Albumin Is Predictive of 1-Year Mortality After Transcatheter Aortic Valve Replacement

Deep-learning survival analysis for patients with calcific aortic valve disease undergoing valve replacement

Calcification of the aortic valve (CAVDS) is a major cause of aortic stenosis (AS) leading to loss of valve function which requires the substitution by surgical aortic valve replacement (SAVR) or transcatheter aortic valve intervention (TAVI). These procedures are associated with high post-intervention mortality, then the corresponding risk assessment is relevant from a clinical standpoint. This study compares the traditional Cox Proportional Hazard (CPH) against Machine Learning (ML) based methods, such as Deep Learning Survival (DeepSurv) and Random Survival Forest (RSF), to identify variables able to estimate the risk of death one year after the intervention, in patients undergoing either to SAVR or TAVI. We found that with all three approaches the combination of six variables, named albumin, age, BMI, glucose, hypertension, and clonal hemopoiesis of indeterminate potential (CHIP), allows for predicting mortality with a c-index of approximately 80 % . Importantly, we found that the ML models have a better prediction capability, making them as effective for statistical analysis in medicine as most state-of-the-art approaches, with the additional advantage that they may expose non-linear relationships. This study aims to improve the early identification of patients at higher risk of death, who could then benefit from a more appropriate therapeutic intervention.

Sarcopenia and adipose tissue evaluation by artificial intelligence predicts the overall survival after TAVI

Sarcopenia is a serious systemic disease that reduces overall survival. TAVI is selectively performed in patients with severe aortic stenosis who are not indicated for open cardiac surgery due to severe polymorbidity. Artificial intelligence-assisted body composition assessment from available CT scans appears to be a simple tool to stratify these patients into low and high risk based on future estimates of all-cause mortality. Within our study, the segmentation of preprocedural CT scans at the level of the lumbar third vertebra in patients undergoing TAVI was performed using a neural network (AutoMATiCA). The obtained parameters (area and density of skeletal muscles and intramuscular, visceral, and subcutaneous adipose tissue) were analyzed using Cox univariate and multivariable models for continuous and categorical variables to assess the relation of selected variables with all-cause mortality. 866 patients were included (median(interquartile range)): age 79.7 (74.9-83.3) years; BMI 28.9 (25.9-32.6) kg/m2. Survival analysis was performed on all automatically obtained parameters of muscle and fat density and area. Skeletal muscle index (SMI in cm2/m2), visceral (VAT in HU) and subcutaneous adipose tissue (SAT in HU) density predicted the all-cause mortality in patients after TAVI expressed as hazard ratio (HR) with 95% confidence interval (CI): SMI HR 0.986, 95% CI (0.975-0.996); VAT 1.015 (1.002-1.028) and SAT 1.014 (1.004-1.023), all p < 0.05. Automatic body composition assessment can estimate higher all-cause mortality risk in patients after TAVI, which may be useful in preoperative clinical reasoning and stratification of patients.

Clinical Outcomes of Urgent or Emergency Transcatheter Aortic Valve Implantation - Insights From the Nationwide Registry of Japan Transcatheter Valve Therapies

BACKGROUND

Limited data are available for clinical outcomes in patients who underwent urgent or emergency transcatheter aortic valve implantation (TAVI). This study investigated in-hospital and 1-year outcomes and explored prognostic covariates in urgent/emergency TAVI using nationwide registry data.Methods and Results: Among 26,775 patients who underwent TAVI between August 2013 and December 2019, 25,495 with 1-year follow-up information were analyzed in this study. Baseline and procedural characteristics, as well as clinical adverse events, were compared between the urgent/emergency and elective TAVI groups. The primary outcome was all-cause mortality within 1 year after TAVI. Multivariable Cox regression models were constructed to identify independent predictors after urgent or emergency TAVI. Urgent or emergency TAVI was performed in 578 (2.3%) patients. The Society of Thoracic Surgeons score was significantly higher in the urgent/emergency than elective TAVI group (13.3% vs. 6.0%; P<0.001). Device success rate was comparable between the 2 groups. All-cause death-free survival within 1 year was lower in the urgent/emergency than elective TAVI group (77.2% vs. 92.2%; log rank P<0.001). Malignancy, albumin and creatinine concentrations, ejection fraction, and mean pressure gradient were associated with 1-year mortality in the urgent/emergency TAVI group.

CONCLUSIONS

Despite higher surgical risk and more comorbidities, the procedure was successfully performed in patients undergoing urgent/emergency TAVI, although it should be noted that prognosis was worse than for elective TAVI.

Impact of cardiac rehabilitation on pre- and post-operative transcatheter aortic valve replacement prognoses

Transcatheter aortic valve replacement (TAVR) is a relatively new treatment method for aortic stenosis (AS) and has been demonstrated to be suitable for patients with varying risk levels. Indeed, among high-risk patients, TAVR outcomes are comparable to, or even better, than that of the traditional surgical aortic valve replacement (SAVR) method. TAVR outcomes, with respect to post-surgical functional capacity and quality of life, have also been found to be improved, especially when combined with cardiac rehabilitation (CR). CR is a multidisciplinary system, which integrates cardiology with other medical disciplines, such as sports, nutritional, mind-body, and behavioral medicine. It entails the development of appropriate medication, exercise, and diet prescriptions, along with providing psychological support, ensuring the cessation of smoking, and developing risk factor management strategies for cardiovascular disease patients. However, even with CR being able to improve TAVR outcomes and reduce post-surgical mortality rates, it still has largely been underutilized in clinical settings. This article reviews the usage of CR during both pre-and postoperative periods for valvular diseases, and the factors involved in influencing subsequent patient prognoses, thereby providing a direction for subsequent research and clinical applications.

