Abstract Advanced chronic kidney disease (CKD) is associated with poor outcomes in patients undergoing surgical aortic valve replacement while its prognostic role in transcatheter aortic valve ...implantation (TAVI) remains unclear. This study aimed to investigate outcomes in patients with advanced CKD undergoing TAVI. 1904 consecutive patients undergoing balloon-expandable TAVI in 33 centers between 2007-2012 were enrolled in the I talian T ranscatheter Balloon- E xpandable Valve Implantation R egistry (ITER). Advanced CKD was defined according to estimated glomerular filtration rate (eGFR): 15-29 mL/min/1.73m2 stage 4 (S4), <15 mL/min/1.73m2 stage 5 (S5). Edwards Sapien or Sapien-XT prosthesis were used. Primary end-point was all-cause mortality during follow-up. Secondary end-points were 30-days and FU major-adverse-cardiac-events (MACE), defined with VARC-2 criteria. 421 patients were staged S5 (n=74) or S4 (n=347). S5 patients were younger, had more frequently porcelain aorta and lower incidence of previous stroke. Peri-procedural and 30-days outcomes were similar in S5 and S4 patients. During a 670 (±466) days of FU, S5 patients suffered higher mortality rates (69% vs. 39%, p<0.01) and cardiac death (19% vs. 9%, p=0.02) compared to S4. Male sex (HR 1.6, 95%CI 1.2-2.2), LVEF<30% (HR 2.3, 95% CI: 1.3-4), atrial fibrillation (HR 1.4, 95%CI:1.0-1.9) and S5 CKD (HR 1.5, 95%CI: 1.0-2.1) were independent predictors of death. In conclusion, TAVI in pre-dialytic or dialytic patients (i.e. S5) is independently associated with poor outcomes with more than double risk of death compared to patients with stage 4 renal function. Conversely, in severe CKD (i.e. S4) a rigorous risk stratification is required to avoid the risk of futility risk.
The aim of this multicentre study is to report the clinical experiences of all patients undergoing transcatheter aortic valve implantation (TAVI) with a balloon-expandable device in Italy.
The ...Italian Transcatheter balloon-Expandable valve Registry (ITER) is a real-world registry that includes patients who have undergone TAVI with the Sapien (Edwards Lifesciences, Irvine, CA, USA) bioprosthesis in Italy since it became available in clinical practice. From 2007 to 2012, 1904 patients were enrolled to undergo TAVI in 33 Italian centres. Outcomes were classified according to the updated Valve Academic Research Consortium (VARC-2) definitions. A multivariable analysis was performed to identify independent predictors of all-cause mortality.
Mean age was 81.7 (SD:6.2) years, and 1147 (60.2%) patients were female. Mean Logistic EuroSCORE was 21.1% (SD:13.7). Transfemoral, transapical, transaortic and transaxillary TAVI was performed in 1252 (65.8%), 630 (33.1%), 18 (0.9%) and 4 (0.2%) patients, respectively. Operative mortality was 7.2% (137 patients). The VARC-2 outcomes were as follows: device success, 88.1%; disabling stroke, 1.0%; life-threatening and major bleeding 9.8 and 10.5%, respectively; major vascular complication, 9.7%; acute kidney injury, 8.2%; acute myocardial infarction ≤72 h, 1.5%. Perioperative pacemaker implantation was necessary in 116 (6.1%) patients. At discharge, the mean transprosthetic gradient was 10.7 (SD:4.5) mmHg. Incidence of postoperative mild, moderate or severe paravalvular leak was, respectively, 32.1, 5.0 and 0.4%. A total of 444/1767 (25.1%) deaths after hospital discharge were reported: of these, 168 (37.8%) were classified as cardiac death. Preoperative independent predictors of all-cause mortality were male gender (HR: 1.395; 95% CI:1.052-1.849); overweight, BMI 25-30 kg/m
(HR: 0.775; 95% CI: 0.616-0.974); serum creatinine level (every 1 mg/dl increase; HR: 1.314; 95% CI:1.167-1.480); haemoglobin level (every 1 g/dl increase; HR: 0.905; 95% CI:0.833-0.984); critical preoperative state (HR: 2.282; 95% CI: 1.384-3.761); neurological dysfunction (HR: 1.552; 95% CI:1.060-2.272); atrial fibrillation (HR: 1.556; 95% CI:1.213-1.995); pacemaker rhythm (HR: 1.948; 95% CI:1.310-2.896); NYHA Class III or IV (HR: 1.800; 95% CI:1.205-2.689 or HR: 2.331; 95% CI:1.392-3.903, respectively).
