ObjectiveFunctional tricuspid regurgitation (TR) is a frequent finding in echocardiography. Literature suggests significant TR is associated with poor prognosis. Still, data remain limited. This ...study aimed to evaluate long-term prognostic implications in patients with TR.MethodsIn this observational cohort study, data from 1650 consecutive patients were analysed. Primary endpoint was all-cause mortality. Mean follow-up time was 1090 days. TR grades at baseline and follow-up were compared. Survival analyses were performed to identify prognostic factors.ResultsAt baseline, 14.1% patients showed no, 63.8% mild, 17.4% moderate and 4.7% severe TR. 359 patients (21.8%) died within the study period. TR at baseline was associated with excess mortality. Moderate and severe TR were of prognostic implication in all subgroups irrespective of systolic pulmonary artery pressure (sPAP) (</≥40 mm Hg) and left ventricular ejection fraction (LV-EF) (</≥50%). Survival was worst in patients with moderate and severe TR and concomitant elevated sPAP or reduced LV-EF at 1 and 3 years, respectively (p<0.001; p<0.001). In a multivariate model, including cardiac and non-cardiac risk factors, moderate and severe TR, sPAP and impaired right ventricular (RV) function were independent predictors for survival (HR 1.89, CI 1.07 to 3.36, p=0.029; HR 2.93, CI 1.57 to 5.49, p=0.001; HR 1.44, CI 1.25 to 1.65, p<0.001; HR 1.43, CI 1.14 to 1.79, p=0.002). Overall progression of TR on follow-up was 28.4%. Patients with TR progression showed significantly worse survival (HR 1.44, CI 1.11 to 1.81; p=0.006).ConclusionWhile TR progressed over time, it was associated with impaired long-term survival. TR grade, RV dysfunction, sPAP and TR progression were independent predictors for survival.
Abstract
Introduction
Severe complications after transcatheter aortic valve implantation (TAVI) are rare due to increasing procedural safety. However, TAVI procedure-related haemodynamic instability ...and increased risk of infection may affect renal functional reserve with subsequent renal acidosis and hyperkalaemia.
Objective
In this study, we investigated incidence, modifiable risk factors and prognosis of acute kidney injury (AKI) and AKI complicated by hyperkalaemia, pulmonary oedema or metabolic acidosis after TAVI.
Methods
In a retrospective single-centre study, 804 consecutive patients hospitalized during 2017 and 2018 for elective TAVI were included. AKI was defined according to the ‘Kidney Disease Improving Global Outcome’ (KDIGO) initiative. Variables on co-morbidities, intra-/post-interventional complications and course of renal function up to 6 months after index-hospitalization were assessed. In multivariate regression analyses, risk factors for the development of AKI, complicated AKI, renal non-recovery from AKI and in-hospital mortality were determined.
Results
Incidence of AKI was 13.8% (111/804); in-hospital mortality after TAVI was 2.3%. AKI was an independent risk factor for in-hospital mortality, odds ratio (OR) 10.3 (3.4–31.6), P < 0.001, further increasing to OR = 21.8 (6.6–71.5), P < 0.001 in patients with AKI complicated by hyperkalaemia, pulmonary oedema or metabolic acidosis, n = 57/111 (51.4%). Potentially modifiable, interventional factors independently associated with complicated AKI were infection OR = 3.20 (1.61–6.33), P = 0.001 and red blood cell transfusion OR = 5.04 (2.67–9.52), P < 0.001. Valve type and size, contrast volume and other intra-interventional characteristics, such as the need for tachycardial pacing, did not influence the development of AKI. Eleven of 111 (9.9%) patients did not recover from AKI, mostly affecting patients with cardiac decompensation. In 18/111 (16.2%) patients, information concerning AKI was provided in discharge letter. Within 6 months after TAVI, higher proportion of patients with AKI showed progression of pre-existing chronic kidney disease compared with patients without AKI 14/29, 48.3% versus 54/187, 28.9%, OR = 2.3 (95% confidence interval 1.0–5.1), P = 0.036.
