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Grayburn PA, Mack MJ, Manandhar P, Kosinski AS, Sannino A, Smith RL, Szerlip M, Vemulapalli S. Comparison of Transcatheter Edge-to-Edge Mitral Valve Repair for Primary Mitral Regurgitation Outcomes to Hospital Volumes of Surgical Mitral Valve Repair. Circ Cardiovasc Interv 2024; 17:e013581. [PMID: 38436084 DOI: 10.1161/circinterventions.123.013581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/26/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Transcatheter edge-to-edge mitral valve (MV) repair (TEER) is an effective treatment for patients with primary mitral regurgitation at prohibitive risk for surgical MV repair (MVr). High-volume MVr centers and high-volume TEER centers have better outcomes than low-volume centers, respectively. However, whether MVr volume predicts TEER outcomes remains unknown. We hypothesized that high-volume MV surgical centers would have superior risk-adjusted outcomes for TEER than low-volume centers. METHODS We combined data from the American College of Cardiology/Society of Thoracic Surgeons Transcatheter Valve Therapy registry and the Society of Thoracic Surgeons adult cardiac surgery database. MVr was defined as leaflet resection or artificial chords with or without annuloplasty and was evaluated as a continuous variable and as predefined categories (<25, 25-49, and ≥50 MV repairs/year). A generalized linear mixed model was used to evaluate risk-adjusted in-hospital/30-day mortality, 30-day heart failure readmission, and TEER success (mitral regurgitation ≤2+ and gradient <5 mm Hg). RESULTS The study comprised 41 834 patients from 500 sites of which 332 (66.4%) were low, 102 (20.4%) intermediate, and 66 (13.2%) high-volume surgical centers (P<0.001). TEER success was 54.6% and was not statistically significantly different across MV surgical site volumes (P=0.4271). TEER mortality at 30 days was 3.5% with no significant difference across MVr volume on unadjusted (P=0.141) or adjusted (P=0.071) analysis of volume as a continuous variable. One-year mortality was 15.0% and was lower for higher MVr volume centers when adjusted for clinical and demographic variables (P=0.027). Heart failure readmission at 1 year was 9.4% and was statistically significantly lower in high-volume centers on both unadjusted (P=0.017) or adjusted (P=0.015) analysis. CONCLUSIONS TEER can be safely performed in centers with low volumes of MV repair. However, 1-year mortality and heart failure readmission are superior at centers with higher MVr volume.
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Affiliation(s)
- Paul A Grayburn
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
| | - Michael J Mack
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
| | | | | | - Anna Sannino
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
| | - Robert L Smith
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
| | - Molly Szerlip
- Baylor Scott and White Heart Hospital Plano, TX (P.A.G., M.J.M., A.S., R.L.S., M.S.)
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Hung A, Yang J, Wallace M, Zwischenberger BA, Vemulapalli S, Mentz RJ, Thoma E, Goates S, Lewis J, Strong S, Reed SD. Patient Risk-Benefit Preferences for Transcatheter Versus Surgical Mitral Valve Repair. J Am Heart Assoc 2024; 13:e032807. [PMID: 38471830 PMCID: PMC11010000 DOI: 10.1161/jaha.123.032807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/31/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Transcatheter edge-to-edge repair (TEER) of mitral regurgitation is less invasive than surgery but has greater 5-year mortality and reintervention risks, and leads to smaller improvements in physical functioning. The study objective was to quantify patient preferences for risk-benefit trade-offs associated with TEER and surgery. METHODS AND RESULTS A discrete choice experiment survey was administered to patients with mitral regurgitation. Attributes included procedure type; 30-day mortality risk; 5-year mortality risk and physical functioning for 5 years; number of hospitalizations in the next 5 years; and risk of additional surgery in the next 5 years. A mixed-logit regression model was fit to estimate preference weights. Two hundred one individuals completed the survey: 63% were female and mean age was 74 years. On average, respondents preferred TEER over surgery. To undergo a less invasive procedure (ie, TEER), respondents would accept up to a 13.3% (95% CI, 8.7%-18.5%) increase in reintervention risk above a baseline of 10%, 4.6 (95% CI, 3.1-6.2) more hospitalizations above a baseline of 1, a 10.7% (95% CI, 6.5%-14.5%) increase in 5-year mortality risk above a baseline of 20%, or more limited physical functioning representing nearly 1 New York Heart Association class (0.7 [95% CI, 0.4-1.1]) over 5 years. CONCLUSIONS Patients in general preferred TEER over surgery. When holding constant all other factors, a functional improvement from New York Heart Association class III to class I maintained over 5 years would be needed, on average, for patients to prefer surgery over TEER.
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Affiliation(s)
- Anna Hung
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNCUSA
- Center of Innovation to Accelerate Discovery and Practice TransformationDurham Veterans Affairs Health Care SystemDurhamNCUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNCUSA
| | - Jui‐Chen Yang
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNCUSA
| | - Matthew Wallace
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNCUSA
| | - Brittany A. Zwischenberger
- Division of Cardiovascular and Thoracic Surgery, Department of SurgeryDuke University Medical CenterDurhamNCUSA
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNCUSA
- Division of Cardiology, Department of MedicineDuke University Medical CenterDurhamNCUSA
| | - Robert J. Mentz
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNCUSA
- Division of Cardiology, Department of MedicineDuke University Medical CenterDurhamNCUSA
| | | | | | | | | | - Shelby D. Reed
- Duke Clinical Research Institute, Duke University School of MedicineDurhamNCUSA
- Department of Population Health SciencesDuke University School of MedicineDurhamNCUSA
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Kumbhani DJ, Manandhar P, Bavry AA, Chhatriwalla AK, Giri J, Mack M, Carroll J, Pandey A, Kosinski A, Peterson ED, Kaneko T, de Lemos JA, Vemulapalli S. National Variation in Hospital MTEER Outcomes and Correlation With TAVR Outcomes: STS/ACC TVT Registry Analysis. JACC Cardiovasc Interv 2024; 17:505-515. [PMID: 38340102 DOI: 10.1016/j.jcin.2023.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND A single, multitiered valve center designation has been proposed to publicly identify centers with expertise for all valve therapies. The correlation between transcatheter aortic valve replacement (TAVR) and mitral transcatheter edge-to-edge repair (MTEER) procedures is unknown. OBJECTIVES The authors sought to examine the relationship between site-level volumes and outcomes for TAVR and MTEER. We further explored variability between sites for MTEER outcomes. METHODS Using the STS/ACC TVT (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy) national registry, TAVR and MTEER procedures at sites offering both therapies from 2013 to 2022 were examined. Sites were ranked into deciles of adjusted in-hospital and 30-day outcomes separately for TAVR and MTEER and compared. Stepwise, hierarchical multivariable models were constructed for MTEER outcomes, and the median OR was calculated. RESULTS Between 2013 and 2022, 384,394 TAVRs and 53,274 MTEERs (median annualized volumes: 93.6 and 18.8, respectively) were performed across 453 U.S. sites. Annualized TAVR and MTEER volumes were moderately correlated (r = 0.48; P < 0.001). After adjustment, 14.3% of sites had the same decile rank for TAVR and MTEER 30-day composite outcome, 50.6% were within 2 decile ranks; 35% had more discordant outcomes for the 2 procedures (P = 0.0005). For MTEER procedures, the median OR for the 30-day composite outcome was 1.57 (95% CI: 1.51-1.64), indicating a 57% variability in outcome by site. CONCLUSIONS There is modest correlation between hospital-level volumes for TAVR and MTEER but low interprocedural correlation of outcomes. For similar patients, site-level variability for mortality/morbidity following MTEER was high. Factors influencing outcomes and "centers of excellence" as a whole may differ for TAVR and MTEER.
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Affiliation(s)
- Dharam J Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - Pratik Manandhar
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Anthony A Bavry
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Jay Giri
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Mack
- Baylor Scott and White Heart Hospital, Plano, Texas, USA
| | - John Carroll
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Andrzej Kosinski
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Eric D Peterson
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Tsuyoshi Kaneko
- Division of Cardiothoracic Surgery, Washington University, St. Louis, Missouri, USA
| | - James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
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Vora AN, Gada H, Manandhar P, Kosinski A, Kirtane A, Nazif T, Reardon M, Kodali S, Cohen DJ, Thourani V, Sherwood M, Julien H, Vemulapalli S. National Variability in Pacemaker Implantation Rate Following TAVR: Insights From the STS/ACC TVT Registry. JACC Cardiovasc Interv 2024; 17:391-401. [PMID: 38355267 DOI: 10.1016/j.jcin.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/29/2023] [Accepted: 12/05/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Although permanent pacemaker (PPM) implantation is a common complication of transcatheter aortic valve replacement (TAVR), hospital variation and change in PPM implantation rates are ill defined. OBJECTIVES The aim of this study was to determine hospital-level variation and temporal trends in the rate of PPM implantation following TAVR. METHODS Using the American College of Cardiology/Society of Thoracic Surgeons TVT (Transcatheter Valve Therapy) Registry, temporal changes in variation of in-hospital and 30-day PPM implantation were determined among 184,452 TAVR procedures across 653 sites performed from 2016 to 2020. The variation in PPM implantation adjusted for valve type by annualized TAVR volume was determined, and characteristics of sites below, within, and above the 95% boundary were identified. A series of stepwise multivariable hierarchical models were then fit, and the median OR was used to measure variation in pacemaker rates among sites. RESULTS From 2016 to 2020, the overall rate of PPM implantation was 11.3%, with wide variation across sites (range: 0%-36.4%); rates trended lower over time. Adjusted for annualized volume, there were 34 sites with PPM implantation rates above the 95th percentile CI and 28 with rates below, with wide variation among the remaining sites. After adjusting for patient-level covariates, there was variation among sites in the probability of PPM implantation (median OR: 1.39; 95% CI: 1.35-1.43, P < 0.001); although some of the variation was explained by the addition of valve type, residual variation in PPM implantation rates persisted in additional models incorporating site-level covariates (annualized volume, region, teaching status, hospital beds, etc). CONCLUSIONS Although PPM implantation rates have decreased over time, substantial site-level variation remains even after accounting for observed patient characteristics and site-level factors. As there are numerous outlier sites both above and below the 95% confidence limit, dissemination of best practices from high-performing sites to low-performing sites and guideline-based education may be important quality improvement initiatives to reduce rates of this common complication.
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Affiliation(s)
- Amit N Vora
- UPMC Pinnacle Heart and Vascular Institute, Harrisburg, Pennsylvania, USA; Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Yale University School of Medicine, New Haven, CT.
| | - Hemal Gada
- UPMC Pinnacle Heart and Vascular Institute, Harrisburg, Pennsylvania, USA
| | - Pratik Manandhar
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrezej Kosinski
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Ajay Kirtane
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Tamim Nazif
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | - Michael Reardon
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Susheel Kodali
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
| | | | | | | | - Howard Julien
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
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5
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Chhatriwalla AK, Cohen DJ, Vemulapalli S, Vekstein A, Huded CP, Gallup D, Kosinski AS, Brothers L, Lindenfeld J, Stone GW, Sorajja P. Transcatheter Edge-to-Edge Repair in COAPT-Ineligible Patients With Functional Mitral Regurgitation. J Am Coll Cardiol 2024; 83:488-499. [PMID: 38267110 DOI: 10.1016/j.jacc.2023.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/06/2023] [Accepted: 10/06/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Mitral valve transcatheter edge-to-edge repair (MTEER) was approved in the United States for treatment of functional mitral regurgitation (FMR) based on results from the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial. OBJECTIVES The authors sought to analyze outcomes of MTEER in FMR patients who would have been excluded from COAPT. METHODS MTEER procedures performed for FMR in the TVT (Transcatheter Valve Therapy) Registry between January 1, 2013, and April 30, 2020, were categorized as "trial-ineligible" if any of the following were present: cardiogenic shock, inotropic support, left ventricular ejection fraction <20%, left ventricular end-systolic dimension >7 cm, home oxygen use, or severe tricuspid regurgitation. Trial-ineligible and trial-eligible groups were compared through 1 year using multivariable models. The primary endpoint was 1-year death or heart failure hospitalization (HFH). RESULTS Of 6,675 patients who underwent MTEER for FMR, 3,721 (55.7%) were trial-eligible and 2,954 (44.3%) were trial-ineligible. Trial-ineligible patients had lower rates of technical procedural success (86.9% vs 92.6%; P < 0.001) and more frequent in-hospital complications (11.8% vs 5.7%; P < 0.001) compared with trial-eligible patients. A clinically meaningful improvement in health status at 30 days was observed in 78.9% and 77.0% of patients in the trial-ineligible and trial-eligible groups, respectively. There was a higher risk of 1-year death or HFH (HR: 1.73; 95% CI: 1.57-1.91; P < 0.001) in trial-ineligible patients. CONCLUSIONS Among patients who underwent MTEER for FMR in the TVT Registry, nearly one-half would have been ineligible for the COAPT trial. Health status improvement at 30 days was similar in COAPT-ineligible and COAPT-eligible patients, but trial-ineligible patients had higher 1-year rates of death or HFH.
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Affiliation(s)
- Adnan K Chhatriwalla
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA.
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA; St Francis Hospital and Heart Center, Roslyn, New York, USA
| | | | - Andrew Vekstein
- Duke University and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Chetan P Huded
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Dianne Gallup
- Duke University and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Andrzej S Kosinski
- Duke University and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Leo Brothers
- Duke University and Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
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6
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Hirji SA, Wegermann Z, Vemulapalli S, Newell P, Grau-Sepulveda M, O'Brien S, Thourani VH, Badhwar V, Kaneko T. Benchmarking Outcomes of Surgical Aortic Valve Replacement in Patients With Bicuspid Aortic Valves. Ann Thorac Surg 2023; 116:1222-1231. [PMID: 37454786 DOI: 10.1016/j.athoracsur.2023.06.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The relative roles for transcatheter and surgical aortic valve replacement (SAVR) for bicuspid aortic valve (AV) stenosis are debated. This study analyzes the 5-year longitudinal outcomes of isolated SAVR in bicuspid vs tricuspid AV patients, particularly in low-risk patients. METHODS All patients undergoing isolated index SAVR at 1146 United States hospitals in The Society of Thoracic Surgeons (STS) Adult Cardiac database between July 1, 2011, and December 31, 2018, with linkage to Medicare claims, were analyzed. RESULTS A total of 65,687 patients were analyzed, including of 9131 bicuspid patients (13.9%). Compared with tricuspid patients, bicuspid patients were significantly younger (median 70 vs 74 years, P < .001) with lower Society of Thoracic Surgeons predicted risk of mortality scores (mean 1.6% vs 2.3%, P < .001) and lower risk profile. Risk-adjusted 30-day mortality and major morbidity were similar, but risk-adjusted 5-year mortality was significantly lower in the bicuspid patients (adjusted hazard ratio, 0.72; 95% CI, 0.66-0.77), specifically in low-risk patients (adjusted hazard ratio, 0.69; 95% CI, 0.64-0.76). Additionally, the bicuspid cohort had a lower 5-year readmission risk of heart failure, stroke, bleeding, or other cardiovascular causes (all P < .05). CONCLUSIONS In this nationally representative study, 30-day mortality was similar, but risk-adjusted 5-year mortality was significantly lower in bicuspid patients undergoing isolated SAVR compared with tricuspid patients, specifically low-risk and normal left ventricular ejection fraction patients. This analysis provides a much-needed 5-year longitudinal national-level benchmark to better inform the discussion of transcatheter vs SAVR in bicuspid patients.
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Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | | | | | - Paige Newell
- Division of Cardiac Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | | | - Sean O'Brien
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Tsuyoshi Kaneko
- Department of Surgery, Washington University School of Medicine in St. Louis, St Louis, Missouri.
