Performance of the SHARPEN Score and the Charlson Comorbidity Index for In-Hospital and Post-Discharge Mortality Prediction in Infective Endocarditis

BACKGROUND

Central Illustration : Performance of the SHARPEN Score and the Charlson Comorbidity Index for In-Hospital and Post-Discharge Mortality Prediction in Infective Endocarditis.

BACKGROUND

SHARPEN was the first dedicated score for in-hospital mortality prediction in infective endocarditis (IE) regardless of cardiac surgery.

OBJECTIVES

To analyze the ability of the SHARPEN score to predict in-hospital and post-discharge mortality and compare it with that of the Charlson comorbidity index (CCI).

METHODS

Retrospective cohort study including definite IE (Duke modified criteria) admissions from 2000 to 2016. The area under the ROC curve (AUC-ROC) was calculated to assess predictive ability. Kaplan-Meier curves and Cox regression was performed. P-value < 0.05 was considered statistically significant.

RESULTS

We studied 179 hospital admissions. In-hospital mortality was 22.3%; 68 (38.0%) had cardiac surgery. Median (interquartile range, IQR) SHARPEN and CCI scores were 9(7-11) and 3(2-6), respectively. SHARPEN had better in-hospital mortality prediction than CCI in non-operated patients (AUC-ROC 0.77 vs. 0.62, p = 0.003); there was no difference in overall (p = 0.26) and in operated patients (p = 0.41). SHARPEN > 10 at admission was associated with decreased in-hospital survival in the overall (HR 3.87; p < 0.001), in non-operated (HR 3.46; p = 0.006) and operated (HR 6.86; p < 0.001) patients. CCI > 3 at admission was associated with worse in-hospital survival in the overall (HR 3.0; p = 0.002), and in operated patients (HR 5.57; p = 0.005), but not in non-operated patients (HR 2.13; p = 0.119). Post-discharge survival was worse in patients with SHARPEN > 10 (HR 3.11; p < 0.001) and CCI > 3 (HR 2.63; p < 0.001) at admission; however, there was no difference in predictive ability between these groups.

CONCLUSION

SHARPEN was superior to CCI in predicting in-hospital mortality in non-operated patients. There was no difference between the scores regarding post-discharge mortality.

Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure

BACKGROUND

Central Illustration : Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure Transcatheter devices for monitoring and treating advanced chronic heart failure patients. PA: pulmonary artery; LA: left atrium; AFR: atrial flow regulator; TASS: Transcatheter Atrial Shunt System; VNS: vagus nerve stimulation; BAT: baroreceptor activation therapy; RDN: renal sympathetic denervation; F: approval by the American regulatory agency (FDA); E: approval by the European regulatory agency (CE Mark).

BACKGROUND

Innovations in devices during the last decade contributed to enhanced diagnosis and treatment of patients with cardiac insufficiency. These tools progressively adapted to minimally invasive strategies with rapid, widespread use. The present article focuses on actual and future directions of device-related diagnosis and treatment of chronic heart failure.

Non-contrast transcatheter aortic valve implantation for patients with aortic stenosis and chronic kidney disease: a pilot study

Background

Acute kidney injury (AKI) is frequently observed after transcatheter aortic valve implantation (TAVI). Of note, it is associated with a threefold increase in all-cause and cardiac death. We propose a new non-contrast strategy for evaluating and performing the TAVI procedure that can be especially valuable for patients with aortic stenosis (AS) and chronic kidney disease (CKD) to prevent AKI.

Methods

Patients with severe symptomatic AS and CKD stage ≥3a were evaluated for TAVI using four non-contrast imaging modalities for procedural planning: transesophageal echocardiogram (TEE), cardiac magnetic resonance, multidetector computed tomography (MDCT), and aortoiliac CO₂ angiography. Patients underwent transfemoral (TF) TAVI using the self-expandable Evolut R/Pro, and the procedures were guided by fluoroscopy and TEE. Contrast MDCT and contrast injection at certain checkpoints during the procedure were used in a blinded fashion to guarantee patient safety.

Results

A total of 25 patients underwent TF-TAVI with the zero-contrast technique. The mean age was 79.9 ± 6.1 years, 72% in NYHA class III/IV, with a mean STS-PROM of 3.0% ± 1.5%, and creatinine clearance of 49 ± 7 ml/min. The self-expandable Evolut R and Pro were implanted in 80% and 20% of patients, respectively. In 36% of the cases, the transcatheter heart valve (THV) chosen was one size larger than the one by contrast MDCT, but none of these cases presented adverse events. Device success and the combined safety endpoint (at 30 days) both achieved 92%. Pacemaker implantation was needed in 17%.

Conclusion

This pilot study demonstrated that the zero-contrast technique for procedural planning and THV implantation was feasible and safe and might become the preferable strategy for a significant population of CKD patients undergoing TAVR. Future studies with a larger number of patients are still needed to confirm such interesting findings.

