Catheter versus surgical approach for the management of concomitant aortic stenosis and coronary artery disease: An inverse probability treatment weighting analysis.

BACKGROUND: Two therapeutic strategies are available when aortic stenosis and coronary artery disease coexist: a transcatheter approach, with percutaneous coronary intervention followed by transcatheter aortic valve replacement; and a surgical approach, consisting of surgical aortic valve replacement combined with coronary artery bypass graft. AIM: We sought to compare the outcomes of these two strategies. METHODS: The study population consisted of 241 patients who benefited from aortic valve replacement and coronary revascularization (transcatheter, n=150; surgery, n=91). RESULTS: Patients in the transcatheter population were older (83.5 vs. 71.8years; P<0.001) and had a higher Logistic EuroSCORE (11.1% vs. 5.7%; P<0.001). At 30days postprocedure, patients who had surgery exhibited more life-threatening bleedings (12.1% vs 4.5%; P=0.034), acute kidney injury (12.1% vs. 1.3%; P<0.001) and atrial fibrillation (55.6% vs. 8.7%; P<0.001). After a median follow-up of 27months, the risk of major adverse cardiovascular or cerebrovascular events did not differ significantly between the two strategies (hazard ratio [HR] 1.41, 95% confidence interval [CI] 0.97-2.04; P=0.07), whereas estimated glomerular filtration rate<60mL/min (HR 2.22, 95% CI 1.58-3.12; P<0.001), peripheral artery disease (HR 2.00, 95% CI 1.37-2.91; P<0.001) and left ventricular ejection fraction<50% (HR 1.69, 95% CI 1.12-2.55; P=0.012) were associated with a negative prognosis. CONCLUSIONS: In our study, patients with aortic stenosis and coronary artery disease treated by catheter were older and had a higher co-morbidity burden than those treated by surgery. The surgical strategy was associated with a higher rate of 30-day complications, but long-term outcomes were similar between the two strategies.

Radiation Exposure During Transcatheter Aortic Valve Replacement: Impact of Arterial Approach and Prosthesis Type.

BACKGROUND: The impact of novel alternative access and valve type on radiation exposure during transcatheter aortic valve replacement (TAVR) has not yet been evaluated. This study sought to determine the impact of a transarterial approach and prosthesis type on physician and patient exposure to radiation during TAVR. METHODS: This was a prospective study including 140 consecutive patients undergoing TAVR by transfemoral (n = 102) or transcarotid (TC) (n = 38) access at 2 centers. Implanted valves were the self-expanding Evolut R/PRO system (Medtronic, Minneapolis, MN; n = 38) and the balloon-expandable SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA; n = 102). The primary endpoint was first operator radiation exposure. The secondary endpoint was patient radiation exposure. RESULTS: First operator radiation exposure was 4-fold greater during TC TAVR (P < .001). The use of a self-expanding valve was associated with a longer x-ray time (P = .015) and a 2-fold greater first operator radiation dose (P = .018). Patient radiation dose was not significantly affected by arterial approach (P = .055) or valve type (P = .095). After adjustment for potential confounders, the TC approach remained associated with a 174.8% (95% confidence interval, 80.6-318.3, P < .001) increase in first operator radiation dose, whereas the use of a self-expanding valve no longer influenced the first operator dose (P = .630). CONCLUSIONS: TC access and the use of a self-expanding valve were associated with a 4- and 2-fold greater first operator radiation exposure during TAVR procedures, respectively. Unlike the arterial approach, the effect of bioprosthesis type on radiation exposure was mainly related to x-ray time and was no longer significant after adjustment.

Comparison of clinical outcomes after transcarotid and transsubclavian versus transfemoral transcatheter aortic valve implantation: A propensity-matched analysis.

