Femoral Versus Nonfemoral Peripheral Access for Transcatheter Aortic Valve Replacement.

BACKGROUND: Femoral access is the gold standard for transcatheter aortic valve replacement (TAVR). Guidelines recommend reconsidering surgery when this access is not feasible. However, alternative peripheral accesses exist, although they have not been accurately compared with femoral access. OBJECTIVES: This study compared nonfemoral peripheral (n-FP) TAVR with femoral TAVR. METHODS: Using the data from the national prospective French registry (FRANCE TAVI [French Transcatheter Aortic Valve Implantation]), this study compared the characteristics and outcomes of TAVR procedures according to whether they were performed through a femoral or a n-FP access, using a pre-specified propensity score-based matching between groups. Subanalysis during 2 study periods (2013 to 2015 and 2016 to 2017) and among low/intermediate-low and intermediate-high/high volume centers were performed. RESULTS: Among 21,611 patients, 19,995 (92.5%) underwent femoral TAVR and 1,616 (7.5%) underwent n-FP TAVR (transcarotid, n = 914 or trans-subclavian, n = 702). Patients in the n-FP access group had more severe disease (mean logistic EuroSCORE 19.95 vs. 16.95; p < 0.001), with a higher rate of peripheral vascular disease, known coronary artery disease, chronic pulmonary disease, and renal failure. After matching, there was no difference in the rate of post-procedural death and complications according to access site, except for a 2-fold lower rate of major vascular complications (odds ratio: 0.45; 95% confidence interval: 0.21 to 0.93; p = 0.032) and unplanned vascular repairs (odds ratio: 0.41; 95% confidence interval: 0.29 to 0.59; p < 0.001) in those who underwent n-FP access. The comparison of outcomes provided similar results during the second study period and in intermediate-high/high volume centers. CONCLUSIONS: n-FP TAVR is associated with similar outcomes compared with femoral peripheral TAVR, except for a 2-fold lower rate of major vascular complications and unplanned vascular repairs. n-FP TAVR may be favored over surgery in patients who are deemed ineligible for femoral TAVR and may be a safe alternative when femoral access risk is considered too high.

Hypoalbuminemia in elderly patients with acute diastolic heart failure.

OBJECTIVES: This study evaluated the relative contribution of serum colloid osmotic pressure (COP) lowering and pulmonary artery wedge pressure (PAWP) elevation in the pathogenesis of pulmonary edema in patients with systolic or isolated diastolic heart failure (DHF). BACKGROUND: The role of hypoalbuminemia and the resulting low COP have been shown in some patients with acute systolic heart failure (SHF). Colloid osmotic pressure and PAWP were determined in 100 patients with acute heart failure (HF) (56 with DHF and 44 with SHF; mean age, 78 +/- 12 years), in 35 patients with acute dyspnea from pulmonary origin, and in 15 normal controls. Pulmonary artery wedge pressure was estimated using transthoracic Doppler echocardiography. RESULTS: Colloid osmotic pressure was significantly lower in the DHF group (20.5 +/- 5 mm Hg) than in the SHF group (24.2 +/- 3.7 mm Hg, p < 0.001), pulmonary disease group (25.1 +/- 4.2 mm Hg, p < 0.001), or normal control group (24.7 +/- 3 mm Hg). Low COP resulted from hypoalbuminemia due to age, malnutrition, and sepsis. Pulmonary artery wedge pressure was significantly higher in patients with SHF (26 +/- 6.3 mm Hg) than in the patients with DHF (20.3 +/- 7 mm Hg, p < 0.001) and was significantly higher in the patients with DHF than in the patients with pulmonary disease (13 +/- 4.2 mm Hg, p < 0.001). The COP-PAWP gradient was similar in patients with SHF (-1.6 +/- 7.1 mm Hg) and patients with DHF (0.7 +/- 6 mm Hg). CONCLUSIONS: Frequent hypoalbuminemia resulting in low COP facilitates the onset of pulmonary edema in patients with DHF who usually have lower PAWP than patients with SHF.

