Impact of Severe Sarcopenia on Rehospitalization and Survival One Year After a TAVR Procedure in Patients Aged 75 and Older

BACKGROUND

Transcatheter aortic-valve replacement (TAVR) reduces mortality and improves quality of life in patients with severe aortic valve stenosis. One third of patients have no benefit one year after TAVR. Sarcopenia, an age-related loss of skeletal muscle mass, is associated with increased physical disability and mortality. The main purpose was to evaluate the impact of severe sarcopenia on rehospitalization one year after TAVR in older patients.

METHODS

All patients aged ≥75 referred for a TAVR in 2018 were included. Severe sarcopenia was defined by a loss of skeletal muscle mass defined on CT-scan measurement associated with a gait speed ≤0.8m/s. The main outcome was rehospitalization one year after TAVR.

RESULTS

Median age of the 182 included patients was 84, and 35% had an unplanned hospitalization at one year. Severe sarcopenia was diagnosed in 9 patients (4.9%). Univariable analysis showed that gait speed was a factor associated with readmission [HR=0.32, 95% CI (0.10-0.97), p=0.04] but not severe sarcopenia. In multivariable analysis, only diabetes was significantly associated with rehospitalization [HR=2.06, 95% CI (1.11-3.84), p=0.02]. Prevalence of severe sarcopenia varied according to different thresholds of skeletal muscle mass on CT-scan.

CONCLUSION

Even though severe sarcopenia was not correlated with rehospitalization and mortality at one year after TAVR, our results emphasize the changes in the prevalence according to cutoff used. It highlights the need to define standardized methods and international threshold for sarcopenia diagnosis by CT-scan measurements, in general population and for patients with valvular heart disease.

Prognostic Implication of Tricuspid Regurgitation in ST-segment Elevation Myocardial Infarction Patients

BACKGROUND

Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations but currently no data is available about the prevalence and prognostic implication of TR in ST-segment elevation myocardial infarction (STEMI) patients.

OBJECTIVES

To investigate the possible implication of TR among STEMI patients.

METHODS

We conducted a retrospective study of STEMI patients undergoing primary percutaneous coronary intervention (PCI), and its relation to major clinical and echocardiographic parameters. Patient records were assessed for the prevalence and severity of TR as well as the relation to the clinical profile, key echocardiographic parameters, in-hospital outcomes, and long-term mortality. Patients with previous myocardial infarction or known previous TR were excluded.

RESULTS

The study included 1071 STEMI patients admitted between September 2011 and May 2016 (age 61 ± 13 years; predominantly male). A total of 205 patients (19%) had mild TR while another 32 (3%) had moderate or greater TR. Patients with significant TR demonstrated worse echocardiographic parameters, were more likely to have in-hospital complications, and had higher long-term mortality (28% vs. 6%, P < 0.001). Following adjustment for significant clinical and echocardiographic parameters, mortality hazard ratio of at least moderate to severe TR remained significant (2.44, 95% confidence interval 1.06-5.6, P = .036) for patients with moderate to severe TR.

CONCLUSIONS

Among STEMI patients after primary PCI, the presence of moderate to severe TR was independently associated with adverse outcomes and significantly lower survival rate.

Early and long-term results of hypothermic circulatory arrest in aortic surgery: a 20-year single-centre experience

AIMS

The aim of this study was to document the postoperative outcomes of patients who underwent hypothermic circulatory arrest (HCA), the evolution of HCA management over time and to identify the risks factor for early mortality and postoperative stroke.

METHODS

Four hundred and twenty-four patients who underwent aortic surgery with HCA at our institution between January 1995 and June 2016 were consecutively included.

RESULTS

The main indications were degenerative aneurysm (254; 59.9%) and acute type A aortic dissection (146; 34.4%). Interventions were performed under deep (18.4 ± 0.9°C; n = 350; 82.5%) or moderate (23.9 ± 1.9°C; n = 74; 17.5%) hypothermia. Antegrade cerebral perfusion (ACP) was employed in 86 (20.3%) cases. The use of moderate hypothermia significantly increased from 2011, to become the preferred strategy in 2016. The in-hospital mortality was 12.5% and the postoperative stroke rate was 7.1%. Kaplan--Meier 5-year survival was 65.7%. Nonelective timing [odds ratio (OR) 4.05; P < 0.001], stroke (OR 3.77' P = 0.032), renal failure (OR 2.49; P = 0.023), redo surgery (2.42; P = 0.049) and CPB time (OR 1.05; P = 0.03) were independent risk factors for in-hospital mortality in multivariate analysis. Femoral cannulation was the only independent risk factor for stroke (OR 3.97; P = 0.002). The level of hypothermia and the use of ACP were not associated with either in-hospital mortality or postoperative stroke.

CONCLUSION

HCA might be widely considered to achieve a radical treatment of the aortic disease, provided that hypothermia is maintained below the 24°C safety threshold and ACP is used for HCA exceeding 30 min, to ensure optimal brain, spinal cord and visceral organs protection.

Preoperative versus Post-operative Radiotherapy for Extremity Soft tissue Sarcoma: a Systematic Review and Meta-analysis of Long-term Survival

BACKGROUND

The role of perioperative radiotherapy in the management of resectable extremity soft tissue sarcoma (ESTS) is widely recognised for local tumour control, wound complications (WC) and long-term function. However, debate continues regarding its implications on long-term survival. This study aimed to determine whether the timing of perioperative radiotherapy affects long-term survival outcomes in adults with ESTS.

METHODS

A systematic literature search of MEDLINE, EMBASE, Web of Science and Cochrane was performed. The primary outcome measure was the pooled hazard ratio (HR) at 95% confidence intervals. Secondary outcomes and subgroup analyses were presented as cumulative odds ratios (OR). A random-effects, generic inverse variance method and sensitivity analysis were performed to minimise heterogeneity.

RESULTS

Six studies (n = 4192 patients) were identified. Time-to-event analysis demonstrated a statistically significant advantage in post-operative radiotherapy for overall survival (HR 1.15 and p = 0.05). Combined HRs for disease-free (1.25 and p = 0.22) and disease-specific (1.06 and p = 0.43) survival also favoured post-operative radiotherapy but did not achieve statistical significance. Post-operative radiotherapy was shown to confer an overall (OR 1.19 and p = 0.01), disease-free (OR 1.19 and p = 0.01) and disease-specific (OR 1.19 and p = 0.01) survival advantage on subgroup analysis. This survival benefit was best observed at three years in the disease-free survival comparison (OR 1.55 and p = 0.003). Preoperative radiotherapy was associated with more WC (OR 2.74 and p<0.00001).

