Preferred monotherapy after short-term dual antiplatelet therapy: Systematic review and network meta-analysis of randomized trials.

BACKGROUND: Randomized controlled trials (RCTs) have demonstrated the efficacy and safety of P2Y12 inhibitor monotherapy following short-term dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI). However, no studies have compared P2Y12 inhibitor and aspirin monotherapy following short-term DAPT. We aimed to compare available strategies for DAPT duration and post-DAPT antiplatelet monotherapy following PCI. METHODS: Seven DAPT strategies [ticagrelor or clopidogrel following 1-month DAPT, ticagrelor following 3-month DAPT, aspirin following 3-6 months of DAPT (reference strategy), aspirin or P2Y12 inhibitor following 6-18-months of DAPT, and DAPT for ≥18 months] were compared using a network meta-analysis. The primary efficacy outcome was defined as a composite of all-cause death, myocardial infarction, and stroke. The primary bleeding outcome was trial-defined major or minor bleeding. RESULTS: Our analysis identified 25 eligible RCTs, including 89,371 patients who underwent PCI. Overall, none of the strategies negatively affected the primary efficacy outcomes. For primary bleeding outcomes, ticagrelor following 3-month DAPT was associated with a reduced risk of primary bleeding outcomes (HR 0.73; 95 % CI 0.57-0.95). Clopidogrel following 1-month DAPT was also associated with a reduced risk of primary bleeding outcomes (HR 0.54; 95 % CI 0.34-0.85), however, the strategy was associated with an increased risk of myocardial infarction or stent thrombosis. Similar trends were observed among patients with acute coronary syndrome and high bleeding risk. CONCLUSIONS: Compared with aspirin monotherapy following short-term DAPT, ticagrelor following 3-month DAPT was associated with a reduced risk of primary bleeding outcomes without increasing any ischemic outcomes.

Cardiac Reoperation or Transcatheter Mitral Valve Replacement for Patients With Failed Mitral Prostheses.

BACKGROUND: Evidence is limited regarding patient outcomes comparing redo surgical mitral valve replacement (redo SMVR) vs transcatheter mitral valve replacement (TMVR) for failed prostheses. OBJECTIVES: The goal of this study was to compare the outcomes of redo SMVR vs TMVR in patients with failed prostheses, as well as evaluate the association between case volume and outcomes. METHODS: Medicare beneficiaries aged ≥65 years who underwent redo SMVR or TMVR for failed mitral prostheses between 2016 and 2020 were included. The primary endpoint was mid-term (up to 3 years) major adverse cardiovascular events (MACE), including all-cause death, heart failure rehospitalization, stroke, or reintervention. Propensity score-matched analysis was used. RESULTS: A total of 4,293 patients were included (redo SMVR: 64%; TMVR: 36%). TMVR recipients were older, with a higher comorbidity burden. In matched cohort (n = 1,317 in each group), mid-term risk of MACE was similar (adjusted HR: 0.92; 95% CI: 0.80-1.04; P = 0.2). However, landmark analysis revealed a lower risk of MACE with TMVR in the first 6 months (adjusted HR: 0.75; 95% CI: 0.63-0.88; P < 0.001) albeit with a higher risk beyond 6 months (adjusted HR: 1.28; 95% CI: 1.04-1.58; P = 0.02). Increasing procedural volume was associated with decreased risk of mid-term MACE after redo SMVR (P = 0.001) but not after TMVR (P = 0.3). CONCLUSIONS: In this large cohort of Medicare beneficiaries with failed mitral prostheses, outcomes were similar between redo SMVR and TMVR at 3 years, with TMVR showing a lower initial risk but a higher risk of MACE after 6 months. These findings highlight the importance of striking a balance between surgical risk, anticipated longevity, and hospital expertise when selecting interventions.

Hybrid Closure of Postinfarction Apical Ventricular Septal Defect Using Septal Occluder Device and Right Ventricular Free Wall: The Apical BASSINET Concept.