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7
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Bansal K, Soni A, Shah M, Kosinski AS, Gilani F, Khera S, Vemulapalli S, Elmariah S, Kolte D. Association Between Polyvascular Disease and Transcatheter Aortic Valve Replacement Outcomes: Insights From the STS/ACC TVT Registry. Circ Cardiovasc Interv 2023; 16:e013578. [PMID: 37870587 DOI: 10.1161/circinterventions.123.013578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/13/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Atherosclerotic cardiovascular disease is highly prevalent in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). Polyvascular disease (PVD), defined as involvement of ≥2 vascular beds (VBs), that is, coronary, cerebrovascular, or peripheral, portends a poor prognosis in patients with atherosclerotic cardiovascular disease; however, data on the association of PVD with outcomes of patients undergoing TAVR are limited. METHODS The Society of Thoracic Surgeons and the American College of Cardiology Transcatheter Valve Therapy Registry was analyzed to identify patients who underwent TAVR from November 2011 to March 2022. The exposure of interest was PVD. The primary outcome was all-cause mortality. Secondary outcomes included major vascular complications, major/life-threatening bleeding, myocardial infarction, transient ischemic attack/stroke, and valve- and non-valve-related readmissions. Outcomes were assessed at 30 days and 1 year. RESULTS Of 443 790 patients who underwent TAVR, PVD was present in 150 823 (34.0%; 111 425 [25.1%] with 2VB-PVD and 39 398 [8.9%] with 3VB-PVD). On multivariable analysis, PVD was associated with increased all-cause mortality at 1 year (hazard ratio, 1.17 [95% CI, 1.14-1.20]). There was an incremental increase in 1-year mortality with an increasing number of VBs involved (no PVD [reference]; 2VB-PVD: hazard ratio, 1.12 [95% CI, 1.09-1.15]: and 3VB-PVD: hazard ratio, 1.31 [95% CI, 1.26-1.36]). Patients with versus without PVD had higher rates of major vascular complications, major/life-threatening bleeding, transient ischemic attack/stroke, and non-valve-related readmissions at 30 days and 1 year. CONCLUSIONS PVD is associated with worse outcomes after TAVR, and the risk is highest in patients with 3VB-PVD.
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Affiliation(s)
- Kannu Bansal
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA (K.B., A.S.)
| | - Aakriti Soni
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA (K.B., A.S.)
| | - Miloni Shah
- Duke Clinical Research Institute, Durham, NC (M.S., A.S.K.)
| | | | - Fahad Gilani
- Division of Cardiovascular Medicine, Catholic Medical Center, Manchester, NH (F.G.)
| | - Sahil Khera
- Division of Interventional Cardiology, Mount Sinai Hospital, New York, NY (S.K.)
| | - Sreekanth Vemulapalli
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (S.V.)
- Division of Cardiology, Duke University Medical Center, Durham, NC (S.V.)
| | - Sammy Elmariah
- Division of Cardiology, University of California, San Francisco (S.E.)
| | - Dhaval Kolte
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston (D.K.)
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8
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Varshney AS, Shah M, Vemulapalli S, Kosinski A, Bhatt AS, Sandhu AT, Hirji S, DeFilippis EM, Shah PB, Fiuzat M, O'Gara PT, Bhatt DL, Kaneko T, Givertz MM, Vaduganathan M. Heart failure medical therapy prior to mitral transcatheter edge-to-edge repair: the STS/ACC Transcatheter Valve Therapy Registry. Eur Heart J 2023; 44:4650-4661. [PMID: 37632738 DOI: 10.1093/eurheartj/ehad584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND AND AIMS Guideline-directed medical therapy (GDMT) is recommended before mitral valve transcatheter edge-to-edge repair (MTEER) in patients with heart failure (HF) and severe functional mitral regurgitation (FMR). Whether MTEER is being performed on the background of optimal GDMT in clinical practice is unknown. METHODS Patients with left ventricular ejection fraction (LVEF) < 50% who underwent MTEER for FMR from 23 July 2019 to 31 March 2022 in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry were identified. Pre-procedure GDMT utilization was assessed. Cox proportional hazards models were constructed to evaluate associations between pre-MTEER therapy (no/single, double, or triple therapy) and risk of 1-year mortality or HF hospitalization (HFH). RESULTS Among 4199 patients across 449 sites, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, mineralocorticoid receptor antagonists, and angiotensin receptor-neprilysin inhibitors were used in 85.1%, 44.4%, 28.6%, and 19.9% before MTEER, respectively. Triple therapy was prescribed for 19.2%, double therapy for 38.2%, single therapy for 36.0%, and 6.5% were on no GDMT. Significant centre-level variation in the proportion of patients on pre-intervention triple therapy was observed (0%-61%; adjusted median odds ratio 1.48 [95% confidence interval (CI) 1.25-3.88]; P < .001). In patients eligible for 1-year follow-up (n = 2014; 341 sites), the composite rate of 1-year mortality or HFH was lowest in patients prescribed triple therapy (23.0%) compared with double (24.8%), single (35.7%), and no (41.1%) therapy (P < .01 comparing across groups). Associations persisted after accounting for relevant clinical characteristics, with lower risk in patients prescribed triple therapy [adjusted hazard ratio (aHR) 0.73, 95% CI .55-.97] and double therapy (aHR 0.69, 95% CI .56-.86) before MTEER compared with no/single therapy. CONCLUSIONS Under one-fifth of patients with LVEF <50% who underwent MTEER for FMR in this US nationwide registry were prescribed comprehensive GDMT, with substantial variation across sites. Compared with no/single therapy, triple and double therapy before MTEER were independently associated with reduced risk of mortality or HFH 1 year after intervention.
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Affiliation(s)
- Anubodh S Varshney
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, CA, USA
| | - Miloni Shah
- Duke Clinical Research Institute, Durham, NC, USA
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | | | - Ankeet S Bhatt
- Kaiser Permanente San Francisco Medical Center and Division of Research, San Francisco, CA, USA
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, CA, USA
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
| | - Pinak B Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Mona Fiuzat
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Patrick T O'Gara
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Tsuyoshi Kaneko
- Division of Cardiothoracic Surgery, Washington University in St Louis, St Louis, MO, USA
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
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9
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Hahn RT, Lawlor MK, Davidson CJ, Badhwar V, Sannino A, Spitzer E, Lurz P, Lindman BR, Topilsky Y, Baron SJ, Chadderdon S, Khalique OK, Tang GHL, Taramasso M, Grayburn PA, Badano L, Leipsic J, Lindenfeld J, Windecker S, Vemulapalli S, Redfors B, Alu MC, Cohen DJ, Rodés-Cabau J, Ailawadi G, Mack M, Ben-Yehuda O, Leon MB, Hausleiter J. Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints. Eur Heart J 2023; 44:4508-4532. [PMID: 37793121 PMCID: PMC10645050 DOI: 10.1093/eurheartj/ehad653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/12/2023] [Accepted: 08/08/2023] [Indexed: 10/06/2023] Open
Abstract
Interest in the pathophysiology, etiology, management, and outcomes of patients with tricuspid regurgitation (TR) has grown in the wake of multiple natural history studies showing progressively worse outcomes associated with increasing TR severity, even after adjusting for multiple comorbidities. Historically, isolated tricuspid valve surgery has been associated with high in-hospital mortality rates, leading to the development of transcatheter treatment options. The aim of this first Tricuspid Valve Academic Research Consortium document is to standardize definitions of disease etiology and severity, as well as endpoints for trials that aim to address the gaps in our knowledge related to identification and management of patients with TR. Standardizing endpoints for trials should provide consistency and enable meaningful comparisons between clinical trials. A second Tricuspid Valve Academic Research Consortium document will focus on further defining trial endpoints and will discuss trial design options.
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Affiliation(s)
- Rebecca T Hahn
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York,USA
| | - Matthew K Lawlor
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Charles J Davidson
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Anna Sannino
- Baylor Research Institute, The Heart Hospital Baylor Plano, Plano, Texas, USA
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, Naples, Italy
| | - Ernest Spitzer
- Cardialysis, Rotterdam, the Netherlands
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Philipp Lurz
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Brian R Lindman
- Structural Heart and Valve Center, Cardiovascular Division, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yan Topilsky
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Suzanne J Baron
- Division of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
- Baim Institute of Clinical Research, Boston, Massachusetts, USA
| | - Scott Chadderdon
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Omar K Khalique
- Division of Cardiology, Saint Francis Hospital and Catholic Health, Roslyn, New York, USA
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York, USA
| | - Maurizio Taramasso
- Herzzentrum Hirslanden Zürich, Zürich, Switzerland
- University of Zürich, Zürich, Switzerland
| | - Paul A Grayburn
- Baylor Scott and White Heart and Vascular Hospital at Plano, Plano, Texas, USA
| | - Luigi Badano
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Jonathon Leipsic
- Department of Radiology and Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephan Windecker
- Department of Cardiology, University Cardiovascular Center, Bern University Hospital, Inselspital, Bern, Switzerland
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York,USA
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York,USA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York,USA
- Division of Cardiology, Saint Francis Hospital and Catholic Health, Roslyn, New York, USA
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Mack
- Baylor Scott and White Health, Dallas, Texas, USA
| | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, New York, New York,USA
- University of California-San Diego, San Diego, California, USA
| | - Martin B Leon
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York,USA
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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10
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Huded CP, Arnold SV, Cohen DJ, Manandhar P, Vemulapalli S, Saxon JT, Chhatriwalla AK, Kosinski A, Spertus JA. Outcomes of Transcatheter Aortic Valve Replacement in Asymptomatic or Minimally Symptomatic Aortic Stenosis. JACC Cardiovasc Interv 2023; 16:2631-2641. [PMID: 37737793 DOI: 10.1016/j.jcin.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/26/2023] [Accepted: 07/11/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Little is known about the outcomes of transcatheter aortic valve replacement (TAVR) in minimally symptomatic patients. OBJECTIVES The authors aimed to evaluate the outcomes of patients with minimally symptomatic severe aortic stenosis treated with TAVR in the STS/ACC TVT registry. METHODS Minimally symptomatic status was defined as a baseline Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OS) ≥75. Clinical and health status outcomes of TAVR in patients with severe aortic stenosis and normal left ventricular ejection fraction were compared between minimally symptomatic patients and those with moderate or severe symptoms. RESULTS Among 231,285 patients who underwent TAVR between 2015 and 2021 (median age 80.0 years [IQR: 74.0-86.0 years], 47.5% female), 20.0% were minimally symptomatic before TAVR. Survival at 1 year was higher in minimally symptomatic patients vs those with moderate or severe symptoms (adjusted HR for death: 0.70 [95% CI: 0.66-0.75]). Mean KCCQ-OS increased by 2.7 points (95% CI: 2.6-2.9 points) at 30 days and 3.8 points (95% CI: 3.6-4.0 points) at 1 year in minimally symptomatic patients compared with increases of 32.2 points (95% CI: 32.0-32.3 points) at 30 days and 34.9 points (95% CI: 34.7-35.0 points) at 1 year in more symptomatic patients. Minimally symptomatic patients had higher odds of being alive and well at 1 year (OR: 1.19 [95% CI: 1.16-1.23]). CONCLUSIONS Although minimally symptomatic patients treated with TAVR experience only small improvements in health status, their overall outcomes are favorable with a higher likelihood of survival with good health status at 1 year compared with more symptomatic patients.
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Affiliation(s)
- Chetan P Huded
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri - Kansas City, Kansas City, Missouri, USA.
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri - Kansas City, Kansas City, Missouri, USA
| | - David J Cohen
- St. Francis Hospital and Heart Center, Roslyn, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | | | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina, USA; Duke University Medical Center, Durham, North Carolina, USA
| | - John T Saxon
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri - Kansas City, Kansas City, Missouri, USA
| | - Adnan K Chhatriwalla
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri - Kansas City, Kansas City, Missouri, USA
| | | | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri - Kansas City, Kansas City, Missouri, USA
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11
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Hahn RT, Lawlor MK, Davidson CJ, Badhwar V, Sannino A, Spitzer E, Lurz P, Lindman BR, Topilsky Y, Baron SJ, Chadderdon S, Khalique OK, Tang GHL, Taramasso M, Grayburn PA, Badano L, Leipsic J, Lindenfeld J, Windecker S, Vemulapalli S, Redfors B, Alu MC, Cohen DJ, Rodés-Cabau J, Ailawadi G, Mack M, Ben-Yehuda O, Leon MB, Hausleiter J. Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints. Ann Thorac Surg 2023; 116:908-932. [PMID: 37804270 DOI: 10.1016/j.athoracsur.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 10/09/2023]
Abstract
Interest in the pathophysiology, etiology, management, and outcomes of patients with tricuspid regurgitation (TR) has grown in the wake of multiple natural history studies showing progressively worse outcomes associated with increasing TR severity, even after adjusting for multiple comorbidities. Historically, isolated tricuspid valve surgery has been associated with high in-hospital mortality rates, leading to the development of transcatheter treatment options. The aim of this first Tricuspid Valve Academic Research Consortium document is to standardize definitions of disease etiology and severity, as well as endpoints for trials that aim to address the gaps in our knowledge related to identification and management of patients with TR. Standardizing endpoints for trials should provide consistency and enable meaningful comparisons between clinical trials. A second Tricuspid Valve Academic Research Consortium document will focus on further defining trial endpoints and will discuss trial design options.
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Affiliation(s)
- Rebecca T Hahn
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York.
| | - Matthew K Lawlor
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York
| | | | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Anna Sannino
- Baylor Research Institute, The Heart Hospital Baylor Plano, Plano, Texas; Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Ernest Spitzer
- Cardialysis, Rotterdam, the Netherlands; Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Philipp Lurz
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Brian R Lindman
- Structural Heart and Valve Center, Cardiovascular Division, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yan Topilsky
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Suzanne J Baron
- Division of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts; Baim Institute of Clinical Research, Boston, Massachusetts
| | - Scott Chadderdon
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Omar K Khalique
- Division of Cardiology, Saint Francis Hospital and Catholic Health, Roslyn, New York
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York
| | - Maurizio Taramasso
- Herzzentrum Hirslanden Zürich, Zürich, Switzerland; University of Zürich, Zürich, Switzerland
| | - Paul A Grayburn
- Baylor Scott and White Heart and Vascular Hospital at Plano, Plano, Texas
| | - Luigi Badano
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy; Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Jonathon Leipsic
- Department of Radiology and Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephan Windecker
- Department of Cardiology, University Cardiovascular Center, Bern University Hospital, Inselspital, Bern, Switzerland
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina; Duke University School of Medicine, Durham, North Carolina
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York; Division of Cardiology, Saint Francis Hospital and Catholic Health, Roslyn, New York
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, New York, New York; University of California-San Diego, San Diego, California
| | - Martin B Leon
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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12
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Schwann TA, Vekstein AM, Engelman DT, Thibault D, Chikwe J, Engoren M, Gaudino M, Vemulapalli S, Thourani VH, Ailawadi G, Rousou A, Habib RH. Long-term Outcomes and Anticoagulation in Mitral Valve Surgery-A Report From The Society of Thoracic Surgeons Database. Ann Thorac Surg 2023; 116:944-953. [PMID: 37308066 PMCID: PMC10592308 DOI: 10.1016/j.athoracsur.2023.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/20/2023] [Accepted: 05/23/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Anticoagulation after bioprosthetic mitral valve (MV) replacement (BMVR) and repair (MVrep) is controversial. We explore outcomes among BMVR and MVrep patients in The Society of Thoracic Surgeons Adult Cardiac Surgery Database based on discharge anticoagulation status. METHODS BMVR and MVrep patients aged ≥65 years in The Society of Thoracic Surgeons Adult Cardiac Surgery Database were linked to the Centers for Medicare and Medicaid Services claims database. Long-term mortality, ischemic stroke, bleeding, and a composite of the primary end points were compared as a function of anticoagulation. Hazard ratios (HRs) were calculated using multivariable Cox regression. RESULTS A total of 26,199 BMVR and MVrep patients were linked to the Centers for Medicare and Medicaid Services database; of these, 44%, 4%, and 52% were discharged on warfarin, non-vitamin K-dependent anticoagulant (NOAC), and no anticoagulation (no-AC; reference), respectively. Warfarin was associated with increased bleeding in the overall study cohort (HR, 1.38; 95% CI 1.26-1.52) and in the BMVR (HR, 1.32; 95% CI, 1.13-1.55) and MVrep subcohorts (HR, 1.42; 95% CI, 1.26-1.60). Warfarin was associated with decreased mortality only among BMVR patients (HR, 0.87; 95% CI, 0.79-0.96). Stroke and the composite outcome did not differ across cohorts with warfarin. NOAC use was associated with increased mortality (HR, 1.33; 95% CI 1.11-1.59), bleeding (HR, 1.37; 95% CI, 1.07-1.74), and the composite outcome (HR, 1.26; 95% CI, 1.08-1.47). CONCLUSIONS Anticoagulation was used in fewer than half of mitral valve operations. In MVrep patients, warfarin was associated with increased bleeding and was not protective against stroke or mortality. In BMVR patients, warfarin was associated with a modest survival benefit, increased bleeding, and equivalent stroke risk. NOAC was associated with increased adverse outcomes.
