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Ali N, Hildick-Smith D, Parker J, Malkin CJ, Cunnington MS, Gurung S, Mailey J, MacCarthy PA, Bharucha A, Brecker SJ, Hoole SP, Dorman S, Doshi SN, Wiper A, Buch MH, Banning AP, Spence MS, Blackman DJ. Long-term durability of self-expanding and balloon-expandable transcatheter aortic valve prostheses: UK TAVI registry. Catheter Cardiovasc Interv 2023; 101:932-942. [PMID: 36924015 DOI: 10.1002/ccd.30627] [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: 12/18/2022] [Revised: 02/07/2023] [Accepted: 03/01/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND With expansion of transcatheter aortic valve implantation (TAVI) into younger patients, valve durability is critically important. AIMS We aimed to evaluate long-term valve function and incidence of severe structural valve deterioration (SVD) among patients ≥ 10-years post-TAVI and with echocardiographic follow-up at least 5-years postprocedure. METHODS Data on patients who underwent TAVI from 2007 to 2011 were obtained from the UK TAVI registry. Patients with paired echocardiograms postprocedure and ≥5-years post-TAVI were included. Severe SVD was determined according to European task force guidelines. RESULTS 221 patients (79.4 ± 7.3 years; 53% male) were included with median echocardiographic follow-up 7.0 years (range 5-13 years). Follow-up exceeded 10 years in 43 patients (19.5%). Valve types were the supra-annular self-expanding CoreValve (SEV; n = 143, 67%), balloon-expandable SAPIEN/XT (BEV; n = 67, 31%), Portico (n = 4, 5%) and unknown (n = 7, 3%). There was no difference between postprocedure and follow-up peak gradient in the overall cohort (19.3 vs. 18.4 mmHg; p = NS) or in those with ≥10-years follow-up (21.1 vs. 21.1 mmHg; p = NS). Severe SVD occurred in 13 patients (5.9%; median 7.8-years post-TAVI). Three cases (23.1%) were due to regurgitation and 10 (76.9%) to stenosis. Valve-related reintervention/death occurred in 5 patients (2.3%). Severe SVD was more frequent with BEV than SEV (11.9% vs. 3.5%; p = 0.02), driven by a difference in patients treated with small valves (BEV 28.6% vs. SEV 3.0%; p < 0.01). CONCLUSIONS Hemodynamic function of transcatheter heart valves remains stable up to more than 10 years post-TAVI. Severe SVD occurred in 5.9%, and valve-related death/reintervention in 2.3%. Severe SVD was more common with BEV than SEV.
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Affiliation(s)
- Noman Ali
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Jessica Parker
- Department of Cardiology, Royal Sussex County Hospital, Brighton, UK
| | | | | | - Shuslim Gurung
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jonathan Mailey
- Department of Cardiology, Royal Victoria Hospital, Belfast, UK
| | | | - Apurva Bharucha
- Department of Cardiology, King's College Hospital, London, UK
| | | | - Stephen P Hoole
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Stephen Dorman
- Department of Cardiology, Bristol Heart Institute, Bristol, UK
| | - Sagar N Doshi
- Department of Cardiology, Queen Elizabeth University Hospital, Birmingham, UK
| | - Andrew Wiper
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool, UK
| | - Mamta H Buch
- Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Adrian P Banning
- Department of Cardiology, Oxford Universities Hospital, Oxford, UK
| | - Mark S Spence
- Department of Cardiology, Royal Victoria Hospital, Belfast, UK
| | - Daniel J Blackman
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Straw S, Gupta A, Johnson K, Cole CA, Kneizeh K, Gierula J, Kearney MT, Malkin CJ, Paton MF, Witte KK, Schlosshan D. Atrial secondary mitral regurgitation: prevalence, characteristics, management, and long-term outcomes. Echo Res Pract 2023; 10:4. [PMID: 36882790 PMCID: PMC9993529 DOI: 10.1186/s44156-023-00015-y] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/06/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND The prevalence, clinical characteristics, management and long-term outcomes of patients with atrial secondary mitral regurgitation (ASMR) are not well described. METHODS We performed a retrospective, observational study of consecutive patients with grade III/IV MR determined by transthoracic echocardiography. The aetiology of MR was grouped as being either primary (due to degenerative mitral valve disease), ventricular SMR (VSMR: due to left ventricular dilatation/dysfunction), ASMR (due to LA dilatation), or other. RESULTS A total of 388 individuals were identified who had grade III/IV MR; of whom 37 (9.5%) had ASMR, 113 (29.1%) had VSMR, 193 had primary MR (49.7%), and 45 (11.6%) were classified as having other causes. Compared to MR of other subtypes, patients with ASMR were on average older (median age 82 [74-87] years, p < 0.001), were more likely to be female (67.6%, p = 0.004) and usually had atrial fibrillation (83.8%, p = 0.001). All-cause mortality was highest in patients with ASMR (p < 0.001), but similar to that in patients with VSMR once adjusted for age and sex (hazard ratio [HR] 0.81, 95% confidence interval [CI] 0.52-1.25). Hospitalisation for worsening heart failure was more commonly observed in those with ASMR or VSMR (p < 0.001) although was similar between these groups when age and sex were accounted for (HR 0.74, 95% CI 0.34-1.58). For patients with ASMR, the only variables associated with outcomes were age and co-morbidities. CONCLUSIONS ASMR is a prevalent and distinct disease process associated with a poor prognosis, with much of this related to older age and co-morbidities.
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Affiliation(s)
- Sam Straw
- University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | | | | | - John Gierula
- University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | | | - Maria F Paton
- University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Klaus K Witte
- University of Leeds, Leeds, UK. .,University Hospital Aachen, RWTH, Aachen, Germany.
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Parfrey S, Abdelrahman A, Blackman D, Blaxill JM, Cunnington MS, Greenwood JP, Malkin CJ, Mozid AM, Rossington JA, Veerasamy M, Wassef N, Wheatcroft SB, Bulluck H. Safety and efficacy of interrupting dual antiplatelet therapy one month following percutaneous coronary intervention: a meta-analysis of randomized controlled trials. BMC Cardiovasc Disord 2022; 22:450. [PMID: 36307769 PMCID: PMC9615356 DOI: 10.1186/s12872-022-02900-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 10/04/2022] [Indexed: 11/24/2022] Open
Abstract
Very short duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) has recently attracted a lot of attention with the introduction of newer generations stents. This is appealing, especially in patients at high bleeding risk. However, none of the trials were powered for the individual ischemic and bleeding endpoints. All randomised controlled trials (RCTs) investigating one-month versus routine duration of DAPT in patients undergoing PCI and reporting outcomes from the time of cessation of DAPT (1 month) to 1 year were eligible for inclusion in the meta-analysis. The pooled risk ratios (RR) with their 95% confidence interval (CI) were calculated with the random-effects model using the Mantel-Haenszel method. Four RCTs involving 26,576 patients were included in this meta-analysis. Cessation of DAPT after 1 month was associated with significantly less major bleeding [RR 0.70, 95%CI (0.51–0.95), P = 0.02, heterogeneity (I2) = 42%]. There was no statistically significant difference in all-cause mortality [RR 0.84 (95%CI 0.69–1.03), P = 0.10, I2 = 0%] and stroke [RR 0.71 (95%CI 0.45–1.13), P = 0.15, I2 = 42%] when compared to routine duration of DAPT. There was also no difference in myocardial infarction (MI) [RR 1.12 (95%CI 0.91–1.39), P = 0.28, I2 = 0%], and definite or probable stent thrombosis [RR 1.49 (95%CI 0.92–2.41), P = 0.11, I2 = 0%] with cessation of DAPT after 1 month. Cessation of DAPT 1 month after PCI was associated with significantly less major bleeding, but there was no difference in the rate of all-cause mortality, stroke, MI and stent thrombosis.
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Krishnamurthy A, Keeble CM, Anderson M, Burton-Wood N, Somers K, Harland C, Baxter PD, McLenachan JM, Blaxill JM, Blackman DJ, Malkin CJ, Wheatcroft SB, Greenwood JP. Association between operator volume and mortality in primary percutaneous coronary intervention. Open Heart 2022; 9:openhrt-2022-002072. [PMID: 36192035 PMCID: PMC9535214 DOI: 10.1136/openhrt-2022-002072] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/23/2022] [Indexed: 11/07/2022] Open
Abstract
Background There is a paucity of real-world data assessing the association of operator volumes and mortality specific to primary percutaneous coronary intervention (PPCI). Methods Demographic, clinical and outcome data for all patients undergoing PPCI in Leeds General Infirmary, UK, between 1 January 2009 and 31 December 2011, and 1 January 2013 and 31 December 2013, were obtained prospectively. Operator volumes were analysed according to annual operator PPCI volume (low volume: 1–54 PPCI per year; intermediate volume: 55–109 PPCI per year; high volume: ≥110 PPCI per year). Cox proportional hazards regression analyses were undertaken to investigate 30-day and 12-month all-cause mortality, adjusting for confounding factors. Results During this period, 4056 patients underwent PPCI, 3703 (91.3%) of whom were followed up for a minimum of 12 months. PPCI by low-volume operators was associated with significantly higher adjusted 30-day mortality (HR 1.48 (95% CI 1.05 to 2.08); p=0.02) compared with PPCI performed by high-volume operators, with no significant difference in adjusted 12-month mortality (HR 1.26 (95% CI 0.96 to 1.65); p=0.09). Comparisons between low-volume and intermediate-volume operators, and between intermediate and high-volume operators, showed no significant differences in 30-day and 12-month mortality. Conclusions Low operator volume is independently associated with higher probability of 30-day mortality compared with high operator volume, suggesting a volume–outcome relationship in PPCI at a threshold higher than current recommendations.
