Periprocedural Myocardial Injury and Coronary Artery Disease in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND/PURPOSE: PPMI and CAD are common in patients undergoing TAVR. Despite several studies evaluating their interaction as well as the influence these factors play on outcomes, there remains no consensus. We sought to evaluate the impact of peri-procedural myocardial injury (PPMI) and incidental coronary artery disease (iCAD) on outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS/MATERIALS: We analyzed prospective data from 400 patients undergoing TAVI for severe aortic stenosis between 2008 and 2018 to determine rates of PPMI (troponin 15× the upper limit of normal) and iCAD (≥50% stenosis) and their impact on long-term mortality. RESULTS: Mean age was 83 ± 6 years; 45% were female. PPMI was observed in 65% (254/400). On multivariable logistic regression analysis, higher left ventricular ejection fraction (LVEF) (OR 1.04, 95%CI 1.01-1.06, p = 0.002), and first generation valves (OR 3.00, 95%CI 1.75-5.15, p < 0.001) were independently associated with PPMI, while oral anticoagulation was inversely associated (OR 0.48, 95%CI 0.28-0.82, p = 0.007). PPMI was not associated with 30-day, 1-year or long-term mortality. After excluding previous bypass grafting, iCAD was observed in 40% (129/324). In patients with iCAD, PCI was associated with reduced long-term mortality compared to medical management in adjusted analysis (OR 0.37, 95%CI 0.16-0.88, p = 0.03). CONCLUSIONS: PPMI and iCAD in patients undergoing TAVR are common. PPMI is associated with older generation valves and higher LVEF rather than traditional cardiovascular risk factors. In our study, PPMI was not associated with long-term mortality. However, in patients with iCAD, PCI was associated with reduced long-term mortality compared to medical management.

Impact of Gender on Transcatheter Aortic Valve Implantation Outcomes.

Previous studies indicate that women who underwentwho underwent transcatheter aortic valve implantation (TAVI) have poorer 30-day outcomes compared with men. However, the effect of gender as a prognostic factor for long-term outcomes following TAVI remains unclear. Between 2008 and 2018, all patients (n = 683) who underwent TAVI in 2 centres in Melbourne, Australia were prospectively included in a registry. The primary end-point was long-term mortality. The secondary end points were Valve Academic Research Consortium-2 (VARC-2) in-hospital complications and mortality at 30-days and 1-year. Of 683 patients, 328 (48%) were women. Women had a higher mean STS-PROM score (5.2 ± 3.1 vs 4.6 ± 3.5, p < 0.001) but less co-morbidities than men. Women had a significantly higher in-hospital bleeding rates (3.3% vs 1.0%, Odds Ratio 4.21, 95% confidence interval [CI] 1.16 to15.25, p = 0.027) and higher 30-day mortality (2.4% vs 0.3%, hazard ratio [HR] 8.75, 95% CI 1.09 to 69.6, p = 0.040) than men. Other VARC-2 outcomes were similar between genders. Overall mortality rate was 36% (246) over a median follow up of 2.7 (interquartile rang [IQR] 1.7 to 4.2) years. Median time to death was 5.3 (95% CI 4.7 to 5.7) years. One-year mortality was similar between genders (8.3% vs 7.8%), as was long-term mortality (HR = 0.91, 95% CI 0.71 to 1.17, p = 0.38). On multivariable analysis, female gender was an independent predictor for 1-year mortality (HR = 2.33, 95% CI 1.11 to 4.92, p = 0.026), but not long-term mortality (HR = 0.78, 95% CI 0.54 to 1.14, p = 0.20). In the women only cohort, STS-PROM was the only independent predictor of long-term mortality (HR 1.88, 95% CI 1.42 to 2.48, p < 0.001). In conclusion, women had higher rates of peri-procedural major bleeding and 30-day mortality following TAVI. However, long-term outcomes were similar between genders.

Five-Meter Walk Test as a Predictor of Prolonged Index Hospitalization After Transcatheter Aortic Valve Implantation.

There are no studies evaluating comprehensive predictors of transcatheter aortic valve implantation (TAVI) outcomes encompassing frailty assessments in a South-East Asian cohort. In this longitudinal single-center cohort, all patients who underwent TAVI in a tertiary cardiac center and comprehensively assessed for frailty at baseline were included in a registry. The primary outcome was to investigate frailty indices predictive of prolonged index hospitalization after TAVI. Seventy-six patients with a mean age of 77.6 ± 8.5 years were included. Mean Society of Thoracic Society Predicted Risk of Mortality score was 5.2 ± 3.0, with 11 (14.5%) patients classified as high-risk (Society of Thoracic Society Predicted Risk of Mortality >8). Mean and median index hospitalization duration were 9.2 ± 5.6 and 7 [4.5 to 9.5] days, respectively. Univariate analysis demonstrated that lower hemoglobin (Hb) (p <0.01), longer 5-meter walk test (5MWT) (p <0.01), lower dominant hand grip strength (p <0.01), the use of transaortic access (p = 0.01), new atrial fibrillation post-TAVI (p <0.01), and lower postprocedural Hb (p <0.01) were associated with longer index hospitalization duration. Multivariate linear regression demonstrated preoperative Hb, preoperative atrial fibrillation and 5MWT were independent baseline predictors of index hospitalization duration (p <0.05). Additionally, a 5MWT cutoff of 11 seconds (0.45 m/s) had a high specificity (88.6%) in predicting prolonged index hospitalization duration. In conclusion, this is the first comprehensive frailty assessment in a South-East Asian cohort demonstrating 5MWT to be a significant predictor of prolonged index hospitalization. This simple and effective frailty assessment index may be considered to optimize patient selection for TAVI.

