Abstract
Aims
We sought to perform a head-to-head comparison of contemporary 30-day outcomes and readmissions between valve-in-valve transcatheter aortic valve replacement (VIV-TAVR) patients and a ...matched cohort of high-risk reoperative surgical aortic valve replacement (re-SAVR) patients using a large, multicentre, national database.
Methods and results
We utilized the nationally weighted 2012–16 National Readmission Database claims to identify all US adult patients with degenerated bioprosthetic aortic valves who underwent either VIV-TAVR (n = 3443) or isolated re-SAVR (n = 3372). Thirty-day outcomes were compared using multivariate analysis and propensity score matching (1:1). Unadjusted, VIV-TAVR patients had significantly lower 30-day mortality (2.7% vs. 5.0%), 30-day morbidity (66.4% vs. 79%), and rates of major bleeding (35.8% vs. 50%). On multivariable analysis, re-SAVR was a significant risk factor for both 30-day mortality adjusted odds ratio (aOR) of VIV-SAVR (vs. re-SAVR) 0.48, 95% confidence interval (CI) 0.28–0.81 and 30-day morbidity aOR for VIV-TAVR (vs. re-SAVR) 0.54, 95% CI 0.43–0.68. After matching (n = 2181 matched pairs), VIV-TAVR was associated with lower odds of 30-day mortality (OR 0.41, 95% CI 0.23–0.74), 30-day morbidity (OR 0.53, 95% CI 0.43–0.72), and major bleeding (OR 0.66, 95% CI 0.51–0.85). Valve-in-valve TAVR was also associated with shorter length of stay (median savings of 2 days, 95% CI 1.3–2.7) and higher odds of routine home discharges (OR 2.11, 95% CI 1.61–2.78) compared to re-SAVR.
Conclusion
In this large, nationwide study of matched high-risk patients with degenerated bioprosthetic aortic valves, VIV-TAVR appears to confer an advantage over re-SAVR in terms of 30-day mortality, morbidity, and bleeding complications. Further studies are warranted to benchmark in low- and intermediate-risk patients and to adequately assess longer-term efficacy.
The United Network for Organ Sharing (UNOS) implemented a revised donor heart allocation system on October 18, 2018 with principle aims to reduce waitlist mortality, enhance geographic organ sharing, ...and improve organ distribution equity. Five recently published analyses compared outcomes of heart transplant (HT) recipients transplanted under the revised versus previous system. All demonstrated increased pre-transplant temporary mechanical circulatory support use and graft ischemic times under the revised system. However, despite using data from the same UNOS Registry, three analyses demonstrated increased risk of post-transplant mortality under the revised system, while two others found no significant difference in mortality risk. These studies differed in their analytic cohorts, study periods, follow-up duration, and statistical methodologies. Additionally, some may have introduced survivor bias or violated non-informative censoring. Given these variable findings, longer-term outcome assessment is warranted before the HT community can truly understand the impact of the 2018 UNOS system revision on post-transplant outcomes.
Atrial functional mitral regurgitation (FMR) occurs because of left atrial dilatation or atrial fibrillation in heart failure with preserved left ventricular (LV) function, contrary to ventricular ...FMR, which occurs because of LV dysfunction. Despite pathophysiological differences, current guidelines do not discriminate between these 2 entities.
From January 2002 to March 2019, all adult patients with ≥3+ mitral regurgitation who underwent mitral valve repair or replacement were identified. Postoperative outcomes and midterm time-to-event rates (survival and reoperation) were compared.
Overall, 94 atrial FMR (mean age, 67.6 years) and 84 ventricular FMR (mean age, 64 years) patients met inclusion criteria. Differences in baseline cardiac morphology and function of the atrial FMR and ventricular FMR patients were as follows: concomitant atrial fibrillation (37.2% vs 14.3%), heart failure (42.6% vs 63.1%), LV ejection fraction (60% vs 37%), at least moderate LV dilation (4.8% vs 40.6%), and moderate/severe right heart dysfunction (15.2% vs 5.1%), respectively. Operative mortality was 0% in the atrial FMR versus 1.2% in the ventricular FMR cohort. Actuarial estimates of survival and freedom from reoperation at 5 and 10 years was significantly higher in the atrial FMR cohort versus the ventricular FMR cohort. Ventricular FMR also remained a significant predictor of midterm mortality in our risk-adjusted analysis (adjusted hazard ratio for ventricular FMR, 1.8; 95% confidence interval, 1.001-3.26).
There are important differences in baseline characteristics in terms of cardiac morphology and function among atrial FMR and ventricular FMR patients, which appear to affect in-hospital and midterm outcomes. Because of these discrepancies, early discrimination between these 2 etiologies of FMR might facilitate more tailored approaches to management.
Visual graphical summary of mechanistic insights and possible treatment considerations between atrial functional mitral regurgitation (FMR) and ventricular FMR. MR, Mitral regurgitation; MV, mitral valve; LV, left ventricular; AF, atrial fibrillation; GDMT, goal-directed medical therapy; HF, heart failure; CABG, coronary artery bypass grafting. Display omitted
Tricuspid regurgitation (TR), particularly secondary or functional TR, is the most prevalent right heart valvular lesion associated with significant morbidity and mortality.1 Moderate-to-severe ...functional TR affects approximately 1.6 million people in the United States, with only 8,000 undergoing surgical repair, yearly, often in the setting of left heart surgery, as surgical repair is limited to severe TR based on current guidelines (Class I, Level of Evidence – C).2,3 Currently, heart failure (HF) is associated with a high prevalence of 5.7 million in the United States, with an alarming projection of 46% increase in prevalence by the year 2030.4 Despite these concerning epidemiological estimates, the data outlining the mortality burden of non-rheumatic TR which includes functional TR in the United States is not known, but relevant in the context of clinical care, patient education, guideline development and policy-related changes. The present analysis utilized deidentified records from the public-use “Multiple Cause of Death data” via the Centers for Disease Control and Prevention Wide‐Ranging On-line Data for Epidemiologic Research (CDC WONDER) datasets, 2008 to 2018. The Multiple Cause of Death data comprises of national mortality and population data based on death certificates containing a single underlying cause of death, up to 20 additional multiple causes, and demographic data for the United States counties.
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