Comparative accuracy of color M-mode and tissue Doppler echocardiography in the emergency diagnosis of congestive heart failure in chronic hypertensive patients with normal left ventricular ejection fraction.

The accuracy of the tissue Doppler E/Ea and color M-mode Doppler E/Vp indexes in diagnosing congestive heart failure (HF) was investigated in 20 chronic hypertensive patients with acute dyspnea and normal left ventricular ejection fractions who met Vasan's criteria for definite diastolic HF, compared with 20 gender- and age-matched hypertensive patients with noncardiac cause of acute dyspnea. The E/Ea ratio appeared to be more reproducible (variability 4% to 9% vs 6 to 14%) and more precise (sensitivity 77.8%, specificity 100%, and accuracy 89.5% for the optimal cutoff of 11 vs sensitivity 73.7%, specificity 75%, and accuracy 74.3% for the optimal cutoff of 1.5) than the E/Vp ratio in this clinical setting.

B-type natriuretic peptide and tissue Doppler study findings in elderly patients hospitalized for acute diastolic heart failure.

The imbalance of Starling's forces was investigated in 25 elderly patients hospitalized for acute diastolic heart failure. Tissue Doppler evidence of elevated left ventricular filling pressures was present on admission in 17 patients with high B-type natriuretic peptide (BNP) levels. Serum proteins concentrations and colloid osmotic pressure, related to malnutrition and severe sepsis, were significantly less in the 8 patients without tissue Doppler evidence of elevated filling pressures, and a high level of BNP was consistent with paroxysmal elevation in filling pressures in this setting.

Prevalence of angiographic coronary artery disease in patients hospitalized for acute diastolic heart failure without clinical and electrocardiographic evidence of myocardial ischemia on admission.

The prevalence of coronary artery disease was investigated in 18 patients hospitalized for acute diastolic heart failure without clinical and electrocardiographic evidence of myocardial ischemia on admission. On the basis of coronary angiography, 7 patients had coronary artery disease and 4 had ischemic heart disease. In addition, besides uncontrolled hypertension and several systemic factors, silent myocardial ischemia potentially contributed to acute exacerbation of heart failure for at least 5 patients with coronary artery disease, according to either elevation in troponin I or segmental wall motion abnormalities.

Usefulness of serum albumin and serum total cholesterol in the prediction of hospital death in older patients with severe, acute heart failure.

BACKGROUND: Acute heart failure (HF) carries high hospital mortality rates in older patients; a multimarker strategy may help identify patients at high risk. AIMS: To investigate prospectively the prognostic relevance of serum albumin and serum total cholesterol (TC) in older patients with severe, acute HF. METHODS: Usual prognostic variables were collected on admission in 207 consecutive patients aged>70 years with severe, acute HF. Serum albumin and serum TC were obtained soon after clinical improvement. RESULTS: Hospital mortality rate was 19%. Patients who died were similar to patients who survived in terms of age, sex, heart rate, serum haemoglobin and left ventricular ejection fraction. Patients who died had higher concentrations of B-type natriuretic peptide (BNP), blood urea nitrogen, serum creatinine, C-reactive protein and serum troponin I, lower systolic blood pressure, and lower concentrations of serum albumin and serum TC than patients who survived (P<0.01 for all). Serum albumin was the best independent predictor of hospital death (odds ratio 0.82 [0.74-0.90], P<0.001), with blood urea nitrogen (P=0.02) and log (BNP) (P=0.02). A simple risk score based on serum albumin (<3g/dL; 2 points), BNP (>840pg/mL; 1 point) and blood urea nitrogen (>15.3mmol/L; 1 point) discriminated patients without (score 0 to 1, hospital death 4%) from patients with (score 2 to 4, hospital death 35%, P<0.001) a high risk of death. CONCLUSION: Hypoalbuminaemia offers powerful additional prognostic information to usual prognostic variables in older patients with severe, acute HF, and deserves further attention in multimarker strategies.

