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Suhai FI, Varga A, Szilveszter B, Nagy-Vecsey M, Apor A, Nagy AI, Kolossváry M, Karády J, Bartykowszki A, Molnár L, Jermendy ÁL, Panajotu A, Maurovich-Horvat P, Merkely B. Predictors and neurological consequences of periprocedural cerebrovascular events following transcatheter aortic valve implantation with self-expanding valves. Front Cardiovasc Med 2022; 9:951943. [PMID: 36277778 PMCID: PMC9581280 DOI: 10.3389/fcvm.2022.951943] [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: 05/24/2022] [Accepted: 09/09/2022] [Indexed: 11/13/2022] Open
Abstract
Aims To evaluate the patient- and procedure-related predictors of transcatheter aortic-valve implantation (TAVI)-associated ischemic brain lesions and to assess the effect of silent cerebral ischemic lesions (SCIL) on neurocognitive function. Methods and results We investigated 113 consecutive patients with severe aortic stenosis who underwent brain magnetic resonance imaging (MRI) within a week following TAVI. To assess periprocedural cerebral ischemic lesions, diffusion-weighted MRI was utilized. We used multivariate linear regression to identify the independent predictors of TAVI-related ischemic lesion volume (ILV) and periprocedural stroke. Neurocognitive evaluation was performed before and following TAVI at 6-month and one-year follow-up. Following TAVI, a total of 944 new cerebral ischemic lesions were detected in 104 patients (92%). The median ILV was 257 μl (interquartile range [IQR]:97.1–718.8μl) with a median lesion number of 6/patient [IQR:2–10]. The majority of ischemic lesions were clinically silent (95%), while 5% of the lesions induced a stroke, which was confirmed by MRI. Predilatation (β = 1.13[95%CI:0.32–1.93], p = 0.01) and the number of valve positioning attempts during implantation (β = 0.28[95%CI:0.06–0.50], p = 0.02) increased the log-transformed total ILV. Predilatation (OR = 12.04[95%CI:1.46–99.07], p = 0.02) and alternative access routes (OR = 7.84[95%CI:1.01–61.07], p = 0.02) were associated with stroke after adjustments for comorbidities and periprocedural factors. The presence of SCILs were not associated with a change in neurocognitive function that remained stable during the one-year follow-up. Conclusion While periprocedural ischemic lesions are frequent, most of them are clinically silent and might not impact the patients' neurocognitive function. The number of valve positioning attempts, predilatation, and alternative access routes should be taken into consideration during TAVI to reduce the ILV and risk for stroke.
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Affiliation(s)
- Ferenc Imre Suhai
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Andrea Varga
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bálint Szilveszter
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary,*Correspondence: Bálint Szilveszter
| | - Milán Nagy-Vecsey
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Astrid Apor
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Anikó Ilona Nagy
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary,Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Márton Kolossváry
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary,Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Júlia Karády
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary,Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Andrea Bartykowszki
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Levente Molnár
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ádám L. Jermendy
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Alexisz Panajotu
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Béla Merkely
- Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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2
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Transcatheter aortic valve implantation in patients with uninterrupted vitamin K antagonists. Catheter Cardiovasc Interv 2022; 100:235-242. [DOI: 10.1002/ccd.30248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/13/2022] [Accepted: 05/17/2022] [Indexed: 12/19/2022]
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3
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Elbaz-Greener G, Rozen G, Kusniec F, Marai I, Carasso S, Ko DT, Wijeysundera HC, Alcalai R, Planer D, Amir O. Comparing Trajectory of Surgical Aortic Valve Replacement in the Early vs. Late Transcatheter Aortic Valve Replacement Era. Front Cardiovasc Med 2021; 8:680123. [PMID: 34239904 PMCID: PMC8258156 DOI: 10.3389/fcvm.2021.680123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/21/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Traditionally, the only effective treatment for aortic stenosis was surgical aortic valve replacement (SAVR). Transcatheter aortic valve replacement (TAVR) was approved in the United States in late 2011 and provided a critical alternative therapy. Our aims were to investigate the trends in the utilization of SAVR in the early vs. late TAVR era and to assess SAVR and TAVR outcomes. Methods: Using the 2011-2017 National