Predictors for all-cause mortality in men after transcatheter aortic valve replacement: A report from the LAPLACE-TAVI registry

Background

Information regarding the outcomes of transcatheter aortic valve replacement (TAVR) in men is limited. This study aimed to investigate short- to mid-term outcomes and prognostic predictors in this population.

Method and Results

The data of 519 men were analyzed from 1,693 consecutive patients with symptomatic severe aortic stenosis who underwent TAVR at six hospitals between April 2010 and July 2020. The primary endpoint was all-cause mortality at 30 days after TAVR. The mean age and Society of Thoracic Surgeons (STS) score were 83.7 ± 5.9 years and 6.3 ± 4.7%, respectively. Overall, 23.5% of patients consumed alcohol with a frequency of > 1 drinks/week, and 12.1% consumed alcohol with a frequency of > 8 drinks/week, while 66.1% were former smokers and 4.2% were current smokers. Mortality at 30 days was 0.8%. During the median follow-up period of 448 days, the estimated survival rates at 1 year post-TAVR was 90.7 ± 1.4%. In multivariate analysis, the serum albumin level [hazard ratio (HR): 2.20, 95% confidence interval (CI):1.36-3.62, p = 0.001], atrial fibrillation (HR: 1.79, 95% CI: 1.13-2.82, p = 0.012), and STS score (HR: 1.33, 95% CI: 1.06-1.67, p = 0.015) were independently associated with all-cause mortality following TAVR. Adjusted hazard ratios of current smoking, heavy drinking, and presence of cancer were 1.05 (95% CI: 0.36-2.98),1.37 (95% CI: 0.75-2.48), and 1.13 (95% CI: 0.75-2.48), respectively.

Conclusion

Our study demonstrated that serum albumin levels, atrial fibrillation, and STS score were independently associated with all-cause mortality following TAVR in men.

Association between serum albumin and outcomes in heart failure and secondary mitral regurgitation: the COAPT trial

AIMS

Low serum albumin levels are associated with poor prognosis in numerous chronic disease states but the relationship between albumin and outcomes in patients with heart failure (HF) and secondary mitral regurgitation (SMR) has not been described.

METHODS AND RESULTS

The randomized COAPT trial evaluated the safety and effectiveness of transcatheter edge-to-edge repair (TEER) with the MitraClip^TM plus guideline-directed medical therapy (GDMT) versus GDMT alone in patients with symptomatic HF and moderate-to-severe or severe SMR. Baseline serum albumin levels were measured at enrolment. Among 614 patients enrolled in COAPT, 559 (91.0%) had available baseline serum albumin levels (median 4.0 g/dl, interquartile range 3.7-4.2 g/dl). Patients with albumin <4.0 g/dl compared with ≥4.0 g/dl were older and more likely to have ischaemic cardiomyopathy and a hospitalization within the year prior to enrolment. After multivariable adjustment, patients with albumin <4.0 g/dl had higher 4-year rates of all-cause death (63.7% vs. 47.6%; adjusted hazard ratio 1.34, 95% confidence interval 1.02-1.74; p = 0.032), but there were no significant differences in HF hospitalizations (HFH) or all-cause hospitalizations according to baseline serum albumin level. The relative effectiveness of TEER plus GDMT versus GDMT alone was consistent in patients with low and high albumin levels (p_interaction  = 0.19 and 0.35 for death and HFH, respectively).

CONCLUSION

Low baseline serum albumin levels were independently associated with reduced 4-year survival in patients with HF and severe SMR enrolled in the COAPT trial, but not with HFH. Patients treated with TEER derived similarly robust reductions in both death and HFH regardless of baseline albumin level.

Temporal Trends in Internal vs. External Referrals for TAVR in a Large Academic Center: Patients Characteristics and Outcomes

Background

Since transcatheter aortic valve replacement (TAVR) first became approved for inoperable patients followed by high, intermediate-, and low-risk patients, referrals to TAVR centers have rapidly increased. The purpose of this study was to investigate referral patterns to a large academic TAVR center in the state of North Carolina and evaluate differences between externally and internally referred patients.

Methods

Data for all patients who underwent TAVR at our institution between November 2014 and March 2020 were pulled from the Transcatheter Valve Therapy Registry. The electronic medical record was used to determine the referral source. The descriptive statistical analysis was performed using Excel (Microsoft, Redmond, Washington).

Results

491 patients underwent TAVR at our institution between November 2014 and March 2020. Half of the patients were referred by a cardiologist within the same health system (N = 250, 50.9%). Other referral sources included a cardiologist external to the health system (N = 210, N = 42.8%) and a surgeon or proceduralist (such as urologist, surgeon, or gastroenterologist) during the workup for another procedure (N = 26, 5.3%). Over time, there was a trend toward an increasing proportion of patients referred by a cardiologist external to our system, but this trend did not reach statistical significance (20.0% in 2014, 29.2% in 2015, 30.7% in 2016, 53.0% in 2017, 36% in 2018, 48.4% in 2019, and 56.8% in 2020, p=0.06 using the Mann–Kendall trend test). Externally referred patients were less likely to have private insurance and were more likely to have a reduced ejection fraction and had a higher mean gradient across the valve. Postprocedure, externally referred patients were more likely to have the procedure under moderate sedation and less likely to be discharged home.