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Affiliation(s)
- Thomas A Schwann
- Department of Surgery, University of Massachusetts-Baystate, Springfield, Massachusetts.
| | - Andrew M Vekstein
- Department of Surgery, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Daniel T Engelman
- Department of Surgery, University of Massachusetts-Baystate, Springfield, Massachusetts
| | - Dylan Thibault
- Duke Clinical Research Institute, Durham, North Carolina
| | - Joanna Chikwe
- Department of Surgery, Cedars-Sinai, Los Angeles, California
| | - Milo Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill-Cornell Medicine, New York, New York
| | | | - Vinod H Thourani
- Department of Cardiovascular Surgery, Piedmont Heart Institute, Atlanta, Georgia
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Anthony Rousou
- Department of Surgery, University of Massachusetts-Baystate, Springfield, Massachusetts
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, Chicago, Illinois
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13
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Hahn RT, Lawlor MK, Davidson CJ, Badhwar V, Sannino A, Spitzer E, Lurz P, Lindman BR, Topilsky Y, Baron SJ, Chadderdon S, Khalique OK, Tang GHL, Taramasso M, Grayburn PA, Badano L, Leipsic J, Lindenfeld J, Windecker S, Vemulapalli S, Redfors B, Alu MC, Cohen DJ, Rodés-Cabau J, Ailawadi G, Mack M, Ben-Yehuda O, Leon MB, Hausleiter J. Tricuspid Valve Academic Research Consortium Definitions for Tricuspid Regurgitation and Trial Endpoints. J Am Coll Cardiol 2023; 82:1711-1735. [PMID: 37804294 DOI: 10.1016/j.jacc.2023.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/12/2023] [Accepted: 08/08/2023] [Indexed: 10/09/2023]
Abstract
Interest in the pathophysiology, etiology, management, and outcomes of patients with tricuspid regurgitation (TR) has grown in the wake of multiple natural history studies showing progressively worse outcomes associated with increasing TR severity, even after adjusting for multiple comorbidities. Historically, isolated tricuspid valve surgery has been associated with high in-hospital mortality rates, leading to the development of transcatheter treatment options. The aim of this first Tricuspid Valve Academic Research Consortium document is to standardize definitions of disease etiology and severity, as well as endpoints for trials that aim to address the gaps in our knowledge related to identification and management of patients with TR. Standardizing endpoints for trials should provide consistency and enable meaningful comparisons between clinical trials. A second Tricuspid Valve Academic Research Consortium document will focus on further defining trial endpoints and will discuss trial design options.
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Affiliation(s)
- Rebecca T Hahn
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA.
| | - Matthew K Lawlor
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Charles J Davidson
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Anna Sannino
- Baylor Research Institute, The Heart Hospital Baylor Plano, Plano, Texas, USA; Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, Naples, Italy. https://twitter.com/AnnaSannino198
| | - Ernest Spitzer
- Cardialysis, Rotterdam, the Netherlands; Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Philipp Lurz
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Brian R Lindman
- Structural Heart and Valve Center, Cardiovascular Division, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yan Topilsky
- Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Suzanne J Baron
- Division of Cardiology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA; Baim Institute of Clinical Research, Boston, Massachusetts, USA
| | - Scott Chadderdon
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA. https://twitter.com/PDXHeartValveMD
| | - Omar K Khalique
- Division of Cardiology, Saint Francis Hospital and Catholic Health, Roslyn, New York, USA
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York, USA
| | - Maurizio Taramasso
- Herzzentrum Hirslanden Zürich, Zürich, Switzerland; University of Zürich, Zürich, Switzerland
| | - Paul A Grayburn
- Baylor Scott and White Heart and Vascular Hospital at Plano, Plano, Texas, USA
| | - Luigi Badano
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy; Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Jonathon Leipsic
- Department of Radiology and Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephan Windecker
- Department of Cardiology, University Cardiovascular Center, Bern University Hospital, Inselspital, Bern, Switzerland
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina, USA; Duke University School of Medicine, Durham, North Carolina, USA
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York, USA; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York, USA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA; Division of Cardiology, Saint Francis Hospital and Catholic Health, Roslyn, New York, USA
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Mack
- Baylor Scott and White Health, Dallas, Texas, USA
| | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, New York, New York, USA; University of California-San Diego, San Diego, California, USA. https://twitter.com/oribenyehuda
| | - Martin B Leon
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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14
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Udelson JE, Kelsey MD, Nanna MG, Fordyce CB, Yow E, Clare RM, Mark DB, Patel MR, Rogers C, Curzen N, Pontone G, Maurovich-Horvat P, De Bruyne B, Greenwood JP, Marinescu V, Leipsic J, Stone GW, Ben-Yehuda O, Berry C, Hogan SE, Redfors B, Ali ZA, Byrne RA, Kramer CM, Yeh RW, Martinez B, Mullen S, Huey W, Anstrom KJ, Al-Khalidi HR, Chiswell K, Vemulapalli S, Douglas PS. Deferred Testing in Stable Outpatients With Suspected Coronary Artery Disease: A Prespecified Secondary Analysis of the PRECISE Randomized Clinical Trial. JAMA Cardiol 2023; 8:915-924. [PMID: 37610768 PMCID: PMC10448368 DOI: 10.1001/jamacardio.2023.2614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]
Abstract
Importance Guidelines recommend deferral of testing for symptomatic people with suspected coronary artery disease (CAD) and low pretest probability. To our knowledge, no randomized trial has prospectively evaluated such a strategy. Objective To assess process of care and health outcomes in people identified as minimal risk for CAD when testing is deferred. Design, Setting, and Participants This randomized, pragmatic effectiveness trial included prespecified subgroup analysis of the PRECISE trial at 65 North American and European sites. Participants identified as minimal risk by the validated PROMISE minimal risk score (PMRS) were included. Intervention Randomization to a precision strategy using the PMRS to assign those with minimal risk to deferred testing and others to coronary computed tomography angiography with selective computed tomography-derived fractional flow reserve, or to usual testing (stress testing or catheterization with PMRS masked). Randomization was stratified by PMRS risk. Main Outcome Composite of all-cause death, nonfatal myocardial infarction (MI), or catheterization without obstructive CAD through 12 months. Results Among 2103 participants, 422 were identified as minimal risk (20%) and randomized to deferred testing (n = 214) or usual testing (n = 208). Mean age (SD) was 46 (8.6) years; 304 were women (72%). During follow-up, 138 of those randomized to deferred testing never had testing (64%), whereas 76 had a downstream test (36%) (at median [IQR] 48 [15-78] days) for worsening (30%), uncontrolled (10%), or new symptoms (6%), or changing clinician preference (19%) or participant preference (10%). Results were normal for 96% of these tests. The primary end point occurred in 2 deferred testing (0.9%) and 13 usual testing participants (6.3%) (hazard ratio, 0.15; 95% CI, 0.03-0.66; P = .01). No death or MI was observed in the deferred testing participants, while 1 noncardiovascular death and 1 MI occurred in the usual testing group. Two participants (0.9%) had catheterizations without obstructive CAD in the deferred testing group and 12 (5.8%) with usual testing (P = .02). At baseline, 70% of participants had frequent angina and there was similar reduction of frequent angina to less than 20% at 12 months in both groups. Conclusion and Relevance In symptomatic participants with suspected CAD, identification of minimal risk by the PMRS guided a strategy of initially deferred testing. The strategy was safe with no observed adverse outcome events, fewer catheterizations without obstructive CAD, and similar symptom relief compared with usual testing. Trial Registration ClinicalTrials.gov Identifier: NCT03702244.
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Affiliation(s)
- James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Michelle D. Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher B. Fordyce
- Division of Cardiology, Department of Medicine, and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Robert M. Clare
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - Nick Curzen
- Faculty of Medicine, University of Southampton and Cardiothoracic Unit, University Hospital Southampton, Southampton, United Kingdom
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino Instituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, and Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, Onze Lieve Vrouwziekenhuis-Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - John P. Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, and Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Victor Marinescu
- Midwest Cardiovascular Institute, Chicago Medical School, Edward-Elmhurst Health, Naperville, Illinois
- Edward-Elmhurst Health, Naperville, Illinois
| | - Jonathon Leipsic
- Departments of Radiology and Medicine (Cardiology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Shea E. Hogan
- CPC Clinical Research, and University of Colorado School of Medicine, Aurora
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ziad A. Ali
- St Francis Hospital & Heart Center, Roslyn, New York
| | - Robert A. Byrne
- Department of Cardiology and Cardiovascular Research Institute Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Hussein R. Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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15
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Douglas PS, Nanna MG, Kelsey MD, Yow E, Mark DB, Patel MR, Rogers C, Udelson JE, Fordyce CB, Curzen N, Pontone G, Maurovich-Horvat P, De Bruyne B, Greenwood JP, Marinescu V, Leipsic J, Stone GW, Ben-Yehuda O, Berry C, Hogan SE, Redfors B, Ali ZA, Byrne RA, Kramer CM, Yeh RW, Martinez B, Mullen S, Huey W, Anstrom KJ, Al-Khalidi HR, Vemulapalli S. Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease: The PRECISE Randomized Clinical Trial. JAMA Cardiol 2023; 8:904-914. [PMID: 37610731 PMCID: PMC10448364 DOI: 10.1001/jamacardio.2023.2595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]
Abstract
Importance Trials showing equivalent or better outcomes with initial evaluation using coronary computed tomography angiography (cCTA) compared with stress testing in patients with stable chest pain have informed guidelines but raise questions about overtesting and excess catheterization. Objective To test a modified initial cCTA strategy designed to improve clinical efficiency vs usual testing (UT). Design, Setting, and Participants This was a pragmatic randomized clinical trial enrolling participants from December 3, 2018, to May 18, 2021, with a median of 11.8 months of follow-up. Patients from 65 North American and European sites with stable symptoms of suspected coronary artery disease (CAD) and no prior testing were randomly assigned 1:1 to precision strategy (PS) or UT. Interventions PS incorporated the Prospective Multicenter Imaging Study for the Evaluation of Chest Pain (PROMISE) minimal risk score to quantitatively select minimal-risk participants for deferred testing, assigning all others to cCTA with selective CT-derived fractional flow reserve (FFR-CT). UT included site-selected stress testing or catheterization. Site clinicians determined subsequent care. Main Outcomes and Measures Outcomes were clinical efficiency (invasive catheterization without obstructive CAD) and safety (death or nonfatal myocardial infarction [MI]) combined into a composite primary end point. Secondary end points included safety components of the primary outcome and medication use. Results A total of 2103 participants (mean [SD] age, 58.4 [11.5] years; 1056 male [50.2%]) were included in the study, and 422 [20.1%] were classified as minimal risk. The primary end point occurred in 44 of 1057 participants (4.2%) in the PS group and in 118 of 1046 participants (11.3%) in the UT group (hazard ratio [HR], 0.35; 95% CI, 0.25-0.50). Clinical efficiency was higher with PS, with lower rates of catheterization without obstructive disease (27 [2.6%]) vs UT participants (107 [10.2%]; HR, 0.24; 95% CI, 0.16-0.36). The safety composite of death/MI was similar (HR, 1.52; 95% CI, 0.73-3.15). Death occurred in 5 individuals (0.5%) in the PS group vs 7 (0.7%) in the UT group (HR, 0.71; 95% CI, 0.23-2.23), and nonfatal MI occurred in 13 individuals (1.2%) in the PS group vs 5 (0.5%) in the UT group (HR, 2.65; 95% CI, 0.96-7.36). Use of lipid-lowering (450 of 900 [50.0%] vs 365 of 873 [41.8%]) and antiplatelet (321 of 900 [35.7%] vs 237 of 873 [27.1%]) medications at 1 year was higher in the PS group compared with the UT group (both P < .001). Conclusions and Relevance An initial diagnostic approach to stable chest pain starting with quantitative risk stratification and deferred testing for minimal-risk patients and cCTA with selective FFR-CT in all others increased clinical efficiency relative to UT at 1 year. Additional randomized clinical trials are needed to verify these findings, including safety. Trial Registration ClinicalTrials.gov Identifier: NCT03702244.
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Affiliation(s)
- Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Michelle D. Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Christopher B. Fordyce
- Division of Cardiology, Department of Medicine, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, Cardiothoracic Unit, University Hospital Southampton, Southampton, United Kingdom
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino Instituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, Onze Lieve Vrouwziekenhuis Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - John P. Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, United Kingdom
| | - Victor Marinescu
- Midwest Cardiovascular Institute, Chicago Medical School, Edward-Elmhurst Health, Naperville, Illinois
| | - Jonathon Leipsic
- Departments of Radiology and Medicine (Cardiology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Shea E. Hogan
- CPC Clinical Research, University of Colorado School of Medicine, Aurora
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ziad A. Ali
- St Francis Hospital & Heart Center, Roslyn, New York
| | - Robert A. Byrne
- Department of Cardiology, Cardiovascular Research Institute Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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16
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Khan MS, Arshad MS, Greene SJ, Van Spall HGC, Pandey A, Vemulapalli S, Perakslis E, Butler J. Artificial intelligence and heart failure: A state-of-the-art review. Eur J Heart Fail 2023; 25:1507-1525. [PMID: 37560778 DOI: 10.1002/ejhf.2994] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/11/2023] Open
Abstract
Heart failure (HF) is a heterogeneous syndrome affecting more than 60 million individuals globally. Despite recent advancements in understanding of the pathophysiology of HF, many issues remain including residual risk despite therapy, understanding the pathophysiology and phenotypes of patients with HF and preserved ejection fraction, and the challenges related to integrating a large amount of disparate information available for risk stratification and management of these patients. Risk prediction algorithms based on artificial intelligence (AI) may have superior predictive ability compared to traditional methods in certain instances. AI algorithms can play a pivotal role in the evolution of HF care by facilitating clinical decision making to overcome various challenges such as allocation of treatment to patients who are at highest risk or are more likely to benefit from therapies, prediction of adverse outcomes, and early identification of patients with subclinical disease or worsening HF. With the ability to integrate and synthesize large amounts of data with multidimensional interactions, AI algorithms can supply information with which physicians can improve their ability to make timely and better decisions. In this review, we provide an overview of the AI algorithms that have been developed for establishing early diagnosis of HF, phenotyping HF with preserved ejection fraction, and stratifying HF disease severity. This review also discusses the challenges in clinical deployment of AI algorithms in HF, and the potential path forward for developing future novel learning-based algorithms to improve HF care.
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Affiliation(s)
| | | | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Harriette G C Van Spall
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ambarish Pandey
- Canada Population Health Research Institute, Hamilton, ON, Canada
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Sreekanth Vemulapalli
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
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17
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Arnold SV, Manandhar P, Vemulapalli S, Vekstein AM, Kosinski AS, Carroll JD, Thourani VH, Mack MJ, Cohen DJ. Mediators of Improvement in TAVR Outcomes Over Time: Insights From the STS-ACC TVT Registry. Circ Cardiovasc Interv 2023; 16:e013080. [PMID: 37357776 PMCID: PMC10527153 DOI: 10.1161/circinterventions.123.013080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/05/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Over the past decade, there has been substantial improvement in outcomes after transcatheter aortic valve replacement. Many patient and procedural factors have also changed over that time, making it challenging to untangle the drivers of those improvements. METHODS Among patients who underwent transcatheter aortic valve replacement from 2012 to 2018 within the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry, we examined the relative contribution of changes in patient factors, device modifications, improving experience/skill, and advances in periprocedural care to the observed improvement in outcomes after transcatheter aortic valve replacement. Mediator clusters included demographics, noncardiovascular comorbidities, cardiovascular comorbidities, device-related factors, and nondevice-related procedural factors. Using logistic regression, we serially adjusted for the mediator clusters to examine the contribution of each to the observed improvement in outcomes over time. RESULTS Among 161 196 patients treated with transcatheter aortic valve replacement at 596 sites, outcomes improved steadily from 2012 to 2018, including 30-day mortality (6.7% to 2.4%), 30-day composite adverse events (25.3% to 10.5%), and 1-year mortality (19.9% to 10.1%; all P<0.001). In sequential models, the unadjusted odds ratio for 30-day mortality was 0.82 per year (95% CI, 0.80-0.84), which was progressively attenuated with addition of each covariate cluster. Most of the improvement was explained by device factors and nondevice procedural factors. Results were similar for 30-day composite adverse events, although the observed temporal improvement was not fully explained by measured factors, suggesting improved technical skill as an additional mediator. In contrast to 30-day outcomes, each cluster of patient and procedural factors contributed similarly to the temporal improvement in 1-year mortality, indicating a greater impact of patient factors on longer-term outcomes. CONCLUSIONS While US patients undergoing transcatheter aortic valve replacement have become younger, healthier, and lower risk over time, the most important factors contributing to improvements in short-term outcomes relate to advances in device technology and procedural factors, whereas changing patient characteristics had a greater impact on improvement in 1-year outcomes.
