P1517Risk of acute kidney injury in transcatheter aortic valve implantation procedures and impact on 30-day outcome

Background

Transcatheter aortic valve implantation (TAVI) is a safe and effective procedure for patients with symptomatic aortic stenosis who do not qualify for surgery. Nevertheless, post-procedure acute kidney injury (AKI) is a frequent complication and it is associated with worse outcomes.

Aim

To assess the impact of acute kidney injury (AKI) occurring immediately after the TAVI procedure on patients' outcome.

Methods

We conducted a multicenter retrospective study on patients treated with TAVI from 2010 to 2018. The assigned treatment, the selection of the device (self-expandable/balloon-expandable valve) and the type of approach used were determined by each individual Center on the basis of the patient's characteristics and the choice of the operator. All patients had an intermediate or high Society of Thoracic Surgeons (STS) score. Basal creatinine and glomerular filtrate (using the body mass index, sex and age) were evaluated for each patient. According to the KDIGO criteria, AKI is defined as an increase in serum creatinine (SCr) ≥0,3mg/dl within 48 hours or an increase in SCr ≥1.5 times baseline or urine volume <0,5ml/kg/h for 6 hours. The incidence of post procedural AKI and its correlation with the short-term mortality and outcomes was evaluated as primary end point (stroke/TIA/RIND, cardiac tamponade, bleeding, vascular complications, cardiocirculatory arrest with subsequent ROSC, definitive pacemaker implantation, postoperative atrial fibrillation, left bundle branch block de novo).Postoperative outcomes were defined according to the updated Valve Academic Research Consortium 2 definitions

Results

A total of 371 pts were analysed. Mean age was 82.3±5.9 and the majority of the pts had an STS score>10 (97.6%). Incidence of Acute kidney Injury (AKI) stage 3 post TAVI, according to VARC-2 criteria, was 16,2%. In patient with AKI, the hospitalization time was longer 18,7±6,1 days vs 8,4±6,1 days without AKI (p<0,01). Patients with AKI had an increased risk of in hospital mortality (OR 50,0; 95% CI 5,2–390,16; p<0,01) and 30 day mortality (OR: 5,88; 95% CI 2,08–16,60; p<0,01). Acute Kidney Injury instead was more common in patients treated with transapical access (OD 3,9-CI 95% 2,16–7,07; p<0,01) or with PAD (OR 1,87 - CI 95% 1,03–3,41; p=0,03)

AKI and short term mortality

Conclusion

Acute kidney injury is a frequent complication after TAVI. AKI seems to be the strongest predictor for 30 day mortality and increases the hospitalization time. AKI was more common in patients treated with a transapical approach or if they presented a PAD. In contrast, pre-procedural chronic kidney disease did not seem to correlate directly with an increased risk of AKI.

Interactions between commonly used left and right ventricular function indexes in stable patients

AIM

Aim of this study was to better understand interactions between left ventricular (LV) and right ventricular (RV) systolic and diastolic function echocardiographic indexes in stable cardiovascular diseased patients and in subjects with cardiovascular risk factors.

METHODS

The study enrolled 683 stable patients who were submitted to standard transthoracic echocardiography with evaluation of left ventricular ejection fraction (LVEF) (Simpson biplane method), LV and RV systolic peak on Doppler tissue imaging (LVSys and RVSys), tricuspid annulus plane systolic excursion (TAPSE), pulmonary artery systolic pressure (PASP), and multiparameter evaluation of LV and RV diastolic function utilizing E and A peak, their ratio, E peak deceleration time, E' and A' peak on Doppler tissue imaging, their ratio, and E/E' ratio.

RESULTS

Part of the considered indexes had interactions but only LVEF and TAPSE were related to all the others (LVEF P<0.001 with all the considered parameters; TAPSE P<0.001 with all parameters except with PASP=0.003). Unexpectedly TAPSE seems to have, such as LVEF, a pivotal position among LV and RV function.

CONCLUSION

The study demonstrates the existence of interactions between LV and RV function indexes; these results may be considered as a piece of evidence in favor of heart seen as a single structure.

[The accidental diagnosis of a left atrial myxoma in an 80-year-old female]

Left atrial myxoma is usually diagnosed in patients between the ages of 30 and 60 and this diagnosis follows non-specific symptoms (i.e. temperature, anemia, weakness), and obstructive or embolic episodes. There are few cases in the literature of this disease in patients older than 80. We report the case of an 80-year-old female admitted to our institute for an episode of supraventricular tachycardia. After successful treatment of the arrhythmia using verapamil i.v., a routine echocardiographic examination showed the presence of a left atrial mass, and its appearance suggested the diagnosis of a left atrial myxoma. A CT scan and a transesophageal echocardiography confirmed the diagnosis. The patient subsequently underwent cardiac catheterization and coronary angiography. In the absence of significant lesions of the coronary artery, a decision was made to remove the myxoma surgically, based on two considerations: the good clinical status of the patient and the high current risk of peripheral embolization. The operation was successful in removing the myxoma and the patient continues to be in good clinical condition.