Transcatheter aortic valve implantation without contrast media technique in chronic kidney disease population – pilot study

Background/Introduction

Acute Kidney Injury (AKI) is frequently observed after Transcatheter aortic valve implantation (TAVI), with rates ranging from 3% to 50%. In the Brazilian TAVI Registry, the incidence of AKI following TAVI was 18%, with 4.5% requiring dialysis. Its occurrence is associated with an increase in 3-fold all-cause and cardiac death. Since AKI is related to the volume of contrast media, avoiding contrast during TAVI procedure is advisable, especially in chronic kidney disease (CKD) patients.

Purpose

The aims of the proposed study are to: (1) evaluate the feasibility and safety of a zero-contrast technique for CKD patients undergoing TAVI and (2) define the role of each of the non-contrast imaging modalities in the preoperative assessment for TAVI and (3) evaluate the incidence of AKI post-TAVI in this population.

Methods

Patients with severe symptomatic aortic stenosis (AS) and CKD stage ≥3a where evaluated for TAVI with four preoperative exams: transesophageal echocardiogram (TEE), cardiac magnetic resonance, contrast and noncontrast computed tomography (MDCT) and aortoiliac co2 angiography. After safety measures of transfemoral (TF) viability and aortic valve favorable anatomy, patients were submitted to TF-TAVI with self-expandable Evolut R/Pro. The contrast MDCT was blinded to the operators and it is checked before the procedure, at a safety checkpoint, to exclude high-risk conditions not detected by non-contrast methods. During the procedure, another safety checkpoint was accomplished. Clinical and echocardiographic outcomes were assessed at 30 days.

Results

Between december 2020 to december 2021, a total of 25 patients underwent TF TAVI with zero-contrast technique. Mean age of 79.9±6.1 years, 52% male, 18 patients (72%) NYHA functional class III or IV, mean STS-PROM 3.0±1.5%, 12% had severe systolic dysfunction (left ventricle ejection fraction &lt;35%) and mean creatinine clearance of 49.1±7 mL/min. Self-expandable Evolut R was implanted in 80% of patients and Evolut Pro in 20% of them, the most frequent THV size was 29 mm (52%) and the mean implant depth was 6 mm in fluoroscopy and 4.5 mm in TEE. The mean procedural time was 138±56 minutes, with a median radiation dose of 6.6 mGy/cm2 [IQR, 2–6 mGy]. Definitive pacemaker was implanted in 17% of patients and AKI was seen in 6 patients (24%), with stage I (20%), stage II (4%) and no case needed hemodialysis. At 30 days, 84% were at functional class I, there was no death, one embolization requiring a second valve and the rate of device success (VARC-2) was 92%.

Conclusion

The proposed pilot study for transfemoral TAVI in CKD population with zero contrast technique was safe, with promising results and similar rates of success and complication, compared with the conventional TAVI approach.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): MedtronicAngiodroid

SHARPEN score: an independent predictor of survival after infective endocarditis discharge

Background

Infective endocarditis (IE) presents high mortality even in patients that were adequately treated. Proper identification of these patients is imperative for better care delivery. SHARPEN score (Systolic BP, Heart failure, Age, Renal function, Pneumonia, Elevated peak CRP, and Non-intravenous drug abusers) was validated to predict in-hospital mortality due to IE; its performance in predicting survival after hospital discharge, however, has not yet been evaluated.

Purpose

To assess the SHARPEN score in predicting survival after hospital discharge due to IE.

Methods

Retrospective cohort study including all patients ≥18 years discharged after definitive IE (modified Duke criteria) admission at a public tertiary teaching hospital in southern Brazil, between 2000–16. Only the first hospitalization for IE was considered in those patients with &gt;1 admission for that reason in the studied period. The SHARPEN score was calculated at admission, and each patient was classified as low-moderate (2–10 points) or high (11–20 points) risk. Follow-up was carried out through the review of medical records, and the assessed outcome was death by any cause. Survival analysis was performed using the Kaplan-Meier curves, which were compared using the Log-rank test.

Results

A total of 135 patients (mean age: 53±17 years, 97 [72%] male) were discharged after IE episode. Staphylococcus aureus was the main etiologic agent (29 [21.5%]), and cardiac surgery was performed in 54 (40%) patients. The median SHARPEN score was 9 (IQR: 7–11 points), being classified as low-moderate risk (96 [71%]) and high risk (39 [29%]) patients, respectively. Median post-discharge follow-up was 3.4 (IQR: 0.19–9) years (682 patient-years), with 37 deaths during the period. Mean post-discharge survival was 12.4 years (95% CI: 10.7–14), significantly higher in patients classified as low-moderate risk (13.7 years) in comparison to high risk (8.4 years) (Log-rank P=0.006; Figure).

Conclusion

Patients classified as high-risk by SHARPEN score during IE admission present significantly higher mortality after discharge, despite being effectively treated for the IE episode. SHARPEN score could also be used to assess morbimortality after discharge, helping to implement special care programs for high-risk patients.

Funding Acknowledgement

Type of funding sources: None.