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Affiliation(s)
- Suzanne V. Arnold
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO
| | | | | | | | | | | | - Vinod H. Thourani
- Marcus Heart and Valve Center, Piedmont Heart Institute, Atlanta, GA
| | | | - David J. Cohen
- St. Francis Hospital, Roslyn, NY and Cardiovascular Research Foundation, New York, NY
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18
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Nanna MG, Yow E, Vemulapalli S, Mark DB, Kelsey M, Patel MR, Al-Khalidi HR, Rogers C, Udelson JE, Douglas PS. Clinical and cost implications of deferred testing in low-risk patients with stable chest pain: a simulation using the PROMISE trial. Am Heart J 2023; 261:124-126. [PMID: 36828202 PMCID: PMC10903188 DOI: 10.1016/j.ahj.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/05/2023] [Accepted: 02/16/2023] [Indexed: 05/26/2023]
Abstract
Current guidelines recommend a deferred testing approach in low-risk patients presenting with stable chest pain. After simulating a deferred testing approach using the PROMISE Minimal Risk Score to identify 915 minimal risk participants with cost data from the PROMISE trial, a deferred testing strategy was associated with an adjusted cost savings of -$748.74 (95% CI: -1646.97, 158.06) per participant and 74.6% of samples had better clinical outcomes and lower mean cost. This supports the current guideline recommended deferred testing approach in low-risk patients with stable chest pain.
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Affiliation(s)
- Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT.
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Daniel B Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Michelle Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - James E Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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19
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Vemulapalli S, Simonato M, Ben Yehuda O, Wu C, Feldman T, Popma JJ, Sundareswaren K, Krohn C, Hardy KM, Guibone K, Christensen B, Alu MC, Ng VG, Chau KH, Chen S, Shahim B, Vincent F, MacMahon J, James S, Mack M, Leon MB, Thourani VH, Carroll J, Krucoff MW. Minimum Core Data Elements for Transcatheter Mitral Therapies: Scientific Statement by PASSION CV, HVC, and TVTR. JACC Cardiovasc Interv 2023; 16:1437-1447. [PMID: 37380225 DOI: 10.1016/j.jcin.2023.03.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 03/16/2023] [Accepted: 03/21/2023] [Indexed: 06/30/2023]
Abstract
Mitral regurgitation is the most common valvular disease and is estimated to affect over 5 million Americans. Real-world data collection contributes to safety and effectiveness evidence for the U.S. Food and Drug Administration, quality evaluation for the Centers for Medicare and Medicaid Services and hospitals, and clinical best practice research. We aimed to establish a minimum core data set in mitral interventions to promote efficient, reusable real-world data collection for all of these purposes. Two expert task forces separately evaluated and reconciled a list of candidate elements derived from: 1) 2 ongoing transcatheter mitral trials; and 2) a systemic literature review of high-impact mitral trials and U.S multicenter, multidevice registries. From 703 unique data elements considered, unanimous consensus agreement was achieved on 127 "core" data elements, with the most common reasons for exclusion from the minimum core data set being burden or difficulty in accurate assessment (41.2%), duplicative information (25.0%), and low likelihood of affecting outcomes (19.6%). After a systematic review and extensive discussions, a multilateral group of academicians, industry representatives, and regulators established and implemented into the national Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapies Registry 127 interoperable, reusable core data elements to support more efficient, consistent, and informative transcatheter mitral device evidence for regulatory submissions, safety surveillance, best practice development, and hospital quality assessments.
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Affiliation(s)
- Sreekanth Vemulapalli
- Duke University Health/Duke Clinical Research Institute, Durham, North Carolina, USA.
| | | | - Ori Ben Yehuda
- University of California San Diego, San Diego, California, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Changfu Wu
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ted Feldman
- Edwards Lifesciences, Irvine, California, USA
| | | | | | - Carole Krohn
- Society of Thoracic Surgeons, Chicago, Illinois, USA
| | | | - Kimberly Guibone
- Beth Israel Deaconness Medical Center, Boston, Massachusetts, USA
| | | | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York, USA
| | - Vivian G Ng
- Columbia University Irving Medical Center, New York, New York, USA
| | - Katherine H Chau
- Columbia University Irving Medical Center, New York, New York, USA
| | - Shmuel Chen
- Cornell Weill Medical Center/New York-Presbyterian, New York, New York, USA
| | | | | | - John MacMahon
- Mitre Medical Corporation, Morgan Hill, California, USA
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Martin B Leon
- Columbia University Irving Medical Center, New York, New York, USA
| | | | - John Carroll
- University of Colorado School of Medicine, Denver, Colorado, USA
| | - Mitchell W Krucoff
- Duke University Health/Duke Clinical Research Institute, Durham, North Carolina, USA
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20
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Makkar RR, Chikwe J, Chakravarty T, Chen Q, O’Gara PT, Gillinov M, Mack MJ, Vekstein A, Patel D, Stebbins AL, Gelijns AC, Makar M, Bhatt DL, Kapadia S, Vemulapalli S, Leon MB. Transcatheter Mitral Valve Repair for Degenerative Mitral Regurgitation. JAMA 2023; 329:1778-1788. [PMID: 37219553 PMCID: PMC10208157 DOI: 10.1001/jama.2023.7089] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/12/2023] [Indexed: 05/24/2023]
Abstract
Importance There are limited data on the outcomes of transcatheter edge-to-edge mitral valve repair for degenerative mitral regurgitation (MR) in a real-world setting. Objective To evaluate the outcomes of transcatheter mitral valve repair for degenerative MR. Design, Setting, and Participants Cohort study of consecutive patients in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry who underwent nonemergent transcatheter mitral valve repair for degenerative MR in the US from 2014 through 2022. Exposure Transcatheter edge-to-edge mitral valve repair with the MitraClip device (Abbott). Main Outcomes and Measures The primary end point was MR success, defined as moderate or less residual MR and a mean mitral gradient of less than 10 mm Hg. Clinical outcomes were evaluated based on the degree of residual MR (mild or less MR or moderate MR) and mitral valve gradients (≤5 mm Hg or >5 to <10 mm Hg). Results A total of 19 088 patients with isolated moderate to severe or severe degenerative MR who underwent transcatheter mitral valve repair were analyzed (median age, 82 years; 48% women; median Society of Thoracic Surgeons predicted risk of mortality with surgical mitral valve repair, 4.6%). MR success was achieved in 88.9% of patients. At 30 days, the incidence of death was 2.7%; stroke, 1.2%; and mitral valve reintervention, 0.97%. MR success compared with an unsuccessful procedure was associated with significantly lower mortality (14.0% vs 26.7%; adjusted hazard ratio, 0.49; 95% CI, 0.42-0.56; P < .001) and heart failure readmission (8.4% vs 16.9%; adjusted hazard ratio, 0.47; 95% CI, 0.41-0.54; P < .001) at 1 year. Among patients with MR success, the lowest mortality was observed in patients who had both mild or less residual MR and mean mitral gradients of 5 mm Hg or less compared with those with an unsuccessful procedure (11.4% vs 26.7%; adjusted hazard ratio, 0.40; 95% CI, 0.34-0.47; P < .001). Conclusions and Relevance In this registry-based study of patients with degenerative MR undergoing transcatheter mitral valve repair, the procedure was safe and resulted in successful repair in 88.9% of patients. The lowest mortality was observed in patients with mild or less residual MR and low mitral gradients.
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Affiliation(s)
- Raj R. Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joanna Chikwe
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Tarun Chakravarty
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Qiudong Chen
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | | | | | - Dhairya Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Moody Makar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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21
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Nelson AJ, Wegermann ZK, Gallup D, O’Brien S, Kosinski AS, Thourani VH, Kumbhani DJ, Kirtane A, Allen J, Carroll JD, Shahian DM, Desai ND, Brindis RG, Peterson ED, Cohen DJ, Vemulapalli S. Modeling the Association of Volume vs Composite Outcome Thresholds With Outcomes and Access to Transcatheter Aortic Valve Implantation in the US. JAMA Cardiol 2023; 8:492-502. [PMID: 37017940 PMCID: PMC10077135 DOI: 10.1001/jamacardio.2023.0477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 02/13/2023] [Indexed: 04/06/2023]
Abstract
Importance Professional societies and the Centers for Medicare & Medicaid Services suggest volume thresholds to ensure quality in transcatheter aortic valve implantation (TAVI). Objective To model the association of volume thresholds vs spoke-and-hub implementation of outcome thresholds with TAVI outcomes and geographic access. Design, Setting, and Participants This cohort study included patients who enrolled in the US Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry. Site volume and outcomes were determined from a baseline cohort of adults undergoing TAVI between July 1, 2017, and June 30, 2020. Exposures Within each hospital referral region, TAVI sites were categorized by volume (<50 or ≥50 TAVIs per year) and separately by risk-adjusted outcome on the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy 30-day TAVI composite during the baseline period (July 2017 to June 2020). Outcomes of patients undergoing TAVIs from July 1, 2020, to March 31, 2022, were then modeled as though the patients had been treated at (1) the nearest higher volume (≥50 TAVIs per year) or (2) the best outcome site within the hospital referral region. Main Outcomes and Measures The primary outcome was the absolute difference in events between the adjusted observed and modeled 30-day composite of death, stroke, major bleeding, stage III acute kidney injury, and paravalvular leak. Data are presented as the number of events reduced under the above scenarios with 95% bayesian credible intervals (CrIs) and median (IQR) driving distance. Results The overall cohort included 166 248 patients with a mean (SD) age of 79.5 (8.6) years; 74 699 (47.3%) were female and 6657 (4.2%) were Black; 158 025 (95%) were treated in higher-volume sites (≥50 TAVIs) and 75 088 (45%) were treated in best-outcome sites. Modeling a volume threshold, there was no significant reduction in estimated adverse events (-34; 95% CrI, -75 to 8), while the median (IQR) driving time from the existing site to the alternate site was 22 (15-66) minutes. Transitioning care to the best outcome site in a hospital referral region resulted in an estimated 1261 fewer adverse outcomes (95% CrI, 1013-1500), while the median (IQR) driving time from the original site to the best site was 23 (15-41) minutes. Directionally similar findings were observed for Black individuals, Hispanic individuals, and individuals from rural areas. Conclusions and Relevance In this study, compared with the current system of care, a modeled outcome-based spoke-and-hub paradigm of TAVI care improved national outcomes to a greater extent than a simulated volume threshold, at the cost of increased driving time. To improve quality while maintaining geographic access, efforts should focus on reducing site variation in outcomes.
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Affiliation(s)
- Adam J. Nelson
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Dianne Gallup
- Duke Clinical Research Institute, Durham, North Carolina
| | - Sean O’Brien
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | - Dharam J. Kumbhani
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Ajay Kirtane
- Department of Medicine, Columbia University, New York, New York
- Cardiovascular Research Foundation, New York, New York
- Associate Editor, JAMA Cardiology
| | - Joseph Allen
- American College of Cardiology, Gaithersburg, Maryland
| | - John D. Carroll
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora
| | - David M. Shahian
- Division of Cardiac Surgery and Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Nimesh D. Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia
| | - Ralph G. Brindis
- Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco
| | - Eric D. Peterson
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, New York
- St Francis Hospital, Roslyn, New York
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22
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Rao VN, Giczewska A, Chiswell K, Felker GM, Wang A, Glower DD, Gaca JG, Parikh KS, Vemulapalli S. Long-term outcomes of phenoclusters in severe tricuspid regurgitation. Eur Heart J 2023:7078718. [PMID: 36924209 DOI: 10.1093/eurheartj/ehad133] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 01/24/2023] [Accepted: 02/20/2023] [Indexed: 03/18/2023] Open
Abstract
AIMS Severe tricuspid regurgitation (TR) exhibits high 1-year morbidity and mortality, yet long-term cardiovascular risk overall and by subgroups remains unknown. This study characterizes 5-year outcomes and identifies distinct clinical risk profiles of severe TR. METHODS AND RESULTS Patients were included from a large US tertiary referral center with new severe TR by echocardiography based on four-category American Society of Echocardiography grading scale between 2007 and 2018. Patients were categorized by TR etiology (with lead present, primary, and secondary) and by supervised recursive partitioning (survival trees) for outcomes of death and the composite of death or heart failure hospitalization. The Kaplan-Meier estimates and Cox regression models were used to evaluate any association by (i) TR etiology and (ii) groups identified by survival trees and outcomes over 5 years. Among 2379 consecutive patients with new severe TR, median age was 70 years, 61% were female, and 40% were black. Event rates (95% confidence interval) were 30.9 (29.0-32.8) events/100 patient-years for death and 49.0 (45.9-52.2) events/100 patient-years for the composite endpoint, with no significant difference by TR etiology. After applying supervised survival tree modeling, two separate groups of four phenoclusters with distinct clinical prognoses were separately identified for death and the composite endpoint. Variables discriminating both outcomes were age, albumin, blood urea nitrogen, right ventricular function, and systolic blood pressure (all P < 0.05). CONCLUSION Patients with newly identified severe TR have high 5-year risk for death and death or heart failure hospitalization. Partitioning patients using supervised survival tree models, but not TR etiology, discriminated clinical risk. These data aid in identifying relevant subgroups in clinical trials of TR and clinical risk/benefit analysis for TR therapies.
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Affiliation(s)
- Vishal N Rao
- Division of Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA.,Duke Clinical Research Institute, Duke University School of Medicine, 300 W Morgan Street, Durham, NC 27701, USA
| | - Anna Giczewska
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W Morgan Street, Durham, NC 27701, USA
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W Morgan Street, Durham, NC 27701, USA
| | - G Michael Felker
- Division of Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA.,Duke Clinical Research Institute, Duke University School of Medicine, 300 W Morgan Street, Durham, NC 27701, USA
| | - Andrew Wang
- Division of Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Donald D Glower
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Kishan S Parikh
- Division of Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA.,Duke Clinical Research Institute, Duke University School of Medicine, 300 W Morgan Street, Durham, NC 27701, USA
| | - Sreekanth Vemulapalli
- Division of Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
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23
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Duran J, Rao V, Giczewska A, Chiswell KE, Felker GM, Wang A, Glower DD, Gaca J, Parikh KS, Vemulapalli S. BEDSIDE RISK PREDICTION OF ADVERSE OUTCOMES IN MEDICALLY TREATED PATIENTS WITH SEVERE TRICUSPID REGURGITATION. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02417-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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24
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Lowenstern AM, Vekstein AM, Grau-Sepulveda M, Badhwar V, Thourani VH, Cohen DJ, Sorajja P, Goel K, Barker CM, Lindman BR, Glower DG, Wang A, Vemulapalli S. Impact of Transcatheter Mitral Valve Repair Availability on Volume and Outcomes of Surgical Repair. J Am Coll Cardiol 2023; 81:521-532. [PMID: 36754512 PMCID: PMC10464889 DOI: 10.1016/j.jacc.2022.11.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/31/2022] [Accepted: 11/07/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND The impact of transcatheter edge-to-edge repair (TEER) on national surgical mitral valve repair (MVr) volume and outcomes is unknown. OBJECTIVES This study aims to assess the impact of TEER availability on MVr volumes and outcomes for degenerative mitral regurgitation. METHODS MVr volume, 30-day and 5-year outcomes, including mortality, heart failure rehospitalization and mitral valve reintervention, were obtained from the Society of Thoracic Surgeons database linked with Medicare administrative claims and were compared within TEER centers before and after the first institutional TEER procedure. A difference-in-difference approach comparing parallel trends in coronary artery bypass grafting outcomes was used to account for temporal improvements in perioperative care. RESULTS From July 2011 through December 2018, 13,959 patients underwent MVr at 278 institutions, which became TEER-capable during the study period. There was no significant change in median annualized institutional MVr volume before (32 [IQR: 17-54]) vs after (29 [IQR: 16-54]) the first TEER (P = 0.06). However, higher-risk (Society of Thoracic Surgeons predicted risk of mortality ≥2%) MVr procedures declined over the study period (P < 0.001 for trend). The introduction of TEER was associated with reduced risk-adjusted odds of mortality after MVr at 30 days (adjusted OR: 0.73; 95% CI: 0.54-0.99) and over 5 years (adjusted HR: 0.75; 95% CI: 0.66-0.86). These improvements in 30-day and 5-year mortality were significantly greater than equivalent trends in coronary artery bypass grafting. CONCLUSIONS The introduction of TEER has not significantly changed overall MVr case volumes for degenerative mitral regurgitation but is associated with a decrease in higher-risk surgical operations and improved 30-day and 5-year outcomes within institutions adopting the technology.
