The Zwolle score is recommended to identify ST-segment elevation myocardial infarction (STEMI) patients with low-risk eligible for early discharge. Our aim was to ascertain if creatinine variation ...(Δ-sCr) would improve Zwolle score in the decision-making of early discharge after primary percutaneous coronary intervention (PCI).
A total of 3296 patients with STEMI that underwent primary PCI were gathered from the Portuguese Registry on Acute Coronary Syndromes. A Modified-Zwolle score, including Δ-sCr, was created and compared with the original Zwolle score. Δ-sCr was also compared between low (Zwolle score ≤3) and non-low-risk patients (Zwolle score >3). The primary endpoint is 30-day mortality and the secondary endpoints are in-hospital mortality and complications. Thirty-day mortality was 1.5% in low-risk patients (35 patients) and 9.2% in non-low-risk patients (92 patients). The Modified-Zwolle score had a better performance than the original Zwolle score in all endpoints: 30-day mortality (area under curve 0.853 versus 0.810, P < 0.001), in-hospital mortality (0.889 versus 0.845, P < 0.001) and complications (0.728 versus 0.719, P = 0.037). Reclassification of patients lead to a net reclassification improvement of 6.8%. Additionally, both original Zwolle score low-risk patients and non-low-risk patients who had a Δ-sCr ≥0.3 mg/dl had higher 30-day mortality (low-risk: 1% versus 6.6%, P < 0.001; non-low-risk 4.4% versus 20.7%, P < 0.001), in-hospital mortality and complications.
Δ-sCr enhanced the performance of Zwolle score and was associated with higher 30-day mortality, in-hospital mortality and complications in low and non-low-risk patients. This data may assist the selection of low-risk patients who will safely benefit from early discharge after STEMI.
INTRODUCTIONProlonged afterload increase in aortic stenosis (AS) may alter left ventricular (LV) contractility, irrespective of LV ejection fraction (LVEF). The prevalence and morbimortality ...associated with the apical sparing strain pattern (ASP), a typical finding of cardiac amyloidosis (CA), are not fully understood in patients with AS. We assessed the prevalence of the ASP in patients with severe AS and its clinical impact after transcatheter aortic valve implantation (TAVI). METHODSEighty-nine consecutive patients with severe AS and LV hypertrophy referred for TAVI were included. Baseline clinical and echocardiographic data were assessed, including the ASP in bull's eye plots (ASPB), relative apical longitudinal strain (RALS) and EF to global longitudinal strain (EF/GLS) ratio. We analysed all-cause mortality; a composite of all-cause mortality, stroke, and heart failure hospitalizations; and the rate of pacemaker implantation, after TAVI. RESULTSMean age was 82 ± 6 years and mean LVEF was 57 ± 10%. ASPB and RALS >1 were present in 43.8% and 24.7% of patients, respectively. Over a median follow-up of 13 months (IQR 6-32), ASPB was associated with higher rates of all-cause mortality (log-rank P=0.001) and was an independent predictor of all-cause mortality in multivariate analysis. Combination of the ASPB and GLS or EF/GLS ratio improved the risk stratification. Patients with RALS >1 were more likely to have new BBB and an indication for pacemaker implantation (P=0.048). CONCLUSIONThe ASP, as assessed by the ASPB and RALS, was frequent in patients with AS regardless of the diagnosis of CA. The ASPB may refine risk stratification in patients referred for TAVI.
There is a paucity of prospective and controlled data on the comparative effectiveness of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in a real-world ...setting.
This analysis aims to describe 1-year clinical outcomes of a large series of propensity-matched patients who underwent SAVR and transfemoral TAVR.
The OBSERVANT (Observational Study of Effectiveness of SAVR-TAVI Procedures for Severe Aortic Stenosis Treatment) trial is an observational prospective multicenter cohort study that enrolled patients with aortic stenosis (AS) who underwent SAVR or TAVR. The propensity score method was applied to select 2 groups with similar baseline characteristics. All outcomes were adjudicated through a linkage with administrative databases. The primary endpoints of this analysis were death from any cause and major adverse cardiac and cerebrovascular events (MACCE) at 1 year.
