First 5-year TAVR/TAVI Outcomes from the South African SHARE-TAVI national registry and the influence of malignancy on late outcomes

Introduction

The South African (SA) national prospective multicentre observational SHARE-TAVI registry aims to provide local outcomes data on all TAVIs in State & Private sectors, to support local evidence-based policy evaluations, comparing outcomes to international data & identifying local variations.

Method

All 20 implant centres voluntarily capture all-comers data into the web-based registry. 2266 patients from 1 Sept 2014 to 28 Feb 2022 had pre-TAVI clinical evaluations and 1502 proceeded to TAVI & had procedural data & complications (VARC2 criteria), 30d & annual follow up recorded. The 5-yr cohort of 289 patients have clinical history and profile similar to international data (Table 1).

Results

Procedural success of 93.43% and 1-year mortality of 15.92% in the 5-yr cohort (STS score 8.85%) are similar to reported international data in early TAVI programmes. All-cause mortality at 5-years is 44.3% (in PARTNER 1 – 67.8%, PARTNER 2.0 – 46.0%), and the greatest proportion of non-cardiac mortality (38.5%) occurs in period >1–2yr post-TAVI (lowest proportion 29.4% in >3–4yr period). Outcomes measures in a more recent 2020 patient cohort (n=219, success 98.63% and 1-yr mortality 8.85%, STS risk score 5.51%) have improved compared to the 5-yr cohort.

Patients with “Prior or current malignancy” (POCM) at TAVI evaluation have increased mortality in both the 1-yr outcome (n=637) cohort, 18.7% 1-yr mortality vs 9.3% in those without POCM, and same trend in the 2-year outcome cohort n=443 (28.0% 2-year mortality vs 12.8% without malignancy). Frail patients with POCM in the 2-yr cohort have substantially higher mortality at 2 years, 34.8% than frail patients without POCM 15.9%

At evaluation 66% of patients are NYHA class III+IV, post-TAVI only 5.9% at 30d & 8.8% at 1-year, at 1-year 30% of patients have maintained improvement by 2 or 3 NYHA classes.

Conclusion

5-yr outcomes in SA are comparable to international data, and procedural outcomes have improved further as to be expected with maturation of the programme and technology. The NYHA class distribution at 1-yr shows improvements which should translate into improved quality of life, future studies should include patient self-reported quality of life assessments to verify this benefit. Malignancy, even if prior, may predict poorer outcomes in the longer term, possibly due to reported higher frailty in these patients. Amongst other factors, prior or current malignancy may be considered relevant when assessing patients for futility for TAVI in SA's severely constrained healthcare resource environment.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Educational and Research Grants from SA Heart Association and Medtronic, Edwards Life Sciences

2022 SASCI/SCTSSA joint consensus statement and guideline on transcatheter aortic valve implantation (TAVI) in South Africa

Patients with severe symptomatic aortic stenosis (AS) have traditionally been treated with surgical aortic valve replacement (sAVR). Transcatheter aortic valve implantation is a percutaneous option that has been shown to be at least as effective as sAVR in numerous subgroups of patients with severe AS. This is an update on the previous joint consensus statement and guideline on transcatheter aortic valve implantation (TAVI) in South Africa, published in 2016. It provides guidance on which patients should preferably be offered TAVI over sAVR, with special consideration of the resource-constrained environment in South Africa.

Dosimetric and Clinical Predictors for Acute and Late Gastrointestinal Toxicity Following Chemoradiotherapy of Locally Advanced Anal Cancer

AIMS

To analyse dosimetric and clinical predictors for acute and late gastrointestinal toxicity following chemoradiotherapy of anal cancer.

MATERIALS AND METHODS

Consecutive patients with locally advanced (T2 ≥4 cm - T4 or N+) anal cancer were selected from an institutional database (n = 114). All received intensity-modulated radiotherapy with concomitant 5-fluorouracil and mitomycin C. Gastrointestinal toxicity was retrospectively graded according to Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 and bowel cavity, small bowel and large bowel were contoured. Dosimetric and clinical variables were tested for associations with acute grade ≥3 gastrointestinal toxicity and late grade ≥2 gastrointestinal toxicity using the Mann-Whitney test, area under receiver operating characteristic curve (AUC) and logistic regression.

RESULTS

The median follow-up was 40 months. Acute grade ≥3 gastrointestinal toxicity was seen in 51 (44.7%) of the patients; late grade ≥2 gastrointestinal toxicity was seen in 36 of the patients (39.6% of 91 patients with >1 year recurrence-free follow-up). Bowel cavity V30Gy was the best dosimetric predictor for acute gastrointestinal toxicity (AUC 0.633; P = 0.02). Large bowel V20Gy was the best dosimetric predictor for late gastrointestinal toxicity (AUC 0.698; P = 0.001) but showed no association with acute gastrointestinal toxicity. In multivariate logistic regression, increasing age was significantly associated with acute gastrointestinal toxicity; smoking and large bowel V20Gy were significantly associated with late gastrointestinal toxicity. Patients who experienced acute grade ≥3 gastrointestinal toxicity were not at an increased risk of late grade ≥2 gastrointestinal toxicity (odds ratio 1.3; P = 0.55).

CONCLUSIONS

Factors of importance for acute and late gastrointestinal toxicity were not the same. Bowel cavity V30Gy is a good metric to use for the prediction of acute gastrointestinal toxicity, but the results of our study indicate that individual large and small bowel loops need to be contoured for better prediction of late gastrointestinal toxicity. The role of the large bowel as an important organ at risk for late gastrointestinal toxicity merits further research.

