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•French nationwide analysis of 36,549 TAVI recipients.•Approximately one fifth of patients underwent PPI within 30days of TAVI.•In-hospital PPI was not associated with 30-day ...survival.•PPI within 30days of TAVI was associated with a higher 5-year risk of HHF.•PPI within 30days of TAVI was associated with a higher 5-year risk of mortality.•Further efforts are needed to mitigate the risk of PPI after TAVI.
The influence of permanent pacemaker implantation upon outcomes after transcatheter aortic valve implantation (TAVI) remains controversial.
To evaluate the impact of permanent pacemaker implantation after TAVI on short- and long-term mortality, and on the risk of hospitalization for heart failure.
Data from the large FRANCE-TAVI registry, linked to the French national health single-payer claims database, were analysed to compare 30-day and long-term mortality rates and hospitalization for heart failure rates among patients with versus without permanent pacemaker implantation after TAVI. Multivariable regressions were performed to adjust for confounders.
A total of 36,549 patients (mean age 82.6years; 51.6% female) who underwent TAVI from 2013 to 2019 were included in the present analysis. Among them, 6999 (19.1%) received permanent pacemaker implantation during the index hospitalization, whereas 232 (0.6%) underwent permanent pacemaker implantation between hospital discharge and 30days after TAVI, at a median of 11 (interquartile range: 7–18) days. In-hospital permanent pacemaker implantation was not associated with an increased risk of death between discharge and 30days (adjusted odds ratio: 0.91, 95% confidence interval: 0.64–1.29). At 5years, the incidence of all-cause death was higher among patients with versus without permanent pacemaker implantation within 30days of the procedure (adjusted hazard ratio: 1.13, 95% confidence interval: 1.07–1.19). Permanent pacemaker implantation within 30days of TAVI was also associated with a higher 5-year rate of hospitalization for heart failure (adjusted subhazard ratio: 1.17, 95% confidence interval: 1.11–1.23).
Permanent pacemaker implantation after TAVI is associated with an increased risk of long-term hospitalization for heart failure and all-cause mortality. Further research to mitigate the risk of postprocedural permanent pacemaker implantation is needed as TAVI indications expand to lower-risk patients.
Abstract
Structural valve deterioration is a well-studied phenomenon in bioprosthetic heart valves. Conversely, structural valve deterioration after transcatheter aortic valve implantation is not as ...well-elucidated. Therefore, late surgical explantation after transcatheter aortic valve implantation is an infrequent procedure, and thus, surgical findings and management of such cases remain unclear, particularly in patients previously labelled as ‘inoperable’ or at ‘high risk’. Herein, we report the case of a late surgical explantation of a transcatheter heart valve (THV) 7 years after its implantation in a patient with a porcelain aorta and periprosthetic regurgitation.
We aimed at investigating the long-term durability of the Epic bioprosthesis for surgical aortic valve replacement (SAVR) in a single-centre series of 888 implantations (2001-2018), expanding ...previous evaluations with shorter follow-up.
We retrieved prospectively collected in-hospital data and performed a systematic follow-up focusing on valve-related events (SVD, structural valve deterioration; PPM, patient-prosthesis mismatch; reoperation) (competing risks, CIF and Kaplan--Meier methods). We distinguished between SVD (permanent changes in valve function due to evolutive structural deterioration, ≥10 mmHg average gradient vs. reference echocardiography) and PPM.
Average age at SAVR was 75.4 ± 7 years; 855 (96.3%) bioprostheses entered the follow-up and 396 (46.4%) were alive at last assessment. Follow-up was 99.9% complete, median duration was 7.7 years (entire cohort) and 9.9 years (survivors). At 10 years, overall survival was 50% ± 1.9, freedom from SVD was 99.4% ± 0.3 (competing risks) (seven SVD events after 8.1 ± 4.3 years). Freedom from SVD at 15 years was 98.4% ± 0.8 (competing risks). Prevalence of severe PPM was higher in 19 mm (6.5%) and 21 mm (10.2%) size cohorts. PPM (severe or moderate/severe) had no significant impact on overall survival (log-rank P = 0.27 and P = 0.21, respectively). Freedom from any reintervention (reoperation or TAVI Valve-in-Valve) for SVD at 10 years was 99.4% ± 0.3 (competing risks); freedom from any valve-related reintervention was 97.4% ± 0.6 (competing risks).
The Epic bioprosthesis for SAVR is limited by nonnegligible rates of PPM, which have nonetheless no impact on late survival. This device shows excellent durability and low rates of adverse valve-related events.
Despite significant improvement in patient blood management, cardiac surgery remains a high hemorrhagic risk procedure. Platelet transfusion is used commonly to treat thrombocytopenia-associated ...perioperative bleeding. Allogeneic platelet transfusion may induce transfusion-related immunomodulation. However, its association with postoperative healthcare-associated infections is still a matter of debate. The objective was to evaluate the impact of allogeneic platelet transfusion during cardiac surgery on postoperative healthcare-associated infection incidence.