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Affiliation(s)
- Arvindra Krishnamurthy
- Department of Cardiology, Leeds General Infirmary, Leeds, UK,Leeds Instutute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Claire M Keeble
- Leeds Instutute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK,Leeds Institute of Data Analytics, Leeds, UK
| | | | | | - Kathryn Somers
- Department of Cardiology, Leeds General Infirmary, Leeds, UK
| | | | - Paul D Baxter
- Leeds Instutute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK,Leeds Institute of Data Analytics, Leeds, UK
| | | | | | | | | | - Stephen B Wheatcroft
- Department of Cardiology, Leeds General Infirmary, Leeds, UK,Leeds Instutute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John P Greenwood
- Department of Cardiology, Leeds General Infirmary, Leeds, UK,Leeds Instutute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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5
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Toff WD, Hildick-Smith D, Kovac J, Mullen MJ, Wendler O, Mansouri A, Rombach I, Abrams KR, Conroy SP, Flather MD, Gray AM, MacCarthy P, Monaghan MJ, Prendergast B, Ray S, Young CP, Crossman DC, Cleland JGF, de Belder MA, Ludman PF, Jones S, Densem CG, Tsui S, Kuduvalli M, Mills JD, Banning AP, Sayeed R, Hasan R, Fraser DGW, Trivedi U, Davies SW, Duncan A, Curzen N, Ohri SK, Malkin CJ, Kaul P, Muir DF, Owens WA, Uren NG, Pessotto R, Kennon S, Awad WI, Khogali SS, Matuszewski M, Edwards RJ, Ramesh BC, Dalby M, Raja SG, Mariscalco G, Lloyd C, Cox ID, Redwood SR, Gunning MG, Ridley PD. Effect of Transcatheter Aortic Valve Implantation vs Surgical Aortic Valve Replacement on All-Cause Mortality in Patients With Aortic Stenosis: A Randomized Clinical Trial. JAMA 2022; 327:1875-1887. [PMID: 35579641 PMCID: PMC9115619 DOI: 10.1001/jama.2022.5776] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [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: 01/02/2023]
Abstract
IMPORTANCE Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical aortic valve replacement and is the treatment of choice for patients at high operative risk. The role of TAVI in patients at lower risk is unclear. OBJECTIVE To determine whether TAVI is noninferior to surgery in patients at moderately increased operative risk. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial conducted at 34 UK centers, 913 patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk due to age or comorbidity were enrolled between April 2014 and April 2018 and followed up through April 2019. INTERVENTIONS TAVI using any valve with a CE mark (indicating conformity of the valve with all legal and safety requirements for sale throughout the European Economic Area) and any access route (n = 458) or surgical aortic valve replacement (surgery; n = 455). MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality at 1 year. The primary hypothesis was that TAVI was noninferior to surgery, with a noninferiority margin of 5% for the upper limit of the 1-sided 97.5% CI for the absolute between-group difference in mortality. There were 36 secondary outcomes (30 reported herein), including duration of hospital stay, major bleeding events, vascular complications, conduction disturbance requiring pacemaker implantation, and aortic regurgitation. RESULTS Among 913 patients randomized (median age, 81 years [IQR, 78 to 84 years]; 424 [46%] were female; median Society of Thoracic Surgeons mortality risk score, 2.6% [IQR, 2.0% to 3.4%]), 912 (99.9%) completed follow-up and were included in the noninferiority analysis. At 1 year, there were 21 deaths (4.6%) in the TAVI group and 30 deaths (6.6%) in the surgery group, with an adjusted absolute risk difference of -2.0% (1-sided 97.5% CI, -∞ to 1.2%; P < .001 for noninferiority). Of 30 prespecified secondary outcomes reported herein, 24 showed no significant difference at 1 year. TAVI was associated with significantly shorter postprocedural hospitalization (median of 3 days [IQR, 2 to 5 days] vs 8 days [IQR, 6 to 13 days] in the surgery group). At 1 year, there were significantly fewer major bleeding events after TAVI compared with surgery (7.2% vs 20.2%, respectively; adjusted hazard ratio [HR], 0.33 [95% CI, 0.24 to 0.45]) but significantly more vascular complications (10.3% vs 2.4%; adjusted HR, 4.42 [95% CI, 2.54 to 7.71]), conduction disturbances requiring pacemaker implantation (14.2% vs 7.3%; adjusted HR, 2.05 [95% CI, 1.43 to 2.94]), and mild (38.3% vs 11.7%) or moderate (2.3% vs 0.6%) aortic regurgitation (adjusted odds ratio for mild, moderate, or severe [no instance of severe reported] aortic regurgitation combined vs none, 4.89 [95% CI, 3.08 to 7.75]). CONCLUSIONS AND RELEVANCE Among patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk, TAVI was noninferior to surgery with respect to all-cause mortality at 1 year. TRIAL REGISTRATION isrctn.com Identifier: ISRCTN57819173.
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Affiliation(s)
| | - William D Toff
- Department of Cardiovascular Sciences, University of Leicester, Leicester, England
- National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, England
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, England
| | - Jan Kovac
- Department of Cardiovascular Sciences, University of Leicester, Leicester, England
- National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, England
| | - Michael J Mullen
- Institute of Cardiovascular Science, University College London, London, England
| | - Olaf Wendler
- Department of Cardiothoracic Surgery, King's College Hospital NHS Foundation Trust, London, England
| | - Anita Mansouri
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Ines Rombach
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Keith R Abrams
- Centre for Health Economics, University of York, York, England
- Department of Statistics, University of Warwick, Coventry, England
- Department of Health Sciences, University of Leicester, Leicester, England
| | - Simon P Conroy
- Department of Health Sciences, University of Leicester, Leicester, England
| | - Marcus D Flather
- Norwich Medical School, University of East Anglia, Norwich, England
| | - Alastair M Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England
| | - Philip MacCarthy
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, England
| | - Mark J Monaghan
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, England
| | | | - Simon Ray
- Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, England
| | | | | | - John G F Cleland
- Robertson Centre for Biostatistics and Glasgow Clinical Trials Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - Mark A de Belder
- National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, London, England
| | - Peter F Ludman
- Institute of Cardiovascular Sciences, Birmingham University, Birmingham, England
| | - Stephen Jones
- Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, England
| | - Cameron G Densem
- Department of Cardiology, Royal Papworth Hospital, Cambridge, England
| | - Steven Tsui
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, England
| | - Manoj Kuduvalli
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, England
| | - Joseph D Mills
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, England
| | - Adrian P Banning
- Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Rana Sayeed
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Ragheb Hasan
- Department of Cardiothoracic Surgery, Manchester University NHS Foundation Trust, Manchester, England
| | - Douglas G W Fraser
- Department of Cardiovascular Medicine, University of Manchester, Manchester, England
| | - Uday Trivedi
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, England
| | - Simon W Davies
- Cardiac Department, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, England
| | - Alison Duncan
- Cardiac Department, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, England
| | - Nick Curzen
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, England
| | - Sunil K Ohri
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, England
| | | | - Pankaj Kaul
- Department of Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, England
| | - Douglas F Muir
- Department of Cardiology, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, England
| | - W Andrew Owens
- Department of Cardiothoracic Surgery, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, England
| | - Neal G Uren
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Renzo Pessotto
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Simon Kennon
- Barts Heart Centre, Barts Health NHS Trust, London, England
| | - Wael I Awad
- Barts Heart Centre, Barts Health NHS Trust, London, England
| | - Saib S Khogali
- Heart and Lung Centre, New Cross Hospital, Wolverhampton, England
| | | | - Richard J Edwards
- Cardiothoracic Department, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, England
| | | | - Miles Dalby
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, England
| | - Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, England
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, University of Leicester, Leicester, England
- National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, England
| | - Clinton Lloyd
- Department of Cardiothoracic Surgery, Derriford Hospital, Plymouth, England
| | - Ian D Cox
- Department of Cardiology, Derriford Hospital, Plymouth, England
| | - Simon R Redwood
- Cardiovascular Division, King's College London, British Heart Foundation Centre of Research Excellence, Rayne Institute, St Thomas' Hospital, London, England
| | - Mark G Gunning
- Cardiology Department, Royal Stoke University Hospital, Stoke-on-Trent, England
| | - Paul D Ridley
- Department of Cardiothoracic Surgery, Royal Stoke University Hospital, Stoke-on-Trent, England
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6
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Arunothayaraj S, Cockburn J, Tanseco KV, Newton JD, Banning AP, Kharbanda RK, Cotton JM, Khogali SS, Ludman P, Blackman DJ, Malkin CJ, Palmer SC, Whitbourn RJ, Hildick-Smith D. Procedural Mortality With Transcatheter Aortic Valve Replacement - Balloon Inflation is Associated With Increased Risk. J Invasive Cardiol 2021; 33:E761-E768. [PMID: 34521771] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To assess the impact of balloon use for predilation, valve implantation, or postdilation on in-hospital mortality among patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND TAVR utilizes self-expanding, mechanically expanding, or balloon-expandable valves. Balloon inflation is inherent to deployment of balloon-expandable valves. Balloons may additionally be used with all valve types for pre- and postdilation. The relationships between valve mechanism, balloon use, and in-hospital mortality are not fully characterized. METHODS Prospective data were collected on 4063 patients undergoing TAVR for aortic stenosis at 4 high-volume centers in the United Kingdom. In-hospital mortality was analyzed according to valve expansion mechanism, use of balloons for pre- and postdilation, and specific cause of death. RESULTS Mean patient age was 83 ± 8 years. Implanted valves were self expanding (n = 2241; 55%), mechanically expanding (n = 1092; 27%), or balloon expandable (n = 727; 18%). In-hospital death occurred in 66 cases (1.6%). Thirty-six deaths (54.5%) were classified as implantation-related mortalities, with rates of 0.8%, 0.5%, and 1.7% (P=.04) among self-expanding, mechanically expanding, and balloon-expandable technologies, respectively. Patients who underwent balloon inflation at any stage of their procedure (n = 2556; 63%) had significantly higher implantation-related mortality than those who did not (1.3% vs 0.3%, respectively; P<.01). Balloon-expandable valve procedures were associated with significantly higher all-cause mortality (2.6% vs 1.4%; P=.02) and implantation-related mortality (1.7% vs 0.7%; P=.02) than non-balloon-expandable valve procedures. Balloon-related complications accounted for 18 cases (26%) of total in-hospital mortality, including all 12 cases (17.4%) of annular rupture and 5 cases (7.2%) of coronary occlusion. CONCLUSIONS Balloon use for predilation, valve implantation, or postdilation was associated with an increased mortality risk. Balloon-related complications were the largest contributor to in-hospital mortality, comprising all cases of annular rupture and the majority of coronary occlusion cases.
