bluuebunny/crossref_metadata_2025 huggingface dataset:
Developing a fully 3d animated educational application to teach bifurcation lesion treatment
Authors: Kini A , Vengrenyuk A , Bhatheja S , Chamaria S , Barman N , Krishnamoorthy P , Sharma S
Published: November 2020

Background

Coronary bifurcation lesions make up around 15 to 20 percent of interventions. Especially for younger interventionalists, they pose a steep difficulty curve due to the daunting set of ways treatment can diverge from the initial plan based on plaque shift or other complications.

Purpose

BifurcAID 3D was designed to intuitively show some of the key phenomena during bifurcation lesion treatment. Plaque shift, the importance of proximal optimization, the opening of a jailed side branch, and the overlapping layers of stent in the Culotte technique are among some of the aspects of bifurcation lesion treatment that can benefit from a clear visual format.

Methods

Iterating on the bifurcation algorithm developed at a high volume metropolitan PCI center, this fully animated application has many branching points where plaque shift is assessed and the treatment plan and animation varies accordingly to show reactive balloon angioplasty, stenting, or entirely switching to dedicated two stent techniques.

Results

The resulting application is an easy-to-navigate algorithm for left and non left main bifurcation lesion treatment with fully animated clear depictions of bifurcation lesion treatments including provisional, bail-out strategies, and dedicated two stent techniques alongside descriptive text.

Conclusions

Creating free educational content for aspiring and current physicians serves to elevate the field and lower the barriers to entry. BifurcAID 3D will make available intuitive education on complex bifurcation lesion treatment worldwide.

Representative Images of BifurcAID 3D

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Abbott Vascular Education Grant
A simple nomogram to predict contrast-induced acute kidney injury in patients with congestive heart failure undergoing coronary angiography
Authors: Lei L , He Y , Guo Z , Liu B , Liu J , Nie Z , Chen S , Liu Y , Chen J
Published: November 2020

Background

Patients with congestive heart failure (CHF) are vulnerable to contrast-induced acute kidney injury (CI-AKI), but few prediction models are currently available.

Objectives

We aimed to establish a simple nomogram for CI-AKI risk assessment for patients with CHF undergoing coronary angiography.

Methods

A total of 1876 consecutive patients with CHF (defined as New York Heart Association functional class II-IV or Killip class II-IV) were enrolled and randomly (2:1) assigned to a development cohort and a validation cohort. The endpoint was CI-AKI defined as serum creatinine elevation of ≥0.3 mg/dL or 50% from baseline within the first 48–72 hours following the procedure. Predictors for the nomogram were selected by multivariable logistic regression with a stepwise approach. The discriminative power was assessed using the area under the receiver operating characteristic (ROC) curve and was compared with the classic Mehran score in the validation cohort. Calibration was assessed using the Hosmer–Lemeshow test and 1000 bootstrap samples.

Results

The incidence of CI-AKI was 9.06% (n=170) in the total sample, 8.64% (n=109) in the development cohort and 9.92% (n=61) in the validation cohort (p=0.367). The simple nomogram including four predictors (age, intra-aortic balloon pump, acute myocardial infarction and chronic kidney disease) demonstrated a similar predictive power as the Mehran score (area under the curve: 0.80 vs 0.75, p=0.061), as well as a well-fitted calibration curve.

Conclusions

The present simple nomogram including four predictors is a simple and reliable tool to identify CHF patients at risk of CI-AKI, whereas further external validations are needed.

Figure 1

Funding Acknowledgement

Type of funding source: None
Post-infectious myocardial infarction: does percutaneous coronary intervention improves outcomes?
Authors: Putot A , Chague F , Manckoundia P , Cottin Y , Zeller M
Published: November 2020

Introduction and objectives

Acute infections are frequent triggers for myocardial infarction (MI), and associated with poor prognosis. However, whether percutaneous coronary intervention (PCI) improves post-infectious MI prognosis remains unknown. We aimed to evaluate the prognostic impact of PCI at the acute phase of post-infectious MI in patients with significant coronary stenosis.

Methods

Observational study in 4573 consecutive MI patients of the RICO Survey in coronary units, of whom 476 patients (10%) had a concurrent diagnosis of acute infection at admission. Among them, 321 patients with a significant stenosis (>50%) at coronary angiography were analysed. After propensity score matching based on clinical and angiography data, in-hospital and one-year outcomes were compared between patients with and without PCI.

Results

Among the 321 patients (mean age 74y), most (n=195 (61%)) underwent PCI. Acute atherothrombotic event (type 1 MI) and STEMI were much more frequent in the PCI group (53 vs 19%, p<0.001, and 51% vs 32%, p=0.001, respectively). As expected, Troponin Ic peak was almost 3 times higher in the PCI group (17 [4–72] vs 6 [1–20] ng/mL, p<0.001). Coronary lesions were less severe in the PCI group (3-vessels disease: 36% vs 52%, p<0.004; SYNTAX score: 11 [6–19] vs 19 [11–28], p<0.001). At one year follow up, recurrence rate (5% for both groups, p=0.8), and cardiovascular (CV) mortality (15% vs 13%, p=0.6) were similar for both groups. After propensity score matching, in-hospital (OR = 1.45 (0.43–4.85), p=0.5) and 1-year CV mortality: OR = 1.73 (0.66–4.54), p=0.3) were similar in patients with and without PCI.

Conclusion

In this first observational work investigating treatment strategy in post-infectious MI, PCI might not improve short and long-term prognosis. These findings do not support the use of systematic invasive procedures after post-infectious MI. Interventional studies are urgently needed to confirm these findings.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Agence Régionale de Santé Bourgogne Franche Comté, CHU Dijon Bourgogne
Viability and functional recovery after chronic total occlusion percutaneous coronary intervention
Authors: De Winter R , Schumacher S.P , Everaars H , Stuijfzand W.J , Van Diemen P.A , Driessen R.S , Bom M.J , Huynh J.W , Van Loon R.B , Van De Ven P.M , Van Rossum A.C , Opolski M.P , Nap A , Knaapen P
Published: November 2020

Background

Current guidelines advocate viability assessment to guide percutaneous coronary intervention (PCI) of chronic coronary total occlusions (CTO).

