The aim of this study was to examine the frequency, timing, and association of access-site and non–access-site bleeding with mortality in the setting of transcatheter aortic valve replacement (TAVR) ...during long-term follow-up.
Bleeding is frequent and associated with impaired prognosis in patients undergoing TAVR. It is currently unknown whether the site of bleeding differentially influences the outcomes of TAVR patients.
In total, 926 consecutive patients undergoing TAVR from 2007 through 2014 were evaluated. Bleeding was assessed according to the Valve Academic Research Consortium 2 criteria. The primary outcome of interest was all-cause mortality up to 5 years of follow-up.
A total of 285 patients (30.7%) experienced at least 1 (minor, major, or life-threatening) bleeding event up to 5 years. Compared with patients not experiencing bleeding, the adjusted risk for all-cause mortality was significantly increased among patients with access-site (hazard ratio: 1.34; 95% confidence interval: 1.01 to 1.76; p = 0.04) and non–access-site bleeding (hazard ratio: 2.08; 95% confidence interval: 1.60 to 2.71; p < 0.001). However, non–access-site bleeding conferred a significantly higher risk for mortality compared with access-site bleeding (hazard ratio: 1.56; 95% confidence interval: 1.12 to 2.18; p = 0.009). At multivariate analysis, female sex was a significant correlate of access-site bleeding, whereas chronic kidney disease and the Society of Thoracic Surgeons score were significantly associated with non–access-site bleeding.
Among patients with severe aortic stenosis undergoing TAVR, access-site and non–access-site bleeding were independently associated with an increased risk for mortality, with the greatest risk related to non–access-site bleeding during long-term follow-up.
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To analyse reasons, timing and predictors of hospital readmissions after transcatheter aortic valve implantation (TAVI).
Patients included in the Bern TAVI Registry between August 2007 and June 2014 ...were analysed. Fine and Gray competing risk regression was used to identify factors predictive of hospital readmission within 1 year after TAVI with bootstrap analysis for internal validation. Of 868 patients alive at discharge, 221 (25.4%) were readmitted within 1 year. Compared with patients not requiring readmission, those with at least one readmission more frequently were male and more often had atrial fibrillation and higher creatinine values (P < 0.05 for all cases). For overall 308 readmissions, cardiovascular causes accounted for 46.1% with heart failure as the most frequent indication; non-cardiovascular readmissions occurred for surgery (11.7%), gastrointestinal disorders (9.7%), malignancy (4.9%), respiratory diseases (4.6%) and chronic kidney failure (2.6%). Male gender (subhazard ratio, SHR, 1.33, 95% confidence intervals, CI, 1.02-1.73, P = 0.035) and stage 3 kidney injury (SHR 2.04, 95% CI 1.12-3.71, P = 0.021) were found independent risk factors for any hospital readmission, whereas previous myocardial infarction (SHR 1.88, 95% CI 1.22-2.90, P = 0.004) and in-hospital life-threatening bleeding (SHR 2.18, 95%CI 1.24-3.85, P = 0.007) were associated with cardiovascular readmissions. The event rate for mortality was significantly increased after readmissions for any cause (RR 4.29, 95% CI 2.86-6.42, P < 0.001).
Hospital readmission was observed in one out of four patients during the first year after TAVI and was associated with a significant increase in mortality.
Background The prevalence of calcific aortic stenosis and amyloid transthyretin cardiomyopathy (ATTR-CM) increase with age, and they often coexist. The objective was to determine the prevalence of ...ATTR-CM in patients with severe aortic stenosis and evaluate differences in presentations and outcomes of patients with concomitant ATTR-CM undergoing transcatheter aortic valve implantation. Methods and Results Prospective screening for ATTR-CM with Technetium
-3,3-diphosphono-1,2-propanodicarboxylic acid bone scintigraphy was performed in 315 patients referred with severe aortic stenosis between August 2019 and August 2021. Myocardial Technetium
-3,3-diphosphono-1,2-propanodicarboxylic acid tracer uptake was detected in 34 patients (10.8%), leading to a diagnosis of ATTR-CM in 30 patients (Perugini ≥2: 9.5%). Age (85.7±4.9 versus 82.8±4.5;
=0.001), male sex (82.4% versus 57.7%;
=0.005), and prior carpal tunnel surgery (17.6% versus 4.3%;
=0.007) were associated with coexisting ATTR-CM, as were ECG (discordant QRS voltage to left ventricular wall thickness 42% versus 12%;
<0.001), echocardiographic (left ventricular ejection fraction 48.8±12.8 versus 58.4±10.8;
<0.001; left ventricular mass index, 144.4±45.8 versus 117.2±34.4g/m
;
<0.001), and hemodynamic parameters (mean aortic valve gradient, 23.4±12.6 versus 35.5±16.6;
<0.001; mean pulmonary artery pressure, 29.5±9.7 versus 25.8±9.5;
=0.037). Periprocedural (cardiovascular death: hazard ratio HR, 0.71 95% CI, 0.04-12.53; stroke: HR, 0.46 95% CI, 0.03-7.77; pacemaker implantation: HR, 1.54 95% CI, 0.69-3.43) and 1-year clinical outcomes (cardiovascular death: HR, 1.04 95% CI, 0.37-2.96; stroke: HR, 0.34 95% CI, 0.02-5.63; pacemaker implantation: HR, 1.50 95% CI, 0.67-3.34) were similar between groups. Conclusions Coexisting ATTR-CM was observed in every 10th elderly patient with severe aortic stenosis referred for therapy. While patients with coexisting pathologies differ in clinical presentation and echocardiographic and hemodynamic parameters, peri-interventional risk and early clinical outcomes were comparable up to 1 year after transcatheter aortic valve implantation. REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT04061213.
