Transcatheter aortic valve implantation versus surgical aortic valve replacement in patients over 85 years old.

OBJECTIVES: Surgical aortic valve replacement (SAVR) for the treatment of in very old patients with severe aortic stenosis is associated with a high risk of morbidity and mortality. Transcatheter aortic valve implantation (TAVI) has become the preferred alternative. Therefore, we sought to evaluate outcomes in very old patients who underwent SAVR versus TAVI. METHODS: A total of 169 consecutive patients aged ≥85 years underwent TAVI (n = 68) or SAVR (n = 101). A propensity score adjustment was used to compare outcomes including cost analysis. RESULTS: The propensity score generated 40 pairs of patients with similar baseline characteristics. The TAVI group experienced atrioventricular block (37.5% vs 5%, P < 0.01) more frequently, a longer stay in the intensive care unit (median 5 days, range 1-35 vs median 2 days, range 1-6, P < 0.01) but a lower rate of new-onset atrial fibrillation (15% vs 47.5%, P < 0.01). The 30-day mortality rate was similar in the unmatched and matched cohorts (8.8% vs 5.0%, P = 0.32; 10% vs 7.5%, P = 0.69). One, 3- and 5-year overall survival rates (80% vs 90%, 56% vs 79%, 37% vs 71%, P < 0.01) and freedom from major adverse cardiac and cardiovascular events (72% vs 90%, 46% vs 76%, 17% vs 68%, P < 0.01) were lower in the TAVI group. An overall cost analysis indicated that TAVI was more expensive (€2084 vs €19 891). CONCLUSIONS: In patients 85 years and older, SAVR seems to offer good short- and mid-term clinical outcomes compared to TAVI. Advanced age alone would not be an indication for TAVI in old-old patients.

Short and long-term outcome in very old patients with ST-elevation myocardial infarction after primary percutaneous coronary intervention.

BACKGROUND: Although octogenarians constitute a fast-growing portion of cardiovascular patients, few data are available on the outcome of patients aged ≥85 years with ST-Elevation Myocardial Infarction (STEMI). METHODS AND RESULTS: We analyzed 126 consecutive patients aged ≥85 years (age 88±2 years) with STEMI, undergoing primary percutaneous coronary intervention (pPCI) within 12 hours from symptoms onset. Long-term follow-up (median 898 days) was obtained for the 102 patients surviving the index-hospitalization. In-hospital mortality rate was 19%. Nonagenarians, diabetes mellitus, severe left ventricular systolic dysfunction and intra-aortic balloon pumping were significantly and independently correlated to in-hospital mortality at the multivariate analysis. A low rate of complications was detected. Among patients surviving the index hospitalization, 32 (31%) patients died during follow-up. 55 patients (54%) had re-hospitalization due to cardiovascular causes. The univariate analysis identified chronic renal failure, Killip class ≥ 3, TIMI Risk Score >8 and very high risk of bleeding as predictors of long-term overall mortality. At the multivariate analysis only chronic renal failure and very high risk of bleeding were significantly and independently correlated to long-term all-cause mortality. Renal function and anterior myocardial infarction were significantly and independently associated with the combined end-point of cardiac mortality and re-hospitalization due to cardiovascular disease at the multivariate analysis. CONCLUSIONS: PPCI in patients ≥85 years old is relatively safe. In this population, pPCI is associated with a good long-term survival, although still worse than in younger patients, despite a considerable incidence of re-hospitalization due to cardiovascular events.

Predictive value of electrocardiogram in diagnosing acute coronary artery lesions among patients with out-of-hospital-cardiac-arrest.

AIMS: Acute coronary lesions are known to be the most common trigger of out of hospital cardiac arrest (OHCA). Aim of the present study was to assess the predictive value of ST-segment changes in diagnosing the presence of acute coronary lesions among OHCA patients METHODS: Findings of coronary angiography (CA) performed in patients resuscitated from OCHA were retrospectively reviewed and related to ST-segment changes on post-ROSC electrocardiogram (ECG) RESULTS: Ninety-one patients underwent CA after OHCA; 44% of patients had ST-segment elevation and 56% of patients had other ECG patterns on post-ROSC ECG. Significant coronary artery disease (CAD) was found in 86% of patients; CAD was observed in 98% of patients with ST-segment elevation and in 77% of patients with other ECG patterns on post-ROSC ECG (p=0.004). Acute or presumed recent coronary artery lesions were diagnosed in 56% of patients, respectively in 85% of patients with ST-segment elevation and in 33% of patients with other ECG patterns (p<0.001). ST-segment analysis on post-ROSC ECG has a good positive predictive value but a low negative predictive value in diagnosing the presence of acute or presumed recent coronary artery lesions (85% and 67%, respectively) CONCLUSIONS: Electrocardiographic findings after OHCA should not be considered as strict selection criteria for performing emergent CA in patients resuscitated from OHCA without obvious extra-cardiac cause; even in the absence of ST-segment elevation on post-ROSC ECG, acute culprit coronary lesions may be present and considered the trigger of cardiac arrest.