Atrial Fibrillation Management During Surgical vs Transcatheter Aortic Valve Replacement.

BACKGROUND: Societal guidelines support atrial fibrillation (AF) treatment during surgical aortic valve replacement (SAVR). Recently, many patients with AF at low to intermediate risk are managed by transcatheter aortic valve replacement (TAVR). Therefore, we evaluated longitudinal outcomes in these populations. METHODS: The United States Centers for Medicare and Medicaid Services inpatient claims database was evaluated for all beneficiaries with AF undergoing TAVR or SAVR with/without AF treatment (2018-2020). Treatment of AF included concomitant left atrial appendage obliteration, with/without surgical ablation, or endovascular appendage occlusion and/or catheter ablation at any time. Diagnosis-related group and International Classification of Diseases, 10th Revision, codes defined procedures with doubly robust risk adjustment across each group. RESULTS: A total of 24,902 patients were evaluated (17,453 TAVR; 7,449 SAVR). Of patients undergoing SAVR, 3176 (42.6%) underwent AF treatment (SAVR+AF). Only 656 TAVR patients (4.5%) received AF treatment. Comparing well-balanced SAVR+AF vs SAVR vs TAVR, there were no differences in the in-hospital incidence of renal failure, bleeding, or stroke, but increased pacemaker requirement (odds ratio [OR], 3.45; P < .0001) and vascular injury (OR, 9.09; P < .0001) were noted in TAVR and higher hospital mortality (OR, 4.02; P < .0001) in SAVR+AF. SAVR+AF was associated with lower readmission for stroke compared with SAVR alone (hazard ratio [HR], 0.87; P = .029) and TAVR (HR, 0.68; P < .0001) and with improved survival vs TAVR (HR, 0.79; P = .019). CONCLUSIONS: In Medicare beneficiaries with AF requiring aortic valve replacement, SAVR+AF was associated with improved longitudinal survival and freedom from stroke compared with TAVR. SAVR+AF treatment should be considered first-line therapy for patients with AF requiring aortic valve replacement.

Surgical versus transcatheter aortic valve replacement in low-risk Medicare beneficiaries.

OBJECTIVE: Recent approval of transcatheter aortic valve replacement (TAVR) in patients at low surgical risk has resulted in a rapid real-world expansion of TAVR in patients not otherwise examined in recent low-risk trials. We sought to evaluate the outcomes of surgical aortic valve replacement (SAVR) versus TAVR in low-risk Medicare beneficiaries. METHODS: Using the US Centers for Medicare and Medicaid Services claims database, we evaluated all beneficiaries undergoing isolated SAVR (n = 33,210) or TAVR (n = 77,885) (2018-2020). International Classification of Diseases 10th revision codes were used to define variables and frailty was defined by the validated Kim index. Doubly robust risk adjustment was performed with inverse probability weighting and multilevel regression models, as well as competing-risk time to event analysis. A low-risk cohort was identified to simulate recent low-risk trials. RESULTS: A total of 15,749 low-risk patients (8144 SAVR and 7605 TAVR) were identified. Comparison was performed with doubly robust risk adjustment accounting for all factors. TAVR was associated with lower perioperative stroke (odds ratio, 0.62; P < .001) and hospital mortality (odds ratio, 0.16; P < .001) compared with SAVR. However, risk-adjusted longitudinal analysis demonstrated TAVR was associated with higher late risk of stroke (hazard ratio, 1.65; P < .001), readmission for valve reintervention (hazard ratio, 1.88; P < .001), and all-cause mortality (hazard ratio, 1.54; P < .001) compared with SAVR. CONCLUSIONS: Among low-risk Medicare beneficiaries younger than age 75 years undergoing isolated AVR, SAVR was associated with higher index morbidity and mortality but improved 3-year risk-adjusted stroke, valve reintervention, and survival compared with TAVR.

Multimodality assessment of high- vs. low-gradient aortic stenosis using echocardiography and cardiac CT.