Conclusions

This study presents the referral pattern to a large TAVR center in North Carolina. Over time, there was an increase in external referrals suggesting that TAVR is increasingly adopted as an important component of the management of aortic valve stenosis. Internally and externally referred patients have differences in baseline demographic and clinical characteristics which may have an impact on clinical outcomes.

C-Reactive Protein to Albumin Ratio in Patients Undergoing Transcatheter Aortic Valve Replacement

OBJECTIVE

To evaluate whether the serum C-reactive protein to albumin ratio (CAR) could be used for risk stratification of patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS).

PATIENTS AND METHODS

Frailty is a predictor of poor outcomes in patients undergoing AS interventions. The CAR reflects key components of frailty (systemic inflammation and nutrition) and could potentially be implemented into assessment and management strategies for patients with AS. From March 1, 2010, through February 29, 2020, 1836 patients were prospectively enrolled in an observational TAVR database. Patients (prospective development cohort, n=763) were grouped into CAR quartiles to compare the upper quartile (CAR Q4) with the lower quartiles (CAR Q1-3). Primary end point was all-cause mortality. Results were verified in an independent retrospective cohort (n=1403).

RESULTS

The CAR Q4 had a higher prevalence of impaired left ventricular function, atrial fibrillation, diabetes, and cerebrovascular disease and a higher median logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) vs CAR Q1-3. After median follow-up of 15.0 months, all-cause mortality was significantly higher in CAR Q4 vs CAR Q1-3 (P<.001). In multivariable analyses, risk factors for all-cause mortality were CAR Q4 (>0.1632; hazard ratio, 1.45; 95% confidence interval, 1.05 to 2.00; P=.03), N-terminal pro-B-type natriuretic peptide Q4 (>3230 pg/mL [to convert to ng/L, multiply by 1), high-sensitivity troponin T Q4 (>0.0395 ng/mL [to convert to μg/L, multiply by 1]), above-median logistic EuroSCORE (16.1%), myocardial infarction, Acute Kidney Injury Network stage 3, and life-threatening bleeding.

CONCLUSION

Elevated CAR was associated with increased risk of all-cause mortality in patients undergoing transfemoral TAVR. The CAR, a simple, objective tool to assess frailty, could be incorporated into assessing patients with AS being considered for TAVR.

The safety of exercise for older patients with severe aortic stenosis undergoing conservative management: A narrative review

The incidence of aortic stenosis (AS) increases with age and is a serious problem in an aging society. In recent years, transcatheter aortic valve implantation (TAVI) has been performed widely; however, older patients may be ineligible for TAVI or surgical treatment because of medical ineligibility. Symptom-based rehabilitation is required for these patients to maintain and improve their physical function and ability to perform activities of daily living. No studies have examined exercise safety for older patients with severe AS who are ineligible for TAVI or surgery. We summarized the safety of exercise for older patients with severe AS, collecting 7 studies on maximal exercise stress tests and 16 studies on preoperative physical examinations. From this review, it may be unlikely that exercise under appropriate management can cause hemodynamic changes, leading to death. However, there were no studies on exercise intervention for older patients with AS who are chosen for conservative management. The optimal exercise intensity for symptomatic older patients with AS undergoing conservative management and the effects of continuous exercise intervention require future study.

Psoas Muscle Volume and Attenuation are Better Predictors than Muscle Area for Hospital Readmission in Older Patients after Transcatheter Aortic Valve Implantation

OBJECTIVE

This study aimed to determine whether the psoas muscle volume (PMV) and its muscle attenuation (MA) are associated with hospital readmission after transcatheter aortic valve implantation (TAVI).

METHOD

We included 113 older patients with aortic stenosis who underwent TAVI at Sakakibara Heart Institute (mean age 85 ± 5 years, 69% women). We measured PMV and psoas muscle area (PMA) as well as total muscle area (TMA) at the third lumbar vertebra using preoperative computed tomography (CT) images. The crude values of the PMV, PMA, and TMA were normalized by dividing by height squared.

RESULTS

The median follow-up period was 724 days (interquartile range: 528-730 days), and there were 25 all-cause readmissions during the follow-up period (22% of all patients). In the multivariate Cox regression analysis adjusted for age, sex, and EuroSCORE II, the PMV and its MA and crude PMA were significantly associated with all-cause readmission [HR: 0.957 (0.930-0.985), p = 0.003, HR: 0.927 (0.862-0.997), p = 0.040], whereas the PMA and TMA and each MA were not (all p > 0.05). The groups with low PMV and MA had significantly higher incidences of all-cause readmission than that with high PMV and MA (log-rank test: p = 0.011).

CONCLUSION

PMV and its MA measured from preoperative CT images were independent predictors of all-cause readmission in TAVI patients.

Value of prognostic nutritional index for survival prediction in trans-catheter aortic valve replacement compared to other common nutritional indexes

BACKGROUND

Nutritional status predicts outcomes after TAVR. Predictive value of Prognostic Nutritional Index (PNI) was investigated in patients undergoing TAVR, and compared to other nutritional indexes.

METHODS

A cohort of 114 patients undergoing TAVR in a high-volume centre was studied. A prospective 1-year follow-up was completed. PNI was estimated as follows: (10 × serum albumin[g/dl])+(0.005 × total lymphocytes [1000/μl]). One-year survival was compared in patients with PNI above vs below median; Kaplan-Meier curves were created. A multivariate analysis was used to assess predictive value of PNI for 1-year mortality. ROC curves were used to assess discrimination by PNI, and to compare it with Geriatric Nutritional Risk Index (GNRI) and Body Mass Index (BMI).