CONCLUSIONS

Pooled analysis of published literature suggests that post-operative radiotherapy confers a significant long-term survival advantage with fewer WC. Further large multicentre randomised controlled trials with long-term follow-up are required to determine the optimal perioperative radiotherapy regime in adult ESTS.

Sex Differences in All-Cause Mortality in the Decade Following Complex Coronary Revascularization

BACKGROUND

The poorer prognosis of coronary artery disease in females compared with males is related mainly to differences in baseline characteristics. In the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial, the effect of treatment with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting surgery (CABG) on mortality at 5 years differed significantly between females and males; however, the optimal revascularization beyond 5 years according to sex has not been evaluated.

OBJECTIVES

The aim of this study was to investigate the impact of sex on mortality and sex-treatment interaction at 10 years.

METHODS

The SYNTAXES (SYNTAX Extended Survival) study evaluated vital status up to 10 years in 1,800 patients with de novo 3-vessel and/or left main coronary artery disease randomized to treatment with PCI or CABG in the SYNTAX trial. All-cause death at 10 years was separately evaluated in female and male patients with complex coronary artery disease.

RESULTS

Of 1,800 patients, 402 (22.3%) were female and 1,398 (77.7%) were males. Females had a higher 10-year mortality rate compared with males (32.8% vs. 24.7%; log-rank p = 0.002), but female sex was not an independent predictor of mortality (adjusted hazard ratio: 1.02; 95% confidence interval: 0.76 to 1.36). Mortality at 10 years tended to be lower after CABG than after PCI, with a similar treatment effect for female and male patients (adjusted hazard ratio for females: 0.90 [95% confidence interval: 0.54 to 1.51]; adjusted hazard ratio for males: 0.76 [95% confidence interval: 0.56 to 1.02]; p for interaction = 0.952).

CONCLUSIONS

Female sex was not an independent predictor of mortality at 10 years in patients with complex coronary artery disease. The interaction between sex and treatment with PCI or CABG that was observed at 5 years was no longer present at 10 years. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES], NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX], NCT00114972).

Extravalvular Cardiac Damage and Renal Function Following Transcatheter Aortic Valve Implantation for Severe Aortic Stenosis

BACKGROUND

In this study we sought to determine the differences in incidence of acute kidney injury (AKI) and acute kidney recovery (AKR) among patients undergoing transcatheter aortic valve implantation (TAVI), according to the degree of extravalvular cardiac damage (EVCD).

METHODS

From the Verona Valvular Heart Disease Registry, 674 symptomatic severe aortic stenosis (AS) patients were selected and retrospectively analysed. Using echocardiographic data, patients were classified based on the degree of EVCD.

RESULTS

After dichotomized analysis, patients in EVCD stage 3 or 4 reported a significantly higher rate of AKI (29.5% vs 11.2%; P < 0.001). Using a multivariate analysis model, higher EVCD stage, lower glomerular filtrate rate (GFR) at admission, and amount of contrast used were found to be independent predictors of AKI, whereas stage of cardiac damage and GFR were found to be independent predictors of AKR. For the overall population after multivariate analysis AKI was associated with a higher incidence of 12-month all-cause mortality (hazard ratio, 2.142; 95% confidence interval, 1.082-4.239; P = 0.029) with a significant impact in the advanced cardiac damage stages, but not in the early stages (P for interaction = 0.006). AKR did not reduce adverse clinical outcomes but was associated with improved renal function at 12 months.

CONCLUSIONS

Increase in EVCD stage was associated with a higher rate of AKI after TAVI. AKI had a negative impact on long-term clinical outcomes but only in patients with advanced cardiac damage. AKR did not reduce adverse clinical outcomes but was associated with improved renal function at 12 months.

Development, Validation, and Clinical Utility Assessment of a Prognostic Score for 1-Year Unplanned Rehospitalization or Death of Adult Sepsis Survivors

IMPORTANCE

The longer-term risk of rehospitalizations and death of adult sepsis survivors is associated with index sepsis illness characteristics.

OBJECTIVE

To derive and validate a parsimonious prognostic score for unplanned rehospitalizations or death in the first year after hospital discharge of adult sepsis survivors.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the Intensive Care National Audit & Research Centre Case Mix Programme database on adult sepsis survivors identified from consecutive critical care admissions to 192 adult general critical care units in England, United Kingdom, between April 1, 2009, and March 31, 2014 (94 748 patients in the derivation cohort), and between April 1, 2014, and March 31, 2015 (24 669 patients in the validation cohort). Statistical analysis was performed from July 5 to October 31, 2019. Generic characteristics (age, sex, race/ethnicity, 2015 Index of Multiple Deprivation [IMD2015] in England quintiles, preadmission dependence, previous hospitalizations in the year preceding index sepsis admission, comorbidity, admission type, Acute Physiology and Chronic Health Evaluation II physiology score, hospital length of stay, worst blood lactate and blood hemoglobin concentrations, and type of hospital) and sepsis-specific characteristics (site of infection, numbers of organ dysfunctions, and organ support) at the index sepsis admission were used as predictors.

MAIN OUTCOMES AND MEASURES

Prognostic score derived and validated using multivariable logistic regression for the outcome of unplanned rehospitalization or death in the first year after hospital discharge of adult sepsis survivors, as well as clinical usefulness assessed using decision curve analysis. Prognostic score validation was performed for internal validation with bootstrapping and temporal cohort external validation.

RESULTS

This cohort study included 94 748 patients (51 164 men [54.0%]; mean [SD] age, 61.3 [17.0] years) in the derivation cohort and 24 669 patients (13 255 men [53.7%]; mean [SD] age, 62.1 [16.8%]) in the validation cohort. Unplanned rehospitalization or death in the first year after hospital discharge occurred for 48 594 patients (51.3%) in the derivation cohort and 13 129 patients (53.2%) in the validation cohort. Eight independent predictors were identified and weighted to generate a prognostic score for every patient: previous hospitalizations, age in 10-year increments, IMD2015 in England quintiles, preadmission dependence, comorbidities, admission type, blood hemoglobin level, and site of infection. The total prognostic score ranged from 0 to 22 points, with lower scores indicating a lower risk of the outcome. The derivation and validation cohorts had similar rates of prognostic scores of 0 to 4 points (5088 of 16 684 patients [30.5%] and 471 of 1725 patients [27.3%]) and prognostic scores of 11 points or more (15 732 of 21 641 patients [72.7%] and 5753 of 7952 patients [72.3%]). The area under the receiver operating characteristic curve for the prognostic score was 0.675 (95% CI, 0.672-0.679). The decision curve analysis highlighted an optimal score cutoff of 7 points or more.