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Affiliation(s)
- Angela M Lowenstern
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA. https://twitter.com/A_Lowenstern
| | - Andrew M Vekstein
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | | | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Heart and Vascular Center, Piedmont Heart and Vascular Institute, Atlanta, Georgia, USA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA; St Francis Hospital and Heart Center, Roslyn, New York, USA
| | - Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Kashish Goel
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Colin M Barker
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brian R Lindman
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Donald G Glower
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrew Wang
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, USA
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25
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Jawitz OK, Vekstein AM, Young R, Vemulapalli S, Zwischenberger BA, Thibault DP, O'Brien S, Shahian DM, Badhwar V, Thourani VH, Jacobs JP, Smith PK. Comparing Consumer-Directed Hospital Rankings With STS Adult Cardiac Surgery Database Outcomes. Ann Thorac Surg 2023; 115:533-540. [PMID: 35932793 DOI: 10.1016/j.athoracsur.2022.06.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Public interest in stratifying hospital performance has led to the proliferation of commercial, consumer-oriented hospital rankings. In cardiac surgery, little is known about how these rankings correlate with clinical registry quality ratings. METHODS The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was queried for isolated coronary artery bypass grafting or coronary artery bypass grafting/valve patients at hospitals among the top 100 U.S. News & World Report (USNWR) Cardiology & Heart Surgery rankings from 2016 to 2020. Hospitals were grouped into deciles by risk-adjusted observed/expected (O/E) ratios for morbidity and mortality using the STS 2018 risk models. Agreement between STS Adult Cardiac Surgery Database and USNWR ranked deciles was calculated by Bowker symmetry test. The association between each center's annual change in STS O/E ratio and change in USNWR ranking was modeled in repeated measures regression analysis. RESULTS Inclusion criteria were met by 524 393 patients from 149 hospitals that ranked in USNWR top 100 at least once during the study period. There was no agreement between USNWR ranking and STS major morbidity and mortality O/E ratio (P > .50 for all years). Analysis of patients undergoing surgery at the 65 hospitals that were consistently ranked in the top 100 during the study period demonstrated no association between annual change in hospital ranking and change in O/E ratio (P all > .3). CONCLUSIONS There was no agreement between annual USNWR hospital ranking and corresponding risk-adjusted STS morbidity or mortality. Furthermore, annual changes in USNWR rankings could not be accounted for using clinical outcomes. These findings suggest that factors unrelated to key surgical outcomes may be driving consumer-directed rankings.
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Affiliation(s)
- Oliver K Jawitz
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University, Durham, North Carolina; Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina.
| | - Andrew M Vekstein
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University, Durham, North Carolina; Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Rebecca Young
- Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina; Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
| | - Brittany A Zwischenberger
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University, Durham, North Carolina; Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Dylan P Thibault
- Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Sean O'Brien
- Department of Medicine, Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - David M Shahian
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Piedmont Heart Institute, Atlanta, Georgia
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, Florida
| | - Peter K Smith
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University, Durham, North Carolina
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26
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Weissler EH, Osazuwa-Peters OL, Greiner MA, Hardy NC, Kougias P, O’Brien SM, Mark DB, Jones WS, Secemsky EA, Vekstein AM, Shalhub S, Mussa FF, Patel MR, Vemulapalli S. Initial Thoracic Endovascular Aortic Repair vs Medical Therapy for Acute Uncomplicated Type B Aortic Dissection. JAMA Cardiol 2023; 8:44-53. [PMID: 36334259 PMCID: PMC9637274 DOI: 10.1001/jamacardio.2022.4187] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/30/2022] [Indexed: 11/07/2022]
Abstract
Importance Thoracic endovascular aortic repair (TEVAR) has increasingly been used for uncomplicated type B aortic dissection (uTBAD) despite limited supporting data. Objective To assess whether initial TEVAR following uTBAD is associated with reduced mortality or morbidity compared with medical therapy alone. Design, Setting, and Participants This cohort study included Centers for Medicare & Medicaid Services inpatient claims data for adults aged 65 years or older with index admissions for acute uTBAD from January 1, 2011, to December 31, 2018, with follow-up available through December 31, 2019. Exposures Initial TEVAR was defined as TEVAR within 30 days of admission for acute uTBAD. Main Outcomes and Measures Outcomes included all-cause mortality, cardiovascular hospitalizations, aorta-related and repeated aorta-related hospitalizations, and aortic interventions associated with initial TEVAR vs medical therapy. Propensity score inverse probability weighting was used. Results Of 7105 patients with eligible index admissions for acute uTBAD, 1140 (16.0%) underwent initial TEVAR (623 [54.6%] female; median age, 74 years [IQR, 68-80 years]) and 5965 (84.0%) did not undergo TEVAR (3344 [56.1%] female; median age, 76 years [IQR, 69-83 years]). Receipt of TEVAR was associated with region (vs South; Midwest: adjusted odds ratio [aOR], 0.66 [95% CI, 0.53-0.81]; P < .001; Northeast: aOR, 0.63 [95% CI, 0.50-0.79]; P < .001), Medicaid dual eligibility (aOR, 0.76; 95% CI, 0.63-0.91; P = .003), hypertension (aOR, 1.26; 95% CI, 1.03-1.54; P = .03), peripheral vascular disease (aOR, 1.24; 95% CI, 1.02-1.49; P = .03), and year of admission (2012, 2013, 2014, and 2015 were associated with greater odds of TEVAR compared with 2011). After inverse probability weighting, mortality was similar for the 2 strategies up to 5 years (hazard ratio [HR], 0.95; 95% CI, 0.85-1.06), as were aorta-related hospitalizations (HR, 1.12; 95% CI, 0.99-1.27), aortic interventions (HR, 1.01; 95% CI, 0.84-1.20), and cardiovascular hospitalizations (HR, 1.05; 95% CI, 0.93-1.20). In a sensitivity analysis that included deaths within the first 30 days, initial TEVAR was associated with lower mortality over a period of 1 year (adjusted HR [aHR], 0.86; 95% CI, 0.75-0.99; P = .03), 2 years (aHR, 0.85; 95% CI, 0.75-0.96; P = .008), and 5 years (aHR, 0.87; 95% CI, 0.80-0.96; P = .004). Conclusions and Relevance In this study, 16.0% of patients underwent initial TEVAR within 30 days of uTBAD, and receipt of initial TEVAR was associated with hypertension, peripheral vascular disease, region, Medicaid dual eligibility, and year of admission. Initial TEVAR was not associated with improved mortality or reduced hospitalizations or aortic interventions over a period of 5 years, but in a sensitivity analysis that included deaths within the first 30 days, initial TEVAR was associated with lower mortality. These findings, along with cost-effectiveness and quality of life, should be assessed in a prospective trial in the US population.
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Affiliation(s)
- E. Hope Weissler
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Melissa A. Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - N. Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Panagiotis Kougias
- Division of Vascular and Endovascular Surgery, SUNY Downstate Health Sciences University, Brooklyn, New York
| | | | - Daniel B. Mark
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - W. Schuyler Jones
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Eric A. Secemsky
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Andrew M. Vekstein
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Sherene Shalhub
- Division of Vascular Surgery, University of Washington, Seattle
| | - Firas F. Mussa
- Section of Vascular Surgery, Imperial College London, London, England
| | - Manesh R. Patel
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke University Medical Center, Durham, North Carolina
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27
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Friedman DJ, Pierre D, Wang Y, Gambone L, Koutras C, Segawa C, Farb A, Vemulapalli S, Varosy PD, Masoudi FA, Lansky A, Curtis JP, Freeman JV. Development and validation of an automated algorithm for end point adjudication for a large U.S. national registry. Am Heart J 2022; 254:102-111. [PMID: 36007567 DOI: 10.1016/j.ahj.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 08/14/2022] [Accepted: 08/17/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Clinical events committee (CEC) evaluation is the standard approach for end point adjudication in clinical trials. Due to resource constraints, large registries typically rely on site-reported end points without further confirmation, which may preclude use for regulatory oversight. METHODS We developed a novel automated adjudication algorithm (AAA) for end point adjudication in the National Cardiovascular Data Registry Left Atrial Appendage Occlusion (LAAO) Registry using an iterative process using CEC adjudication as the "gold standard." A ≥80% agreement rate between automated algorithm adjudication and CEC adjudication was prespecified as clinically acceptable. Agreement rates were calculated. RESULTS A total of 92 in-hospital and 127 post-discharge end points were evaluated between January 1, 2016 and June 30, 2019 using AAA and CEC. Agreement for neurologic events was >90%. Percent agreement for in-hospital and post-discharge events was as follows: ischemic stroke 95.7% and 94.5%, hemorrhagic stroke 97.8% and 96.1%, undetermined stroke 97.8% and 99.2%, transient ischemic attack 98.9% and 98.4% and intracranial hemorrhage 100.0% and 94.5%. Agreement was >80% for major bleeding (83.7% and 90.6%) and major vascular complication (89.1% and 97.6%). With this approach, <1% of site reported end points require CEC adjudication. Agreement remained very good during the period after algorithm derivation. CONCLUSIONS An AAA-guided approach for end point adjudication was successfully developed and validated for the LAAO Registry. With this approach, the need for formal CEC adjudication was substantially reduced, with accuracy maintained above an 80% agreement threshold. After application specific validation, these methods could be applied to large registries and clinical trials to reduce the cost of event adjudication while preserving scientific validity.
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Affiliation(s)
- Daniel J Friedman
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT; Duke Clinical Research Institute, Durham, NC
| | - Dominique Pierre
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Yongfei Wang
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT; Yale Cardiovascular Research Group, Yale University School of Medicine, New Haven, CT
| | - Louise Gambone
- Yale Cardiovascular Research Group, Yale University School of Medicine, New Haven, CT
| | | | | | - Andrew Farb
- U.S. Food and Drug Administration, Silver Spring, MD
| | | | - Paul D Varosy
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO; VA Eastern Colorado Health Care System, Aurora, CO
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO; Ascension Health, St. Louis, MO
| | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT; Yale Cardiovascular Research Group, Yale University School of Medicine, New Haven, CT
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT.
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28
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Rao V, Giczewska A, Chiswell K, Felker GM, Wang A, Parikh K, Vemulapalli S. Clinical outcomes among distinct groups of patients with severe tricuspid valve regurgitation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Severe tricuspid valve regurgitation (TR) is associated with increased 1-year morbidity and mortality. Characterization by valve etiology (primary, secondary, and lead-associated), a classification borrowed from mitral valve disease, has not been universally shown to correlate with outcomes.
Purpose
Among a large, racially diverse cohort with newly identified severe TR, we aimed to 1) characterize outcomes of severe TR by etiology, and 2) assess whether unsupervised phenoclustering or supervised outcome-driven prediction trees were more effective in establishing subgroups of TR with differential clinical risk profiles.
Methods
We retrospectively analyzed outcomes of 5-year all-cause death and a composite of death or heart failure hospitalization (HFH) among adult patients with new severe TR identified by echocardiography between 2007 to 2018 at a large academic tertiary referral center in the United States. Patients were initially categorized by etiology of TR, including primary, secondary, and lead-associated. Second, we separately applied unsupervised hierarchical clustering to identify distinct clusters using demographics, clinical, and echo data at the time of diagnosis. Third, we applied a supervised recursive partitioning algorithm (survival trees) by each outcome to identify distinct TR subgroups. We estimated the cumulative incidence of death and composite death or HFH over 5 years by 1) etiology of TR, 2) distinct clusters, and 3) groups identified by supervised learning (prediction trees).
Results
Among 2,379 consecutive patients with newly identified severe TR, the median age was 70 years, 61% were female, and 40% were Black. Event rates (95% CI) were 30.9 (29.0 to 32.8) events/100 PY for death and 49.0 (45.9 to 52.2) events/100 PY for composite death or HFH over median follow-up of 1.6 years. Event rates were similarly high across TR etiology groups for both death and composite death or HFH (Figure 1). Multiple methods of unsupervised clustering did not yield distinct clusters by patient demographic and imaging characteristics. After applying supervised survival tree modeling, four phenoclusters with distinct clinical prognoses were separately identified for death and composite death or HFH (Figure 2). Variables identified to partition the cohort to discriminate both death and composite death or HFH were age, albumin, blood urea nitrogen, right ventricular contractility, and right ventricular systolic pressure (all p<0.05).
Conclusions
Five-year cumulative incidence of adverse events among patients with newly diagnosed severe TR was 69% for death and 80% for composite death or HFH. TR etiology did not stratify prognosis, while supervised survival tree models identified phenoclusters with distinct clinical risk. The identified subgroups of severe TR with differential outcomes offer insights towards enrichment in clinical trials of TR and risk/benefit analysis in patients undergoing TR therapies.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Abbott
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Affiliation(s)
- V Rao
- Duke Clinical Research Institute , Durham , United States of America
| | - A Giczewska
- Duke Clinical Research Institute , Durham , United States of America
| | - K Chiswell
- Duke Clinical Research Institute , Durham , United States of America
| | - G M Felker
- Duke Clinical Research Institute , Durham , United States of America
| | - A Wang
- Duke University Medical Center , Durham , United States of America
| | - K Parikh
- Duke Clinical Research Institute , Durham , United States of America
| | - S Vemulapalli
- Duke University Medical Center , Durham , United States of America
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29
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Kaneko T, Hirji SA, Yazdchi F, Sun YP, Nyman C, Shook D, Cohen DJ, Stebbins A, Zeitouni M, Vemulapalli S, Thourani VH, Shah PB, O'Gara P. Association Between Peripheral Versus Central Access for Alternative Access Transcatheter Aortic Valve Replacement and Mortality and Stroke: A Report From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Circ Cardiovasc Interv 2022; 15:e011756. [PMID: 36126131 DOI: 10.1161/circinterventions.121.011756] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In some patients, the alternative access route for transcatheter aortic valve replacement (TAVR) is utilized because the conventional transfemoral approach is not felt to be either feasible or optimal. However, accurate prognostication of patient risks is not well established. This study examines the associations between peripheral (transsubclavian/transaxillary, and transcarotid) versus central access (transapical and transaortic) in alternative access TAVR and 30-day and 1-year end points of mortality and stroke for all valve platforms. METHODS Using data from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry with linkage to Medicare claims, patients who underwent alternative access TAVR from June 1, 2015 to June 30, 2018 were identified. Adjusted and unadjusted Cox proportional hazards modeling were performed to determine the association between alternate access TAVR site and 30-day and 1-year end points of mortality and stroke. RESULTS Of 7187 alternative access TAVR patients, 3725 (52%) had peripheral access and 3462 (48%) had central access. All-cause mortality was significantly lower in peripheral access versus central access group at in-hospital and 1 year (2.9% versus 6.3% and 20.3% versus 26.6%, respectively), but stroke rates were higher (5.0% versus 2.8% and 7.3% versus 5.5%, respectively; all P<0.001). These results persisted after 1-year adjustment (death adjusted hazard ratio, 0.72 [95% CI, 0.62-0.85] and stroke adjusted hazard ratio, 2.92 [95% CI, 2.21-3.85]). When broken down by individual subtypes, compared with transaxillary/subclavian access patients, transapical, and transaortic access patients had higher all-cause mortality but less stroke (P<0.05). CONCLUSIONS In this real-world, contemporary, nationally representative benchmarking study of alternate access TAVR sites, peripheral access was associated with favorable mortality and morbidity outcomes compared with central access, at the expense of higher stroke. These findings may allow for accurate prognostication of risk for patient counseling and decision-making for the heart team with regard to alternative access TAVR.
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Affiliation(s)
- Tsuyoshi Kaneko
- Division of Thoracic and Cardiac Surgery (T.K., S.H., F.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sameer A Hirji
- Division of Thoracic and Cardiac Surgery (T.K., S.H., F.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Farhang Yazdchi
- Division of Thoracic and Cardiac Surgery (T.K., S.H., F.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yee-Ping Sun
- Division of Cardiovascular Medicine (Y.P.S., P.S., P.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Charles Nyman
- Division of Cardiac Anesthesia (C.N., D.S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Douglas Shook
- Division of Cardiac Anesthesia (C.N., D.S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, NY (D.J.C.).,Duke Clinical Research Institute, Durham, NC (D.J.C.)
| | | | | | | | | | - Pinak B Shah
- Division of Cardiovascular Medicine (Y.P.S., P.S., P.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Patrick O'Gara
- Division of Cardiovascular Medicine (Y.P.S., P.S., P.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Drescher CS, Kelsey MD, Yankey GS, Sun AY, Wang A, Sadeghpour A, Glower DD, Vemulapalli S, Kelsey AM. Imaging Considerations and Clinical Implications of Mitral Annular Disjunction. Circ Cardiovasc Imaging 2022; 15:e014243. [PMID: 36126123 DOI: 10.1161/circimaging.122.014243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Mitral annular disjunction is increasingly recognized as an important anatomic feature of mitral valve disease. The presence of mitral annular disjunction, defined as separation between the left atrial wall at the point of mitral valve insertion and the left ventricular free wall, has been associated with increased degeneration of the mitral valve and increased incidence of sudden cardiac death. The clinical importance of this entity necessitates standard reporting on cardiovascular imaging reports if patients are to receive adequate risk stratification and management. We provide a narrative review of the literature pertaining to mitral annular disjunction, its clinical implications, and areas needing further research.