The impact of baseline renal dysfunction on early and late clinical outcomes after transcatheter aortic valve implantation (TAVI) remains to be defined.
927 patients included in the prospective Bern ...TAVI registry were classified on the basis of the baseline estimated glomerular filtration rate (eGFR), as having none or mild (eGFR ≥60mL/min/1.73m2, n=284, 30.6%), moderate (eGFR between 30 and 59mL/min/1.73m2, n=535, 57.7%) and severe (eGFR <30mL/min/1.73m2, n=108, 11.7%) renal dysfunction.
A graded relationship between stages of renal dysfunction and increasing risk profile was observed with higher STS score and lower left ventricular ejection fraction among patients with eGFR<30 (p<0.001 across groups). In patients with none or mild, moderate, and severe renal dysfunction the rate of all-cause mortality was 1.8%, 5.2% and 8.3% at 30-day and 11.0%, 15.0% and 19.5% at 1-year, respectively. After adjusting for relevant confounders, severe renal dysfunction was associated with an increased risk of cardiovascular death (adjusted Hazard Ratio, HRadj, 3.90, 95% Confidence Interval, CI 1.15–13.2) and stage 3 acute kidney injury (HRadj 5.15, 95% CI 1.72–15.5) at 30-day follow-up, however no significant association was found for clinical outcomes at 1-year follow-up. Moreover, moderate and severe renal dysfunction were found to be associated with bleeding at 1-year follow-up (HRadj, 1.36, 95% CI 1.04–1.78 and HRadj 1.49, 95% CI 1.00–2.21, respectively).
Pre-procedural renal dysfunction differentially affects early clinical outcomes, although the magnitude of this association is diluted over time by the overriding effect of underlying risk and comorbidities.
Surgical aortic valve replacement (SAVR) is the treatment of choice in severe symptomatic aortic valve disease. New techniques and prostheses have been recently developed to facilitate the procedure ...and reduce aortic cross-clamp time (AOx). The aim of this study was to analyse the different procedural steps in order to identify the most time-consuming part during aortic clamping time and to compare impact of experience on procedural aspects.
AOx during SAVR was divided into five consecutive steps. Duration of each step was measured. The first procedural step started with clamping of the aorta and ended with the beginning of the second step starting with the resection of the native aortic valve. The third step started with placement of the first valve anchoring suture, the fourth step started with tying of the first suture and the fifth and final step started after the cut of the last suture and ended with removal of the aortic clamp. Surgeons were divided into two groups based on their experience, which in our analysis was defined as a total SAVR experience of more than 100 procedures.
From March 2013 to August 2015 57 nonconsecutive patients (33% female; age, median 71.0 years, interquartile range 65.0-76.0) undergoing isolated SAVR for severe aortic valve stenosis in our institution were included in this process analysis. Two different prostheses were implanted. Forty-eight (84%) patients received a tissue valve (Perimount Magna Ease, Edwards Lifesciences, Irvine, USA) and 9 (16%) patients received a mechanical prosthesis (Medtronic AP 360, St-Paul, MN, USA). The mean estimated risk of mortality was 1.1% (0.7-1.6) according to the logistic EUROScore II. Overall duration of AOx was 50.5 ± 13.8 min, with 32.3% (16.4 ± 5.9 min) accounting for placing the sutures into the native annulus and the prosthetic sewing ring and 18.5% (9.2 ± 3.0min) accounting for tying and cutting the sutures. Surgeons with more experience performed 35 operations (61.4%) and needed an average of 44.1 ± 11.5 min versus 60.6 ± 11.0 min (p <0.001) for less experienced surgeons. Surgeons with more experience needed 14.0 ± 5.0 min for the suturing step and 8.4 ± 2.8 min for tying the sutures compared with 20.2 ± 5.2 min and 10.5 ± 3.0 min, respectively, for the less experienced surgeons with (p <0.001 and p = 0.010).