Purpose

Aim of the present study was to evaluate viability as well as global and regional functional recovery after successful CTO PCI using quantitative cardiac magnetic resonance (CMR) imaging.

Methods

132 patients with sequential CMR at baseline and 3-months after successful CTO PCI were prospectively recruited between 2013 and 2018. Segmental wall thickening (SWT) and percentage late gadolinium enhancement (LGE) were quantitatively measured per segment. Viability was defined as dysfunctional myocardium (<2.84mm SWT) with no or limited scar (≤50% LGE).

Results

Significant improvements in left ventricular (LV) ejection fraction (from 48.1±11.8 to 49.5±12.1%, p<0.01), LV end-diastolic volume (from 99.1±31.8 to 95.7±30.2ml, p<0.01), and LV end-systolic volume (from 54.4±30.5 to 51.2±29.3ml, p<0.01) were observed after CTO PCI. CTO segments with viability (N=216, (31%)) demonstrated a significantly higher increase in SWT (0.80±1.39mm) compared to CTO segments with pre-procedural preserved function (N=456 (65%), 0.07±1.43mm, p<0.01) or extensive scar (LGE >50%, N=26 (4%), −0.08±1.09mm, p<0.01). Improvement in SWT was comparable between segments with viability if further stratified to 0, >0–25, and >25–50% hyperenhancement (p=0.94). Patients with ≥2 CTO segments viability showed more SWT increase in the CTO territory compared to patients with 0–1 segment viability (0.49±0.93 vs. 0.12±0.98mm, p=0.03).

Conclusions

Improvements in LV function and volumes were significant but modest following CTO PCI. Detection of dysfunctional myocardial segments without extensive scar (≤50% LGE) as a marker for viability may aid in identifying subjects with significant regional functional recovery after CTO PCI.

Funding Acknowledgement

Type of funding source: None
Sex sub analysis from observational multicenter registry of patients treated with Impella mechanical circulatory support device in Italy: the IMP-IT women
Authors: Ziviello F , Burzotta F , Briguori C , Trani C , Nicolini E , Masiero G , Pagnotta P , Pazzanese V , Scandroglio M , Piva T , De Marco F , Di Biasi M , Montorfano M , Tarantini G , Chieffo A
Published: November 2020

Background

Women-specific data on safety, effectiveness, and outcomes for mechanical support in the setting of cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR-PCI) are still unsettled. The IMP-IT study was a multicenter observational national registry that enrolled all patients treated with Impella 2.5, Impella CP, Impella 5.0 and Impella RP, both for CS and HR-PCI indications, across 17 Italian centers from 2004 to June 2018

Purpose

To analyze the characteristics of female population enrolled in IMP-IT registry and to assess differences in presentation, timing to interventions and outcomes between men and women.

Methods

The Women-IMP-IT study is a multicenter observational national registry focusing on female population enrolled in IMP-IT study. Baseline, procedural and hemodynamics characteristics, such as outcome were collected. Differences between men and women were examined.

Results

Mean age of female population was 66.9±16.1 years, Body mass index was 26.3±5.5 kg/m2. There was a higher rate of cardiogenic shock (66.7% vs. 49.1%; p=0.06), NSTEMI (18% vs 9%, p=0.03) and acute myocarditis (9.6% vs 1.4%, p=0.01) in women vs men, associated with a lower rate of protected PCI (33.3% vs 50.9%, p=0.06). We did not observed a statistically difference in device related complications (27.4% vs 23.3%; p=0.50), respectively in women compared to men. In particular, no differences were observed in access site bleedings (10.8% vs 9%; p=0.70) and life threatening or severe bleeding (15.3% vs 11.4%; p=0.40). At one year, all-cause death rate was 45.1% in women vs 30.1% in men (p=0.016), and cardiac death rate was 42.5% in women and 27.5% in men (p=0.013). At 1-year no significant difference was observed in the rate of myocardial infarction (3.7% vs 2.3%; p=0.44), stroke (3.7% vs 2.6%; p=0.70), heat-failure hospitalization (7.7% vs 7.5%; p=1.0), need for left ventricular assist device or heart transplantation (1.3% vs 5.5%; p=0.21).

Conclusions

In our series, use of Impella is CS and HR-PCI is increasing in female population. Sex-differences in mortality are mostly explained by clinical differences at presentation.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): EAPCI Education and Training Grants
Left ventricular assist device versus intra-aortic balloon pump for treatment of acute myocardial infarction complicated by cardiogenic shock: a systematic review and meta-analysis
Authors: Yang Y.X , Wang J.X , Li X.W , Lu P.J , Bai M.N , Gao M.D , Liu Y , Gao J
Published: November 2020

Background

1. Despite early revascularization, the mortality of patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) remains high.

2. Mechanical circulation support devices (MCS) are widely utilized in clinical due to unloading left ventricle and augmenting cardiac output.

3. Whether left ventricular assist device (LVAD) including TandemHeart and Impella is superior to Intra-aortic balloon pump (IABP) for AMI-CS remains unclear.

Aim

To investigate the efficacy and safety of LVAD versus IABP for AMI-CS.

Methods

1. We searched the relevant literature on PUBMED, EMBASE and Cochrane Library.

2. The primary endpoint was 30-day mortality. The secondary endpoints were in-hospital myocardial infarction (MI), stent thrombosis (ST), stroke, sepsis, major bleeding and limb ischemia.

3. Two investigators performed the studies selection and data extraction independently.

4. The quality of randomized controlled trials and observational studies was assessed by using the Cochrane Collaboration's tool and Newcastle-Ottawa Scale respectively.