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Affiliation(s)
- Caitlin S Drescher
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
| | - Michelle D Kelsey
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
| | - George S Yankey
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
| | - Albert Y Sun
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
| | - Andrew Wang
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
| | - Anita Sadeghpour
- Medstar Health Research Institute, Washington, D.C. (A.S.).,Duke Cardiovascular MR Center, Durham, NC (A.S.)
| | - Donald D Glower
- Department of Surgery, Duke University, Durham, North Carolina (D.D.G.)
| | - Sreekanth Vemulapalli
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
| | - Anita M Kelsey
- Division of Cardiology, Duke University, Durham, North Carolina (C.S.D., M.D.K., G.S.Y., A.Y.S., A.W., S.V., A.M.K.)
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Lowenstern A, Hung A, Manandhar P, Wegermann ZK, Kapadia SR, Lindman BR, Goel K, Levack M, Barker CM, Reed SD, Cohen DJ, Vemulapalli S. Association of Transcatheter Aortic Valve Replacement Reimbursement, New Technology Add-on Payment, and Procedure Volumes With Embolic Protection Device Use. JAMA Cardiol 2022; 7:945-952. [PMID: 35976635 PMCID: PMC9386613 DOI: 10.1001/jamacardio.2022.2608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/01/2022] [Indexed: 11/14/2022]
Abstract
Importance In the setting of uncertain efficacy and additional, unreimbursed cost, use of an embolic protection device (EPD) during transcatheter aortic valve replacement (TAVR) has had variable uptake. The Centers for Medicare & Medicaid Services (CMS) instituted a new technology add-on payment to cover EPD use in October 2018. Objective To evaluate the association between CMS TAVR reimbursement rates and EPD use. Design, Setting, and Participants This cohort study used the Society for Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry to identify patients who underwent TAVR between January 2018 and September 2019. Analysis took place between July 2020 and February 2022. Main Outcomes and Measures The association between EPD use and CMS reimbursement was assessed using multivariable logistic regression models adjusted for patient characteristics (model 1) and patient/hospital (annualized TAVR volume and teaching status) characteristics (model 2). Results Among 511 institutions, CMS reimbursement for TAVR ranged from $28 062 to $111 280 with a median (IQR) of $45 884 ($40 331-$53 627). Among 84 353 patients (median [IQR] age, 81.0 [75.0-86.0] years; 46 247 male individuals [54.8%]; 3958 [4.7%] of Hispanic or Latino ethnicity; 78 170 White individuals [92.7%]) treated at the sites, 6012 (7.1%) underwent TAVR with EPD. Patient characteristics associated with EPD use included prior stroke (adjusted odds ratio [aOR], 1.13 [95% CI, 1.00-1.27]; P = .048), female sex (aOR, 0.85 [95% CI, 0.78-0.93]; P < .001), hemodialysis (aOR, 0.52 [95% CI, 0.40-0.68]; P < .001), and shock (aOR, 0.62 [95% CI, 0.41-0.94]; P = .03). Higher CMS reimbursement up to $50 000 per TAVR was associated with greater likelihood of EPD use in model 1 (per $1000; aOR, 1.08 [95% CI, 1.01-1.16]; P = .02). However, this association was no longer apparent after adjusting for site characteristics (model 2; aOR, 1.03 [95% CI, 0.96-1.11]; P = .38). Higher TAVR volume was associated with increased EPD use (per 25 TAVRs; aOR, 1.15 [95% CI, 1.09-1.21]; P < .001). There was no significant change in the odds of EPD uptake before vs after institution of the CMS new technology add-on payment across tertiles of CMS TAVR reimbursement (Wald χ2 = 3.59; P = .17). Conclusions and Relevance EPD use during TAVR remains infrequent and is associated with multiple patient and site characteristics. While CMS reimbursement varies significantly across institutions, TAVR case volume, rather than CMS TAVR reimbursement or the CMS new technology add-on payment, appears to be the predominant factor associated with EPD use. Ongoing work is needed to understand the economic drivers that contribute to the association between procedural volume and EPD use.
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Affiliation(s)
- Angela Lowenstern
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna Hung
- Duke Clinical Research Institute, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | | | - Zachary K. Wegermann
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Samir R. Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian R. Lindman
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kashish Goel
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Colin M. Barker
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shelby D. Reed
- Duke Clinical Research Institute, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, New York
- St Francis Hospital and Heart Center, Roslyn, New York
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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Chew DS, Zhou K, Pokorney SD, Matchar DB, Vemulapalli S, Allen LA, Jackson KP, Samad Z, Patel MR, Freeman JV, Piccini JP. Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation : A Decision Analysis. Ann Intern Med 2022; 175:1230-1239. [PMID: 35969865 DOI: 10.7326/m21-4653] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) is a potential alternative to oral anticoagulants in selected patients with atrial fibrillation (AF). Compared with anticoagulants, LAAO decreases major bleeding risk, but there is uncertainty regarding the risk for ischemic stroke compared with anticoagulation. OBJECTIVE To determine the optimal strategy for stroke prevention conditional on a patient's individual risks for ischemic stroke and bleeding. DESIGN Decision analysis with a Markov model. DATA SOURCES Evidence from the published literature informed model inputs. TARGET POPULATION Women and men with nonvalvular AF and without prior stroke. TIME HORIZON Lifetime. PERSPECTIVE Clinical. INTERVENTION LAAO versus warfarin or direct oral anticoagulants (DOACs). OUTCOME MEASURES The primary end point was clinical benefit measured in quality-adjusted life-years. RESULTS OF BASE-CASE ANALYSIS The baseline risks for stroke and bleeding determined whether LAAO was preferred over anticoagulants in patients with AF. The combined risks favored LAAO for higher bleeding risk, but that benefit became less certain at higher stroke risks. For example, at a HAS-BLED score of 5, LAAO was favored in more than 80% of model simulations for CHA2DS2-VASc scores between 2 and 5. The probability of LAAO benefit in QALYs (>80%) at lower bleeding risks (HAS-BLED score of 0 to 1) was limited to patients with lower stroke risks (CHA2DS2-VASc score of 2). Because DOACs carry lower bleeding risks than warfarin, the net benefit of LAAO is less certain than that of DOACs. RESULTS OF SENSITIVITY ANALYSIS Results were consistent using the ORBIT bleeding score instead of the HAS-BLED score, as well as alternative sources for LAAO clinical effectiveness data. LIMITATION Clinical effectiveness data were drawn primarily from studies on the Watchman device. CONCLUSION Although LAAO could be an alternative to anticoagulants for stroke prevention in patients with AF and high bleeding risk, the overall benefit from LAAO depends on the combination of stroke and bleeding risks in individual patients. These results suggest the need for a sufficiently low stroke risk for LAAO to be beneficial. The authors believe that these results could improve shared decision making when selecting patients for LAAO. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada (D.S.C.)
| | - Ke Zhou
- Duke-National University of Singapore Medical School, Singapore (K.Z.)
| | - Sean D Pokorney
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - David B Matchar
- Duke-National University of Singapore Medical School, Singapore, and Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina (D.B.M.)
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - Larry A Allen
- University of Colorado School of Medicine, Aurora, Colorado (L.A.A.)
| | - Kevin P Jackson
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina (K.P.J.)
| | - Zainab Samad
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, and Department of Medicine, Aga Khan University, Karachi, Pakistan (Z.S.)
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - James V Freeman
- Yale University School of Medicine, New Haven, Connecticut (J.V.F.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
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Riad FS, Grau-Sepulveda M, Jawitz OK, Vekstein AM, Sundaram V, Sahadevan J, Habib RH, Jacobs JP, O’Brien S, Thourani VH, Vemulapalli S, Xian Y, Waldo AL, Sabik J. Anticoagulation in new-onset postoperative atrial fibrillation: An analysis from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Heart Rhythm O2 2022; 3:325-332. [PMID: 36097451 PMCID: PMC9463707 DOI: 10.1016/j.hroo.2022.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background New-onset postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery and is associated with increased long-term stroke and mortality. Anticoagulation has been suggested as a potential therapy, but data on safety and efficacy are scant. Objectives To determine the association between anticoagulation for POAF and long-term outcomes. Methods Adult patients with POAF after isolated coronary artery bypass surgery (CABG) were identified through the Society of Thoracic Surgeons Adult Cardiac Surgery Database and linked to the Medicare Database. Propensity-matched analyses were performed for all-cause mortality, stroke, myocardial infarction, and major bleeding for patients discharged with or without anticoagulation. Interaction between anticoagulation and CHA2DS2-VASc score was also assessed. Results Of 38,936 patients, 9861 (25%) were discharged on oral anticoagulation. After propensity score matching, discharge anticoagulation was associated with increased mortality (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.06–1.26). There was no difference in ischemic stroke between groups (HR 0.97, 95% CI 0.82–1.15), but there was significantly higher bleeding (HR 1.60, 95% CI 1.38–1.85) among those discharged on anticoagulation. Myocardial infarction was lower in the first 30 days for those discharged on anticoagulation, but this effect decreased over time. The incidence of all complications was higher for patients with CHA2DS2-VASc scores ≥5 compared to patients with scores of 2–4. Anticoagulation did not appear to benefit either subgroup. Conclusion Anticoagulation is associated with increased mortality after new-onset POAF following CABG. There was no reduction in ischemic stroke among those discharged on anticoagulation regardless of CHA2DS2-VASc score.
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Attar R, Wu A, Wojdyla D, Jensen SE, Andell P, Mahaffey KW, Roe MT, James SK, Wallentin L, Vemulapalli S, Alexander JH, Lopes RD, Ohman EM, Hernandez AF, Patel MR, Jones WS. Outcomes After Acute Coronary Syndrome in Patients With Diabetes Mellitus and Peripheral Artery Disease (from the TRACER, TRILOGY-ACS, APPRAISE-2, and PLATO Clinical Trials). Am J Cardiol 2022; 178:11-17. [PMID: 35835600 DOI: 10.1016/j.amjcard.2022.04.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 11/18/2022]
Abstract
Patients with acute coronary syndrome (ACS) are at risk for recurrent adverse events, and multiple reports suggest that this risk is increased in patients with concomitant diabetes mellitus (DM) and peripheral artery disease (PAD). The aim of this article was to investigate cardiovascular outcomes in patients with DM presenting with ACS, stratified by PAD status. Data were derived from 4 randomized post-ACS trials (PLATO [Platelet Inhibition and Patient Outcomes], APPRAISE-2 p Apixaban for Prevention of Acute Ischemic Events 2], TRILOGY [Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage], and TRACER [Thrombin Receptor Agonist for Clinical Event Reduction in Acute Coronary Syndrome]). Using Cox regression analysis, we investigated major adverse cardiovascular events (MACEs), a composite of cardiovascular mortality, myocardial infarction (MI), or stroke and the individual components of MACE and all-cause mortality in patients with DM, presenting with ACS, stratified by PAD status as the risk modifier. This study included 15,387 patients with a diagnosis of DM and ACS, of whom 1,751 had an additional diagnosis of PAD. PAD was associated with more than doubled rates of MACE (hazard ratio [HR] 2.03, 95% confidence interval [CI] 1.81 to 2.27), all-cause mortality (HR 2.48, 95% CI 2.14 to 2.87), cardiovascular mortality (HR 2.42, 95% CI 2.04 to 2.86), and MI (HR 2.07, 95% CI 1.79 to 2.38). Patients with both PAD and DM were also more optimally treated with antihypertensive, antidiabetic, and statin medication at baseline. In conclusion, this analysis of 4 major post-ACS trials showed that patients with DM and PAD had a substantially higher risk of MACE, cardiovascular mortality, all-cause mortality, and MI despite being optimally treated with guideline-based therapies.
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Affiliation(s)
- Rubina Attar
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Department of Cardiology and Clinical Sciences, Lund University, Sweden.
| | - Angie Wu
- Duke Clinical Research Institute, Durham, North Carolina
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Pontus Andell
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Division, Karolinska University Hospital, Stockholm, Sweden
| | | | - Matthew T Roe
- Duke Clinical Research Institute, Durham, North Carolina
| | - Stefan K James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Sweden
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Sweden
| | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Durham, North Carolina
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Manesh R Patel
- Duke Clinical Research Institute, Durham, North Carolina
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Barnes JA, Eid MA, Moore K, Aryal S, Gebre E, Woodard JN, Kitpanit N, Mao J, Kuwayama DP, Suckow BD, Schneider D, Abushaikha T, Zusterzeel R, Vemulapalli S, Shenkman EA, Williams J, Sedrakyan A, Goodney P. Use of real-world data and clinical registries to identify new uses of existing vascular endografts: combined use of GORE EXCLUDER Iliac Branch Endoprosthesis and GORE VIABAHN VBX Balloon Expandable Endoprosthesis. BMJ Surg Interv Health Technologies 2022; 4:e000085. [PMID: 35989872 PMCID: PMC9345049 DOI: 10.1136/bmjsit-2021-000085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 12/21/2021] [Indexed: 11/06/2022] Open
Abstract
Objective To assess the feasibility of collecting, examining and reporting observational, real-world evidence regarding the novel use of the GORE EXCLUDER Iliac Branch Endoprosthesis (IBE) in conjunction with the GORE VIABAHN VBX Balloon Expandable Endoprosthesis (IBE+VBX stent graft). Design Multicentre retrospective cohort study. Setting Four real-world data sources were used: a national quality improvement registry, a statewide clinical research network, a regional quaternary health system and two tertiary academic medical centres. Participants In total, 30 patients with 37 IBE+VBX stent graft were identified. Of those, the mean age was 72±10.2 years and 90% were male. The cohort was 77% white, 10% black, 3% Hispanic and 10% other. Main outcome measures Outcome measures included: proportion of percutaneous vs open surgical access, intensive care admission, intensive care unit (ICU) length-of-stay (LOS), total LOS, postoperative complications, discharge disposition and 30-day mortality. Results The majority (89%) of cases were performed percutaneously, 5% required surgical exposure following failed percutaneous access and 6% required open surgical exposure outright. Nearly half (43%) required intensive care admission with a median ICU LOS of 1 day (range: 1–2). Median total LOS was 1 day (IQR: 1–2). There were zero postoperative myocardial infarctions, zero reported leg embolisations and no reported reinterventions. Access site complications were described in 1 of 28 patients, manifesting as a haematoma or pseudoaneurysm. Ultimately, 97% were discharged to home and one patient was discharged to a nursing home or rehabilitation facility. There were no 30-day perioperative deaths. Conclusions This project demonstrates the feasibility of identifying and integrating real-world evidence, as it pertains to an unapproved combination of endovascular devices (IBE+VBX stent graft), for short-term outcomes analysis. This new paradigm of evidence has potential to be used for device monitoring, submission to regulatory agencies, or consideration in indication expansions and approvals with further efforts to systematise data collection and transmission mechanisms.
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Affiliation(s)
- Jonathan Aaron Barnes
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Mark A Eid
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Kayla Moore
- The Dartmouth Institute, Dartmouth College, Hanover, New Hampshire, USA
| | - Suvekshya Aryal
- Department of Health Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Eden Gebre
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Jennifer Nicole Woodard
- Department of Health Outcomes & Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | - Napong Kitpanit
- Division of Vascular and Endovascular Surgery, New York - Presbyterian Hospital, New York, New York, USA
- Department of Surgery, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - Jialin Mao
- Department of Health Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - David P Kuwayama
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Bjoern D Suckow
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Darren Schneider
- Division of Vascular and Endovascular Surgery, New York - Presbyterian Hospital, New York, New York, USA
| | - Tiffany Abushaikha
- National Evaluation System for health Technology Coordinating Center (NESTcc), Medical Device Innovation Consortium (MDIC), Arlington, Virginia, USA
| | - Robbert Zusterzeel
- National Evaluation System for health Technology Coordinating Center (NESTcc), Medical Device Innovation Consortium (MDIC), Arlington, Virginia, USA
| | | | - Elizabeth A Shenkman
- Department of Health Outcomes & Biomedical Informatics, University of Florida, Gainesville, Florida, USA
| | | | - Art Sedrakyan
- Department of Health Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Philip Goodney
- Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- The Dartmouth Institute, Dartmouth College, Hanover, New Hampshire, USA
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Simonato M, Vemulapalli S, Ben-Yehuda O, Krucoff M. Reply. JACC Cardiovasc Interv 2022; 15:1387-1388. [DOI: 10.1016/j.jcin.2022.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 05/31/2022] [Indexed: 10/17/2022]
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Simonato M, Vemulapalli S, Ben-Yehuda O, Wu C, Wood L, Popma J, Feldman T, Krohn C, Hardy KM, Guibone K, Christensen B, Alu MC, Chen S, Ng VG, Chau KH, Shahim B, Vincent F, MacMahon J, James S, Mack M, Leon MB, Thourani VH, Carroll J, Krucoff M. Minimum Core Data Elements for Evaluation of TAVR: A Scientific Statement by PASSION CV, HVC, and TVT Registry. JACC Cardiovasc Interv 2022; 15:685-697. [PMID: 35367168 DOI: 10.1016/j.jcin.2022.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/03/2021] [Accepted: 01/10/2022] [Indexed: 01/07/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is the standard of care for severe, symptomatic aortic stenosis. Real-world TAVR data collection contributes to benefit/risk assessment and safety evidence for the U.S. Food and Drug Administration, quality evaluation for the Centers for Medicare and Medicaid Services and hospitals, as well as clinical research and real-world implementation through appropriate use criteria. The essential minimum core dataset for these purposes has not previously been defined but is necessary to promote efficient, reusable real-world data collection supporting quality, regulatory, and clinical applications. The authors performed a systematic review of the published research for high-impact TAVR studies and U.S. multicenter, multidevice registries. Two expert task forces, one from the Predictable and Sustainable Implementation of National Cardiovascular Registries/Heart Valve Collaboratory and another from The Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry convened separately and then met to reconcile a final list of essential data elements. From 276 unique data elements considered, unanimous consensus agreement was achieved on 132 "core" data elements, with the most common reasons for exclusion from the minimum core dataset being burden or difficulty in accurate assessment (36.9%), duplicative information (33.3%), and low likelihood of affecting outcomes (10.7%). After a systematic review and extensive discussions, a multilateral group of academicians, industry representatives, and regulators established 132 interoperable, reusable essential core data elements essential to supporting more efficient, consistent, and informative TAVR device evidence for regulatory submissions, safety surveillance, best practice, and hospital quality assessments.
