frank
- Department of Internal Medicine III, Cardiology, Angiology, and Critical Care, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Hatim Seoudy
- Department of Internal Medicine III, Cardiology, Angiology, and Critical Care, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Tanja Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Heart and Diabetes Center North Rhine-Westphalia, Bad Oeynhausen, Germany
| | - Max Potratz
- Clinic for General and Interventional Cardiology/Angiology, Heart and Diabetes Center North Rhine-Westphalia, Bad Oeynhausen, Germany
| | - Lenard Conradi
- German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Luebeck, Germany.,Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Niklas Schofer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Luebeck, Germany
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15
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Caval Valve Implantation. Interv Cardiol Clin 2021; 11:95-102. [PMID: 34838301 DOI: 10.1016/j.iccl.2021.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Transcathetertherapy has expanded the treatment options for patients with heart valve disease. Interventional therapy for aortic, mitral, and pulmonic valve disease is well established; however, catheter-based approaches to tricuspid regurgitation (TR) are still in early stages of development. For some of the interventional concepts to TR, including the edge-to-edge-repair, transcatheter annuloplasty, the tricuspid spacer, and caval valves, procedural feasibility and favorable early clinical outcome have been demonstrated in small compassionate case series. This article reviews the pathophysiological background and current evidence for caval valve implantation and examines the potential role of this approach for the treatment of severe TR.
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16
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Head-to-Head Comparison of Different Software Solutions for AVC Quantification Using Contrast-Enhanced MDCT. J Clin Med 2021; 10:jcm10173970. [PMID: 34501418 PMCID: PMC8432112 DOI: 10.3390/jcm10173970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/23/2021] [Accepted: 09/01/2021] [Indexed: 01/07/2023] Open
Abstract
Aortic valve calcification (AVC) in aortic stenosis patients has diagnostic and prognostic implications. Little is known about the interchangeability of AVC obtained from different multidetector computed tomography (MDCT) software solutions. Contrast-enhanced MDCT data sets of 50 randomly selected aortic stenosis patients were analysed using three different software vendors (3Mensio, CVI42, Syngo.Via). A subset of 10 patients were analysed twice for the estimation of intra-observer variability. Intra- and inter-observer variability were determined using the ICC reliability method, Bland-Altman analysis and coefficients of variation. No differences were revealed between the software solutions in the AVC calculations (3Mensio 941 ± 623, Syngo.Via 948 mm3 ± 655, CVI42 941 ± 637; p = 0.455). The best inter-vendor agreement was found between the CVI42 and the Syngo.Via (ICC 0.997 (CI 0.995-0.998)), followed by the 3Mensio and the CVI42 (ICC 0.996 (CI 0.922-0.998)), and the 3Mensio and the Syngo.Via (ICC 0.992 (CI 0.986-0.995)). There was excellent intra- (3Mensio: ICC 0.999 (0.995-1.000); CVI42: ICC 1.000 (0.999-1.000); Syngo.Via: ICC 0.998 (0.993-1.000)) and inter-observer variability (3Mensio: ICC 1.000 (0.999-1.000); CVI42: ICC 1.000 (1.000-1.000); Syngo.Via: ICC 0.996 (0.985-0.999)) for all software types. Contrast-enhanced MDCT-derived AVC scores are interchangeable between and reproducible within different commercially available software solutions. This is important since sufficient reproducibility, interchangeability and valid results represent prerequisites for accurate TAVR planning and its widespread clinical use.
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17
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Gender specific differences in functional capacity in asymptomatic patients with severe aortic stenosis. COR ET VASA 2021. [DOI: 10.33678/cor.2020.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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18
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Choudhary KV, Kakouros N, Aurigemma GP, Parker MW, Fitzgibbons T. Differentiating Pseudo Versus True Aortic Stenosis in Patients Without Contractile Reserve: A Diagnostic Dilemma. Cureus 2021; 13:e14086. [PMID: 33903843 PMCID: PMC8064426 DOI: 10.7759/cureus.14086] [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] [Indexed: 12/01/2022] Open
Abstract
Low-flow, low-gradient (LF-LG) aortic stenosis with depressed left ventricular (LV) ejection fraction is a diagnostic challenge that is frequently encountered in the management of valvular heart disease. True-severe LF-LG aortic stenosis is amenable to valve replacement, whereas pseudo-severe aortic stenosis requires management of the underlying cardiomyopathy. This distinction is important as it serves as a critical branch point in guiding therapeutic decisions. We present the case of a 71-year-old male with LF-LG aortic stenosis who had a reduced and biphasic augmentation of LV flow during dobutamine stress echocardiography (DSE). Further evaluation revealed a stenotic left subclavian artery proximal to the left internal mammary artery graft to the left anterior descending (LAD) artery. Bypass of the subclavian stenosis reversed the LAD territory ischemia and confirmed pseudo-severe aortic stenosis on repeat DSE. Traditional DSE parameters are inconclusive in patients with LF-LG aortic stenosis with poor flow reserve. Calculation of the projected orifice area or measurement of aortic valve calcium via multidetector computed tomography (MDCT) may be required in this scenario. Most importantly, reversible causes of LV dysfunction identified during DSE for LF-LG aortic stenosis require a different treatment approach than that of true aortic stenosis.
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Affiliation(s)
- Khushal V Choudhary
- Department of Internal Medicine, Roger Williams Medical Center, Providence, USA
| | - Nikolaos Kakouros
- Cardiovascular Division, Department of Medicine, University of Massachusetts Medical School, Massachusetts, USA
| | - Gerard P Aurigemma
- Cardiovascular Division, Department of Medicine, University of Massachusetts Medical School, Massachusetts, USA
| | - Matthew W Parker
- Cardiovascular Division, Department of Medicine, University of Massachusetts Medical School, Massachusetts, USA
| | - Timothy Fitzgibbons
- Cardiovascular Division, Department of Medicine, University of Massachusetts Medical School, Massachusetts, USA
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19
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Anand V, Mankad SV, Eleid M. What Is New in Low Gradient Aortic Stenosis: Surgery, TAVR, or Medical Therapy? Curr Cardiol Rep 2020; 22:78. [DOI: 10.1007/s11886-020-01341-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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20
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Ludwig S, Goßling A, Waldschmidt L, Linder M, Bhadra OD, Voigtländer L, Schäfer A, Deuschl F, Schirmer J, Reichenspurner H, Blankenberg S, Schäfer U, Westermann D, Seiffert M, Conradi L, Schofer N. TAVR for low-flow, low-gradient aortic stenosis: Prognostic impact of aortic valve calcification. Am Heart J 2020; 225:138-148. [PMID: 32502877 DOI: 10.1016/j.ahj.2020.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 03/16/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Compared to high gradient aortic stenosis (AS), patients with low-flow, low-gradient AS have higher mortality after transcatheter aortic valve replacement (TAVR), but distinct outcome predictors in this patient subset are yet to be determined. The present study investigated the prognostic impact of aortic valve calcification (AVC) in patients with low-flow, low-gradient AS undergoing TAVR. METHODS This retrospective single-center analysis includes all patients undergoing TAVR for severe low-flow, low-gradient AS (n = 526), ie, low EF low gradient AS (LEF-LG AS; n = 290) and paradoxical low-flow, low-gradient AS (PLF-LG AS; n = 236), in whom AVC was quantified from contrast-enhanced multislice computed tomography images. AVCdensity was defined as calcium volume per annulus area. Patients were trichotomized according to sex-specific AVCdensity tertiles in both subgroups. All-cause mortality was assessed by Kaplan-Meier analyses and independent outcome predictors were determined by multivariable analyses. RESULTS In both subgroups, patients with high AVCdensity had higher mean transvalvular gradients at baseline and higher rates of PVL after TAVR. High AVCdensity was associated with lowest 1- and 3-year mortality after TAVR in the LEF-LG AS but not in the PLF-LG AS group. According to multivariable analysis AVCdensity was independently associated with better survival in LEF-LG AS patients (HR 0.73 [0.60-0.88], P = .0011), but not in those with PLF-LG AS (HR 0.91 [0.73-1.14], P = .42). CONCLUSIONS Quantification of AVC may not only be of diagnostic but also of prognostic value, as it facilitates the selection of LEF-LG AS patients with higher probability of beneficial outcome after TAVR.
