A streamlined pathway for transcatheter aortic valve implantation: the BENCHMARK study

BACKGROUND AND AIMS

There is significant potential to streamline the clinical pathway for patients undergoing transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate the effect of implementing BENCHMARK best practices on the efficiency and safety of TAVI in 28 sites in 7 European countries.

METHODS

This was a study of patients with severe symptomatic aortic stenosis (AS) undergoing TAVI with balloon-expandable valves before and after implementation of BENCHMARK best practices. Principal objectives were to reduce hospital length of stay (LoS) and duration of intensive care stay. Secondary objective was to document patient safety.

RESULTS

Between January 2020 and March 2023, 897 patients were documented prior to and 1491 patients after the implementation of BENCHMARK practices. Patient characteristics were consistent with a known older TAVI population and only minor differences. Mean LoS was reduced from 7.7 ± 7.0 to 5.8 ± 5.6 days (median 6 vs. 4 days; P < .001). Duration of intensive care was reduced from 1.8 to 1.3 days (median 1.1 vs. 0.9 days; P < .001). Adoption of peri-procedure best practices led to increased use of local anaesthesia (96.1% vs. 84.3%; P < .001) and decreased procedure (median 47 vs. 60 min; P < .001) and intervention times (85 vs. 95 min; P < .001). Thirty-day patient safety did not appear to be compromised with no differences in all-cause mortality (0.6% in both groups combined), stroke/transient ischaemic attack (1.4%), life-threatening bleeding (1.3%), stage 2/3 acute kidney injury (0.7%), and valve-related readmission (1.2%).

CONCLUSIONS

Broad implementation of BENCHMARK practices contributes to improving efficiency of TAVI pathway reducing LoS and costs without compromising patient safety.

Residual volume of extruded disc material and residual spinal cord compression measured on postoperative MRI do not predict neurological outcomes in dogs following decompressive surgery for thoracolumbar intervertebral disc extrusion

Published studies on the validity of using quantitative MRI measures of pre- and postoperative spinal cord (SC) compression as prognostic indicators for dogs undergoing surgery for intervertebral disc extrusion (IVDE) are currently limited. The aim of this retrospective analytical study was to describe the volume of postoperative residual extradural material (VREM) and the ratio of the cross-sectional area (CSA) of maximum SC compression to the CSA of SC in a compression-free intervertebral space as MRI measures of preoperative and postoperative compression (residual spinal cord compression, RSCC), and to compare these measures between the neurological outcome in a group of dogs. Inclusion criteria were dogs that underwent surgery for thoracolumbar IVDE, were imaged pre- and immediately postoperatively by MRI, and had a neurological follow-up examination 2 to 5 weeks postoperatively. Two blinded observers independently performed measurements in pre- and postoperative MRI studies. Dogs were classified into positive outcome (PO) and negative outcome (NO) groups based on follow-up neurologic examination scores. Seventeen dogs were included (12 PO, 5 NO). Interobserver agreement for MRI measurements was good to excellent (ICCs: 0.76-0.97). The prevalence of residual extradural material in postoperative MRI studies was 100%. No significant differences in mean preoperative SC compression, mean RSCC, mean SC decompression, or VREM were found between outcome groups (P = .25; P = .28; P = .91, P = .98). In conclusion, neither postoperative VREM nor RSCC could predict successful neurological outcomes.

Clinical effects of permanent pacemaker implantation after transcatheter aortic valve implantation: Insights from the nationwide FRANCE-TAVI registry

BACKGROUND

The influence of permanent pacemaker implantation upon outcomes after transcatheter aortic valve implantation (TAVI) remains controversial.

AIMS

To evaluate the impact of permanent pacemaker implantation after TAVI on short- and long-term mortality, and on the risk of hospitalization for heart failure.

METHODS

Data from the large FRANCE-TAVI registry, linked to the French national health single-payer claims database, were analysed to compare 30-day and long-term mortality rates and hospitalization for heart failure rates among patients with versus without permanent pacemaker implantation after TAVI. Multivariable regressions were performed to adjust for confounders.

RESULTS

A total of 36,549 patients (mean age 82.6years; 51.6% female) who underwent TAVI from 2013 to 2019 were included in the present analysis. Among them, 6999 (19.1%) received permanent pacemaker implantation during the index hospitalization, whereas 232 (0.6%) underwent permanent pacemaker implantation between hospital discharge and 30days after TAVI, at a median of 11 (interquartile range: 7-18) days. In-hospital permanent pacemaker implantation was not associated with an increased risk of death between discharge and 30days (adjusted odds ratio: 0.91, 95% confidence interval: 0.64-1.29). At 5years, the incidence of all-cause death was higher among patients with versus without permanent pacemaker implantation within 30days of the procedure (adjusted hazard ratio: 1.13, 95% confidence interval: 1.07-1.19). Permanent pacemaker implantation within 30days of TAVI was also associated with a higher 5-year rate of hospitalization for heart failure (adjusted subhazard ratio: 1.17, 95% confidence interval: 1.11-1.23).

CONCLUSIONS

Permanent pacemaker implantation after TAVI is associated with an increased risk of long-term hospitalization for heart failure and all-cause mortality. Further research to mitigate the risk of postprocedural permanent pacemaker implantation is needed as TAVI indications expand to lower-risk patients.

Transcatheter or Surgical Aortic Valve Replacement in Patients With Severe Aortic Stenosis and Small Aortic Annulus: A Randomized Clinical Trial

BACKGROUND

The optimal treatment in patients with severe aortic stenosis and small aortic annulus (SAA) remains to be determined. This study aimed to compare the hemodynamic and clinical outcomes between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with a SAA.

METHODS

This prospective multicenter international randomized trial was performed in 15 university hospitals. Participants were 151 patients with severe aortic stenosis and SAA (mean diameter <23 mm) randomized (1:1) to TAVR (n=77) versus SAVR (n=74). The primary outcome was impaired valve hemodynamics (ie, severe prosthesis patient mismatch or moderate-severe aortic regurgitation) at 60 days as evaluated by Doppler echocardiography and analyzed in a central echocardiography core laboratory. Clinical events were secondary outcomes.

RESULTS

The mean age of the participants was 75.5±5.1 years, with 140 (93%) women, a median Society of Thoracic Surgeons predicted risk of mortality of 2.50% (interquartile range, 1.67%-3.28%), and a median annulus diameter of 21.1 mm (interquartile range, 20.4-22.0 mm). There were no differences between groups in the rate of severe prosthesis patient mismatch (TAVR, 4 [5.6%]; SAVR, 7 [10.3%]; P=0.30) and moderate-severe aortic regurgitation (none in both groups). No differences were found between groups in mortality rate (TAVR, 1 [1.3%]; SAVR, 1 [1.4%]; P=1.00) and stroke (TAVR, 0; SAVR, 2 [2.7%]; P=0.24) at 30 days. After a median follow-up of 2 (interquartile range, 1-4) years, there were no differences between groups in mortality rate (TAVR, 7 [9.1%]; SAVR, 6 [8.1%]; P=0.89), stroke (TAVR, 3 [3.9%]; SAVR, 3 [4.1%]; P=0.95), and cardiac hospitalization (TAVR, 15 [19.5%]; SAVR, 15 [20.3%]; P=0.80).

CONCLUSIONS

In patients with severe aortic stenosis and SAA (women in the majority), there was no evidence of superiority of contemporary TAVR versus SAVR in valve hemodynamic results. After a median follow-up of 2 years, there were no differences in clinical outcomes between groups. These findings suggest that the 2 therapies represent a valid alternative for treating patients with severe aortic stenosis and SAA, and treatment selection should likely be individualized according to baseline characteristics, additional anatomical risk factors, and patient preference. However, the results of this study should be interpreted with caution because of the limited sample size leading to an underpowered study, and need to be confirmed in future larger studies.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03383445.

Echocardiographic estimation of pulmonary pressure in patients with severe tricuspid regurgitation

OBJECTIVES

The estimation of systolic pulmonary artery pressure (sPAP) by transthoracic echocardiography (TTE) is challenging in patients with severe tricuspid regurgitation (TR). The study aimed to determine the reliability of the assessment of sPAP by TTE in this population.

