Transcatheter Aortic Valve Replacement in Patients With a Small Annulus　- From the Japanese Nationwide Registry (J-TVT).

BACKGROUND: The details and consequences of a small aortic annulus among transcatheter aortic valve replacement (TAVR) patients remain uncertain. This study investigated the short-term outcomes in patients with small annular size and compared the 30-day outcome between intra- and supra-annular devices, with similar outer casing diameter in this subgroup.Methods and Results:Cases registered in the Japanese national TAVR registry between August 2013 and December 2017 were analyzed. Among a total of 5,870 registered patients, 647 (11.0%) had small annulus (area ≤314 mm2) measured by multi-detector computed tomography. Patients with a small annulus had a significantly smaller indexed effective orifice area (iEOA, 1.10 cm2/m2[0.92-1.35] vs. 1.16 cm2/m2[0.96-1.39], P<0.001) and higher mean pressure gradient (mPG, 10.0 mmHg [6.9-14.2] vs. 8.5 mmHg [6.0-11.5], P<0.001) compared with a normal-sized annulus. Among patients with a small annulus, those receiving a 20 mm intra-annular device had a smaller iEOA (0.94 cm2/m2[0.78-1.06] vs. 1.07 cm2/m2[0.8-1.24], P=0.001) and higher mPG (14.0 mmHg [10.0-18.5] vs. 11.0 [7.0-14.0], P<0.001) compared with those receiving a 23-mm supra-annular device, although the incidence of paravalvular leakage (≥moderate) was similar (14.4% vs. 16.5%, P=0.69). CONCLUSIONS: Patients with a small annulus were associated with less hemodynamic improvement. A supra-annular device is associated with better echocardiographic improvement in patients with a small annulus, without increasing paravalvular leakage.

Low skeletal muscle density combined with muscle dysfunction predicts adverse events after adult cardiovascular surgery.

BACKGROUND AND AIMS: Although muscle dysfunctions are widely known as a poor prognostic factor in patients with cardiovascular disease, no study has examined whether the addition of low skeletal muscle density (SMD) assessed by computed tomography (CT) to muscle dysfunctions is useful. This study examined whether SMDs can strengthen the predictive ability of muscle dysfunctions for adverse events in patients who underwent cardiovascular surgery. METHODS AND RESULTS: We retrospectively reviewed 853 patients aged ≥40 years who had preoperative CT for risk management purposes and who measured muscle dysfunctions (weakness: low grip strength and slowness: slow gait speed). Low SMD based on transverse abdominal CT images was defined as a mean Hounsfield unit of the psoas muscle <45. All definitions of muscle dysfunction (weakness only, slowness only, weakness or slowness, weakness and slowness), the addition of SMDs was shown to significantly improve the continuous net reclassification improvement and integrated discrimination improvement for adverse events in all analyses (p < 0.05). Low SMDs combined with each definition of muscle dysfunction had the highest risk of all-cause death (hazard ratio: lowest 3.666 to highest 6.002), and patients with neither low SMDs nor muscle dysfunction had the lowest risk of all-cause and cardiovascular-related events. CONCLUSION: The addition of SMDs consistently increased the predictive ability of muscle dysfunctions for adverse events. Our results suggest that when CT is performed for any clinical investigation, the addition of the organic assessment of skeletal muscle can strengthen the diagnostic accuracy of muscle wasting.

Characteristics of carotid atherosclerosis in patients with plaque erosion.

Plaque erosion (PE) is a major underlying mechanism of acute coronary syndrome (ACS). Patients with PE may have less systemic atherosclerosis. We aimed to clarify the status of carotid atherosclerosis in patients with PE. A total of 115 consecutive patients with ACS who underwent optical coherence tomography (OCT) imaging of the culprit lesion were enrolled. Patients were classified into PE (n = 26), plaque rupture (n = 56) or calcified plaque (CP, n = 33) based on OCT findings of the culprit lesions. The status of carotid atherosclerosis was assessed by the findings of carotid echography. The mean IMT was the lowest in the PE group (1.5 ± 0.6 mm) among the three groups (p = 0.004) with a significant difference between the PE group and the CP group (2.1 ± 0.6 mm, p < 0.001). The plaque score was the lowest in the PE group (6.6 ± 2.5) among the three groups (p = 0.004) with a significant difference between the PE group and the CP group (9.0 ± 2.7, p < 0.001). Multivariate analyses demonstrated that the PE was independently associated with the presence of lower mean IMT (below median; 1.85 mm) (odds ratio 3.34; 95 % confidence interval 1.07-10.4; p = 0.035) and the lack of heterogenous plaque (odds ratio 2.92; 95 % confidence interval 1.02-8.32; p = 0.037). Patients with PE were associated with less atherosclerosis in the carotid artery than other patients with ACS. These findings may help further clarify the distinct pathophysiology of PE. Carotid atherosclerosis and plaque erosion.