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Affiliation(s)
- Sandeep Arunothayaraj
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, BN2 5BE Brighton, United Kingdom.
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7
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Maznyczka AM, McCartney PJ, Oldroyd KG, Lindsay M, McEntegart M, Eteiba H, Rocchiccioli JP, Good R, Shaukat A, Robertson K, Malkin CJ, Greenwood JP, Cotton JM, Hood S, Watkins S, Collison D, Gillespie L, Ford TJ, Weir RAP, McConnachie A, Berry C. Risk Stratification Guided by the Index of Microcirculatory Resistance and Left Ventricular End-Diastolic Pressure in Acute Myocardial Infarction. Circ Cardiovasc Interv 2021; 14:e009529. [PMID: 33591821 DOI: 10.1161/circinterventions.120.009529] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The index of microcirculatory resistance (IMR) of the infarct-related artery and left ventricular end-diastolic pressure (LVEDP) are acute, prognostic biomarkers in patients undergoing primary percutaneous coronary intervention. The clinical significance of IMR and LVEDP in combination is unknown. METHODS IMR and LVEDP were prospectively measured in a prespecified substudy of the T-TIME clinical trial (Trial of Low Dose Adjunctive Alteplase During Primary PCI). IMR was measured using a pressure- and temperature-sensing guidewire following percutaneous coronary intervention. Prognostically established thresholds for IMR (>32) and LVEDP (>18 mm Hg) were predefined. Contrast-enhanced cardiovascular magnetic resonance imaging (1.5 Tesla) was acquired 2 to 7 days and 3 months postmyocardial infarction. The primary end point was major adverse cardiac events, defined as cardiac death/nonfatal myocardial infarction/heart failure hospitalization at 1 year. RESULTS IMR and LVEDP were both measured in 131 patients (mean age 59±10.7 years, 103 [78.6%] male, 48 [36.6%] with anterior myocardial infarction). The median IMR was 29 (interquartile range, 17-55), the median LVEDP was 17 mm Hg (interquartile range, 12-21), and the correlation between them was not statistically significant (r=0.15; P=0.087). Fifty-three patients (40%) had low IMR (≤32) and low LVEDP (≤18), 18 (14%) had low IMR and high LVEDP, 31 (24%) had high IMR and low LVEDP, while 29 (22%) had high IMR and high LVEDP. Infarct size (% LV mass), LV ejection fraction, final myocardial perfusion grade ≤1, TIMI (Thrombolysis In Myocardial Infarction) flow grade ≤2, and coronary flow reserve were associated with LVEDP/IMR group, as was hospitalization for heart failure (n=18 events; P=0.045) and major adverse cardiac events (n=21 events; P=0.051). LVEDP>18 and IMR>32 combined was associated with major adverse cardiac events, independent of age, estimated glomerular filtration rate, and infarct-related artery (odds ratio, 5.80 [95% CI, 1.60-21.22] P=0.008). The net reclassification improvement for detecting major adverse cardiac events was 50.6% (95% CI, 2.7-98.2; P=0.033) when LVEDP>18 was added to IMR>32. CONCLUSIONS IMR and LVEDP in combination have incremental value for risk stratification following primary percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02257294.
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Affiliation(s)
- Annette M Maznyczka
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (A.M.M., P.J.M., K.G.O., M.M., H.E., D.C., C.B.), University of Glasgow, United Kingdom.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - Peter J McCartney
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (A.M.M., P.J.M., K.G.O., M.M., H.E., D.C., C.B.), University of Glasgow, United Kingdom.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - Keith G Oldroyd
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (A.M.M., P.J.M., K.G.O., M.M., H.E., D.C., C.B.), University of Glasgow, United Kingdom.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - Mitchell Lindsay
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - Margaret McEntegart
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (A.M.M., P.J.M., K.G.O., M.M., H.E., D.C., C.B.), University of Glasgow, United Kingdom.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - Hany Eteiba
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (A.M.M., P.J.M., K.G.O., M.M., H.E., D.C., C.B.), University of Glasgow, United Kingdom.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - J Paul Rocchiccioli
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - Richard Good
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - Aadil Shaukat
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - Keith Robertson
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - Christopher J Malkin
- Leeds University and Leeds Teaching Hospitals NHS Trust, United Kingdom (C.J.M., J.P.G.)
| | - John P Greenwood
- Leeds University and Leeds Teaching Hospitals NHS Trust, United Kingdom (C.J.M., J.P.G.)
| | - James M Cotton
- Wolverhampton University Hospital NHS Trust, United Kingdom (J.M.C.)
| | - Stuart Hood
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - Stuart Watkins
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - Damien Collison
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (A.M.M., P.J.M., K.G.O., M.M., H.E., D.C., C.B.), University of Glasgow, United Kingdom.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - Lynsey Gillespie
- Project Management Unit, Greater Glasgow and Clyde Health Board, United Kingdom (L.G.)
| | - Thomas J Ford
- Faculty of Medicine, University of Newcastle, Callaghan NSW, Australia (T.J.F.).,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
| | - Robin A P Weir
- University Hospital Hairmyres, East Kilbride, United Kingdom (R.A.P.W.)
| | - Alex McConnachie
- Robertson Centre for Biostatistics (A.M.), University of Glasgow, United Kingdom
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (A.M.M., P.J.M., K.G.O., M.M., H.E., D.C., C.B.), University of Glasgow, United Kingdom.,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, Glasgow, United Kingdom (A.M.M., P.J.M., K.G.O., M.L., M.M., H.E., J.P.R., R.G., A.S., K.R., S.H., S.W., D.C., T.J.F., C.B.)
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8
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Ali N, Patel P, Wahab A, Das A, Blackman DJ, Cunnington MS, Malkin CJ. A cohort study examining urgent and emergency treatment for decompensated severe aortic stenosis. J Cardiovasc Med (Hagerstown) 2021; 22:126-132. [PMID: 32941330 DOI: 10.2459/jcm.0000000000001112] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS We compared strategies in the treatment of decompensated severe aortic stenosis. The hypothesis was that undertaking urgent or emergency transcatheter aortic valve implantation (TAVI) directly in such patients is safer and more effective than urgent or emergency balloon aortic valvuloplasty (BAV) followed by elective TAVI or surgical aortic valve replacement (SAVR). METHODS This was a single-centre retrospective study including all consecutive patients who underwent urgent or emergency BAV or TAVI for decompensated severe aortic stenosis between September 2014 and February 2018. Primary endpoints were 30-day and 1-year mortality. RESULTS Fifty-two patients underwent urgent or emergency BAV and 87 underwent TAVI. Baseline characteristics of the two groups were well matched. Significant differences were noted between the two groups in 30-day all-cause mortality (88.5% BAV patients alive at 30 days, 97.7% TAVI patients; P < 0.05) and 1-year all-cause mortality (44.2% BAV patients alive at 1 year, 88.5% TAVI patients; P < 0.001). At 1 year, the estimated hazard ratio for patients undergoing BAV was 11.2 (95% confidence interval: 4.67-26.9; P < 0.001) when adjusted for potential confounding variables. Patients in the BAV group who successfully underwent subsequent TAVI or SAVR all survived for 365 days, but there was no significant 1-year mortality difference compared with those who underwent urgent or emergency TAVI (100 vs. 88.5%; P > 0.155). CONCLUSION Our results suggest treatment of decompensated severe aortic stenosis with urgent or emergency TAVI may be associated with improved survival outcomes when compared with a strategy of performing BAV as a bridge to subsequent TAVI or SAVR.
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Affiliation(s)
- Noman Ali
- Department of Cardiology, Leeds General Infirmary, Leeds, UK
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9
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Ali N, Malkin CJ, Cunnington MS, Lederman RJ, Blackman DJ. Untreatable Severe Structural Degeneration of a Transcatheter Aortic Heart Valve. JACC Case Rep 2020; 2:347-351. [PMID: 34291227 PMCID: PMC8290901 DOI: 10.1016/j.jaccas.2020.01.023] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/14/2020] [Indexed: 10/25/2022]
Abstract
We describe a patient who presented with heart failure 7 years post-transcatheter aortic valve implantation (TAVI) as a result of severe structural valve degeneration. Anatomic challenges, combined with the type of transcatheter heart valve used initially, meant that TAVI-in-TAVI risked obstructing the coronary arteries, even if preceded by bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction. The patient was treated with balloon aortic valvuloplasty.