Inpatient Sample database, we identified hospitalizations for patients with a most responsible diagnosis of aortic stenosis during which an aortic valve replacement (AVR) was performed, either SAVR or TAVR. Patients' sociodemographic and clinical characteristics, procedure complications, length of stay, and mortality were analyzed. Multivariable analyses were performed to identify predictors of in-hospital mortality. Piecewise regression analyses were performed to assess temporal trends in SAVR and TAVR utilization. Results: A total of 542,734 AVR procedures were analyzed. The utilization of SAVR was steady until 2014 with a significant downward trend in the following years 2015-2017 (P = 0.026). In contrast, a steady upward trend was observed in the TAVR procedure with a significant increase during the years 2015-2017 (P = 0.006). Higher in-hospital mortality was observed in SAVR patients. The mortality rate declined from 2011 to 2017 in a significantly higher proportion in the TAVR compared with the SAVR group. Conclusion: Utilization of SAVR showed a downward trend during the late TAVR era (2015-2017), and TAVR utilization demonstrated a steady upward trend during the years 2011-2017. Higher in-hospital mortality was recorded in patients who underwent SAVR.
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Affiliation(s)
- Gabby Elbaz-Greener
- Department of Cardiology, The Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel.,Division of Cardiovascular Medicine, Baruch Padeh Medical Center, Poria, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Guy Rozen
- Division of Cardiovascular Medicine, Baruch Padeh Medical Center, Poria, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.,Cardiology Division, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Fabio Kusniec
- Division of Cardiovascular Medicine, Baruch Padeh Medical Center, Poria, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Ibrahim Marai
- Division of Cardiovascular Medicine, Baruch Padeh Medical Center, Poria, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Shemy Carasso
- Division of Cardiovascular Medicine, Baruch Padeh Medical Center, Poria, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Dennis T Ko
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Harindra C Wijeysundera
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Ronny Alcalai
- Department of Cardiology, The Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Planer
- Department of Cardiology, The Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Offer Amir
- Department of Cardiology, The Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel.,Division of Cardiovascular Medicine, Baruch Padeh Medical Center, Poria, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
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4
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Halapas A, Kapelouzou A, Chrissoheris M, Pattakos G, Cokkinos DV, Spargias K. The effect of Remote Ischemic Preconditioning (RIPC) on myocardial injury and inflammation in patients with severe aortic valve stenosis undergoing Transcatheter Aortic Valve Replacement (TAVΙ). Hellenic J Cardiol 2021; 62:423-428. [PMID: 33617961 DOI: 10.1016/j.hjc.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/01/2021] [Accepted: 02/12/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Remote ischemic preconditioning (RIPC) is being evaluated as a strategy to reduce cardiac injury and inflammation in patients undergoing diverse cardiac invasive and surgical procedures. However, it is unclear whether RIPC has protective effects in patients undergoing the transfemoral- transcatheter aortic valve implantation (TF-TAVΙ) procedure. METHODS Between September 2013 and September 2015, 55 random consecutive patients were prospectively assigned to receive SHAM preconditioning (SHAM, 22 patients) or Remote Ischemic Preconditioning (RIPC) (4 cycles of 5 min intermittent leg ischemia and 5 min reperfusion, 33 patients) prior to TF-TAVI. The primary endpoint was to determine the serum levels of: hs-cTn-I (necrosis), CK-18 (apoptosis), and IL-1b (inflammation). Quantification was performed using commercially available ELISA kits. Patients were sampled 1-day pre TF-TAVΙ and 24-hours post TF-TAVΙ. Secondary endpoints included: total mortality, incidence of periprocedural clinical acute myocardial infarction (AMI), acute kidney injury (AKI), and stroke. RESULTS 22 SHAM patients and 33 RIPC patients were finally analyzed. Our data revealed no significant difference in serum levels of hs-cTn-I and CK-18 among various groups. However, in the RIPC group, the increase in IL1b level was significantly lower for 24-h post TF-TAVΙ, (p < 0.01). There were no significant differences between groups in the secondary endpoints at the follow-up interval of one month. RIPC-related adverse events were not observed. CONCLUSIONS Our data suggest that RIPC did not exhibit significant cardiac or kidney protective effects regarding necrosis and apoptosis in patients undergoing TF-TAVΙ. However, an important anti-inflammatory effect was detected in the RIPC group.