5. Results were analyzed by computing pooled risk ratios (RR) with 95% Confidence Intervals (CIs).

Results

1. The process of literature search strategy is shown in Figure 1.

2. Main characteristics of the included studies can be seen in Table 1.

3. There was no significant difference in 30-day mortality (RR:0.97, 95% CI:0.80–1.17, P=0.76), in-hospital MI (RR:0.64, 95% CI:0.22–1.85, P=0.41), ST (RR:0.74, 95% CI:0.13–4.12, P=0.73), stroke (RR:1.36, 95% CI:0.37–4.94, P=0.64) and sepsis (RR:1.30, 95% CI:0.54–3.13, P=0.56) between LVAD and IABP group. However, the incidences of in-hospital major bleeding (RR:2.61,95% CI:1.61–4.23, P=0.0001) and limb ischemia (RR:4.91, 95% CI:2.07–11.64, P=0.0003) were significantly higher in LVAD than IABP group.

Conclusion

LVAD was not associated with reduced 30-day mortality but with increased in-hospital major bleeding and limb ischemia for patients with AMI-CS compared with IABP.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): National 135 Key Research and Development Program in 2016
Predictive impact of PVL assessments on clinical outcomes in patients undergoing TAVR
Authors: Matsushita K , Marchandot B , Kibler M , Sato C , Heger J , Peillex M , Trimaille A , Hess S , Grunebaum L , Ohana M , Reydel A , Jesel L , Ohlmann P , Morel O
Published: November 2020

Introduction

Paravalvular leakage (PVL) following transcatheter aortic valve replacement (TAVR) is associated with greater mortality. In clinical practice, determining PVL severity after TAVR remains challenging and often requires multiparametric assessment.

Purpose

This study sought to evaluate the respective value of various modalities of PVL assessments, including transthoracic echocardiography (TTE), cine-angiography, aortic regurgitation index (ARI), and closure time with adenosine diphosphate (CT-ADP), in the prediction of adverse clinical outcomes.

Methods

We included 1044 patients from our prospective TAVR registry between February 2010 and May 2019. Major adverse cardiac and cerebrovascular events (MACCE) was defined as a composite of all-cause death, myocardial infarction, stroke, and heart failure hospitalization within 1-year. Established cutoff values of ARI (<25) and CT-ADP (>180 sec) were used to assess the presence of PVL after TAVR.

Results

Moderate to severe PVL occurred in 14.2% and 5.2% of patients as measured by TTE and angiography. The rate of patients with ARI <25 and CT-ADP >180 sec were 36.5% and 24.9%, respectively. Among the four modalities, PVL evaluated by angiography predicted poorer clinical outcomes (Log rank test; p=0.001), whereas TTE, ARI <25, and CT-ADP >180 sec were not associated with 1-year MACCE. By multivariate Cox regression analysis, moderate to severe PVL by angiography was an independent predictor of 1-year MACCE (hazard ratio: 1.96; 95% confidence interval: 1.22–3.00; p=0.007).

Conclusions

Paravalvular leakage measured by angiography was evidenced as the most meaningful modality in the prediction of adverse clinical outcomes. Future multicenter studies are warranted to ensure these findings in the current TAVR era.

Figure 1

Funding Acknowledgement

Type of funding source: None
Assessment of long-term structural deterioration of transcatheter aortic bioprosthetic valves
Authors: Durand E , Hemery T , Levesque T , Tron C , Litzler P.Y , Dacher J.N , Eltchaninoff H
Published: November 2020

Background

The durability of transcatheter aortic bioprosthetic valves is a crucial issue in the context of extension of indications in younger and lower-risk patients, but data are scarce, especially beyond 5 years of follow-up. This study sought to evaluate the incidence of structural valve degeneration (SVD) 5 to 10 years post-procedure.

Methods

Demographic, procedural, and in-hospital outcome data on patients who underwent transcatheter aortic valve implantation (TAVI) from 2002 to 2014 were obtained from our prospective institutional database. Patients in whom echocardiographic data were available both at baseline and 5 years post-TAVI were included. Clinical and echocardiographic follow-up were performed on site annually. Hemodynamic SVD was determined according to European task force committee guidelines.

Results

A total of 208 patients (82.5±7.6 years of age; 53% female) with paired post-procedure and late echocardiographic follow-up (median 5.3 years, range 5 to 11.4 years) were included. Eleven (5.3%) patients were treated with a self-expandable valve and 197 (94.7%) patients with a balloon-expandable valve. Mean aortic valve gradient and effective aortic valve area remained unchanged during follow-up. There were 2 cases (1.0%) of severe SVD 6 and 7 years after implantation requiring redo-TAVI. There were 4 cases (1.9%) of moderate SVD (mean 6.0 years post-implantation; range 5 to 7 years).

Conclusions

Our data do not demonstrate any alarm on transcatheter aortic valve durability. Careful prospective assessment in younger and lower risk patients and comparison with surgical bioprosthetic valves are required to further assess long-term durability of transcatheter valves.

Funding Acknowledgement

Type of funding source: None
Use and outcomes of emergency treatment strategies in patients with aortic valve stenosis
Authors: Piepenburg S.M , Kaier K , Olivier C , Zehender M , Bode C , Von Zur Muehlen C , Stachon P
Published: November 2020

Introduction and aim

Current emergency treatment options for severe aortic valve stenosis include surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR) and balloon valvuloplasty (BV). So far no larger patient population has been evaluated regarding clinical characteristics and outcomes. Therefore we aimed to describe the use and outcome of the three therapy options in a broad registry study.

Method and results

Using German nationwide electronic health records, we evaluated emergency admissions of symptomatic patients with severe aortic valve stenosis between 2014 and 2017. Patients were grouped according to SAVR, TAVR or BV only treatments. Primary outcome was in-hospital mortality. Secondary outcomes were stroke, acute kidney injury, periprocedural pacemaker implantation, delirium and prolonged mechanical ventilation >48 hours. Stepwise multivariable logistic regression analyses including baseline characteristics were performed to assess outcome risks.