Placing and tying sutures in the prostheses accounts for over half (50.8%) of AOx during isolated SAVR. Experienced surgeons have significantly reduced AOx. This shortening is equally distributed between all five procedural steps.
The fate of nonaortic arterial segments in Marfan patients Schoenhoff, Florian S.; Yildiz, Murat; Langhammer, Bettina ...
The Journal of thoracic and cardiovascular surgery,
June 2019, 2019-06-00, 20190601, Letnik:
157, Številka:
6
Journal Article
Recenzirano
Odprti dostop
The aim of this study was to investigate the fate of nonaortic arterial segments in patients with Marfan syndrome (MFS).
This was a retrospective analysis of 100 consecutive patients with MFS ...fulfilling Ghent criteria who underwent 192 interventions on any segment of the arterial tree and were followed over the past 20 years. A review of the available imaging regarding 9 defined regions of interest of the carotid, innominate, subclavian, iliac, and femoral arteries was performed.
Mean follow-up interval was 11.6 ± 7.7 years. Of 600 measurements that were performed, 414 (69%) arterial segments showed dilatation above the upper range of normal. There were no significant sex differences. In 100 patients, 66 dissections in nonaortic arterial segments in 33 patients were identified. Nineteen patients with or without previous dissection underwent 34 interventions. Most interventions were performed on the iliac arteries (56%), followed by the subclavian arteries (21%), the intercostal arteries (9%), the carotid arteries (6%), the visceral arteries (6%), and the innominate artery (3%). Most iliac artery interventions (88%) were caused by dilatations due to previous dissections, whereas this was only the case in 17% of interventions on the subclavian arteries.
Most patients with MFS presented with at least 2 dilated nonaortic arterial segments. The current data suggest that 20% of MFS patients will need some form of intervention on nonaortic arterial segments 5 to 6 years after their first aortic intervention, referring to the first aortic dissection of the patient if the patient had a history of dissection. Routine long-term follow-up imaging should include the iliac arteries as well as the supra-aortic branches.
Aim of this study was to explore sex and gender differences regarding aortic events in Marfan patients.
We analysed all data from our connective tissue disorder database. Only patients with Marfan ...syndrome were included. For analysis, patients were divided by sex. Female patients were further divided into 2 subgroups; with vs without children. Aortic events were defined as Stanford type A or type B aortic dissection or any aortic intervention.
A population of 183 Marfan patients was analysed for the purpose of this study. One-hundred-four (57%) were male and 79 (43%) were female patients. Thirty-seven (47%) of the 79 female patients had at least one child. Male patients had a significantly higher probability of experiencing an aortic event (p = 0.015) compared to female patients. However, there was no increased probability for recurrent events in male patients compared to female patients (p = 0.063). Follow-up revealed no sex and gender differences in the occurrence of Stanford type A or B aortic dissection between male and female patients (p = 0.324/p = 0.534). While 11% of women with children suffered from peripartum aortic events, 24% experienced Stanford Type A aortic dissection unrelated to pregnancy.
Male patients have a higher risk of aortic events than female patients. The majority of women were not aware of their Marfan syndrome diagnosis before conceiving. One out of ten women suffered from peripartum Stanford Type A or B aortic dissection. Twice as many female patients with children suffered from aortic dissection unrelated to childbirth. There were no sex and gender differences affecting mortality in Marfan patients.
Abstract
Aims
To assess the incidence, management and long-term outcomes of transcatheter heart valve thrombosis (THVT).
Methods and results
Between August 2007 and February 2016, 1396 patients were ...included in the Bern TAVI Registry and prospectively followed-up through echocardiographic and clinical evaluation. THVT was suspected in case of: (i) a mean transvalvular pressure gradient greater than 20 mmHg at transthoracic echocardiography, or (ii) an increase of more than 50% of the mean transvalvular pressure gradient compared with previous measurements or (iii) new symptoms or signs of heart failure with the presence of thrombus documented by transoesophageal echocardiography or multi-slice computed tomography. THVT occurred in 10 patients (0.71%) at variable time points after TAVI. Increased transvalvular pressure gradients were recorded in all patients and 7 out of 10 patients were symptomatic. Oral anticoagulant therapy (with vitamin K antagonists or non-Vitamin K antagonists) was initiated in all but two patients and resulted in normalization of transvalvular pressure gradients and amelioration of clinical status within 1 month. At long-term follow-up (between 10 and 25 months after valve thrombosis), echocardiographic findings were stable and no adverse events were reported.
Conclusion
THVT is rarely detected at routine clinical and echocardiographic evaluation after TAVI. Oral anticoagulation appears effective to normalize transvalvular gradients in the majority of cases with stable clinical and haemodynamic evolution during long-term follow-up.
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