Introduction
Transcatheter aortic valve implantation (TAVI) continues to be the most common modality of treating aortic stenosis in the United States. While infective endocarditis (IE) and its ...outcomes have been well documented after surgical aortic valve replacement, the incidence and outcomes of early IE after TAVI have not been well described.
Methods
All patients who underwent TAVI from 2012 through 2018 were identified using the National Readmission Database. Among them, patients who underwent TAVI at the index admission and readmitted within 90 days were included. Patients who died or had IE during the index admission were excluded. Clinical outcomes were compared between patients readmitted with IE (IE group) and those without (non‐IE group).
Results
A total of 168,283 patients were readmitted to a hospital within 90 days after TAVI. The median age of the IE group and non‐IE group were 81 and 82 years old, respectively (p = 0.21). Of those, 525 (0.3%) were readmitted with IE. The median time from TAVI to readmission was 20 days. During readmissions, 11.6% of the IE group died while only 3.15% of the non‐IE group experienced death (p < 0.001). The most common causative organism of IE was enterococcus (22.1%). Multivariable analysis revealed that congestive heart failure, cerebrovascular disease, dialysis, concomitant valve disease, Medicaid, and discharge to a facility were independently associated with readmission with IE within 90 days.
Conclusion
The incidence of readmission with IE is low after TAVI. However, the mortality was markedly high during readmissions. Surgical intervention was rarely performed for IE during the first admission. Enterococcus was the most common organism observed in IE after TAVI.
Disclosure
IS receives institutional research support from Abbott, Atricure, cryolife, and Medtronic. None related to this manuscript.
Clinical Trial Registration
Not applicable.
Long-term outcomes of valve-sparing aortic root replacement (VSARR) with reimplantation vs remodeling in patients undergoing aortic root surgery remains a controversial subject.
This study was a ...pooled meta-analysis of Kaplan-Meier-derived data from comparative studies published by December 31, 2022.
Fifteen studies met our eligibility criteria, comprising 3044 patients (1991 in the reimplantation group and 2018 in the remodeling group). Patients who underwent VSARR with remodeling had a higher risk of all-cause death (hazard ratio HR, 1.54; 95% CI, 1.16-2.03; P = .002, log-rank test P < .001). Landmark analysis (with 4 years as the landmark time point) demonstrated that survival was lower in patients who underwent VSARR with remodeling (HR, 2.15; 95% CI, 1.43-3.24; P < .001) in the first 4 years. Beyond the 4-year time point, no difference in survival was observed (HR, 1.04; 95% CI, 0.72-1.50; P = .822). The risk for need of aortic valve and/or root reintervention was higher in patients undergoing VSARR with remodeling (HR, 1.49; 95% CI, 1.07-2.07; P = .019, log-rank test P < .001). We did not find statistically significant coefficients for the covariates of age, female sex, connective tissue disorders, bicuspid aortic valve, aortic dissection, coronary bypass surgery, total arch replacement, or annular stabilization, which means that these covariates did not modulate the effects observed in our pooled analyses.
VSARR with reimplantation is associated with better overall survival and lower risk of need for reintervention over time compared with VSARR with remodeling. Regarding overall survival, we observed a time-varying effect that favored the reimplantation technique up to 4 years of follow-up, but not beyond this time point.
Background We performed a meta-analysis of reconstructed time-to-event data from randomized controlled trials (RCTs) and propensity-score matched (PSM) studies comparing transcatheter versus surgical ...aortic valve replacement (TAVR versus SAVR) to evaluate midterm outcomes in patients considered low risk for SAVR. Methods and Results Study-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of RCTs and PSM studies published by December 31, 2022 was conducted. Eight studies (3 RCTs, 5 PSM studies) met our eligibility criteria and included 5444 patients; 2639 patients underwent TAVR, and 2805 patients underwent SAVR. TAVR showed a higher risk of all-cause mortality at 8 years of follow-up (hazard ratio HR 1.22, 95% CI, 1.03-1.43,
=0.018). Up to 2 years of follow-up, TAVR was not inferior to SAVR (HR, 1.08 95% CI, 0.89-1.31,
=0.448); however, we observed a statistically significant difference after 2 years with higher mortality with TAVR (HR, 1.51 95% CI, 1.14-2.00;
=0.004). This difference was driven by PSM studies; our sensitivity analysis showed a statistically significant difference between TAVR and SAVR when we included only PSM studies (HR, 1.41 95% CI, 1.16-1.72,
=0.001) but no statistically significant difference when we included only RCTs (HR, 0.89 95% CI, 0.69-1.16,
=0.398). Conclusions In comparison with TAVR, SAVR appeared to be associated with improved survival beyond 2 years in low-risk patients. However, the survival benefit of SAVR was observed only in PSM studies and not in RCTs. The addition of data from ongoing RCTs as well as longer follow-up in previous RCTs will help to confirm if there is a difference in mid- and long-term survival between TAVR versus SAVR in the low-risk population.