Achilles tendon thickening is associated with higher incidence of adverse cardiovascular event in patients with coronary artery disease.

Achilles tendon thickening (ATT) is a marker of high risk for coronary artery disease (CAD). However, the association between the presence of ATT and the incidence of cardiovascular events in patients with CAD is unclear. A total of 406 consecutive patients who underwent percutaneous coronary intervention (PCI) and ATT assessment were analyzed. ATT was defined as the Achilles tendon thickness of 9 mm or more on radiography. The incidence of major adverse cardiovascular events (MACE) at 1-year was compared between patients with ATT and those without ATT. MACE included cardiac death, non-fatal myocardial infarction, stroke, target vessel revascularization (TVR), and non-TVR. ATT was found in 67 patients (16.5%). The incidence of cardiac death (3.2 vs. 0.0%, p = 0.001), TVR (12.7 vs. 4.0%, p = 0.005) and MACE (20.6 vs. 9.6%, p = 0.011) was significantly higher in the ATT group than the no ATT group. Patients with ATT had significantly higher incidence of cardiac death (5.6 vs. 0%, p < 0.001) than those without ATT even if they did not meet the diagnostic criteria of familial hypercholesterolemia. A multivariate model demonstrated that ATT was independently associated with the MACE at 1-year (Hazard ratio, 2.09; 95% Confidence Interval, 1.09-4.00, p = 0.026). The presence of ATT was independently associated with 1-year recurrence of cardiovascular events in patients with CAD undergoing PCI. Assessment of ATT might be useful for risk stratification of secondary cardiovascular events.

Six-Minute Walk Test Predicts Postoperative Delirium After Transcatheter Aortic Valve Replacement.

OBJECTIVE: This study investigated the incidence and risk factors of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR) and to evaluate the association between preoperative conditions, particularly frailty, and POD. DESIGN: Observational, case-control study. SETTING: Single-center university hospital. PARTICIPANTS: The study comprised 124 patients who underwent TAVR and were divided into the following two groups: group D (patients diagnosed with POD) and group C (patients without POD). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twenty-seven patients (21.7%) developed POD (95% confidence interval 14.9%-30.1%). POD was defined as a diagnosis of delirium using the Confusion Assessment Method for Intensive Care Unit scale during the patients' intensive care unit stay. Preoperative and postoperative data of patient characteristics were obtained from their medical records. A multivariate logistic regression analysis was performed using variables associated with POD incidence. Frailty scores were significantly higher in group D than in group C. The distance covered in the six-minute walk test (6MD) was significantly shorter in group D than in group C. The risk of developing POD was significantly higher in patients with a 6MD shorter than 220 m. Multivariate logistic regression analysis showed that a shorter 6MD was an independent risk factor for POD (odds ratio 5.66; p = 0.004). CONCLUSION: In the present study, POD was seen in 21.7% of the patients who underwent TAVR. A 6MD shorter than 220 m was an independent preoperative risk factor for POD. For patients at high risk of POD, more careful management in the perioperative period may reduce POD.

Clinical outcome of biodegradable polymer sirolimus-eluting stent and durable polymer everolimus-eluting stent in patients with diabetes.