Tissue Doppler echocardiography for the diagnosis of new-onset heart failure with normal ejection fraction: influence of serum protein concentration on clinical interpretation in elderly patients.

INTRODUCTION: According to Starling's law, low serum colloid osmotic pressure related to hypoproteinaemia is likely to modulate the pulmonary capillary hydrostatic pressure threshold of pulmonary oedema formation. We therefore examined the clinical relevance of bedside tissue Doppler echocardiography in the emergency diagnosis of new-onset heart failure with normal ejection fraction (HFnlEF) according to serum protein concentration. METHODS: A total of 105 consecutive elderly patients presenting with acute severe dyspnoea were prospectively enrolled. B-type natriuretic peptide (BNP) concentration and spectral tissue Doppler-derived septal E/E' ratio were obtained at presentation. Serum protein concentration was measured immediately after clinical stabilization, with a value of less than 6g/dL defining hypoproteinaemia. RESULTS: The diagnostic performance of E/E' was excellent in normoproteinaemic patients (n=71; area under the receiver-operating characteristic [ROC] curve 0.97; p<0.001) and reasonable in hypoproteinaemic patients (n=34; area under ROC curve 0.83; p<0.001). By multivariable logistic regression analysis, E/E' provided independent and incremental diagnostic information over the Boston score and BNP concentration in patients with a normal serum protein concentration (p<0.01). Critical elevation of pulmonary capillary pressure, defined as E/E'>15, was present in 93% of patients with HFnlEF and normoproteinaemia versus 55% of patients with HFnlEF and hypoproteinaemia (p=0.0017). CONCLUSION: Septal E/E'>15 is clinically relevant for the emergency diagnosis of new-onset HFnlEF among elderly patients with normal serum protein concentration. Lower abnormal values less than 15 should be considered predictive of this condition in the setting of hypoproteinaemia.

Angiographic coronary artery disease associated with hypertensive heart failure and normal ejection fraction. Insights from a prospective monocenter study.

The prevalence of underlying coronary artery disease (CAD) was examined in 23 consecutive hypertensive patients presenting with acute onset of heart failure and normal ejection fraction (HFnlEF) without clinical, electrocardiographic and biochemical evidence of myocardial ischemia. By coronary angiography, 2 patients had 1-vessel disease, 5 patients had 2-vessels disease and 1 patient had 3-vessels disease. 26% of patients was classified as having ischemic heart disease. Underlying CAD is not an uncommon finding in hypertensive HFnlEF and must be checked with the aim to enhance the therapeutic management.

Comparison of B-type natriuretic peptide with left atrial enlargement by echocardiography for the diagnosis of new-onset congestive heart failure with a preserved left ventricular systolic function in the setting of longstanding hypertension.

The present study attempted to determine the accuracy of B-type natriuretic peptide (BNP) compared with left atrial enlargement at echocardiography in the emergency diagnosis of new-onset heart failure with preserved systolic function (HFPSF) related to longstanding hypertension. The study comprised 57 patients in sinus rhythm hospitalized for acute dyspnea, 30 with hypertensive HFPSF and 27 with noncardiac cause. By stepwise logistic regression analysis, BNP provided independent and incremental diagnostic information over the score of Boston criteria. There was a trend toward superiority of this biomarker compared to the left atrial area index for the diagnosis of HFPSF. A BNP concentration >142 pg/ml was 93% sensitive and 85% specific for the diagnosis of HFPSF in this clinical setting (area under the ROC curve of 0.91 [0.8-0.97], p<0.001).

Accuracy of the isovolumic relaxation time in the emergency diagnosis of new-onset congestive heart failure with preserved left ventricular systolic function in the setting of B-type natriuretic peptide levels in the mid-range.

Despite the fact that B-type natriuretic peptide (BNP) is a useful diagnostic complement to clinical and radiographic data in the emergency diagnosis of acute congestive heart failure, levels of BNP in the mid-range (100-500 pg/ml) are acknowledged to be inconclusive for the diagnosis. We assessed the diagnostic value of the pulsed Doppler-derived isovolumic relaxation time (IVRT) by bedside Doppler echocardiography in the emergency diagnosis of new-onset congestive heart failure with preserved systolic function in 43 patients presenting with acute severe dyspnea and inconclusive BNP levels. A short IVRT <50 ms was a good predictor of acute congestive heart failure in this clinical setting, with a positive predictive value of 94%.