METHODS

This study was a single-centre analysis of consecutive patients at the University Hospital of Rennes with right heart catheterisation and TTE, performed with a maximum delay of 48 hours. Lin's concordance coefficient (LCC) and Bland-Altman analysis were used to compare the values.

RESULTS

After applying the exclusion criteria, 236 patients were included in the analysis (age 71±11.5 years old; male 56%). The two principal indications were TR (34.3%) and mitral regurgitation (32.2%). The correlation between the two procedures was good in the total population (LCC=0.80; 95% limits of agreement (LOA): 0.74, 0.84), but weaker in the 78 patients (33%) with severe TR (LCC=0.67; 95% LOA: 0.49, 0.80), with a propensity to an underestimation by TTE. An elevated right atrial pressure (RAP) was associated with an underestimation by TTE of about 8 mmHg. The presence of a 'V-wave cut-off' sign on continuous-wave Doppler (OR=3.74; 95% CI 1.48, 9.30; p<0.01), found exclusively in patients with severe TR, was an independent predictor of sPAP misestimation by TTE.

CONCLUSION

The reliability of the estimation of sPAP in patients with severe TR could be altered by high RAP which cannot be estimated with current thresholds.

Transcatheter aortic valve implantation impact on left ventricular myocardial damage: long term follow-up

INTRODUCTION

Aortic stenosis (AS) is causing myocardial damages and replacement is mainly indicated based on symptoms. Non-invasive estimation of myocardial work (MW) provide a less afterload dependent tool that, we sought to look at the impact of transcatheter aortic valve implantation (TAVI) on the myocardium at long-term follow-up and according to current indications.

METHODS

We conducted an observational, cross-sectional, single-center study. Patients were selected based on the validated indication for a TAVI. Standardized echocardiographies were repeated.

RESULTS

102 patients were included. Mean age was 85-year-old, 45% were female, 68% get high-blood pressure and 52% had a coronary disease. One fifth was suffering from low-flow low-gradient aortic stenosis. Follow-up was performed at 22 ± 9.5 months after the TAVI. No TAVI-dysfunction was observed. LVEF was stable (62 ± 8%), and global longitudinal strain get improved (-14.0% ± 3.7 vs -16.0% ± 3.6, p-value <0.0001). No improvement of the MW-parameters was noticed (Global Work Index (LV GWI) 2099 ± 692mmHg% vs 2066 ± 706mmHg%, p=0.8, Global Constructive (LV GCW) 2463 ± 736mmHg% vs 2463 ± 676mmHg%, p=0.8). Global Wasted Work increased (214 [149; 357] mmHg% vs 247 [177; 394] mmHg%, p= 0.0008).

CONCLUSION

In a population of severe symptomatic AS-patients who had undergone a TAVI, the non-invasive myocardial indices that assess the LV performance at long term follow-up did not improve. These results are questioning the timing of the intervention and the need for a more attention in the pharmacological management of these AS-patients.

Flecainide to prevent atrial arrhythmia after patent foramen ovale closure Rationale and design of the randomized AFLOAT study

INTRODUCTION

Atrial arrhythmia is the most common complication of patent foramen ovale (PFO) closure. The real incidence of post-PFO closure atrial arrhytmia and whether this complication can be prevented is unknown.

METHODS/DESIGN

The Assessment of Flecainide to Lower the patent foramen Ovale closure risk of Atrial fibrillation or Tachycardia (AFLOAT) trial is a prospective, national, multicentre, randomized, open-label, superiority trial with a blind evaluation of all the endpoints (PROBE design). A total of 186 patients are randomized in a 1:1:1 ratio immediately after PFO closure to receive Flecainide (150 mg per day in a single sustained-release dose) for 6 months (Group 1), Flecainide (150 mg per day in a single sustained-release dose) for 3 months (Group 2), or no additional treatment (standard of care) for 6 months (Group 3). The primary endpoint is the percentage of patients with at least one episode of symptomatic or asymptomatic atrial arrhythmia episode (≥30s) recorded within 3 months after PFO closure on long-term monitoring with an insertable cardiac monitor. Whether 3 months of treatment is sufficient compared to 6 months will be analyzed as a secondary objective of the study.

CONCLUSION

AFLOAT is the first trial to test the hypothesis that a short treatment with oral Flecainide can prevent the new-onset of atrial arrhythmia after PFO closure. Clinical trial registration: NCT05213104 (clinicaltrials.gov).

Major adverse cardiovascular events in patients with atopic dermatitis treated with oral Janus kinase inhibitors: a systematic review and meta-analysis

BACKGROUND

On the basis of safety data for patients with inflammatory rheumatism or inflammatory bowel disease, treatment with Janus kinase (JAK) inhibitors (JAKi) has been linked to the occurrence of major adverse cardiovascular events (MACE). However, these inflammatory diseases are proatherogenic; in contrast, patients with atopic dermatitis (AD) do not usually have a high cardiovascular (CV) comorbidity burden.

OBJECTIVES

To perform a systematic review and meta-analysis of MACE in patients with AD treated with JAKi.

METHODS

We systematically searched PubMed, Embase, Cochrane Library and Google Scholar from their inception to 2 September 2022. Cohort studies, randomized controlled trials and pooled safety analyses providing CV safety data on patients taking JAKi for AD were selected. We included patients aged ≥ 12 years. We built a 'controlled-period' cohort (n = 9309; 6000 exposed to JAKi and 3309 exposed to comparators) and an 'all-JAKi' cohort (n = 9118 patients exposed to a JAKi in any of the included studies). The primary outcome was a composite of acute coronary syndrome (ACS), ischaemic stroke and CV death. The broader secondary MACE outcome encompassed ACS, stroke (whether ischaemic or haemorrhagic), transient ischaemic attack and CV death. The frequency of primary and secondary MACE was assessed in both cohorts. A fixed-effects meta-analysis using the Peto method was used to calculate the odds ratio (OR) for MACE in the 'controlled-period' cohort. Evaluation of the risk of bias was done using the Cochrane risk-of-bias tool (version 2). Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Eight per cent of the records identified initially met the selection criteria, corresponding to 23 records included in the 'all-JAKi' cohort. Patients had been exposed to baricitinib, upadacitinib, abrocitinib, ivarmacitinib, placebo or dupilumab. Four primary events (three with JAKi and one with placebo) and five secondary events (four with JAKi and one with placebo) occurred among 9309 patients in the 'controlled-period' cohort (MACE frequency 0.04% and 0.05%, respectively). Eight primary events and 13 secondary events occurred among 9118 patients in the 'all-JAKi' cohort (MACE frequency 0.08% and 0.14%, respectively). The OR for primary MACE in patients with AD treated with JAKi vs. placebo or dupilumab was 1.35 (95% confidence interval 0.15-12.21; I2 = 12%, very low certainty of evidence).

CONCLUSIONS

Our review highlights rare cases of MACE among JAKi users for AD. JAKi may have little-to-no effect on the occurrence of MACE in patients with AD vs. comparators, but the evidence is uncertain. Real-life long-term population-level safety studies are needed.

Conductive disturbances in the transcatheter aortic valve implantation setting: An appraisal of current knowledge and unmet needs

New-onset conduction disturbances, including left bundle branch block and permanent pacemaker implantation, remain a major issue after transcatheter aortic valve implantation. Preprocedural risk assessment in current practice is most often limited to evaluation of the baseline electrocardiogram, whereas it may benefit from a multimodal approach, including ambulatory electrocardiogram monitoring and multidetector computed tomography. Physicians may encounter equivocal situations during the hospital phase, and the management of follow-up is not fully defined, despite the publication of several expert consensuses and the inclusion of recommendations regarding the role of electrophysiology studies and postprocedural monitoring in recent guidelines. This review provides an overview of current knowledge and future perspectives regarding the management of new-onset conduction disturbances in the setting of transcatheter aortic valve implantation, from the preprocedural phase to long-term follow-up.