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Affiliation(s)
- Antonios Halapas
- THV Department, Heart Team Hygeia Hospital Athens Greece, Er. Stavrou 9, Marousi, Athens, Greece.
| | - Alkistis Kapelouzou
- Center of Clinical, Experimental Surgery, & Translation Research, Biomedical Research Foundation Academy of Athens (BRFAA), Soranou Efesiou 4, 11527, Athens, Greece
| | - Michael Chrissoheris
- THV Department, Heart Team Hygeia Hospital Athens Greece, Er. Stavrou 9, Marousi, Athens, Greece
| | - Gregory Pattakos
- THV Department, Heart Team Hygeia Hospital Athens Greece, Er. Stavrou 9, Marousi, Athens, Greece
| | - Dennis V Cokkinos
- Center of Clinical, Experimental Surgery, & Translation Research, Biomedical Research Foundation Academy of Athens (BRFAA), Soranou Efesiou 4, 11527, Athens, Greece
| | - Konstantinos Spargias
- THV Department, Heart Team Hygeia Hospital Athens Greece, Er. Stavrou 9, Marousi, Athens, Greece
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5
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Elbaz-Greener G, Ghanim D, Kusniec F, Rabin A, Sudarsky D, Carasso S, Czeiger T, Shoan-Dayan M, Sakhnini A, Grosman-Rimon L, Strauss BH, Wijeysundra HC, Amir O. Pre- and Post-Transcatheter Aortic Valve Replacement Serum Brain Natriuretic Peptide Levels and All-Cause Mortality. Cardiology 2020; 145:813-821. [PMID: 33070124 DOI: 10.1159/000509857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/29/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Risk stratification in patients post-transcatheter aortic valve replacement (TAVR) is limited to and is based on clinical judgment and surgical scoring systems. Serum natriuretic peptides are used for general risk stratification in patients with aortic stenosis, reflecting the increase in their afterload and thereby stressing the need for valve intervention. The objective of this study was to determine the predictive value of pre- and post-procedural serum brain natriuretic peptide (BNP) on 1-year all-cause mortality in patients who underwent TAVR. METHODS In this population-based study, we included 148 TAVR patients treated at the Poriya Medical Center between June 1, 2015, and May 31, 2018. Routine blood samples for serum BNP levels (pg/mL) were taken just before the TAVR and 24 h post-TAVR. Our primary clinical outcome was defined as 1-year all-cause mortality. We used backward regression models and included all variables that had a p value <0.1 in the univariable analysis. A receiver-operating characteristic curve was calculated for the prediction of all-cause mortality by serum BNP levels using the median as the cut-off point. RESULTS In this study cohort, BNP levels 24 h post-TAVR higher than the cohort median versus lower than the cohort median (387.5 pg/mL; IQR 195-817.6) were the strongest predictor of 1-year mortality (hazard ratio 9; 95% CI 2.72-30.16; p < 0.001). The statistically significant relationship was seen in the unadjusted regression model as well as after the adjustment for clinical variables. CONCLUSIONS Serum BNP levels 24 h post-procedure were found to be a meaningful marker in predicting 1-year all-cause mortality in patients after TAVR procedure.