BACKGROUND: Postinfarction ventricular septal defect (VSD) is a catastrophic complication of myocardial infarction. Surgical repair still has poor outcomes. This report describes clinical outcomes after a novel hybrid transcatheter/surgical repair in patients with apical VSD. METHODS: Seven patients with postmyocardial infarction apical VSD underwent hybrid transcatheter repair via subxiphoid surgical access. A transcatheter occluder (Amplatzer Septal Occluder) with a trailing premounted suture was deployed through the right ventricular wall and through the ventricular septum into the left ventricular apex. The trailing suture was used to connect an anchor external to the right ventricular wall. Tension on the suture then collapses the right ventricular free wall against the septum and left ventricular occluder, thereby obliterating the VSD. Outcomes were compared with 9 patients who underwent surgical repair using either patch or primary suture closure. RESULTS: All patients had significant left-to-right shunt (Qp:Qs 2.5:1; interquartile range [IQR, 2.1-2.6] hybrid repair versus 2.0:1 [IQR, 2.0-2.5] surgical repair), and elevated right ventricular systolic pressure (62 [IQR, 46-71] versus 49 [IQR, 43-54] mm Hg, respectively). All had severely depressed stroke volume index (22 versus 21 mL/m2) with ≈45% in each group requiring mechanical support preprocedurally. The procedure was done 15 (IQR, 10-50) versus 24 (IQR, 10-134) days postmyocardial infarction, respectively. Both groups of patients underwent repair with technical success and without intraprocedural death. One patient in the hybrid group and 4 in the surgical group developed multiorgan failure. The hybrid group had a higher survival at discharge (86% versus 56%) and at 30 days (71% versus 56%), but similar at 1 year (57% versus 56%). During follow-up, 1 patient in each group required reintervention for residual VSD (hybrid: 9 months versus surgical: 5 days). CONCLUSIONS: Early intervention with a hybrid transcatheter/surgical repair may be a viable alternative to traditional surgery for postinfarction apical VSD.

Transcatheter Mitral Valve Replacement in Failed Bioprosthetic Valve, Ring, and Mitral Annular Calcification Associated Mitral Valve Disease Using Balloon Expandable Transcatheter Heart Valve.

Transcatheter mitral valve replacement (TMVR) using the SAPIEN platform has been performed in failed bioprosthetic valves (valve-in-valve), surgical annuloplasty rings (valve-in-ring), and native valves with mitral annular calcification (MAC) (valve-in-MAC). Experience over the past decade has identified important challenges and solutions to improve clinical outcomes. In this review, we discuss the indication, trend in utilization, unique challenges, procedural planning, and clinical outcomes of valve-in-valve, valve-in-ring, and valve-in-MAC TMVR.

Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation and bioprosthetic valves: A meta-analysis.

BACKGROUND: The optimal anticoagulation strategy for patients with bioprosthetic valves and atrial fibrillation remains uncertain. We conducted a meta-analysis using updated evidence comparing direct anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with bioprosthetic valves and atrial fibrillation. METHODS: Medline and Embase were searched through March 2021 to identify randomized controlled trials (RCTs) and observational studies investigating the outcomes of DOAC therapy and VKA therapy in patients with bioprosthetic valves and atrial fibrillation. The outcomes of interest were all-cause death, major bleeding, and stroke or systemic embolism. RESULTS: Our analysis included 4 RCTs and 6 observational studies enrolling a total of 6405 patients with bioprosthetic valves and atrial fibrillation assigned to a DOAC group (n = 2142) or a VKA group (n = 4263). Pooled analysis demonstrated the similar rates of all-cause death (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.77-1.05; P = .18; I2 = 0%) in the DOAC and VKA groups. However, the rate of major bleeding was significantly lower in the DOAC group (HR, 0.66; 95% CI, 0.48-0.89; P = .006; I2 = 0%), whereas the rate of stroke or systemic embolism was similar in the 2 groups (HR, 0.72; 95% CI, 0.44-1.17; P = .18; I2 = 39%). CONCLUSIONS: DOAC might decrease the risk of major bleeding without increasing the risk of stroke or systemic embolism or all-cause death compared with VKA in patients with bioprosthetic valves and atrial fibrillation.

A Comparison of Thirty-Day Clinical and Echocardiographic Outcomes of Patients Undergoing Transcatheter vs. Surgical Aortic Valve Replacement for Native Aortic Insufficiency.