Association of Arterial Blood pH at Cannulation With 1 Year Survival Among Veno-Arterial Extracorporeal Membrane Oxygenation Recipients: The Three Seven Rule

We aimed to describe the clinical outcomes of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy in our institution considering clinical context and pH at cannulation. All patients treated by VA-ECMO during the 2005-2020 period with 1 year complete follow-up were included. Our cohort was divided in three groups according to the pH level at cannulation: pH <7 (group 1), pH 7-7.2 (group 2), and pH>7.2 (group 3). Survival was analyzed using Kaplan-Meier method. Association between pH group and survival was estimated using a Cox model. A total of 572 patients were included: 60 patients in group 1, 115 in group 2, and 397 in group 3. Refractory cardiogenic shock (36%) was the main indication. One year survival rates were 13%, 36%, and 43% in groups 1, 2, and 3, respectively ( p < 0.001). Death mainly occurred within the first month. The strong correlation between pH and lactates led to propose a simple "three seven rule": pH <7 and lactate >7 was associated with <7% survival. Veno-arterial extracorporeal membrane oxygenation should be considered with caution in patients with pH <7. Lactates and pH might be important parameters to elaborate a new score to predict survival in this population. The "three seven rule" can be very relevant when facing emergency situations.

Incidence, Clinical Characteristics, and Impact of Absent Echocardiographic Signs in Patients With Infective Endocarditis After Transcatheter Aortic Valve Implantation

BACKGROUND

Echocardiography is the primary imaging modality for diagnosis of infective endocarditis (IE) in prosthetic valve endocarditis (PVE) including IE after transcatheter aortic valve implantation (TAVI). This study aimed to evaluate the characteristics and clinical outcomes of patients with absent compared with evident echocardiographic signs of TAVI-IE.

METHODS

Patients with definite TAVI-IE derived from the Infectious Endocarditis after TAVI International Registry were investigated comparing those with absent and evident echocardiographic signs of IE defined as vegetation, abscess, pseudo-aneurysm, intracardiac fistula, or valvular perforation or aneurysm.

RESULTS

Among 578 patients, 87 (15.1%) and 491 (84.9%) had absent (IE-neg) and evident (IE-pos) echocardiographic signs of IE, respectively. IE-neg were more often treated via a transfemoral access with a self-expanding device and had higher rates of peri-interventional complications (eg, stroke, major vascular complications) during the TAVI procedure (P < .05 for all). IE-neg had higher rates of IE caused by Staphylococcus aureus (33.7% vs 23.2%; P = .038) and enterococci (37.2% vs 23.8%; P = .009) but lower rates of coagulase-negative staphylococci (4.7% vs 20.0%, P = .001). IE-neg was associated with the same dismal prognosis for in-hospital mortality in a multivariate binary regression analysis (odds ratio: 1.51; 95% confidence interval [CI]: .55-4.12) as well as a for 1-year mortality in Cox regression analysis (hazard ratio: 1.10; 95% CI: .67-1.80).

CONCLUSIONS

Even with negative echocardiographic imaging, patients who have undergone TAVI and presenting with positive blood cultures and symptoms of infection are a high-risk patient group having a reasonable suspicion of IE and the need for an early treatment initiation.

Evolution of non-invasive myocardial work variables after transcatheter aortic valve implantation in patients with severe aortic stenosis

INTRODUCTION

Guidelines recommend aortic valve replacement in patients with severe aortic stenosis who present with symptoms or left ventricular ejection fraction<50%, both conditions representing a late stage of the disease. Whereas global longitudinal strain is load dependent, but interesting for assessing prognosis, myocardial work has emerged.

AIM

To evaluate acute changes in myocardial work occurring in patients undergoing transcatheter aortic valve implantation (TAVI).

METHODS

Patients who underwent TAVI were evaluated before and after by echocardiography. Complete echocardiographies were considered. Myocardial work indices (global work index, global constructive work, global work efficiency, global wasted work) were calculated integrating mean transaortic pressure gradient and brachial cuff systolic pressure.

RESULTS

One hundred and twenty-five patients underwent successful TAVI, with a significant decrease in mean transaortic gradient (from 52.5±16.1 to 12.2±5.0; P<0.0001). There was no significant change in left ventricular ejection fraction after TAVI. Myocardial work data after TAVI showed a significant reduction in global work index (1389±537 vs. 2014±714; P<0.0001), global constructive work (1693±543 vs. 2379±761; P<0.0001) and global work efficiency (85.0±7.06 vs. 87.1±5.98; P=0.0034). The decrease in global work index and global constructive work after TAVI was homogeneous among different subgroups, based on global longitudinal strain, left ventricular ejection fraction and New York Heart Association status before TAVI. We observed a significant association between global work index and global constructive work before TAVI, and global longitudinal strain degradation after TAVI.

CONCLUSIONS

Myocardial work variables show promising potential in best understanding the left ventricular myocardial consequences of aortic stenosis and its correction. Given their ability to discriminate between New York Heart Association status and global longitudinal strain evolution, we can hypothesize about their clinical value.

Standing Surgical Management of Splint Bone Fractures in 13 Horses: A Comparison to Management Under General Anaesthesia

OBJECTIVE

 The aim of this article was to describe the technique and outcomes of standing surgical management of splint bone fractures and to compare outcome variables and hospitalization cost to a group with similar fractures treated under general anaesthesia.

STUDY DESIGN

 It is a single-institution retrospective study. Surgical technique, surgical time, hospitalization cost and complications were retrieved from the medical records of horses treated surgically for splint bone fractures (2008-2020). Owner telephone follow-up provided data about athletic outcome, client satisfaction and cosmetic appearance.

RESULTS

 Forty-nine horses (13 standing, 36 under general anaesthesia) with 57 fractures (18 contaminated and 39 non-contaminated) were included. Seven fractures were in the proximal third (4 standing, 3 under general anaesthesia), 18 in the middle third (5 standing, 13 under general anaesthesia) and 30 were distal (4 standing, 26 under general anaesthesia). No significant difference between groups in surgical time was found (p= 0.8). Average total cost was 522 CAN$ lower for the standing group for non-contaminated fractures (p= 0.02). Three horses of the general anaesthesia group demonstrated postoperative colic signs and one case of the standing group was re-operated due to sequestration. Based on follow-up information (range: 3.8-151.2 months), no significant differences in cosmetic and athletic outcomes were found between groups.

CONCLUSION

 Surgical management of splint bone fractures in the standing horse is a valuable alternative for horses selected based on behaviour. When compared to general anaesthesia, standing management of splint bone fractures did not alter the surgical time or outcome variables and avoided general anaesthesia-associated risks.

How myocardial work could be relevant in patients with an aortic valve stenosis?

AIMS

Myocardial work (MW) calculation is an attractive method to assess left ventricular (LV) myocardial function. In case of aortic stenosis (AS), assessment of work indices is challenging because it requires an accurate evaluation of LV-pressure curves. We sought to evaluate the performances of two distinct methods and to provide a quantitative comparison with invasive data.

METHODS AND RESULTS

Model-based and template-based methods were defined and applied for the evaluation of LV-pressures on 67 AS-patient. Global Constructive (GCW), Wasted (GWW), Positive (GPW), Negative (GNW) MW and Global Work Efficiency (GWE), and Index (GWI) parameters were calculated using the available software computing the indices using brachial blood-pressure and trans-aortic mean pressure gradient (MPG) for estimating the LV-pressures vs. using a model-based and homemade software. A complete comparison was performed with invasive measurements. Patients were characterized by MPG of 49.8 ± 14.8 mmHg, the global longitudinal strain (GLS) was -15.0 ± 4.04%, GCW was 2107 ± 800 mmHg.% (model-based) and 2483 ± 1068 mmHg.% (template-based). The root mean square error (RMSE) and correlation were calculated for each patient and pressure estimation methods. The mean RMSE are 33.9 mmHg and 40.4 mmHg and the mean correlation coefficients are 0.81 and 0.72 for the model-based and template-based methods, respectively. The two methods present correlation coefficient r2 >0.75 for all the indices.

