Functional status and quality of life after transcatheter aortic valve replacement: a systematic review.

BACKGROUND: The functional and quality-of-life benefits of transcatheter aortic valve replacement (TAVR) have not been established. PURPOSE: To evaluate the changes in functional status and quality of life after TAVR. DATA SOURCES: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from 1 January 2002 to 30 September 2013. STUDY SELECTION: Studies of TAVR that reported the New York Heart Association (NYHA) class, Short Form-12/36 Health Survey physical and mental component summary (points), or other measures of functional status. DATA EXTRACTION: Two reviewers independently extracted the mean change (follow-up minus baseline) in primary outcomes. Because of substantial heterogeneity, data were not pooled; the range of mean change was summarized. DATA SYNTHESIS: We identified 60 observational studies (56 pre­post comparison and 4 head-to-head comparative studies) and 2 randomized, controlled trials (11 205 patients). Most studies showed a clinically important decrease in NYHA class at 6 to 11 months (range, -0.8 to -2.1 classes) and 12 to 23 months (range, -0.8 to -2.1 classes). The improvement in the Short Form-12/36 Health Survey physical component score was clinically important over 12 months (range, 4.9 to 26.9 points), and the change in mental component score was smaller (range, 1.0 to 8.9 points).Clinically important improvements were seen in other disease-specific measures but were less consistently seen in general health measures. LIMITATIONS: Comparative evidence is limited by few head-to-head studies. Survivor bias may have overestimated the benefits. CONCLUSION: Transcatheter aortic valve replacement provides clinically important benefits in physical function and disease-specific measures of quality of life but modest benefits in psychological and general health measures. More comparative studies on functional status and quality of life are needed for informed treatment decision making.

Inappropriate ICD shocks caused by T-wave oversensing due to acute alcohol intoxication.

T-wave oversensing can be a serious problem that often results in inappropriate device therapy. We report here a patient with binge alcohol use who received multiple, inappropriate ICD shocks due to T-wave oversensing from repolarization changes induced by acute alcohol intoxication and no other relevant metabolic derangements. Following recovery from his alcohol intoxication a few days later, the T-wave amplitude decreased so the device no longer inappropriately sensed or delivered therapies. This case represents an uncommon, but reversible, cause of T-wave oversensing that should be considered before more aggressive measures are taken to correct the abnormality.

Ascending and descending thoracic aorta calcification in type 2 diabetes mellitus.

BACKGROUND: Calcification of the thoracic aorta is a risk factor for cardiovascular disease and peripheral arterial disease but has not been well studied in diabetics. In addition, many studies consider aortic calcium as a single anatomic entity, whereas calcification of the ascending and descending portions of the thoracic aorta may represent separate phenotypes. We sought to characterize the prevalence of ascending and descending aortic calcium among diabetics and to assess their associations with cardiovascular risk factors, coronary artery calcium, and peripheral arterial disease. METHODS: Within the Penn Diabetes Heart Study, a cross-sectional study of subjects with type 2 diabetes mellitus but without coronary or renal disease, we quantified Agatston scores of the ascending and descending thoracic aorta in 1739 subjects (63% male, 61% Caucasian). Multivariate logistic and Tobit regressions were used to assess associations with cardiovascular risk factors, coronary calcium, and peripheral arterial disease. RESULTS: Of all subjects, 54% had thoracic aortic calcium; of these, 37% had calcium solely in the ascending thoracic aorta and 20% solely in the descending thoracic aorta. In multivariate regression, age, Caucasian race, systolic blood pressure, low-density lipoprotein cholesterol, smoking, and diabetes duration were independently associated with calcium of both the ascending and descending thoracic aorta (P < .001 for all). Ascending and descending aortic calcium were each independently associated with coronary calcium in multivariate regression, but only calcification of the descending thoracic aortic was associated with low ankle-brachial index. CONCLUSION: Ascending and descending thoracic aortic calcium have similar associations with traditional cardiovascular risk factors in diabetics and are independently associated with coronary artery calcium. Only calcium in the descending aorta is associated with peripheral arterial disease. Delineation of both phenotypes may provide information about the individualized vascular disease and risk profile of patients with type 2 diabetes mellitus.

Cardiovascular risk factors and mitral annular calcification in type 2 diabetes.

OBJECTIVE: Mitral annular calcification (MAC) is a degenerative process of the mitral annulus associated with cardiac disease and stroke. Although thought to be more prevalent in type 2 diabetes (T2DM), MAC remains poorly characterized in this population, due to confounding by renal and cardiac disease. Our goal was to study the risk factors for MAC in a sample of T2DM subjects without renal and cardiac disease. METHODS: The Penn Diabetes Heart Study (PDHS) is a cross-sectional study of diabetic individuals without clinical cardiovascular or renal disease. We quantified and analyzed MAC Agatston scores in baseline cardiac CTs from 1753 individuals. Logistic and tobit regression were used to assess MAC's relationship with risk factors and coronary artery calcium (CAC). RESULTS: MAC was present in 12.0% of subjects, with a median Agatston score of 72.3 [Interquartile range (22.2-256.9)]. Older age, female gender, Caucasian race, and longer diabetes duration were independently associated with both the presence and extent MAC even after controlling for CAC; however, hypertension, hyperlipidemia, tobacco use, CRP levels, and other comorbidities were not associated. CAC was strongly associated with MAC [OR of 4.0 (95% CI 2.4-6.6)] in multivariable models. CONCLUSIONS: Age, female gender, Caucasian race, and diabetes duration were associated with the presence and extent of MAC in T2DM subjects, independent of CAC, which was also strongly associated with MAC. These data suggest that additional mechanisms for MAC formation in diabetics may exist which are distinct from those related to generalized atherosclerosis and deserve further investigation.