Conclusions
AKI is common and may impede patient outcome after TAVI with acute complications such as hyperkalaemia or metabolic acidosis and adverse renal function until 6 months after intervention. Our study findings may contribute to refinement of allocation of appropriate level of care in and out of hospital after TAVI.
Right heart failure is a major challenge in clinical practice. Soluble Suppression of Tumorigenicity-2 (sST2), a member of the interleukin-1-receptor family, may have clinical prognostic value. The ...aim of this study was to analyze whether sST2 correlates with signs of acute right heart decompensation. This prospective single-center study included 50 patients admitted for clinical signs of predominant right heart decompensation. Signs of reduced blood supply to other organs (e.g., renal function parameter, troponin T, NT-proBNP), diuretics, and signs of venous congestion (inferior vena cava (IVC) diameter) with fluid retention (weight gain, peripheral edema) resulting from reduced RV function were analyzed. The degree of peripheral edema was defined as none, mild (5-6 mm depressible, regression in 15-60 s) or severe (>7 mm depressible, regression in 2-3 min). sST2 levels were measured at the day of hospitalization. A total of 78.7% showed severe peripheral edema. The median concentration of sST2 was 35.2 ng/mL (25.-75. percentiles 17.2-46.7). sST2 is correlated with the peripheral edema degree (rSpearman = 0.427,
= 0.004) and the diameter of IVC (r = 0.786,
= 0.036), while NT-proBNP (r = 0.114,
= 0.456), troponin T (r = 0.123,
= 0.430), creatinine-based eGFR (r = -0.207,
= 0.195), or cystatin C-based eGFR (r = -0.032,
= 0.839) did not. sST2, but no other established marker, is correlated with peripheral and central fluid status in patients with decompensated right heart failure.
Aim: The impact of chronic kidney disease (CKD) on patient-related outcomes in patients with tricuspid regurgitation (TR) is well known. However, the impact of the progression of CKD in patients with ...TR and potentially modifiable risk factors of progressing CKD is unknown. Methods: 444 consecutive adult patients with TR and CKD stage 1−4 admitted in an inpatient setting between January 2010 and December 2017 were included. During a median follow-up of two years, eGFR and survival status were collected. Independent risk factors for CKD progression and all-cause mortality were determined. Patient survival statuses were grouped according to different combinations of the presence or absence of CKD progression and the TR grade. Results: Progression of CKD (OR 2.38 (95% confidence interval 1.30−4.35), p = 0.005), the grade of TR (OR 2.38 (1.41−4.00), p = 0.001) and mitral regurgitation (OR 1.72 (1.20−2.46), p = 0.003) were independent risk factors for all-cause mortality. Haemoglobin at admission (OR 0.80 (0.65−0.99), p = 0.043) and the presence of type 2 diabetes (OR 1.67 (1.02−2.73), p = 0.042) were independent risk factors for CKD progression. The combination of the status of CKD progression and the TR grade showed a stepwise pattern for all-cause mortality (p < 0.001). Patients with CKD progression and TR grade 1 had comparable all-cause mortality with patients without CKD progression but with TR grade 2 or 3. Even in patients with TR grade 1, the risk for all-cause mortality doubled if CKD progression occurred (OR 2.49 (95% CI 1.38−4.47), p = 0.002). Conclusion: CKD progression appears to be a risk factor for all-cause mortality in patients with TR. Anaemia and diabetes are potential modifiers of CKD progression.
Aims:
To compare intermediate performance and mortality rates in patients, who underwent transcatheter aortic valve implantation (TAVI) with two different types of prostheses: Edwards Sapien 3 (ES3) ...and Direct Flow Medical (DFM).