CONCLUSION

The two non-invasive methods of LV pressure estimation and work indices computation correlate with invasive measurements. Although the model-based approach requires less information and is associated with slightly better performances, the implementation of template-based method is easier and is appropriate for clinical practice.

Management and outcomes of ventricular septal defects after acute myocardial infarction: A multicenter retrospective study

BACKGROUND AND AIM

The mortality rate of patients with post-myocardial infarction (MI) ventricular septal defects (VSDs) is high, and the benefit of surgery is unclear. We aimed to investigate the management and outcomes of post-MI VSD over a 10-year period in a large cohort.

METHODS

Data of patients with post-MI VSD admitted in three French university hospitals from 2008 to 2019 were examined. The characteristics of those who underwent surgery were compared with those who received medical treatment. Mortality risk factors, survival curves, and outcomes at 30 days and 1 year after treatment were determined.

RESULTS

Of the 92 patients whose data were examined, 50 underwent surgery and 42 received exclusive medical treatment. All patients were critically ill. Overall, 76.1% of patients received inotropic support, and 63% received mechanical ventilation. Circulatory assistance, mainly via intra-aortic balloon pump and extra-corporeal membrane oxygenation, was provided to 46.7% patients, with 14.1% requiring a second assistance. The median time to surgery was 4 days. At 1 year, mortality was 46% in those who underwent surgery and 83.3% in those treated medically (p < .001). Survival curves at 1 and 3 months showed major differences, and the survival rate showed little change 30 days after treatment. Cardiogenic shock and cardiac arrest emerged as risk factors for mortality.

CONCLUSIONS

In our retrospective, multicenter study, the mortality resulting from post-MI VSD did not seem to improve over the last decade. Although surgery carried considerable risks, it improved survival.

Transcatheter edge-to-edge repair following surgical valve repair with ring implantation: Results from the multicentre "Clip-in-Ring" registry

BACKGROUND

Management of mitral regurgitation recurrence after failed surgical valve repair with ring implantation is controversial.

AIM

To describe the French experience regarding midterm safety and efficacy of transcatheter edge-to-edge mitral valve repair (TEER) in patients with failed surgical valve repair with ring implantation.

METHODS

The "Clip-in-Ring" registry is a multicentre registry conducted in 11 centres in France, approved by local institutional review boards, of consecutive TEER following surgical valve repair with ring implantation. Outcomes were Mitral Valve Academic Research Consortium (MVARC) technical success, modified 30-day device and procedural success (where 10mmHg is considered as a cut-off for significant mitral stenosis) and MVARC complications.

RESULTS

Twenty-three patients were studied: mean age, 69±10years; male sex, 74%; EuroSCORE II, 16±17; left ventricular ejection fraction, 53±12%; mitral regurgitation grade 3+/4+, 17%/78%; New York Heart Association class III/IV, 47%/22%; median surgery to TEER delay, 23 (6-94) months. Technical success was 100%. At discharge, residual mitral regurgitation grade was≤2+ in 87% and median transmitral gradient was 4 (3-5) mmHg. Thirty-day modified MVARC device and procedural success was 82%: four patients (17%) had residual mitral regurgitation grade>2+, including two patients who needed complementary surgery. No patient had a 30-day transmitral gradient>7mmHg. No patient died or had a stroke or any life-threatening complications. One patient presented a vascular access complication requiring transfusion. No other MVARC-2 adverse event was reported.

CONCLUSIONS

TEER in patients with failed mitral ring is feasible and safe. Further studies shoulddelineate its exact role in the therapeutic armamentarium for this medical issue.

Delayed hospitalisation for heart failure after transcatheter repair or medical treatment for secondary mitral regurgitation: a landmark analysis of the MITRA-FR trial

BACKGROUND

In the MITRA-FR trial, transcatheter mitral valve repair (TMVR) was not associated with a 2-year clinical benefit in patients with secondary mitral regurgitation (SMR).

AIMS

This landmark analysis aimed at investigating a potential reduction of the hospitalisation rate for heart failure (HF) between 12 and 24 months after inclusion in the MITRA-FR trial in patients randomised to the intervention group (TMVR with the MitraClip device), as compared with patients randomised to the control group (guideline-directed medical therapy [GDMT]).

METHODS

The MITRA-FR trial randomised 307 patients with SMR for TMVR on top of GDMT (TMVR group; n=152) or for GDMT alone (control group; n=155). We conducted a 12-month landmark analysis in surviving patients who were not hospitalised for HF within the first 12 months of follow-up. The primary endpoint was the 1-year cumulative number of HF hospitalisations.

RESULTS

A total of 140 patients (TMVR group: 67; GDMT group: 73) were selected for this landmark analysis with similar characteristics at inclusion in the trial. The primary endpoint was 28 events per 100 patient-years in the TMVR group, as compared with 60 events per 100 patient-years in the GDMT group (hazard ratio [HR] 0.46, 95% confidence interval [CI]: 0.20-1.02; p=0.057).

CONCLUSIONS

In this landmark analysis of the MITRA-FR trial, the cumulative rate of HF hospitalisation between 12 and 24 months among patients treated with TMVR on top of GDMT was approximately half as many as those of patients treated with GDMT alone, a difference which did not reach statistical significance in the setting of a low number of events.

Sex Differences in Infective Endocarditis After Transcatheter Aortic Valve Replacement

BACKGROUND

Outcomes after transcatheter aortic valve replacement (TAVR) and infectious diseases may vary according to sex.

METHODS

This multicenter study aimed to determine the sex differences in clinical characteristics, management, and outcomes of infective endocarditis (IE) after TAVR. A total of 579 patients (217 women, 37.5%) were included retrospectively from the Infectious Endocarditis after TAVR International Registry who had the diagnosis of definite IE following TAVR.

RESULTS

Women were older (80±8 vs. 78±8 years, p=0.001) and exhibited a lower comorbidity burden. Clinical characteristics and microbiological profile were similar between men and women, but culture-negative IE was more frequent in women (9.9% vs. 4.3%, p=0.009). A high proportion of patients had a clinical indication for surgery (54.4% in both groups, p=0.99), but a surgical intervention was performed in a minority of patients (women: 15.2%, men: 20.3%, p=0.13). The mortality rate at index IE hospitalization was similar in both groups (women: 35.4%, men: 31.7%, p=0.373), but women exhibited a higher mortality rate at 2-year follow-up (63% vs. 52.1%, p=0.021). Female sex remained an independent risk factor for cumulative mortality in the multivariable analysis (HR_adj: 1.28, 95% CI: 1.02-1.62, p=0.035). After adjustment for in-hospital events, surgery was not associated with better outcomes in women.

CONCLUSIONS

There were no significant sex-related differences in the clinical characteristics and management of IE after TAVR. However, female sex was associated with increased two-years mortality risk.

Mitral Valve Infective Endocarditis after Trans-Catheter Aortic Valve Implantation

Scarce data exist on mitral valve (MV) infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). This multicenter study included a total of 579 patients with a diagnosis of definite IE after TAVI from the IE after TAVI International Registry and aimed to evaluate the incidence, characteristics, management, and outcomes of MV-IE after TAVI. A total of 86 patients (14.9%) had MV-IE. These patients were compared with 284 patients (49.1%) with involvement of the transcatheter heart valve (THV) only. Two factors were found to be associated with MV-IE: the use of self-expanding valves (adjusted odds ratio 2.49, 95% confidence interval [CI] 1.23 to 5.07, p = 0.012), and the presence of an aortic regurgitation ≥2 at discharge (adjusted odds ratio 3.33; 95% CI 1.43 to 7.73, p <0.01). There were no differences in IE timing and causative microorganisms between groups, but surgical management was significantly lower in patients with MV-IE (6.0%, vs 21.6% in patients with THV-IE, p = 0.001). All-cause mortality rates at 2-year follow-up were high and similar between patients with MV-IE (51.4%, 95% CI 39.8 to 64.1) and patients with THV-IE (51.5%, 95% CI 45.4 to 58.0) (log-rank p = 0.295). The factors independently associated with increased mortality risk in patients with MV-IE were the occurrence of heart failure (adjusted p <0.001) and septic shock (adjusted p <0.01) during the index hospitalization. One of 6 IE episodes after TAVI is localized on the MV. The implantation of a self-expanding THV and the presence of an aortic regurgitation ≥2 at discharge were associated with MV-IE. Patients with MV-IE were rarely operated on and had a poor prognosis at 2-year follow-up.