The Natural history of Epicardial Adipose Tissue Volume and Attenuation: A long-term prospective cohort follow-up study.

Epicardial adipose tissue (EAT) is associated with cardiovascular risk. The longitudinal change in EAT volume (EATv) and density (EATd), and potential modulators of these parameters, has not been described. We prospectively recruited 90 patients with non-obstructive coronary atherosclerosis on baseline computed tomography coronary angiography (CTCA) performed for suspected coronary artery disease to undergo a repeat research CTCA. EATv in millilitres (mL) and EATd in Hounsfield units (HU) were analysed and multivariable regression analysis controlling for traditional cardiovascular risk factors (CVRF) performed to assess for any predictors of change. Secondary analysis was performed based on statin therapy. The median duration between CTCA was 4.3years. Mean EATv increased at follow-up (72 ± 33 mL to 89 ± 43 mL, p < 0.001) and mean EATd decreased (baseline -76 ± 6 HU vs. -86 ± 5 HU, p < 0.001). There were no associations between baseline variables of body mass index, age, sex, hypertension, hyperlipidaemia, diabetes or smoking on change in EATv or EATd. No difference in baseline, follow-up or delta EATv or EATd was seen in patients with (60%) or without baseline statin therapy. In this select group of patients, EATv consistently increased and EATd consistently decreased at long-term follow-up and these changes were independent of CVRF, age and statin use. Together with the knowledge of strong associations between EAT and cardiac disease, these findings may suggest that EAT is an independent parameter rather than a surrogate for cardiovascular risk.

Comparison of Outcomes of Transcatheter Aortic Valve Implantation in Patients Aged >90 Years Versus <90 Years.

Limited data exist regarding transcatheter aortic valve implantation (TAVI) in nonagenarians. This study evaluates the short- and mid-term outcomes of nonagenarians after TAVI. Between 2008 and 2017, all patients who underwent TAVI in 2 centers in Australia were prospectively included in a registry and followed-up for 5 years. Outcomes were based on VARC-2 criteria. Additionally, the patient's reliance on daily living support at 1 year was evaluated. Of the 588 patients, 71 (12.1%) were ≥90 years old (mean age 92.2 ± 2 vs 83.2 ± 6 years in <90-year-old patients), with a median STS-PROM score of 5.7 (vs 3.9 in <90-year-old patients, odds ratio [OR] 1.07, 95% confidence interval 1.01 to 1.13, p = 0.02) and a median clinical frailty score of 4 (vs 4 <90-year-old patients, OR 0.88, p = 0.44). Mortality was 0% in ≥90-year-old patients at 30 days (vs 1.4% in <90-year-old patients; p = 0.82) and 12% at 1 year (vs 7.4%, in <90-year-old patients; hazard ratio 1.64, p = 0.20). There were no significant differences in periprocedural complications and mortality at 5 years between the 2 groups. At 1 year, nonagenarians were significantly more likely to live in an aged-care facility compared with <90-year-old patients (25% vs 16%, OR 5.99, 95% confidence interval 2.62 to 13.67, p <0.001). In conclusion, carefully selected nonagenarians have excellent short- and mid-term outcomes post-TAVI and should therefore not be refused based on age alone. Nevertheless, the significantly higher rate of transfer to an aged-care facility highlights the importance of a more refined frailty assessment before TAVI than the currently widely used clinical frailty score.

Opioids and ST Elevation Myocardial Infarction: A Systematic Review.

BACKGROUND: Traditionally, opioids have been the analgesia of choice for patients with ST-Elevation Myocardial Infarction (STEMI). Recent studies, however, have raised the possibility of harmful effects of opioid administration through delayed onset of antiplatelet agents. OBJECTIVE: To perform a systematic review of the effects of parenteral opioids in patients presenting with STEMI. METHODS: Medical databases were systematically searched to 28 February 2018. Randomised control trials (RCTs) and observational studies were included if they interrogated the effects of parenteral opioids as compared to no opioid administration in STEMI patients. Outcomes included in-hospital, 30-day, one-year major adverse cardiac events (MACE) and platelet reactivity measures. The studies were evaluated using GRADE (Grade of Recommendation, Assessment, Development and Evaluation). RESULTS: One (1) RCT and 17 non-randomised, non-controlled observational studies were identified. The only RCT was of high quality, but only evaluated the pharmacokinetics of STEMI patients and had a small sample size. The remaining studies were of low-moderate quality, mainly due to eligibility criteria and confounding. Most studies report higher platelet reactivity with opioids, but clinical outcomes (MACE) were equivocal. CONCLUSION: This systematic review highlights the paucity of quality research evaluating the effect of opioids on its clinical and pharmacological effect on STEMI patients. Current literature indicates that opioids are associated with prolonged platelet reactivity. Whether this affects clinical outcomes remains to be established. Given the widespread use of opioids in STEMI, there is an urgent need for adequately powered trials investigating their safety.