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Affiliation(s)
- Gabby Elbaz-Greener
- Cardiovascular Institute, Baruch Padeh Medical Center, Poriya, Israel, .,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel, .,Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel, .,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel,
| | - Diab Ghanim
- Cardiovascular Institute, Baruch Padeh Medical Center, Poriya, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Fabio Kusniec
- Cardiovascular Institute, Baruch Padeh Medical Center, Poriya, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Asaf Rabin
- Cardiovascular Institute, Baruch Padeh Medical Center, Poriya, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Doron Sudarsky
- Cardiovascular Institute, Baruch Padeh Medical Center, Poriya, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Shemy Carasso
- Cardiovascular Institute, Baruch Padeh Medical Center, Poriya, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Tal Czeiger
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Mirit Shoan-Dayan
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Ali Sakhnini
- Cardiovascular Institute, Baruch Padeh Medical Center, Poriya, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Liza Grosman-Rimon
- Cardiovascular Institute, Baruch Padeh Medical Center, Poriya, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Bradley H Strauss
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Harindra C Wijeysundra
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada.,Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Offer Amir
- Cardiovascular Institute, Baruch Padeh Medical Center, Poriya, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.,Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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6
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Abstract
Aortic valve replacement has stood the test of time but is no longer an operation that is exclusively approached through a median sternotomy using only sutured prostheses. Currently, surgical aortic valve replacement can be performed through a number of minimally invasive approaches employing conventional mechanical or bioprostheses as well as sutureless valves. In either case, the direct surgical access allows inspection of the valve, complete excision of the diseased leaflets, and debridement of the annulus in a controlled and thorough manner under visual control. It can be employed to treat aortic valve pathologies of all natures and aetiologies. When compared with transcatheter valves in patients with a high or intermediate preoperative predictive risk, conventional surgery has not been shown to be inferior to transcatheter valve implants. As our understanding of sutureless valves and their applicability to minimally invasive surgery advances, the invasiveness and trauma of surgery can be reduced and outcomes can improve. This warrants further comparative trials comparing sutureless and transcatheter valves.
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Affiliation(s)
- Cristiano Spadaccio
- Department of Cardiac Surgery, Golden Jubilee National Hospital, Agamemnon Street, Glasgow, G81 4DY, UK
| | - Khalid Alkhamees
- Department of Cardiac Surgery, Prince Sultan Cardiac Center Al Hassa, Prince Fawaz bin Abdulaziz St., Hofuf city, 31982, Saudi Arabia
| | - Nawwar Al-Attar
- Department of Cardiac Surgery, Golden Jubilee National Hospital, Agamemnon Street, Glasgow, G81 4DY, UK
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7
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Elbaz-Greener G, Qiu F, Webb JG, Henning KA, Ko DT, Czarnecki A, Roifman I, Austin PC, Wijeysundera HC. Profiling Hospital Performance on the Basis of Readmission After Transcatheter Aortic Valve Replacement in Ontario, Canada. J Am Heart Assoc 2019; 8:e012355. [PMID: 31165666 PMCID: PMC6645639 DOI: 10.1161/jaha.119.012355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Readmission rates are a widely accepted quality indicator. Our objective was to develop models for calculating case‐mixed adjusted readmission rates after transcatheter aortic valve replacement for the purpose of profiling hospitals. Methods and Results In this population‐based study in Ontario, Canada, we identified all transcatheter aortic valve replacement procedures between April 1, 2012, and March 31, 2016. For each hospital, we first calculated 30‐day and 1‐year risk‐standardized (predicted versus expected) readmission rates, using 2‐level hierarchical logistic regression models, including clustering of patients within hospitals. We also calculated the risk‐adjusted (observed versus expected) readmission rates, accounting for the competing risk of death using a Fine‐Gray competing risk model. We categorized hospitals into 3 groups: those performing worse than expected, those performing better than expected, or those performing as expected, on the basis of whether the 95% CI was above, below, or included the provincial average readmission rate respectively. Our cohort consisted of 2129 transcatheter aortic valve replacement procedures performed at 10 hospitals. The observed readmission rate was 15.4% at 30 days and 44.2% at 1 year, with a range of 10.9% to 21.7% and 38.8% to 55.0%, respectively, across hospitals. Incorporating the competing risk of death translated into meaningful different results between models; as such, we concluded that the risk‐adjusted readmission rate was the preferred metric. On the basis of the 30‐day risk‐adjusted readmission rate, all hospitals performed as expected, with a 95% CI that included the provincial average. However, we found that there was significant variation in 1‐year risk‐adjusted readmission rate. Conclusions There is significant interhospital variation in 1‐year adjusted readmission rates among hospitals, suggesting that this should be a focus for quality improvement efforts in transcatheter aortic valve replacement.