The unadjusted enrolled population (N = 7,618) included 5,707 SAVR patients and 1,911 TAVR patients. The matched population had a total of 1,300 patients (650 per group). The propensity score method generated a low-intermediate risk population (mean logistic EuroSCORE 1:10.2 ±9.2%±7.1%, SAVR vs. transfemoral TAVR; p = 0.104). At 1 year, the rate of death from any cause was 13.6% in the surgical group and 13.8% in the transcatheter group (hazard ratio HR: 0,99%; 95% confidence interval CI: 0.72 to 1.35; p = 0.936). Similarly, there were no significant differences in the rates of MACCE, which were 17.6% in the surgical group and 18.2% in the transcatheter group (HR: 1.03; 95% CI: 0.78 to 1.36; p = 0.83). The cumulative incidence of cerebrovascular events, and rehospitalization due to cardiac reasons and acute heart failure was similar in both groups at 1 year.
The results suggest that SAVR and transfemoral TAVR have comparable mortality, MACCE, and rates of rehospitalization due to cardiac reasons at 1 year. The data need to be confirmed in longer term and dedicated ongoing randomized trials.
We report a case of a 73‐year‐old male with multiple comorbidities, including postpoliomyelitis severe scoliosis, referred to our tertiary center due to a severe symptomatic aortic stenosis, ...considered high risk for surgical aortic valve replacement (AVR). Due to unsuitable femoral and subclavian accesses, the patient underwent a transcaval transcatheter AVR (TAVR) procedure, complicated by the development of an iatrogenic infrarenal aortic pseudoaneurysm with aortocaval fistula. Scoliosis can cause varying anatomic relationships between retroperitoneal vessels and intervertebral disk spaces, which increase the difficulty of the procedure and consequently lead to this vascular complication. Although most aortocaval fistulas close spontaneously after 1 year, the risk of pseudoaneurysm rupture in this critical area was crucial in the decision of a new successful percutaneous aortic stent intervention.
ABSTRACT Introduction and objectives: The Lotus Valve device (Boston Scientific) is a second-generation fully-retrievable and repositionable transcatheter aortic valve. We report the initial ...multicenter experience with the Lotus valve in the management of patients with severe aortic stenosis. Methods: Observational study that described the short and long-term results of implanting the Lotus valve in 8 Spanish and Portuguese centers from March 2014 through April 2016. Results: The study included 102 patients (mean age 80.4 ± 6.1 years; STS score 5.2% ± 3.3%) with severe symptomatic aortic stenosis (mean aortic valve area 0.66 ± 0.17 cm2, aortic gradients 74.3 / 45.6 mmHg). The valve was successfully implanted in 100 patients (98%), with significant improvement in both the peak and mean aortic valve gradients and with only one patient showing moderate paravalvular regurgitation. Upon hospital discharge, mortality rate was 3.9% while the stroke rate was 2.9%. No cases of valve embolization, ectopic valve deployment or additional valve implantation (valve-in-valve) were seen. Thirty-three patients (32.3%) received a permanent pacemaker. Conclusions: The Lotus Valve System is effective and safe for the management of patients with severe symptomatic aortic stenosis. In particular, considering the low rate of periprosthetic regurgitation and lack of complications like embolization or ectopic valve deployment; however at the expense of a high pacemaker implantation rate.
ABSTRACT Introduction and objectives: Transfemoral access is globally accepted as the preferential access route for transcatheter aortic valve implantation (TAVI). However, in up to 15% of the ...patients, this access is considered inadequate. Considering the various alternatives available, the fully percutaneous access routes have been chosen preferentially. This analysis aims to compare outcomes and complications of 3 alternative access routes for transfemoral, trans-subclavian and transcaval TAVI. Methods: Retrospective analysis of patients referred for TAVI using transfemoral, trans-subclavian, and transcaval accesses in a single tertiary center from 2008 through 2021. The primary endpoints were 30-day and 1-year all-cause mortality rates. The secondary endpoints were technical success, residual moderate-to-severe paravalvular leak, major vascular complication, 30-day stroke, 30-day Valve Academic Research Consortium-2 (VARC-2) major bleeding, and 30-day acute kidney injury (AKIN criteria 2 or 3). Results: A total of 642 TAVIs were performed (601 transfemoral, 24 trans-subclavian, and 10 transcaval). A total of 7 patients treated via transapical access were excluded. As expected, baseline comorbidities like left ventricular dysfunction, coronary artery disease, atrial fibrillation, chronic kidney disease, and previous stroke were more frequent in the non-femoral groups. The 1-year and 30-day all-cause mortality rates were higher in the non-transfemoral population (HR, 2.88 and HR, 3.53, respectively). The rates of 30-day stroke and acute kidney injury (AKIN 2 or 3) were also significantly lower in transfemoral patients, but similar between trans-subclavian and transcaval patients. The rates of 30-day major bleeding showed a statistically significant tendency towards lower rates in the transfemoral group. The rates of technical success, major vascular complications, and residual moderate or severe perivalvular leak were similar among the 3 groups. Conclusions: After careful selection, transfemoral access is the preferential access route for TAVI procedures. In intermediate surgical risk patients with severe symptomatic aortic stenosis, non-transfemoral TAVI approaches have poorer outcomes. The worse outcomes of percutaneous alternative access routes are partially associated with worse baseline characteristics.