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Affiliation(s)
- Noman Ali
- Department of Cardiology, Leeds General Infirmary, Leeds, United Kingdom
| | | | | | | | - Daniel J. Blackman
- Department of Cardiology, Leeds General Infirmary, Leeds, United Kingdom
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10
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Dowling C, Firoozi S, Panoulas V, Dalby M, Kashyap MN, Kabir T, Kalogeras K, Buch MH, Levy R, Chowdhary S, Saraf S, Roberts D, More R, Wiper A, Abdelaziz HK, Neylon A, Mylotte D, Pisaniello AD, Fraser DGW, Anderson R, Cunnington MS, Malkin CJ, Blackman DJ, Brennan PF, Owens CG, Manoharan G, Spence MS, Brecker SJ. Initial experience of a self-expanding transcatheter aortic valve with an outer pericardial wrap: The United Kingdom and Ireland Implanters' registry. Catheter Cardiovasc Interv 2019; 95:1340-1346. [PMID: 31713325 DOI: 10.1002/ccd.28512] [Citation(s) in RCA: 5] [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: 04/09/2019] [Revised: 07/12/2019] [Accepted: 09/16/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The United Kingdom and Ireland Implanters' registry is a multicenter registry which reports on real-world experience with new transcatheter heart valves. BACKGROUND The Evolut PRO (Medtronic, Minneapolis, MN) transcatheter aortic valve is a self-expanding transcatheter aortic valve with an outer pericardial wrap, designed to minimize paravalvular regurgitation. METHODS Between July 2017 and December 2018, clinical, procedural, and 30-day outcome data were prospectively collected from all patients receiving the Evolut PRO valve across nine participating centers in the United Kingdom and Ireland. The primary efficacy outcome was the Valve Academic Research Consortium-2 (VARC-2)-defined endpoint of device success. The primary safety outcome was the VARC-2-defined composite endpoint of early safety at 30 days. RESULTS A total of 317 patients underwent implantation. Mean age was 81.8 ± 6.4 years and Society of Thoracic Surgeons Predicted Risk of Mortality Score 5.5 ± 1.8%. Iliofemoral access was used in 99.1% of patients. Device success was 91.2%. Mean gradient was 7.6 ± 4.7 mmHg and effective orifice area 1.9 ± 0.7 cm2 . The incidence of moderate paravalvular regurgitation was 1.7% and there was no severe paravalvular regurgitation. A new permanent pacemaker was implanted in 17.8% of patients without a pacemaker at baseline. Early safety was demonstrated in 92.7%. At 30 days, all-cause mortality was 0.6%, stroke 3.8%, and major vascular complication 2.8%. CONCLUSIONS Real-world experience of the Evolut PRO transcatheter aortic valve demonstrated favorable procedural success, safety, valve function, and incidence of new permanent pacemaker implantation.
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Affiliation(s)
- Cameron Dowling
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's Hospital, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Sami Firoozi
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's Hospital, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Vasileios Panoulas
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Miles Dalby
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Mavin N Kashyap
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Tito Kabir
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Konstantinos Kalogeras
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Mamta H Buch
- North West Cardiac Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Richard Levy
- North West Cardiac Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Saqib Chowdhary
- North West Cardiac Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Smriti Saraf
- North West Cardiac Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Department of Cardiology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - David Roberts
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Ranjit More
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Andrew Wiper
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Hesham K Abdelaziz
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK.,Cardiovascular Department, Ain Shams University, Cairo, Egypt
| | - Antoinette Neylon
- Department of Cardiology, University Hospital Galway, Galway University Hospitals, Galway, Ireland
| | - Darren Mylotte
- Department of Cardiology, University Hospital Galway, Galway University Hospitals, Galway, Ireland
| | - Anthony D Pisaniello
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Douglas G W Fraser
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Michael S Cunnington
- Department of Cardiology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christopher J Malkin
- Department of Cardiology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Daniel J Blackman
- Department of Cardiology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul F Brennan
- Belfast Heart Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Colum G Owens
- Belfast Heart Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Ganesh Manoharan
- Belfast Heart Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Mark S Spence
- Belfast Heart Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Stephen J Brecker
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's Hospital, St. George's University Hospitals NHS Foundation Trust, London, UK
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11
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Abstract
Use of angiography for the assessment of coronary lesions is limited by its inability to provide information regarding the functional significance of stenoses. A number of studies have demonstrated the presence of ischaemia to be the most important determinant of the benefit associated with coronary revascularisation in stable coronary artery disease. Assessment of intra-coronary physiology can guide percutaneous coronary intervention, and is often used for angiographically borderline stenoses. There is now increasing evidence to suggest that more routine use can improve clinical outcomes. Fractional flow reserve (FFR) is the most established measure of intra-coronary physiology, but is currently under-utilised. The main drawback of FFR is the dependence on a pharmacological infusion to maintain hyperaemia. An alternative technique which measures flow at a specific point in the cardiac cycle (instantaneous wave-free ratio) has been developed which obviates the need for hyperaemia and may replace FFR as the default measure.
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12
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Witte KK, Lipiecki J, Siminiak T, Meredith IT, Malkin CJ, Goldberg SL, Stark MA, von Bardeleben RS, Cremer PC, Jaber WA, Celermajer DS, Kaye DM, Sievert H. The REDUCE FMR Trial: A Randomized Sham-Controlled Study of Percutaneous Mitral Annuloplasty in Functional Mitral Regurgitation. JACC Heart Fail 2019; 7:945-955. [PMID: 31521683 DOI: 10.1016/j.jchf.2019.06.011] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/12/2019] [Accepted: 06/17/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVES This study sought to evaluate the effects of the Carillon device on mitral regurgitation severity and left ventricular remodeling. BACKGROUND Functional mitral regurgitation (FMR) complicates heart failure with reduced ejection fraction and is associated with a poor prognosis. METHODS In this blinded, randomized, proof-of-concept, sham-controlled trial, 120 patients receiving optimal heart failure medical therapy were assigned to a coronary sinus-based mitral annular reduction approach for FMR or sham. The pre-specified primary endpoint was change in mitral regurgitant volume at 12 months, measured by quantitative echocardiography according to an intention-to-treat analysis. RESULTS Patients (69.8 ± 9.5 years of age) were randomized to either the treatment (n = 87) or the sham-controlled (n = 33) arm. There were no significant differences in baseline characteristics between the groups. In the treatment group, 73 of 87 (84%) had the device implanted. The primary endpoint was met, with a statistically significant reduction in mitral regurgitant volume in the treatment group compared to the control group (decrease of 7.1 ml/beat [95% confidence interval [CI]: -11.7 to -2.5] vs. an increase of 3.3 ml/beat [95% CI: -6.0 to 12.6], respectively; p = 0.049). Additionally, there was a significant reduction in left ventricular volumes in patients receiving the device versus those in the control group (left ventricular end-diastolic volume decrease of 10.4 ml [95% CI: -18.5 to -2.4] vs. an increase of 6.5 ml [95% CI: -5.1 to 18.2]; p = 0.03 and left ventricular end-systolic volume decrease of 6.2 ml [95% CI: -12.8 to 0.4] vs. an increase of 6.1 ml [95% CI: -1.42 to 13.6]; p = 0.04). CONCLUSIONS The Carillon device significantly reduced mitral regurgitant volume and left ventricular volumes in symptomatic patients with functional mitral regurgitation receiving optimal medical therapy. (Carillon Mitral Contour System for Reducing Functional Mitral Regurgitation [REDUCE FMR]; NCT02325830).
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Affiliation(s)
- Klaus K Witte
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
| | | | - Tomasz Siminiak
- Poznan University of Medical Sciences, HCP Medical Center, Poznan, Poland
| | - Ian T Meredith
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Christopher J Malkin
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Steven L Goldberg
- Tyler Heart Institute at Community Hospital of the Monterey Peninsula, Monterey, California; Cardiac Dimensions, Kirkland, Washington
| | | | | | - Paul C Cremer
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Wael A Jaber
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - David S Celermajer
- Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Horst Sievert
- CardioVascular Center Sankt Katherinen, Frankfurt, Germany; Anglia Ruskin University, Chelmsford, United Kingdom
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13
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Goldberg SL, Kapadia S, Witte KK, Kaye DM, Lipiecki J, Siminiak T, Malkin CJ, Sievert H. Impact of Carillon on COAPT Eligible/Non-Eligible Patients. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.486] [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] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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14
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Ali N, Blackman DJ, Cunnington M, Malkin CJ. Use of the MANTA device to rescue failed pre-closure following transfemoral transcatheter aortic valve implantation. J Cardiol Cases 2019; 19:81-84. [DOI: 10.1016/j.jccase.2018.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/21/2018] [Accepted: 12/12/2018] [Indexed: 11/15/2022] Open
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15
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Blackman DJ, Saraf S, MacCarthy PA, Myat A, Anderson SG, Malkin CJ, Cunnington MS, Somers K, Brennan P, Manoharan G, Parker J, Aldalati O, Brecker SJ, Dowling C, Hoole SP, Dorman S, Mullen M, Kennon S, Jerrum M, Chandrala P, Roberts DH, Tay J, Doshi SN, Ludman PF, Fairbairn TA, Crowe J, Levy RD, Banning AP, Ruparelia N, Spence MS, Hildick-Smith D. Long-Term Durability of Transcatheter Aortic Valve Prostheses. J Am Coll Cardiol 2019; 73:537-545. [DOI: 10.1016/j.jacc.2018.10.078] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 10/23/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
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16
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Waduud MA, Giannoudi M, Drozd M, Malkin CJ, Patel JV, Scott DJA. Coronary subclavian steal syndrome-is there a need for routine assessment for subclavian artery stenosis following coronary bypass surgery? Oxf Med Case Reports 2018; 2018:omy102. [PMID: 30487988 PMCID: PMC6247140 DOI: 10.1093/omcr/omy102] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 09/05/2018] [Accepted: 09/24/2018] [Indexed: 11/14/2022] Open
Abstract
Subclavian artery stenosis (SAS) resulting in coronary subclavian steal syndrome (CSSS) is a common but under recognized pathology following coronary artery bypass surgery (CABG). Patients with SAS may be asymptomatic due to the sub-clinical diversion of blood flow from the myocardium and retrograde blood flow during catheter angiography in the left internal mammary artery (LIMA) may be the first suggestion of CSSS. The management of SAS, causing CSSS, may rarely require acute assessment and intervention. However, full anatomical assessment of the stenosis morphology may be limited on fluoroscopy. Correction of SAS may be essential to achieve effective reperfusion therapy.