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Serum Biomarkers of Cardiovascular Remodelling Reflect Extra-Valvular Cardiac Damage in Patients with Severe Aortic Stenosis. Int J Mol Sci 2020; 21:ijms21114174. [PMID: 32545310 PMCID: PMC7312014 DOI: 10.3390/ijms21114174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 12/20/2022] Open
Abstract
In patients with aortic stenosis (AS), a novel staging classification of extra-valvular left and right heart damage with prognostic relevance was introduced in 2017. The aim of the study was to evaluate the biomarkers of cardiovascular tissue remodelling in relation to this novel staging classification. Patients were categorized according to the novel staging classification into stages 0 to 4. The levels of matrix metalloproteinase 9 (MMP-9), tissue inhibitor of metalloproteinases 1 (TIMP-1), B and C domain containing tenascin-C (B+ Tn-C, C+ Tn-C), the ED-A and ED-B domain containing fibronectin (ED-A+ Fn, ED-B+ Fn), endothelin 1 (ET-1) and neutrophil gelatinase-associated lipocalin (NGAL) were determined in serum by ELISA. There were significantly decreased serum levels of MMP-9 and increased levels of B+ Tn-C and C+ Tn-C when comparing stages 0 and 1 with stage 2, with no further dynamics in stages 3 and 4. In contrast, for TIMP-1, C+ Tn-C, ED-A+ Fn, ET-1 and NGAL, significantly increased serum levels could be detected in stages 3 and 4 compared to both stages 0 and 1 and stage 2. ED-A+ Fn and ET-1 could be identified as independent predictors of the presence of stage 3 and/or 4. To the best of our knowledge, this is the first study identifying novel serum biomarkers differentially reflecting the patterns of left and right heart extra-valvular damage in patients suffering from AS. Our findings might indicate a more precise initial diagnosis and risk stratification.
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Saeed S, Dweck MR, Chambers J. Sex differences in aortic stenosis: from pathophysiology to treatment. Expert Rev Cardiovasc Ther 2020; 18:65-76. [PMID: 32066291 DOI: 10.1080/14779072.2020.1732209] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Introduction: In aortic stenosis (AS), there are clear sex differences in clinical presentation, left ventricular (LV) response to pressure overload, and pathophysiology of valvular calcification. These differences may affect outcome following valve intervention.Area covered: This review aims to discuss sex differences in clinical presentation, pathophysiology of aortic valve calcification, LV remodeling in view of historic and recent echocardiographic and cardiac magnetic resonance imaging studies, and outcome after valve intervention. In addition, it will also provide some brief insights on the exercise physiology in women and men with AS.Expert commentary: Women at presentation are often older, have higher prevalence of hypertension and diastolic dysfunction, while men are younger, and more often have a bicuspid aortic valve and higher atherosclerotic disease burden. Men have more valve calcification than women for a given severity of AS and develop different patterns of LV remodeling and myocardial fibrosis. Although women tend to walk shorter on treadmill and achieve lower metabolic equivalents, they achieve similar peak heart rates and blood pressure, and the frequency of revealed symptoms during exercise test is comparable in both sexes. Men are more likely to undergo a surgical AVR with better outcome, while women have generally better outcome after TAVI.
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Affiliation(s)
- Sahrai Saeed
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - John Chambers
- Cardiothoracic Centre, Guy's & St Thomas' Hospital, London, UK
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23
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Amer MR, Mosleh W, Memon S, Joshi S, Sullivan B, Sharkawi M, Mather JF, Kiernan FJ, McMahon S, Duvall WL, McKay RG. Comparison of Benefit of Transcatheter Aortic Valve Implantation in Patients With Low Gradient Versus High Gradient Aortic Stenosis and Left Ventricular Dysfunction. Am J Cardiol 2020; 125:1543-1549. [PMID: 32273053 DOI: 10.1016/j.amjcard.2020.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 11/30/2022]
Abstract
Patients with low gradient severe aortic stenosis (LG-AS) often exhibit significant limitations in functional status and quality of life. We aimed to evaluate the clinical effect of transcatheter aortic valve implantation (TAVI) on LG-AS patients compared to those with high transvalvular gradients and similar left ventricular dysfunction. Retrospective analysis of records for all patients with a left ventricular ejection fraction <50% who underwent TAVI at our institution was performed. Patients were grouped according to their transvalvular gradient. Data were collected from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Clinical benefit endpoints included improvements in left ventricular ejection fraction and changes in the Kansas City Cardiomyopathy Questionnaire. Additional outcomes analyzed included 1-year all-cause mortality, stroke rates, rates of rehospitalization, need for a permanent pacemaker, and hospital length of stay. Two hundred three patients met our inclusion criteria. one hundred one LG-AS patients (mean transvalvular gradient <40 mm Hg) were compared to 102 patients with high transvalvular gradients (mean transvalvular gradient >40 mm Hg). LG-AS patients yielded similar improvements in left ventricular ejection fraction (43.5% ± 63.7 vs 37.7% ± 58.7; p = 0.525) and Kansas City Cardiomyopathy Questionnaire scores (423.51% ± 1257.02 vs 266.56% ± 822.81; p = 0.352). There were no differences between the groups with respect to 1-year mortality (16.8% vs 12.7%; p = 0.412), stroke rates, hospital length of stay, need for permanent pacemaker implantation or hospital readmissions. In conclusion, we found that TAVI is associated with comparable improvement in clinical and echocardiographic outcomes in LG-AS patients as compared to those with high gradient severe aortic stenosis.
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Affiliation(s)
- Mostafa R Amer
- Division of Cardiology, University of Connecticut, Farmington, Connecticut
| | - Wassim Mosleh
- Division of Cardiology, University of Connecticut, Farmington, Connecticut
| | - Sarfaraz Memon
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Saurabh Joshi
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Bethany Sullivan
- Division of Cardiology, University of Connecticut, Farmington, Connecticut
| | - Musa Sharkawi
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Jeffrey F Mather
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Francis J Kiernan
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Sean McMahon
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - W Lane Duvall
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Raymond G McKay
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut.
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Alushi B, Curini L, Christopher MR, Grubitzch H, Landmesser U, Amedei A, Lauten A. Calcific Aortic Valve Disease-Natural History and Future Therapeutic Strategies. Front Pharmacol 2020; 11:685. [PMID: 32477143 PMCID: PMC7237871 DOI: 10.3389/fphar.2020.00685] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 04/27/2020] [Indexed: 12/20/2022] Open
Abstract
Calcific aortic valve disease (CAVD) is the most frequent heart valve disorder. It is characterized by an active remodeling process accompanied with valve mineralization, that results in a progressive aortic valve narrowing, significant restriction of the valvular area, and impairment of blood flow.The pathophysiology of CAVD is a multifaceted process, involving genetic factors, chronic inflammation, lipid deposition, and valve mineralization. Mineralization is strictly related to the inflammatory process in which both, innate, and adaptive immunity are involved. The underlying pathophysiological pathways that go from inflammation to calcification and, finally lead to severe stenosis, remain, however, incompletely understood. Histopathological studies are limited to patients with severe CAVD and no samples are available for longitudinal studies of disease progression. Therefore, alternative routes should be explored to investigate the pathogenesis and progression of CAVD.Recently, increasing evidence suggests that epigenetic markers such as non-coding RNAs are implicated in the landscape of phenotypical changes occurring in CAVD. Furthermore, the microbiome, an essential player in several diseases, including the cardiovascular ones, has recently been linked to the inflammation process occurring in CAVD. In the present review, we analyze and discuss the CAVD pathophysiology and future therapeutic strategies, focusing on the real and putative role of inflammation, calcification, and microbiome.