BACKGROUND: Diabetes mellitus is a risk for increased incidence of adverse clinical events after percutaneous coronary intervention. However, the difference in the incidence of adverse clinical events according to stent type in patients with diabetes remains to be elucidated. In the present study, we aimed to compare the clinical outcomes between patients treated with the biodegradable polymer sirolimus-eluting stents (BP-SES) and the durable polymer everolimus-eluting stents (DP-EES) among patients with diabetes. METHODS: Among 631 lesions in 510 consecutive patients treated with either BP-SES or DP-EES, 165 lesions in 141 patients with diabetes mellitus and stable angina pectoris were identified and classified into the BP-SES group (48 lesions in 44 patients) and the DP-EES group (117 lesions in 100 patients). The incidence of adverse clinical events after stent implantation was compared between the 2 groups. RESULTS: There was no significant difference in the prevalence of conventional risk factors, lesion characteristics, and procedural characteristics between the 2 groups. During median 386 [334-472] days follow-up, the incidence of target lesion revascularization (11.4 vs. 2.0%, p = 0.003) and device-oriented clinical endpoint (13.6 vs. 6.0%, p = 0.035) in the BP-SES group was significantly greater than that in the DP-EES group. A univariate model demonstrated that the BP-SES usage was significantly associated with the higher incidence of target lesion revascularization (odds ratio, 6.686; 95% confidence interval, 1.234-36.217; p = 0.028). CONCLUSION: BP-SES was associated with the greater incidence of TLR than the DP-EES in patients with diabetes mellitus. Further studies with larger cohorts and longer follow-up are required to confirm the present results.

Novel volumetric analysis for stent expansion after drug-eluting stent implantation: An optical coherence tomography study.

OBJECTIVES: To assess the clinical significance of a novel optical coherence tomography (OCT)-derived volumetric parameter of stent expansion by comparing it with the conventional parameters in real-world practice. BACKGROUND: The clinical significance of novel parameters in real-world practice including longer and smaller stents remains to be elucidated. METHODS: A total of 226 de novo lesion treated with drug-eluting stents in 208 consecutive patients were enrolled. Stent expansion was retrospectively assessed on the final OCT images after stent implantation. The novel parameter was the minimum expansion index (MEI) calculated using a novel algorithm that yields the ideal lumen area in each frame by taking into account vessel tapering. The device-oriented clinical end point (DoCE) included cardiac death, target vessel-related myocardial infarction, ischemia-driven target lesion revascularization. RESULTS: The MEI in the lesions with a DoCE (n = 22) at 2 years and cases without a DoCE (n = 204) was 64.3 ± 12.0% and 78.5 ± 14.6%, respectively (p < .001). In the receiver operating characteristic curve analyses, the areas under the curve for the MEI (0.787; p < .001) were larger than that for %stent expansion (0.718; p = .001) and minimum stent area (0.664; p = .004) in predicting the DoCE. The best cutoff of MEI for predicting the DoCE was 74.0. CONCLUSIONS: The novel MEI was better than the conventional %stent expansion and minimum stent area for predicting DoCE.

Age- and Gender-Related Differences in Coronary Lesion Plaque Composition on Optical Coherence Tomography.

BACKGROUND: The pathophysiology and chronological course of atherosclerosis seems to be different between men and women due to biological differences, and age and gender differences in plaque composition of coronary lesions remain to be elucidated.Methods and Results:A total of 860 consecutive patients with a median age of 69 years (IQR, 60-78 years) who underwent optical coherence tomography (OCT) of culprit lesions was included. The composition of culprit plaque on OCT was compared between female (n=171) and male (n=689) subjects in younger (<70 years old) and elderly (≥70 years old) patients. In elderly patients, the prevalence of thin-cap fibroatheroma (TCFA) was significantly higher in women than in men (30.6 vs. 15.2%, P<0.001). In younger patients, the prevalence of large calcification was significantly higher in women than in men (60.0 vs. 32.8%, P<0.001). The prevalence of other vulnerable plaque characteristics (i.e., macrophages, microchannels, and spotty calcification), was similar between women and men. Elderly women had a significantly higher prevalence of TCFA (OR, 2.13; 95% CI: 1.33-3.44, P=0.002) than other patients. CONCLUSIONS: Women had a higher prevalence of TCFA and of large calcification than men in patients ≥70 and <70 years old, respectively. This may facilitate the understanding of gender differences in the pathogenesis of coronary atherosclerosis, and the tailoring of therapy and of prevention according to age and gender.