Usefulness of serum albumin concentration for in-hospital risk stratification in frail, elderly patients with acute heart failure. Insights from a prospective, monocenter study.

The present study examined the usefulness of serum albumin concentration measured immediately after clinical stabilization for in-hospital risk stratification in 64 consecutive elderly, institutionalized patients with definite evidence of acute heart failure, of whom 17 died during their in-hospital stay. Serum albumin concentration was a powerful predictor of in-hospital death in this clinical setting (hazard ratio of 0.80 [0.71-0.89], p<0.001). A serum albumin concentration of <3 g/dl (median value) had a sensitivity of 94% and a specificity of 68% for the prediction of in-hospital mortality. Furthermore, this biomarker was able to provide incremental prognostic information over usual prognostic variables obtained at presentation such as age, systolic blood pressure and blood urea nitrogen.

Accuracy of bedside tissue Doppler echocardiography for the prediction of in-hospital mortality in elderly patients with acute heart failure with preserved left ventricular systolic function. comparison with B-type natriuretic peptide measurement.

According to recent studies, tissue Doppler echocardiography used as a non-invasive surrogate for left ventricular diastolic pressures regardless of rhythm is likely to offer additional information beyond the clinical judgment and the B-type natriuretic peptide (BNP) assay in the emergency diagnosis of acute heart failure with preserved left ventricular systolic function (HFPSF). The present study attempted to determine the usefulness of bedside tissue Doppler echocardiography as compared with BNP, both obtained at presentation before unloading therapy, for the prediction of in-hospital outcome in 75 consecutive elderly patients with acute HFPSF, of whom 16 died during their in-hospital stay. Unlike BNP (p=0.002), the spectral tissue Doppler-derived E/Ea ratio was not able to provide prognostic information in such patients before tailored therapy (p=0.9).

Usefulness of bedside tissue Doppler echocardiography and B-type natriuretic peptide (BNP) in differentiating congestive heart failure from noncardiac cause of acute dyspnea in elderly patients with a normal left ventricular ejection fraction and permanent, nonvalvular atrial fibrillation: insights from a prospective, monocenter study.

BACKGROUND: The incremental role of bedside tissue Doppler echocardiography and B-type natriuretic peptide (BNP) over the clinical judgment has been recently reported in the emergency diagnosis of congestive heart failure with a normal left ventricular ejection fraction (HFNEF). However, how well does this diagnostic strategy be applicable in the setting of atrial fibrillation is unknown. OBJECTIVE: To investigate the usefulness of bedside tissue Doppler echocardiography and BNP in the emergency diagnosis of HFNEF in elderly patients with permanent, nonvalvular atrial fibrillation. METHODS: Forty-one consecutive elderly patients with an ejection fraction > or =50% (mean age 84 years; 22 with HFNEF and 19 with noncardiac cause), hospitalized for acute dyspnea at rest, were prospectively enrolled; bedside septal E/Ea and BNP were obtained at admission. RESULTS: By multivariable logistic regression analysis including the clinical judgment of heart failure, E/Ea and BNP, E/Ea (P = 0.014) and BNP (P = 0.018) provided independent diagnostic information. Optimal cutoffs were 13 for E/Ea (area under the ROC curve of 0.846, P < 0.0001; sensitivity 81.8%, specificity 89.5%) and 253 pg/ml for BNP (area under the ROC curve of 0.928, P < 0.0001; sensitivity 86.4%, specificity 89.5%). The concordance between the clinical judgment and BNP concentration at the cutoff of 253 pg/ml correctly classified 24 of 25 patients; E/Ea at the cutoff of 13 correctly classified 14 of the 16 patients with discrepancy. CONCLUSION: Bedside tissue Doppler echocardiography and BNP provide useful additional diagnostic information over the clinical judgment for the emergency diagnosis of HFNEF in elderly patients with permanent, nonvalvular atrial fibrillation.