BACKGROUND: Transcarotid and trans-subclavian access routes are increasingly used as alternative approaches for transcatheter aortic valve implantation (TAVI) when transfemoral access is not suitable. However, concerns remain about the risk of periprocedural stroke and long-term outcomes following transcarotid/trans-subclavian TAVI. AIMS: The present study sought to compare early and long-term outcomes of transcarotid/trans-subclavian TAVI versus transfemoral TAVI after propensity-score matching. METHODS: The 260 patients who underwent TAVI through a transfemoral (n=220), transcarotid (n=32) or trans-subclavian (n=8) approach at our institution over a 4-year period were identified. A 1:1 matching based on propensity score was performed, and led to a study population of 80 patients (40 transfemoral and 40 transcarotid/trans-subclavian). Primary endpoints were early complications; secondary endpoints were long-term outcomes. RESULTS: There were no differences in the baseline characteristics of the two groups. At 30 days after TAVI there were no significant differences between transfemoral and transcarotid/trans-subclavian TAVI in terms of death rates (5% vs 5%, respectively; P=1.00) and stroke rates (5% vs 2.5%, respectively; P=1.00). After a median follow-up of 21 months, the risk of death (P=0.95), stroke (P=0.82) and myocardial infarction (P=0.16) did not differ between the two groups. CONCLUSIONS: After propensity-score matching, no significant differences in early and long-term outcomes were observed between transfemoral and transcarotid/trans-subclavian TAVI. These findings should encourage heart teams to consider a transcarotid or trans-subclavian approach when transfemoral access is unavailable.

Exposure to Ionizing Radiation in Patients Undergoing Transfemoral Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) is currently becoming an alternative to surgical valve replacement for patients at low risk, a population that is likely to experience an increase in the radiation-induced cancer risk following TAVI. We aimed to evaluate the overall exposure to ionizing radiation in patients who underwent transfemoral TAVI, including the procedure itself as well as the procedures performed in the preintervention work-up and the post-TAVI interventions. All patients who underwent transfemoral TAVI for symptomatic aortic stenosis in our center over a 26 months period were included. Dosimetric indicators from preprocedural coronary angiography and computed tomography (CT), the TAVI procedure, and any postprocedural interventions (electrophysiology study and/or pacemaker implantation) were collected and converted into an effective dose. A total of 119 transfemoral TAVI procedures were included. The mean cumulative effective dose (ED) was 37.3 mSv. Three irradiating procedures were necessary for 84 patients (71% of the population, i.e., coronary angiography, CT scan and the TAVI procedure itself), whereas 30 patients (25%) required a fourth procedure, and 5 required a fifth (4%). The majority of the dose was from the CT, while only 11% of the dose derived from the TAVI procedure itself. In conclusion, overall exposure to ionizing radiation for patients who underwent transfemoral TAVI seems acceptable, and the majority of the overall ED comes from the CT scan.

Abdominal aorta tortuosity on computed tomography identifies patients at risk of complications during transfemoral transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement is now indicated in patients at intermediate surgical risk and will probably soon be indicated in patients at low surgical risk, for whom the occurrence of serious procedural complications is not acceptable. AIMS: We aimed to investigate whether simple arterial variables from computed tomography scanning can predict the occurrence of severe early complications in patients undergoing transfemoral TAVR. METHODS: All patients with symptomatic severe aortic stenosis treated by transfemoral transcatheter aortic valve replacement in our centre, and for whom computed tomography images were available, were included. An exhaustive analysis of preprocedural computed tomography scans was performed retrospectively, in search of arterial tortuosity and vascular calcifications. The primary endpoint was a composite 30-day safety endpoint. RESULTS: Overall, 175 patients were included. The primary endpoint was observed in 60 patients (35%). Abdominal aorta tortuosity was identified in 28 patients (16%) and was strongly associated with the occurrence of a complication (adjusted odds ratio 2.7, 95% confidence interval 1.1-6.6; P=0.03). There was no significant association between iliofemoral tortuosity or vascular calcification and the occurrence of complications. CONCLUSIONS: A tortuous abdominal aorta was found to be a predictor of the occurrence of a complication in patients undergoing transfemoral transcatheter aortic valve replacement. This computed tomography variable should therefore be taken into account when choosing the approach, especially for patients at intermediate and low surgical risk.

IMPACT OF THE TABLE HEIGHT AND THE OPERATOR'S HEIGHT ON THE LEVEL OF RADIATION DELIVERED TO INTERVENTIONAL CARDIOLOGISTS.