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Affiliation(s)
- M A Waduud
- Leeds Vascular Institute, Leeds General Infirmary, Leeds, UK
| | - M Giannoudi
- Leeds Vascular Institute, Leeds General Infirmary, Leeds, UK
| | - M Drozd
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - C J Malkin
- Department of Cardiology, Leeds General Infirmary, Leeds, UK
| | - J V Patel
- Leeds Vascular Institute, Leeds General Infirmary, Leeds, UK
| | - D J A Scott
- Leeds Vascular Institute, Leeds General Infirmary, Leeds, UK
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17
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Dowling C, Firoozi S, Doyle N, Blackman DJ, Malkin CJ, Cunnington MS, Saraf S, Buch MH, Levy R, Chowdhary S, Spence MS, Manoharan G, Owens CG, Brennan PF, Roberts D, More R, Wiper A, Abdelaziz HK, Mylotte D, Neylon A, Martin N, Mercanti F, Dorman S, Panoulas V, Dalby M, Kashyap MN, Kabir T, Kovac J, Kontoprias K, Malik IS, Ghada MW, Sen S, Ruparelia N, Demir OM, Frame A, Uren NG, Anderson R, Rajathurai T, Tapp L, Deegan L, Grech E, Hall I, Neville M, Rampat R, Hildick-Smith D, Mullen M, Kennon S, Chandrala P, Doshi S, Brecker SJ. Initial experience of a large, self-expanding, and fully recapturable transcatheter aortic valve: The UK & Ireland Implanters' registry. Catheter Cardiovasc Interv 2018; 93:751-757. [PMID: 30394657 DOI: 10.1002/ccd.27934] [Citation(s) in RCA: 10] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/04/2018] [Accepted: 09/23/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The UK & Ireland Implanters' registry is a multicenter registry which reports on real-world experience with novel transcatheter heart valves. BACKGROUND The 34 mm Evolut R transcatheter aortic valve is a self-expanding and fully recapturable transcatheter aortic valve, designed to treat patients with a large aortic annulus. METHODS Between January 2017 and April 2018, clinical, procedural and 30-day outcome data were prospectively collected from all patients receiving the 34 mm Evolut R valve across 17 participating centers in the United Kingdom and Ireland. The primary efficacy outcome was the Valve Academic Research Consortium-2(VARC-2)-defined endpoint of device success. The primary safety outcome was the VARC-2-defined composite endpoint of early safety at 30 days. RESULTS A total of 217 patients underwent attempted implant. Mean age was 79.5 ± 8.8 years and Society of Thoracic Surgeons Predicted Risk of Mortality Score 5.2% ± 3.4%. Iliofemoral access was used in 91.2% of patients. Device success was 79.7%. Mean gradient was 7.0 ± 4.6 mmHg and effective orifice area 2.0 ± 0.6 cm2 . Paravalvular regurgitation was more than mild in 7.2%. A new permanent pacemaker was implanted in 15.7%. Early safety was demonstrated in 91.2%. At 30 days, all-cause mortality was 3.2%, stroke 3.7%, and major vascular complication 2.3%. CONCLUSIONS Real-world experience of the 34 mm Evolut R transcatheter aortic valve demonstrated acceptable procedural success, safety, valve function, and incidence of new permanent pacemaker implantation.
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Affiliation(s)
- Cameron Dowling
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sami Firoozi
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Niamh Doyle
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Daniel J Blackman
- Department of Cardiology, Leeds General Infirmary, Leeds, United Kingdom
| | | | | | - Smriti Saraf
- Department of Cardiology, Leeds General Infirmary, Leeds, United Kingdom.,Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Mamta H Buch
- Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Richard Levy
- Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Saqib Chowdhary
- Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Mark S Spence
- Belfast Heart Centre, Royal Victoria Hospital, Belfast, United Kingdom
| | - Ganesh Manoharan
- Belfast Heart Centre, Royal Victoria Hospital, Belfast, United Kingdom
| | - Colum G Owens
- Belfast Heart Centre, Royal Victoria Hospital, Belfast, United Kingdom
| | - Paul F Brennan
- Belfast Heart Centre, Royal Victoria Hospital, Belfast, United Kingdom
| | - David Roberts
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Ranjit More
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Andrew Wiper
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Hesham K Abdelaziz
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, United Kingdom.,Cardiovascular Department, Ain Shams University, Cairo, Egypt
| | - Darren Mylotte
- Department of Cardiology, University Hospital Galway, Galway, Ireland
| | - Antoinette Neylon
- Department of Cardiology, University Hospital Galway, Galway, Ireland
| | - Niamh Martin
- Department of Cardiology, University Hospital Galway, Galway, Ireland
| | - Federico Mercanti
- Department of Cardiology, University Hospital Galway, Galway, Ireland
| | - Stephen Dorman
- Department of Cardiology, Bristol Heart Institute, Bristol, United Kingdom
| | | | - Miles Dalby
- Department of Cardiology, Harefield Hospital, London, United Kingdom
| | - Mavin N Kashyap
- Department of Cardiology, Harefield Hospital, London, United Kingdom
| | - Tito Kabir
- Department of Cardiology, Harefield Hospital, London, United Kingdom
| | - Jan Kovac
- Biomedical Research Unit, University of Leicester, Leicester, United Kingdom
| | - Kosmas Kontoprias
- Biomedical Research Unit, University of Leicester, Leicester, United Kingdom
| | - Iqbal S Malik
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Mikhail W Ghada
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sayan Sen
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Neil Ruparelia
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ozan M Demir
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Angela Frame
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Neal G Uren
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom
| | | | - Luke Tapp
- Department of Cardiology, University Hospital, Coventry, United Kingdom
| | - Lauren Deegan
- Department of Cardiology, University Hospital, Coventry, United Kingdom
| | - Ever Grech
- Department of Cardiology, Northern General Hospital, Sheffield, United Kingdom
| | - Ian Hall
- Department of Cardiology, Northern General Hospital, Sheffield, United Kingdom
| | - Melanie Neville
- Department of Cardiology, Northern General Hospital, Sheffield, United Kingdom
| | - Rajiv Rampat
- Department of Cardiology, Royal Sussex County Hospital, Brighton, United Kingdom
| | - David Hildick-Smith
- Department of Cardiology, Royal Sussex County Hospital, Brighton, United Kingdom
| | - Michael Mullen
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Simon Kennon
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Pavan Chandrala
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Sagar Doshi
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Stephen J Brecker
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
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Ali N, Saraf S, Schlosshan D, Cunnington M, Malkin CJ, Blackman DJ. Trans-catheter aortic valve implantation without contrast using the Lotus mechanically-expanded heart valve. J Cardiol Cases 2018; 18:141-144. [DOI: 10.1016/j.jccase.2018.06.007] [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] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/08/2018] [Accepted: 06/11/2018] [Indexed: 11/30/2022] Open
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19
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Krishnamurthy A, Keeble C, Burton-Wood N, Somers K, Anderson M, Harland C, Baxter PD, McLenachan JM, Blaxill JM, Blackman DJ, Malkin CJ, Wheatcroft SB, Greenwood JP. Clinical outcomes following primary percutaneous coronary intervention for ST-elevation myocardial infarction according to sex and race. European Heart Journal: Acute Cardiovascular Care 2017; 8:264-272. [DOI: 10.1177/2048872617735803] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Female sex and South Asian race have been associated with poor clinical outcomes following primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) but remain understudied in large real-world series. We therefore investigated the association of sex and race with clinical outcomes following PPCI. Methods: We conducted a prospective study of all patients undergoing PPCI for STEMI between January 2009 and December 2011 at a large UK cardiac centre. Clinical characteristics and outcomes were compared according to sex and race using Chi-square test, independent samples Student’s t-test and Mann–Whitney U-test. Primary and secondary outcomes were 12-month major adverse cardiovascular events (MACEs) – defined as all-cause mortality, myocardial infarction and unplanned revascularization, analysed using Cox proportional hazard models adjusting for cardiovascular risk factors. Results: Three thousand and forty-nine patients were included. Women ( n=826) were older than men ( n=2223) (median age 69 vs. 60 years, p <0.01). Mortality (hazard ratio 1.48 (1.15–1.90)) and MACE (hazard ratio 1.40 (1.14–1.72)) were higher in women in univariable analysis. However, there were no significant sex-differences in mortality or MACE after age-stratification alone. Multivariable analysis also showed no significant differences in outcomes between sexes. South Asians ( n=297) were younger but had a higher prevalence of most risk factors than White patients ( n=2570). Mortality and MACE did not differ significantly between South Asian and White patients in univariable or multivariable analysis. Conclusion: MACE and mortality was not greater in women, or in South Asian patients following PPCI after adjustment for cardiovascular risk factors including age, which was most strongly associated with both outcomes.