Clinical Benefit of Extubation in Patients on Venoarterial Extracorporeal Membrane Oxygenation

OBJECTIVES

Although patients on venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock are usually supported with mechanical ventilation, it is not clear whether sedation cessation and extubation might improve outcomes.

DESIGN

Retrospective cohort study with propensity score overlap weighting analysis.

SETTING

Three ICUs in a 1,500-bed tertiary university hospital.

PATIENTS

From an overall cohort of 641 patients with venoarterial-extracorporeal membrane oxygenation support, the primary analysis was performed in 344 patients who had been successfully decannulated in order to reduce immortal time bias.

MEASUREMENTS AND MAIN RESULTS

Seventy-five patients (22%) were extubated during extracorporeal membrane oxygenation support and were subsequently decannulated alive. Forty-nine percent received noninvasive ventilation, and 25% had emergency reintubation for respiratory, neurologic, or hemodynamic reasons. Higher Simplified Acute Physiology Score II at admission (odds ratio, 0.97; 95% CI [0.95-0.99]; p = 0.008) was associated with a lower probability of extubation, whereas cannulation in cardiac surgery ICU (odds ratio, 3.14; 95% CI [1.21-8.14]; p = 0.018) was associated with an increased probability. Baseline characteristics were well balanced after propensity score overlap weighting. The number of ICU-free days within 30 days of extracorporeal membrane oxygenation decannulation was significantly higher among extubated patients compared with nonextubated patients (22 d [11-26 d] vs 18 d [7-25 d], respectively; p = 0.036). There were no differences in other outcomes including ventilator-associated pneumonia (odds ratio, 0.96; 95% CI [0.51-1.82]; p = 0.90) and all-cause mortality within 30 days of extracorporeal membrane oxygenation decannulation (5% vs 17%; hazard ratio, 0.54; 95% CI [0.19-1.59]; p = 0.27).As a secondary analysis, outcomes were compared in the overall cohort of 641 venoarterial extracorporeal membrane oxygenation-supported patients. Results were consistent with the primary analysis as extubated patients had a higher number of ICU-free days (18 d [0-24 d] vs 0 d [0-18 d], respectively; < 0.001) and a lower risk of death within 30 days of extracorporeal membrane oxygenation cannulation (hazard ratio, 0.45; 95% CI [0.29-0.71]; p = 0.001).

CONCLUSIONS

Extubation during venoarterial-extracorporeal membrane oxygenation support is safe, feasible, and associated with greater ICU-free days.

Validation of a Whole Heart Segmentation from Computed Tomography Imaging Using a Deep-Learning Approach

The aim of this study is to develop an automated deep-learning-based whole heart segmentation of ECG-gated computed tomography data. After 21 exclusions, CT acquired before transcatheter aortic valve implantation in 71 patients were reviewed and randomly split in a training (n = 55 patients), validation (n = 8 patients), and a test set (n = 8 patients). A fully automatic deep-learning method combining two convolutional neural networks performed segmentation of 10 cardiovascular structures, which was compared with the manually segmented reference by the Dice index. Correlations and agreement between myocardial volumes and mass were assessed. The algorithm demonstrated high accuracy (Dice score = 0.920; interquartile range: 0.906-0.925) and a low computing time (13.4 s, range 11.9-14.9). Correlations and agreement of volumes and mass were satisfactory for most structures. Six of ten structures were well segmented. Deep-learning-based method allowed automated WHS from ECG-gated CT data with a high accuracy. Challenges remain to improve right-sided structures segmentation and achieve daily clinical application.

Very early infective endocarditis after transcatheter aortic valve replacement

BACKGROUND

Scarce data exist about early infective endocarditis (IE) after trans-catheter aortic valve replacement (TAVR).

OBJECTIVE

The objective was to evaluate the characteristics, management, and outcomes of very early (VE) IE (≤ 30 days) after TAVR.

METHODS

This multicenter study included a total of 579 patients from the Infectious Endocarditis after TAVR International Registry who had the diagnosis of definite IE following TAVR.

RESULTS

Ninety-one patients (15.7%) had VE-IE. Factors associated with VE-IE (vs. delayed IE (D-IE)) were female gender (p = 0.047), the use of self-expanding valves (p < 0.001), stroke (p = 0.019), and sepsis (p < 0.001) after TAVR. Staphylococcus aureus was the main pathogen among VE-IE patients (35.2% vs. 22.7% in the D-IE group, p = 0.012), and 31.2% of Staphylococcus aureus infections in the VE-IE group were methicillin-resistant (vs. 14.3% in the D-IE group, p = 0.001). The second-most common germ was enterococci (34.1% vs. 24.4% in D-IE cases, p = 0.05). VE-IE was associated with very high in-hospital (44%) and 1-year (54%) mortality rates. Acute renal failure following TAVR (p = 0.001) and the presence of a non-enterococci pathogen (p < 0.001) were associated with an increased risk of death.

CONCLUSION

A significant proportion of IE episodes following TAVR occurs within a few weeks following the procedure and are associated with dismal outcomes. Some baseline and TAVR procedural factors were associated with VE-IE, and Staphylococcus aureus and enterococci were the main causative pathogens. These results may help to select the more appropriate antibiotic prophylaxis in TAVR procedures and guide the initial antibiotic therapy in those cases with a clinical suspicion of IE. Very early infective endocarditis after trans-catheter aortic valve replacement. VE-IE indicates very early infective endocarditis (≤30 days post TAVR). D-IE indicates delayed infective endocarditis.

Surgical Treatment of Patients With Infective Endocarditis After Transcatheter Aortic Valve Implantation

BACKGROUND

The optimal treatment of patients developing infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is uncertain.

OBJECTIVES

The goal of this study was to investigate the clinical characteristics and outcomes of patients with TAVI-IE treated with cardiac surgery and antibiotics (IE-CS) compared with patients treated with antibiotics alone (IE-AB).

METHODS

Crude and inverse probability of treatment weighting analyses were applied for the treatment effect of cardiac surgery vs medical therapy on 1-year all-cause mortality in patients with definite TAVI-IE. The study used data from the Infectious Endocarditis after TAVI International Registry.

RESULTS

Among 584 patients, 111 patients (19%) were treated with IE-CS and 473 patients (81%) with IE-AB. Compared with IE-AB, IE-CS was not associated with a lower in-hospital mortality (HR_unadj: 0.85; 95% CI: 0.58-1.25) and 1-year all-cause mortality (HR_unadj: 0.88; 95% CI: 0.64-1.22) in the crude cohort. After adjusting for selection and immortal time bias, IE-CS compared with IE-AB was also not associated with lower mortality rates for in-hospital mortality (HR_adj: 0.92; 95% CI: 0.80-1.05) and 1-year all-cause mortality (HR_adj: 0.95; 95% CI: 0.84-1.07). Results remained similar when patients with and without TAVI prosthesis involvement were analyzed separately. Predictors for in-hospital and 1-year all-cause mortality included logistic EuroSCORE I, Staphylococcus aureus, acute renal failure, persistent bacteremia, and septic shock.

CONCLUSIONS

In this registry, the majority of patients with TAVI-IE were treated with antibiotics alone. Cardiac surgery was not associated with an improved all-cause in-hospital or 1-year mortality. The high mortality of patients with TAVI-IE was strongly linked to patients' characteristics, pathogen, and IE-related complications.

How myocardial work could be relevant in patients with an aortic valve stenosis?

Funding Acknowledgements

Type of funding sources: None.

Background

Speckle tracking based myocardial work calculation is an attractive method to assess left ventricular (LV) myocardial function. In case of aortic stenosis (AS), assessment of work indices is challenging because it requires an accurate evaluation of LV-pressure curves. Therefore, we sought to evaluate the performances of two distinct methods for the estimation of myocardial work indices and to provide a quantitative comparison with invasively measured data.