OBJECTIVES: We aim to compare in-hospital and 30-day outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) for native aortic insufficiency (AI). BACKGROUND: TAVR is increasingly used off-label in patients with AI deemed high risk for SAVR. There is a paucity of data comparing TAVR and SAVR with current commercially available TAVR devices. METHODS: A single-center, retrospective cohort study of patients undergoing TAVR or SAVR for native AI between 2014 and 2020 was performed. Data were obtained from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database, Transcatheter Valve Therapy (TVT) registry, and chart review. In-hospital and 30-day outcomes are reported. RESULTS: Of 125 total patients, 91 underwent SAVR and 34 underwent TAVR. The TAVR group had a higher STS predictive risk of mortality (PROM) (TAVR = 3.96 %, SAVR = 1.25 %, p < 0.0001). In the postoperative period, the SAVR group had higher rates of new-onset atrial fibrillation (20.9 % vs. 0 %, p < 0.001), while the TAVR group had higher rates of complete heart block requiring permanent pacemaker implantation (20.6 % vs. 2.2 %, p < 0.001). There was no difference in in-hospital or 30-day mortality, stroke, myocardial infarction, residual AI, or repeat valve intervention. CONCLUSIONS: Despite higher STS PROM and more comorbidities, patients who underwent TAVR for AI had similar in-hospital and 30-day outcomes as patients who underwent SAVR for AI. These results support TAVR in selected high-risk patients with AI, with the knowledge that pacemaker needs may be higher than patients undergoing SAVR.

Revascularization strategies in patients with diabetes and stable ischemic heart disease: a systematic review and meta-analysis of randomized trials.

AIMS: The optimal treatment strategy comparing invasive revascularization versus optimal medical therapy (OMT) in patients with diabetes mellitus (DM) and stable ischemic heart disease (SIHD) still remains unclear. We aimed to investigate clinical outcomes of invasive revascularization (percutaneous coronary intervention, coronary artery bypass grafting or both) versus OMT in patients with DM and SIHD from updated published randomised-controlled trials (RCTs). METHODS: We conducted a comprehensive literature search through PubMed and EMBASE to investigate the effect of revascularization versus OMT for patients with DM and SIHD. The studies were limited to RCTs or their subgroup data for a meta-analysis. The outcomes of interest were major adverse cardiovascular events (MACE) in patients with DM and SIHD. RESULTS: Our search identified subgroup data with DM of four RCTs including a total of 5742 patients with SIHD. Our results showed that invasive revascularization was not associated with a decreased risk of MACE when compared to OMT [hazard ratio (95% confidence interval): 0.95 (0.85-1.05), P = 0.31; I2 = 0%]. CONCLUSION: Invasive revascularization was not associated with a decreased risk of MACE when compared with OMT.

Maintenance immunosuppression in heart transplantation: insights from network meta-analysis of various immunosuppression regimens.

Previous studies have reported superiority of mechanistic target-of-rapamycin (mTOR) antagonists (mTA) over calcineurin inhibitors (CNI) as part of maintenance immunosuppression (IS) in mitigating cardiac allograft vasculopathy (CAV) after heart transplantation (HT). MEDLINE and EMBASE were searched through October 2019 for studies comparing maintenance IS with mTA + antimetabolites (AM), CNI + mTA or CNI + AM post HT. The main outcomes were all-cause mortality, CAV, acute rejection, CMV infections, and change in eGFR. To compare different IS antagonists, a random-effects network meta-analysis was performed. We used p-scores to rank best treatments per outcome. Our search identified fifteen eligible studies (5 studies comparing mTA + AM vs. CNI + AM, 9 comparing CNI + mTA vs. CNI + AM, 1 comparing mTA + AM vs. CNI + mTA, 8 using everolimus and 7 sirolimus as mTA) reporting the selected outcomes. We did not identify any statistical difference in all-cause mortality among the three IS regimens without heterogeneity among studies. CAV rates were significantly lower with CNI + mTA (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.3-0.92). Acute rejection rates were significantly lower with CNI + AM (OR 0.26, 95% CI 0.12-0.56) and with CNI + mTA (OR 0.16, 95% CI 0.07-0.33) compared with mTA + AM without significant heterogeneity (I2 = 43%, p = 0.9). CMV infections were significantly lower with mTA + AM (OR 0.13, 95% CI 0.03-0.46) and with CNI + mTA (OR 0.27, 95% CI 0.2-0.38) compared with CNI + AM without heterogeneity. mTA + AM led to higher eGFR compared with CNI + AM (9.06 ml/min/1.73 m2, 95% CI 3.15-14.97) and CNI + Mta (9.64 ml/min/1.73 m2, 95% CI 0.91-18.36), but the heterogeneity among studies was significant. CNI + mTA ranked better for CAV (p = 0.78), and acute rejection (p = 0.99) while mTA + AM for CMV infection (p = 0.94) and improvement in renal function (p = 0.93) than other regimens. Different IS regimens have similar effects on survival post HT, but CNI + mTA was associated with lower CAV rates, and acute rejection, while mTA + AM with less CMV infection post HT.