RESULTS

Mean age was 82.2 years, 59.6% were male. Mean PNI was 46 ± 5. Pre-procedurally, no differences were found between patients with high vs. low PNI. One-year mortality was significantly higher in patients with low PNI values (19/57 vs. 4/57; p < .001). Complications did not differ. A higher PNI predicted 1-year survival, even after adjusting for clinical factors (model 1: HR 0.8, 95% CI 0.7-0.9, p < .0001) and laboratory parameters (NT-proBNP, IL-6, CRP, eGFR, cystatin C, haemoglobin) (model 2: HR 0.8, 95% CI 0.7-0.9, p < .05). ROC curves revealed a stronger predictive value for PNI (AUC 0.80) compared to GNRI (0.77) and BMI (0.6). The optimal cut-off for PNI was 45.

CONCLUSION

PNI is a useful and practical nutritional marker reflecting malnutrition and inflammation prior to the intervention, and strongly predicts 1-year survival. PNI seems to be a better prognostic marker than BMI or GNRI after TAVR.

Impact of Severe Sarcopenia on Rehospitalization and Survival One Year After a TAVR Procedure in Patients Aged 75 and Older

BACKGROUND

Transcatheter aortic-valve replacement (TAVR) reduces mortality and improves quality of life in patients with severe aortic valve stenosis. One third of patients have no benefit one year after TAVR. Sarcopenia, an age-related loss of skeletal muscle mass, is associated with increased physical disability and mortality. The main purpose was to evaluate the impact of severe sarcopenia on rehospitalization one year after TAVR in older patients.

METHODS

All patients aged ≥75 referred for a TAVR in 2018 were included. Severe sarcopenia was defined by a loss of skeletal muscle mass defined on CT-scan measurement associated with a gait speed ≤0.8m/s. The main outcome was rehospitalization one year after TAVR.

RESULTS

Median age of the 182 included patients was 84, and 35% had an unplanned hospitalization at one year. Severe sarcopenia was diagnosed in 9 patients (4.9%). Univariable analysis showed that gait speed was a factor associated with readmission [HR=0.32, 95% CI (0.10-0.97), p=0.04] but not severe sarcopenia. In multivariable analysis, only diabetes was significantly associated with rehospitalization [HR=2.06, 95% CI (1.11-3.84), p=0.02]. Prevalence of severe sarcopenia varied according to different thresholds of skeletal muscle mass on CT-scan.

CONCLUSION

Even though severe sarcopenia was not correlated with rehospitalization and mortality at one year after TAVR, our results emphasize the changes in the prevalence according to cutoff used. It highlights the need to define standardized methods and international threshold for sarcopenia diagnosis by CT-scan measurements, in general population and for patients with valvular heart disease.

Assessment of postoperative nutritional status and physical function between open surgical aortic valve replacement and transcatheter aortic valve implantation in elderly patients

Background and aims : Severe aortic stenosis (AS) has been normally treated with surgical aortic valve replacement (AVR) whereas recently, transcatheter aortic valve implantation (TAVI) has been introduced as a minimally invasive operation for patients with high surgical risk and frailty. In this study, we have evaluated postoperative physical function and nutrition intake in the patients following AVR and TAVI. Methods : This prospective observational study involved 9 patients with surgical aortic valve replacement (AVR) and 7 patients with transcatheter aortic valve implantation (TAVI). Body composition was measured one day prior surgery, postoperative day (POD) 1, POD 3, POD 5 and POD 7. Hand grip strength, calf circumference and gait speed were measured one day before surgery and on the day of discharge. Results : Skeletal muscle was significantly decreased in AVR patients at postoperative day 3 and 7, while there was no change in TAVI patients. Patients with TAVI showed higher dietary intake after surgery compared to patients with AVR, and they maintained hand grip strength and calf circumference at discharge. Conclusions : In elderly patients with AS, TAVI can improve post-operative recovery maintaining nutritional status and physical function even. J. Med. Invest. 67 : 139-144, February, 2020.

Tools for the Assessment of the Malnutrition Status and Possible Interventions in Elderly with Cardiovascular Diseases

Malnutrition represents a common and important feature in elderly people affected by cardiovascular diseases. Several studies have investigated its prevalence and prognostic role in most clinical settings, including cardiovascular disease. However, in daily practice it usually remains unrecognized and consequently untreated. The present review was ideated to answer the main questions about nutritional status assessment in patients with cardiovascular disease: why, when, where, how to evaluate it, and what to do to improve it. The three main cardiovascular diseases, namely aortic stenosis, ischaemic heart disease, and heart failure were considered. First, the main evidence supporting the prognostic role of malnutrition are summarized and analyzed. Second, the main tools for the assessment of malnutrition in the hospital and outpatient setting are reported for each condition. Finally, the possible strategies and interventions to address malnutrition are discussed.

National Trends and Correlates of Dysphagia After Anterior Cervical Discectomy and Fusion Surgery

Objective

Anterior cervical discectomy and fusion (ACDF) is the most common performed surgery in the cervical spine. Dysphagia is one of the most frequent complications following ACDF. Several studies have identified certain demographic and perioperative risk factors associated with increased dysphagia rates, but few have reported recent trends. Our study aims to report current trends and factors associated with the development of inpatient postoperative dysphagia after ACDF.

Methods

The National Inpatient Sample was evaluated from 2004 to 2014 and discharges with International Classification of Diseases procedure codes indicating ACDF were selected. Time trend series plots were created for the yearly treatment trends for each fusion level by dysphagia outcome. Separate univariable followed by multivariable logistic regression analyses were performed to evaluate predictors of dysphagia.