8,651 patients with emergency admission for severe aortic valve stenosis were identified. The median age was 79 years and comorbidities included NYHA classes III-IV (52%), coronary artery disease (50%), atrial fibrillation (41%) and diabetes mellitus (33%). Overall in-hospital mortality was 6.2% during a mean length of stay of 22±15 days. TAVR was the most common treatment (6,357 [73.5%]), followed by SAVR (1,557 [18%]) and BV (737 8.5%]).

Patients who were treated with TAVR or BV were significantly older than patients with SAVR (mean age 81.3±6.5 and 81.2±6.9 versus 67.2±11.0 years, p<0.001), had more relevant comorbidities (coronary artery disease 52–91% vs. 21.8%; p<0.001), worse NYHA classes III-IV (55–65% vs. 34.5%; p<0.001) and higher EuroSCORES (24.6±14.3 and 23.4±13.9 vs. 9.5±7.6; p<0.001) than SAVR patients. Patients treated with BV only had the highest in-hospital mortality compared with TAVR or SAVR (20.9% vs. 5.1 and 3.5%; p<0.001).

Compared with BV only, SAVR patients (adjusted odds ratio [aOR] 0.25; 95% confidence interval [CI] 0.14–0.46; p<0.001) and TAVR patients (aOR 0.37; 95% CI 0.28–0.50; p<0.001) had a lower risk for in-hospital mortality.

Conclusion

In-hospital mortality for emergency patients with symptomatic severe aortic valve stenosis is high. Our results showed that BV only therapy was associated with highest mortality, which is in line with current research. Yet, there is a trend towards more TAVR interventions and this study might imply that balloon valvuloplasty alone is insufficient. The role of BV as a bridging strategy to TAVR or SAVR needs to be further investigated.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany
Early discharge after TAVI: should we still be afraid of conduction disturbances?
Authors: Ribeiro Da Silva M , Rodrigues A , Guerreiro C , Mosalina Manuel A , Santos Silva G , Teixeira P , Ribeiro Queiros P , Brandao M , Ferreira D , Caeiro D , Dias A , Sousa O , Oliveira M , Primo J , Braga P
Published: November 2020

Introduction

Conduction disturbances (CD) after TAVI remains the most frequent complication of the procedure, frequently increasing the length of hospital stay. A lack of consensus exists regarding in-hospital management of CD post-TAVI.

Purpose

To evaluate if an early discharge (ED) protocol could be safely implemented in patients (pts) with CD post-TAVI.

Methods

Retrospective study of all pts submitted to TAVI between 2016 and 2018. Pts with prior permanent pacemaker (PP) and non-transfemoral approach were excluded. ECG data before, immediately after the procedure and at day 3 post-TAVI were collected, and continuous telemetry monitoring was recorded. We applied a recently proposed ED algorithm (adapted from Management of Conduction Disturbances Associated With Transcatheter Aortic Valve Replacement - JACC Scientific Expert Panel; JACC 2019; 74(8):1086–106) to identify which pts could have been candidates for ED. ED was defined as discharge in the first 72 hours (h) after the procedure. We evaluated if an ED strategy would have been safe at 1-year follow-up (FUP), as defined by the absence of need for PP, syncope and mortality.

Results

242 pts were included, 44,8% males, mean age 80,4 years, mean Euroscore II 5,4 and the majority implanted a self-expandable prosthesis (64,1%). Mean hospital stay after TAVI was 7,7 days. The most frequent CD after TAVI were: new onset left bundle brunch block (36%) and high degree atrioventricular block (HAVB) (16,3%). During hospital stay 21,6% needed PP, mainly because of HAVB (mainly implanted in the first 72h).

According to the proposed algorithm, 70,7% of our pts were ED-candidates. ED-candidates had lower prevalence of predilation (18,5% vs 36,8%, p=0,008) with no significant differences between type of prosthesis or baseline ECG. ED-candidates had smaller PR interval post-TAVI (184,5 vs 202,5 ms, p=0,044) and smaller PR and QRS at 72h (p<0,001 in both).

At 1-year FUP, only 2,3% of ED-candidates needed a PP (vs 37,7% non-ED, p<0,001). It is noteworthy that in those ED-candidates who needed a PP during FUP, the percentage of ventricular pacing was less than 2% at 6 months. In the FUP period, 3,2% of ED candidates presented at the ER because of syncope, with no significant differences to non-ED pts. No differences between groups were found in 30-days and 1-year ER presentation because of syncope or all-cause mortality.

Conclusions

According to the proposed algorithm for ED in pts with CD post-TAVI, pts with specific ECG characteristics and without rhythm events during continuous telemetry monitoring can be early discharged with long-term safety.

Funding Acknowledgement

Type of funding source: None
Clinical outcomes after surgical or transcatheter aortic valve replacement in patients with chronic kidney disease: an analysis in 29 893 patients from the German Aortic Valve Registry
Authors: Mas-Peiro S , Faerber G , Bauer T , Bleiziffer S , Bekeredjian R , Boening A , Frerker C , Beckmann A , Moellmann H , Vasa-Nicotera M , Ensminger S , Hamm C.W , Beyersdorf F , Walther T , Fichtlscherer S
Published: November 2020

Background

Chronic kidney disease (CKD) is a key risk factor in patients undergoing transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR).

Purpose

We analyzed the impact of eGFR and different stages of chronic kidney disease (CKD), on short- and mid-term survival in patients undergoing TAVI or SAVR.

Methods

Data from 29893 patients enrolled in the German Aortic Valve registry (GARY) from January 2011 to December 2015 receiving TAVI (n=12834) or SAVR (n=17059) at 88 sites were included. The impact of renal impairment, as measured by eGFR and CKD stages, was investigated. The primary endpoint was 1-year cumulative all-cause mortality. A propensity score method was used to compare TAVI vs. SAVR in patients with intermediate risk and mild-to-moderate renal disease being eligible for both therapies.