Interventional cardiologists count among the health professionals that are most exposed to ionising radiation. To minimise exposure, it is recommended that the patient be placed at the maximum distance possible from the X-ray source, but this recommendation has not been clinically validated. We aimed to investigate the impact of the average table height on the level of radiation delivered to cardiologists performing coronary interventions. The population for analysis included all invasive coronary procedures performed in our centre from March to June 2017. The primary endpoint was operator radiation exposure, as assessed using personal electronic dosimeters located on the operator's left arm. In total, 225 invasive coronary procedures were analysed. When the average table height was 1126 mm or more, the operators received a radiation dose that was, on average, 53% lower than when the table was lower than 1126 mm. This reduction remained significant by multivariate analysis adjusted for the operator.

Reduction in exposure of interventional cardiologists to ionising radiation over a 10-year period.

Exposure of operators to ionising radiation in interventional cardiology has likely diminished, but data confirming the magnitude of the reduction are lacking. The aim of this study was to compare the dose of radiation received by interventional cardiology operators at 11 years interval (2006 vs 2017). The study population comprised all interventional coronary procedures performed by a single operator in one catheterization laboratory (cathlab) of a large university hospital in north-eastern France. Exposure was compared between two periods, namely period 1 (from October 2005 to March 2006) and period 2 (from March 2017 to June 2017). The primary endpoint was the dose of radiation received by the operator, measured using an electronic dosimeter placed on the operator's left arm. In 2017, the dose of radiation received by the operators was, on average, 95% lower than the dose received in 2006 (p < 0.0001), even though the average fluoroscopy time increased by 73% over the same period (p < 0.0001). By multivariable analysis including body mass index, fluoroscopy time and performance of at least one (1) coronary angioplasty, the reduction in the operator's exposure to radiation remained significant. The dose of radiation received by interventional cardiology operators has decreased by 95% over the last ten years.

Minimizing exposure to radiation in invasive cardiology using modern dose-reduction technology: Evaluation of the real-life effects.

OBJECTIVES: We aimed to measure the reduction in the estimated dose of radiation received by patients that can be achieved using dose-reduction technology (ClarityIQ, Philips Healthcare, The Netherlands), among all patients undergoing invasive cardiology procedures. BACKGROUND: Medical procedures remain the primary source of exposure to ionizing radiation in the general population. METHODS: The study population comprised all patients (without exclusion criteria) undergoing invasive coronary procedures over a 1-year study period in a large referral centre equipped with two catheterization laboratories (cathlabs). Both cathlabs (A and B) were equipped with the Allura Xper FD10 imaging system (Philips Healthcare, The Netherlands), but only Cathlab B was equipped with ClarityIQ technology. The primary endpoint was the estimated total dose of radiation received by the patient, as assessed by Air Kerma (AK) and dose area product (DAP). RESULTS: In total, 2095 invasive coronary procedures were analyzed. The patients who underwent procedures in Cathlab B received an average estimated dose that was 23% (AK) and 43% (DAP) lower than the dose received by patients undergoing procedures in Cathlab A (P < .0001). The reduction remained significant by multivariate analysis after adjustment for total X-ray time, body mass index, arterial approach, PCI of at least one lesion, sex, and patient age. CONCLUSION: In our study, the ClarityIQ technology reduced the estimated radiation dose received by patients by 23-43%, according to the method of measurement.

Trends in Patient Exposure to Radiation in Percutaneous Coronary Interventions Over a 10-Year Period.

Technological progress has made it possible to reduce the dose of radiation delivered by medical x-ray systems. In parallel, interventional coronary procedures have become increasingly complex and consequently, last longer. This study aimed to compare the estimated dose of radiation received by patients in interventional cardiology at 10 years interval (2006 vs 2016). The study population included all patients who underwent interventional coronary procedures in one of the catheterization laboratories of our institution during 2 periods, namely, period 1 from October 2005 to March 2006, and period 2 from November 2015 to October 2016. The primary end point was the estimated dose of radiation received by the patient as assessed by dose area product. In 2016, the estimated dose of radiation received by patients who underwent interventional coronary procedures was on average 78% lower than that received in 2006 (p <0.0001), whereas the fluoroscopy time increased by 54% on average over the same period (p <0.0001). By multivariate analysis, including age, approach, body mass index, fluoroscopy time, and performance of angioplasty, the reduction in radiation remained significant. The radial approach was significantly associated with an increased estimated dose of radiation received (p <0.0001). In conclusion, the estimated dose of radiation received by patients who underwent interventional cardiology procedures has been reduced by 78% over the last decade.