Network meta-analysis of anticoagulation strategies for venous thromboembolism in patients with cancer.

Cancer-associated thrombosis (CAT) is a common complication in patients with malignancy. Although direct oral anticoagulants (DOACs) have emerged as a treatment option for CAT, there have not been head-to-head comparisons of these agents. We searched MEDLINE and EMBASE from inception to April 2020 for studies comparing the effect of different long-term anticoagulation strategies for venous thromboembolism (VTE) in patients with cancer. We performed a network meta-analysis comparing the antithrombotic strategies in the selected studies using random-effects model. We identified a total of 20 studies [9 randomized control trials (RCTs) and 11 subgroup analyses from other unique RCTs] with total of 6699 patients for inclusion in our analysis. There was no significant difference in recurrent VTE, all-cause death, major bleeding and clinically relevant non-major bleeding among DOACs. When DOACs were combined, recurrent VTE was significantly decreased in DOACs compared to low-molecular weight heparin (LMWH) and Vitamin K antagonist (VKA) [RR (95% CI) 0.75 (0.59-0.94); RR (95% CI) 0.51 (0.39-0.66), respectively] without significant increase in major bleeding or clinically relevant non-major bleeding. In patients with CAT, there was no significant difference in recurrent thrombotic event among different DOACs. Bleeding risk was comparable among all anticoagulation strategies. When DOACs were combined, DOACs were associated with a significant decrease in recurrent VTE with comparable bleeding risk to LMWH and VKA.

In-Hospital Outcomes of Left Ventricular Assist Device Implantation and Concomitant Valvular Surgery.

Valvular heart disease is common among left ventricular assist device (LVAD) recipients. However, its management at the time of LVAD implantation remains controversial. Patients who underwent LVAD implantation and concomitant aortic (AVR), mitral (MVR), or tricuspid valve (TVR) repair or replacement from 2010 to 2017 were identified using the national inpatient sample. End points were in-hospital outcomes, length of stay, and cost. Procedure-related complications were identified via ICD-9 and ICD-10 coding and analysis was performed via mixed effect models. A total of 25,171 weighted adults underwent LVAD implantation without valvular surgery, 1,329 had isolated TVR, 1,021 AVR, 377 MVR, and 615 had combined valvular surgery (411 had TVR + AVR, 115 TVR + MVR, 62 AVR + MVR, 25 AVR + MVR + TVR). During the study period, rates of AVR decreased and combined valvular surgeries increased. Patients who underwent TVR or combined valvular surgery had overall higher burden of co-morbidities than LVAD recipients with or without other valvular procedures. Postoperative bleeding was higher with AVR whereas acute kidney injury requiring dialysis was higher with TVR or combined valvular surgery. In-hospital mortality was higher with AVR, MVR, or combined surgery without differences in the rates of stroke. Length of stay did not differ significantly among groups but cost of hospitalization and nonroutine discharge rates were higher for cases of TVR and combined surgery. Approximately 1 in 9 LVAD recipients underwent concomitant valvular surgery and TVR was the most frequently performed procedure. In-hospital mortality and cost were lower among those who did not undergo valvular surgery.

Mortality in patients undergoing revascularization with paclitaxel eluting devices for infrainguinal peripheral artery disease: Insights from a network meta-analysis of randomized trials.