Physical exertion as a trigger of acute coronary syndrome caused by plaque erosion.

Distinct clinical characteristics have been demonstrated in patients with plaque erosion as compared with those with plaque rupture. We reasoned that greater physical activity might influence the onset of plaque erosion. In total, 97 consecutive patients with non ST-segment elevation acute coronary syndrome (ACS) who underwent optical coherence tomography (OCT) imaging of the culprit lesion were enrolled. OCT-determined culprit plaque characteristics were plaque erosion (18.6%), calcified plaque (26.8%), plaque rupture (32.0%) and other (22.7%). The physical activity evaluated by estimated metabolic equivalents (METs) at ACS onset was significantly greater in the plaque erosion group than in the plaque rupture group (3.3 ± 1.7 vs. 2.1 ± 1.0, p = 0.011). The rate of ACS onset outdoors was the highest (61.1%) in the plaque erosion group. The combination of greater physical activity (> 3 METs), outdoor onset and higher body mass index (> 25.1 kg/m2) had a significant odds ratio for the incidence of plaque erosion (odds ratio 15.0, 95% confidence interval 3.81 to 59.0, p < 0.001). Plaque erosion was associated with greater physical activity at the onset. This finding may help to further clarify the pathogenesis of ACS Impact of physical exertion on the incidence of plaque erosion. NSTE-ACS, non ST-segment elevation acute coronary syndrome.

Transaortic Access Using Vascular Graft for Transcatheter Aortic Valve Implantation.

A 92-year-old man with acute heart failure due to severe aortic stenosis underwent transcatheter aortic valve implantation (TAVI). Computed tomography demonstrated severe stenosis of the right common iliac artery, occlusion of the left external iliac artery, and stenosis of the left subclavian artery. Severe calcification was observed in the sinotubular junction, which was considered a risk factor for aortic dissection with transapical TAVI using a balloon-expanding bioprosthetic valve. Therefore, transaortic (TAo) access was the only option for this high-risk surgical patient. As the maximum distance from the aortic valve annulus to the sheath insertion point was less than 60 mm, TAVI was performed transaortically using a vascular graft that extended this distance, in order to avoid sheath dislocation. Our experience demonstrates that vascular graft application is a viable option in patients with an inadequate distance between the aortic valve annulus and the puncture site in TAo-TAVI.

Contrast Volume and Decline in Kidney Function in Optical Coherence Tomography-Guided Percutaneous Coronary Intervention.

Optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) may increase contrast volume. However, the impact of OCT-guided PCI on the decline in kidney function (DKF) in actual clinical practice remains unclear.Among 1,003 consecutive patients who underwent either OCT-guided or intravascular ultrasound (IVUS)-guided PCI in our institute, we identified 202 propensity score-matched pairs adjusted by baseline factors. The incidence of DKF was compared between the OCT-guided PCI group and the IVUS-guided PCI group. DKF was defined as an increase in serum creatinine level of ≥ 0.5 mg/dL or a relative increase of ≥ 25% over baseline within 48 hours (acute DKF) or 1 month (sustained DKF) after PCI.Baseline characteristics, including the prevalence of chronic kidney disease (54% versus 46%, P = 0.09), were comparable between the OCT- and IVUS-guided PCI groups except for the age. The contrast volume was comparable between the two groups (153 ± 56 versus 144 ± 60 mL, P = 0.09), although it was significantly greater in the OCT-guided PCI group in patients with acute coronary syndrome (ACS; 175 ± 55 versus 159 ± 43 mL, P = 0.04). The incidence of acute DKF (0.5% versus 2.5%, P = 0.22) and sustained DKF (5.0% versus 10.4%, P = 0.31) was comparable between the two groups. Multivariate analysis demonstrated that ACS (odds ratio 4.74, 95% confidence interval 2.72-8.25, P < 0.001) was a predictor of sustained DKF.Compared with IVUS-guided PCI, OCT-guided PCI did not increase the incidence of DKF in actual clinical practice, although the increased contrast volume was observed in ACS cases.

Impaired Flow-Mediated Dilation and Severity and Vulnerability of Culprit Plaque in Patients with Coronary Artery Disease.