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Affiliation(s)
- Gabby Elbaz-Greener
- 1 Division of Cardiology Schulich Heart Center Sunnybrook Health Sciences Center University of Toronto Ontario Canada.,2 Baruch Padeh Poriya Medical Centre Poriya Israel
| | | | - John G Webb
- 4 Center for Heart Valve Innovation St. Paul's Hospital University of British Columbia Vancouver British Columbia Canada
| | | | - Dennis T Ko
- 1 Division of Cardiology Schulich Heart Center Sunnybrook Health Sciences Center University of Toronto Ontario Canada.,3 ICES Toronto Ontario Canada.,5 Sunnybrook Research Institute University of Toronto Ontario Canada.,6 Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
| | - Andrew Czarnecki
- 1 Division of Cardiology Schulich Heart Center Sunnybrook Health Sciences Center University of Toronto Ontario Canada.,3 ICES Toronto Ontario Canada.,5 Sunnybrook Research Institute University of Toronto Ontario Canada.,6 Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
| | - Idan Roifman
- 1 Division of Cardiology Schulich Heart Center Sunnybrook Health Sciences Center University of Toronto Ontario Canada.,3 ICES Toronto Ontario Canada.,5 Sunnybrook Research Institute University of Toronto Ontario Canada.,6 Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
| | - Peter C Austin
- 3 ICES Toronto Ontario Canada.,5 Sunnybrook Research Institute University of Toronto Ontario Canada.,6 Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
| | - Harindra C Wijeysundera
- 1 Division of Cardiology Schulich Heart Center Sunnybrook Health Sciences Center University of Toronto Ontario Canada.,3 ICES Toronto Ontario Canada.,5 Sunnybrook Research Institute University of Toronto Ontario Canada.,6 Institute for Health Policy Management and Evaluation University of Toronto Ontario Canada
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8
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Veulemans V, Piayda K, Afzal S, Polzin A, Quast C, Jung C, Westenfeld R, Zeus T, Kelm M, Hellhammer K. Cost-comparison of third generation transcatheter aortic valve implantation (TAVI) devices in the German Health Care System. Int J Cardiol 2019; 278:40-45. [DOI: 10.1016/j.ijcard.2018.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 10/17/2018] [Accepted: 12/03/2018] [Indexed: 11/27/2022]
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9
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Elbaz-Greener G, Qiu F, Masih S, Fang J, Austin PC, Cantor WJ, Dvir D, Asgar AW, Webb JG, Ko DT, Wijeysundera HC. Profiling Hospital Performance Based on Mortality After Transcatheter Aortic Valve Replacement in Ontario, Canada. Circ Cardiovasc Qual Outcomes 2018; 11:e004947. [PMID: 30562064 DOI: 10.1161/circoutcomes.118.004947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Public reporting of hospital-level outcomes is increasingly common as a means to target quality improvement strategies to ensure the delivery of optimal care. Despite the rapid dissemination of transcatheter aortic valve replacement (TAVR), there is a paucity of reliable case-mix adjustment models for hospital profiling in TAVR. Our objective was to develop and evaluate different models for calculating risk-standardized all-cause mortality rates (RSMRs) post-TAVR. METHODS AND RESULTS In this population-based study in Ontario, Canada, we identified all patients who underwent a TAVR procedure between April 1, 2012, and March 31, 2016. For each hospital, we calculated 30-day and 1-year RSMR, using 2-level hierarchical logistic regression models that accounted for patient-specific demographic and clinical characteristics, as well as the clustering of patients within the same hospital using a hospital-specific random effects. We classified each hospital into one of 3 groups: performing worse than expected, better