Transcatheter aortic valve replacement (TAVR) use is increasing in patients with longer life expectancy, yet robust data on the durability of transcatheter heart valves (THVs) are limited. Redo-TAVR ...may play a key strategy in treating patients in whom THVs fail.
The authors sought to examine outcomes following redo-TAVR.
The Redo-TAVR registry collected data on consecutive patients who underwent redo-TAVR at 37 centers. Patients were classified as probable TAVR failure or probable THV failure if they presented within or beyond 1 year of their index TAVR, respectively.
Among 63,876 TAVR procedures, 212 consecutive redo-TAVR procedures were identified (0.33%): 74 within and 138 beyond 1 year of the initial procedure. For these 2 groups, TAVR-to-redo-TAVR time was 68 (38 to 154) days and 5 (3 to 6) years. The indication for redo-TAVR was THV stenosis in 12 (16.2%) and 51 (37.0%) (p = 0.002) and regurgitation or combined stenosis–regurgitation in 62 (83.8%) and 86 (62.3%) (p = 0.028), respectively. Device success using VARC-2 criteria was achieved in 180 patients (85.1%); most failures were attributable to high residual gradients (14.1%) or regurgitation (8.9%). At 30-day and 1-year follow-up, residual gradients were 12.6 ± 7.5 mm Hg and 12.9 ± 9.0 mm Hg; valve area 1.63 ± 0.61 cm2 and 1.51 ± 0.57 cm2; and regurgitation ≤mild in 91% and 91%, respectively. Peri-procedural complication rates were low (3 stroke 1.4%, 7 valve malposition 3.3%, 2 coronary obstruction 0.9%, 20 new permanent pacemaker 9.6%, no mortality), and symptomatic improvement was substantial. Survival at 30 days was 94.6% and 98.5% (p = 0.101) and 83.6% and 88.3% (p = 0.335) at 1 year for patients presenting with early and late valve dysfunction, respectively.
Redo-TAVR is a relatively safe and effective option for selected patients with valve dysfunction after TAVR. These results are important for applicability of TAVR in patients with long life expectancy in whom THV durability may be a concern.
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Surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) are now both used to treat aortic stenosis in patients in whom life expectancy may exceed valve durability. The ...choice of initial bioprosthesis should therefore consider the relative safety and efficacy of potential subsequent interventions.
The aim of this study was to compare TAVR in failed transcatheter aortic valves (TAVs) versus surgical aortic valves (SAVs).
Data were collected on 434 TAV-in-TAV and 624 TAV-in-SAV consecutive procedures performed at centers participating in the Redo-TAVR international registry. Propensity score matching was applied, and 330 matched (165:165) patients were analyzed. Principal endpoints were procedural success, procedural safety, and mortality at 30 days and 1 year.
For TAV-in-TAV versus TAV-in-SAV, procedural success was observed in 120 (72.7%) versus 103 (62.4%) patients (p = 0.045), driven by a numerically lower frequency of residual high valve gradient (p = 0.095), ectopic valve deployment (p = 0.081), coronary obstruction (p = 0.091), and conversion to open heart surgery (p = 0.082). Procedural safety was achieved in 116 (70.3%) versus 119 (72.1%) patients (p = 0.715). Mortality at 30 days was 5 (3%) after TAV-in-TAV and 7 (4.4%) after TAV-in-SAV (p = 0.570). At 1 year, mortality was 12 (11.9%) and 10 (10.2%), respectively (p = 0.633). Aortic valve area was larger (1.55 ± 0.5 cm
vs. 1.37 ± 0.5 cm
; p = 0.040), and the mean residual gradient was lower (12.6 ± 5.2 mm Hg vs. 14.9 ± 5.2 mm Hg; p = 0.011) after TAV-in-TAV. The rate of moderate or greater residual aortic regurgitation was similar, but mild aortic regurgitation was more frequent after TAV-in-TAV (p = 0.003).
In propensity score-matched cohorts of TAV-in-TAV versus TAV-in-SAV patients, TAV-in-TAV was associated with higher procedural success and similar procedural safety or mortality.