OBJECTIVES: We aimed to evaluate whether paclitaxel eluting devices increased the risk of death in patients undergoing revascularization for infrainguinal peripheral artery disease using network meta-analyses. METHODS: PUBMED and EMBASE were searched through April 2020 for randomized trials in patients with infrainguinal peripheral artery disease who underwent revascularization with or without a paclitaxel eluting device (balloon/stent). Short-term mortality defined as death at 6-12 months, and long-term mortality defined as death at >12 months after revascularization. RESULTS: Our search identified 57 eligible randomized controlled studies enrolling a total of 9,362 patients comparing seven revascularization strategies (balloon angioplasty vs. bare metal stent vs. covered stent vs. paclitaxel eluting stent vs. other drug eluting stent vs. paclitaxel-coated balloon vs. bypass surgery). Overall, paclitaxel eluting stent and paclitaxel-coated balloons did not increase short-term mortality (eg, vs. balloon angioplasty: paclitaxel-coated balloon OR [95% CI] 1.21 [0.88-1.66], p = .24; paclitaxel eluting stent OR [95%CI] 1.01 [0.63-1.63], p = .97, respectively). In addition, paclitaxel eluting stent did not show significant increase in long-term mortality (eg, vs. balloon angioplasty: OR [95%CI] 1.06 [0.70-1.59], p = .79). However, paclitaxel-coated balloon showed significant increase in long-term mortality compared to balloon angioplasty and bypass (vs. balloon angioplasty: OR [95% CI] 1.48 [1.06-2.07], p = .021; vs. bypass: OR [95%CI] 1.73 [1.05-2.84], p = .031, respectively). CONCLUSIONS: In this meta-analysis of randomized trials, there was no significant increase in mortality with paclitaxel eluting stent, but there was increased risk of long-term mortality in paclitaxel-coated balloon for the treatment of infrainguinal peripheral artery disease.

P2Y12 inhibitor monotherapy versus aspirin monotherapy after short-term dual antiplatelet therapy for percutaneous coronary intervention: Insights from a network meta-analysis of randomized trials.

BACKGROUND: A number of trials have assessed the efficacy and safety of short-term dual antiplatelet therapy (DAPT) in patients who undergo percutaneous coronary intervention (PCI). However, whether to continue aspirin or a P2Y12 inhibitor after a short course of DAPT is actively debated. METHODS: PUBMED and EMBASE were searched through March 2020 for randomized controlled trials evaluating short-term DAPT (≤6 months) when compared with longer-term (≥12 months) DAPT among patients undergoing PCI. The ischemic outcomes were all-cause death, myocardial infarction, stent thrombosis, and stroke. The safety outcome was major and/or clinically relevant bleeding. The primary objective was to investigate the outcomes with aspirin monotherapy (Aspirin group) versus P2Y12 inhibitor monotherapy (P2Y12i group) after short-term DAPT. RESULTS: Our search identified 17 eligible trials enrolling a total of 54,625 patients comparing different DAPT duration. Either of the 2 monotherapy groups did not increase the risk of ischemic outcomes when compared with the long-term DAPT group, without difference between the Aspirin versus the P2Y12i groups. However, both monotherapy groups significantly reduced bleeding when compared with long-term DAPT (Aspirin group: hazard ratio [95% CI]: 0.62 [0.45-0.86], P=.004 and P2Y12i group: 0.68 [0.50-0.93], P=.015). There was no difference in bleeding between the Aspirin versus P2Y12i groups (hazard ratio=0.91 [0.58-1.43], P=.70). CONCLUSIONS: Among patients undergoing PCI, short-term DAPT with continuation of either aspirin or P2Y12i reduced bleeding without increasing ischemic outcomes when compared with long-term DAPT. The choice of antiplatelet therapy after short-term DAPT should be evaluated in well-powered trials.

Racial disparities in in-hospital outcomes after left ventricular assist device implantation.

BACKGROUND: Previous studies of patients undergoing various cardiac surgeries demonstrated worse outcomes among African-American (AA) patients. It remains unclear if the race is a predictor of outcomes among left ventricular assist device (LVAD) recipients. METHODS: Patients who underwent LVAD implantation between 2010 and 2017 were identified using the National Inpatient Sample. The race was classified as Caucasians vs AA vs Hispanics, and endpoints were in-hospital outcomes, length of stay, and cost. Procedure-related complications were identified via the International Classification of Diseases-9 (ICD-9) and ICD-10 coding and analysis performed via mixed-effect models. RESULTS: A total of 27 132 adults (5114 unweighted) underwent LVAD implantation in the U.S. between 2010 and 2017, including Caucasians (63.8%), AA (23.8%), and Hispanics (6%). The number of LVAD implantations increased in both Caucasians and AA during the study period. AA LVAD recipients were younger, with higher rates of females and mostly comorbidities, but lower rates of coronary artery disease and bypass grafting compared to Caucasians and Hispanics. Medicaid and median income at the lowest quartile were more frequent among AA LVAD recipients. We did not identify differences in stroke, bleeding complications, tamponade, infectious complications, acute kidney injury requiring hemodialysis, and in-hospital mortality among racial groups. AA LVAD recipients had lower rates of routine discharge than Caucasians and Hispanics, longer length of stay than Caucasians, but similar cost of hospitalization. After adjustment for clinical comorbidities, race was not a predictor of in-hospital mortality. CONCLUSION: We identified differences in clinical characteristics but not in in-hospital complications among LVAD recipients of a different races.