than expected, or performing as expected, based on whether the 95% CI of the RSMR was above, below, or included the provincial average mortality rate, respectively. Our cohort consisted of 2129 TAVR procedures performed at 10 hospitals. The observed mortality was 7.0% at 30 days and 16.4% at 1 year, with a range of 4% to 10% and 8% to 22%, respectively, across hospitals. We developed case-mix adjustment models using 28 clinically relevant variables. Using 30-day and 1-year RSMR to profile each hospital, we found that all hospitals performed as expected, with 95% CI that included the provincial average. CONCLUSIONS We found no significant interhospital variation in RSMR among hospitals, suggesting that quality improvement efforts should be directed at aspects other than the variation in observed mortality.
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Affiliation(s)
- Gabby Elbaz-Greener
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (G.E.-G., D.T.K., H.C.W.).,Cardiovascular Institute, Baruch Padeh Medical Center, Poriya, Israel (G.E.-G.)
| | - Feng Qiu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.Q., S.M., J.F., P.C.A., D.T.K., H.C.W.)
| | - Shannon Masih
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.Q., S.M., J.F., P.C.A., D.T.K., H.C.W.).,Chronic Disease and Injury Prevention, Public Health, Region of Peel (S.M.)
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.Q., S.M., J.F., P.C.A., D.T.K., H.C.W.)
| | - Peter C Austin
- Sunnybrook Research Institute, University of Toronto, Ontario, Canada (P.C.A., D.T.K., H.C.W.).,Institute for Health Policy Management and Evaluation, University of Toronto, Ontario, Canada (P.C.A., D.T.K., H.C.W.).,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.Q., S.M., J.F., P.C.A., D.T.K., H.C.W.)
| | - Warren J Cantor
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, Ontario, Canada (W.J.C.)
| | - Danny Dvir
- Division of Cardiology, University of Washington, Seattle (D.D.)
| | - Anita W Asgar
- Institute for Cardiology, University of Montréal, Quebec, Canada (A.W.A.)
| | - John G Webb
- Center for Heart Valve Innovation, St Paul's Hospital, University of British Columbia, Vancouver (J.G.W.)
| | - Dennis T Ko
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (G.E.-G., D.T.K., H.C.W.).,Sunnybrook Research Institute, University of Toronto, Ontario, Canada (P.C.A., D.T.K., H.C.W.).,Institute for Health Policy Management and Evaluation, University of Toronto, Ontario, Canada (P.C.A., D.T.K., H.C.W.).,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.Q., S.M., J.F., P.C.A., D.T.K., H.C.W.)
| | - Harindra C Wijeysundera
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (G.E.-G., D.T.K., H.C.W.).,Sunnybrook Research Institute, University of Toronto, Ontario, Canada (P.C.A., D.T.K., H.C.W.).,Institute for Health Policy Management and Evaluation, University of Toronto, Ontario, Canada (P.C.A., D.T.K., H.C.W.).,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (F.Q., S.M., J.F., P.C.A., D.T.K., H.C.W.)
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10
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Elbaz-Greener G, Masih S, Fang J, Ko DT, Lauck SB, Webb JG, Nallamothu BK, Wijeysundera HC. Temporal Trends and Clinical Consequences of Wait Times for Transcatheter Aortic Valve Replacement. Circulation 2018; 138:483-493. [DOI: 10.1161/circulationaha.117.033432] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Transcatheter aortic valve replacement (TAVR) represents a paradigm shift in the therapeutic options for patients with severe aortic stenosis. However, rapid and exponential growth in TAVR demand may overwhelm capacity, translating to inadequate access and prolonged wait times. Our objective was to evaluate temporal trends in TAVR wait times and the associated clinical consequences.