Methods

Model-based and template-based methods were defined and applied for the evaluation of LV pressures on 67 AS patients. Global Constructive (GCW), Wasted (GWW), Positive (GPW), Negative (GNW) myocardial work and Global Work Efficiency (GWE) and Index (GWI) parameters were calculated using the available software computing the indices using brachial blood pressure and trans-aortic mean pressure gradient for estimating the LV pressures versus using a model-based and homemade software. A complete comparison was performed with invasive measurements.

Results

Patients were characterized by mean pressure gradient of 49.8 ± 14.8 mmHg, LV ejection fraction of 59 ± 8%, the global longitudinal strain was -15.0 ± 4.04%, GCW was 2107 ± 800mmHg.% (model-based method) and 2483 ± 1068mmHg.% (template-based method). The root mean square error (RMSE) and correlation were calculated for each patient and for each pressure estimation methods. The mean RMSE are 33.9mmHg and 40.4mmHg and the mean correlation coefficients are 0.81 and 0.72 for the model-based and template-based methods respectively. Correlation coefficient and Bland-Altman analysis were performed for the six work indices. The two methods present correlation coefficient r2 &gt; 0.75 for almost all the indices.

Conclusion

The two non-invasive methods of LV pressure estimation and the work indices computation correlate with invasive measurements and computations for AS patients. Although the model-based approach requires less information and is associated with slightly better performances, the implementation of template-based method is easier and seems more appropriate in a clinical practice. Abstract Figure. SUMMARY

Early and late ventricular arrhythmias complicating ST-segment elevation myocardial infarction

BACKGROUND

Ventricular arrhythmias can be life-threatening complications of ST-segment elevation myocardial infarction (STEMI).

AIMS

To describe the incidence, predictors and in-hospital impact of early ventricular arrhythmia (EVA, occurring<day 2 after STEMI) and late ventricular arrhythmia (LVA, occurring≥day 2 after STEMI) in patients with STEMI.

METHODS

Data from 13,523 patients enrolled in a prospective registry were analysed. Logistic and Cox regressions were performed to identify predictors of EVA, LVA and in-hospital all-cause mortality. Predictors of LVA were used to build a risk score.

RESULTS

EVA occurred in 678 patients (5%), whereas 120 patients (0.9%) experienced LVA, at a median timing of 3days after STEMI. EVA was associated with a significantly higher risk of all-cause mortality (hazard ratio: 1.44, 95% confidence interval: 1.17-1.76; P=0.001), whereas no association was observed with LVA (hazard ratio 0.86, 95% confidence interval 0.57-1.28; P=0.45). Multivariable predictors of LVA were: age≥65years; serum creatinine≥85μmol/L on admission; pulse pressure≤45mmHg on admission; presence of a Q wave on admission electrocardiogram; Thrombolysis In Myocardial Infarction flow grade<3 after percutaneous coronary intervention; and left ventricular ejection fraction≤45%. The score derived from these variables allowed the classification of patients into four risk categories: low (0-21); low-to-intermediate (22-34); intermediate-to-high (35-44); and high (≥45). Observed LVA rates were 0.2%, 0.3%, 0.9% and 2.5%, across the four risk categories, respectively. The model demonstrated good discrimination (20-fold cross-validated c-statistic of 0.76) and adequate calibration (Hosmer-Lemeshow P=0.23).

CONCLUSIONS

EVA is 5-fold more common than LVA in the setting of STEMI, and portends a higher risk of in-hospital all-cause mortality. LVA is mainly associated with the patient's baseline risk profile and surrogate markers of larger infarct size. We developed and internally validated a risk score identifying patients at high risk of LVA for whom early intensive care unit discharge may not be suitable.

Perivalvular Extension of Infective Endocarditis after Transcatheter Aortic Valve Replacement

BACKGROUND

Infective endocarditis (IE) following transcatheter aortic valve replacement (TAVR) has been associated with a dismal prognosis. However, scarce data exist on IE perivalvular extension (PEE) in such patients.

METHODS

This multicenter study included a total of 579 patients who had the diagnosis of definite IE at a median of 171 (53-421) days following TAVR. PEE was defined as the presence of an intracardiac abscess, pseudoaneurysm or fistula confirmed by transthoracic/transophageal echocardiography, computed tomography or peri-operative findings.

RESULTS

A total of 105 patients (18.1%) were diagnosed with PEE (perivalvular abscess, pseudoaneurysm, fistula, or a combination in 87, 7, 7, and 4 patients, respectively). A history of chronic kidney disease (ORadj: 2.08; 95% CI: [1.27-3.41], p=0.003) and IE secondary to coagulase-negative staphylococci (ORadj: 2.71; 95% CI: [1.57-4.69], p<0.001) was associated with an increased risk of PEE. Surgery was performed at index IE episode in 34 patients (32.4%) with PEE (vs. 15.2% in patients without PEE, p<0.001). In-hospital and 2-year mortality rates among PEE-IE patients were 36.5% and 69.4%, respectively. Factors independently associated with an increased mortality risk were the occurrence of other complications (stroke post-TAVR, acute renal failure, septic shock) and the lack of surgery at index IE hospitalization (padj<0.05 for all).

CONCLUSION

PEE occurred in about one fifth of IE post-TAVR patients, with the presence of coagulase-negative staphylococci and chronic kidney disease determining an increased risk. Patients with PEE-IE exhibited very high early and late mortality rates, and surgery during IE hospitalization seemed to be associated with better outcomes.

Infective Endocarditis Caused by Staphylococcus Aureus after Transcatheter Aortic Valve Replacement

BACKGROUND

Staphylococcus aureus (S aureus) has been extensively studied as causative microorganism of surgical prosthetic-valve infective endocarditis (IE). However, scarce evidence exists on S aureus IE after transcatheter aortic valve replacement (TAVR).

METHODS

Data was obtained from the Infectious Endocarditis after TAVR International Registry including patients with definite IE following TAVR from 59 centers in 11 countries. Patients were divided into two groups according to microbiological etiology (non-S aureus-IE, non-SA-IE vs. S aureus-IE, SA-IE).

RESULTS

SA-IE was identified in 141 out of 573 (24.6%) patients, methicillin-sensitive S aureus in most cases (115/141, 81.6%). SEV were more common than BEV in patients with early SA-IE. Major bleeding and sepsis complicating TAVR, neurological symptoms or systemic embolism at admission and IE with cardiac device involvement other than the TAVR prosthesis were associated with SA-IE (p<0.05 for all). Among IE post-TAVR patients, the likelihood of SA-IE increased from 19% in the absence of those risk factors to 84.6% if ≥3 risk factors were present. In-hospital (47.8% vs. 26.9%, p<0.001) and 2-year mortality (71.5% vs. 49.6%, p<0.001) rates were higher among SA-IE (vs. non-SA-IE) patients. Surgery at the time of index SA-IE was associated with a lower mortality rate at follow-up (HR_adj: 0.46, 95% CI: 0.22-0.96, p=0.038).

CONCLUSIONS

SA-IE represented ∼ 25% of IE cases after TAVR and was associated with a very high in-hospital and late mortality. The presence of some features determined a higher likelihood of SA-IE and could help to orientate early antibiotic regimen selection. Surgery at index SA-IE was associated with improved outcomes, and its role should be evaluated in future studies.

TAVR Patients Requiring Anticoagulation: Direct Oral Anticoagulant or Vitamin K Antagonist?

OBJECTIVES

Using French transcatheter aortic valve replacement (TAVR) registries linked with the nationwide administrative databases, the study compared the rates of long-term mortality, bleeding, and ischemic events after TAVR in patients requiring oral anticoagulation with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs).

BACKGROUND

The choice of optimal drug for anticoagulation after TAVR remains debated.

METHODS

Data from the France-TAVI and FRANCE-2 registries were linked to the French national health single-payer claims database, from 2010 to 2017. Propensity score matching was used to reduce treatment-selection bias. Two primary endpoints were death from any cause (efficacy) and major bleeding (safety).