BACKGROUND: Aortic valve area (AVA) using CT-LVOT area (AVACT-LVOT) <1.2 â€‹cm2 has been shown comparable to echocardiography AVA of <1.0 â€‹cm2 for severe aortic stenosis (AS). Current study evaluates how AS diagnosis will be affected when we substitute CT-LVOT with echo derived LVOT. METHODS: We retrospectively studied 367 patients who underwent cardiac CTA and echocardiogram for assessment of high- and low-gradient AS (HG-AS and LG-AS). AVACT-LVOT was derived from CT-LVOT area and echo doppler data. Three AVACT-LVOT categories were created (<1.0, 1.0-1.2 and â€‹> â€‹1.2 â€‹cm2). Outcomes were defined as composite of all-cause mortality and/or valve intervention. RESULTS: Median echocardiographic profiles were consistent with severe AS across three AVACT-LVOT categories for HG-AS. HG-AS patients with AVACT-LVOT >1.2 â€‹cm2 had larger median CT-LVOT area (5.06 â€‹cm2) and AVC (2917AU). Among LG-AS with AVACT-LVOT â€‹≤1.2 cm2, 57% met echo criteria for low-flow LG-AS and 63% met criteria for severe AS using aortic valve calcium (AVC). Additionally, 45% with AVACT-LVOT >1.2 â€‹cm2 had larger median CT-LVOT area (5.43 â€‹cm2) and AVC (2389AU). Patients with AVACT-LVOT >1.2 â€‹cm2 and high AVC had large body surface area and were mostly characterized as severe with indexed AVA and AVC. Stroke volume index using CT-LVOT reclassified 70% of low-flow, LG-AS as normal flow, LG-AS. Composite outcomes were higher among patients with AVACT-LVOT ≤1.2 â€‹cm2 (p â€‹< â€‹0.01), however, with no superior net reclassification improvement compared to AVAecho <1.0 â€‹cm2. CONCLUSION: AVACT-LVOT ≤1.2 â€‹cm2 is a reasonable CT criterion for severe AS. Large LVOT with elevated AVC identified a severe AS phenotype despite an AVACT-LVOT >1.2 â€‹cm2, best characterized by indexed AVA and AVC.

Contemporary Coronary Artery Bypass Grafting vs Multivessel Percutaneous Coronary Intervention.

BACKGROUND: Interpretation of recent alterations to the guideline priority of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for multivessel disease contests historical data and practice. To reevaluate contemporary outcomes, a large contemporary analysis was conducted comparing CABG with multivessel PCI among Medicare beneficiaries. METHODS: The United States Centers for Medicare and Medicaid Services database was evaluated all beneficiaries with acute coronary syndrome undergoing isolated CABG or multivessel PCI (2018-2020). Risk adjustment was performed using multilevel regression analysis, Cox proportional hazards time to event models, and inverse probability of treatment weighting propensity scores. RESULTS: A total of 104,127 beneficiaries were identified undergoing CABG (n = 51,389) or multivessel PCI (n = 52,738). Before risk adjustment, compared with PCI, CABG patients were associated with younger age (72.9 vs 75.2 years, P < .001), higher Elixhauser Comorbidity Index (5.0 vs 4.2, P < .001), more diabetes (48.5% vs 42.2%, P < .001), higher cost ($54,154 vs $33,484, P < .001), and longer length of stay (11.9 vs 5.8 days, P < .001). After inverse probability of treatment weighting propensity score adjustment, compared with PCI, CABG was associated with lower hospital mortality (odds ratio, 0.74; P < .001), fewer hospital readmissions at 3 years (odds ratio, 0.85; P < .001), fewer coronary reinterventions (hazard ratio, 0.37; P < .001), and improved 3-year survival (hazard ratio, 0.51; P < .001). CONCLUSIONS: Contemporary real-world data from Medicare patients with multivessel disease reveal that CABG outcomes were superior to PCI, providing important longitudinal data to guide patient care and policy development.

Cardiac Computed Tomography Angiography for Device-Related Thrombus Assessment After WATCHMAN FLX™ Occluder Device Implantation: A Single-Center Retrospective Observational Study.

BACKGROUND/PURPOSE: Device-related thrombosis (DRT) is one of the greatest challenges of transcatheter left atrial appendage device occlusion. Due to the invasive nature of transesophageal echocardiography (TEE), cardiac computed tomography angiography (CCTA) is being increasingly utilized in several centers for assessing adequate left atrial appendage closure and monitoring for DRT. There is a paucity of data regarding the standardized definition of DRT on CCTA for the WATCHMAN FLX™ device. METHODS/MATERIALS: A retrospective review was conducted on 43 patients receiving WATCHMAN FLX™ device implantation with CCTA performed at the first follow-up at our institution. A comparative review of DRT predictors was performed on 10 patients who had both CCTA and TEE at the time of follow-up. RESULTS: Hypoattenuated thickening (HAT) was a common finding on CCTA and was noted to be present in 95.35% of the patients. The combination of a large device size, peridevice gap >4 mm, and HAT located on the device gutter and 1 shoulder were characteristics present on CCTA observed in 2 patients with confirmed DRT on TEE. CONCLUSION: CCTA is a noninvasive imaging modality for DRT monitoring, with guidelines still in development. We report potential predictors of DRT on CCTA. Additional studies are needed to further determine standardized parameters for DRT detection on CCTA and the significance of HAT with multimodality correlation.