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Affiliation(s)
- Brunilda Alushi
- Department of Cardiology, Charite´ Universitätsmedizin Berlin and German Centre for Cardiovascular Research (DZHK), Berlin, Germany.,Department of General and Interventional Cardiology, Helios Klinikum Erfurt, Erfurt, Germany
| | - Lavinia Curini
- Department of Cardiology, Charite´ Universitätsmedizin Berlin and German Centre for Cardiovascular Research (DZHK), Berlin, Germany.,Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Mary Roxana Christopher
- Department of Cardiology, Charite´ Universitätsmedizin Berlin and German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Herko Grubitzch
- Berlin Institute of Health, Berlin, Germany.,Department of Cardiology, German Heart Centre Berlin (DHZB), Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charite´ Universitätsmedizin Berlin and German Centre for Cardiovascular Research (DZHK), Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Amedeo Amedei
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy.,Sod of Interdisciplinary Internal Medicine, Azienda Ospedaliera Universitaria Careggi (AOUC), Florence, Italy
| | - Alexander Lauten
- Department of Cardiology, Charite´ Universitätsmedizin Berlin and German Centre for Cardiovascular Research (DZHK), Berlin, Germany.,Department of General and Interventional Cardiology, Helios Klinikum Erfurt, Erfurt, Germany
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25
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2 Dysfunctional Valves and 1 Poor Ventricle: Is There Still Hope? JACC Cardiovasc Interv 2020; 13:580-582. [PMID: 32061599 DOI: 10.1016/j.jcin.2019.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 12/27/2019] [Indexed: 11/22/2022]
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26
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Ahmed A, Alsidawi S, Bae R, Cavalcante J, Fukui M, Gössl M, Sorajja P, Garcia S. Changes in quality of life in patients with low‐flow aortic stenosis undergoing transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2020; 96:972-978. [DOI: 10.1002/ccd.28805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/23/2020] [Accepted: 02/10/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Aisha Ahmed
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital Minneapolis Minnesota
| | - Said Alsidawi
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital Minneapolis Minnesota
| | - Richard Bae
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital Minneapolis Minnesota
| | - Joao Cavalcante
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital Minneapolis Minnesota
| | - Miho Fukui
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital Minneapolis Minnesota
| | - Mario Gössl
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital Minneapolis Minnesota
| | - Paul Sorajja
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital Minneapolis Minnesota
| | - Santiago Garcia
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital Minneapolis Minnesota
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27
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Maes F, Lerakis S, Barbosa Ribeiro H, Gilard M, Cavalcante JL, Makkar R, Herrmann HC, Windecker S, Enriquez-Sarano M, Cheema AN, Nombela-Franco L, Amat-Santos I, Muñoz-García AJ, Garcia Del Blanco B, Zajarias A, Lisko JC, Hayek S, Babaliaros V, Le Ven F, Gleason TG, Chakravarty T, Szeto W, Clavel MA, de Agustin A, Serra V, Schindler JT, Dahou A, Salah-Annabi M, Pelletier-Beaumont E, Côté M, Puri R, Pibarot P, Rodés-Cabau J. Outcomes From Transcatheter Aortic Valve Replacement in Patients With Low-Flow, Low-Gradient Aortic Stenosis and Left Ventricular Ejection Fraction Less Than 30%: A Substudy From the TOPAS-TAVI Registry. JAMA Cardiol 2020; 4:64-70. [PMID: 30566185 DOI: 10.1001/jamacardio.2018.4320] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance In low-flow, low-gradient aortic stenosis (LFLG AS), the severity of left ventricular dysfunction remains a key factor in the evaluation of aortic valve replacement. Objective To evaluate the clinical outcomes and changes in left ventricular ejection fraction (LVEF) after transcatheter aortic valve replacement (TAVR) in patients with LFLG AS and severe left ventricular dysfunction. Design, Setting, and Participants This multicenter registry is a substudy of the True or Pseudo-Severe Aortic Stenosis-TAVI registry that included patients with classic LFLG AS, defined as a mean transvalvular gradient less than 35 mm Hg, an effective orifice area less than 1.0 cm2, and an LVEF of 40% or less. Patients were divided in groups with very low (<30%) LVEF and low (30%-40%) LVEF. Dobutamine stress echocardiography (DSE) was performed before TAVR in a subset with very low LVEF, and presence of contractile reserve was defined as an increase of 20% or more in stroke volume. Clinical outcomes were assessed at 1 and 12 months and yearly thereafter, and echocardiography was performed at 1-year follow-up. Retrospective data were collected from 2007 to 2013 and prospective data from January 2013 to March 2018. Data were analyzed from March to October 2018. Exposures Transcatheter aortic valve replacement in patients with LFLG AS. Main Outcomes and Measures Changes in LVEF over time; periprocedural and late mortality. Results A total of 293 patients were included, including 128 (43.7%) with very low LVEF and 165 with low LVEF (56.3%). Their mean (SD) age was 80 (7) years, and most (214 [73.0%]) were men. The mean (SD) LVEF in the very low LVEF group was 22% (5%), compared with 37% (7%) in the low LVEF group (P < .001). There were no differences between groups in rates of periprocedural mortality and late mortality (median [interquartile range], 23 [6-38] months). Patients with very low LVEF displayed a greater increase in LVEF at the 1-year follow-up examination (mean absolute increase, 11.9% [95% CI, 8.8%-15.1%]), than the low LVEF group (3.6% [95% CI, 1.1%-6.1%]; P < .001). In 92 patients with very low LVEF who had preprocedural DSE, results showed a lack of contractile reserve in 45 (49%), but this had no effect on clinical outcomes or changes in LVEF over time. Conclusions and Relevance In patients with LFLG AS and severe left ventricular dysfunction, TAVR was associated with similar clinical outcomes as in counterparts with milder left ventricular dysfunction. The TAVR procedure was associated with a significant increase in LVEF, irrespective of contractile reserve. These results support TAVR for LFLG AS, irrespective of the severity of left ventricular dysfunction and DSE results.
