Outcomes of transcatheter aortic valve replacement in patients with chronic liver disease.

OBJECTIVE: Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to high-risk surgery in patients with comorbid conditions. The role of TAVR in patients with liver disease has not been examined. METHODS: We examined the procedural and intermediate to long-term follow-up outcomes of patients with severe symptomatic aortic valve stenosis and chronic liver disease, identified by liver biopsy or from a combination of clinical findings. All patients were treated with balloon-expandable transfemoral (TF) or transapical (TA) TAVR between November 2007 and February 2014. RESULTS: A total of 17 of 706 (2.41%) patients treated at our institution with TF [n=14] or TA [n=3] TAVR had chronic liver disease (mean age 77.65±9.06 years, 7 women, mean STS score 8.37, mean Charlson score 5.00, mean MELD score 11.35, Child-Turcotte-Pugh (CTP) Class A [n=11], B [n=6], C [n=0], biopsy proven liver disease [n=5]). Median follow-up was 466 days (range=12-1,403 days). The mean post-procedure length of hospital stay was 5.88±3.08 days. Procedural success was achieved in all cases. In-hospital mortality was 5.88% and 90-day mortality was 17.65%. Safety and efficacy endpoints as defined by the valve academic research consortium (VARC) were significant for one perioperative death from a proximate cardiac cause (post-operative day 14), one death after hospital discharge of unknown cause (post-operative day 12), two late deaths from non-cardiac causes (post-operative days 50 and 487, respectively), and one late death of unknown cause (post-operative day 1,005). There were no life-threatening or major bleeding complications. One patient had an MI, one had a transient ischemic attack, four had transient, Stage I, acute kidney injury and one had transient, Stage II, acute kidney injury. CONCLUSION: TF and TA TAVR are feasible methods for treating aortic stenosis in patients with chronic liver disease. In patients with mild to moderate chronic liver disease there are acceptable rates of early and late complications, however, outcomes in patients with advanced liver disease (MELD>20 or CTP class C) warrant further study.

The utility of prescreening transesophageal echocardiograms: a prospective study.

BACKGROUND: Recent emphasis on the judicious use of imaging prompted the publication of the 2007 ACC/ASE Appropriateness Use Criteria (AUC) for Echocardiography. However, the intersection of the AUC with the safety and clinical use of transesophageal echocardiography (TEE) is not well established. METHODS: We reviewed 490 consecutive orders for TEEs for appropriateness, significant findings, and reasons for cancellation. RESULTS: We found that 79% (389/490) of ordered studies were performed and 21% (101/490) were not. The number of TEEs cancelled for safety reasons (n = 29) was similar to that cancelled for inappropriateness (n = 36). Only 2% (6/389) of those performed were inappropriate vs. 16% of those that were cancelled. New or unsuspected findings were obtained in half of all performed TEEs; the majority of which were ordered to detect cardiac source of embolism (CSE). CONCLUSIONS: The AUC should specifically consider the utility of clinician-based prescreening of TEEs to encourage appropriate use and safety. Furthermore, given the incremental value of TEE over transthoracic echocardiography in detection of CSE, in some cases, TEE may be considered an appropriate initial test for this indication.

A Pilot Study Comparing Aortic Valve Area Estimates Derived from Fick Cardiac Output with Estimates Based on Cheetah-NICOM Cardiac Output.

Cardiac output during cardiac catheterization is often estimated using the modified Fick method (COFick). In this proof-of-concept, prospective non-randomized study carried out in a single academic healthcare centre, we examined whether replacing COFick in the Gorlin formula with Cheetah-NICOM monitor cardiac output (COCheetah) could produce an accurate and precise estimate of aortic valve area in patients with severe aortic stenosis. In twenty-six subjects, COFick and COCheetah were obtained concurrently. A spot and 3-minute running average of COCheetah was used. Bland and Altman analysis was used to derive bias, 95% limits of agreement (LOA) and confidence intervals (CI). The mean difference (bias) between AVACheetah (average) and AVAFick was 0.11 cm2 and the 95% LOA were ±0.42 cm2. The 95% CI of the bias was 0.02-0.2 cm2. The bias and 95% LOA of AVACheetah (spot value) were 0.14 ± 0.42cm2, with a 95% CI of 0.06-0.23 cm2. No proportional bias was present. AVACheetah thus appears to be a reasonably accurate measure of AVA in patients with severe aortic stenosis compared to AVAFick measured using a modified Fick CO. However, the limits of agreement were not narrow enough to consider AVACheetah and AVAFick interchangeable.

Factors associated with vascular complications in patients undergoing balloon-expandable transfemoral transcatheter aortic valve replacement via open versus percutaneous approaches.

BACKGROUND: Vascular complications after transfemoral transcatheter aortic valve replacement are common and associated with significant morbidity and mortality. Little is known about the effect of access approach on vascular complications. METHODS AND RESULTS: Between 2007 and 2013, 331 patients underwent transfemoral transcatheter aortic valve replacement via open surgical (OS) or fully percutaneous (PC) approaches. Patient data and clinical outcomes were collected. Valve Academic Research Consortium-defined vascular complications were noted. Multivariable analysis with propensity matching was performed, and vascular complications, mortality, and length of stay were assessed. One hundred twenty patients were treated with the OS approach and 211 patients via the PC approach. There were fewer major vascular complications (11% versus 20%; P=0.03) and shorter length of stay (7.5 versus 9.9 days; P=0.003) in the PC group when compared with those in the OS group. In multivariable analysis, vascular complications were more likely in women (odds ratio, 2.2; P=0.02) and with increasing differences between sheath outer diameter and minimal artery diameter (overall vascular complications: odds ratio, 1.4; P=0.02 and major vascular complications: odds ratio, 2.0; P<0.001). Propensity-matched analysis demonstrated no difference in vascular complications between the OS and the PC groups (22% versus 19%; P=0.73) but significantly reduced length of stay in the PC group (7.9 versus 10.0 days; P=0.04). CONCLUSIONS: Transfemoral transcatheter aortic valve replacement performed via the PC route is associated with similar risk of vascular complications and significantly lower postprocedural length of stay than the OS route. The degree of sheath oversizing with respect to iliofemoral minimal artery diameter and female sex are associated with vascular complications regardless of access approach.

Application of appropriateness criteria in outpatient transthoracic echocardiography.

BACKGROUND: Appropriateness criteria were applied to outpatient transthoracic echocardiographic (TTE) studies. METHODS: Indications were rated as appropriate, inappropriate, or unclassifiable, considering provider-stated indications, previous TTE studies, symptom changes, and patient-stated indications. Clinically important new or unexpected findings were recorded. RESULTS: Of 368 TTE studies, 206 (56%) were appropriate, 31 (8%) were inappropriate, and 131 (35%) were unclassifiable. Appropriateness was not correlated with patient or provider demographics. In 288 cases with prior TTE studies, there were 92 (32%) important new findings and 63 (22%) unexpected findings, of which 20% were from inappropriately ordered and 31% from unclassifiable TTE studies. Appropriateness was not associated with new (odds ratio, 1.23; 95% confidence interval, 0.48-3.18) or unexpected (odds ratio, 1.15; 95% confidence interval, 0.38-3.52) findings. Provider type and level of training were not correlated with new or unexpected findings. CONCLUSIONS: Many indications for TTE studies were unclassifiable. A high percentage of inappropriately ordered TTE studies yielded important information. Care must be taken in judging the value of TTE studies solely on the basis of appropriateness criteria.