Acute coronary syndromes in the very elderly: Short term prognostic performance of the SYNTAX score.

Acute coronary syndromes (ACS) frequently occur in elderly subjects. The high mortality associated with ACS in this population justifies the identification of factors related to poor prognosis. We aimed to evaluate the short-term prognostic performance of the SYNTAX score in a population of patients aged 85years or more presenting ACS and undergoing coronary angiography. Secondary objectives were to identify factors related to length of stay and potential markers of in-hospital death. We performed a retrospective, single-centre prognostic study including patients aged 85years or more who underwent coronary angiography for ACS over a 4year period. The primary endpoint was length of stay, and the secondary endpoint was in-hospital mortality. In total, 70 patients were included (37 men), average age 87.0±2.5years. Average SYNTAX score was 19.0±14.9. Average length of stay was 13.1±7.8days. By multivariate analysis, SYNTAX score was correlated with length of stay (p=0.008). Seven (10%) patients died in-hospital. Patients who died had a higher SYNTAX score (p=0.013) (threshold value of 25) and a lower left ventricular ejection fraction (p=0.001). They more frequently had signs of heart failure at admission (p=0.002), ST segment elevation ACS (p=0.046) and left main stem involvement (p=0.041) than survivors. In our study, SYNTAX score was associated with length of stay and in-hospital mortality. A SYNTAX score of 25 or more seems to be an indicator of poor short-term prognosis in very elderly patients with ACS.

Risk factors for infection of implantable cardiac devices: data from a registry of 2496 patients.

AIMS: The increased use of implantable cardiac devices has been accompanied by an increase in infection. However, risk factors for infection of implanted devices are poorly documented. We aimed to identify risk factors in patients with long-term follow-up after implantation of cardiac devices. METHODS AND RESULTS: Patients with first implantation of a cardiac device in our centre between October 1996 and July 2007 were entered in a registry. Each confirmed infection of the implanted device was matched to two controls for age, sex, and implantation year. We recorded cardiovascular risk factors (hypertension, diabetes), previous history of heart disease, renal failure, antiplatelet or anticoagulant therapy, as well as pre- and post-procedural characteristics (antibiotic prophylaxis, hyperthermia, number of leads, associated interventions, and early complications). During the study period, 2496 patients underwent implantation of a cardiac device; 35 infections were diagnosed (1.2%). Among these, 75% occurred during the first year after implantation. Early non-infectious complication requiring surgical intervention was observed only in patients with infection (9 of 35, P < 0.001). Factors independently associated with infection were diabetes [odds ratio (OR) 3.5, 95% confidence interval (CI) [1.03, 12.97]], underlying heart disease (OR 3.12, 95% CI [1.13; 8.69]), and use of >1 lead (OR 4.07, 95% CI [1.23, 13.47]). These latter two risk factors were also independently associated with occurrence of infection within 1 year of implantation. CONCLUSION: Our data show that the presence of diabetes and underlying heart disease are independent risk factors for infection after cardiac device implantation. As regards procedural characteristics, the use of several leads and early re-intervention are associated with a higher infection rate.

Financial impact of coronary stenting in emergency for acute coronary syndromes.