TAVI with a balloon-expandable device in the 'real world' shows good mid-term outcomes in terms of survival, technical success, valve-related adverse events and haemodynamic performance.
Recent spaceflights involving nonprofessional people have opened the doors to the suborbital space tourism business. However, they have also drawn public attention to the safety and hazards ...associated with space travel. Unfortunately, space travel involves a myriad of health risks for people, ranging from DNA damage caused by radiation exposure to the hemodynamic changes that occur when living in microgravity. In fact, the primary pathogenetic role is attributed to cosmic radiation, since deep space lacks the protective benefit of Earth's magnetic shielding. The second risk factor for space-induced pathologies is microgravity, which may affect organ function and cause a different distribution of fluid inside the human body. Both cosmic radiation and microgravity may lead to the alteration of cellular homeostasis and molecular changes in cell function. These, in turn, might have a direct impact on heart function and structure. The aim of this review is to draw attention to the fact that spaceflights constitute a novel frontier in biomedical research. We summarize the most important clinical and experimental evidence regarding the cardiovascular effects of cosmic radiation and microgravity. Finally, we highlight that unraveling the mechanisms underlying how space radiation and microgravity affect the cardiovascular system is crucial for identifying potential countermeasures and developing effective therapeutic strategies.
A 68-year-old man was referred for severe aortic regurgitation 10 years after aortic root replacement with a valved conduit containing a stented bioprosthesis that had been sutured inside of the ...vascular tube graft, rather than at its extremity. Because of this simple modification of the Bentall concept, replacing the prosthetic valve within the aortic conduit was easy and uneventful.
Objectives Patient selection is crucial to achieve good outcomes and to avoid futile procedures in patients undergoing transcatheter aortic valve replacement. The aim of this multicenter ...retrospective study was to identify independent predictors of 1-year mortality in patients surviving after transapical transcatheter aortic valve replacement. Methods We analyzed data from the Italian registry of transapical transcatheter aortic valve replacement that includes patients undergoing operation in 21 centers from 2007 to 2012. Futility was defined as mortality within 1 year after transapical transcatheter aortic valve replacement in patients surviving at 30 days. Thirty-day survivors were divided in 2 groups: futility (group F) and nonfutility (group NF). Cox proportional hazard regression analysis was performed to identify independent predictors of futility. Results We analyzed data from 645 patients with survival of 30 days or more after transapical transcatheter aortic valve replacement. Groups F and NF included 60 patients (10.8%) and 585 patients (89.2%), respectively. Patients in group F were more likely to have insulin-dependent diabetes (15% vs 7.2%, P = .03), creatinine 2.0 mg/dL or greater or dialysis (18.3% vs 8.2%, P = .01), logistic European System for Cardiac Operative Risk Evaluation greater than 20% (66.7% vs 50.3%, P = .02), preoperative rhythm disorders (40% vs 25.3%, P = .03), critical preoperative state (8.3% vs 1.8%, P = .002), and left ventricular ejection fraction less than 30% (15% vs 2.9%, P < .001). The multivariate analysis identified the following as independent predictors of futility: insulin-dependent diabetes (odds ratio, 3.1; P = .003), creatinine 2.0 mg/dL or greater or dialysis (odds ratio, 2.52; P = .012), preoperative rhythm disorders (odds ratio, 1.88; P = .04), and left ventricular ejection fraction less than 30% (odds ratio, 4.34; P = .001). Conclusions According to our data, among patients undergoing transapical transcatheter aortic valve replacement, those with insulin-dependent diabetes, advanced chronic kidney disease, rhythm disorders, and low left ventricular ejection fraction have a higher risk to undergo futile procedures.