[Treatment of diastolic dysfunction of the left ventricle]

Numerous studies have already recognized the importance of diastole in the pathogenesis of congestive heart failure. Non-invasive evaluations are based particularly on echo-Doppler, on radionuclide angiography and on cine-nuclear magnetic resonance: they have enabled an accurate evaluation of diastolic function and dysfunction, although invasive hemodynamic study maintains a gold standard position. All these methods of study have consented the identification of 3 basic components (anatomic and functional): active relaxation, passive elastic relaxation, atrial function. The Authors have identified the causes of diastolic failure with a particular attention to the various components of diastole. They have analyzed the implication of therapy on the basis of a clear understanding of the etiology, pathogenesis and pathophysiology of the underlying cardiac disease.

[Acute hemodynamic effects of nicardipine in patients with chronic congestive heart failure]

We evaluated haemodynamic parameters in 13 patients suffering from chronic heart failure (CHF) in III and IV NYHA class. They were 10 males and 3 females, average age 57 +/- 11 years. Haemodynamic monitoring was made at basal condition and for 40 min after the administration of nicardipine (10 mg iv). We observed that mean arterial pressure and systemic vascular resistances (SVR) showed an important decrease (respectively -10.8%, p less than 0.001 and -22%, p less than 0.001); total pulmonary resistances (TPR) also decreased (-16.6%, p less than 0.001), while mean pulmonary pressure did not show significant reduction. Cardiac index increased with the highest value at the fifteenth minute (-11.7%, p less than 0.01). Pulmonary wedge pressure (PWP) did not show statistic variations, and heart rate too. Cardiac index (CI) did not rise in 3 patients with clinical worsening during the monitoring (patients non responders) (CI increase was less than 15%); while in 10 patients CI increased more than 15% (patients responders). Patients non responders did not show any decrease of TPR and only a transitory reduction of SVR; patients responders showed an important decrease of TPR, SVR, PWP. We observed that at baseline, the difference between the 2 groups was based on the value of TPR and PWP. We conclude that nicardipine is an efficient drug in patients affected by CHF without severe hemodynamic failure.

[Delayed-action nicardipine in the prolonged treatment of chronic congestive heart failure in responsive subjects]

We performed hemodynamic monitoring in 13 patients, 10 males and 3 females, mean age 57 +/- 11 years, affected by congestive heart failure, NYHA class III and IV. Hemodynamic evaluation was made at basal condition and for 40 min after the administration of nicardipine (10 mg iv). We observed that in 3 patients cardiac index didn't rise (increase less than 15%) with clinical worsening during the monitoring (patients non responders), while in 10 patients cardiac index increased more than 15% (patients responders). Patients responders, 8 males and 2 females, mean age 57 +/- 10 years, have been treated with oral nicardipine administered at the dosage of 40 mg td for 3 months. Three months after nicardipine treatment we observed a significant increase of exercise capacity and O2 uptake (respectively p less than 0.05 and p less than 0.01); we noted also an improvement of cardio-thoracic ratio and of San Diego index (p less than 0.05). We conclude that patients responders to iv nicardipine receive beneficial clinical effects by chronic oral nicardipine.

Hemodynamic effects of transdermal nitroglycerin in subjects with angina and without congestive heart failure: comparison between never treated and chronically treated subjects

Two groups of patients with angina were studied: Group A, 9 patients not treated previously with nitroderivatives; Group B, 8 patients, treated with transdermally administered nitroderivatives for at least 4 weeks. Hemodynamic parameters did not differ significantly in these groups under baseline conditions; only systolic blood pressure was higher in Group B (165 +/- 16 mmHg) than in Group A (144 +/- 15 mmHg). Hemodynamic modifications produced by administering nitroglycerin transdermally in these patient groups were evaluated 100 min after the transdermal application. In Group A significant reduction of systolic (144 +/- 15 to 126 +/- 18 mmHg, p less than 0.01) and diastolic blood pressure (83.36 +/- 70.1 +/- 13 mmHg, p less than 0.05), mean right atrial pressure (4.8 +/- 2.1 to 3 +/- 1.7 mmHg, p less than 0.005), mean pulmonary arterial pressure (18.6 +/- 2.6 to 16.7 +/- 2.8 mmHg, p less than 0.01), and significant increase of heart rate (72 +/- 10 to 83.5 +/- 12.4 beats/min, p less than 0.005) were noted. In Group B we noted only a significant reduction in systolic (170 +/- 25 to 150.5 +/- 16 mmHg, p less than 0.05) and diastolic blood pressure (88.7 +/- 15.5 to 77.5 +/- 9.2 mmHg, p less than 0.05) without other modifications. We conclude that prolonged treatment with adequate doses of transdermal nitroglycerin causes the hemodynamic effects of the medication to dissipate from the venous tone and significant arteriodilative effect to persist.