Results

A total of 1,212,475 ACDFs were identified in which 3.3% experienced postoperative dysphagia. A significant increase in annual dysphagia rates was observed from 2004–2014. Frailty, intraoperative neuromonitoring, 4 or more level fusions, African American race, fluid/electrolyte disorders, blood loss, and coagulopathy were all identified as significant independent risk factors for the development of postoperative dysphagia following ACDF.

Conclusion

Postoperative dysphagia is a well-known postsurgical complication associated with ACDF. Our cohort showed a significant increase in the annual dysphagia rates independent of levels fused. We identified several risk factors associated with the development of postoperative dysphagia after ACDF.

Predicting and measuring mortality risk after transcatheter aortic valve replacement

Introduction: Over the last decade, transcatheter aortic valve replacement (TAVR) has emerged as a treatment option for most patients with severe symptomatic aortic stenosis (AS). With growing indications and exponential increase in the number of TAVR procedures, it is important to be able to accurately predict mortality after TAVR.Areas covered: Herein, we review the surgical and TAVR-specific mortality prediction models (MPMs) and their performance in their original derivation and external validation cohorts. We then discuss the role of other important risk assessment tools such as frailty, echocardiographic parameters, and biomarkers in patients, being considered for TAVR.Expert opinion: Conventional surgical MPMs have suboptimal predictive performance and are mis-calibrated when applied to TAVR populations. Although a number of TAVR-specific MPMs have been developed, their utility is also limited by their modest discriminative ability when applied to populations external to their original derivation cohorts. There is an unmet need for robust TAVR MPMs that accurately predict post TAVR mortality. In the interim, heart teams should utilize the currently available TAVR-specific MPMs in conjunction with other prognostic factors, such as frailty, echocardiographic or computed tomography (CT) imaging parameters, and biomarkers for risk assessment of patients, being considered for TAVR.

Three-Year Survival after Transcatheter Aortic Valve Replacement: Findings from the Marshfield Aortic Valve Experience (MAVE) Study

Background: Transcatheter aortic valve replacement (TAVR) is a rapidly evolving treatment for severe aortic stenosis. However, uncertainties exist for optimal valve selection as there are few long-term studies comparing patient survival by valve type.Objective: We hypothesized that self-expandable valves (SEV) would provide a survival advantage over balloon expandable valves (BEV), as SEV continue to expand and might better accommodate to the anatomy of the aortic valve over time.Methods: We examined outcomes according to valve type from a rural tertiary referral center between 2012 and 2017.Results: Out of 269 patients, 77 deaths (28.6%) occurred over the study period with 6 deaths by 1 month post-TAVR and 37 deaths by 1 year post-TAVR. The median observation time for survivors was 21.5 months. The probability of survival at 3 years was 60.7% and 61.9% for patients who underwent treatment with SEV and BEV, respectively. There was no statistically significant difference in overall patient survival with or without adjustment for factors such as age, sex, race, and aortic valve area. Additionally, in a secondary analysis restricted to those patients treated in later years (2015-2017) survival among patients with BEV appeared superior (HR=0.456, P=0.015).Conclusion: Patients who underwent TAVR at a rural medical center with SEV showed similar survival compared to those who received a BEV. Superior survival was observed among those who received BEV versus SEV between 2015 and 2017.

Frailty is an independent risk factor of one-year mortality after elective orthopedic surgery: a prospective cohort study

Frailty is associated with perioperative adverse outcomes, especially for the elderly. This study aimed to assess whether frailty was an independent risk factor of one-year mortality in frail patients after elective orthopedic surgery. In this prospective study, three hundred and thirteen patients aged ≥ 65 years, undergoing elective orthopedic surgery were finally included. Frailty assessed by the Clinical Frailty Score (CFS) before the surgery was present in 29.7% (93/313). Among them, 7.7% of patients (24/313) died at one year after surgery. In multivariate logistic analysis, higher CFS (OR = 2.271, 95% CI= 1.472–3.504) was found to be an independent risk factor of one-year mortality after surgery in elderly orthopedic patients. The area under the receiver operating characteristic curve of the model was 0.897 (95% CI 0.834–0.959). In addition, we found higher Charlson comorbidity index (OR= 1.498, 95% CI = 1.082–2.073) was also a significant risk factor. In conclusion, frailty is associated with increased one-year mortality in elderly patients after elective orthopedic surgery, which should be considered as a routine assessment tool in preoperative practice.

Usefulness of Thoracic Aortic Calcium to Predict 1-Year Mortality After Transcatheter Aortic Valve Implantation