To evaluate outcomes in the follow up of thoracic endovascular aortic repair (TEVAR) vs. medical therapy in patients with acute type B aortic intramural haematoma (IMH).
The following sources were ...searched for articles meeting the inclusion criteria and published by July 2023: PubMed/MEDLINE, EMBASE, CENTRAL/CCTR (Cochrane Controlled Trials Register).
This systematic review with pooled meta-analysis of time to event data followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, and its protocol was registered on the public platform PROSPERO (CRD42023456222). The following were analysed: overall survival (all cause mortality), aortic related mortality, and restricted mean survival time. Certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool.
Eight studies met the eligibility criteria, including 1 015 patients (440 in the TEVAR group and 575 in the medical therapy group). All studies were observational, and the pooled cohort had a median follow up of 5.1 years. Compared with patients who received medical therapy alone, those who underwent TEVAR had a statistically significantly lower risk of all cause death (HR 0.44, 95% CI 0.30 – 0.65; p < .001; GRADE certainty: low), lower risk of aortic related death (HR 0.04, 95% CI 0.01 – 0.31; p = .002; GRADE certainty: low) and lifetime gain (restricted mean survival time was overall 201 days longer with TEVAR; p < .001).
Thoracic endovascular aortic repair may be associated with lower risk of all cause and aortic related death compared with medical therapy in patients with acute type B IMH; however, the underlying data are not strong enough to draw robust clinical conclusions. Randomised controlled trials with large sample sizes and longer follow up are warranted to elucidate this question.
Endovascular repair of the aortic arch: State of the art Brown, James A.; Arnaoutakis, George J.; Szeto, Wilson Y. ...
Journal of cardiac surgery,
November 2021, 2021-11-00, 20211101, Letnik:
36, Številka:
11
Journal Article
Recenzirano
Odprti dostop
Background
Open total arch replacement remains the gold standard treatment for aneurysms and dissections involving the aortic arch. However, high‐risk surgical candidates may benefit from ...endovascular techniques to reduce the risk of perioperative mortality and morbidity, especially neurologic complications. Numerous endografts are available for investigational use in the aortic arch as part of investigational device exemption (IDE) programs. Some devices are fenestrated or scalloped, while others are branched, ranging from single branch to triple branch stent‐grafts. Furthermore, chimney techniques and in situ fenestration may be utilized in bailout or emergent situations.
Results
Initial results describing outcomes of complete endovascular repair of the aortic arch are encouraging, with current data estimating that technical success ranges from 84.2% to 100%. Moreover, operative mortality may be as high as 13.2%, while neurologic complications also remain common, with stroke rates being as high as 20% and spinal cord ischemia being as high as 3.1%. However, more data are necessary to determine the comparative treatment effect of endovascular stent‐grafting of the aortic arch, compared with conventional open and hybrid repairs. Longitudinal follow‐up is also lacking, which will determine the long‐term durability of endografts in the aortic arch. Nevertheless, endovascular repair represents an important opportunity for improving outcomes in patients with complex and potentially devastating pathologies of the aortic arch.
It remains controversial whether prosthesis-patient mismatch (PPM) impacts long-term outcomes after surgical aortic valve replacement. We aimed to evaluate the association of PPM with mortality, ...rehospitalizations, and aortic valve reinterventions.
We performed a systematic review with meta-analysis of reconstructed time-to-event data of studies published by March 2023 (according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Sixty-five studies met our eligibility criteria and included 122 989 patients (any PPM: 68 332 patients, 55.6%). At 25 years of follow-up, the survival rates were 11.8% and 20.6% in patients with and without any PPM, respectively (hazard ratio HR, 1.16 95% CI, 1.13-1.18,
<0.001). At 20 years of follow-up, the survival rates were 19.5%, 12.1%, and 8.8% in patients with no, moderate, and severe PPM, respectively (moderate versus no PPM: HR, 1.09 95% CI, 1.06-1.11,
<0.001; severe versus no PPM: HR, 1.29 95% CI, 1.24-1.35,
<0.001). PPM was associated with higher risk of cardiac death, heart failure-related hospitalizations, and aortic valve reinterventions over time (
<0.001). Statistically significant associations between PPM and worse survival were observed regardless of valve type (bioprosthetic versus mechanical valves), contemporary PPM definitions unadjusted and adjusted for body mass index, and PPM quantification method (in vitro, in vivo, Doppler echocardiography). Our meta-regression analysis revealed that populations with more women tend to have higher HRs for all-cause death associated with PPM.
The results of the present study suggest that any degree of PPM is associated with poorer long-term outcomes following surgical aortic valve replacement and provide support for implementation of preventive strategies to avoid PPM after surgical aortic valve replacement.
