Outcomes of transcatheter versus surgical aortic valve replacement among solid organ transplant recipients.

BACKGROUND: There is a paucity of data regarding the outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) among solid-organ transplant recipients. METHODS: Temporal trends in hospitalizations for aortic valve replacement among solid-organ transplant recipients were determined using the National Inpatient Sample database years 2012-2017. Propensity matching was conducted to compare admissions who underwent TAVR versus SAVR. The primary outcome was in-hospital mortality. RESULTS: The analysis included 1,730 hospitalizations for isolated AVR; 920 (53.2%) underwent TAVR and 810 (46.7%) underwent SAVR. TAVR was increasingly utilized for solid-organ transplant recipients (Ptrend = 0.01), while there was no change in the number of SAVR procedures (Ptrend = 0.20). The predictors of undergoing TAVR for solid-organ transplant recipients included older age, diabetes, and prior coronary artery bypass surgery, while TAVR was less likely utilized in small-sized hospitals. TAVR was associated with lower in-hospital mortality after matching (0.9 vs. 4.7%, odds ratio [OR] 0.19; 95% confidence interval [CI] 0.11-0.35, p < .001) and after multivariable adjustment (OR 0.07; 95% CI 0.03-0.21, p < .001). TAVR was associated with lower rate of acute kidney injury, acute stroke, postoperative bleeding, blood transfusion, vascular complications, discharge to nursing facilities, and shorter median length of hospital stay. There was no difference between both groups in the use of mechanical circulatory support, hemodialysis, arrhythmias, or pacemaker insertion. CONCLUSION: This contemporary observational nationwide analysis showed that TAVR is increasingly performed among solid-organ transplant recipients. Compared with SAVR, TAVR was associated with lower in-hospital mortality, complications, and shorter length of stay.

The Impact of Novel X-Ray Systems and X-Ray System Optimization on Patient Radiation Dose Administered During Cardiac Catheterization.

INTRODUCTION: The effect of x-ray system optimization on patient radiation dose has received limited study. METHODS: We analyzed patient radiation dose in 1786 cardiac catheterization procedures (diagnostic coronary angiography and/or percutaneous coronary intervention [PCI]) performed at a single tertiary-care center before and after x-ray system optimization. RESULTS: After optimization, cineangiography dose-area product (DAP) dose was lower in the overall group of patients who underwent diagnostic angiography and/or PCI (1347 µGy•m² [IQR, 645-2345 µGy•m²] vs 1658 µGy•m² [IQR, 640- 2757 µGy•m²]; P=.03), as well as in the diagnostic angiography group (1795 µGy•m² [IQR, 1140-2994 µGy•m²] vs 2356 µGy•m² [IQR, 311-3576 µGy•m²]; P<.01) and PCI group (2152 µGy•m² [IQR, 1338-3477 µGy•m²] vs 2562 µGy•m² [IQR, 1681-3859 µGy•m²]; P=.02). Cineangiography DAP per exposure was also lower in the overall group (143 µGy•m² [IQR, 91-212 µGy•m²] vs 164 µGy•m² [IQR, 106-233 µGy•m²] per exposure; P<.01) and in the diagnostic angiography group (158 µGy•m² [IQR, 102-225 µGy•m²] vs 184 µGy•m² [IQR, 125-271 µGy•m²] per exposure; P<.01). After optimization, cineangiography air kerma (AK) dose (319 mGy [IQR, 197-531 mGy] vs 421 mGy [IQR, 241-600 mGy]; P=.01) and cineangiography AK per exposure (20.7 mGy [IQR, 12.9-29.0 mGy] vs 23.6 mGy [IQR, 14.1-32.9 mGy] per exposure; P=.03) were also lower in the PCI group. There was no significant change in fluoroscopy AK dose after optimization (20.7 mGy [IQR, 12.7-30.1 mGy] vs 20.4 mGy [IQR, 12.8-31.3 mGy] per minute; P=.71) and fluoroscopy DAP dose (156 µGy•m² [IQR, 101-242 µGy•m²] vs 156 µGy•m² [IQR, 102-236 µGy•m²] per minute; P=.91). CONCLUSION: X-ray system optimization was associated with lower cineangiography DAP, but similar fluoroscopy radiation dose.

Losartan for Preventing Aortic Root Dilatation in Patients with Marfan Syndrome: A Meta-Analysis of Randomized Trials.