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Affiliation(s)
| | | | - Ori Ben-Yehuda
- University of California-San Diego, San Diego, California, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Changfu Wu
- U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Larry Wood
- Edwards Lifesciences, Irvine, California, USA
| | | | - Ted Feldman
- Edwards Lifesciences, Irvine, California, USA
| | - Carole Krohn
- The Society of Thoracic Surgeons, Chicago, Illinois, USA
| | | | - Kimberly Guibone
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York, USA
| | - Shmuel Chen
- Columbia University Irving School of Medicine, New York, New York, USA
| | - Vivian G Ng
- Columbia University Irving School of Medicine, New York, New York, USA
| | - Katherine H Chau
- Columbia University Irving School of Medicine, New York, New York, USA
| | - Bahira Shahim
- Cardiovascular Research Foundation, New York, New York, USA
| | | | - John MacMahon
- Mitre Medical Corporation, Morgan Hill, California, USA
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala, Sweden
| | - Michael Mack
- Baylor Scott and White Health, Dallas, Texas, USA
| | - Martin B Leon
- Columbia University Irving School of Medicine, New York, New York, USA
| | | | - John Carroll
- University of Colorado School of Medicine, Denver, Colorado, USA
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Simonato M, Vemulapalli S, Ben-Yehuda O, Wu C, Wood L, Popma J, Feldman T, Krohn C, Hardy KM, Guibone K, Christensen B, Alu MC, Chen S, Ng VG, Chau KH, Shahim B, Vincent F, MacMahon J, James S, Mack M, Leon MB, Thourani VH, Carroll J, Krucoff M. Minimum Core Data Elements for Evaluation of TAVR: A Scientific Statement by PASSION CV, HVC, and TVT Registry. Ann Thorac Surg 2022; 113:1730-1742. [PMID: 35367049 DOI: 10.1016/j.athoracsur.2022.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/10/2022] [Indexed: 11/20/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) is the standard of care for severe, symptomatic aortic stenosis. Real-world TAVR data collection contributes to benefit/risk assessment and safety evidence for the U.S. Food and Drug Administration, quality evaluation for the Centers for Medicare and Medicaid Services and hospitals, as well as clinical research and real-world implementation through appropriate use criteria. The essential minimum core dataset for these purposes has not previously been defined but is necessary to promote efficient, reusable real-world data collection supporting quality, regulatory, and clinical applications. The authors performed a systematic review of the published research for high-impact TAVR studies and U.S. multicenter, multidevice registries. Two expert task forces, one from the Predictable and Sustainable Implementation of National Cardiovascular Registries/Heart Valve Collaboratory and another from The Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry convened separately and then met to reconcile a final list of essential data elements. From 276 unique data elements considered, unanimous consensus agreement was achieved on 132 "core" data elements, with the most common reasons for exclusion from the minimum core dataset being burden or difficulty in accurate assessment (36.9%), duplicative information (33.3%), and low likelihood of affecting outcomes (10.7%). After a systematic review and extensive discussions, a multilateral group of academicians, industry representatives, and regulators established 132 interoperable, reusable essential core data elements essential to supporting more efficient, consistent, and informative TAVR device evidence for regulatory submissions, safety surveillance, best practice, and hospital quality assessments.
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Affiliation(s)
| | | | - Ori Ben-Yehuda
- University of California-San Diego, San Diego, California; Cardiovascular Research Foundation, New York, New York
| | - Changfu Wu
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Larry Wood
- Edwards Lifesciences, Irvine, California
| | | | | | - Carole Krohn
- The Society of Thoracic Surgeons, Chicago, Illinois
| | | | | | | | - Maria C Alu
- Cardiovascular Research Foundation, New York, New York
| | - Shmuel Chen
- Columbia University Irving School of Medicine, New York, New York
| | - Vivian G Ng
- Columbia University Irving School of Medicine, New York, New York
| | - Katherine H Chau
- Columbia University Irving School of Medicine, New York, New York
| | - Bahira Shahim
- Cardiovascular Research Foundation, New York, New York
| | | | | | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Martin B Leon
- Columbia University Irving School of Medicine, New York, New York
| | | | - John Carroll
- University of Colorado School of Medicine, Denver, Colorado
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Kaneko T, Vemulapalli S, Kohsaka S, Shimamura K, Stebbins A, Kumamaru H, Nelson AJ, Kosinski A, Maeda K, Bavaria JE, Saito S, Reardon MJ, Kuratani T, Popma JJ, Inohara T, Thourani VH, Carroll JD, Shimizu H, Takayama M, Leon MB, Mack MJ, Sawa Y. Practice Patterns and Outcomes of Transcatheter Aortic Valve Replacement in the United States and Japan: A Report From Joint Data Harmonization Initiative of STS/ACC TVT and J-TVT. J Am Heart Assoc 2022; 11:e023848. [PMID: 35243902 PMCID: PMC9075277 DOI: 10.1161/jaha.121.023848] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background The practice pattern and outcome of medical devices following their regulatory approval may differ by country. The aim of this study is to compare postapproval national clinical registry data on transcatheter aortic valve replacement between the United States and Japan on patient characteristics, periprocedural outcomes, and the variability of outcomes as a part of a partnership program (Harmonization‐by‐Doing) between the 2 countries. Methods and Results The patient‐level data were extracted from the US Society of Thoracic Surgeons /American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) and the J‐TVT (Japanese Transcatheter Valvular Therapy) registry, respectively, to analyze transcatheter aortic valve replacement outcomes between 2013 and 2019. Data entry for these registries was mandated by the federal regulators, and the majority of variable definitions were harmonized to allow direct data comparison. A total of 244 722 transcatheter aortic valve replacements from 646 institutions in the United States and 26 673 transcatheter aortic valve replacements from 171 institutions in Japan were analyzed. Median volume per site was 65 (interquartile range, 45–97) in the United States and 28 (interquartile range, 19–41) in Japan. Overall, patients in J‐TVT were older (United States: mean‐age, 80.1±8.7 versus Japan: 84.4±5.2; P<0.001), were more frequently women (45.9% versus 68.1%; P<0.001), and had higher median Society of Thoracic Surgeons Predicted Risk of Mortality (5.27% versus 6.20%; P<0.001) than patients in the United States. Japan had lower unadjusted 30‐day mortality (1.3% versus 3.2%; P<0.001) and composite outcomes of death, stroke, and bleeding (17.5 versus 22.5%; P<0.001) but had higher conversion to open surgery (0.94% versus 0.56%; P<0.001). Conclusions This collaborative analysis between the United States and Japan demonstrated the feasibility of international comparison using the national registries coded under mutual variable definitions. Both countries obtained excellent outcomes, although the Japanese had lower 30‐day mortality and major morbidity. Harmonization‐by‐Doing is one of the key steps needed to build global‐level learning to improve patient outcomes.
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Affiliation(s)
- Tsuyoshi Kaneko
- Division of Cardiac Surgery Brigham and Women's Hospital Boston MA
| | | | - Shun Kohsaka
- Department of Cardiology Keio University School of Medicine Tokyo Japan
| | - Kazuo Shimamura
- Department of Cardiovascular Surgery Osaka University Hospital Osaka Japan
| | | | - Hiraku Kumamaru
- Department of Healthcare Quality Assessment Graduate School of Medicine Faculty of Medicine The University of Tokyo Japan
| | | | | | - Koichi Maeda
- Department of Cardiovascular Surgery Osaka University Graduate School of Medicine Suita City Japan
| | - Joseph E Bavaria
- Division of Cardiac Surgery University of Pennsylvania Philadelphia PA
| | - Shigeru Saito
- Division of Cardiology Shonan Kamakura Hospital Kamakura Japan
| | | | - Toru Kuratani
- Department of Cardiovascular Surgery Osaka University Hospital Osaka Japan
| | | | - Taku Inohara
- Duke Clinical Research Institute Durham NC.,Department of Cardiology Keio University School of Medicine Tokyo Japan
| | - Vinod H Thourani
- Department of Cardiac Surgery Piedmont Heart Institute Atlanta GA
| | | | - Hideyuki Shimizu
- Department of Cardiovascular Surgery Keio University School of Medicine Tokyo Japan
| | | | - Martin B Leon
- Division of Cardiology Columbia University Irving Medical CenterNew York-Presbyterian Hospital New York NY
| | - Michael J Mack
- Cardiovascular Service line Baylor Scott & White HealthBaylor Scott & White Research Institute Dallas TX
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery Osaka University Hospital Osaka Japan
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40
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Nelson AJ, Wegermann Z, Gallup D, O’Brien S, Kosinski A, Thourani VH, Kumbhani DJ, Kirtane AJ, Allen J, Carroll JD, Shahian DM, Desai N, Brindis RG, Peterson ED, Cohen D, Vemulapalli S. COMPARING VOLUME VERSUS QUALITY THRESHOLDS ON OUTCOMES AND ACCESS TO TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR) IN THE UNITED STATES: INSIGHTS FROM THE TVT REGISTRY. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01650-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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41
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Carnicelli AP, Clare RM, Hofmann P, Chiswell K, DeVore AD, Vemulapalli S, Felker GM, Kelsey AM, DeWald TA, Sarocco P, Mentz RJ. Clinical trajectory of patients with a worsening heart failure event and reduced ventricular ejection fraction. Am Heart J 2022; 245:110-116. [PMID: 34932997 DOI: 10.1016/j.ahj.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/11/2021] [Accepted: 12/14/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recent data suggest that patients with heart failure with reduced ejection fraction (HFrEF) and worsening heart failure (WHF) have potential for greater benefit from newer HF therapies. We investigated characteristics and outcomes of patients with HFrEF and WHF by severity of left ventricular dysfunction. METHODS We identified patients with chronic symptomatic HFrEF (left ventricular ejection fraction [LVEF] ≤35%) and evidence of WHF (emergency department visit or hospitalization for acute HF within 12 months of index echocardiogram) treated at Duke University between 1/2009 and 12/2018. Patients were stratified by LVEF≤25% or 26% to35%. Cox models were used to estimate cause-specific hazard ratios and 5-year event incidence of death and hospitalization across the range of LVEF. RESULTS Of 2823 patients with HFrEF and WHF, 1620 (57.4%) had an LVEF≤25% and 1203 (42.6%) had an LVEF 26% to35%. Compared to patients with LVEF 26% to35%, those with LVEF≤25% were younger and more commonly men with a lower cardiovascular comorbidity burden. Patients with LVEF≤25% were less commonly on beta blockers (85.9% vs 90.5%) but more commonly treated with mineralocorticoid receptor antagonists (49.3% vs 41.1%) and implantable defibrillators (41.3% vs 28.2%). Patients with LVEF≤25% had significantly higher hazards for death (HR 1.24 [95% CI 1.11 - 1.38]), all-cause hospitalization (HR 1.21 [95% CI 1.10 - 1.33]), and HF hospitalization (HR 1.25 [95% CI 1.1 - 1.38]) through 5-years. CONCLUSIONS More than half of patients with chronic HFrEF and WHF have severe LV dysfunction. Important differences in comorbidities, HF therapies, and outcomes exist between those with LVEF≤25% and those with LVEF 26% to35%.
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Affiliation(s)
- Anthony P Carnicelli
- Duke Clinical Research Institute, Duke University, Durham, NC; Duke University Hospital, Duke University, Durham, NC.
| | - Robert M Clare
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Paul Hofmann
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Adam D DeVore
- Duke Clinical Research Institute, Duke University, Durham, NC; Duke University Hospital, Duke University, Durham, NC
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University, Durham, NC; Duke University Hospital, Duke University, Durham, NC
| | - G Michael Felker
- Duke Clinical Research Institute, Duke University, Durham, NC; Duke University Hospital, Duke University, Durham, NC
| | - Anita M Kelsey
- Duke Clinical Research Institute, Duke University, Durham, NC; Duke University Hospital, Duke University, Durham, NC
| | - Tracy A DeWald
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Phil Sarocco
- Health Economics and Outcomes Research, Cytokinetics, Inc., South San Francisco, CA
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University, Durham, NC; Duke University Hospital, Duke University, Durham, NC
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Nanna MG, Vemulapalli S, Fordyce CB, Mark DB, Patel MR, Al-Khalidi HR, Kelsey M, Martinez B, Yow E, Mullen S, Stone GW, Ben-Yehuda O, Udelson JE, Rogers C, Douglas PS. The prospective randomized trial of the optimal evaluation of cardiac symptoms and revascularization: Rationale and design of the PRECISE trial. Am Heart J 2022; 245:136-148. [PMID: 34953768 PMCID: PMC8979644 DOI: 10.1016/j.ahj.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/14/2021] [Accepted: 12/14/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Clinicians vary widely in their preferred diagnostic approach to patients with non-acute chest pain. Such variation exposes patients to potentially avoidable risks, as well as inefficient care with increased costs and unresolved patient concerns. METHODS The Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization (PRECISE) trial (NCT03702244) compares an investigational "precision" diagnostic strategy to a usual care diagnostic strategy in participants with stable chest pain and suspected coronary artery disease (CAD). RESULTS PRECISE randomized 2103 participants with stable chest pain and a clinical recommendation for testing for suspected CAD at 68 outpatient international sites. The investigational precision evaluation strategy started with a pre-test risk assessment using the PROMISE Minimal Risk Tool. Those at lowest risk were assigned to deferred testing (no immediate testing), and the remainder received coronary computed tomographic angiography (cCTA) with selective fractional flow reserve (FFRCT) for any stenosis meeting a threshold of ≥30% and <90%. For participants randomized to usual care, the clinical care team selected the initial noninvasive or invasive test (diagnostic angiography) according to customary practice. The use of cCTA as the initial diagnostic strategy was proscribed by protocol for the usual care strategy. The primary endpoint is time to a composite of major adverse cardiac events (MACE: all-cause death or non-fatal myocardial infarction) or invasive cardiac catheterization without obstructive CAD at 1 year. Secondary endpoints include health care costs and quality of life. CONCLUSIONS PRECISE will determine whether a precision approach comprising a strategically deployed combination of risk-based deferred testing and cCTA with selective FFRCT improves the clinical outcomes and efficiency of the diagnostic evaluation of stable chest pain over usual care.