In patients who underwent transcatheter aortic valve implantation (TAVI), vascular disease is associated with increased risk of mortality. Thoracic aortic calcification (TAC), an objective surrogate of vascular disease, could be a predictor of mortality after TAVI. We aimed to analyze the association between TAC burden and 1-year all-cause mortality in patients who underwent TAVI in a US population. From July 2015 through July 2017, a retrospective review of TAVI procedures was performed at Baylor Scott & White-The Heart Hospital, Plano, Texas. Patients were analyzed for comorbidities, cardiac risk factors, and 30-day and 1-year all-cause mortality. Restricted cubic splines analysis was used to define low, moderate, and high TAC categories. The association between TAC and survival was evaluated using unadjusted and adjusted Cox models. A total of 431 TAVI procedures were performed, of which TAC was measured in 374 (81%) patients. Median (interquartile range) age was 82 (77, 87) years, and 51% were male. Median (interquartile range) STS PROM was 5.6 (4.1, 8.2) %. Overall 30-day and 1-year all-cause mortality was 1% and 10%, respectively. TAC was categorized as low (<1.6 cm³), moderate (1.6 to 2.9 cm³), and high (>2.9 cm³). At 1 year, all-cause mortality was 16% in patients with high TAC compared with 6% in the low and moderate TAC categories (p = 0.008). Unadjusted and adjusted Cox regression analysis showed a significant increase in mortality for patients with high TAC compared with low TAC (hazard ratio 2.98, 95% confidence interval [1.34-6.63]), but not significant compared with moderate TAC group. TAC is a predictor of late mortality after TAVI. In conclusion, adding TAC to preoperative evaluation may provide an objective, reproducible, and potentially widely available tool that can help in shared decision-making.

Sarcopenia in Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI): A Systematic Review of the Literature

BACKGROUND

In older patients, sarcopenia is a prevalent disease associated with negative outcomes. Sarcopenia has been investigated in patients undergoing transcatheter aortic valve implantation (TAVI), but the criteria for diagnosis of the disease are heterogeneous. This systematic review of the current literature aims to evaluate the prevalence of sarcopenia in patients undergoing TAVI and to analyse the impact of sarcopenia on clinical outcomes.

METHODS

A comprehensive search of the literature has been performed in electronic databases from the date of initiation until March 2020. Using a pre-defined search strategy, we identified studies assessing skeletal muscle mass, muscle quality and muscle function as measures for sarcopenia in patients undergoing TAVI. We evaluated how sarcopenia affects the outcomes mortality at ≥1 year, prolonged length of hospital stay, and functional decline.

RESULTS

We identified 18 observational studies, enrolling a total number of 9'513 patients. For assessment of skeletal muscle mass, all included studies used data from computed tomography. Cut-off points for definition of low muscle mass were heterogeneous, and prevalence of sarcopenia varied between 21.0% and 70.2%. In uni- or multivariate regression analysis of different studies, low muscle mass was found to be a significant predictor of mortality, prolonged length of hospital stay, and functional decline. No interventional study was identified measuring the effect of nutritional or physiotherapy interventions on sarcopenia in TAVI patients.

CONCLUSIONS

Sarcopenia is highly prevalent among patients undergoing TAVI, and negatively affects important outcomes. Early diagnosis of this condition might allow a timely start of nutritional and physiotherapy interventions to prevent negative outcomes in TAVI patients.

Epidemiology of Hypoalbuminemia in Hospitalized Patients: A Clinical Matter or an Emerging Public Health Problem?

Serum albumin levels are strongly associated with the morbidity, prognosis, and mortality rates of patients with hypoalbuminemia, which is a frequent problem during hospitalization. An observational retrospective study was carried out to analyze changes in albumin levels in hospitalized patients at the “Fondazione Policlinico Tor Vergata—PTV” in 2018. The prevalence of preexisting hypoalbuminemia at the time of discharge from hospital was investigated using a sample of 9428 patients. Information was collected from the discharge files recorded in the central informatics system of the hospital. Analysis of albumin levels at admission and at discharge was conducted by classes of albuminemia and then stratified by age. At the time of admission, hypoalbuminemia was found to be present in more than half of the sample, with no sex differences. The serum albumin level tended to decrease with age, with pathologic levels appearing from 50 years and progressive worsening thereafter. The condition of marked and mild hypoalbuminemia was more prevalent in patients over 65 years of age. Our findings suggest that hypoalbuminemia should be considered a dangerous condition in itself and a serious public health problem. We aimed to emphasize the role of albumin as useful marker of the in-hospital malnutrition and frailty, to be integrated in the routinely assessment of patients for reconsidering ad hoc healthcare pathways after discharge from hospital, especially when dealing with fragile populations.

Effects of Body Mass Index on Perioperative Outcomes in Patients Undergoing Anterior Cervical Discectomy and Fusion Surgery

Objective

Obesity has become a public health crisis and continues to be on the rise. An elevated body mass index has been linked to higher rates of spinal degenerative disease requiring surgical intervention. Limited studies exist that evaluate the effects of obesity on perioperative complications in patients undergoing anterior cervical discectomy and fusion (ACDF). Our study aims to determine the incidence of obesity in the ACDF population and the effects it may have on postoperative inpatient complications.

Methods

The National Inpatient Sample was evaluated from 2004 to 2014 and discharges with International Classification of Diseases procedure codes indicating ACDF were identified. This cohort was stratified into patients with diagnosis codes indicating obesity. Separate univariable followed by multivariable logistic regression analysis were performed for the likelihood of perioperative inpatient outcomes among the patients with obesity.

Results

From 2004 to 2014, estimated 1,212,475 ACDFs were identified in which 9.2% of the patients were obese. The incidence of obesity amongst ACDF patients has risen dramatically during those years from 5.8% to 13.4%. Obese ACDF patients had higher inpatient likelihood of dysphagia, neurological, respiratory, and hematologic complications as well as pulmonary emboli, and intraoperative durotomy.

Conclusion

Obesity is a well-established modifiable comorbidity that leads to increased perioperative complications in various surgical specialties. We present one of the largest retrospective analyses evaluating the effects of obesity on inpatient complications following ACDF. Our data suggest that the number of obese patients undergoing ACDF is steadily increasing and had a higher inpatient likelihood of developing perioperative complications.