The association between endothelial function, evaluated using flow-mediated dilatation (FMD), and the severity of coronary artery disease remains to be elucidated.A total of 245 consecutive patients with stable angina were prospectively enrolled. FMD was evaluated in the brachial artery before percutaneous coronary intervention. Patients were divided into 2 groups according to the FMD value (lower FMD group [FMD < 2.0], n = 82; higher FMD group [FMD ≥ 2.0], n = 163). The severity of coronary artery disease was evaluated using findings of angiography and optical coherence tomography, and compared between the 2 groups.The prevalence of left main (LM) disease was significantly higher in the lower FMD group than in the higher FMD group (8.5% versus 2.5%, P = 0.046), although the prevalence of multivessel disease was comparable between the groups. Lower FMD was independently associated with a higher prevalence of LM disease (odds ratio, 3.89; 95% confidence interval, 1.12-15.5; P = 0.033). A general linear model with multiple variables revealed that the minimal lumen area (MLA) in the culprit lesion was significantly smaller in patients with lower FMD than in those with higher FMD (regression coefficient b, -0.249 mm2; 95% confidence interval, -0.479--0.018 mm2; P = 0.035). The prevalence ofvulnerable plaque characteristics was comparable between the 2 groups.Patients with lower FMD had a higher incidence of LM disease and a smaller MLA in the culprit lesion. FMD may be a useful, noninvasive indicator for identifying patients with severe coronary artery disease.

Early Safety and Efficacy of Sapien 3 20 mm Transcatheter Heart Valve Implantation in Small Japanese Body Size.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is effective in treating severe aortic stenosis in inoperable or high-risk surgical patients, however, the little is known about outcomes after Sapien 3 20 mm transcatheter heart valve (THV) implantation. The purpose of this study was to investigate the short term outcomes of Sapien 3 20 mm THV implantation in Japanese people with a small body size. METHODS: We retrospectively collected the hospital records of consecutive patients who underwent TAVI using the Sapien 3 20 mm THV between October 2016 and March 2017. Clinical and echocardiographic data from before and one week after TAVI were collected. RESULTS: Six Japanese patients (all female, mean age 89 ± 5 years, body surface area [BSA] 1.29 ± 0.16m2) received a Sapien 3 20 mm THV. All the procedures were feasible and successful, and the 30-day mortality rate was 0%. The functional class and the echocardiographic findings significantly improved (aortic valve area, 0.5 ± 0.1 cm2 to 0.8 ± 0.1cm2; mean pressure gradient, 55 ± 15 mmHg to 19 ± 7 mmHg; P = .043, respectively). However, the values of the indexed effective orifice area in all patients after Sapien 3 20 mm THV implantation were less than 0.85 cm2/m2, suggesting prosthesis-patient mismatch (PPM). CONCLUSIONS: The implantation of a Sapien 3 20 mm THV was safe and effective in high surgical risk elderly Japanese patients with a small body size. PPM after Sapien 3 20mm THV may be prevalent among Asians with small body sizes. Careful clinical follow-up will be necessary after Sapien 3 20 mm THV implantation.

Effects on bone metabolism markers and arterial stiffness by switching to rivaroxaban from warfarin in patients with atrial fibrillation.