Enlargement of left atrium occurs in patients with longstanding mitral valve disease due to chronic pressure and volume overload and occasionally left atrium reaches a massive enlargement, condition ...known as giant left atrium. It is most commonly associated with rheumatic mitral valve disease, both stenosis and regurgitation. This unique case deals with a 70-year-old woman who developed a giant left atrium due to a severe mitral regurgitation from complete prolapse of both mitral leaflets, as a consequence of previous undersized mitral ring annuloplasty.
After a decline in interest in space missions following the cessation of the Apollo missions, there has been a recent resurgence. Activities on the International Space Station have raised awareness ...of a positive resumption of space travel to more challenging destinations such as Mars and a possible adaptation of human life on the Moon. The biological and physiological studies conducted on these stations in low Earth orbit are crucial in familiarizing humanity with the potential problems that can arise during long journeys. Cosmic rays and microgravity are the 2 main negative phenomena in space flights. Microgravity in the interplanetary environment plays a special role in altering normal organic processes. These studies are compared to studies conducted on Earth with laboratory technologies that mimic the space environment. To date, the molecular and physiological adaptations of the human body to this unnatural environment are very poor. The aim of this review is therefore to provide an overview of the most important findings on the molecular and physiological anomalies that develop during microgravity in short and long space flights.
It remains unclear today whether risk scores created specifically to predict early mortality after cardiac operations for infective endocarditis (IE) outperform or not the European System for Cardiac ...Operative Risk Evaluation II (EuroSCORE II).
Perioperative data and outcomes from a European multicenter series of patients undergoing surgery for definite IE were retrospectively reviewed. Only the cases with known pathogen and without missing values for all considered variables were retained for analyses. A comparative validation of EuroSCORE II and five specific risk scores for early mortality after surgery for IE – (1) STS-IE (Society of Thoracic Surgeons for IE); (2) PALSUSE (Prosthetic valve, Age ≥70, Large intra-cardiac destruction, Staphylococcus spp, Urgent surgery, Sex (female), EuroSCORE ≥10); (3) ANCLA (Anemia, New York Heart Association class IV, Critical state, Large intra-cardiac destruction, surgery on thoracic Aorta); (4) AEPEI II (Association pour l’Étude et la Prévention de l'Endocardite Infectieuse II); (5) APORTEI (Análisis de los factores PROnósticos en el Tratamiento quirúrgico de la Endocarditis Infecciosa) – was carried out using calibration plot and receiver-operating characteristic curve analysis. Areas under the curve (AUCs) were compared 1:1 according to the Hanley-McNeil's method. The agreement between APORTEI score and EuroSCORE II of the 30-day mortality prediction after surgery was also appraised.
A total of 1,012 patients from five European university-affiliated centers underwent 1,036 cardiac operations, with a 30-day mortality after surgery of 9.7%. All IE-specific risk scores considered achieved better results than EuroSCORE II in terms of calibration; AEPEI II and APORTEI score showed the best performances. Despite poor calibration, EuroSCORE II overcame in discrimination every specific risk score (AUC, 0.751 vs. 0.693 or less, p=0.01 or less). For a higher/lesser than 20% expected mortality, the agreement of prediction between APORTEI score and EuroSCORE II was 86%.
EuroSCORE II discrimination for 30-day mortality after surgery for IE was higher than five established IE-specific risk scores. AEPEI II and APORTEI score showed the best results in terms of calibration.
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