Retrospective cohort study.
Tertiary referral academic center.
Patients undergoing cardiac surgery from 2012 to 2018.
None.
Intraoperative platelet transfusion was defined as exposure in a causal model. The primary outcome was the incidence of healthcare-associated infections comprised of bloodstream infection, hospital-acquired pneumonia, and surgical-site infection. Among 7,662 included patients, 528 patients (6.8%) were exposed to intraoperative platelet transfusion, and 329 patients (4.3%) developed 454 postoperative infections. Bloodstream infection affected 106 patients (1.4%), hospital-acquired pneumonia affected 174 patients (2.3%), and surgical-site infection affected 148 patients (1.9%). Intraoperative platelet transfusion was associated with an increased risk of bloodstream infection after adjustment by multivariable logistic regression (odds ratio OR 2.85; 95% CI 1.40-5.8; p = 0.004; n = 7,662), propensity score matching (OR 3.95; 95% CI 1.57-12.0), p = 0.007; n = 766), and propensity score overlap weighting (OR 3.04; 95% CI 1.51-6.1, p = 0.002; n = 7,762). Surgical-site infection and hospital-acquired pneumonia were not significantly associated with platelet transfusion.
These results suggested that intraoperative allogeneic platelet transfusion is a risk factor for bloodstream infection after cardiac surgery. These results supported the development of patient blood management strategies aimed at minimizing perioperative platelet transfusion in cardiac surgery.
Transfemoral approach stands as the reference access-route for transcatheter aortic valve implantation (TAVI). Nonetheless, alternatives approaches are still needed in a significant proportion of ...patients. This study aimed at comparing outcomes between transthoracic-approach (transapical or transaortic) and transarterial-approach (transcarotid or subclavian) TAVI. Data from 191 consecutive patients who underwent surgical-approach TAVI from May 2009 to September 2017 were analyzed. Patients were allocated in 2 groups according to the approach. The primary end point was the 30-day composite of death of any cause, need for open surgery, tamponade, stroke, major or life-threatening bleeding, stage 2 or 3 acute kidney injury, coronary obstruction, or major vascular complications. During the study period, 104 patients underwent transthoracic TAVI (transapical: 60.6%, transaortic: 39.4%) whereas 87 patients underwent transarterial TAVI (subclavian: 83.9%, transcarotid: 16.1%). Logistic EuroSCORE I tended to be higher in transthoracic-TAVI recipients. In-hospital and 30-day composite end point rates were 25.0% and 11.5% (p = 0.025), and 26.0% and 14.9% (p = 0.075) for the transthoracic and transarterial cohorts, respectively. Propensity score-adjusted logistic regression demonstrated no significant detrimental association between the 30-day composite end point and transthoracic access (odds ratio 2.12 95% confidence interval 0.70 to 6.42; p = 0.18). Transarterial TAVI was associated with a shorter length of stay (median: 6 vs 7 days, p <0.001). TAVI approach was not an independent predictor of midterm mortality. In conclusion, nontransfemoral transarterial-approach TAVI is safe, feasible, and associated with comparable rates of major perioperative complications, and midterm mortality compared with transthoracic-approach TAVI.
To evaluate the incidence and consequences of preoperative iron deficiency in elective cardiac surgery.
A prospective observational study.
The cardiac surgery unit of a university hospital, from ...November 2016 to February 2017.
All patients presenting for elective cardiac surgery during the study period, with the exclusion of noncardiac thoracic surgeries, surgeries of the descending aorta, endovascular procedures, and patients affected by an iron-metabolism disease.
Transferrin saturation and serum ferritin levels were systematically assessed before surgery, and the care of patients was maintained as usual.
Routine analyses, clinical data, and the number of blood transfusions were recorded during the hospital stay. Among the 272 patients included, 31% had preoperative iron deficiency and 13% were anemic. Patients with iron deficiency had significantly lower hemoglobin levels throughout the hospital stay and received blood transfusions more frequently during surgical procedures (31% v 19%, p = 0.0361). Detailed analysis showed that patients with iron deficiency received more red blood cell units. There were no differences in postoperative bleeding, morbidity, or mortality.
Iron deficiency appears to be related to lower hemoglobin levels and more frequent transfusions in elective cardiac surgery. Assessing iron status preoperatively and correcting any iron deficiencies should be one of the numerous actions involved in patient blood management for such surgeries, with the aim of reducing morbidity associated with both anemia and transfusion.
Abstract
OBJECTIVES
Our goal was to evaluate the operative outcomes of the frozen elephant trunk technique using the E-Vita Open Plus® hybrid prosthesis in chronic aortic arch diseases and report ...clinical and radiological outcomes at the 1-year follow-up.
METHODS
As determined from a prospective multicentre registry, 94 patients underwent frozen elephant trunk procedures using the E-Vita Open Plus hybrid device for the treatment of chronic aortic conditions, including 50% chronic aortic dissections, 40% degenerative aneurysms and 10% miscellaneous indications. Fifty percent of the cases were reoperations.