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Affiliation(s)
- Arvindra Krishnamurthy
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Leeds General Infirmary, UK
| | - Claire Keeble
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
| | | | | | | | | | - Paul D Baxter
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
| | | | | | | | | | - Stephen B Wheatcroft
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Leeds General Infirmary, UK
| | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Leeds General Infirmary, UK
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20
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Grube E, Van Mieghem NM, Bleiziffer S, Modine T, Bosmans J, Manoharan G, Linke A, Scholtz W, Tchétché D, Finkelstein A, Trillo R, Fiorina C, Walton A, Malkin CJ, Oh JK, Qiao H, Windecker S, Grube E, Windecker S, Bosmans J, Bleiziffer S, Manoharan G, Modine T, Van Mieghem N, Sinhal A, Gooley R, Walton T, Yong G, Bosmans J, Webb J, Chu M, Radhakrishnan S, Dager A, Branny M, Tchetche D, Modine T, Teiger E, Chevalier B, Himbert D, Schymik G, Zeus T, Jensen C, Rassaf T, Fichtlscherer S, Nickenig G, Linke A, Bleiziffer S, Kempfert J, Scholtz W, Harnath A, Strasser R, Frerker C, Spargias K, Merkely BP, Finkelstein A, Tamburino C, Colombo A, Petronio AS, Fiorina C, Bedogni F, Amoroso G, van der Heijden J, Van Mieghem N, Tonino P, Echeverria Beliz P, Witkowski A, Gama Ribeiro V, Al Abdullah M, Weich H, Trillo R, Hernández García JM, Moris C, Jönsson AL, Malkin CJ, Khogali S, Hildick-Smith D, Manoharan G. Clinical Outcomes With a Repositionable Self-Expanding Transcatheter Aortic Valve Prosthesis. J Am Coll Cardiol 2017; 70:845-853. [DOI: 10.1016/j.jacc.2017.06.045] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 06/13/2017] [Accepted: 06/13/2017] [Indexed: 11/30/2022]
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21
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Krishnamurthy A, M Keeble C, Burton-Wood N, Somers K, Anderson M, Harland C, M McLenachan J, M Blaxill J, J Blackman D, J Malkin C, B Wheatcroft S, P Greenwood J. 26 Clinical outcomes following primary percutaneous coronary intervention: a comparison of clopidogrel, prasugrel and ticagrelor. Heart 2017. [DOI: 10.1136/heartjnl-2017-311726.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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22
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Dobson LE, Musa TA, Uddin A, Fairbairn TA, Bebb OJ, Swoboda PP, Haaf P, Foley J, Garg P, Fent GJ, Malkin CJ, Blackman DJ, Plein S, Greenwood JP. The impact of trans-catheter aortic valve replacement induced left-bundle branch block on cardiac reverse remodeling. J Cardiovasc Magn Reson 2017; 19:22. [PMID: 28222749 PMCID: PMC5320804 DOI: 10.1186/s12968-017-0335-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/02/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Left bundle branch block (LBBB) is common following trans-catheter aortic valve replacement (TAVR) and has been linked to increased mortality, although whether this is related to less favourable cardiac reverse remodeling is unclear. The aim of the study was to investigate the impact of TAVR induced LBBB on cardiac reverse remodeling. METHODS 48 patients undergoing TAVR for severe aortic stenosis were evaluated. 24 patients with new LBBB (LBBB-T) following TAVR were matched with 24 patients with a narrow post-procedure QRS (nQRS). Patients underwent cardiovascular magnetic resonance (CMR) prior to and 6 m post-TAVR. Measured cardiac reverse remodeling parameters included left ventricular (LV) size, ejection fraction (LVEF) and global longitudinal strain (GLS). Inter- and intra-ventricular dyssynchrony were determined using time to peak radial strain derived from CMR Feature Tracking. RESULTS In the LBBB-T group there was an increase in QRS duration from 96 ± 14 to 151 ± 12 ms (P < 0.001) leading to inter- and intra-ventricular dyssynchrony (inter: LBBB-T 130 ± 73 vs nQRS 23 ± 86 ms, p < 0.001; intra: LBBB-T 118 ± 103 vs. nQRS 13 ± 106 ms, p = 0.001). Change in indexed LV end-systolic volume (LVESVi), LVEF and GLS was significantly different between the two groups (LVESVi: nQRS -7.9 ± 14.0 vs. LBBB-T -0.6 ± 10.2 ml/m2, p = 0.02, LVEF: nQRS +4.6 ± 7.8 vs LBBB-T -2.1 ± 6.9%, p = 0.002; GLS: nQRS -2.1 ± 3.6 vs. LBBB-T +0.2 ± 3.2%, p = 0.024). There was a significant correlation between change in QRS and change in LVEF (r = -0.434, p = 0.002) and between change in QRS and change in GLS (r = 0.462, p = 0.001). Post-procedure QRS duration was an independent predictor of change in LVEF and GLS at 6 months. CONCLUSION TAVR-induced LBBB is associated with less favourable cardiac reverse remodeling at medium term follow up. In view of this, every effort should be made to prevent TAVR-induced LBBB, especially as TAVR is now being extended to a younger, lower risk population.
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Affiliation(s)
- Laura E. Dobson
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Tarique A. Musa
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Akhlaque Uddin
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Timothy A. Fairbairn
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Owen J. Bebb
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Peter P. Swoboda
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Philip Haaf
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - James Foley
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Pankaj Garg
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | - Graham J. Fent
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
| | | | - Daniel J. Blackman
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX UK
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX UK
| | - John P. Greenwood
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Clarendon Way, Leeds, LS2 9JT UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX UK
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Malkin CJ, Long WR, Baxter PD, Gale CP, Wendler O, Monaghan M, Thomas MT, Ludman PF, de Belder MA, Cunningham AD, Moat NE, Blackman DJ. Impact of left ventricular function and transaortic gradient on outcomes from transcatheter aortic valve implantation: data from the UK TAVI Registry. EUROINTERVENTION 2016; 11:1161-9. [PMID: 25539417 DOI: 10.4244/eijy14m12_12] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [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: 11/23/2022]
Abstract
AIMS Aortic valve surgery in the presence of reduced ejection fraction (EF) or low transaortic gradient is associated with adverse outcome. Low gradient (LG) may be associated with reduced EF, known as low EF-low gradient (LEF-LG), or "paradoxically" low with normal EF (P-LG). Our aim was to investigate the impact of EF and transaortic gradient on outcome following transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS We retrospectively analysed the UK TAVI Registry from 2007 to 2011 (n=2,535 consecutive patients, mean age 81.3±7.5, logistic EuroSCORE 21.8±14). Thirty-day mortality was 7.8%, low EF (<50%) was present in 39%, low gradient (<64 mmHg) was present in 27%, LEF-LG in 15% and P-LG in 12% of patients, respectively. LEF-LG patients had the highest risk profile vs. the other groups (EuroSCORE 30±16 vs. 20±12, p<0.001). Neither EF nor gradient impacted on procedural outcome or 30-day mortality. Mortality at two years was significantly higher in LEF-LG patients (34.7%), whereas, in patients with low EF/high gradient (27.8%) or normal EF/low gradient (23%), mortality was not significantly different from that of normal EF/high gradient (23%) patients. LEF-LG independently predicted reduced survival, HR 1.7 (1.4-2.1). CONCLUSIONS Neither low EF nor low gradient affected procedural success or 30-day mortality. Long-term survival was reduced in LEF-LG patients but not in those with low EF and high gradient or P-LG with normal EF.
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Dobson LE, Musa TA, Uddin A, Fairbairn TA, Swoboda PP, Erhayiem B, Foley J, Garg P, Haaf P, Fent GJ, Malkin CJ, Blackman DJ, Plein S, Greenwood JP. Acute Reverse Remodelling After Transcatheter Aortic Valve Implantation: A Link Between Myocardial Fibrosis and Left Ventricular Mass Regression. Can J Cardiol 2016; 32:1411-1418. [DOI: 10.1016/j.cjca.2016.04.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 04/18/2016] [Accepted: 04/21/2016] [Indexed: 10/21/2022] Open
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Dobson L, Musa TA, Akhlaque U, Fairbairn TA, Bebb OJ, Swoboda PP, Haaf P, Foley J, Garg P, Fent GJ, Malkin CJ, Blackman DJ, Plein S, Greenwood JP. 39 The Impact of New Left Bundle Branch Block Following Trans-Catheter Aortic Valve Impantation. Is There a TAVI LBBB-induced Cardiomyopathy? Insights from Cardiovascular Magnetic Resonance Imaging. Heart 2016. [DOI: 10.1136/heartjnl-2016-309890.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Foley JRJ, Dobson LE, Musa TA, Fairbairn TA, Uddin A, Swoboda PP, Garg P, Fent G, Haaf P, Malkin CJ, Blackman DJ, Plein S, Greenwood JP. 42 Gender Differences in Response to Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis Assessed by Feature Tracking. Heart 2016. [DOI: 10.1136/heartjnl-2016-309890.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Musa TA, Uddin A, Dobson LE, Swoboda PP, Garg P, Fent GJ, Foley JRJ, Malkin CJ, Plein S, Blackman DJ, Greenwood JP. 40 Quantification of Aortic Regurgitation Following Transcatheter Aortic Valve Implantation (TAVI): A CMR Study of Two Prosthesis Designs. Heart 2016. [DOI: 10.1136/heartjnl-2016-309890.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Dobson L, Musa TA, Uddin A, Fairbairn TA, Swoboda PP, Ripley DP, Erhayiem B, McDiarmid AK, Garg P, Evans B, Malkin CJ, Blackman DJ, Plein S, Greenwood JP. 38 Myocardial Infarction following Surgical and Trans-Catheter Aortic Valve Replacement – Is Peri-Procedural Revascularisation for TAVI Necessary? Heart 2016. [DOI: 10.1136/heartjnl-2016-309890.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Krishnamurthy A, Somers K, Burton-Wood N, Anderson M, Harland C, Keeble C, Mclenachan JM, Blaxill JM, Malkin CJ, Blackman DJ, Wheatcroft SB, Greenwood JP. 33 Influence of ethnicity on outcomes in primary percutaneous coronary intervention for ST-elevation myocardial infarction. Heart 2016. [DOI: 10.1136/heartjnl-2016-309588.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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30
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Dobson LE, Fairbairn TA, Musa TA, Uddin A, Mundie CA, Swoboda PP, Ripley DP, McDiarmid AK, Erhayiem B, Garg P, Malkin CJ, Blackman DJ, Sharples LD, Plein S, Greenwood JP. Sex-related differences in left ventricular remodeling in severe aortic stenosis and reverse remodeling after aortic valve replacement: A cardiovascular magnetic resonance study. Am Heart J 2016; 175:101-11. [PMID: 27179729 DOI: 10.1016/j.ahj.2016.02.010] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 02/10/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cardiac adaptation to aortic stenosis (AS) appears to differ according to sex, but reverse remodeling after aortic valve replacement has not been extensively described. The aim of the study was to determine using cardiac magnetic resonance imaging whether any sex-related differences exist in AS in terms of left ventricular (LV) remodeling, myocardial fibrosis, and reverse remodeling after valve replacement. METHODS One hundred patients (men, n = 60) with severe AS undergoing either transcatheter or surgical aortic valve replacement underwent cardiac magnetic resonance scans at baseline and 6 months after valve replacement. RESULTS Despite similar baseline comorbidity and severity of AS, women had a lower indexed LV mass than did men (65.3 ± 18.4 vs 81.5 ± 21.3 g/m(2), P < .001) and a smaller indexed LV end-diastolic volume (87.3 ± 17.5 vs 101.2 ± 28.6 mL/m(2), P = .002) with a similar LV ejection fraction (58.6% ± 10.2% vs 54.8% ± 12.9%, P = .178). Total myocardial fibrosis mass was similar between sexes (2.3 ± 4.1 vs 1.3 ± 1.1 g, P = .714), albeit with a differing distribution according to sex. After aortic valve replacement, men had more absolute LV mass regression than did women (18.3 ± 10.6 vs 12.7 ± 8.8 g/m(2), P = .007). When expressed as a percentage reduction of baseline indexed LV mass, mass regression was similar between the sexes (men 21.7% ± 10.1% vs women 18.4% ± 11.0%, P = .121). There was no sex-related difference in postprocedural LV ejection fraction or aortic regurgitation. Sex was not found to be a predictor of LV reverse remodeling on multiple regression analysis. CONCLUSIONS There are significant differences in the way that male and female hearts adapt to AS. Six months after aortic valve replacement, there are no sex-related differences in reverse remodeling, but superior reverse remodeling in men as a result of their more adverse remodeling profile at baseline.