Introduction and objectives: Transfemoral access is globally accepted as the preferential access route for transcatheter aortic valve implantation (TAVI). However, in up to 15% of the patients, this ...access is considered inadequate. Considering the various alternatives available, the fully percutaneous access routes have been chosen preferentially. This analysis aims to compare outcomes and complications of 3 alternative access routes for transfemoral, trans-subclavian and transcaval TAVI.
Methods: Retrospective analysis of patients referred for TAVI using transfemoral, trans-subclavian, and transcaval accesses in a single tertiary center from 2008 through 2021. The primary endpoints were 30-day and 1-year all-cause mortality rates. The secondary endpoints were technical success, residual moderate-to-severe paravalvular leak, major vascular complication, 30-day stroke, 30-day Valve Academic Research Consortium-2 (VARC-2) major bleeding, and 30-day acute kidney injury (AKIN criteria 2 or 3).
Results: A total of 642 TAVIs were performed (601 transfemoral, 24 trans-subclavian, and 10 transcaval). A total of 7 patients treated via transapical access were excluded. As expected, baseline comorbidities like left ventricular dysfunction, coronary artery disease, atrial fibrillation, chronic kidney disease, and previous stroke were more frequent in the non-femoral groups. The 1-year and 30-day all-cause mortality rates were higher in the non-transfemoral population (HR, 2.88 and HR, 3.53, respectively). The rates of 30-day stroke and acute kidney injury (AKIN 2 or 3) were also significantly lower in transfemoral patients, but similar between trans-subclavian and transcaval patients. The rates of 30-day major bleeding showed a statistically significant tendency towards lower rates in the transfemoral group. The rates of technical success, major vascular complications, and residual moderate or severe perivalvular leak were similar among the 3 groups.
Conclusions: After careful selection, transfemoral access is the preferential access route for TAVI procedures. In intermediate surgical risk patients with severe symptomatic aortic stenosis, non-transfemoral TAVI approaches have poorer outcomes. The worse outcomes of percutaneous alternative access routes are partially associated with worse baseline characteristics.
Introducción y objetivos: El acceso transfemoral (aTF) es el de elección para el implante percutáneo de válvula aórtica (TAVI). Sin embargo, hasta en el 15% de los pacientes este acceso es inadecuado. De las alternativas disponibles, el acceso totalmente percutáneo es el preferido. El objetivo del estudio es comparar los resultados clínicos de los pacientes tratados por aTF frente a los de aquellos con acceso transubclavio (aTS) o transcava (aTCv).
Métodos: Análisis retrospectivo de los pacientes tratados con TAVI (2008-2021) en un centro terciario mediante aTF, aTS y aTCv. El objetivo primario fue la mortalidad por cualquier causa a 30 días y 1 año. Los objetivos secundarios fueron el éxito técnico, la regurgitación perivalvular moderada o grave, las complicaciones vasculares mayores, el accidente vascular cerebral, el sangrado mayor y el daño renal agudo a 30 días (Valve Academic Research Consortium II VARC-2).
Resultados: Se realizaron 642 TAVI (601 por aTF, 24 por aTS y 10 por aTCv). Fueron excluidos 7 pacientes tratados por vía transapical. En los pacientes con acceso alternativo fue más frecuente la comorbilidad, incluyendo disfunción ventricular izquierda, enfermedad coronaria, fibrilación auricular, enfermedad renal e ictus previo. La mortalidad a 1 año y a 30 días fue también más alta en este grupo de pacientes (hazard ratio HR = 2,88 y 3,53, respectivamente). A 30 días, las tasas de ictus y daño renal (grado 2 o 3) fueron significativamente más bajas para el aTF, y similares en los pacientes con aTS y aTCv. Hubo también una tendencia a menor sangrado en el grupo de aTF. El éxito técnico, las complicaciones vasculares mayores y la regurgitación perivalvular moderada o grave fueron similares en los tres grupos.
Conclusiones: Tras una adecuada selección, el aTF es el preferido para el TAVI. En pacientes de riesgo intermedio con estenosis aórtica grave sintomática, un acceso no transfemoral tiene peores resultados. Los inferiores resultados del uso de vías percutáneas alternativas están parcialmente relacionados con las peores características clínicas basales.
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