RESULTS
The perioperative mortality rate was 11.7%. Spinal cord ischaemia and stroke rates were 4% and 9.6%, respectively. The mean cardiopulmonary bypass time was 252 ± 97 min, cardiac ischaemia time was 152 ± 53 min and cerebral perfusion time was 82 ± 22 min. Concomitant procedures were observed in 15% of patients. Among the 83 surviving patients, the survival rate after the 1-year follow-up was 98%. Eleven percent of patients underwent endovascular completion, whereas 4% of patients required aortic reintervention at 1 year.
CONCLUSIONS
The E-Vita Open Plus hybrid device confirms the favourable short- and mid-term outcomes offered by its predecessor in frozen elephant trunk procedures in patients with chronic aortic arch disease. Implantation of the E-Vita Open Plus is associated with good 1-year survival rates, good rates of favourable aortic remodelling in both chronic dissection and degenerative aneurysms and a reproducible technique in a multicentre registry. Continued follow-up is required due to the risk of evolution at the downstream aorta.
Abstract
Background/introduction
Published in 2016, PARTNER II study has shown TAVR to be non inferior to SAVR in intermediate risk patients. This result might influence the type of SAVR chosen in ...patients for whom a redo surgery would surely be a procedure at intermediate risk, based on estimated age at time for redo and taking into account ViV TAVI as a game changer for treating a degenerated biological prosthesis.
Purpose
To assess the choice of type of valve according to age in aortic position through the French National Database EPICARD before and after the publication of Parter II study.
Methods
We extracted from EPICARD all valvular patients operated on from 2007 to 2022 in 24 participating public or private centers chosen to represent a balanced representation of center sizes and geographical discrepancies. Patients with associated pathology of the aorta (aneurysm or dissection) and requiring a vascular aortic prosthesis were excluded.
Results
From the obtained representative study population of 101,070 valvular patients, we studied 72,375 SAVR (mean age 71.4 +/- 12.2). We observed a mechanical versus biological prosthesis ratio (MBPR) of 0.14 for the overall aortic SAVR population. Before 50 y-o, MBPR was >1.3 (p<0.001) while patients above 60 y-o received principally biological SAVR (p<0.0001). Concerning patients between 50-60 y-o patients, MBPR was 1.04 (p=0.03). Patients 50-60 y-o from the first and second quartile (before August 2015) received preferentially mechanical SAVR (p<0.001). We observed a shift towards more biological SAVR (p<0.001) for patients from the third and fourth quartile to reach a MBPR at 0.43 during the last years of the series. Incidentally, the choice of type of SAVR was influenced by associated procedures. Simultaneous mitral valve replacement were more common in case of mechanical SAVR (p<0.0001), while associated CABGs were more frequent in case of biological SAVR (p<0.0001).
Conclusion
In a large contemporary French patient population, real world practice showed that publication of the PARTNER II study was followed by a shift towards a lower threshold for biological SAVR as compared to ESC Guidelines.
Prevention of postoperative pulmonary complications and aggregation of marginal gains Anselmi, Amedeo, MD, PhD; Verhoye, Jean-Philippe, MD, PhD
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
03/2017, Volume:
153, Issue:
3
Journal Article
Abstract
Aims
Secondary tricuspid regurgitation (STR) is commonly found in patients with aortic stenosis and is associated with increased morbidity. The study sought to evaluate the prevalence of ...pre-operative STR and its progression after surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI). Also, it sought to analyse the predictors of post-operative changes in STR.
Methods and results
We prospectively evaluated 116 patients (aged 75.1 ± 9.8 years, predominantly male) who undergo SAVR or TAVI for severe aortic stenosis (AS) from September 2013 to April 2015. Patients with associated valve disease requiring intervention, significant coronary artery disease or left ventricular ejection fraction (LVEF) <50% were excluded. Clinical and echocardiographic data, including TR grade and right ventricular (RV) size and function, were assessed at baseline and at the 1-year follow-up. At baseline, significant TR was documented in 13 patients (11.1%) and non-significant TR was documented in 103 patients (88.9%). Atrial fibrillation (AF) was more prevalent in patients with a tricuspid annulus diameter ≥40 mm (P < 0.0051). At the 1-year follow-up, the TR grade had improved in 17 patients (14.7%), was unchanged in 68 patients (58.6%) and had worsened in 31 patients (26.7%). Moderate to severe TR was found in 30 patients (25.8%). Tricuspid annulus diameter >40 mm was the only echocardiographic predictor of significant postoperative TR (relative risk (RR) = 2.12 1.26–3.54, P = 0.004). Right heart function and size were not independent predictors.
Conclusion
Significant TR was present pre-operatively in 11.1% of patients. Post-operative progression was observed in 26.7% of patients. Only tricuspid annulus size >40 mm was an independent echocardiographic predictor of moderate to severe TR at the 1-year follow-up.
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