RESULTS

A total of 24,581 patients who underwent TAVR were included and 8,962 (36.4%) were treated with OAC. Among anticoagulated patients, 2,180 (24.3%) were on DOACs. After propensity matching, at 3 years, mortality (hazard ratio [HR]: 1.37; 95% confidence interval [CI]: 1.12-1.67; P < 0.005) and major bleeding including hemorrhagic stroke (HR: 1.64; 95% CI: 1.17-2.29; P < 0.005) were lower in patients on DOACs compared with those on VKAs. The rates of ischemic stroke (HR: 1.32; 95% CI: 0.81-2.15; P = 0.27) and acute coronary syndrome (HR: 1.17; 95% CI: 0.68-1.99; P = 0.57) did not differ among groups.

CONCLUSIONS

In these large multicenter French TAVR registries with an exhaustive clinical follow-up, the long-term mortality and major bleeding were lower with DOACs than VKAs at discharge. The present study supports preferential use of DOACs rather than VKAs in patients requiring oral anticoagulation therapy after TAVR.

Epinephrine administration in venoarterial extracorporeal membrane oxygenation patients is associated with mortality: a retrospective cohort study

Aims

Knowledge about the impact of epinephrine on the outcome in venoarterial (VA) extracorporeal membrane oxygenation (ECMO) patients is limited, and existing data are conflicting.

Methods and results

We conducted a retrospective cohort study in a 1500 bed tertiary university hospital. Five hundred and eighty‐nine VA‐ECMO patients were analysed. The median age was 57 years [47–65], 68% of male. The major indications for ECMO were post‐cardiotomy cardiogenic shock (CS) (38%) and medical CS (36%). Two hundred and sixty‐two (44.5%) patients received epinephrine alone or associated with another catecholamine while on ECMO. Baseline factors significantly associated with epinephrine administration were younger age, higher sequential organ failure assessment score, cardiac arrest at implantation, and intra‐aortic balloon pump support at implantation, whereas medical CS and dobutamine administration were significantly associated with a lower risk of epinephrine administration. Epinephrine administration was independently associated with death [hazard ratio = 1.68 (1.44–2.23); P < 0.01]. A sensitivity analysis with propensity score inverse probability weighting in complete cases confirmed a significant association of epinephrine administration with death [hazard ratio = 1.69 (1.43–2.00); P < 0.001].

Conclusions

Among patients who required VA‐ECMO, epinephrine administration was associated with an increased risk for death.

ST-Segment Elevation Myocardial Infarction Following Transcatheter Aortic Valve Replacement

BACKGROUND

Among patients with acute coronary syndrome following transcatheter aortic valve replacement (TAVR), those presenting with ST-segment elevation myocardial infarction (STEMI) are at highest risk.

OBJECTIVES

The goal of this study was to determine the clinical characteristics, management, and outcomes of STEMI after TAVR.

METHODS

This was a multicenter study including 118 patients presenting with STEMI at a median of 255 days (interquartile range: 9 to 680 days) after TAVR. Procedural features of STEMI after TAVR managed with primary percutaneous coronary intervention (PCI) were compared with all-comer STEMI: 439 non-TAVR patients who had primary PCI within the 2 weeks before and after each post-TAVR STEMI case in 5 participating centers from different countries.

RESULTS

Median door-to-balloon time was higher in TAVR patients (40 min [interquartile range: 25 to 57 min] vs. 30 min [interquartile range: 25 to 35 min]; p = 0.003). Procedural time, fluoroscopy time, dose-area product, and contrast volume were also higher in TAVR patients (p < 0.01 for all). PCI failure occurred more frequently in patients with previous TAVR (16.5% vs. 3.9%; p < 0.001), including 5 patients in whom the culprit lesion was not revascularized owing to coronary ostia cannulation failure. In-hospital and late (median of 7 months [interquartile range: 1 to 21 months]) mortality rates were 25.4% and 42.4%, respectively (20.6% and 38.2% in primary PCI patients), and estimated glomerular filtration rate <60 ml/min (hazard ratio [HR]: 3.02; 95% confidence interval [CI]: 1.42 to 6.43; p = 0.004), Killip class ≥2 (HR: 2.74; 95% CI: 1.37 to 5.49; p = 0.004), and PCI failure (HR: 3.23; 95% CI: 1.42 to 7.31; p = 0.005) determined an increased risk.

CONCLUSIONS

STEMI after TAVR was associated with very high in-hospital and mid-term mortality. Longer door-to-balloon times and a higher PCI failure rate were observed in TAVR patients, partially due to coronary access issues specific to the TAVR population, and this was associated with poorer outcomes.

Stroke Complicating Infective Endocarditis After Transcatheter Aortic Valve Replacement

BACKGROUND

Stroke is one of the most common and potentially disabling complications of infective endocarditis (IE). However, scarce data exist about stroke complicating IE after transcatheter aortic valve replacement (TAVR).

OBJECTIVES

The purpose of this study was to determine the incidence, risk factors, clinical characteristics, management, and outcomes of patients with definite IE after TAVR complicated by stroke during index IE hospitalization.

METHODS

Data from the Infectious Endocarditis after TAVR International Registry (including 569 patients who developed definite IE following TAVR from 59 centers in 11 countries) was analyzed. Patients were divided into two groups according to stroke occurrence during IE admission (stroke [S-IE] vs. no stroke [NS-IE]).

RESULTS

A total of 57 (10%) patients had a stroke during IE hospitalization, with no differences in causative microorganism between groups. S-IE patients exhibited higher rates of acute renal failure, systemic embolization, and persistent bacteremia (p < 0.05 for all). Previous stroke before IE, residual aortic regurgitation ≥moderate after TAVR, balloon-expandable valves, IE within 30 days after TAVR, and vegetation size >8 mm were associated with a higher risk of stroke during the index IE hospitalization (p < 0.05 for all). Stroke rate in patients with no risk factors was 3.1% and increased up to 60% in the presence of >3 risk factors. S-IE patients had higher rates of in-hospital mortality (54.4% vs. 28.7%; p < 0.001) and overall mortality at 1 year (66.3% vs. 45.6%; p < 0.001). Surgical treatment was not associated with improved outcomes in S-IE patients (in-hospital mortality: 46.2% in surgical vs. 58.1% in no surgical treatment; p = 0.47).

CONCLUSIONS

Stroke occurred in 1 of 10 patients with IE post-TAVR. A history of stroke, short time between TAVR and IE, vegetation size, valve prosthesis type, and residual aortic regurgitation determined an increased risk. The occurrence of stroke was associated with increased in-hospital and 1-year mortality rates, and surgical treatment failed to improve clinical outcomes.

Temporal Trends, Characteristics, and Outcomes of Infective Endocarditis After Transcatheter Aortic Valve Replacement

BACKGROUND

Procedural improvements combined with the contemporary clinical profile of patients undergoing transcatheter aortic valve replacement (TAVR) may have influenced the incidence and outcomes of infective endocarditis (IE) following TAVR. We aimed to determine the temporal trends, characteristics, and outcomes of IE post-TAVR.

METHODS

Observational study including 552 patients presenting definite IE post-TAVR. Patients were divided in 2 groups according to the timing of TAVR (historical cohort [HC]: before 2014; contemporary cohort [CC]: after 2014).

RESULTS

Overall incidence rates of IE were similar in both cohorts (CC vs HC: 5.45 vs 6.52 per 1000 person-years; P = .12), but the rate of early IE was lower in the CC (2.29‰ vs 4.89‰, P < .001). Enterococci were the most frequent microorganism. Most patients presented complicated IE ( CC: 67.7%; HC: 69.6%; P = .66), but the rate of surgical treatment remained low (CC: 20.7%; HC: 17.3%; P = .32). The CC exhibited lower rates of in-hospital acute kidney injury (35.1% vs 44.6%; P = .036) and in-hospital (26.6% vs 36.4%; P = .016) and 1-year (37.8% vs 53.5%; P < .001) mortality. Higher logistic EuroScore, Staphylococcus aureus etiology, and complications (stroke, heart failure, and acute renal failure) were associated with in-hospital mortality in multivariable analyses (P < .05 for all).