Methods and Results:
42 consecutive patients implanted with a DFM prosthesis for severe aortic stenosis were matched 1:1 with an equal number of patients, who received an ES3 during the same period. Primary endpoint was mortality. MACE, as a composite of all-cause death, stroke, and re-do-procedure (valve-in-valve), was defined as secondary endpoint. Moreover, we compared NYHA class, NT-proBNP-levels and the extent of restenosis. Patients were followed for 2 years. DFM patients showed echocardiographic elevated mean pressure gradients compared to ES3 patients before discharge (11.2 mmHg ± 5.3 vs. 3.5 mmHg ± 2.7;
p
< 0.001) and upon 6-months follow-up (20.3 mmHg ± 8.8 vs. 12.3 mmHg ± 4.4;
p
< 0.001). ES3 candidates showed superior NYHA class at follow-up (
p
= 0.001). Kaplan-Meier analysis revealed significantly worse survival in patients receiving a DFM prosthesis compared to ES3 (Breslow
p
= 0.020). MACE occurred more often in DFM patients compared to ES3 (Breslow
p
= 0.006).
Conclusions:
Patients receiving DFM valve prostheses showed worse survival and higher rates in MACE compared to ES3. Prosthesis performance regarding mean pressure gradients and patients' NYHA class also favored ES3.
Lesen hilft Hähnel, Valentin
Intensiv : Fachzeitschrift für Intensivpflege und Anästhesie,
07/2017, Letnik:
25, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Zusammenfassung
Psychotherapeutische Komponente in der Intensivtherapie
Bietet ein Intensivtagebuch die Möglichkeit zur Aufarbeitung einer nicht
gelebten Zeit? Dieser Frage ist Valentin Hähnel ...nachgegangen und hat dazu nicht nur die Effekte eines Intensivtagebuchs auf die betroffenen
Patienten untersucht. Auch die Bedeutung für Pflegende und Angehörige ist bemerkenswert – und das noch weit nach der Entlassung des
Patienten aus der Klinik.
Functional tricuspid regurgitation (TR) is a frequent finding in echocardiography. Despite general consent that right ventricular (RV) dysfunction impacts outcome of patients with TR, it is still ...unknown which echocardiographic parameters most accurately reflect prognosis. In this study we aimed to evaluate the prevalence of RV dysfunction and its prognostic value in patients with TR.
Data from 1089 consecutive patients were analysed. Tricuspid annular plane systolic excursion (TAPSE), fractional area change, and right ventricular free wall longitudinal strain (RV strain) were used to define RV dysfunction. Patients were followed for 2-year all-cause mortality. For prediction of survival, reclassification and C statistics of RV functional parameters using TR grade as reference model were performed.
Among the patients studied, 13.9% showed no TR, 61.2% had mild TR, 19.6% had moderate TR, and 5.3% had severe TR. The TR grade was associated with increased mortality (log rank, P < 0.001). Impaired RV strain and TAPSE were independent predictors for mortality (RV: hazard ratio HR, 1.130; 95% confidence interval CI, 1.099-1.160; P < 0.001; TAPSE: HR, 1.131; 95% CI, 1.085-1.175; P < 0.001). Both RV strain and TAPSE improved the reference model for survival prediction (RV: integrated discrimination improvement IDI, 0.184; 95% CI, 0.146-0.221; P < 0.001; TAPSE: IDI, 0.057; 95% CI, 0.037-0.077; P < 0.001).
Echocardiographic evaluation of RV function appears to useful for patients with TR. Assessment of RV strain provides additional value for prediction of 2-year mortality.
Une insuffisance tricuspide (IT) fonctionnelle est une observation fréquente en échocardiographie. Bien qu'il soit généralement admis que la dysfonction du ventricule droit (VD) a un impact sur le pronostic des patients atteints d'IT, on ne sait toujours pas quels sont les paramètres échocardiographiques qui reflètent le plus précisément ce pronostic. Dans cette étude, nous avons cherché à évaluer la prévalence de la dysfonction du VD et sa valeur pronostique chez les patients atteints d'IT.