CONCLUSIONS AND RELEVANCE

The prognostic score reported in this study uses 8 internationally feasible predictors measured during the index sepsis admission and provides clinically useful information on sepsis survivors' risk of unplanned rehospitalization or death in the first year after hospital discharge.

The MitraClip Procedure in Patients With Moderate Resting but Severe Exercise-Induced Mitral Regurgitation

BACKGROUND

Optimal timing for percutaneous mitral regurgitation (MR) treatment using MitraClip (Abbott Vascular) remains unclear. We evaluated the outcome after MitraClip in patients with moderate resting MR, progressing to severe exercise- induced MR (MR2+) compared to patients with severe resting MR (MR3).

METHODS

We retrospectively investigated 221 patients undergoing MitraClip. All-cause deaths and heart failure (HF) hospitalizations were assessed as the combined primary endpoint.

RESULTS

We identified 55 MR2+ and 166 MR3 patients. At baseline, MR3 patients showed higher STS scores (6.7 ± 7.3 vs 4.4 ± 5.5; P<.01), more HF hospitalizations in the 2 years prior to the procedure (51% vs 29%; P<.01), worse left ventricular ejection fraction (44.9 ± 16.5% vs 52.5 ± 14.3%; P<.01), larger left ventricular end-diastolic diameter (LVEDd; 57.0 ± 9.3 mm vs 51.7 ± 8.2 mm; P<.001), and larger left atrial volumes (118.3 ± 55.8 mL vs 98.6 ± 35.2 mL; P=.02). Long-term outcome according to the combined endpoint was significantly worse in MR3 patients (P=.01). HF hospitalizations significantly declined in both groups 2 years after MitraClip (P<.001 in MR3 patients, P=.03 in MR2+ patients). Multivariate Cox regression analysis revealed LVEDd (hazard ratio, 1.035; 95% confidence interval, 1.005-1.066; P=.02) and previous HF hospitalizations (hazard ratio, 1.813; 95% confidence interval, 1.016-3.234; P=.04) as strong outcome predictors.

CONCLUSIONS

Symptomatic patients with moderate resting and severe exercise-induced MR during handgrip echocardiography may represent an MR cohort at an earlier disease stage with improved treatment response following MitraClip implantation compared to individuals with severe resting MR. Larger left ventricular diameters and preprocedural HF hospitalizations were identified as independent adverse outcome predictors.

Relationship of Body Mass Index With Outcomes After Transcatheter Aortic Valve Replacement: Results From the National Cardiovascular Data-STS/ACC TVT Registry

OBJECTIVE

To investigate the relationship of body mass index (BMI) with short- and long-term outcomes after transcatheter aortic valve replacement (TAVR).

PATIENTS AND METHODS

The relationship between BMI and baseline characteristics and procedural characteristics was assessed for 31,929 patients who underwent TAVR between November 1, 2011, and March 31, 2015, from the STS/ACC TVT Registry. Registry data on 20,429 patients were linked to the Centers for Medicare and Medicaid Services to assess the association of BMI with 30-day and 1-year mortality using multivariable Cox proportional hazards models. The effect of BMI on mortality was also assessed with BMI as a continuous variable. Restricted cubic regression splines were used to model the effect of BMI and to determine appropriate cut points of BMI.

RESULTS

Among 31,929 patients, 806 (2.5%) were underweight (BMI, <18.5 kg/m²), 10,755 (33.7%) had normal weight (BMI, 18.5- 24.9 kg/m²), 10,691 (33.5%) were overweight (BMI, 25.0-29.9 kg/m²), 5582 (17.5%) had class I obesity (BMI, 30.0-34.9 kg/m²), 2363 (7.4%) had class II obesity (BMI, 35.0-39.9 kg/m²), and 1732 (5.4%) had class III obesity (BMI, ≥40 kg/m²). Patients in various BMI categories were different in most baseline and procedural characteristics. On multivariable analysis, compared with normal-weight patients, underweight patients had higher mortality at 30 days and at 1 year after TAVR (hazard ratio [HR], 1.35; 95% CI, 1.02-1.78 and HR, 1.41; 95% CI, 1.17-1.69, respectively), whereas overweight patients and those with class I and II obesity had a decreased risk of mortality at 1 year (HR, 0.88; 95% CI, 0.81-0.95, HR, 0.80; 95% CI, 0.72-0.89, and HR, 0.84; 95% CI, 0.72-0.98, respectively). For BMI of 30 kg/m² or less, each 1-kg/m² increase was associated with a 2% and 4% decrease in the risk of 30-day and 1-year mortality, respectively; for BMI greater than 30 kg/m², a 1-kg/m² increase was associated with a 3% increased risk of 30-day mortality but not with 1-year mortality.

CONCLUSION

Results of this large registry study evaluating the relationship of BMI and outcomes after TAVR support the existence of an obesity paradox among patients with severe aortic stenosis undergoing TAVR.

The Market Reacts Quickly: Changes in Paclitaxel Vascular Device Purchasing Within the Ascension Healthcare System

BACKGROUND

A meta-analysis of trials in endovascular therapy suggested an increased mortality associated with treatment exposure to paclitaxel. Multiple publications and corrections of prior data were performed, and the United States Food and Drug Administration has issued multiple advisories regarding paclitaxel use. We analyzed how this controversy impacted device purchasing and related utilization patterns in the period immediately following publication of the meta-analysis.

METHODS AND RESULTS

Ascension Healthcare System purchase data over a 14-month period were synthesized across centers for both paclitaxel and non-paclitaxel devices. A fixed-effects regression model and a binary regression model with facility-level controls were used to compare purchasing patterns before and after the meta-analysis. Purchase volumes of each paclitaxel device fell. Pooled purchase volumes of all paclitaxel devices decreased from a 14-month peak of 631 devices in October 2018 to a 14-month nadir of 359 devices in February 2019. An F-test comparing the pooled-month specific fixed effects for the months before vs after the publication of the meta-analysis has an F-statistic of 11.64, suggesting that average purchasing levels in the two periods are statistically different (P<.001). Utilization of non-paclitaxel devices did not decline.

CONCLUSIONS

Purchase volumes of paclitaxel devices decreased immediately during the months following publication of the related meta-analysis. Total Ascension-wide paclitaxel device purchase volume in February 2019 demonstrated a 43.1% reduction from peak monthly purchase volume during the assessed period and a 32.5% reduction compared with November 2019, the last month preceding publication of the meta-analysis.