In recent years, direct oral anticoagulants (DOACs) of dabigatran, rivaroxaban, apixaban, edoxaban, which are all alternatives to warfarin, have been released. The use of DOACs is becoming more widespread in the clinical management of thrombotic stroke risk in patients with atrial fibrillation (AF). In large-scale clinical trials of each drug, DOACs were reported to inhibit intracranial hemorrhage, stroke, and death compared to warfarin. Warfarin is an endogenous vitamin K antagonist; therefore, patients who are taking warfarin must be prohibited from taking vitamin K. Vitamin K is an essential cofactor required for the ɤ-carboxylation of vitamin K-dependent proteins including coagulation factors, osteocalcin (OC), matrix Gla protein (MGP), and the growth arrest-specific 6 (GAS6). OC is a key factor for bone matrix formation. MGP is a local inhibitor of soft tissue calcification in the vessel wall. GAS6 prevents the apoptosis of vascular smooth muscle cells. Therefore, decrease of blood vitamin K levels may cause osteoporosis, vascular calcification, and the inhibition of vessels angiogenesis. This study aimed to evaluate the effects of changing from warfarin to rivaroxaban on bone mineral metabolism, vascular calcification, and vascular endothelial dysfunction. We studied 21 consecutive patients with persistent or chronic AF, who were treated with warfarin at least for 12 months. Warfarin administration was changed to rivaroxaban (10 or 15 mg/day) in all patients. Osteopontin (OPN), bone alkaline phosphatase (BAP), and under-carboxylated osteocalcin (ucOC) were measured. Pulse wave velocity (PWV) and augmentation index (AI) were also measured as atherosclerosis assessments. All measurements were done before and six months after the rivaroxaban treatment. There was a significant increase in serum level of BAP compared to baseline (12.5 ± 4.6 to 13.4 ± 4.1 U/L, P < 0.01). In contrast, there was a significant decrease in the serum level of ucOC (9.5 ± 5.0 to 2.7 ± 1.3 ng/ml, P < 0.01). Also, in the ucOC levels, there was a significant negative correlation between baseline values and baseline to 6-months changes in high ucOC group (r = -0.97, P < 0.01). The atherosclerosis- and osteoporosis-related biomarker, serum level of OPN were significantly decreased compared to baseline (268.3 ± 46.8 to 253.4 ± 47.1 ng/ml, P < 0.01). AI and PWV were significantly decreased after 6 months of treatment with rivaroxaban (33.9 ± 18.4 to 24.7 ± 18.4%, P = 0.04; 1638.8 ± 223.0 to 1613.0 ± 250.1 m/s, P = 0.03, respectively). Switching to rivaroxaban from warfarin in patients with atrial fibrillation was associated with an increase of bone formation markers and a decrease of bone resorption markers, and also improvements of PWV and AI.

Atrial septal defect becoming clinically evident after cardiac surgery for annuloaortic ectasia: a case report.

Background: Right ventricular volume overload is the key finding in a patient with previously undiagnosed atrial septal defect (ASD). Case summary: A 68-year-old female was referred to our hospital due to progressive pulmonary artery dilatation observed on her chest X-ray. Echocardiography revealed a secundum ASD with right ventricular dilatation. She had undergone aortic root replacement and aortic valve replacement for annuloaortic ectasia and aortic insufficiency 12 years prior to the diagnosis. She was also diagnosed with Marfan syndrome, which was supported by family histories. Computed tomography did not show a secundum ASD before the surgery. We finally closed the secundum ASD with catheter closure device. Discussion: Ascending aneurysm might mask the presence of secundum ASD. Monitoring the change in pulmonary artery dilatation overtime is useful for the diagnosing secundum ASD.

Impact of Small Aortic Annuli on the Performance of Transcatheter Aortic Valve Replacement Bioprostheses: An Updated Meta-Analysis of Recent Studies.

A metanalysis of available randomized controlled trials and observational studies comparing self-expanding (SE) and balloon-expandable (BE) bioprostheses in patients with small aortic annulus and aortic stenosis for short- and midterm hemodynamic and clinical outcomes was performed. A total of 21 studies with a total 8,647 patients (SE: n = 4,336 patients vs BE: n = 4,311 patients) were included. SE bioprostheses had a lower postoperative mean gradient at 30 days (Mean Difference [MD] -5.16, 95% confidence interval [CI] 4.7 to 5.5, p <0.001) and at 1 year (MD -6.6, 95%CI 6.1 to 7.03, p <0.001), with a larger indexed effective orifice area (0.17, 95% CI 0.13 to 0.22, p <0.001 and 0.17, 95% CI 0.08 to 0.27, p <0.001) at both time intervals. BE bioprostheses had a higher risk of 30-day and 1-year severe prosthesis-patient mismatch (risk ratio [RR] 1.07, 95% CI 1.04 to 1.09, p <0.001; RR 1.07, 95% CI 1.04 to 1.11, p <0.001). The 30-day and 1 year paravalvular leaks (RR 0.99, 95% CI 0.98 to 0.99, p <0.001; RR 0.89, 95% CI 0.82 to 0.95, p <0.001) and permanent pacemaker implantation (RR 0.97, 95% CI 0.94 to 0.99, p 0.01, I2 = 40%,) were lower in the BE group. BE bioprostheses were associated with a lower risk of in-hospital stroke (RR 0.99, 95% CI 0.98 to 1, p = 0.01). In conclusion, in patients with small aortic annulus and aortic stenosis, SE bioprostheses have superior hemodynamic performance but higher rates of paravalvular leak, permanent pacemaker implantation, and in-hospital stroke. BE bioprostheses were associated with a higher risk of severe prosthesis-patient mismatch.

