Elevated systolic pulmonary artery pressure is a substantial predictor of increased mortality after transcatheter aortic valve replacement in males, not in females.

BACKGROUND: While pulmonary hypertension (PH) in patients with severe aortic valve stenosis (AS) is associated with increased mortality after transcatheter aortic valve replacement (TAVR), there is limited data on gender differences in the effects on long-term survival. OBJECTIVE: The aim of this retrospective, multicenter study was to investigate the prognostic impact of pre-interventional PH on survival of TAVR patients with respect to gender. METHODS: 303 patients undergoing TAVR underwent echocardiography to detect PH prior to TAVR via measurement of systolic pulmonary artery pressure (sPAP). Different cut-off values were set for the presence of PH. The primary endpoint was all-cause mortality at 1, 3 and 5 years. RESULTS: Kaplan-Meier analysis by gender showed that only males exhibited significant increased mortality at elevated sPAP values during the entire follow-up period of 5 years (sPAP ≥ 40 mmHg: p ≤ 0.001 and sPAP ≥ 50 mmHg: p ≤ 0.001 in 1- to 5-year survival), whereas high sPAP values had no effect on survival in females. In Cox regression analysis based on the selected sPAP thresholds, male gender was an independent risk factor for long-term mortality after TAVR in all time courses. CONCLUSION: Male gender was an isolated risk factor for premature death after TAVR in patients with echocardiographic evidence of PH and severe AS. This could mean that, the indication for TAVR should be discussed more critically in men with severe AS and an elevated sPAP, while in females, PH should not be an exclusion criterion for TAVR.

Emerging trends in cardiovascular research: HFpEF in the spotlight. A bibliometric analysis of the years 2009-2016.

INTRODUCTION: Up to 50% of patients suffering from acute decompensated heart failure show normal or slightly reduced left ventricular ejection fraction (LVEF). This syndrome, which is known as heart failure with preserved ejection fraction (HFpEF) is associated with increasing age. Epidemiological studies could portrait an increasing importance and an even emerging prevalence in the past decades. Still, there is currently no evidenced based medical treatment option available. Our aims were to identify upcoming trends and emerging concepts and to point out important centers in the global research of HFpEF. EVIDENCE ACQUISITION: We performed a bibliometric study on current science in the field of HFpEF to identify study characteristics, impact factors and the countries of origin of basic and clinical studies that were published within the years 2009 to 2016. We further prepared density equalizing maps for visualization of the obtained data. EVIDENCE SYNTHESIS: A total of 5413 studies was screened, of which 794 were found eligible. The scientific output in clinical studies rose from 25 in 2009 to 165 in 2016. Most of the publications had a clinical topic, followed by studies on new imaging techniques. Basic research trials were by far beyond. The USA, Japan and Germany were identified as the most important national contributors to global scientific output. CONCLUSIONS: This first bibliometric study in the field of HFpEF shows a substantial increase of research within the last decade, mainly in the USA, Japan, and continental Europe. As an ongoing therapeutic trend in this field, we identified RAAS-blockade and 5-phosphodiesterase-inhibition.

Transcatheter aortic valve implantation without prior balloon valvuloplasty is associated with less pronounced markers of myocardial injury.

BACKGROUND: Aortic valve stenosis is the most common valvulopathy in developed countries. Transcatheter aortic valve implantation (TAVI) is a therapeutic alternative in symptomatic patients at high or prohibitive perioperative risk. Predilatation by balloon aortic valvuloplasty (BAV) under rapid ventricular pacing (RVP) has been a routine part of TAVI. However, both RVP and BAV carry substantial risks and an increasing number of interventional centers are performing TAVI without predilatation (direct TAVI). A transient decrease of left ventricular function and elevated markers of myocardial injury after TAVI with predilatation were observed in previous studies. In this study, we investigated whether direct TAVI was associated with a similar increase in cardiac biomarkers and decrease in ejection fraction in a cohort of our patients. METHODS: Consecutive patients undergoing TAVI without predilatation using a self-expanding system at a single center between April 2013 and December 2015 were followed up for one year and were retrospectively analyzed regarding mortality, safety and efficacy endpoints as well as common laboratory and echocardiographic parameters. RESULTS: A total of 164 patients (83±6 years; 56% female) were included in the analysis. According to the Valve Academic Research Consortium 2 (VARC-2) criteria the technical success rate was 96.3% and 89.1% of patients remained free of a combined safety endpoint at 30 days. Mortality rates at 30 days and 1 year were 3.0% (N.=5) and 10.4% (N.=17), respectively. TAVI without predilatation was highly effective in lowering aortic valve peak velocity from 4.4±0.6 m/s before to 1.7±0.5 m/s (P<0.01), and mean pressure gradient across the valve from 48.7±15.1 mmHg to 8.3±4.5 mmHg (<0.05). Left ventricular function remained unaltered after the intervention (51±10% prior to TAVI and 51±9% post TAVI), whereas high sensitive troponin T (hs-TnT), a well-established marker for myocardial injury, increased significantly from 26 ng/L (interquartile range=18.00-44.00) to 119 ng/L (interquartile range=73.25-166.00, P<0.001) during this time. Notably, an increase in the plasma levels of hs-TnT >15 times the upper limit of normal was associated with mortality both one month and one year after TAVI. CONCLUSIONS: TAVI without predilatation is feasible, safe and effective for aortic valve replacement in symptomatic patients with severe aortic stenosis who are at high perioperative risk. In contrast to a cohort of patients who underwent TAVI with predilatation previously published by another center, our patients did not suffer from transient impairment of left ventricular function. As a marker of myocardial injury, hs-TnT showed a less pronounced increase than reported previously. This might be a marker for a prognostic benefit as hs-TnT has been shown to be a strong predictor of outcome in patients undergoing TAVI. We conclude that direct TAVI is a less invasive option involving less myocardial stress.

In-Hospital Outcome Comparing Bivalirudin to Heparin in Real-World Primary Percutaneous Coronary Intervention.

Randomized controlled trials have shown conflicting results regarding the outcome of bivalirudin in primary percutaneous coronary intervention (PPCI). The aim of this study was to evaluate the in-hospital outcomes of patients receiving heparin or bivalirudin in a real-world setting of PPCI: 7,023 consecutive patients enrolled in the Austrian Acute PCI Registry were included between January 2010 and December 2014. Patients were classified according to the peri-interventional anticoagulation regimen receiving heparin (n = 6430) or bivalirudin (n = 593) with or without GpIIb/IIIa inhibitors (GPIs). In-hospital mortality (odds ratio [OR] 1.13, 95% confidence interval [CI] 0.57 to 2.25, p = 0.72), major adverse cardiovascular events (OR 1.18, 95% CI 0.65 to 2.14, p = 0.59), net adverse clinical events (OR 1.01, 95% CI 0.57 to 1.77, p = 0.99), and TIMI non-coronary artery bypass graft-related major bleeding (OR 0.41, 95% CI 0.09 to 1.86, p = 0.25) were not significantly different between the groups. However, we detected potential effect modifications of anticoagulants on mortality by GPIs (OR 0.12, 95% CI 0.01 to 1.07, p = 0.06) and access site (OR 0.25, 95% CI 0.06 to 1.03, p = 0.06) favoring bivalirudin in femoral access. In conclusion, this large real-world cohort of PPCI, heparin-based anticoagulation showed similar results of short-term mortality compared with bivalirudin. We observed a potential effect modification by additional GPI use and access favoring bivalirudin over heparin in femoral, but not radial, access.