Results

Higher CKD stages were significantly associated to lower in-hospital, 30-day- and 1-year survival rates. Both TAVI- and SAVR-treated patients in CKD 3a, 3b, 4, and 5 stages showed significant and gradually increasing HR values for 1-year all-cause mortality. The same trend persisted in multivariable analysis, although HR values for CKD 3a and 5 did not reach significance in TAVI patients, whereas CKD 4+5 did not reach statistical significance in SAVR. Likewise, eGFR as a continuous variable was a significant predictor for 1-year mortality, with the best cut-off points being 47.4 mL/min/1.73 m2 for TAVI and 59.8 mL/min/1.73 m2 for SAVR. Significant 8.6% and 9.0% increases in 1-year mortality were observed for every 5-mL reduction in eGFR for TAVI and SAVR, respectively. No significant differences in survival were found between TAVI and SAVR in a matched group of intermediate-risk patients potentially eligible for both therapies (HR [(95% CI] for TAVI vs SAVR 1.24 [0.76, 2.02], p=0.240).

Conclusions

CKD≥3b and CKD≥3a is an independent major risk factor for mortality in patients undergoing TAVI and SAVR, respectively. In the overall population of patients with severe aortic stenosis, an appropriate stratification based on CKD substage may contribute to a better selection of patients suitable for such therapies. TAVI and SAVR appear to achieve similar survival rates in intermediate-risk patients with moderate-to-severe renal dysfunction.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Unrestricted grants by medical device companies (Edwards Lifesciences, JenaValve Technology, Medtronic, Sorin, St. Jude Medical, Symetis S.A.). Unrestricted support by funding statisticians by the DZHK (Deutsches Zentrum für Herz-Kreislaufforschung).
Next-day discharge after transcatheter aortic valve implantation
Authors: Gu Z.S , Bates-Powell J , Das R , Zaman A , Edwards R
Published: November 2020

Background

Transcatheter aortic valve implantation (TAVI) is being used increasingly in patients with severe symptomatic aortic stenosis. Few studies focused on hospital length of stay (LOS) and feasibility of next-day discharge.

Purpose

This study aims to evaluate the feasibility and factors associated with next-day discharge post TAVI, which can be used to help selecting suitable patients for a “fast-track” TAVI admission.

Methods

Data from all TAVI procedures conducted at our centre from January 2014 to March 2019 were collected in our local TAVI registry, and analysed retrospectively. Patients discharged within 1 day of TAVI (early discharge group) were compared with consecutive patients discharged after 24 h (late discharge group). Degree of frailty was assessed by the Canadian Study of Health and Aging (CSHA) frailty scale, and baseline functional status was assessed by Katz index of independence in activities of daily living.

Results

Of 502 patients, 274 (54.6%) were male, mean age 83.2±7.3 years, and 87 (17.7%) patients were considered frail by CSHA frailty scale. Median Katz index was 6 (i.e. functionally independent, interquartile range [IQR] 1), and mean logistic Euroscore 17.4±10.7. Percutaneous transfemoral access was performed in 468 (95.5%), and general anaesthesia was used in 64 (14.4%) patients. Early complications before discharge were comparable to national standards: death in 11 (2.3%), myocardial infarction (MI) in 1 (0.2%), permanent pacemaker (PPM) in 20 (4.3%), gastrointestinal bleed in 3 (0.6%), and tamponade in 5 (1.1%) patients. Median LOS post procedure was 2 (IQR 3), median length of total hospital stay was 3 (IQR 5). Early discharge was achieved in 213 (44.7%) patients. Multivariate logistic regression analysis showed that male gender (odds ratio [OR]: 2.81, 95% confidence interval [CI]: 1.68 to 4.7; p<0.001), baseline New York Heart Association (NYHA) class below III (OR: 2.04, 95% CI 1.19 to 3.51; p=0.01) were associated with early discharge after TAVI. Furthermore, advancing age (OR: 0.96, 95% CI 0.93–0.99; p=0.02), and presence of extensive ascending aorta calcification (OR: 0.38, 95% CI 0.16–0.88; p=0.025) were associated with less probability of early discharge (i.e. presence of these features were associated with delayed discharge).

Conclusions

Next-day discharge after TAVI can be achieved in nearly half of all patients. Male younger patients with minimal symptoms at baseline (NYHA < III), without feature of extensive ascending aorta calcification (porcelain aorta) are a potential suitable group to be considered for a “fast-track” next-day TAVI discharge.

Funding Acknowledgement

Type of funding source: None
Acute kidney injury after transcatheter aortic valve replacement: predictors and prognostic impact from a single, high-volume centre
Authors: De Marzo V , Crimi G , Gil Ad V , Benenati S , Pescetelli F , Della Bona R , Balbi M , Porto I
Published: November 2020

Background

Acute kidney injury (AKI) represents a common complication of transcatheter aortic valve replacement (TAVR), occurring in a variable proportion (from 10% to 30%) and being associated with an increased length of hospital stay and a 2- to 6-fold higher risk of mortality.

Purpose

We sought to identify pre-procedural and procedural variables independently associated with AKI and to analyze AKI impact on 1-month and 1-year all-cause mortality.

Methods

We prospectively collected consecutive patients undergoing TAVR at our centre. AKI was defined according to the Valve Academic Research Consortium (VARC)-2 criteria, as an increase of at least 0.3 mg/dL in serum creatinine or a urine output worsening (<0.5 mL/kg for <12 hours) occurring within 7 days after the procedure.

Results

From 664 consecutive TAVR conducted between January 2010 and December 2018 we excluded 19 (2.9%) patients for unsuccessful procedure according to VARC-2 criteria leading to a population of 645 patients.