Patients without prolonged QRS after TAVI with CoreValve device do not experience high-degree atrio-ventricular block.

OBJECTIVE: To identify clinical and electrical factors predicting delayed high-degree atrio-ventricular block (AVB) after transcatheter aortic valve implantation (TAVI). BACKGROUND: TAVI is a new technique for treating severe aortic valve stenosis in patients at high surgical risk but can be followed by high-grade AVB requiring permanent pacing (PP). METHODS AND RESULTS: The study included 79 patients (82 ± 17 years, Euroscore = 23% ± 10%) free of PP need before and immediately after TAVI procedure. Delayed high-degree AVB was defined by types 2 or 3 AVB diagnosed at least 24 hr after the index procedure. Permanent pacemaker implantation was performed for all these patients. We compared clinical and electrical variables before and after TAVI in patients with delayed AVB or not. TAVI was performed successfully in all patients. The 21 (26%) patients who exhibited delayed high-grade AVB had significantly deeper prosthesis implantation (12 ± 4 mm vs. 9 ± 5 mm, P = 0.03) and wider post-TAVI QRS duration (155 ± 17 msec vs. 131 ± 25 msec, P = 0.0004), with no difference in baseline QRS duration. Post-TAVI QRS duration was the only independent predictor of post-TAVI permanent for delayed high-degree AVB (P = 0.02). After a mean follow-up of 10 ± 8 months, all 21 patients with post-TAVI QRS ≤ 128 msec were free of high-grade AVB, whereas 21/55 (38%) patients with post-TAVI QRS >128 msec had PP (P = 0.0016). CONCLUSION: Delayed (>24 hr after the procedure) high-grade AVB necessitating PP is common after TAVI. QRS duration measured immediately after TAVI was the best independent predictor of PP in this population. Patients with QRS ≤ 128 msec immediately after TAVI had no risk of requiring PP.

Correlation between respiratory muscle weakness and frailty status as risk markers for poor outcomes in patients with cardiovascular disease.

AIMS: Although the developmental mechanism of respiratory muscle weakness (RMW) and frailty are partly similar in patients with cardiovascular disease (CVD), their relationship remains unclear. This study aimed to investigate the correlation between RMW and frailty and its impact on clinical outcomes in patients with CVD. METHODS AND RESULTS: In this retrospective observational study, consecutive 1217 patients who were hospitalized for CVD treatment were enrolled. We assessed frailty status by using the Fried criteria and respiratory muscle strength by measuring the maximal inspiratory pressure (PImax) at hospital discharge, with RMW defined as PImax <70% of the predicted value. The endpoint was a composite of all-cause death and/or readmission for heart failure. We examined the prevalence of RMW and frailty and their correlation. The relationships of RMW with the endpoint for each presence or absence of frailty were also investigated. Respiratory muscle weakness and frailty were observed in 456 (37.5%) and 295 (24.2%) patients, respectively, and 149 (12.2%) patients had both statuses. Frailty was detected as a significant indicator of RMW [odds ratio: 1.84, 95% confidence interval (CI): 1.39-2.44]. Composite events occurred in 282 patients (23.2%). Respiratory muscle weakness was independently associated with an increased incidence of events in patients with both non-frailty [hazard ratio (HR): 1.40, 95% CI: 1.04-1.88] and frailty (HR: 1.68, 95% CI: 1.07-2.63). CONCLUSIONS: This is the first to demonstrate a correlation between RMW and frailty in patients with CVD, with 12.2% of patients showing overlap. RMW was significantly associated with an increased risk of poor outcomes in patients with CVD and frailty.