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Affiliation(s)
- Frédéric Maes
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | | | - Martine Gilard
- Centre Hospitalier Régional et Universitaire de Brest, Brest, France
| | - João L Cavalcante
- University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raj Makkar
- Cedars Sinai Heart Institute, Los Angeles, California
| | | | | | | | - Asim N Cheema
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | - Alan Zajarias
- Washington University in St Louis School of Medicine, St Louis, Missouri
| | | | | | | | - Florent Le Ven
- Centre Hospitalier Régional et Universitaire de Brest, Brest, France
| | - Thomas G Gleason
- University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Wilson Szeto
- University of Pennsylvania Medical Center, Philadelphia
| | - Marie-Annick Clavel
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada.,Mayo Clinic, Rochester, Minnesota
| | | | - Vicenç Serra
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - John T Schindler
- University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Abdellaziz Dahou
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | | | - Melanie Côté
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Philippe Pibarot
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
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Fischer-Rasokat U, Renker M, Liebetrau C, Weferling M, Rolf A, Doss M, Möllmann H, Walther T, Hamm CW, Kim WK. Outcome of patients with heart failure after transcatheter aortic valve implantation. PLoS One 2019; 14:e0225473. [PMID: 31770401 PMCID: PMC6879149 DOI: 10.1371/journal.pone.0225473] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/04/2019] [Indexed: 12/12/2022] Open
Abstract
AIMS Patients with aortic stenosis (AS) may have concomitant heart failure (HF) that determines prognosis despite successful transcatheter aortic valve implantation (TAVI). We compared outcomes of TAVI patients with low stroke volume index (SVI) ≤35 ml/m2 body surface area in different HF classes. METHODS AND RESULTS Patients treated by transfemoral TAVI at our center (n = 1822) were classified as 1) 'HF with preserved ejection fraction (EF)' (HFpEF, EF ≥50%), 2) 'HF with mid-range EF' (HFmrEF, EF 40-49%), or 3) 'HF with reduced EF' (HFrEF, EF <40%). Patients with SVI >35 ml/m2 served as controls. The prevalence of cardiovascular disease and symptoms increased stepwise from controls (n = 968) to patients with HFpEF (n = 591), HFmrEF (n = 97), and HFrEF (n = 166). Mortality tended to be highest in HFrEF patients 30 days post-procedure, and it became significant after one year: 10.2% (controls), 13.5% (HFpEF), 13.4% (HFmrEF), and 23.5% (HFrEF). However, symptomatic improvement in survivors of all groups was achieved in the majority of patients without differences among groups. CONCLUSIONS Patients with AS and HF benefit from TAVI with respect to symptom alleviation. TAVI in patients with HFpEF and HFmrEF led to an identical, favorable post-procedural prognosis that was significantly better than that of patients with HFrEF, which remains a high-risk population.
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Affiliation(s)
- Ulrich Fischer-Rasokat
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
- Department of Cardiology and Angiology, Medical Clinic I, University Hospital of Giessen, Giessen, Germany
- * E-mail:
| | - Matthias Renker
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
- Department of Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
- Department of Cardiology and Angiology, Medical Clinic I, University Hospital of Giessen, Giessen, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
| | - Maren Weferling
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
- Department of Cardiology and Angiology, Medical Clinic I, University Hospital of Giessen, Giessen, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
| | - Mirko Doss
- Department of Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany
| | - Helge Möllmann
- Department of Cardiology, Medical Clinic I, St. Johannes Hospital, Dortmund, Germany
| | - Thomas Walther
- Department of Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
- Department of Cardiac, Thoracic and Thoracic Vascular Surgery, University Hospital of the Goethe University, Frankfurt/Main, Germany
| | - Christian W. Hamm
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
- Department of Cardiology and Angiology, Medical Clinic I, University Hospital of Giessen, Giessen, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site RheinMain, Bad Nauheim, Germany
| | - Won-Keun Kim
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
- Department of Cardiology and Angiology, Medical Clinic I, University Hospital of Giessen, Giessen, Germany
- Department of Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany
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29
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Laricchia A, Bellini B, Romano V, Khawaja S, Montorfano M, Chieffo A. Sex and Transcatheter Aortic Valve Implantation: Impact of Female Sex on Clinical Outcomes. Interv Cardiol 2019; 14:137-141. [PMID: 31867058 PMCID: PMC6918465 DOI: 10.15420/icr.2019.07.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/24/2019] [Indexed: 01/09/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment for severe symptomatic aortic stenosis in patients who are not suitable for surgery or are at high surgical risk. Approximately 50% of patients undergoing TAVI are female and this is reflected by a higher inclusion rate of women in TAVI trials. However, women undergoing TAVI have different baseline clinical characteristics in comparison to men, with fewer comorbidities and a more preserved left ventricular ejection fraction. This translates into favourable outcomes after TAVI, despite a higher rate of peri-procedural complications. This article discusses gender differences in terms of presentation, procedural characteristics and post-procedural results in patients with aortic stenosis undergoing TAVI, with particular focus on possible sex-specific factors affecting outcome.
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Affiliation(s)
- Alessandra Laricchia
- Interventional Cardiology Unit, GVM Care and Research, Maria Cecilia HospitalCotignola, Italy
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific InstituteMilan, Italy
| | - Barbara Bellini
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific InstituteMilan, Italy
| | - Vittorio Romano
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific InstituteMilan, Italy
| | - Saud Khawaja
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific InstituteMilan, Italy
| | - Matteo Montorfano
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific InstituteMilan, Italy
| | - Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific InstituteMilan, Italy
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Takagi H, Hari Y, Kawai N, Kuno T, Ando T. A meta-analysis of impact of low-flow/low-gradient aortic stenosis on survival after transcatheter aortic valve implantation. J Cardiovasc Med (Hagerstown) 2019; 20:691-698. [DOI: 10.2459/jcm.0000000000000836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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32
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Osman M, Ghaffar YA, Foster T, Osman K, Alqahtani F, Shah K, Kheiri B, Alkhouli M. Meta-Analysis of Outcomes of Transcatheter Aortic Valve Implantation Among Patients With Low Gradient Severe Aortic Stenosis. Am J Cardiol 2019; 124:423-429. [PMID: 31138402 DOI: 10.1016/j.amjcard.2019.05.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 04/17/2019] [Accepted: 05/06/2019] [Indexed: 10/26/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) has emerged as an effective therapy for patients with severe aortic stenosis (AS). However, data on TAVI outcomes in patients with low gradient (LG) AS are limited. We performed a meta-analysis of studies comparing TAVI outcomes between patients with classic high gradient (HG) and LG AS through November 2018. The 30-day mortality, mid-term all-cause, and cardiovascular mortality at maximum follow-up were compared between patients with HG and LG AS (Pairwise meta-analysis), and between the three distinct groups of AS including HG, paradoxical low-flow low-gradient and low gradient with reduced ejection fraction (rEF-LG) (Network meta-analysis). Nineteen studies (n = 27,204 patients) met the inclusion criteria. The HG group had less 30-day, mid-term all-cause and cardiovascular mortality compared with the low-gradient AS group overall, (6% vs 7.5%, OR 0.76, 95% CI 0.66 to 0.87, I2 = 18%), (21% vs 29%, OR 0.59, 95% CI 0.52 to 0.67, I2 = 62%), and (12.6% vs 18.7%, OR 0.61, 95% CI 0.49 to 0.76, I2 = 62%), respectively, p <0.0001. These outcomes were confirmed in a trial sequential analysis in which the cumulative Z-curve crossed the conventional test boundary as well as the trial sequential monitoring boundary for all outcomes. The network meta-analysis revealed that patients with rEF-LG had similar outcomes to those with pLFLG, and both had worse outcomes than patients with classic HG AS. In conclusion patients with classic HG have better 30-day mortality, mid-term all-cause and cardiovascular mortality compared with LG patients following TAVI. Among patients with LG severe AS, TAVI outcomes were similar in patients with rEF-LG and pLFLG.