The mean follow-up was 9.6±4.3 months, age was 83.2±5.3, 270 (41.9%) were men. AKI complicated TAVR procedure in 141 (21.9%) patients. All-cause mortality occurred in 14 (2.2%) at 1-month and 51 (7.9%) patients at 1-year.

AKI was more likely to complicate TAVR in patients who died within 1-month (4.7% vs. 0.8%, p=0.003) and 1-year (14.1% vs. 5.3%, p<0.001) follow-up period.

Multivariable regression analysis showed that baseline creatinine (OR: 1.46, 95% CI: 1.20–1.78, p<0.001) and VARC-2 bleeding complications (OR: 1.49, 95% CI: 1.04–2.12, p=0.029) were independently associated with AKI incidence, while non-significant covariates were: age, gender, contrast volume, use of self-expandable valve and peri-procedural rapid pacing.

Multivariable analysis adjusted for age and sex showed that AKI (HR: 3.02, 95% CI: 1.03–8.90, p=0.045) and chronic obstructive pulmonary disease (COPD) (HR: 4.12, 95% CI: 1.37–12.40, p=0.012) were independently associated with 1-month all-cause mortality. After 1 month, landmark analysis adjusted for age and sex showed that AKI (HR: 2.41, 95% CI: 1.17–4.96, p=0.017) and peri-procedural myocardial injury (HR: 2.36, 95% CI: 1.05–5.31, p=0.037) were independent predictors of 1-year all-cause mortality, while COPD, non-transfemoral route, and bleeding complications were not independently associated.

Conclusions

In a contemporary cohort of consecutive patients undergoing TAVR, AKI complicated ∼1 out of 5 procedures and is linked with about 4-fold adjusted risk of short-term death at 1-month and about 2-fold adjusted risk of subsequent death events up to 1-year follow-up. Baseline creatinine and bleeding complications, but not contrast volume were independently associated with AKI incidence.

Landmark analysis for 1-year mortality

Funding Acknowledgement

Type of funding source: None
Impact of intervention strategies after failed Mitraclip therapy on mid-term outcome
Authors: Alessandrini H , Geidel S , Wohlmuth P , Meincke F , Hakmi S , Gosau N , Ubben T , Kuck K.H , Willems S
Published: November 2020

Introduction

Procedural failure after MitraClip (MC) therapy has a decisive prognostic influence and Re-treatment after acute procedure failure (APF) remains complex due to the generally high-risk patients. The aim of this work is to analyze the mid-term outcome between the surgical and the percutaneous interventional treatment routes according to APF from our High Volume Center.

Methods

Retrospective analysis of patients (pts.) consecutively treated with MC in the period from 9/2009 - 5/2019 with residual mitral regurgitation (rMR) that is still higher in the case of symptomatic APF (NYHA 3–4). Outcome analysis in primary (PMR) and secondary MR (SMR) with subsequent percutaneous (group Reclip) vs. surgical treatment (group surgery).

Results

Of a total of 824 pts., 63 (73±10 years, 20 women [31,7%]) showed APF (MR>2) peri / postinterventionally. Mitraclip reintervention was performed in 36 pts. (26 SMR, 10 PMR), while 27 (13 SMR, 14 PMR) underwent surgery. Mitral valve replacement (MVR) was surgically performed on 21 pts. (11 PMR, 10 SMR), while reconstruction (MVrec) was performed on n=6 (3 PMR, 3 SMR). The mechanism of the rMR in the surgery group, n=14 (51.9%) was a pure sail injury (LT) or a partial clip detachment (PCD) or a combination of both, n=9 (33.3%) a severe rMI, n=3 (11.1%) device endocarditis and n=1 (3.7%) a technical device problem. In the reclip group n=15 (41.7%) showed an LT and / or a PCD and n=21 (58.3%) a severe rMR. Thirty-day mortality was 13.9% (n=5 deaths) in the ReClip-group (n=4 SMR, n=1 PMR) an 18.5% in the surgical group (n=5 deaths; all SMR patients). In the midterm FU over 18 months (Figure 1), the surgically treated patients with SMR showed a significantly higher mortality rate than in patients with PMR (p=0.002). In the Reclip intervention group, no significant difference between treated PMR and SMR patients can be objectified (p=0.995). The comparison between surgery / reclip in the PMR group shows no significance, whereas a trend (p=0.148) in favor of the reclip can be distinguished between surgery / reclip in SMR in the outcome.

Conclusion

Surgically treated patients after AFP with an SMR as index etiology show a very poor short and medium-term survival both in comparison to the PMR patients and to the two reclip groups. With the combination of AFP and SMR, the reclip treatment can be regarded as the primary treatment option despite the lack of statistical significance compared to surgery. In return, surgery combined with AFP and PMR offers a viable alternative and can be favored over the reclip procedure in younger patients.

Kaplan-Meier plot of the 4 intervention groups

Funding Acknowledgement

Type of funding source: None
Outcomes of transcatheter mitral valve repair from the latest nationwide inpatient sample database 2016–2017
Authors: Mehta H , Kurpad K , Okoh A , Singh S , Berman J , Hawthorne K
Published: November 2020

Background

Transcatheter mitral valve repair (TMVR) is an alternative treatment option for severe mitral regurgitation (severe MR) in patients with high surgical risk. Previous studies have demonstrated safety and efficacy of TMVR. The aim of our study was to assess comorbid and patient outcome data in a nationwide sample.

Methods

From the Nationwide Inpatient Sample (NIS) 2016–2017, all adult patients with mitral valve regurgitation were identified. Patients were divided into two group- TMVR and SMVR (surgical mitral valve repair). Patients requiring surgical valve replacement were excluded. Primary outcomes were inpatient mortality and length of stay. Multivariate analysis was performed to adjust for comorbidities.