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Fröhlich GM, Baxter PD, Malkin CJ, Scott DJA, Moat NE, Hildick-Smith D, Cunningham D, MacCarthy PA, Trivedi U, de Belder MA, Ludman PF, Blackman DJ. Comparative survival after transapical, direct aortic, and subclavian transcatheter aortic valve implantation (data from the UK TAVI registry). Am J Cardiol 2015; 116:1555-9. [PMID: 26409640 DOI: 10.1016/j.amjcard.2015.08.035] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [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: 06/10/2015] [Revised: 08/04/2015] [Accepted: 08/04/2015] [Indexed: 12/20/2022]
Abstract
Many patients have iliofemoral vessel anatomy unsuitable for conventional transfemoral (TF) transcatheter aortic valve implantation (TAVI). Safe and practical alternatives to the TF approach are, therefore, needed. This study compared outcomes of alternative nonfemoral routes, transapical (TA), direct aortic (DA), and subclavian (SC), with standard femoral access. In this retrospective study, data from 3,962 patients in the UK TAVI registry were analyzed. All patients who received TAVI through a femoral, subclavian, TA, or DA approach were eligible for inclusion. The primary outcome measure was survival up to 2 years. Median Logistic EuroSCORE was similar for SC, DA, and TA but significantly lower in the TF cohort (22.1% vs 20.3% vs 21.2% vs 17.0%, respectively, p <0.0001). Estimated 1-year survival rate was similar for TF (84.6 ± 0.7%) and SC (80.5 ± 3%, p = 0.27) but significantly worse for TA (74.7 ± 1.6%, p <0.001) and DA (75.2 ± 3.3%, p <0.001). A Cox proportional hazard model was used to analyze survival up to 2 years. Survival in the SC group was not significantly different from the TF group (hazard ratio [HR] 1.22, 95% confidence interval [CI] 0.88 to 1.70, p = 0.24). In contrast, survival in the TA (HR 1.74, 95% CI 1.43 to 2.11; p <0.001) and DA (HR 1.55, 95% CI 1.13 to 2.14; p <0.01) cohorts was significantly reduced compared with TF. In conclusion, TA and DA TAVI were associated with similar survival, both significantly worse than with the TF route. In contrast, subclavian access was not significantly different from TF and may represent the safest nonfemoral access route for TAVI.
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Affiliation(s)
- Georg M Fröhlich
- Department of Cardiology, Leeds Teaching Hospitals, Leeds, United Kingdom
| | - Paul D Baxter
- Centre for Epidemiology and Biostatistics, University of Leeds, Leeds, United Kingdom
| | | | - D Julian A Scott
- Department of Vascular Surgery, Leeds Teaching Hospitals, Leeds, United Kingdom
| | - Neil E Moat
- Department of Cardiac Surgery, Royal Brompton Hospital, London, United Kingdom
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - David Cunningham
- National Institute for Cardiovascular Outcomes Research, University College London, London, United Kingdom
| | - Philip A MacCarthy
- Department of Cardiology, King's College Hospital, London, United Kingdom
| | - Uday Trivedi
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Mark A de Belder
- Department of Cardiology, James Cook University Hospital, Middlesborough, United Kingdom
| | - Peter F Ludman
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Daniel J Blackman
- Department of Cardiology, Leeds Teaching Hospitals, Leeds, United Kingdom.
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Brogan RA, Malkin CJ, Batin PD, Simms AD, McLenachan JM, Gale CP. Risk stratification for ST segment elevation myocardial infarction in the era of primary percutaneous coronary intervention. World J Cardiol 2014; 6:865-873. [PMID: 25228966 PMCID: PMC4163716 DOI: 10.4330/wjc.v6.i8.865] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 04/30/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Acute coronary syndromes presenting with ST elevation are usually treated with emergency reperfusion/revascularisation therapy. In contrast current evidence and national guidelines recommend risk stratification for non ST segment elevation myocardial infarction (NSTEMI) with the decision on revascularisation dependent on perceived clinical risk. Risk stratification for STEMI has no recommendation. Statistical risk scoring techniques in NSTEMI have been demonstrated to improve outcomes however their uptake has been poor perhaps due to questions over their discrimination and concern for application to individuals who may not have been adequately represented in clinical trials. STEMI is perceived to carry sufficient risk to warrant emergency coronary intervention [by primary percutaneous coronary intervention (PPCI)] even if this results in a delay to reperfusion with immediate thrombolysis. Immediate thrombolysis may be as effective in patients presenting early, or at low risk, but physicians are poor at assessing clinical and procedural risks and currently are not required to consider this. Inadequate data on risk stratification in STEMI inhibits the option of immediate fibrinolysis, which may be cost-effective. Currently the mode of reperfusion for STEMI defaults to emergency angiography and percutaneous coronary intervention ignoring alternative strategies. This review article examines the current risk scores and evidence base for risk stratification for STEMI patients. The requirements for an ideal STEMI risk score are discussed.
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Malkin CJ, George V, Ghobrial MS, Krishnan A, Siotia A, Raina T, Morton AC, Gunn J. Residual SYNTAX score after PCI for triple vessel coronary artery disease: quantifying the adverse effect of incomplete revascularisation. EUROINTERVENTION 2013; 8:1286-95. [DOI: 10.4244/eijv8i11a197] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Siotia A, Morton AC, Malkin CJ, Raina T, Gunn J. Simultaneous kissing drug-eluting stents to treat unprotected left main stem bifurcation disease: medium term outcome in 150 consecutive patients. EUROINTERVENTION 2012; 8:691-700. [DOI: 10.4244/eijv8i6a108] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Malkin CJ, Judd J, Chew DP, Sinhal A. Balloon aortic valvuloplasty to bridge and triage patients in the era of trans-catheter aortic valve implantation. Catheter Cardiovasc Interv 2012; 81:358-63. [DOI: 10.1002/ccd.24325] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 01/03/2012] [Indexed: 11/05/2022]
Affiliation(s)
- Christopher J. Malkin
- Flinders Medical Centre; Flinders Drive; Bedford Park; Adelaide; South Australia; SA5042
| | - Jo Judd
- Flinders Medical Centre; Flinders Drive; Bedford Park; Adelaide; South Australia; SA5042
| | - Derek P. Chew
- Flinders Medical Centre; Flinders Drive; Bedford Park; Adelaide; South Australia; SA5042
| | - Ajay Sinhal
- Flinders Medical Centre; Flinders Drive; Bedford Park; Adelaide; South Australia; SA5042
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Malkin CJ, Ghobrial MSA, Raina T, Siotia A, Morton AC, Gunn J. 046 Impact of incomplete revascularisation in patients undergoing PCI for unprotected left main stem stenosis: Abstract 046 Figure 1. Heart 2012. [DOI: 10.1136/heartjnl-2012-301877b.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Malkin CJ, Prakash R, Chew DP. The impact of increased age on outcome from a strategy of early invasive management and revascularisation in patients with acute coronary syndromes: retrospective analysis study from the ACACIA registry. BMJ Open 2012; 2:e000540. [PMID: 22344538 PMCID: PMC3282292 DOI: 10.1136/bmjopen-2011-000540] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To evaluate the impact of increased age on outcome from a strategy of early invasive management and revascularisation in patients with acute coronary syndromes (ACS). DESIGN Retrospective analysis of a national Acute Coronary Syndrome registry (ACACIA). SETTING Multiple Australian (n=39) centres; 25% rural, 52% with onsite cardiac surgery. PATIENTS Unselected consecutive patients admitted with confirmed ACS, total n=2559, median 99 per centre. INTERVENTIONS Management was at the discretion of the treating physician. Analysis of outcome based on age >75 years was compared using Cox proportional hazard with a propensity model to adjust for baseline covariates. MAIN OUTCOME MEASURES Primary outcome was all-cause mortality. Secondary outcomes were bleeding and a composite of any vascular event or unplanned readmission. RESULTS Elderly patients were more likely to present with high-risk features yet were less likely to receive evidence-based medical therapies or receive diagnostic coronary angiography (75% vs 49%, p<0.0001) and early revascularisation (50% vs 30%, p<0.0001). Multivariate analysis found early revascularisation in the elderly cohort to be associated with lower 12-month mortality hazard (0.4 (0.2-0.7)) and composite outcome (0.6 (0.5-0.8)). Propensity model suggested a greater absolute benefit in elderly patients compared to others. CONCLUSIONS Following presentation with ACS, elderly patients are less likely to receive evidence-based medical therapies, to be considered for an early invasive strategy and be revascularised. Increasing age is a significant barrier to physicians when considering early revascularisation. An early invasive strategy with revascularisation when performed was associated with substantial benefit and the absolute accrued benefit appears to be higher in elderly patients.