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Paradoxical low-flow aortic stenosis - baseline characteristics, impact on mortality. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2019; 15:13-19. [PMID: 31043980 PMCID: PMC6488831 DOI: 10.5114/aic.2019.83770] [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: 10/21/2018] [Accepted: 12/27/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Paradoxical low-flow, low-gradient aortic stenosis (pLF-LGAS) constitutes an important part of the population undergoing transcatheter aortic valve implantation (TAVI). However, it remains the least defined subtype of aortic stenosis (AS). Aim To investigate baseline characteristics and impact on mortality of pLF-LGAS in patients treated with TAVI. Material and methods Two-hundred and thirty-one consecutive patients (mean aortic valve area: 0.76 ±0.41 cm2) who underwent TAVI in our centre during the period of 6 years were included in the study. Based on echocardiographic examination, patients with pLF-LGAS were identified, analysed and compared to a population with high-gradient AS (HGAS) and low-flow, low-gradient AS with reduced ejection fraction (classical, cLF-LGAS). The primary endpoints of the study were all-cause mortality after 30 days and 1 year. Results pLF-LGAS was diagnosed in 42 (18.2%) patients, whereas 40 (17.3%) had cLF-LGAS and 149 (64.5%) had HGAS. The pLF-LGAS population was younger, had higher prevalence of hypertension, and had higher ejection fraction (EF) than the HGAS population, and had a smaller proportion of heavily symptomatic patients than the cLF-LGAS population. Overall, 46 (19.9%) patients died within 12 months after TAVI. The 30-day and 1-year survival was comparable between AS subtypes. Multivariate analysis identified severe renal failure as an independent predictor of mortality among all patients. Conclusions pLF-LGAS is common among subjects undergoing TAVI. Patients with paradoxical AS are younger, more often burdened with hypertension and have higher EF than the HGAS population, while being less symptomatic than the cLF-LGAS group. Presence of pLF-LGAS does not seem to affect short- and mid-term survival. Severe renal failure is an independent predictor of mortality after TAVI.
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Freitas-Ferraz AB, Rodés-Cabau J. Classical and Paradoxical Low-Flow, Low-Gradient Aortic Stenosis: The Evolving Role of TAVR. JACC Cardiovasc Interv 2019; 12:764-766. [PMID: 31000013 DOI: 10.1016/j.jcin.2019.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 02/19/2019] [Indexed: 11/24/2022]
Affiliation(s)
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada.
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Katte F, Franz M, Jung C, Figulla HR, Leistner D, Jakob P, Stähli BE, Kretzschmar D, Lauten A. Impact of concomitant mitral regurgitation on transvalvular gradient and flow in severe aortic stenosis: a systematic ex vivo analysis of a subentity of low-flow low-gradient aortic stenosis. EUROINTERVENTION 2019; 13:1635-1644. [PMID: 28994654 DOI: 10.4244/eij-d-17-00476] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Evaluation of aortic stenosis (AS) is based on echocardiographic measurement of mean pressure gradient (MPG), flow velocity (Vmax) and aortic valve area (AVA). The objective of the present study was to analyse the impact of systemic haemodynamic variables and concomitant mitral regurgitation (MR) on aortic MPG, Vmax and AVA in severe AS. METHODS AND RESULTS A pulsatile circulatory model was designed to study function and interdependence of stenotic aortic (AVA: 1.0 cm², 0.8 cm² and 0.6 cm²) and insufficient mitral prosthetic valves (n=8; effective regurgitant orifice area [EROA] <0.2 cm² vs. >0.4 cm²) using Doppler ultrasound. In the absence of severe MR, a stepwise increase of stroke volume (SV) and a decrease of AVA was associated with a proportional increase of aortic MPG. When MR with EROA <0.2 cm² vs. >0.4 cm² was introduced, forward SV decreased significantly (70.9±1.1 ml vs. 60.8±1.6 ml vs. 47.4±1.1 ml; p=0.02) while MR volume increased proportionally. This was associated with a subsequent reduction of aortic MPG (57.1±9.4 mmHg vs. 48.6±13.8 mmHg vs. 33.64±9.5 mmHg; p=0.035) and Vmax (5.09±0.4 m/s vs. 4.91±0.73 m/s vs. 3.75±0.57 m/s; p=0.007). Calculated AVA remained unchanged (without MR: AVA=0.53±0.04 cm² vs. with MR: AVA=0.52±0.05 cm²; p=ns). In the setting of severe AS without MR, changes of vascular resistance (SVR) and compliance (C) did not impact on aortic MPG (low SVR and C: 66±13.8 mmHg and 61.1±20 mmHg vs. high SVR and C: 60.9±9.2 mmHg and 71.5±13.5 mmHg; p=ns) In concomitant severe MR, aortic MPG and Vmax were not significantly reduced by increased SVR (36.6±2.2 mmHg vs. 34.9±5.6 mmHg, p=0.608; 3.89±0.18 m/s vs. 3.96±0.28 m/s; p=ns). CONCLUSIONS Systemic haemodynamic variables and concomitant MR may potentially affect diagnostic accuracy of echocardiographic AS evaluation. As demonstrated in the present study, MPG and Vmax are flow-dependent and significantly reduced by a reduction of forward SV from concomitant severe MR, resulting in another entity of low-flow low-gradient aortic stenosis. In contrast, calculated AVA appears to be a robust parameter of AS evaluation if severe MR is present. Changes of SVR and C did not affect the diagnostic accuracy of AS evaluation.
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Fischer-Rasokat U, Renker M, Liebetrau C, van Linden A, Arsalan M, Weferling M, Rolf A, Doss M, Möllmann H, Walther T, Hamm CW, Kim WK. 1-Year Survival After TAVR of Patients With Low-Flow, Low-Gradient and High-Gradient Aortic Valve Stenosis in Matched Study Populations. JACC Cardiovasc Interv 2019; 12:752-763. [DOI: 10.1016/j.jcin.2019.01.233] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/09/2019] [Accepted: 01/22/2019] [Indexed: 01/27/2023]
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Alushi B, Beckhoff F, Leistner D, Franz M, Reinthaler M, Stähli BE, Morguet A, Figulla HR, Doenst T, Maisano F, Falk V, Landmesser U, Lauten A. Pulmonary Hypertension in Patients With Severe Aortic Stenosis: Prognostic Impact After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Imaging 2019; 12:591-601. [DOI: 10.1016/j.jcmg.2018.02.015] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 02/06/2018] [Accepted: 02/15/2018] [Indexed: 01/03/2023]
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38
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Imnadze G, Hofmann S, Billion M, Ferdosi A, Kowalski M, Smith KH, Deutsch C, Bramlage P, Warnecke H, Franz N. Transapical transcatheter aortic valve implantation in patients with a low ejection fraction. Interact Cardiovasc Thorac Surg 2019; 26:224-229. [PMID: 29049741 DOI: 10.1093/icvts/ivx315] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 08/21/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES It may be expected that patients with left ventricular dysfunction may be at greater risk of complications after transcatheter aortic valve implantation (TAVI) via transapical (TA) access compared with via transfemoral (TF) access. There is a lack of data comparing the outcomes of TAVI using TA and TF access in patients with a reduced left ventricular ejection fraction (EF). METHODS This is a retrospective analysis of data from a high-volume heart centre in Germany. TAVI access route assignment was based on a 'best for TF' approach, where only patients who met a strict set of criteria underwent TF-TAVI, with the remainder receiving TA-TAVI. For this analysis, patients were included if they had a pre-TAVI EF of ≤ 40%. Early mortality and late (1-year) mortality were compared through multivariate logistic regression. RESULTS A total of 342 patients in the registry had an EF of ≤ 40%, of which 74.9% underwent TA-TAVI and 25.1% underwent TF-TAVI. Higher proportions of the TA group presented with certain comorbidities, and their logistic EuroSCORE and Society of Thoracic Surgeons (STS) risk scores were higher than in the TF group. At 1 year, TA access was associated with greater mortality in the univariate analysis (odd ratio 2.43; 95% confidence interval 1.04-5.69). However, after multivariate adjustment, no significant differences were found in either 30-day or 1-year mortality rates. CONCLUSIONS The data suggest that, for patients with a reduced EF, TA-TAVI is not associated with a poorer outcome compared with TF-TAVI. Therefore, TA access should not be discounted based on the presence of left ventricular dysfunction alone.