Results

A total of 6211 TMVR were performed, while 3789 SMVR were performed. TMVR patients were older (78.34 vs 62.26 years) and had more females (48.86 vs 36.18%). Comorbidities were higher in the TMVR group [heart failure (81.02 vs 46.02%, p<0.001), diabetes mellitus (27.13 vs 15.81%, p<0.001), chronic kidney disease (39.3 vs 13.7%, p<0.001), chronic lung disease (27.13 vs 16.65%, p<0.001). Complications were higher in the SMVR [Cardiogenic shock (3.8 vs 6%, p=0.007), blood transfusion requirement (19.44 vs 4.85%, p=0.001), respiratory failure (10.99 vs 7.37, p=0.012)]. Mean length of stay was higher with SMVR [8.60±0.22 (4.139–5.17) days] compared to TMVR [4.65±0.26 (8.167–9.03) days]. In-patient mortality was lower in TMVR (2.01 vs 2.45%, p-0.02). After adjusting for comorbidities on multivariate analysis, there was no difference in mortality between the groups (adjusted OR=1.081±0.419 (0.506–2.311).

Conclusion

From nationwide data, we report TMVR as a relatively safe treatment modality for severe MR, with comparable inpatient mortality and fewer complications than SMVR, despite having a significantly higher burden of comorbidities.

Funding Acknowledgement

Type of funding source: None
Evaluation of bypass grafts after minimally invasive coronary artery bypass grafting according to the results of MSCT- angiography
Authors: Sichinava L , Payvin A , Denisiuk D , Snegirev M , Khvan N , Drozdova O
Published: November 2020

Background

Minithoracotomy avoids the complications specific to sternotomy access, which in turn creates the conditions for early activation and rehabilitation of patients, especially elderly, with diabetes mellitus, obesity, disorders of the musculo-skeletal system.

Purpose

To assess the patency of grafts after minimally invasive coronary artery bypass grafting (MICS CABG).

Methods

We analyzed the results of 50 MSCT- angiography made to patients with MICS CABG operated between 2014 and 2016 (28,5±13,5 months after surgery). Totally 132 conduits were used, 47 (35.6%) of them – arterial, 85 (64.4%) – venous. In all cases left internal mammary artery (LIMA) was used for revascularization of the left anterior descending artery (LAD). The great saphenous vein was used as a conduit for revascularization of: diagonal branch (DA) – 10 (11.7%) cases, left circumflex artery (LCx) – 44 (51.8%), right coronary artery (RCA) – 12 (14.1%), posterior interventricular branch – 19 (22.4%). Assessment of the patency of grafts were performed: 1–2 years (33 conduits: 13 arterial, 20 venous), after 2–3 years (51 conduits: 19 arterial, 32 venous) and after 3–4 years (48 conduits: 15 arterial, 33 venous).

Results

Assessment of coronary grafts patency in the first period revealed occlusion of 3 (15%) venous conduits. In 2 cases, the venous conduit was anastomosed with the LCx, in 1 case with the RCA. The cumulative patency of the grafts was as follows: arterial – 100%, venous – 85%. In the second point of the study occlusion and stenotic changes of LIMA has not been revealed. Determined occlusion 5 (15,6%) venous grafts. In all cases, the occluded venous conduits revascularized the RCA. Total permeability of conduits: arterial – 100%, venous-84.4%. In the third time interval it was revealed: in 1 case of LIMA occlusion and 7 venous grafts, in 4 cases in the area of the LCx, in 2 – DA and in 1 case – in the area of the RCA. Total patency of grafts: arterial – 93.3%, venous – 78.8%. Total permeability of conduits: arterial – 97.9%, venous – 82.4%.

Conclusion

The analysis shows good long–term results of the functioning of grafts after MICS CABG and their comparability with the results of patency of the conduits after CABG performed by the traditional

Funding Acknowledgement

Type of funding source: None
Comparison of clinical outcomes after transcarotid and transsubclavian versus transfemoral TAVI: a propensity-matched analysis
Authors: Villecourt A , Faroux L , Muneaux A , Tassan-Mangina S , Heroguelle V , Poncet A , Nazeyrollas P , Ruggieri V.G , Metz D
Published: November 2020

Transcarotid (TC) and transsubclavian (TSc) accesses are increasingly used as alternative approaches for TAVI when the transfemoral (TF) access is not suitable. However, concerns remain about the risk of peri-procedural stroke and long-term outcomes following TC or TSc TAVI.

The present study sought to compare early- and long-term outcomes of TC/TSc vs. TF TAVI after propensity-score matching.

260 patients who underwent TAVI through a TF (n=220), TC (n=32) or TSc (n=8) approach at our institution during a 4 years period were identified. A 1:1 matching based on the propensity-score was performed, leading to a population of 40 TF and 40 TC/TSc. Primary endpoints were early complications whereas secondary endpoints were long-term outcomes.

There was no difference in the baseline characteristics. At 30-day post-TAVI, there was no difference in mortality and stroke rates between TF and TC/TSc TAVI (5% vs. 5% mortality, p=1.0 and 2 vs. 1 stroke, p=1.0). After a median follow-up of 21 months, the risk of death (p=0.950), stroke (p=0.817) and myocardial infarction (p=0.155) did not differ between the 2 groups.

After propensity-score matching, no significant difference in early and long-term outcomes was observed between TF and TSc/TSc TAVI. These findings should encourage Heart-Teams to consider a TC or TSc approach when TF access is not available.