Long-term Outcomes of Contemporary Coronary Revascularization by Percutaneous Coronary Intervention or Coronary Artery Bypass Grafting in Young Adults

BACKGROUND

Current guidelines for choosing between revascularization modalities may not be appropriate for young patients.

OBJECTIVES

To compare outcomes and guide treatment options for patients < 40 years of age, who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) between 2008 and 2018.

METHODS

Outcomes were compared for 183 consecutive patients aged < 40 years who underwent PCI or CABG between 2008 and 2018, Outcomes were compared as time to first event and as cumulative events for non-fatal outcomes.

RESULTS

Mean patient age was 36.3 years and 96% were male. Risk factors were similar for both groups. Drug eluting stents were implemented in 71% of PCI patients and total arterial revascularization in 74% of CABG patients. During a median follow-up of 6.5 years, 16 patients (8.6%) died. First cardiovascular events occurred in 35 (38.8%) of the PCI group vs. 29 (31.1%) of the CABG group (log rank P = 0.022), repeat events occurred in 96 vs. 51 (P < 0.01), respectively. After multivariate adjustment, CABG was associated with a significantly reduced risk for first adverse event (hazard ratio [HR] 0.305, P < 0.01) caused by a reduction in repeat revascularization. CABG was also associated with a reduction in overall repeat events (HR 0.293, P < 0.01). There was no difference in overall mortality between CABG and PCI.

CONCLUSIONS

Young patients with coronary disease treated by CABG showed a reduction in the risk for non-fatal cardiac events. Mortality was similar with CABG and PCI.

Effects of Sepsis on Morbidity and Mortality in Critically Ill Patients 2 Years After Intensive Care Unit Discharge

BACKGROUND

Morbidity and mortality after discharge from an intensive care unit appear to be higher in patients with sepsis than in patients without sepsis.

OBJECTIVE

To evaluate morbidity and mortality in patients with and without sepsis within 2 years after intensive care unit discharge.

METHODS

A prospective cohort study was conducted in 2 intensive care units. Patients who stayed in the intensive care unit longer than 24 hours were followed up for 2 years after discharge. Morbidity was assessed by using the Karnofsky scale, the Lawton instrumental activities of daily living scale, presence of pain, and readmissions.

RESULTS

During the study, 74.7% of patients (859 of 1150; 242 with sepsis, 617 without sepsis) were discharged from the intensive care unit. Compared with patients without sepsis, patients with sepsis had higher mortality during follow-up (57.4% vs 34.2%; P < .001) and were 1.34 times as likely to die (per Cox regression). More patients with sepsis had pain (48.5% vs 35.2%, P = .003) and read-missions (65.5% vs 55.0%, P = .02). Patients with sepsis had a greater degree of functional loss, adjusted for confounding factors (mean [SD] change in Lawton scale score from intensive care unit admission to 2 years after intensive care unit discharge, 4.0 [8.0] vs 3.4 [8.2]; P = .31).

CONCLUSION

Compared with patients without sepsis, those with sepsis have higher mortality in the intensive care unit and have more pain, hospital readmissions, and functional decline within 2 years after discharge.

Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke

IMPORTANCE

Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes.

OBJECTIVE

To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019.

MAIN OUTCOMES AND MEASURES

Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation.

RESULTS

Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0%) were men, 5929 (73.4%) were white, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within 1 year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3%; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2% lower odds of 1-year mortality (aOR, 0.69; 95% CI, 0.55-0.87) but was not independently associated with stroke risk.

CONCLUSIONS AND RELEVANCE

Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible.

Suitability of the German version of the Manchester Triage System to redirect emergency department patients to general practitioner care: a prospective cohort study

OBJECTIVES

To investigate the suitability of the German version of the Manchester Triage System (MTS) as a potential tool to redirect emergency department (ED) patients to general practitioner care. Such tools are currently being discussed in the context of reorganisation of emergency care in Germany.

DESIGN

Prospective cohort study.

SETTING

Single centre University Hospital Emergency Department.

PARTICIPANTS

Adult, non-surgical ED patients.

EXPOSURE

A non-urgent triage category was defined as a green or blue triage category according to the German version of the MTS.

PRIMARY AND SECONDARY OUTCOME MEASURES

Surrogate parameters for short-term risk (admission rate, diagnoses, length of hospital stay, admission to the intensive care unit, in-hospital and 30-day mortality) and long-term risk (1-year mortality).

RESULTS

A total of 1122 people presenting to the ED participated in the study. Of these, 31.9% (n=358) received a non-urgent triage category and 68.1% (n=764) were urgent. Compared with non-urgent ED presentations, those with an urgent triage category were older (median age 60 vs 56 years, p=0.001), were more likely to require hospital admission (47.8% vs 29.6%) and had higher in-hospital mortality (1.6% vs 0.8%). There was no significant difference observed between non-urgent and urgent triage categories for 30-day mortality (1.2% [n=4] vs 2.2% [n=15]; p=0.285) or for 1-year mortality (7.9% [n=26] vs 10.5% [n=72]; p=0.190). Urgency was not a significant predictor of 1-year mortality in univariate (HR=1.35; 95% CI 0.87 to 2.12; p=0.185) and multivariate regression analyses (HR=1.20; 95% CI 0.77 to 1.89; p=0.420).

CONCLUSIONS

The results of this study suggest the German MTS is unsuitable to safely identify patients for redirection to non-ED based GP care.

TRIAL REGISTRATION NUMBER

U1111-1119-7564; Post-results.

Acute kidney injury and 1-year mortality after colorectal cancer surgery: a population-based cohort study

OBJECTIVES

Acute kidney injury (AKI) is a frequent postoperative complication, but the mortality impact within different postoperative time frames and severities of AKI are poorly understood. We examined the occurrence of postoperative AKI among colorectal cancer (CRC) surgery patients and the impact of AKI on mortality during 1 year after surgery.

DESIGN

Observational cohort study. We defined the exposure, AKI, as a 50% increase in plasma creatinine or initiation of renal replacement therapy within 7 days after surgery or an absolute increase in creatinine of 26 µmol/L within 48 hours.

SETTING

Population-based Danish medical databases.

PARTICIPANTS

A total of 6580 patients undergoing CRC surgery in Northern Denmark during 2005-2011 were included from the Danish Colorectal Cancer Group database.

OUTCOMES MEASURE

Occurrence of AKI and 8-30, 31-90 and 91-365 days mortality in patient with or without AKI.