Percutaneous coronary intervention or coronary artery bypass graft surgery for left main coronary artery disease: A meta-analysis of randomized trials.

We aimed to investigate long-term (≥5 years) outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD) using a meta-analysis from updated published randomized trials. Our data showed that the risk of all-cause death as well as cardiovascular death, myocardial infarction, and stroke was similar between PCI and CABG, whereas PCI had significantly higher rates of repeat revascularization compared to CABG. Decisions for PCI versus CABG for LMCAD should be based on weighing the upfront morbidity and mortality risk of CABG with late risk of repeat revascularization with PCI and taking into consideration patient preference.

Prognostic impact of baseline C-reactive protein levels on mortality after transcatheter aortic valve implantation.

OBJECTIVES: To determine whether baseline C-reactive protein (CRP) levels can predict mortality after transcatheter aortic valve implantation (TAVI), we performed a meta-analysis of currently available studies. METHODS: All studies investigating the prognostic impact of baseline (preprocedural) CRP levels on all-cause mortality after TAVI were identified by means of searching PubMed and Google Scholar through May 2019. For each study, (preferentially, adjusted rather than unadjusted) odds/hazard ratios (ORs/HRs) with corresponding 95% confidence intervals of mortality per standard-deviation (SD) (or unit) increase in CRP levels or those for high vs low CRP levels. RESULTS: Our search identified 14 eligible studies including a total of 3449 patients undergoing TAVI and reporting early (in-hospital to 3-month) and midterm (1-year to 3-year) all-cause mortality after TAVI. Pooled analyses demonstrated associations of high-baseline CRP levels with a marginal, but statistically nonsignificant increase in early mortality (pooled OR/HR per SD increase in CRP levels, 2.72; P = .09 and pooled OR/HR for high vs low CRP levels, 3.32; P = .07) and a statistically significant increase in midterm mortality after TAVI (pooled OR/HR per SD increase in CRP levels, 1.45; P < .0001 and pooled OR/HR for high vs low CRP levels, 1.78; P < .00001). Excluding HRs for high-sensitivity CRP, combining ORs/HRs of 1-year mortality, pooling HRs of ≥2-year mortality, and combining adjusted HRs did not alter the primary results. CONCLUSION: High-baseline CRP levels may predict increased midterm, but not early, mortality after TAVI.

Baseline left ventricular diastolic dysfunction affects midterm mortality after transcatheter aortic valve implantation.

OBJECTIVES: To determine whether preprocedural left ventricular (LV) diastolic dysfunction impairs midterm mortality after transcatheter aortic valve implantation (TAVI) for patients with severe aortic stenosis (AS), we performed a meta-analysis of currently available evidence. METHODS: We identified all studies investigating impact of preprocedural severity of LV diastolic dysfunction on midterm (≥1-year) all-cause mortality after TAVI for patients with AS through a search of databases (MEDLINE and EMBASE) until September 2019. From each study, we extracted an adjusted (if unavailable, unadjusted) hazard ratio (HR) of midterm mortality. We pooled study-specific estimates in the random-effects model. RESULTS: Ten eligible studies with a total of 2380 patients with AS undergoing TAVI were identified. In accordance with pooled analyses, higher-grade preprocedural LV diastolic dysfunction was associated with significantly worse midterm all-cause mortality after TAVI compared to lower-grade dysfunction (HR for grade II vs I, 1.15; P = .002; HR for grade III vs I, 1.35; P = .001; HR for grade III vs II; 1.16, P = .002; HR for grade II-III vs I, II-III vs 0-I, or III vs I-II, 1.34; P < .00001 [primary meta-analysis]; HR per grade, 1.16; P = .003). No funnel plot asymmetry for the primary meta-analysis (for grade II-III vs I, II-III vs 0-I, or III vs I-II) was identified, which probably indicated no publication bias (P = .381 by the linear-regression test). CONCLUSION: Higher-grade preprocedural LV diastolic dysfunction was associated with worse midterm all-cause mortality after TAVI for patients with AS compared to lower-grade dysfunction.