Table 1. 30-day and 1-year outcomes according to the arterial access (TF vs. TC/TSc) Variables TF-TAVI (n=40) TC/TSc-TAVI (n=40) p-value 30-day outcomes  All-cause mortality 2 (5.0) 2 (5.0) 1.000  All-stroke 2 (5.0) 1 (2.5) 1.000  Life-threatening bleeding 4 (10.0) 1 (2.5) 0.375  Acute kidney injury stage 2 or 3 2 (5.0) 1 (2.5) 1.000  Major vascular complication 6 (15.0) 6 (15.0) 1.000  Coronary obstruction 0 0 –  Early safety composite endpoint (VARC-2) 10 (25.0) 8 (20.0) 0.804 1-year outcomes  All-cause mortality 6 (15.0) 7 (17.5) 1.000  Cardiovascular mortality 5 (12.5) 3 (7.5) 0.727  Stroke 3 (7.5) 2 (5.0) 1.000  Myocardial infarction 0 (0) 2 (5) 0.500  MACCE 8 (20.0) 9 (22.5) 1.000  Readmission for heart failure 6 (15.0) 2 (5) 0.219

Figure 1

Funding Acknowledgement

Type of funding source: None
Are our patients waiting too long for cardiac surgery?
Authors: Menezes Fernandes R , Mota T.F , Bispo J.S , Costa H , Bento D , Marques N , Mimoso J , Jesus I
Published: November 2020

Introduction

Recommended pre-established waiting periods in patients referred for cardiac surgery aim to improve clinical outcomes.

Purpose

To determine the prognostic impact of the delay until cardiac surgery.

Methods

We conducted a retrospective study encompassing patients referred to cardiac surgery from a Cardiology Department, since January 2016 to December 2018. Clinical characteristics, diagnostic studies and follow-up were analysed. Primary endpoints were global mortality and re-hospitalization rates at follow-up. Independent predictors of clinical outcomes were identified through a binary logistic regression analysis, considering p=0,05.

Results

A total of 591 patients were included, with 71,1% male predominance and a mean age of 68,6±11,36 years old. 55,2% of patients had severe valvular disease (aortic – 38,6%, mitral – 9,6%, mixed valvular disease – 2,9%), and 37,1% had surgical coronary artery disease. The mean left ventricle ejection fraction was 56,1% ± 12,2% and the mean Euroscore II was 3,7%. 120 patients (20,3%) required more than one type of surgical intervention. 360 patients (60,9%) were referred to elective procedures, with a mean waiting time of 129,4 days and only 29,2% of them were operated in a 6-week period. The remaining 39,1% of patients needed urgent/emergent surgery, and the mean time until the intervention was 27,2 days (70,1% operated in 2-weeks). Mean waiting time was higher for valvular patients comparing with coronary patients (110,7 vs 48 days; p<0,001). 9,8% and 4,6% of patients were re-hospitalized or died while waiting for surgery, respectively. In a median follow-up of 520 days since the surgical referral, 25,5% of patients were re-hospitalized and 13,7% died. Waiting time was an independent predictor of global mortality (p=0,018), as well as arterial hypertension (p=0,002), severe valvular disease (p<0,001) and higher Euroscore II values (p=0,023). Waiting for surgery in an out-patient setting (p=0,011) and higher Euroscore II values (p=0,002) were independent predictors of re-hospitalization.

Conclusion

In our study, waiting time until surgery was an independent predictor of global mortality. Efforts should be made to enable referral surgical centres to timely respond to the needs of the population, considering the impact that delaying the appropriate treatment can have on the survival of these patients.

Funding Acknowledgement

Type of funding source: None
Renal sympathetic denervation improves heart rate variability and reduces arrhythmia burden
Authors: Plashchinskaya L , Goncharik D , Barsukevich V , Chasnoits A , Persidskikh Y , Rebeko E , Mrochek A
Published: November 2020

Background

Decreased heart rate variability (HRV) is a strong predictor of mortality (particularly sudden death), not only in high-risk patients. The impact of renal denervation (RDN) on HRV and cardiac arrhythmias has not yet been fully investigated.

Purpose

To assess the effect of RDN on HRV and cardiac arrhythmias in patients with blood pressure (BP) >160/100 mmHg despite 3 full-dose antihypertensive drugs.

Methods

The study included 108 patients (46.3% male) with resistant hypertension (RH), the average age was 50.5±9.0. All patients underwent RDN. Procedure was performed by an experienced electrophysiologist at the renal arteries using specialized electrode Symplicity Flex: ablation power = 8–10 W at 55°C, 4–10 points for each renal artery (including brunch, when was appropriate), 2 minutes per point. Office systolic BP (SBP) and diastolic BP (DBP), 24-hour ambulatory BP monitoring and 24-hour monitoring ECG were measured before, at 6 and 12 months of follow-up.

Results

Baseline SBP and DBP in these groups of patients were −185.6±29 and −110.5±19.3 mm Hg respectively. Office BP significantly decreased by −28.2±21.6 /18.0±16.7 mm Hg (p<0.001 for both) at 12 month. 24-hour SBP and DBP was significantly reduced both at 6 and 12 months after RDN. Twenty-four-hour BP was reduced by 13.2/8.4mmHg (P<0.001). The number and dosage of antihypertensive drugs remained unchanged in all patients. Baseline data of general HRV in this group of patients were low: SDNN – 123.4±41.4 msec. The general HRV increased at 12 month since RDN: SDNN from 123.4±41.4 msec to 155.8±51.4 msec (p<0.05), SDANN-i from 105.3±42.7 msec to 122.1±41.1 msec (p<0.05). There was observed increase in RMSSD, reflecting of parasympathetic activity of autonomic nervous system – from 29.7±43.6 msec to 41.1±33.2 msec (p<0.05). The total number of premature supraventricular and ventricular contractions was also significantly decreased both at 6 and at 12 months after RDN (p<0.05 for both cases). Mean 24-hour monitoring heart rate was reduced by 5.8 bpm (p=0.02) at 12 month after RDN. No pauses or conduction abnormalities were observed either at baseline or after RDN.

Conclusions

Besides the important effect of RDN on heart rate and arrhythmic events, a significant improvement the time domain indexes of HRV was evident in patients with resistant hypertension at 12 month after the RDN-procedure. Our prospective single center study shows that RDN results in substantial BP lowering, significant reduction of mean heart rate and arrhythmia burden and restores autonomic balance in patients with resistant uncontrolled hypertension.

Funding Acknowledgement

Type of funding source: None