RESULTS

AKI occurred in 1337 patients (20.3%) of the 6580 patients who underwent CRC surgery. Among patients with AKI, 8-30, 31-90 and 91-365 days mortality rates were 10.1% (95% CI 8.6% to 11.9%), 7.8% (95% CI 6.4% to 9.5%) and 12.0% (95% CI 10.3% to 14.2%), respectively. Compared with patients without AKI, AKI was associated with increased 8-30 days mortality (adjusted HR (aHR)=4.01,95% CI 3.11 to 5.17) and 31-90 days mortality (aHR 2.08,95% CI 1.60 to 2.69), while 91-365 days aHR was 1.12 (95% CI 0.89 to 1.41). We observed no major differences in stratified analyses.

CONCLUSIONS

AKI after surgery for CRC is a frequent postoperative complication associated with a substantially increased 90-day mortality. AKI should be considered a potential target for reducing 90-day mortality.

Association of Long-term Use of Low-Dose Aspirin as Chemoprevention With Risk of Lung Cancer

IMPORTANCE

Low-dose aspirin use for chemoprevention of lung cancer risk remains controversial.

OBJECTIVES

To investigate the association between low-dose aspirin use and lung cancer risk, and to identify specific subgroups that may derive the most benefit from low-dose aspirin use.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide, retrospective, cohort study used data from the Korean National Health Information Database from 2002 to 2015. Data analyses were performed from October 2016 to December 2018. Eligible participants (n = 12 969 400) were people aged 40 to 84 years who had undergone national health screening between 2009 and 2010 and had no history of lung cancer between 2006 and 2010 and no standard-dose aspirin use for 6 months between 2002 and 2010.

MAIN OUTCOMES AND MEASURES

The duration of low-dose aspirin use between January 2002 and December 2010 was calculated for each participant. Lung cancer was defined as the first recorded diagnosis of lung cancer-using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes and expanding benefit coverage-between January 2011 and December 2015.

RESULTS

A total of 63 040 participants with a mean (SD) age of 66.4 (9.3) years received a diagnosis of lung cancer. Of these, 45 156 (71.6%) were men. The incidence rate of lung cancer was 98.8 per 100 000 person-years. The duration of low-dose aspirin use was none for 10 987 417 participants (84.7%), 1 to 2 years for 750 992 participants (5.8%), 3 to 4 years for 506 945 participants (3.9%), 5 to 6 years for 371 062 participants (2.9%), 7 to 8 years for 240 528 participants (1.9%), and 9 years for 112 456 participants (0.9%). Compared with no aspirin use, 5 to 6 years (adjusted hazard ratio, 0.96 [95% CI, 0.92-0.99]), 7 to 8 years (adjusted hazard ratio, 0.94 [95% CI, 0.90-0.99]), and 9 years (adjusted hazard ratio, 0.89 [95% CI, 0.84-0.94]) of aspirin use were significantly associated with reduced lung cancer risk. After stratified analysis, a significant reduction of lung cancer risk was observed among people aged 65 years or older and among people without diabetes.

CONCLUSIONS AND RELEVANCE

Although the use of low-dose aspirin for more than 5 years was associated with decreased risk of lung cancer, particularly among elderly participants and among people without diabetes, the observed effect size was quite modest. Future prospective studies are needed to determine whether there is a causal association.

High comorbidity index is not associated with high morbidity and mortality when employing constrained arthroplasty as a primary treatment for intertrochanteric fractures in elderly patients

AIM

The aim of our study is to investigate the results of constrained total hip arthroplasty as a primary treatment of intertrochanteric fractures (ITF) in elderly patients with high comorbidities.

MATERIALS AND METHODS

Total hip replacement (THR) with a retentive cup was performed on 73 patients with ITF over the age of 54 years who had high comorbidities and a Charlson score above five. Short- and long-term complications were determined by follow-up. Bivariate analysis was conducted in order to determine the possible determinants of mortality and factors associated with comorbidity as measured by the Charlson comorbidities index.

RESULTS

Patient demographics that consisted of females (58.9%) (p < 0.04) with the mean age of both males and females demonstrated no statistical significance. The mean hospitalization time and weight bearing time were 11 and 2.67 days, respectively. Only 4.1% needed re-intervention due to re-fracture and none due to prosthesis failure. There was a statistical significance between the comorbidity index and the mortality rate. However, no statistical significance was identified between the comorbidity index and the functional status after constrained THR.

CONCLUSION

High comorbidity index is not associated with high morbidity and mortality when employing constrained arthroplasty as a primary treatment for ITF in elderly patients.

In-hospital, short-term and long-term adverse clinical outcomes observed in patients with type 2 diabetes mellitus vs non-diabetes mellitus following percutaneous coronary intervention: A meta-analysis including 139,774 patients

BACKGROUND

Several studies have shown that patients with type 2 diabetes mellitus (T2DM) have worse clinical outcomes in comparison to patients without diabetes mellitus (DM) following Percutaneous Coronary Intervention (PCI). However, the adverse clinical outcomes were not similarly reported in all the studies. Therefore, in order to standardize this issue, a meta-analysis including 139,774 patients was carried out to compare the in-hospital, short-term (<1 year) and long-term (≥1 year) adverse clinical outcomes in patients with and without T2DM following PCI.

METHODS

Electronic databases including MEDLINE, EMBASE, and the Cochrane Library were searched for Randomized Controlled Trials (RCTs) and observational studies. The adverse clinical outcomes which were analyzed included mortality, myocardial infarction (MI), major adverse cardiac events (MACEs), stroke, bleeding, target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis. Risk Ratios (RR) with 95% confidence intervals (CI) were used to express the pooled effect on discontinuous variables and the analysis was carried out by RevMan 5.3 software.

RESULTS

A total number of 139,774 participants were assessed. Results of this analysis showed that in-hospital mortality and MACEs were significantly higher in patients with T2DM (RR 2.57; 95% CI: 1.95-3.38; P = .00001) and (RR: 1.38; 95% CI: 1.10-1.73; P = .005) respectively. In addition, majority of the short and long-term adverse clinical outcomes were also significantly higher in the DM group as compared to the non-DM group. Stent thrombosis was significantly higher in the DM compared to the non-DM group during the short term follow-up period (RR 1.59; 95% CI: 1.16-2.18;P = .004). However, long-term stent thrombosis was similarly manifested.

CONCLUSION

According to this meta-analysis including a total number of 139,774 patients, following PCI, those patients with T2DM suffered more in-hospital, short as well as long-term adverse outcomes as reported by most of the Randomized Controlled Trials and Observational studies, compared to those patients without diabetes mellitus.