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Gunn J, Siotia A, Malkin CJ, Iqbal J, Raina T, Morton AC. Novel use of a pericardium-covered stent graft to treat bulky coronary artery thrombus. Catheter Cardiovasc Interv 2011; 80:59-64. [DOI: 10.1002/ccd.23184] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 03/27/2011] [Indexed: 11/09/2022]
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Malkin CJ, Raina T, Morton AC, Gunn JP. 101 Left main stem PCI: ‘real world’ long-term results in a consecutive series of 302 patients. Heart 2010. [DOI: 10.1136/hrt.2010.196071.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
Testosterone is reported to have an acute vasodilating action in vitro, an effect that may impart a favourable haemodynamic response in patients with chronic heart failure. However, the effect of chronic testosterone exposure on general vascular reactivity is poorly described. In the present study, fresh subcutaneous resistance arteries were obtained from patients with heart failure (n=10), healthy controls (n=9) and men with androgen-deficiency (n=17). All arteries were studied using a wire myograph to examine the effect of cumulative additions of testosterone (1 nmol/l–100 μmol/l) compared with vehicle control following maximal pre-constriction with KCl (1–100 μmol/l). The vascular reactivity of arteries from androgen-deficient patients was examined further by recording tension concentration curves to cumulative additions of noradrenaline (1 nmol/l–100 μmol/l) and U46619 (1–300 nmol/l), followed by relaxation concentration curves to additions of ACh (acetylcholine; 10 nmol/l–30 μmol/l) and SNP (sodium nitroprusside; 10 nmol–30 μmol/l) respectively. In all cases, statistical analysis was performed by ANOVA. Patients with proven androgen-deficiency were treated according to clinical recommendations for a minimum of 3 months and further arteries (n=19) were taken for experimentation using the same protocol. In all groups, testosterone was confirmed to be an acute concentration-dependent vasodilator at concentrations ≥1 μmol/l (P=0.0001). The dilating effect of testosterone was augmented in patients with androgen-deficiency prior to treatment, and this effect was abrogated following appropriate testosterone replacement. Testosterone therapy significantly reduced the normal vascular dilating response to ACh and SNP (P<0.01) and significantly increased the contractile response to noradrenaline (P<0.01), but not U46619. Testosterone is an acute dose-dependent vasodilator of resistance arteries. Physiological testosterone replacement attenuates general vascular reactivity in androgen-deficient subjects. The numerous perceived benefits of testosterone replacement may be offset by a decline in vascular reactivity and, therefore, further studies and careful monitoring of patients is recommended.
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Affiliation(s)
- Christopher J Malkin
- Department of Cardiology Research, Royal Hallamshire Hospital Sheffield, Sheffield S10 2JF, UK
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Abstract
Type 2 diabetes mellitus is increasing globally and is an established risk factor for the development of atherosclerotic vascular disease. Insulin resistance is the hallmark feature of type 2 diabetes and is also an important component of the metabolic syndrome. There is evidence to suggest that testosterone is an important regulator of insulin sensitivity in men. Observational studies have shown that testosterone levels are low in men with diabetes, visceral obesity (which is strongly associated with insulin resistance), coronary artery disease and metabolic syndrome. Short-term interventional studies have also demonstrated that testosterone replacement therapy produces an improvement in insulin sensitivity in men. Thus hypotestosteronaemia may have a role in the pathogenesis of insulin-resistant states and androgen replacement therapy could be a potential treatment that could be offered for improvements in glycaemic control and reduction in cardiovascular risk, particularly in diabetic men.
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Affiliation(s)
- D Kapoor
- Centre for Diabetes and Endocrinology, Barnsley NHS Foundation Trust Hospital, Barnsley, UK
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Abstract
Chronic heart failure is responsible for considerable suffering and mortality throughout the world. Clinical trials have consistently demonstrated the benefits of pharmacological therapies such as angiotensin-converting enzyme inhibitors and beta-adrenoceptor blockers. These drugs are often quoted as reducing mortality from heart failure, yet all patients with heart failure deteriorate and most will die because of their disease. Therapies in heart failure are not truly life saving; they modify the natural history of the disease and delay the time to deterioration. The time benefit in survival is not usually reported in clinical trials, which are conducted over fixed time points and report risk reductions during this period only. In this paper, we discuss the use of prolongation of life statistics as an outcome measure in clinical trials and review simple techniques for calculating the lifetime benefit of pharmacological intervention in heart failure using data from a number of major studies
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Affiliation(s)
- C J Malkin
- Department of Cardiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals, Sheffield, UK
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Smith AM, English KM, Malkin CJ, Jones RD, Jones TH, Channer KS. Testosterone does not adversely affect fibrinogen or tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) levels in 46 men with chronic stable angina. Eur J Endocrinol 2005; 152:285-91. [PMID: 15745938 DOI: 10.1530/eje.1.01848] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [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: 01/09/2023]
Abstract
OBJECTIVE In women, sex hormones cause increased morbidity and mortality in patients with coronary heart disease (CHD) and adversely affect the coagulation profile. We have studied the effect of physiological testosterone replacement therapy in men on coagulation factor expression, to determine if there is an increased risk of thrombosis. METHODS Double-blind, randomized, placebo-controlled trial of testosterone in 46 men with chronic stable angina. Measurements of free, total and bioavailable testosterone, luteinising hormone (LH) and follicle-stimulating hormone (FSH), estradiol, plasminogen activator inhibitor-1 (PAI-1), fibrinogen, tissue plasminogen activator (tPA) and full blood count were made at 0, 6 and 14 weeks. RESULTS Bioavailable testosterone levels were: 2.58 +/- 0.58 nmol/l at baseline, compared with 3.35 +/- 0.31 nmol/l at week 14 (P < 0.001) after treatment compared with 2.6 +/- 0.18 nmol/l and 2.44 +/- 0.18 nmol/l in the placebo group (P was not significant). There was no change in fibrinogen (3.03 +/- 0.18 g/l at baseline and 3.02 +/- 0.18 g/l at week 14, P = 0.24), tPA activity (26.77 +/- 4.9 Iu/ml and 25.67 +/- 4.4 Iu/ml, P = 0.88) or PAI-1 activity (0.49 +/- 0.85 Iu/ml and 0.36 +/- 0.06 Iu/ml, P = 0.16) with active treatment and no differences between the groups (at week 14, P value 0.98, 0.59 and 0.8 for fibrinogen, PAI-1 and tPA respectively). Haemoglobin concentration did not change over time, in the testosterone group (1.44 +/- 0.02 g/l and 1.45 +/- 0.02 g/l, P = 0.22). CONCLUSION Physiological testosterone replacement does not adversely affect blood coagulation status.
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Affiliation(s)
- A M Smith
- Hormone & Vascular Biology Group, Academic Unit of Endocrinology, Division of Genomic Medicine, The University of Sheffield, Sheffield S10 2RX, UK
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Malkin CJ, Pugh PJ, Morris PD, Kerry KE, Jones RD, Jones TH, Channer KS. Testosterone replacement in hypogonadal men with angina improves ischaemic threshold and quality of life. Heart 2004; 90:871-6. [PMID: 15253956 PMCID: PMC1768369 DOI: 10.1136/hrt.2003.021121] [Citation(s) in RCA: 187] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Low serum testosterone is associated with several cardiovascular risk factors including dyslipidaemia, adverse clotting profiles, obesity, and insulin resistance. Testosterone has been reported to improve symptoms of angina and delay time to ischaemic threshold in unselected men with coronary disease. OBJECTIVE This randomised single blind placebo controlled crossover study compared testosterone replacement therapy (Sustanon 100) with placebo in 10 men with ischaemic heart disease and hypogonadism. RESULTS Baseline total testosterone and bioavailable testosterone were respectively 4.2 (0.5) nmol/l and 1.7 (0.4) nmol/l. After a month of testosterone, delta value analysis between testosterone and placebo phase showed that mean (SD) trough testosterone concentrations increased significantly by 4.8 (6.6) nmol/l (total testosterone) (p = 0.05) and 3.8 (4.5) nmol/l (bioavailable testosterone) (p = 0.025), time to 1 mm ST segment depression assessed by Bruce protocol exercise treadmill testing increased by 74 (54) seconds (p = 0.002), and mood scores assessed with validated questionnaires all improved. Compared with placebo, testosterone therapy was also associated with a significant reduction of total cholesterol and serum tumour necrosis factor alpha with delta values of -0.41 (0.54) mmol/l (p = 0.04) and -1.8 (2.4) pg/ml (p = 0.05) respectively. CONCLUSION Testosterone replacement therapy in hypogonadal men delays time to ischaemia, improves mood, and is associated with potentially beneficial reductions of total cholesterol and serum tumour necrosis factor alpha.
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Affiliation(s)
- C J Malkin
- Department of Cardiology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
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Malkin CJ, Pugh PJ, Jones RD, Jones TH, Channer KS. Testosterone as a protective factor against atherosclerosis--immunomodulation and influence upon plaque development and stability. J Endocrinol 2003; 178:373-80. [PMID: 12967330 DOI: 10.1677/joe.0.1780373] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.0] [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] [Indexed: 11/27/2022]
Abstract
Inflammation plays a central pathogenic role in the initiation and progression of coronary atheroma and its clinical consequences. Cytokines are the mediators of cellular inflammation and promote local inflammation in the arterial wall, which may lead to vascular smooth muscle apoptosis, degradation of the fibrin cap and plaque rupture. Platelet adhesion and thrombus formation then occur, resulting clinically in unstable angina or myocardial infarction. Recent studies have suggested that cytokines are pathogenic, contributing directly to the disease process. 'Anti-cytokine' therapy may, therefore, be of benefit in preventing or slowing the progression of cardiovascular disease. Both oestrogens and testosterone have been shown to have immune-modulating effects; testosterone in particular appears to suppress activation of pro-inflammatory cytokines. Men with low testosterone levels are at increased risk of coronary artery disease. An anti-inflammatory effect of normal physiological levels of sex hormones may, therefore, be important in atheroprotection. In this Article, we discuss some of the mechanisms involved in atherosclerotic coronary artery disease and the putative link between testosterone deficiency and atheroma formation. We present the hypothesis that the immune-modulating properties of testosterone may be important in inhibiting atheroma formation and progression to acute coronary syndrome.
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Affiliation(s)
- C J Malkin
- Department of Cardiology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
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Affiliation(s)
- C J Malkin
- Department of Cardiology, Royal Hallamshire Hospital, Sheffield, UK
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