Les données obtenues pour 1 089 patients consécutifs ont été analysées. L'excursion systolique du plan de l'anneau tricuspide (TAPSE, de l’anglais « tricuspid annular plane systolic excursion »), la fraction de raccourcissement de surface et la déformation longitudinale de la paroi libre du ventricule droit ont été utilisées pour définir la dysfonction du VD. Les patients ont été suivis pour la mortalité à deux ans toutes causes confondues. Pour la prédiction de la survie, une reclassification et des probabilités de concordance des paramètres fonctionnels du VD en utilisant le niveau d'IT comme modèle de référence ont été réalisées.
Parmi les patients étudiés, 13,9 % ne présentaient aucune IT, 61,2 % présentaient une IT légère, 19,6 % une IT modérée et 5,3% une IR sévère. Le grade d'IT était associé à une mortalité accrue (test logarithmique par rangs, P < 0,001). L'altération de la déformation du VD et du TAPSE était un facteur prédictif indépendant de mortalité (VD : rapport des risques RR, 1,130; intervalle de confiance IC à 95 %, 1,099-1,160; P < 0,001; TAPSE : RR, 1,131; IC à 95 %, 1,085-1,175 ; P < 0,001). La déformation du VD et le TAPSE ont amélioré le modèle de référence pour la prédiction de la survie (déformation du VD : indice d’amélioration de la discrimination intégrée IDI, 0,184 ; IC à 95 %, 0,146-0,221; P < 0,001; TAPSE : IDI, 0,057; IC à 95 %, 0,037-0,077 ; P < 0,001).
L'évaluation échocardiographique de la fonction du VD s’est révélée utile pour les patients atteints d'IT. L'évaluation de la déformation du VD apporte une plus-value pour la prédiction de la mortalité à 2 ans.
•Post-procedural TR predicts long-term survival in PMVR patients.•TR improved in patients after PMVR.•Echocardiographic pulmonary pressure is decreased post PMVR.•TR is associated with more severe ...heart failure symptoms in PMVR patients.
Functional tricuspid regurgitation (TR) is frequently present in patients with severe mitral regurgitation and is associated with worse outcome. While percutaneous mitral valve repair (PMVR) is on the increase, the role of TR in those patients is unclear. This study aimed to compare pre- and post-procedural TR and investigated the impact of post-procedural TR and major clinical risk factors on long-term survival in patients undergoing PMVR.
In this retrospective observational cohort study, data from 213 consecutive patients at a tertiary care center undergoing PMVR from 2010 to 2016 were analyzed. Two different groups, dichotomized according to the degree of TR (none/mild and moderate/severe) were compared. Multivariable analyses were performed assessing predictors for long-term survival adjusting for major risk factors.
Following PMVR TR was significantly reduced by at least 1 grade in 23.0% (p=0.001), while echocardiographic pulmonary pressure was decreased (TR Vmax 3.21±0.49m/s vs. 2.98±0.53m/s; p=<0.001). Patients with moderate or severe TR presented with worse New York Heart Association functional class and elevated N-terminal pro B-type natriuretic peptide levels compared to patients with none or mild TR. Median survival time was 1458 days. Proportional hazards model, adjusted for major risk factors, revealed post-procedural TR grade (HR 2.055, CI 1.317–3.206, p=0.02), severely impaired left ventricular function (HR 3.145, CI 1.199–8.250, p=0.020), and chronic kidney disease glomerular filtration rate (GFR) 30–60ml/min HR 1.917, CI 1.109–3.314, p=0.020; GFR<30ml/min HR 3.969, CI 1.981–7.951, p<0.001 as independent predictors for long-term survival.
Post-procedural moderate and severe TR predicts worsened long-term survival in patients undergoing PMVR and is associated with adverse clinical outcome. Whether outcome might be improved by interventional reduction of post-procedural TR has to be investigated in the future.
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