BACKGROUND: Since the prospective payment system, health institutions have only specific payments for the emergency care in the emergency room. The direct urgent admissions in coronary care units for acute coronary syndrome (ACS) do not collect this complementary refund. For the patient's stay, hospital is remunerated with fixed national prices which are similar even in case of emergent or planed coronary revascularization when realized. AIMS: To analyze and compare the financial impact between emergent and planed coronary stenting in the setting of ACS. PATIENTS AND METHODS: This retrospective study was based on patients suffering from ACS who experienced emergent coronary stenting during the year 2005. On 154 patients, 127 were age-, sex- and diagnosis-related group (called "groupe homogène de malades" in the French Health Care system)-matched with 127 suffering from same ACS but with planed "ad hoc" coronary stenting. The overall charges (medical and paramedical team, pharmacy, biology, implantable coronary devices, radiology) were compared between the two groups. RESULTS: Mean stay duration was 6.7 days and did not differ between the two groups. Mean financial retributions were significantly higher in the emergent group (7338 euro [6831-7846] IC95 vs 6509 euro [5994-7023]; p=0,02) but with a much more raised consumption (6810 euro [6283-7336] vs 5223 euro [4632-5814]; p=0,001). This overcost was due especially to drugs and biological expenses. The hospitalization payments did not cover the overall expenses for 25% of the patients' stays (N=64) among whom 39 have had emergent coronary stenting (30.7%, p=0.04). Among the different GHM, the most important difference was observed in non-STEMI without complication with a negative receipts/costs ratio for 37.8% of the stay with coronary stenting in emergency. CONCLUSION: The application of the recent guidelines for coronary revascularization in the management of ACS represents a financial venture for hospital institutions. The engaged charges for emergent coronary stenting are covered with difficulties contrary to planed revascularization.

Comparison of operator radiation exposure with optimized radiation protection devices during coronary angiograms and ad hoc percutaneous coronary interventions by radial and femoral routes.

AIMS: Although underestimated by interventional cardiologists for a long time, radiation exposure of operators and patients is currently a major concern. The objective of the present operator-blinded registry was to compare related-peripheral arterial route radiation exposure of operators. METHODS AND RESULTS: During 420 consecutive coronary angiograms (CAs) and percutaneous coronary interventions (PCIs), four interventional cardiologists were blindly screened. Radiation exposures were assessed using electronic personal dosimeters. Protection of operator was ensured using a lead apron, low leaded flaps, and leaded glass. Radiation exposure of operators was significantly higher using the radial route when compared with the femoral route for both CAs and CAs followed by ad hoc PCIs: 29.0 [1.0-195.0] microSv vs. 13.0 [1.0-164.0] microSv; P < 0.0001 and 69.5 [4.0-531.0] microSv vs. 41.0 [2.0-360.0] microSv; P = 0.018, respectively. Similarly, radiation exposure of patients was significantly higher using the radial route when compared with the femoral route for both CAs and CAs followed by ad hoc PCIs. Moreover, procedural durations and fluoroscopy times were significantly higher throughout the radial route. CONCLUSIONS: Although the radial route decreases peripheral arterial complication rates, increased radiation exposure of operators despite extensive use of specific protection devices is currently a growing problem for the interventional cardiologist health. Radial route indication should be promptly reconsidered in the light of the present findings.

Tissue Doppler imaging and conventional echocardiography after anthracycline treatment in adults: early and late alterations of left ventricular function during a prospective study.

AIM OF THE STUDY: To evaluate the short and long-term effects of anthracycline chemotherapy in adults using conventional echocardiography and pulsed tissue Doppler imaging (TDI). METHODS AND RESULTS: Twenty patients were included of which 16 had a complete follow up. They underwent an echocardiography before chemotherapy, 1-3 months and 3.5+/-0.6 years after the treatment. We recorded pulsed TDI at the mitral annulus, the basal segments of the left ventricular (LV) lateral and posterior walls; peak velocities in systole (Sm), early (Em) and late diastole and the isovolumic relaxation time (IVRT) were measured. The cumulative dose of doxorubicin was 211+/-82 g/m2. Early after anthracycline therapy, we observed changes in the diastolic LV function with a decrease of the mitral E peak velocity and TDI Em. At the late control, diastolic changes were more pronounced and associated with an alteration of the systolic function (LV ejection fraction and Sm). Four patients had a LV ejection fraction <50%; in these patients we observed a mitral annulus IVRT <80 ms at the early control; this could be of interest to predict later impairment of the LV ejection fraction. CONCLUSION: We found early changes in LV diastolic function and observed that late impairment of the LV ejection fraction occurred frequently after anthracycline therapy, despite normal systolic LV function during the first months of follow-up.