Methods:
In this population-based study in Ontario, Canada, we identified all TAVR referrals from April 1, 2010, to March 31, 2016. The primary outcome was the median total wait time from referral to procedure. Piecewise regression analyses were performed to assess temporal trends in TAVR wait times, before and after provincial reimbursement in September 2012. Clinical outcomes included all-cause death and heart failure hospitalizations while on the wait list.
Results:
The study cohort included 4461 referrals, of which 50% led to a TAVR, 39% were off-listed for other reasons, and 11% remained on the wait list at the conclusion of the study. For patients who underwent a TAVR, the estimated median wait time in the postreimbursement period stabilized at 80 days and has remained unchanged. The cumulative probability of wait-list mortality and heart failure hospitalization at 80 days was ≈2% and 12%, respectively, with a relatively constant increase in events with increased wait times.
Conclusions:
Postreimbursement wait time has remained unchanged for patients undergoing a TAVR procedure, suggesting the increase in capacity has kept pace with the increase in demand. The current wait time of almost 3 months is associated with important morbidity and mortality, suggesting a need for greater capacity and access.
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Affiliation(s)
- Gabby Elbaz-Greener
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (G.E-G., D.T.K., H.C.W.)
| | - Shannon Masih
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (S.M., J.F., D.T.K., H.C.W.)
| | - Jiming Fang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (S.M., J.F., D.T.K., H.C.W.)
| | - Dennis T. Ko
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (G.E-G., D.T.K., H.C.W.)
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (S.M., J.F., D.T.K., H.C.W.)
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada (D.T.K., H.C.W.)
- Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (D.T.K., H.C.W.)
| | - Sandra B. Lauck
- Center for Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (S.B.L., J.G.W.)
| | - John G. Webb
- Center for Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada (S.B.L., J.G.W.)
| | - Brahmajee K. Nallamothu
- Division of Cardiovascular Disease and Department of Internal Medicine, University of Michigan, Ann Arbor, MI (B.K.N.)
| | - Harindra C. Wijeysundera
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada (G.E-G., D.T.K., H.C.W.)
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (S.M., J.F., D.T.K., H.C.W.)
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada (D.T.K., H.C.W.)
- Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (D.T.K., H.C.W.)
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11
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Tavakoli R, Leprince P, Gassmann M, Jamshidi P, Yamani N, Amour J, Lebreton G. Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement. J Vis Exp 2018. [PMID: 29630054 DOI: 10.3791/57323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.
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Affiliation(s)
- Reza Tavakoli
- Department of Cardiovascular and Thoracic Surgery, Pitié Salpêtrière University Hospital, Assistance Publique, Hôpitaux de Paris (APHP), Institut de Cardiologie; Institute of Veterinary Physiology and Zurich Center for Integrative Human Physiology, University of Zurich;
| | - Pascal Leprince
- Department of Cardiovascular and Thoracic Surgery, Pitié Salpêtrière University Hospital, Assistance Publique, Hôpitaux de Paris (APHP), Institut de Cardiologie
| | - Max Gassmann
- Institute of Veterinary Physiology and Zurich Center for Integrative Human Physiology, University of Zurich
| | | | | | - Julien Amour
- Department of Anesthesiology and Intensive Care Unit, Pitié Salpêtrière University Hospital, Assistance Publique, Hôpitaux de Paris (APHP), Institut de Cardiologie
| | - Guillaume Lebreton
- Department of Cardiovascular and Thoracic Surgery, Pitié Salpêtrière University Hospital, Assistance Publique, Hôpitaux de Paris (APHP), Institut de Cardiologie
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