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Affiliation(s)
- Guram Imnadze
- Institut für Gesundheitsforschung und Bildung, Universität Osnabrück, Osnabrück, Germany.,Department of Cardiology, Klinikum Osnabrück, Am Finkenhügel 1, Osnabrück, Germany
| | - Steffen Hofmann
- Department of Cardiac Surgery, Schüchtermann Clinic, Bad Rothenfelde, Germany
| | - Michael Billion
- Department of Cardiac Surgery, Schüchtermann Clinic, Bad Rothenfelde, Germany
| | - Abbas Ferdosi
- Department of Cardiac Surgery, Schüchtermann Clinic, Bad Rothenfelde, Germany
| | - Marek Kowalski
- Department of Cardiology, Schüchtermann Clinic, Bad Rothenfelde, Germany
| | - Katherine H Smith
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Cornelia Deutsch
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Henning Warnecke
- Department of Cardiac Surgery, Schüchtermann Clinic, Bad Rothenfelde, Germany.,Department of Cardiology, Schüchtermann Clinic, Bad Rothenfelde, Germany
| | - Norbert Franz
- Department of Cardiology, Schüchtermann Clinic, Bad Rothenfelde, Germany.,University Witten-Herdecke, Witten, Germany
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Saji M, Highchi R, Iguchi N, Shimuzu J, Tobaru T, Takanashi S, Takayama M, Isobe M. Transcatheter aortic valve replacement in patients with degenerative calcified rheumatic aortic stenosis: A 10-patient case series. Int J Cardiol 2018; 280:38-42. [PMID: 30503242 DOI: 10.1016/j.ijcard.2018.11.090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 10/29/2018] [Accepted: 11/14/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) for patients with rheumatic heart disease (RHD) has not been well-known. This study aimed to assess characteristics and computed tomography (CT) findings of the aortic valve in old patients with RHD and to investigate the safety and efficacy in the patients who underwent TAVR. METHODS AND RESULTS Of 352 consecutive patients with severe aortic stenosis (AS) who underwent TAVR at the Sakakibara Heart Institute between 2013 and 2016, 10 patients (2.8%) were considered to have degenerative calcified rheumatic AS by transthoracic echocardiography. Young patients with rheumatic AS without any calcification were not indicated for TAVR in this study. They were likely to have previous pacemaker implantation, atrial fibrillation, anticoagulants, diuretics, reduced ejection fraction, mitral valve involvement, and high pulmonary artery pressure. CT was able to clearly visualize irregular valve thickening, commissure fusion, and a relatively small amount of calcification from the tip of the leaflet to the base of the aortic valve. Mortality at 30 days after TAVR was 0%, with a mean Society of Thoracic Surgeons Score of 7 ± 4%. Device success was 90%, and no patients met the safety endpoint at 30 days. CONCLUSIONS CT was able to visualize the calcified aortic valve in old patients with RHD, and we demonstrate the safety and efficacy of TAVR in this specific population. Care should be taken for procedural success in particular characteristics with marginal calcified aortic valve, anticoagulant use with low body mass index, or concomitant mitral valve disease.
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Affiliation(s)
- Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan.
| | - Ryosuke Highchi
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Nobuo Iguchi
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Jun Shimuzu
- Department of Anesthesia, Sakakibara Heart Institute, Tokyo, Japan
| | - Tetsuya Tobaru
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Shuichiro Takanashi
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | | | - Mitsuaki Isobe
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
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Prophylactic ECMO during TAVI in patients with depressed left ventricular ejection fraction. Clin Res Cardiol 2018; 108:366-374. [DOI: 10.1007/s00392-018-1364-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/23/2018] [Indexed: 10/28/2022]
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41
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Rodriguez-Gabella T, Nombela-Franco L, Auffret V, Asmarats L, Islas F, Maes F, Ferreira-Neto AN, Paradis JM, Dumont E, Côté M, Jiménez-Quevedo P, Macaya C, Pibarot P, Rodés-Cabau J. Transcatheter Aortic Valve Implantation in Patients With Paradoxical Low-Flow, Low-Gradient Aortic Stenosis. Am J Cardiol 2018; 122:625-632. [PMID: 30064863 DOI: 10.1016/j.amjcard.2018.04.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 04/22/2018] [Accepted: 04/24/2018] [Indexed: 11/13/2022]
Abstract
Controversial data exist on clinical outcomes of patients with paradoxical low-flow, low-gradient aortic stenosis (PLF-LG-AS) undergoing valve replacement. The objective of this study was to determine the clinical outcomes and treatment futility in patients with paradoxical low-flow (PLF), low-gradient (LG) severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). A total of 493 patients with severe symptomatic AS and preserved ejection fraction (>50%) undergoing TAVI were included. Patients were divided in two groups: high gradient AS group (HG-AS; mean gradient ≥40 mm Hg and stroke volume index >35 ml/m2, n = 396); and PLF, LG AS group (PLF-LG-AS; mean AV gradient <40 mm Hg and indexed stroke volume ≤35 ml/m2, n = 97). The primary endpoint was treatment futility defined as death or poor functional status (New York Heart Association class III and/or IV) at 6-month follow-up. There were no differences in mortality between groups (PLF-LG-AS: 5%, HG: 8%; adjusted odds ratio (OR): 0.85, 95% confidence interval (CI):0.29 to 2.46), but PLF-LG-AS patients remained more frequently in New York Heart Association class III to IV (20% vs 8% in the HG group, adjusted OR: 2.46, 95% CI:1.19 to 5.07). TAVI treatment futility was more frequent in the PLF-LG-AS group (24% vs 14%, adjusted OR: 1.90 [1.01 to 3.57]), and patients with PLF-LG-AS exhibited a higher rate of rehospitalization for cardiovascular causes (9% vs 5%, adjusted OR: 2.95, 95% CI:1.08 to 8.09). Previous myocardial infarction and chronic obstructive pulmonary disease were associated with treatment futility (p< 0.03 for both). In conclusion, TAVI was a futile treatment in one fourth of patients with PLF-LG-AS. These results underscore the complexity and need for improving the clinical decision-making process and management of patients with PLF-LG-AS.
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Affiliation(s)
- Tania Rodriguez-Gabella
- Quebec Heart and Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, Canada
| | - Luis Nombela-Franco
- Instituto Cardiovascular, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Vincent Auffret
- Quebec Heart and Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, Canada
| | - Lluis Asmarats
- Quebec Heart and Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, Canada
| | - Fabian Islas
- Instituto Cardiovascular, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Frederic Maes
- Quebec Heart and Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, Canada
| | | | - Jean-Michel Paradis
- Quebec Heart and Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, Canada
| | - Eric Dumont
- Quebec Heart and Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, Canada
| | - Melanie Côté
- Quebec Heart and Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, Canada
| | | | - Carlos Macaya
- Instituto Cardiovascular, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, Canada.