A patient specific forecasting model for human albumin based on deep neural networks

BACKGROUND AND OBJECTIVES

Hypoalbuminemia can be life threatening among critically ill patients. In this study, we develop a patient-specific monitoring and forecasting model based on deep neural networks to predict concentrations of albumin and a set of selected biochemical markers for critically ill patients in real-time.

METHODS

Under the assumption that metabolism of a patient follows a patient-specific dynamical process that can be determined from sufficient prior data taken from the patient, we apply a machine learning method to develop the patient-specific model for a critically ill, poly-trauma patient. Six representative biochemical markers (albumin (ALB), creatinine (Cr), osmotic pressure (OSM), alanine aminotransferase (ALT), total bilirubin (TB), direct bilirubin (DB)) were collected from the patient while scheduled exogenous albumin injection was administered to the patient for the total of 27 consecutive days. A sliding window of data in 11 consecutive days were used to train and test the neural networks in the model.

RESULTS

The obtained dynamical system model represented by neural networks is used to forecast the biochemical markers of the patient in the next 24 h. The relative error between the predictions and the clinical data remains consistently lower than 2%.

CONCLUSIONS

This study demonstrates that a patient-specific dynamical system model can be established to monitor and forecast dynamical behavior of concentrations of patients' biochemical markers (including albumin) using deep learning methods on neural networks.

Development of a new risk model for a prognostic prediction after transcatheter aortic valve replacement

BACKGROUND

Current guidelines for transcatheter aortic valve replacement (TAVR) recommend that TAVR should be performed in patients with a life expectancy > 1 year. However, it is challenging to estimate the patients' life expectancy because it is related to various factors, including frailty and nutritional status.

HYPOTHESIS

A new risk model can estimate the prognosis of patients after TAVR.

METHODS

We randomly divided 388 patients with aortic stenosis (AS) undergoing TAVR from October 2009 to August 2016 into two groups (2:1 ratio; training cohort, 259; validation cohort, 129). Using 94 baseline factors in the training cohort, we developed possible scoring models by the Cox proportional hazard regression model with the overall survival as the endpoint. Then, cross-validated 5-year C-statistics were calculated to assess the accuracy of the model.

RESULTS

Of 94 baseline factors, 12 factors were finally identified (5-year C-statistics in the training cohort: 0.709)-age, gender, body mass index, left ventricular ejection fraction, % vital capacity, forced expiratory volume 1.0 (s) %, albumin, hemoglobin, creatine, platelet, creatine kinase, and prothrombin time-international normalized ratio. The cross-validated 1-, 3-, and 5-year C-statistics in the validation cohort were 0.792, 0.758, and 0.778, respectively. Furthermore, calibration plots in the validation cohort revealed that 5-year survival is well predicted (r = 0.962).

CONCLUSIONS

The new survival prediction model after TAVR could provide appropriate guidance during decision making regarding the TAVR implementation.

Prevalence and Prognostic Implications of Frailty in Transcatheter Aortic Valve Replacement

Assessment of frailty has become engrained in the preprocedural evaluation of older adults referred for transcatheter aortic valve replacement. Addition of frailty and disability to clinical risk scores results in improved discrimination for short- and midterm mortality and identifies patients less likely to be discharged home and more likely to report worsening quality of life over the ensuing 6 to 12 months. In clinical practice, frailty can be evaluated by a tiered approach starting with a brief screening tool such as the Essential Frailty Toolset.

Does Heart Valve Team Risk Assessment Predict Outcomes after Transcatheter Aortic Valve Replacement?

Consideration for transcatheter aortic valve replacement (TAVR) necessitates an integrated risk assessment by members of the Heart Valve Team. The utility of the integrated risk assessment for predicting TAVR outcomes is not established. This article aims to compare the utility of the integrated risk assessment to that of the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score for predicting patient outcomes after TAVR. A total of 274 patients who underwent TAVR from January 2016 to August 2017 were included in this study. Patients were deemed intermediate or high risk by two surgeons on the Heart Valve Team based on an integrated risk assessment that incorporates the STS-PROM score, fragility measures, end-organ dysfunction, and surgeon evaluation. Patients were also deemed low, intermediate, or high risk based solely on their STS-PROM scores of <3%, ≥3% to <8%, and ≥8%, respectively. Differences in postoperative outcomes between intermediate- and high-risk groups as categorized by the integrated risk assessment versus STS-PROM were compared. There were no statistically significant differences in postoperative outcomes between patients who were deemed high and intermediate risk by the Heart Valve Team risk assessment. In contrast, postoperative complication rates were significantly higher in patients deemed high risk as compared with intermediate risk by STS-PROM. Integrated risk assessment by the Heart Valve Team is not superior to STS-PROM in predicting postoperative outcomes in patients undergoing TAVR.

Relation of Frailty to Cost for Patients Undergoing Transcatheter Aortic Valve Implantation

Frailty is associated with significant morbidity and mortality for patients undergoing transcatheter aortic valve implantation (TAVI). In addition to clinical outcomes, cost is an important factor to inform clinical decision-making around TAVI. However, the association of frailty with cost is unknown. This study tested whether frailty was associated with cost for adult patients who underwent TAVI at a moderate-volume single center between December 2012 and April 2018 (n = 431). Frailty was determined from pre-TAVI clinical visits as a composite of 2 markers: 5-meter walk time (abnormal: >6 seconds or unable to perform) and serum albumin (abnormal: <3.5 g/dl). Patients were excluded if missing frailty assessment or covariate data (24). Cost data were derived from financial statements, and assigned at the department-level by charge code. Multivariable regression models were adjusted for age, gender, and procedural co-morbidities. Of 407 patients in the analytical sample (mean age 81 years, 49% female), 74 (18%) were determined to be frail. Adjusted mean total costs were $6,397 higher for frail patients ($78,823 vs $72,425, p = 0.042) compared with nonfrail. Higher total costs were driven by department-level charges associated with longer in-hospital length of stay (7.6 vs 3.3 days, p <0.001): room, physical therapy, pharmacy, laboratory, supply, and imaging services. Providers must address frailty proactively to salvage the benefit associated with TAVI.