INTRODUCTION: The role of losartan in preventing aortic root dilatation in Marfan syndrome has been evaluated in many clinical trials; however, the results are conflicting. METHODS: We performed a computerized search of MEDLINE, EMBASE and COCHRANE databases through February 2019 for randomized clinical trials evaluating the effect of losartan in patients with Marfan syndrome. The main outcome was the change in the aortic root diameter in the losartan versus control groups. RESULTS: Our final analysis included seven randomized trials with a total of 1352 patients and average weighted follow-up of 37.8 months. Change in aortic root diameter was significantly smaller with losartan compared with control [weighted means: 0.44 vs. 0.58 mm, mean difference (MD) = -0.13; 95% CI -0.24 to -0.02; p = 0.02]. Subgroup analysis according to the control group showed no significant subgroup interaction when comparing losartan with beta-blockers versus with standard therapy (pinteraction= 0.27). The composite outcome of aortic surgery, dissection or mortality did not differ between the losartan and control groups (risk ratio = 1.03; 95% CI 0.72-1.49, p = 0.86). CONCLUSION: In this meta-analysis including seven randomized trials, the use of losartan was associated with a significantly smaller change in aortic root diameter in patients with Marfan syndrome.

Perioperative clinical utility of myocardial deformation imaging: a narrative review.

Preoperative cardiac function is an important predictor of postoperative outcomes. Patients with heart failure are at higher risk of perioperative morbidity and mortality. Left ventricular ejection fraction, derived by standard echocardiography, is most frequently used to assess cardiac function in the intraoperative and postoperative periods. Myocardial strain analysis, a measurement of myocardial deformation, can provide additional information to left venricular eject fraction estimation. Here, we provide an overview of myocardial strain and different methods used to evaluate strain, including speckle tracking echocardiography. Speckle tracking echocardiography is an imaging modality that can analyse and track small segments of the myocardium, which provides greater detail for assessing global and regional cardiac motion and function. We further review the literature to illustrate the value of speckle tracking echocardiography-derived myocardial strain in describing cardiac function and its association with adverse surgical outcomes in the perioperative period, including low cardiac output states, need for inotropic support, postoperative arrhythmias, subclinical myocardial ischaemia, and length of hospital stay.

Regadenoson Stress Real-Time Myocardial Perfusion Echocardiography for Detection of Coronary Artery Disease: Feasibility and Accuracy of Two Different Ultrasound Contrast Agents.

BACKGROUND: The aim of this study was to compare the efficacy of myocardial perfusion (MP) and wall motion (WM) analysis obtained with real-time myocardial contrast echocardiography (RTMCE) and two widely used contrast agents in detecting coronary artery disease after injection of the vasodilator regadenoson. METHODS: One hundred fifty patients were studied at two academic centers using regadenoson (400-µg intravenous bolus) vasodilator stress RTMCE (7.5% Optison infusion [n = 50] or 1.5% Definity infusion [n = 100]). Both MP and WM with RTMCE were analyzed at rest and after regadenoson bolus. Comparisons of WM and MP sensitivity, specificity, and accuracy were made. Quantitative angiography was performed in all patients within 1 month of the regadenoson stress study (>50% and >70% diameter stenosis was considered significant). Reviewers were blinded to all clinical and quantitative angiographic data. RESULTS: Rate-pressure product after regadenoson was higher in Optison than Definity patients (P = .004). Using a 50% diameter stenosis on quantitative angiography as a reference standard, overall sensitivity, specificity, and accuracy for combined WM and MP analysis were not different for both agents (Optison, 77%, 64%, and 73%; Definity, 80%, 74%, and 78%; P = NS). The sensitivity, specificity, and accuracy of WM analysis alone for Optison were 68%, 71%, and 69% compared with 60%, 72%, and 66% for Definity (P = NS). Adding MP analysis improved the sensitivity and accuracy of Definity for detecting both >50% and >70% stenoses (P < .001 vs WM), while MP analysis did not improve the sensitivity of Optison for detecting either >50 or >70% stenoses. CONCLUSIONS: RTMCE during regadenoson stress using either Optison or Definity is a rapid and effective method for the detection of coronary artery disease. The ability of MP imaging to improve WM accuracy may depend on the rate-pressure product achieved.