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Mihos CG, Klassen SL, Yucel E. Sex-Specific Considerations in Women with Aortic Stenosis and Outcomes After Transcatheter Aortic Valve Replacement. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:52. [PMID: 29923126 DOI: 10.1007/s11936-018-0651-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Aortic stenosis (AS) is the most common valvular disease in the elderly and is associated with poor outcomes. Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) in high-risk patients. Herein, we describe the gender-related differences in baseline characteristics and pathophysiologic response to severe AS, imaging considerations unique to females, and short- and long-term outcomes after TAVR. Women undergoing TAVR are older and frailer, have less cardiovascular comorbidities, smaller femoral artery size, better left ventricular systolic function, hypertrophied and small left ventricles leading to a higher incidence of paradoxical low-flow low-gradient AS, and a greater prevalence of porcelain aorta, smaller aortic annulus size, and lower coronary ostia heights. Imaging and histopathological data also suggests a sex-related myocardial response to pressure overload from AS. Women experience more vascular complications and blood transfusion requirements, serious procedural complications, and a greater incidence of stroke, but have better long-term outcomes than men. Patient-prosthesis mismatch, which is a concern in patients with a small aortic annulus size undergoing SAVR, has not been problematic with TAVR. The aforementioned findings suggest that TAVR may be preferable for women with severe AS. Further studies are warranted to directly compare TAVR with SAVR in women.
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Affiliation(s)
- Christos G Mihos
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Sheila L Klassen
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 5B, Boston, MA, 02114, USA
| | - Evin Yucel
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 5B, Boston, MA, 02114, USA.
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Stähli BE, Reinthaler M, Leistner DM, Landmesser U, Lauten A. Transcatheter Aortic Valve Replacement and Concomitant Mitral Regurgitation. Front Cardiovasc Med 2018; 5:74. [PMID: 29971238 PMCID: PMC6018074 DOI: 10.3389/fcvm.2018.00074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 05/30/2018] [Indexed: 12/24/2022] Open
Abstract
Mitral regurgitation frequently coexists in patients with severe aortic stenosis. Patients with moderate to severe mitral regurgitation at the time of transcatheter aortic valve replacement are at increased risk of future adverse events. Whether concomitant mitral regurgitation is independently associated with worse outcomes after TAVR remains a matter of debate. The optimal therapeutic strategy in these patients-TAVR with evidence-based heart failure therapy, combined TAVR and transcatheter mitral valve intervention, or staged transcatheter therapies-is ill-defined, and guideline-based recommendations in patients at increased risk for open heart surgery are lacking. Hence, a thorough evaluation of the aortic and mitral valve anatomy and function, along with an in-depth assessment of the patients' baseline risk profile, provides the basis for an individualized treatment approach. The aim of this review is therefore to give an overview of the current literature on mitral regurgitation in TAVR, focusing on different diagnostic and therapeutic strategies and optimal clinical decision making.
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Affiliation(s)
- Barbara E Stähli
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Partner Site Berlin, Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
| | - Markus Reinthaler
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Partner Site Berlin, Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
| | - David M Leistner
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Partner Site Berlin, Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Partner Site Berlin, Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Alexander Lauten
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Partner Site Berlin, Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
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Mangner N, Stachel G, Woitek F, Haussig S, Schlotter F, Höllriegel R, Adam J, Lindner A, Mohr FW, Schuler G, Kiefer P, Leontyev S, Borger MA, Thiele H, Holzhey D, Linke A. Predictors of Mortality and Symptomatic Outcome of Patients With Low-Flow Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement. J Am Heart Assoc 2018; 7:JAHA.117.007977. [PMID: 29654191 PMCID: PMC6015421 DOI: 10.1161/jaha.117.007977] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Impaired left ventricular (LV) ejection fraction is a common finding in patients with aortic stenosis and serves as a predictor of morbidity and mortality after transcatheter aortic valve replacement. However, conflicting data on the most accurate measure for LV function exist. We wanted to examine the impact of LV ejection fraction, mean pressure gradient, and stroke volume index on the outcome of patients treated by transcatheter aortic valve replacement. Methods and Results Patients treated by transcatheter aortic valve replacement were primarily separated into normal flow (NF; stroke volume index >35 mL/m2) and low flow (LF; stroke volume index ≤35 mL/m2). Afterwards, patients were divided into 5 groups: “NF–high gradient,” “NF–low gradient” (NF‐LG), “LF–high gradient,” “paradoxical LF‐LG,” and “classic LF‐LG.” The 3‐year mortality was the primary end point. Of 1600 patients, 789 (49.3%) were diagnosed as having LF, which was characterized by a higher 30‐day (P=0.041) and 3‐year (P<0.001) mortality. LF was an independent predictor of all‐cause (hazard ratio, 1.29; 95% confidence interval, 1.03–1.62; P=0.03) and cardiovascular (hazard ratio, 1.37; 95% confidence interval, 1.06–1.77; P=0.016) mortality. Neither mean pressure gradient nor LV ejection fraction was an independent predictor of mortality. Patients with paradoxical LF‐LG (35.0%), classic LF‐LG (35.1%) and LF–high gradient (38.1%) had higher all‐cause mortality at 3 years compared with NF–high gradient (24.8%) and NF‐LG (27.9%) (P=0.001). However, surviving patients showed a similar improvement in symptoms regardless of aortic stenosis entity. Conclusions LF is a common finding within the aortic stenosis population and, in contrast to LV ejection fraction or mean pressure gradient, an independent predictor of all‐cause and cardiovascular mortality. Despite increased long‐term mortality, high procedural success and excellent functional improvement support transcatheter aortic valve replacement in patients with LF severe aortic stenosis.
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Affiliation(s)
- Norman Mangner
- Heart Center Leipzig-University Hospital, Leipzig, Germany .,Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Georg Stachel
- Heart Center Leipzig-University Hospital, Leipzig, Germany
| | - Felix Woitek
- Heart Center Leipzig-University Hospital, Leipzig, Germany.,Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Stephan Haussig
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | | | - Robert Höllriegel
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Jennifer Adam
- Heart Center Leipzig-University Hospital, Leipzig, Germany
| | - Anna Lindner
- Heart Center Leipzig-University Hospital, Leipzig, Germany
| | | | | | - Philipp Kiefer
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Sergey Leontyev
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Holger Thiele
- Heart Center Leipzig-University Hospital, Leipzig, Germany
| | - David Holzhey
- Department of Cardiac Surgery, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Axel Linke
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
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Puls M, Korte KP, Bleckmann A, Huenlich M, Danner BC, Schoendube F, Hasenfuß G, Jacobshagen C, Schillinger W. Long-term outcomes after TAVI in patients with different types of aortic stenosis: the conundrum of low flow, low gradient and low ejection fraction. EUROINTERVENTION 2018; 13:286-293. [PMID: 28462903 DOI: 10.4244/eij-d-16-00801] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The objective of this study was to examine the impact of guideline-defined subtypes of severe aortic stenosis (AS) on long-term outcomes after TAVI. METHODS AND RESULTS Four hundred (400) consecutive patients who underwent TAVI (203 transapical, 197 transfemoral) at our institution 8/2008-3/2013 were followed systematically (for up to seven years). One hundred and forty-seven (147) individuals suffered from NEF-HG AS (LV-EF ≥50%, high Pmean ≥40 mmHg), 63 from LEF-HG AS (LV-EF <50%, high gradient), 77 from PLF-LG AS (LV-EF ≥50%, low gradient, stroke volume index [SVI] <35 ml/m²), and 81 from LEF-LG AS (LV-EF <50%, low gradient). LEF-LG status was associated with the highest all-cause and cardiovascular mortality and MACCE rate, whereas NEF-HG patients exhibited the best outcome (i.e., median survival 5.1 years in NEF-HG vs. 1.3 years in LEF-LG, p=0.0006; or vs. 3.3 years in PLF-LG, p=0.02). In multivariate analysis, LEF-LG status emerged as the outcome predictor with the highest hazard ratio for all-cause mortality (HR 2.86, p=0.003), cardiovascular mortality (HR 6.53, p<0.0001), and MACCE (HR 2.44, p=0.007), whereas neither baseline EF nor SVI <35 ml/m² independently predicted these endpoints. CONCLUSIONS These findings suggest that an assessment of LV-EF alone for outcome prediction after TAVI is inadequate; it is the guideline-defined subtype of AS that determines outcome.