This study evaluates the impact of donor age on outcomes following donation after circulatory death heart transplantation.
The United Network for Organ Sharing registry was queried to analyze adult ...recipients who underwent isolated donation after circulatory heart transplantation from January 1, 2019, to September 30, 2023. The cohort was stratified into 2 groups according to donor age, where advanced donor age was defined as 40 years or more. Outcomes were 90-day and 1-year post-transplant survival. Propensity score matching was performed. Subgroup analysis was performed to evaluate the effects of recipient age on 90-day survival among the recipients with advanced-age donors.
A total of 994 recipients were included in the study period, and 161 patients (17.1%) received allografts from advanced-age donors. During the study period, the annual incidence of donation after circulatory heart transplantation with advanced-age donors substantially increased. The recipients with advanced-age donors had similar 90-day and 1-year post-transplant survivals compared with the recipients with younger donors. The comparable 90-day survival persisted in a propensity score–matched comparison. In the subgroup analysis among the recipients with advanced-age donors, the recipients aged 60 years or more had significantly reduced 90-day survival compared with the recipients aged less than 60 years.
The use of appropriately selected donation after circulatory donors aged 40 years or more has similar survival compared with that of younger donors. With careful candidate risk stratification and selection, consideration of using donation after circulatory donors aged more than 40 years may further ameliorate ongoing organ shortage with comparable early post-transplant outcomes.
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Background
Outcome comparisons after surgical aortic valve replacement (SAVR) with minimally invasive approaches including mini‐sternotomy (MS) and right mini‐thoracotomy (RMT) and full sternotomy ...(FS) have been conflicting. Furthermore, the synthesis of mid‐term mortality has not been performed.
Methods
MEDLINE and EMBASE were searched through April 2022 to identify propensity score matched (PSM) studies or randomized controlled trial (RCT) which compared outcomes following SAVR among three incisional approaches: FS, MS, or RMT. The network analysis was performed to compare these approaches with random effects model. Mid‐term mortality was defined as 1‐year mortality.
Results
A total of 42 studies met the inclusion criteria enrolling 14,925 patients. RCT and PSM were performed in 13 and 29 studies, respectively. The operative mortality was significantly lower with MS compared to FS (risk ratio RR: 0.60, 95% confidence interval CI: 0.41–0.90, p = .01, I2 = 25.8%) or RMT (RR: 0.51, 95% CI: 0.27–0.97, p = .03, I2 = 25.8%). RMT had significantly higher risk of reoperation for bleeding compared to MS (RR: 1.65, 95% CI: 1.18–2.30, p = .003, I2 = 0%). Hospital length of stay was significantly shorter with MS compared to FS (mean difference: −0.89 days, 95% CI: −1.58 to −0.2, p = .01, I2 = 95.5%) while it was equivocal between FS and RMT. The mid‐term mortality was similar among the three approaches.
Conclusions
While mid‐term mortality was comparable among approaches, MS may be a safe and potentially more effective approach than FS and RMT for SAVR in the short term.
Background Thoracic endovascular aortic repair (TEVAR) has been increasingly used for the treatment of descending thoracic aortic aneurysms and dissections. This study sought to evaluate the ...influence of sex on outcomes after TEVAR. Methods and Results This was an observational study from the Nationwide Readmissions Database analyzing all patients who underwent TEVAR from 2010 to 2018. Sampling weights were used to generate national estimates.
codes were used to identify patients with thoracic aortic aneurysms or dissections who underwent TEVAR. Patients were dichotomized according to sex, and 1:1 propensity score matching was applied. Mixed model regression for in-hospital mortality and weighted logistic regression with bootstrapping for 30-day readmissions were performed. A supplemental analysis was performed according to pathology (aneurysm or dissection). A weighted total of 27 118 patients were identified. Propensity-matching yielded 5026 risk-adjusted pairs. Men were more likely to undergo TEVAR for type B aortic dissection, whereas women were more likely to undergo TEVAR for aneurysm. In-hospital mortality was roughly 5% and was equivalent in the matched groups. Men were more likely to have paraplegia, acute kidney injury, and arrhythmias, while women were more likely to require transfusions after TEVAR. There were no significant differences in myocardial infarction, heart failure, respiratory failure, spinal cord ischemia, mesenteric ischemia, stroke, or 30-day readmission between the matched groups. On regression analysis, sex was not an independent risk factor for in-hospital mortality. Female sex was, however, significantly associated with a
odds of 30-day readmission (odds ratio, 0.90 95% CI, 0.87-0.92;
<0.001). Conclusions Women are more likely to undergo TEVAR for aneurysms, while men are more likely to undergo TEVAR for type B aortic dissection. In-hospital mortality after TEVAR is comparable among men and women irrespective of indication. Female sex is independently associated with a reduced odds of 30-day readmission after TEVAR.