TAVI In South Africa's resource-constrained economy: the role of local data in overcoming funding resistance

 

The South African (SA) prospective multi-centre observational SHARE-TAVI registry aims to provide local outcomes data on all TAVIs in State & Private sectors, to support local evidence-based policy evaluations, comparing outcomes to international data & identifying local variations.

Methods and results

All 14 implants centres voluntarily capture data into the web-based SHARE-TAVI registry. 1375 patients from Sept 2014-Jan 2020 had pre-TAVI clinical evaluations, 998 proceeded to TAVI & procedural data & complications recorded (VARC-2 criteria), 30d & annual follow up. State sector hospitals provide limited tertiary cardiac care due to severe resource constraints. 13% of TAVIs in SA are in State teaching hospitals, 6.2% of State implants are 2nd generation (2G) devices. In the Private sector the roll-out of TAVI is inhibited by funding resistance, particularly to higher-cost 2G valves. 1st generation (1G) implants comprise 30% of 2019 implants, funding policies leave patients with unaffordable co-payments for 2G valves. Local data (Table 1) shows peri- & 1-year mortality, & procedural success (average 95.4%, & in 2019 98.91%), which are comparable with international data. TAVI in SA is successful despite low volumes & resource limitations. Local data supports superiority of 2G over 1G i.t.o this data and hospital stay length, & unplanned valve-in-valves. No significant differences between 1G & 2G in re-admissions in year 1, but improved quality of life patients experience with TAVI implantation is notable in the NYHA class.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): SA Heart Association registry project funding. Unrestricted educational grants by Medtronic and Edwards Life Sciences

P3692Funding resistance and 1-year outcomes in SHARE-TAVI, a local South African TAVR/TAVI registry

Methods and results

Participation in this voluntary registry, with 93% capture compliance, was incentivized by linking the capture of TAVI evaluation data with the funding application process, leading to a reduction in funding decision waiting time from average +180 days (2014) to current average of 92 days. Restrictive funding policies limit the expansion of TAVI in SA, with approximately 200 TAVIs recorded annually each in 2017 and 2018 from combined participation of 8 Private and 3 State TAVI centres, 9 of which do <20 implants/year.

From Sept 2014 to Dec 2018 inclusive, 894 patients were entered into the registry as part of TAVI evaluations, currently 102 patients await funding decisions (outstanding decisions ranging from 2–1185d). Deteriorating patient health during delayed Funder responses resulted in mortality prior to TAVI date for 8 patients whose funding was approved, & ineligibility for TAVI due to deterioration for 9 awaiting decisions (mean wait 115d). Mortality occurred in 21 others awaiting funding approval. 36% of patients declined funding (n=21/59) died within 1 year.

For the 663 patients who received implants, procedural & complications data were entered according to VARC-2 criteria, & postoperative follow-up at 30d & annually to 5 years. The implanted cohort is comparable to similar registry & trial populations (GARY, SOURCE 3, & US Corevalve Pivotal), in mean age [80.1±7.2yrs], gender [54.9% male], & mean risk predictions 7.0±7.4% [STSPROM], 23.0±15.7 [logEuroSCORE] & 6.4±5.0% [EuroSCORE 2], and Clinical History/Risk.

All-cause mortality of 10.48% (n=48/458) at 1-year compares favourably to published TAVI populations [14,2% US Corevalve, 12.6% SOURCE 3, 20% GARY], with non-cardiac mortality at 33% (n=16/48) mostly attributable to cancer, pneumonia and renal failure. State and Private care offer similar procedural success (State 93.1%, Private 93.7%), and hospital stays - mean ICU [State 1.43±1.58d, Private 2.48±1.99d] & total length of stay [State LOS 4.51±2.87d, Private LOS 5.19±4.24d]. At 30d new permanent pacemaker implantation is needed in 7.5% patients (n=50/663), & in 9.85% at 1-year (n=45/458), these comparatively low rates are being investigated in a sub-study of SHARE-TAVI.

Conclusions

Cumbersome TAVI funding processes & funding resistance contribute to unacceptable mortality figures in appropriately selected patients awaiting funding approval decisions, despite the SHARE-TAVI registry offering independent local data that confirms that TAVI in local resource-constrained settings compares favourably to international best practice standards, even with relatively low volumes at both State and Private centres.

Acknowledgement/Funding

Edwards and Medtronic Unrestricted Educational grants, SA Heart Association Registry Projects

Mechanical loadings on pectoral pacemaker implants: correlation of in-line and transverse force of the Pectoralis major

Recently we presented a method for the assessment of in vivo forces on pectoral device implants motivated from technological and clinical advancements toward smaller implantable cardiac pacemakers and the altered structural demands arising from the reduced device size. Objective of this study was the investigation of the intra-species proportionality of in-line force and transverse reaction force of the Pectoralis major for the characterization of mechanical in vivo loadings on pectoral implants. Two Chacma baboons (23.9 ± 1.2 kg) received bilaterally one chronic and one acute pectoral sub-muscular instrumented pacemaker (IPM) implant. The Pectoralis major muscle was electrically stimulated and resulting in-line and transverse muscle force were measured. The correlation of in-line force and transverse force of the Pectoralis major was investigated using linear regression analyses. The proportionality of in-line and transverse force of the Pectoralis major was found to be subject-specific (R² = 0.17, p < 0.003). Including morphometric parameters, i.e., length along line of action, width over implant and stress, in the regression analysis provided a strong intra-species correlation between in-line and transverse force (R² = 0.71, p < 10⁻⁷). The novel intra-species correlation provides a tool toward the characterization of mechanical in vivo loading conditions of pectoral device implants.