CONCLUSIONS

Although overall IE incidence has remained stable, the incidence of early IE has declined in recent years. The microorganism, high rate of complications, and very low rate of surgical treatment remained similar. In-hospital and 1-year mortality rates were high but progressively decreased over time.

Incidence, timing, predictors, and impact of sustained ventricular arrhythmia complicating st-segment elevation myocardial infarction

Aims

To describe the incidence, predictors, and in-hospital impact of early SVA (eSVA, occurring &lt; day 2 post-STEMI) and late SVA (lSVA, occurring ≥ day 2 post-STEMI) in STEMI patients. To derive and internally validate a risk score to identify patients at high-risk of lSVA.

Methods

Data of 13523 patients enrolled in the ORBI registry were analysed. Logistic regression was performed to identify predictors of eSVA, lSVA, and in-hospital all-cause mortality. Predictors of lSVA were used to build a risk score.

Results

eSVA occurred in 678 patients (5%) whereas 120 patients (0.9%) experienced lSVA at a median timing of 3 days post-STEMI. eSVA associated with a significantly higher risk of all-cause mortality (adjusted OR:1.90, 95% CI: 1.39–2.61, p&lt;0.001) whereas only a trend was observed with lSVA (adjusted OR: 1.69, 95% CI:0.91–3.13, p=0.09). Multivariable predictors of eSVA are listed in Table 1. Multivariable predictors of lSVA are listed in the Figure. The score derived from these variables allowed the classification of patients into four risk categories: low (0–21), low-to- intermediate (22–34), intermediate-to-high (35–44), and high (≥45). Observed lSVA rates were 0.2%, 0.4%, 0.8%, and 2.5%, across the four risk categories, respectively. The model demonstrated good discrimination (20-fold cross-validated c-statistic of 0.76) and adequate calibration (Hosmer-Lemeshow p=0.40).

Conclusion

eSVA are 5-fold more common than lSVA in the setting of STEMI, mainly associate with other early complications, and portends a 2-fold higher risk of in-hospital mortality. Moreover, we developed a risk score identifying patients at high risk of lSVA for whom early ICU discharge may not be suitable.

Funding Acknowledgement

Type of funding source: None

Determinants, impact, and association with heart failure therapies of heart failure readmission after transcatheter aortic valve replacement

Aims

To evaluate the incidence, predictors, and impact of heart failure (HF) readmission within 1-year post-transcatheter aortic valve replacement (TAVR), and assess the effects of the prescription of guidelines-recommended therapies (i.e. renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists) at discharge on the risk of HF readmission and death.

Methods and results

Patients included in the TAVR registry of a single expert centre from 2009 to 2017 were analysed. Competing-risk and Cox regressions were performed to identify predictors of HF readmission and death. Among 750 patients, 102 (13.6%) were readmitted for HF within 1-year post-TAVR. The 30-day incidence of HF readmission was 6.6%, 53 patients (7.1%) experienced late readmissions (&gt;30 days post-TAVR), and 17 (2.3%) had multiple readmissions. Independent predictors of HF readmission included diabetes mellitus, chronic lung disease, previous acute HF, grade III or IV aortic regurgitation, and pulmonary hypertension both at discharge from the index hospitalisation but not guidelines-recommended therapies. Overall, HF readmission did not significantly impact all-cause mortality (HR: 1.36, 95% CI: 0.99–1.85). However, late (HR: 1.90, 95% CI: 1.30–2.78) and multiple HF readmissions (HR: 2.10, 95% CI: 1.17–3.76) were significantly associated with all-cause mortality. Prescription of RAS inhibitors at discharge was associated with a lower rate of all-cause mortality, especially among patients receiving doses of 25–&lt;50% (HR: 0.67, 95% CI: 0.48–0.94), and 75–100% (HR: 0.61, 95% CI: 0.37–0.98) of the optimal daily dose.

Conclusion

HF readmission is common within 1-year of TAVR. Late and multiple HF readmissions associate with an increased risk of long-term all-cause mortality. Baseline comorbidities (diabetes, chronic lung disease, previous acute HF) and echocardiographic findings at discharge (grade III or IV aortic regurgitation, pulmonary hypertension) identified patients at high-risk of HF readmission. Guidelines-recommended therapies did not significantly affect the 1-year risk of HF readmission.

Funding Acknowledgement

Type of funding source: None

Similarity measures and attribute selection for case-based reasoning in transcatheter aortic valve implantation

In a clinical decision support system, the purpose of case-based reasoning is to help clinicians make convenient decisions for diagnoses or interventional gestures. Past experience, which is represented by a case-base of previous patients, is exploited to solve similar current problems using four steps-retrieve, reuse, revise, and retain. The proposed case-based reasoning has been focused on transcatheter aortic valve implantation to respond to clinical issues pertaining vascular access and prosthesis choices. The computation of a relevant similarity measure is an essential processing step employed to obtain a set of retrieved cases from a case-base. A hierarchical similarity measure that is based on a clinical decision tree is proposed to better integrate the clinical knowledge, especially in terms of case representation, case selection and attributes weighting. A case-base of 138 patients is used to evaluate the case-based reasoning performance, and retrieve- and reuse-based criteria have been considered. The sensitivity for the vascular access and the prosthesis choice is found to 0.88 and 0.94, respectively, with the use of the hierarchical similarity measure as opposed to 0.53 and 0.79 for the standard similarity measure. Ninety percent of the suggested solutions are correctly classified for the proposed metric when four cases are retrieved. Using a dedicated similarity measure, with relevant and weighted attributes selected through a clinical decision tree, the set of retrieved cases, and consequently, the decision suggested by the case-based reasoning are substantially improved over state-of-the-art similarity measures.

Conduction disturbances following trancatheter aortic valve implantation: increasing the 'pace' towards prospective evidence

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Determinants and Impact of Heart Failure Readmission Following Transcatheter Aortic Valve Replacement

Background:

Heart failure (HF) readmission is common post–transcatheter aortic valve replacement (TAVR). Nonetheless, limited data are available regarding its predictors and clinical impact. This study evaluated the incidence, predictors, and impact of HF readmission within 1-year post-TAVR, and assessed the effects of the prescription of HF therapies at discharge on the risk of HF readmission and death.

Methods:

Patients included in the TAVR registry of a single expert center from 2009 to 2017 were analyzed. Competing-risk and Cox regressions were performed to identify predictors of HF readmission and death.

Results:

Among 750 patients, 102 (13.6%) were readmitted for HF within 1-year post-TAVR. Overall, 53 patients (7.1%) experienced late readmissions (>30 days post-TAVR), and 17 (2.3%) had multiple readmissions. In ≈30% of readmissions, no trigger could be identified. Predominant causes of readmissions were changes in medication/nonadherence and supraventricular arrhythmia. Independent predictors of HF readmission included diabetes mellitus, chronic lung disease, previous acute HF, grade III or IV aortic regurgitation, and pulmonary hypertension both at discharge from the index hospitalization but not HF therapies. Overall, HF readmission did not significantly impact all-cause mortality (hazard ratio [HR], 1.36 [95% CI, 0.99–1.85]). However, late (HR, 1.90 [95% CI, 1.30–2.78]) and multiple HF readmissions (HR, 2.10 [95% CI,1.17–3.76]) were significantly associated with all-cause mortality. Prescription of renin-angiotensin system inhibitors at discharge was associated with a lower rate of all-cause mortality, especially among patients receiving doses of 25% to <50% (HR, 0.67 [95% CI, 0.48–0.94]) and 75% to 100% (HR, 0.61 [95% CI, 0.37–0.98]) of the optimal daily dose.

Conclusions:

HF readmission is common within 1-year of TAVR. Late and multiple HF readmissions associate with an increased risk of long-term all-cause mortality. Baseline comorbidities (diabetes, chronic lung disease, previous acute HF) and echocardiographic findings at discharge (grade III or IV aortic regurgitation, pulmonary hypertension) identified patients at high risk of HF readmission.