Vascular complications are common after transcatheter aortic valve replacement (TAVR) and are associated with increased morbidity and mortality. Stent graft implantation enables percutaneous ...treatment of access site bleeding; however, the efficacy and durability and of this approach are unknown. We studied the immediate outcome of stent graft implantation for control of access site bleeding and the need for repeat vascular interventions after stenting, in a cohort of consecutive patients with severe symptomatic aortic stenosis who underwent transfemoral TAVR. Predictors of access site complications requiring percutaneous or surgical vascular repair were identified. Transfemoral TAVR was performed in 194 patients. Access site complications requiring urgent vascular repair occurred in 34 patients (18%). Stent graft implantation was performed in 31 patients and vascular surgery in 3 patients. When patients who required surgical or percutaneous vascular repair were compared with those who did not, increased body mass index (30 ± 6 vs 28 ± 5, p = 0.035) and reduced activated clotting time (233 ± 47 vs 252 ± 47, p = 0.030) were the only predictors of need for vascular repair. Stenting achieved adequate hemostasis in all patients with a single minor vascular complication. During median follow-up of 797 days (interquartile range 585 to 1,173), no clinically significant vascular complications were detected after stenting. In conclusion, control of bleeding was achieved in all patients who underwent stent graft implantation for treatment of access site vascular complications after transfemoral TAVR. None of these patients needed further vascular interventions during follow-up.
We examined 18,654 patients who underwent cardiac catheterization in a single center to clarify the association between catheterization indication, body mass index (BMI), and long-term survival over ...a mean follow-up of 81 months. Patients were grouped by indication for catheterization: (a) acute coronary syndromes (ACS), 7,426 patients; (b) coronary artery disease (CAD) evaluation in stable clinical presentation, 6,911 patients; and (c) primarily non-CAD cardiac evaluations, 4,317 patients. Compared with normal weight, overweight and obesity (but not morbid obesity) was associated with lower risk of long-term mortality. Underweight patients had the greatest risk of mortality. After multivariate adjustment, survival benefit of the overweight and obese was retained in the ACS group hazard ratio 0.86, 95% confidence interval (0.77–0.96), p = 0.006 and 0.79, (0.68–0.91), p = 0.001, respectively and in overweight patients in the stable presentation CAD group 0.83, (0.72–0.94), p = 0.005, whereas there was no survival benefit in any of the BMI categories in those catheterized primarily for non-CAD indications. Further analysis of matched cohorts showed similar patterns of survival benefit of the overweight/obese. In conclusion, among patients who underwent cardiac catheterization, an inverse association between BMI and long-term mortality was observed, with the lowest risk noted in the overweight and obese population; the obesity paradox was principally demonstrated in patients with ACS, and was eliminated after covariate adjustment in those catheterized primarily for non-CAD indications.
Coronary artery disease often progresses more rapidly in diabetics, but the integrated impact of diabetes and early revascularization status on late or repeat revascularization in the contemporary ...era is less clear.
Coronary angiography was performed in 12,420 patients between the years 2000-2015 and early revascularization status none, percutaneous coronary intervention (PCI) or bypass surgery (CABG) was determined. Subsequent revascularization procedures were recorded over a median follow-up of 67 months and its relation to diabetic and baseline revascularization status was studied.
Early revascularization status was none in 5391, PCI in 5682 and CABG in 1347 patients. Late revascularization rates were 10, 26 and 11.1% respectively. Diabetes was present in 37%; a stepwise relationship of diabetic status with late revascularization was observed: no diabetes (reference) 14.4%, non-insulin treated diabetes 21% (adjusted HR 1.35, 95% CI 1.23-1.49, p < 0.001) and insulin-treated diabetes 32.8% (adjusted HR 2.20, 95% CI 1.91-2.54, p < 0.001), which was similar in magnitude for each early revascularization state (none, PCI or CABG). Further revascularizations (≥ 2) were also significantly more common in diabetics, in particular if insulin-treated. Glycosylated hemoglobin level was moderately associated with late revascularization in diabetics after early PCI but not following diagnostic catheterization or CABG.
Diabetic status graded by treatment, and in particular insulin therapy, is a strong predictor for late or repeat revascularization irrespective of early revascularization status. The high rate of repeat revascularization in diabetics following PCI remains a challenging issue.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Transcatheter aortic valve replacement (TAVR) has transformed the treatment of aortic stenosis and should ideally be performed as a totally percutaneous procedure via the transfemoral (TF) approach. ...Peripheral vascular disease may impede valve delivery, and vascular access site complications are associated with adverse clinical outcome and increased mortality. We review strategies aimed to facilitate TF valve delivery in patients with hostile vascular anatomy and achieve percutaneous management of vascular complications.