Outcomes of Percutaneous Coronary Interventions in Patients With Anemia Presenting With Acute Coronary Syndrome

OBJECTIVE

To study the influence of anemia on long-term outcomes of patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI).

PATIENTS AND METHODS

The study included 5668 consecutive unique patients with acute coronary syndrome who underwent PCI at Mayo Clinic from January 1, 2004, through December 31, 2014. The patients were stratified on the basis of the presence (hemoglobin [Hgb] level, <13 g/dL in men and <12 g/dL in women) and severity (moderate to severe Hgb level, <11 g/dL in men and women) of pre-PCI anemia and compared with patients without anemia. The primary outcomes were in-hospital and long-term all-cause mortality after balancing baseline comorbidities using the inverse propensity weighting method.

RESULTS

Unadjusted all-cause in-hospital mortality (4.6% [84 of 1831] vs 2.0% [75 of 3837]) and 5-year follow-up mortality (44.4% [509] vs 15.4% [323]) were higher in patients with anemia than in those without anemia (P<.001 for both). After applying inverse propensity weighting analysis, the all-cause in-hospital mortality (2.0% [37] vs 2.0% [75]; P=.85) and 5-year mortality (17.8% [203] vs 15.4% [323]; P=.05) were not significantly different between patients with and without anemia; however, there were higher rates of all-cause 5-year mortality in patients with moderate to severe anemia (22.3% [113] vs 15.4% [323]; P<.001) compared with patients without anemia. The trend in 5-year mortality was driven by increased noncardiac mortality in patients with anemia (10.2% [91] vs 7.1% [148]; P=.04) and moderate to severe anemia (10.4% [52] vs 7.1% [148]; P=.006) when compared with nonanemic patients.

CONCLUSION

After accounting for differences in risk profiles of anemic and nonanemic patients, anemia appeared to be an independent risk factor for increased long-term all-cause and noncardiac mortality.

Radial Versus Femoral Approach for Percutaneous Coronary Intervention: MACE Outcomes at Long-Term Follow-up

OBJECTIVE

To compare the main outcomes of radial versus femoral access at long-term follow-up.

BACKGROUND

Little is known about the long-term major cardiovascular events and bleeding complications of patients undergoing percutaneous coronary intervention (PCI) with radial vs femoral approach.

METHODS

A total of 1107 patients from the CENTURY II trial were included. To minimize baseline differences between radial and femoral groups, we applied propensity-score matching for this comparison.

RESULTS

In this multicenter study, the radial approach was used in 73.4% of patients. After propensity-score matching, baseline and procedural characteristics were comparable between both groups. Procedural success was high and similar in radial and femoral approaches (98.2% vs 97.5%; P=.47) while radial access was associated with a shorter hospital stay (1.69 ± 1.92 days vs 2.08 ± 1.98 days; P<.01). The short-term bleeding and vascular complication rates were significantly lower in the radial group (1.7% vs 6.2% [P<.001 in-hospital] and 2.7% vs 9.6% [P<.001 at 1-month follow-up]). At 3-year follow-up, radial access was associated with lower rates of all-cause mortality (3.9 vs 6.9%; P=.04) and cardiovascular death (2.1 vs 4.9%; P=.02). The composite of all-cause mortality, myocardial infarction, and revascularization showed no differences between groups (18.2 vs 21.1%; P=.29).

CONCLUSIONS

Compared to the femoral approach, the radial approach is associated with significantly lower long-term all-cause mortality rate as well as lower in-hospital and short-term bleeding rates. These results suggest additional long-term benefits of radial access for PCI, but should be interpreted within the context of the current study and further verified in future studies.

The Association of Benzodiazepines and z-drugs with Mortality in Patients with Cancer: a Systematic Review

BACKGROUND

Benzodiazepines and Z-drugs are commonly used in patients with cancer for the management of symptoms such as anxiety, agitation and dyspnoea. Clinical staff, patients and relatives have concerns about the impact of these drugs on survival. This potentially decreases prescribing leading to suboptimal symptom control. The aim of this systematic review was to find and assimilate the evidence assessing the association of benzodiazepines and Z-drugs with survival in patients with cancer, to assist in clinical decision-making regarding the use of these drugs in cancer patients.

METHODS

Systematic review with narrative synthesis designed and conducted according to the recommendations set out in Preferred Reporting Items for Systematic Reviews and MetaAnalyses-Protocol (PRISMA-P) and PRISMA statements. The review protocol was registered on the PROSPERO prior to commencing the searches. The electronic databases MEDLINE, EMBASE, PsychINFO, Cochrane Library, AMED were searched and hand-searches were performed. Screening, extraction and quality assessment were performed in duplicate.

RESULTS

A total of 2257 unique records were identified, 116 full-text articles assessed for eligibility, 18 met the inclusion criteria. These contained data on 4117 patients with cancer. All studies were low or very-low quality. Most studies were conducted in patients in the last days/weeks of life. No study found an association between benzodiazepines and survival in patients with cancer.

CONCLUSIONS

There is no evidence demonstrating an association between benzodiazepines and survival in patients with cancer. These results should be interpreted with caution as all studies were low/very low quality, most did not report or account for other medications and did not have survival as a primary outcome. No study assessed the effect of long-term benzodiazepines on survival. Therefore, definitive conclusions regarding survival impact of benzodiazepine in patients with cancer can be made. Further investigation using high-quality long-term randomised control trials with survival as a primary endpoint are needed.

Impact of echocardiography on one-month and one-year mortality of intertrochanteric fracture patients

OBJECTIVE

The aim of this study was to analyze the effects of preoperative echocardiography on patient survival, timing of surgery in length of hospital stay in patients who will undergo hip nailing for an intertrochanteric fracture.

METHODS

The clinical records of the patients who were admitted to a tertiary university hospital with an intertrochanteric femur fracture were retrospectively analyzed. The age, gender, American Society of Anesthesiologists (ASA) score, days to surgery, total hospital stay, cardiac drug prescription/modification, cardiac intervention and presence of an echocardiography assessment including detailed findings were reviewed. Mortality data were accessed from the national civil registration system.

RESULTS

181 (110 women and 71 men; mean age 81 (44-98)) cases were studied whom 65 underwent pre-operative echocardiography. Time to surgery and total hospital stay was 2 days longer at transthoracic echocardiography (TTE) group (p < 0.001). At one month control group survival rate was 93.1% on contrary it was 75.4% at TTE group. One-year survival rates were 77.3% and 55.1% respectively. Likewise mean expected survival time was 21.6 ± 1.03 months for control group and 15.12 ± 1.64 months for TTE group (p < 0.001). Only increased left ventricular end diastolic diameter (LVEDD) was showed to be associated with increasing one-year mortality with a hazard ratio of 10.78 (2.572-45.19) at multivariate model.