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Affiliation(s)
- Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | | | - Christopher B. Fordyce
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Michelle Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Gregg W. Stone
- Icahn School of Medicine at Mount Sinai, Mount Sinai Heart and the Cardiovascular Research Foundation, New York, NY
| | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, NY, NY and the University of California, San Diego
| | - James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA
| | | | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Tanaka A, Trudell A, Smith-Washington A, Hoffstaetter T, Goldenberg R, Vemulapalli S, del Río-Solá L, Arnaoutakis GJ, Mussa F, Ota T. Knowledge Gaps in Surgical Management for Aortic Dissection. Semin Vasc Surg 2022; 35:35-42. [DOI: 10.1053/j.semvascsurg.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 11/11/2022]
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44
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Tanawuttiwat T, Stebbins A, Marquis-Gravel G, Vemulapalli S, Kosinski AS, Cheng A. Use of Direct Oral Anticoagulant and Outcomes in Patients With Atrial Fibrillation after Transcatheter Aortic Valve Replacement: Insights From the STS/ACC TVT Registry. J Am Heart Assoc 2021; 11:e023561. [PMID: 34970918 PMCID: PMC9075194 DOI: 10.1161/jaha.121.023561] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Clinical evidence on the safety and effectiveness of using direct oral anticoagulants (DOACs) in patients with atrial fibrillation after transcatheter aortic valve replacement (TAVR) remains limited. The aim of this study was to investigate the trends and outcomes of using DOACs in patients with TAVR and atrial fibrillation. Methods and Results Data from the STS/ACC TVT (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy) Registry was used to identify patients who underwent successful TAVR with preexisting or incident atrial fibrillation who were discharged on oral anticoagulation between January 2013 and May 2018. Patients with a mechanical valve, valve‐in‐valve procedure, or prior stroke within a year were excluded. The adjusted primary outcome was 1‐year stroke events. The adjusted secondary outcomes included bleeding, intracranial hemorrhage, and death. A total of 21 131 patients were included in the study (13 004 TAVR patients were discharged on a vitamin K antagonist and 8127 were discharged on DOACs.) The use of DOACs increased 5.5‐fold from 2013 to 2018. The 1‐year incidence of stroke was comparable between DOAC‐treated patients and vitamin K antagonist‐treated patients (2.51% versus 2.37%; hazard ratio [HR], 1.00; 95% CI, 0.81–1.23) whereas DOAC‐treated patients had lower 1‐year incidence of any bleeding (11.9% versus 15.0%; HR, 0.81; 95% CI, 0.75–0.89), intracranial hemorrhage (0.33% versus 0.59%; HR, 0.54; 95% CI, 0.33–0.87), and death (15.8% versus 18.2%; HR, 0.92; 95% CI, 0.85–1.00). Conclusions In patients with TAVR and atrial fibrillation, DOAC use, when compared with vitamin K antagonists, was associated with comparable stroke risk and significantly lower risks of bleeding, intracranial hemorrhage, and death at 1 year.
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Affiliation(s)
| | | | | | | | | | - Alan Cheng
- Department of Medicine Johns Hopkins University School of Medicine Baltimore MD
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45
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Dhruva SS, Shah ND, Vemulapalli S, Deshmukh A, Beatty AL, Gamble GM, Freeman JV, Hummel JP, Piccini JP, Akar JG, Ervin K, Arges KL, Emanuel L, Noseworthy PA, Hu T, Bartlett V, Ross JS. Heart Watch Study: protocol for a pragmatic randomised controlled trial. BMJ Open 2021; 11:e054550. [PMID: 35234659 PMCID: PMC8719216 DOI: 10.1136/bmjopen-2021-054550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 12/03/2021] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Personal digital devices that provide health information, such as the Apple Watch, have developed an increasing array of cardiopulmonary tracking features which have received regulatory clearance and are directly marketed to consumers. Despite their widespread and increasing use, data about the impact of personal digital device use on patient-reported outcomes and healthcare utilisation are sparse. Among a population of patients with atrial fibrillation and/or atrial flutter undergoing cardioversion, our primary aim is to determine the impact of the heart rate measurement, irregular rhythm notification, and ECG features of the Apple Watch on quality of life and healthcare utilisation. METHODS AND ANALYSIS We are conducting a prospective, open-label multicentre pragmatic randomised clinical trial, leveraging a unique patient-centred health data sharing platform for enrolment and follow-up. A total of 150 patients undergoing cardioversion for atrial fibrillation or atrial flutter will be randomised 1:1 to receive the Apple Watch Series 6 or Withings Move at the time of cardioversion. The primary outcome is the difference in the Atrial Fibrillation Effect on QualiTy-of-life global score at 6 months postcardioversion. Secondary outcomes include inpatient and outpatient healthcare utilisation. Additional secondary outcomes include a comparison of the Apple Watch ECG and pulse oximeter features with gold-standard data obtained in routine clinical care settings. ETHICS AND DISSEMINATION The Institutional Review Boards at Yale University, Mayo Clinic, and Duke University Health System have approved the trial protocol. This trial will provide important data to policymakers, clinicians and patients about the impact of the heart rate, irregular rhythm notification, and ECG features of widely used personal digital devices on patient quality of life and healthcare utilisation. Findings will be disseminated to study participants, at professional society meetings and in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04468321.
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Affiliation(s)
- Sanket S Dhruva
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California, USA
| | - Nilay D Shah
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, New York, USA
| | - Alexis L Beatty
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Ginger M Gamble
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - James V Freeman
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - James P Hummel
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Joseph G Akar
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Keondae Ervin
- National Evaluation System for health Technology Coordinating Center (NESTcc), Medical Device Innovation Consortium, Arlington, Virginia, USA
| | - Kristine L Arges
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lindsay Emanuel
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter A Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, New York, USA
| | - Tiffany Hu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | | | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Reed SD, Yang JC, Rickert T, Johnson FR, Gonzalez JM, Mentz RJ, Krucoff MW, Vemulapalli S, Adamson PB, Gebben DJ, Rincon-Gonzalez L, Saha A, Schaber D, Stein KM, Tarver ME, Bruhn-Ding D. Quantifying Benefit-Risk Preferences for Heart Failure Devices: A Stated-Preference Study. Circ Heart Fail 2021; 15:e008797. [PMID: 34937393 PMCID: PMC8763248 DOI: 10.1161/circheartfailure.121.008797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Regulatory and clinical decisions involving health technologies require judgements about relative importance of their expected benefits and risks. We sought to quantify heart-failure patients’ acceptance of therapeutic risks in exchange for improved effectiveness with implantable devices. Methods: Individuals with heart failure recruited from a national web panel or academic medical center completed a web-based discrete-choice experiment survey in which they were randomized to one of 40 blocks of 8 experimentally controlled choice questions comprised of 2 device scenarios and a no-device scenario. Device scenarios offered an additional year of physical functioning equivalent to New York Heart Association class III or a year with improved (ie, class II) symptoms, or both, with 30-day mortality risks ranging from 0% to 15%, in-hospital complication risks ranging from 0% to 40%, and a remote adjustment device feature. Logit-based regression models fit participants’ choices as a function of health outcomes, risks and remote adjustment. Results: Latent-class analysis of 613 participants (mean age, 65; 49% female) revealed that two-thirds were best represented by a pro-device, more risk-tolerant class, accepting up to 9% (95% CI, 7%–11%) absolute risk of device-associated mortality for a one-year gain in improved functioning (New York Heart Association class II). Approximately 20% were best represented by a less risk-tolerant class, accepting a maximum device-associated mortality risk of 3% (95% CI, 1%–4%) for the same benefit. The remaining class had strong antidevice preferences, thus maximum-acceptable risk was not calculated. Conclusions: Quantitative evidence on benefit-risk tradeoffs for implantable heart-failure device profiles may facilitate incorporating patients’ views during product development, regulatory decision-making, and clinical practice.
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Affiliation(s)
- Shelby D Reed
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC. (S.D.R., F.R.J., J.M.G.).,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.)
| | - Jui-Chen Yang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.)
| | - Timothy Rickert
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.)
| | - F Reed Johnson
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC. (S.D.R., F.R.J., J.M.G.).,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.)
| | - Juan Marcos Gonzalez
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC. (S.D.R., F.R.J., J.M.G.).,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.)
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.).,Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, NC. (R.J.M., M.W.K., S.V.)
| | - Mitchell W Krucoff
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.).,Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, NC. (R.J.M., M.W.K., S.V.)
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (S.D.R., J.-C.Y., T.R., F.R.J., J.M.G., R.J.M., M.W.K., S.V.).,Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, NC. (R.J.M., M.W.K., S.V.)
| | | | - David J Gebben
- Food and Drug Administration, Center for Devices and Radiological Health, Silver Spring, MD (D.J.G., A.S., M.E.T.)
| | | | - Anindita Saha
- Food and Drug Administration, Center for Devices and Radiological Health, Silver Spring, MD (D.J.G., A.S., M.E.T.)
| | | | | | - Michelle E Tarver
- Food and Drug Administration, Center for Devices and Radiological Health, Silver Spring, MD (D.J.G., A.S., M.E.T.)
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Mack M, Carroll JD, Thourani V, Vemulapalli S, Squiers J, Manandhar P, Deeb GM, Batchelor W, Herrmann HC, Cohen DJ, Hanzel G, Gleason T, Kirtane A, Desai N, Guibone K, Hardy K, Michaels J, DiMaio JM, Christensen B, Fitzgerald S, Krohn C, Brindis RG, Masoudi F, Bavaria J. Transcatheter Mitral Valve Therapy in the United States: A Report From the STS-ACC TVT Registry. J Am Coll Cardiol 2021; 78:2326-2353. [PMID: 34711430 DOI: 10.1016/j.jacc.2021.07.058] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 07/15/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
Data for nearly all patients undergoing transcatheter edge-to-edge repair (TEER) and transcatheter mitral valve replacement (TMVR) with an approved device in the United States is captured in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. All data submitted for TEER or TMVR between 2014 and March 31, 2020, are reported. A total of 37,475 patients underwent a mitral transcatheter procedure, including 33,878 TEER and 3,597 TMVR. Annual procedure volumes for TEER have increased from 1,152 per year in 2014 to 10,460 per year in 2019 at 403 sites and for TMVR from 84 per year to 1,120 per year at 301 centers. Mortality rates have decreased for TEER at 30 days (5.6%-4.1%) and 1 year (27.4%-22.0%). Early off-label use data on TMVR in mitral valve-in-valve therapy led to approval by the U.S. Food and Drug Administration in 2017, and the 2019 30-day mortality rate was 3.9%. Overall improvements in outcomes over the last 6 years are apparent. (STS/ACC TVT Registry Mitral Module; NCT02245763).
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Affiliation(s)
- Michael Mack
- Baylor Scott & White Health, Dallas, Texas, USA.
| | - John D Carroll
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Vinod Thourani
- Department of Surgery, Piedmont Hospital, Atlanta, Georgia, USA
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University Health Care System, Durham, North Carolina, USA
| | | | | | - G Michael Deeb
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Howard C Herrmann
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA; St Francis Hospital, Roslyn, New York, USA
| | | | | | - Ajay Kirtane
- Cardiovascular Research Foundation, New York, New York, USA; Department of Medicine, Columbia University, New York, New York, USA
| | - Nimesh Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kim Guibone
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Karen Hardy
- CommonSpirit Health, Lexington, Kentucky, USA
| | | | | | | | | | - Carole Krohn
- The Society of Thoracic Surgeons, Chicago, Illinois, USA
| | - Ralph G Brindis
- Philip R. Lee Institute for Health Policy Studies, University of California-San Francisco, San Francisco, California, USA
| | | | - Joseph Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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48
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Vemulapalli S, Stebbins A, Jones WS, Gutierrez JA, Patel MR, Dolor RJ, Pellikka PA, Alhanti B, Hoffmann U, Douglas PS. Cardiovascular risk and outcomes in symptomatic patients with suspected coronary artery disease and non coronary vascular disease: A report from the PROMISE trial. Am Heart J 2021; 242:82-91. [PMID: 34384742 PMCID: PMC10399724 DOI: 10.1016/j.ahj.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Non-coronary vascular disease (NCVD) is associated with adverse cardiovascular events. Little is known about physician risk assessment, prevalence of coronary artery disease (CAD), cardiac catheterization, and the performance of the atherosclerotic cardiovascular disease (ASCVD) risk score in patients with NCVD. METHODS Retrospective analysis of outpatients with angina and no known CAD from the PROMISE trial. NCVD included carotid artery stenosis ≥50%, or history of stroke or peripheral artery disease. Multivariable models of physician estimates of the probability of obstructive CAD, prevalence of non-obstructive and obstructive CAD, referral to cardiac catheterization, and all-cause death/myocardial infarction/unstable angina were performed. RESULTS Among 10,001 patients in the PROMISE trial, 379 (3.8%) patients had NCVD. Only 8.5% of participants with NCVD were categorized as high-risk for obstructive CAD by physicians, though 15.5% (25/161) had obstructive CAD in those randomized to coronary computed tomography (CTA). NCVD was independently associated with non-obstructive (aOR = 1.58; 95% CI 1.18-2.61; P = .006) but not obstructive CAD by CTA. Adjusted referral to cardiac catheterization was similar with and without NCVD (aOR 1.04; 95% CI 0.88-1.94, P = .19). NCVD was associated with an increased risk of all-cause death/MI/UA (aOR 2.03; 95% CI 1.37-3.01, P < .001). There was no interaction between NCVD status and ASCVD risk score. CONCLUSIONS Among patients with NCVD and angina, NCVD had increased adjusted risks of CAD and adverse outcomes which were not well described by ASCVD risk score and were underrecognized by physicians. Increased awareness and better risk stratification tools for patients with NCVD may be necessary to recognize the associated CV risk and optimize diagnostic testing and therapies.
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49
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Vemulapalli S, Thourani VH. Aortic Valve Replacement and Patient-Centered Implementation: To Boldly Go Where No Device Has Gone Before. J Am Coll Cardiol 2021; 78:2173-2176. [PMID: 34823660 DOI: 10.1016/j.jacc.2021.09.856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/24/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Sreekanth Vemulapalli
- Duke University School of Medicine, Department of Medicine, Division of Cardiology, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA; Duke-Margolis Center for Health Policy, Durham, North Carolina, USA.
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
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50
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Villablanca PA, Vemulapalli S, Stebbins A, Dai D, So CY, Eng MH, Wang DD, Frisoli TM, Lee JC, Kang G, Szerlip M, Ibrahim H, Staniloae C, Gaba P, Lemor A, Finn M, Ramakrishna H, Williams MR, Leon MB, O'Neill WW, Shah B. Sex-Based Differences in Outcomes With Percutaneous Transcatheter Repair of Mitral Regurgitation With the MitraClip System: Transcatheter Valve Therapy Registry From 2011 to 2017. Circ Cardiovasc Interv 2021; 14:e009374. [PMID: 34784236 DOI: 10.1161/circinterventions.120.009374] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Women have a higher rate of adverse events after mitral valve surgery. We sought to evaluate whether outcomes after transcatheter edge-to-edge repair intervention by sex have similar trends to mitral valve surgery. METHODS The primary outcome was 1-year major adverse events defined as a composite of all-cause mortality, stroke, and any bleeding in the overall study cohort. Patients who underwent transcatheter edge-to-edge repair for mitral regurgitation with the MitraClip system in the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy registry were evaluated. Linked administrative claims from the Centers for Medicare and Medicaid Services were used to evaluate 1-year clinical outcomes. Associations between sex and outcomes were evaluated using a multivariable logistic regression model for in-hospital outcomes and Cox model for 1-year outcomes. RESULTS From November 2013 to March 2017, 5295 patients, 47.6% (n=2523) of whom were female, underwent transcatheter edge-to-edge repair. Females were less likely to have >1 clip implanted (P<0.001) and had a lower adjusted odds ratio of device success (adjusted odds ratio, 0.78 [95% CI, 0.67-0.90]), driven by lower odds of residual mitral gradient <5 mm Hg (adjusted odds ratio, 0.54 [CI, 0.46-0.63]) when compared with males. At 1-year follow-up, the primary outcome did not differ by sex. Female sex was associated with lower adjusted 1-year risk of all-cause mortality (adjusted hazard ratio, 0.80 [CI, 0.68-0.94]), but the adjusted 1-year risk of stroke and any bleeding did not differ by sex. CONCLUSIONS No difference in composite outcome of all-cause mortality, stroke, and any bleeding was observed between females and males. Adjusted 1-year all-cause mortality was lower in females compared with males.
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Affiliation(s)
- Pedro A Villablanca
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | | | - Amanda Stebbins
- Duke Clinical Research Institute, Durham, NC (S.V., A.S., D.D.)
| | - Dadi Dai
- Duke Clinical Research Institute, Durham, NC (S.V., A.S., D.D.)
| | - Chak-Yu So
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - Marvin H Eng
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - Dee Dee Wang
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - Tiberio M Frisoli
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - James C Lee
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - Guson Kang
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | | | - Homam Ibrahim
- Division of Cardiology, NYU Grossman School of Medicine (H.I., C.S., M.R.W., B.S.)
| | - Cezar Staniloae
- Division of Cardiology, NYU Grossman School of Medicine (H.I., C.S., M.R.W., B.S.)
| | - Prakriti Gaba
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY (P.G., M.F., M.B.L.)
| | - Alejandro Lemor
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - Matthew Finn
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY (P.G., M.F., M.B.L.)
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN (H.R.)
| | - Mathew R Williams
- Division of Cardiology, NYU Grossman School of Medicine (H.I., C.S., M.R.W., B.S.)
| | - Martin B Leon
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY (P.G., M.F., M.B.L.).,Cardiovascular Research Foundation, New York, NY (M.B.L.)
| | - William W O'Neill
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - Binita Shah
- Division of Cardiology, NYU Grossman School of Medicine (H.I., C.S., M.R.W., B.S.).,Division of Cardiology, VA New York Harbor Healthcare System (B.S.)
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