We assessed the performance of a new-generation, 256-row computed tomography (CT) scanner for detection of obstructive coronary artery disease (CAD) compared to invasive quantitative coronary ...angiography. A total 121 consecutive symptomatic patients without known CAD referred for invasive coronary angiography (age 59 ± 12 years, 37% women) underwent clinically driven 256-row coronary computed tomographic angiography (CCTA) before the invasive procedure. Obstructive CAD (>50% diameter stenosis) was assessed visually on CCTA by 2 independent observers using the 18-segment society of cardiovascular CT model and on invasive angiograms using quantitative coronary angiography (the reference standard). Observers were unaware of the findings from the alternate modality. Nonassessable coronary computed tomographic angiographic segments were considered obstructive for the purpose of analysis. Quantitative coronary angiography demonstrated obstructive CAD in 145 segments in 82 of 121 patients (68%). Overall, 1,677 coronary segments were available for comparative analysis, of which 39 (2.3%) were nonassessable by CCTA, mostly because of heavy calcification. Patient-based and segment-based analysis showed a sensitivity of 100% and 97% (95% confidence interval 95% to 100%) and specificity of 69% (95% confidence interval 55% to 84%) and 97% (confidence interval 96% to 98%), respectively. Four segments with obstructive CAD in 4 patients were not detected by CCTA. All 4 patients had additional coronary obstructions identified by CCTA. The predictive accuracy was 90% (range 85% to 95%) for patient based and 97% (96% to 98%) for segment based analysis. In conclusion, 256-row CCTA showed high sensitivity and high predictive accuracy for detection of obstructive CAD in patients without previously known disease. Although coronary calcification might still interfere with analysis, the rate of nonassessable segments was low.
Abstract To understand the current impact of diabetes mellitus (DM) on long-term outcomes amongst patients referred for coronary angiography we studied 14,337 consecutive patients 5,279 (37%) ...diabetics referred to coronary angiography for assessment or treatment of coronary artery disease. We investigated long-term all-cause mortality and its interaction with hypoglycemic therapy and presenting coronary status. At baseline, patients with DM had more hypertension, hyperlipidemia and renal failure; more were women, overweight and more had previous coronary interventions. Mortality was higher in those with DM and was related to treatment status: multivariate adjusted hazard ratio (HR) during a median follow-up period of 78 months was 1.41 (95% C.I, 1.11-1.80, p=0.006) for diet only treated DM, 1.63 (95% C.I 1.51-1.77, p<0.001) for DM treated with oral-hypoglycemics and 2.50 (95% C.I. 2.20-2.85, p<0.001) for DM requiring insulin therapy. The above findings were similar in magnitude in patients presenting with acute or stable coronary syndromes. In addition, long-term mortality of medically treated DM presenting with a stable coronary syndrome was even higher than that of non-diabetics presenting with an acute coronary syndrome (HR 1.21, 95% C.I 1.08-1.35, p=0.001). In conclusion, in patients referred for coronary angiography in the current era, DM remained an independent predictor of long-term mortality regardless of the coronary presentation and mortality increased in direct relation to intensity of hypoglycemic therapy at presentation.
Continuity of care between the community and hospital is considered of prime importance for quality of care and patient satisfaction, and for trust in the medical system. In a unique model of ...continuity of care, cardiologists at our hospital serve as primary, community-based cardiologists one day a week. They refer patients from the community to our hospital for interventional procedures such as coronary angiography and angioplasty. We examined the hypotheses that patient anxiety during hospital-based coronary angiography is lower when a patient trusts the referring cardiologist and when the performing cardiologist also treated him/her in the community.
We administered questionnaires to 64 patients in our cardiology department within 90 min of completion of coronary angiography. The questions assessed anxiety, trust in the medical system and trust in the referring physician. Data were also collected regarding patients' demographic variables, the number of visits to the referring physician, and whether the physician who performed the coronary angiography was the physician who referred the patient to the hospital.
Mean levels (on 7-point Likert scales) were 2.1, 5.6 and 6.7 for patient anxiety, trust in the medical system and trust in the referring physician, respectively. Multivariate regression analysis showed that trust in the referring physician was significantly and negatively correlated with anxiety level. The number of visits to referring physicians, patients' demographic characteristics and whether the physician who performed the angiography was the same physician who referred the patient from the community were not found to be associated with patient anxiety.
In this study, trusting the referring physician was associated with lower anxiety among patients who underwent coronary angiography. This trust seemed to have more positive impact than did previous contact with the physician who performed the procedure.
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