CONCLUSION

Cardiac findings and requisite for preoperative TTE and increased LVEDD is a strong predictor for mortality. TTE significantly lengthens the time to surgery. Also LVEDD measurement can be easily performed in the bedside which we believe would save time and reduce mortality.

LEVEL OF EVIDENCE

Level III Diagnostic study.

Prediction of long-term net clinical outcomes using the TIMI-AF score: Comparison with CHA2DS2-VASc and HAS-BLED

The TIMI-AF score was described to predict net clinical outcomes (NCOs) in atrial fibrillation (AF) patients receiving warfarin. However, this score derived from the ENGAGE AF-TIMI 48 trial, and no external validation exists in real world clinical practice. We tested the long-term predictive performance of the TIMI-AF score in comparison with CHA₂DS₂-VASc and HAS-BLED in a 'real-world' cohort of anticoagulated AF patients.

METHODS

We included 1156 consecutive AF patients stable on vitamin K antagonist (INR 2.0-3.0) during 6 months. The baseline risk of NCOs (composite of stroke, life-threatening bleeding, or all-cause mortality) was calculated using the novel TIMI-AF score. During follow-up, all NCOs were recorded and the predictive performance and clinical usefulness of TIMI-AF was compared with CHA₂DS₂-VASc and HAS-BLED.

RESULTS

During 6.5 years (IQR 4.3-7.9), there were 563 NCOs (7.49%/year). 'Low-risk' (6.07%/year) and 'medium-risk' (9.49%/year) patients defined by the TIMI-AF suffered more endpoints that low- and medium-risk patients of CHA₂DS₂-VASc and HAS-BLED (2.37%/year and 4.40%/year for low risk; 3.48%/year and 6.39%/year for medium risk, respectively). The predictive performance of TIMI-AF was not different from CHA₂DS₂-VASc (0.678 vs 0.677, P = .963) or HAS-BLED (0.644 vs 0.671, P = .054). Discrimination and reclassification did not show improvement of prediction using the TIMI-AF score, and decision curves analysis did not demonstrate higher net benefit.

CONCLUSIONS

In VKA-experienced AF patients, the TIMI-AF score has limited usefulness predicting NCOs over a long-term period of follow-up. This novel score was not superior to CHA₂DS₂-VASc and HAS-BLED identifying low-risk AF patients.

[Ischaemia of a femoral stump in short- and long-term periods after limb amputation]

The authors retrospectively analysed medical case histories of 287 patients subjected to femoral amputations over the period from January 1, 1998 to December 31, 2013. The studied parameters were as follows: the frequency of and risk factors for femoral stump ischaemia, as well as the effect on patients' survival after femoral amputation. Amongst 156 patients having endured transfemoral truncation of the limb performed as the first amputation, early femoral stump ischaemia (EFSI) within 3 postoperative months was found to have occurred in 43 (27.6%) patients, whereas amongst 127 patients first subjected to amputation of the crus and then to femoral truncation it occurred in 15 (13.2%) cases; p<0.05. The incidence rate of late femoral stump ischaemia (LFSI) was virtually similar in both groups, amounting to 5.8% (9 of 156) and 5.5% (7 of 127), respectively; p>0.05. The survival rate for patients without stump ischaemia at 12 months after amputation amounted to 79.4%, for those with EFSI to 50.0% (p=0.00928), and for those with LFSI to 71.4% (p=0.22576), whereas by the end of a 5-year follow up period these values appeared to equal 49.2%, 32.1% (p=0.13225) and 7.1% (p=0.01385), respectively. The obtained findings demonstrated that the risk factors for EFSI were as follows: the presence of a femoral stump on the contralateral side, grade III ischaemia, and proximal localization of the lesion of the arterial bed (odds ratio 3.3, 2.7 and 3.8, respectively); a risk factor for LFSI was the presence of a femoral stump on the contralateral side (odds ratio 6.0).

Long-term mortality in older patients discharged after acute decompensated heart failure: a prospective cohort study

BACKGROUND

Data are available on short- and intermediate-term mortality rates after discharge for acutely decompensated heart failure (ADHF). However, few studies specifically addressed ADHF outcomes in patients aged 75 years or over, who contribute more than half of all ADHF admissions. Our objectives here were to estimate the long-term mortality of patients aged 75 years or over who were discharged after admission for ADHF and to identify factors, especially geriatric findings, independently associated with 2-year mortality.

METHODS

This prospective cohort study in five French hospitals included consecutive patients aged 75 years or older and discharged after emergency-department admission for ADHF meeting Framingham criteria (N = 478; median age, 85 years; 68% female). Kaplan-Meier 1-year and 2-year survival curves were plotted. Admission characteristics independently associated with overall 2-year mortality were identified using multivariable Cox proportional-hazards regression.

RESULTS

Mortality was 41.7% (95% confidence interval [95% CI], 37.2%-53.5%) after 1 year and 56.0% (95% CI, 51.5%-60.7%) after 2 years. By multivariable analysis, independent predictors of 2-year mortality were male sex (hazard ratio [HR], 1.36; 95% CI, 1.00-1.82), age >85 years (HR, 1.57; 95% CI, 1.19-2.07), higher number of impaired activities of daily living (HR, 1.11 per impaired item; 95% CI, 1.05-1.17), recent weight loss (HR, 1.61; 95% CI, 1.14-2.28), and lower systolic blood pressure (HR, 0.86 per standard deviation increase; 95% CI, 0.74-0.99). Creatinine clearance ≤30 mL/min showed a trend toward an association with 2-year mortality (HR, 1.36; 95% CI, 0.97-2.00).

CONCLUSION

Functional impairment before admission is associated with higher long-term mortality in patients ≥75 years admitted for ADHF. This study focused on geriatric markers not traditionally collected in heart-failure patients but did not analyse all cardiologic parameters associated with outcomes in other studies. Nevertheless, our findings may contribute to identify those patients admitted for ADHF who have the worst prognosis.