Meta-Analysis of the Impact of Pre-Procedural Serum Albumin on Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement

Pre-procedural serum albumin's impact on prognosis after transcatheter aortic valve replacement (TAVR) has been studied. Literature on the prognostic role of serum albumin in the survival of patients undergoing TAVR shows conflicting results. This meta-analysis was conducted to evaluate the impact of pre-procedural serum albumin on outcomes after TAVR. A comprehensive literature search of EMBASE, MEDLINE, and the Cochrane Library was undertaken through July 2019. The primary end points were 30-day and one-year all-cause mortality after TAVR. Risk ratios (HRs) and 95% confidence intervals (CIs) were calculated using the random-effect model. Ten eligible studies with 8,236 patients were analyzed. Of the 8,236 patients undergoing TAVR, with a mean age of 83 years, 48.8% were men and were categorized into two groups according to low and normal serum albumin (cut-off value: 3.5 or 4 g/dL). Overall, low albumin was significantly associated with an approximately two-fold increase in 30-day all-cause mortality (HR, 2.09; 95% CI, 1.53-2.86) and a 61% increase risk for one-year mortality (HR, 1.61; 95% CI, 1.31-1.98) in patients after TAVR. Sensitivity analyses showed the results to be robust. The association of low albumin level with an increase in one-year mortality risk was not modified by study design, albumin cut-off value, Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM), and study quality. In conclusion, low albumin levels were associated with poor prognosis in patients after TAVR. Pre-procedural albumin can be used as a simple tool related to prognosis after TAVR.

CT-Derived Pretreatment Thoracic Sarcopenia Is Associated with Late Mortality after Thoracic Endovascular Aortic Repair

BACKGROUND

Frailty, characterized by physiologic depletion, predicts postoperative morbidity and mortality in vascular surgery patients. CT-derived sarcopenia is a valuable method for objectively staging frailty preoperatively.

PURPOSE

With prior analyses primarily measuring psoas cross-sectional area on CT, we compared a method of measuring thoracic sarcopenia to existing techniques of lumbar sarcopenia and assessed the association with long-term survival and outcomes post-Thoracic Endovascular Aortic Repair (TEVAR).

METHODS

Prospectively collected data of 217 patients undergoing TEVAR from 2009 to 2012 were reviewed. Thoracic sarcopenia was quantified by measuring total area of the rectus abdominis, latissimus dorsi, intercostal, erector spinae, and external and internal oblique muscles at the T12 vertebral level. Total psoas area at the L3 was used to measure lumbar sarcopenia.

RESULTS

200 patients had preoperative imaging enabling measurements of thoracic sarcopenia, 186 of these patients were also assessed for lumbar sarcopenia. Thoracic sarcopenic patients were older, had lower body mass indices, were more commonly female, and most commonly being treated for aneurysms. Thoracic sarcopenic patients had significantly higher rates of congestive heart failure, hypertension, prior vascular intervention, and TEVAR-related adverse events. Thoracic sarcopenia was associated with significantly higher mortality at 2 and 5 years post-TEVAR (2-year mortality: 19% vs 8%, P = 0.02; 5-year mortality: 31% vs 18%, P = 0.03). Lumbar sarcopenia was not associated with increased mortality at any time point. Patients whose muscle mass degraded over 48-month follow-up did not experience significantly higher rates of adverse events.

CONCLUSIONS

CT-derived thoracic sarcopenia, but not lumbar sarcopenia, is significantly associated with 5-year mortality post-TEVAR.

Effect of Statin Therapy and Long-Term Mortality Following Transcatheter Aortic Valve Implantation

Increased inflammatory response after aortic valve replacement is linked to higher postprocedural mortality. The aim of the present analysis was to assess the impact of baseline statin therapy on procedural outcomes and mortality after transcatheter aortic valve implantation (TAVI). We performed a retrospective analysis on patients who underwent TAVI stratified to 3 statin therapy groups: high-intensity statin (HIS), low-medium intensity statins, and no statin. Included were 1,238 patients. Patients treated with HIS were significantly younger, had higher body mass index, lower Society of Thoracic Surgeons score, and higher prevalence of dyslipidemia, hypertension, past stroke, and ischemic heart disease. Procedural outcomes were similar between groups. There were no statistically significant short-term mortality differences at 1 month (2.2% vs 2.1% vs 3.5%, p = 0.50) and 1 year (6.9% vs 9.3% vs 14.2%, p = 0.15), albeit the observed numerical trend. As for long-term mortality (median follow time of 2.5 years, interquartile range 1.3 to 4.2), lower mortality rates were observed in the HIS group (14.5% vs 25.2% vs 36.6%, p = 0.001). Compared with no statin, the HIS group was significantly associated with reduced risk of long-term mortality in multivariate analysis (hazard ratio = 0.59, 95% CI 0.37 to 0.96, p = 0.03). Baseline HIS therapy is associated with reduced rates of long-term morality after TAVI.