Accuracy of tissue Doppler echocardiography in the diagnosis of new-onset congestive heart failure in patients with levels of B-type natriuretic peptide in the midrange and normal left ventricular ejection fraction.

BACKGROUND: Based on the hypothesis that it reflects left ventricular (LV) diastolic pressures, B-type natriuretic peptide (BNP) is largely utilized as first-line diagnostic complement in the emergency diagnosis of congestive heart failure (HF). The incremental diagnostic value of tissue Doppler echocardiography, a reliable noninvasive estimate of LV filling pressures, has been reported in patients with preserved LV ejection fraction and discrepancy between BNP levels and the clinical judgment, however, its clinical validity in such patients in the presence of BNP concentrations in the midrange, which may reflect intermediate, nondiagnostic levels of LV filling pressures, is unknown. METHODS: 34 patients without history of HF, presenting with acute dyspnea at rest, BNP levels of 100-400 pg/ml and normal LV ejection fraction were prospectively enrolled (17 with congestive HF and 17 with noncardiac cause). Tissue Doppler echocardiography was performed within 3 hours after admission. RESULTS: Unlike BNP (P = 0.78), Boston criteria (P = 0.0129), radiographic pulmonary edema (P = 0.0036) and average E/Ea ratio (P = 0.0032) were predictive of congestive HF by logistic regression analysis. In this clinical setting, radiographic pulmonary edema had a positive predictive value of 80% in the diagnosis of congestive HF. In patients without evidence of radiographic pulmonary edema, average E/Ea > 10 was a powerful predictor of congestive HF (area under the ROC curve of 0.886, P < 0.001, sensitivity 100% and specificity 78.6%). CONCLUSION: By better reflecting LV filling pressures, bedside tissue Doppler echocardiography accurately differentiates congestive HF from noncardiac cause in dyspneic patients with intermediate, nondiagnostic BNP levels and normal LV ejection fraction.

Accuracy of tissue Doppler echocardiography in the emergency diagnosis of decompensated heart failure with preserved left ventricular systolic function: comparison with B-type natriuretic peptide measurement.

BACKGROUND: Tissue Doppler echocardiography provides a reliable noninvasive estimation of left ventricular (LV) filling pressures irrespective of LV ejection fraction. However, the diagnostic accuracy of E/Ea ratio has not been adequately determined in patients with suspected heart failure (HF) with preserved LV systolic function in the acute care setting. OBJECTIVE: To investigate the accuracy of E/Ea ratio in the emergency diagnosis of decompensated HF with preserved LV systolic function. METHODS: Seventy patients with a LV ejection fraction >or=45%, 32 with decompensated HF (77 +/- 12 years of age), and 38 with noncardiac cause of acute dyspnea (74 +/- 12) were enrolled. B-type natriuretic peptide (BNP) was measured on admission; lateral, septal and average E/Ea ratios were calculated within 24 hours. RESULTS: Using receiver-operating characteristic curves to evaluate diagnostic performance, BNP (AUC of 0.875, P < 0.0001) and E/Ea ratios (AUC of 0.90-0.92, P < 0.0001) provided similar accuracy for predicting decompensated HF. Optimal cutoffs were 146 pg/ml for BNP (sensitivity and specificity of 90.6% and 76.3%), 9.8 for lateral E/Ea (83.3% and 88.9%), 12.7 for septal E/Ea (76.7% and 91.4%), and 11.5 for average E/Ea ratio (80% and 94.3%). On multivariate logistic regression analysis, average E/Ea ratio yielded independent additional information to a model based on the clinical judgment and BNP level according to the standard cutoff of 100 pg/ml. CONCLUSIONS: Tissue Doppler echocardiography is accurate for predicting decompensated HF with preserved LV systolic function and may be used as a diagnostic complement to inconclusive BNP level in this setting.