[Remote results of carotid endarterectomy in patients with type 2 diabetes mellitus]

The authors comparatively analysed the remote results of carotid endarterectomy and risk factors for unfavourable outcomes in patients with and without type 2 diabetes mellitus (DM). The outcomes of carotid endarterectomy were studied in a total of 168 patients, with the follow-up terms up to 8 years. Depending on the presence or absence of DM, the patients were divided into two groups. Group One comprised 79 patients with an atherosclerotic lesion of the internal carotid artery and accompanying DM, with Group Two consisting of 89 non-diabetic patients. There were no lethal outcomes in the early postoperative period. The composite measure 'lethality + stroke' in Group One amounted to 2.5% and in Group Two to 2.2%. In the remote period the survival rate was as follows: 65 (82.3%) people for Group One and 83 (93.3%) for Group Two, with the 5-year cumulative survival rate amounting to 75.1±6.4% and 92.5±3.0%, respectively. The index of freedom from acute vascular complications (myocardial infarction, ischaemic stroke) at 5 years in Group One was 54.2±7.2% and in Group Two 86.1±4.3%. Acute vascular complications were causes of lethal outcomes in 13 cases in the group with DM and in 3 cases in the group without DM. Death was most often caused by acute coronary complications. The index of freedom from restenosis at 5 years in Group One amounted to 74.5±8.0% and at 7 years of follow-up in Group Two to 92.3±7.3%. The risk factors for the development of acute vascular complications in diabetic patients according to the findings of the Cox regression analysis were as follows: age above 65 years, DM duration of more than 5 years; the level of glycated haemoglobin above 7.5%; a history of myocardial infarction; presence of degree III arterial hypertension. The risk factors for restenosis included: DM duration of more than 5 years, the level of glycated haemoglobin above 7.5% and presence of degree III arterial hypertension. The results of the study make it possible to regard carotid endarterectomy efficient and safe for both cohorts of patients (with and without DM). In the remote postoperative period, such parameters as survival rate, indices of freedom from acute vascular complications and restenosis turned out to be statistically significantly lower in diabetic patients than in non-diabetic, with the predominating coronary complications induced by insufficient assessment of the coronary reserve and the presence of occult forms of ischaemic heart disease. Long-term results may be improved by means of widening the indications for performing coronarography in patients with DM.

Long-Term Mortality and Quality of Life After Transcatheter Aortic Valve Insertion in Very Elderly Patients

BACKGROUND

We sought to compare long-term mortality and quality of life (QoL) in very elderly (≥80 years) patients undergoing transcatheter aortic valve implantation (TAVI) in comparison with younger patients (<80 years).

METHODS

A total of 101 patients treated with TAVI were divided into two groups according to age: <80 years (n = 42; 41.6%) and ≥80 years (n = 59; 58.4%). The baseline characteristics, including procedural outcomes as well as frailty and QoL assessment were compared between age groups.

RESULTS

Very elderly patients (≥80 years) were more frequently female, with a higher estimated risk of death based on STS score. Other baseline characteristics, including frailty indices, were comparable between groups. No difference in complication rate between age groups was observed. At 12 months, mortality rates were comparable for patients <80 years vs ≥80 years (16.7% vs 18.6%, respectively; P=.99). An improvement in QoL after 12 months as assessed by EQ-5D-3L was confirmed for both age groups, but with more pronounced beneficial effect of TAVI in younger patients.

CONCLUSION

The results of our single-center study showed that older age does not seem to be associated with impaired clinical outcomes after TAVI. However, benefit of TAVI in terms of long-term QoL improvement may be less apparent in very elderly patients.

Use of the Impella Device for Acute Coronary Syndrome Complicated by Cardiogenic Shock - Experience From a Single Heart Center With Analysis of Long-term Mortality

AIMS

Impella is a microaxial rotary pump that is placed across the aortic valve to expel aspirated blood from the left ventricle into the ascending aorta; it can be used in cardiogenic shock. While previous studies have evaluated the efficacy and safety of the Impella device, more clinically relevant data are necessary, especially with regard to outcomes.

METHODS AND RESULTS

We screened our database of Impella patients in our heart center and found 68 consecutive patients who underwent Impella implantation due to acute coronary syndrome (ACS) complicated by cardiogenic shock. Data were evaluated with regard to baseline and procedural characteristics and also included an assessment of the short-term and long-term outcomes. The majority of patients (74%) suffered from an ST-elevation myocardial infarction, and 59% of patients received the Impella device during the initial coronary angiography. In the remaining cases, Impella implantation was performed at a later time, most commonly after IABP implantation. Patient characteristics were not significantly different between both groups. The predominantly implanted device was an Impella 2.5. Mortality in the severely ill patient population remained high, but univariate/multivariate analyses identified significant risk factors. Interestingly, delayed initiation of Impella support was an independent predictor of higher long-term mortality (hazard ratio, 2.157; P=.04) within the Impella patient cohort.

CONCLUSION

This large series of patients with ACS complicated by cardiogenic shock who underwent Impella implantation provides information on the relevant risk factors for mortality. Early (compared with delayed) initiation of Impella support was a predictor of improved survival in this population of patients.

Percutaneous closure of atrial septal defect in adults: very long-term clinical outcome and effects on aortic and mitral valve function

AIM

To investigate the very long-term clinical outcomes of atrial septal defect (ASD) percutaneous closure in adult patients and to evaluate the 12-month effects of the device on aortic and mitral valve function.

METHODS

Over a 12-year period, a total of 110 consecutive patients underwent percutaneous ASD closure. A yearly clinical follow-up was conducted and any adverse event was recorded. In a 55-patient echocardiographic subgroup, the baseline and 12-month aortic and mitral regurgitation rate was recorded.

RESULTS

Mean age was 50.9 ± 17 years and 75% of patients were female. Mean ASD echocardiographic dimension was 17.6 ± 6.2 mm (range, 5-36 mm). Procedural success rate was 97%. After a mean follow-up of 61.8 ± 34.9 months (range, 6-167 months), all-cause death occurred in 2 patients (1.8%) and the composite primary outcome of major adverse cardiovascular event (MACE) occurred in 5 patients (4.5%): 2 non-device related cardiac deaths occurred and 3 surgeries were required. The Kaplan-Meier analysis showed an event-free survival at 140 months of 90%. In the 12-month echocardiographic substudy, no case of significant (moderate or severe) new-onset aortic regurgitation was detected, while 1 case (1.8%) of worsening mild-to-moderate aortic regurgitation was described (P=.90). No case of significant new-onset or worsening mitral regurgitation was noted. No patient needed aortic or mitral surgical repair at very long-term follow-up.

CONCLUSIONS

Transcatheter ASD closure is a safe procedure with satisfactory very long-term clinical outcomes. The ASD device does not significantly affect aortic and mitral valve function.