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Affiliation(s)
- Miriam Puls
- Department of Cardiology, University Medical Center Goettingen, Goettingen, Germany
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Ribeiro HB, Lerakis S, Gilard M, Cavalcante JL, Makkar R, Herrmann HC, Windecker S, Enriquez-Sarano M, Cheema AN, Nombela-Franco L, Amat-Santos I, Muñoz-García AJ, Garcia del Blanco B, Zajarias A, Lisko JC, Hayek S, Babaliaros V, Le Ven F, Gleason TG, Chakravarty T, Szeto WY, Clavel MA, de Agustin A, Serra V, Schindler JT, Dahou A, Puri R, Pelletier-Beaumont E, Côté M, Pibarot P, Rodés-Cabau J. Transcatheter Aortic Valve Replacement in Patients With Low-Flow, Low-Gradient Aortic Stenosis. J Am Coll Cardiol 2018; 71:1297-1308. [DOI: 10.1016/j.jacc.2018.01.054] [Citation(s) in RCA: 111] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 11/30/2022]
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Mechanical Intervention for Aortic Valve Stenosis in Patients With Heart Failure and Reduced Ejection Fraction. J Am Coll Cardiol 2017; 70:3026-3041. [PMID: 29241492 DOI: 10.1016/j.jacc.2017.10.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 12/11/2022]
Abstract
The risk and benefit of mechanical interventions in valvular heart disease have been primarily described among patients with normal ejection fraction. The advent of nonsurgical mechanical interventions for aortic stenosis (transcatheter aortic valve replacement) may alter the risk-benefit ratio for patients who would otherwise be at increased risk for valve surgery. This review describes the epidemiology and pathophysiology of aortic stenosis with heart failure and reduced ejection fraction and summarizes the current registry and clinical trial data applicable to this frequently encountered high-risk group. It concludes with discussion of ongoing trials, new approaches, emerging indications, and a potential clinical algorithm incorporating optimal mechanical intervention for patients with aortic stenosis and concomitant reduced ejection fraction.
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Abstract
Recently, transcatheter therapy has expanded the treatment options for patients with heart valve disease. With the growing understanding of tricuspid regurgitation and its natural history, it becomes increasingly obvious that this patient population is a heterogeneous cohort presenting for treatment in different stages of a continuous disease process. It is still unclear which interventional approach will result in functional and clinical success and in which subtype of patient population. This article reviews the pathophysiologic background and current evidence for caval valve implantation and examines the potential role of this approach for the treatment of severe tricuspid regurgitation.
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Affiliation(s)
- Alexander Lauten
- Department of Cardiology, Charité - Universitaetsmedizin Berlin, German Centre for Cardiovascular Research (DZHK), University Heart Center, Charitéplatz 1, Berlin D-10117, Germany.
| | - Henryk Dreger
- Department of Cardiology, Charité - Universitaetsmedizin Berlin, German Centre for Cardiovascular Research (DZHK), University Heart Center, Charitéplatz 1, Berlin D-10117, Germany
| | - Michael Laule
- Department of Cardiology, Charité - Universitaetsmedizin Berlin, German Centre for Cardiovascular Research (DZHK), University Heart Center, Charitéplatz 1, Berlin D-10117, Germany
| | - Karl Stangl
- Department of Cardiology, Charité - Universitaetsmedizin Berlin, German Centre for Cardiovascular Research (DZHK), University Heart Center, Charitéplatz 1, Berlin D-10117, Germany
| | - Hans R Figulla
- University Heart Center Jena, Erlanger Allee 101, 07747 Jena, Germany
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Carreras ET, Kaneko T, Ramirez-Del Val F, Pelletier MP, Sobieszczyk PS, Bhatt DL, Shah PB. Impact of flow, gradient, and left ventricular function on outcomes after transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2017; 91:798-805. [PMID: 28988432 DOI: 10.1002/ccd.27347] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 08/13/2017] [Accepted: 08/29/2017] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To assess the impact of low flow with and without preserved left ventricular ejection fraction (LVEF) on outcomes after transcatheter aortic valve replacement (TAVR). BACKGROUND Prior studies have shown that patients with low flow, AVG, and LVEF have worse outcomes after TAVR. It is unclear whether low AVG and LVEF remain prognostic after adjusting for flow, and how the outcomes of patients with low flow with and without preserved LVEF compare after TAVR. The goal of this study was to provide insight into these open questions. METHODS Data from 340 TAVR patients at Brigham and Women's Hospital from 2011 through 2015 were analyzed. Low flow was defined as stroke volume index (SVI) ≤35 mL/m2 , low AVG as mean gradient < 40 mmHg, and reduced LVEF as < 50%. RESULTS Low flow was present in 96 (28.2%) patients, 48 (50.0%) of whom also had reduced LVEF. At 1 year, low flow was associated with increased mortality (21.9 vs 7.4%; P = 0.0002) and heart failure (HF) (20.8 vs 5.3%; P = 0.0113). Among patients with low flow, those with preserved LVEF had increased mortality (HR 5.17, 95% CI 2.73-9.80; P < 0.001) and HF (HR 7.69, 95% CI 3.86-15.31; P < 0.001). After adjusting for clinical factors, patients with low flow had increased mortality (HR 6.51, 95% CI 2.98-14.22; P < 0.001) and HF (HR 5.52, 95% CI 2.34-12.98; P < 0.001), while neither low AVG nor low LVEF were associated with increases in mortality or HF. CONCLUSIONS In patients undergoing TAVR, low flow was an independent predictor of 1-year mortality and HF, and a stronger predictor than either low AVG or LVEF. Patients with low flow and preserved EF had increased mortality and HF at 1-year, while those with low flow and reduced EF had outcomes similar to patients with normal flow.
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Affiliation(s)
- Edward T Carreras
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Fernando Ramirez-Del Val
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marc P Pelletier
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Piotr S Sobieszczyk
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Deepak L Bhatt
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Pinak B Shah
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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50
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Saybolt MD, Fiorilli PN, Gertz ZM, Herrmann HC. Low-Flow Severe Aortic Stenosis. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.117.004838. [DOI: 10.1161/circinterventions.117.004838] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 07/03/2017] [Indexed: 12/14/2022]
Affiliation(s)
- Matthew D. Saybolt
- From the Departments of Medicine of the University of Pennsylvania, Philadelphia (M.D.S., P.N.F., H.C.H.) and Virginia Commonwealth University, Richmond (Z.M.G.)
| | - Paul N. Fiorilli
- From the Departments of Medicine of the University of Pennsylvania, Philadelphia (M.D.S., P.N.F., H.C.H.) and Virginia Commonwealth University, Richmond (Z.M.G.)
| | - Zachary M. Gertz
- From the Departments of Medicine of the University of Pennsylvania, Philadelphia (M.D.S., P.N.F., H.C.H.) and Virginia Commonwealth University, Richmond (Z.M.G.)
| | - Howard C. Herrmann
- From the Departments of Medicine of the University of Pennsylvania, Philadelphia (M.D.S., P.N.F., H.C.H.) and Virginia Commonwealth University, Richmond (Z.M.G.)
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