The Benefit of Percutaneous Coronary Intervention Before Transcatheter Aortic Valve Replacement: A Multicenter Retrospective Outcome-Based Study.

There is inadequate evidence regarding the role of percutaneous coronary intervention (PCI) in patients who underwent transcatheter aortic valve replacement (TAVR). The current American Heart Association/American College of Cardiology guidelines are limited to class 2A recommendations for pre-TAVR revascularization in the setting of hemodynamically significant left main (LM), proximal left anterior descending (pLAD), or extensive bifurcation disease regardless of angina status. We performed a multicenter, retrospective, observational study assessing the benefit of PCI in patients with coronary artery disease who underwent transfemoral TAVR for severe symptomatic aortic stenosis. Patients were divided into 2 cohorts: (1) patients who did not undergo pre-TAVR PCI within the preceding 12 months (no-PCI group) and (2) patients who received pre-TAVR PCI within the preceding 12 months (PCI group). The primary outcome was defined as the composite end point of in-hospital and 30-day adverse events, including all-cause mortality, cardiac arrest, and myocardial infarction. Subgroup analyses were performed on patients with LM and/or pLAD disease and other high-risk features, including angina and heart failure. Comparisons were made between 1,809 consecutive patients (1,364 in the no-PCI group and 445 in the PCI group). There were no differences between the 2 cohorts regarding the primary composite outcome (2.0% vs 2.8%, p = 0.918) or individual secondary outcomes. Although LM/pLAD disease, New York Heart Association classes III to IV, and Society of Thoracic Surgeons risk score ≥8 were all independent predictors of the primary outcome, none of the subgroups demonstrated a benefit favoring PCI. In conclusion, there is no observed benefit from PCI within 12 months pre-TAVR in patients with severe aortic stenosis and concomitant coronary artery disease, including patients with LM/pLAD disease.

In-Hospital and One-Year Outcomes of Transcatheter Aortic Valve Replacement in Patients Requiring Supplemental Home Oxygen Use.

Background: There have been limited reports with inconsistent results on the impact of long-term use of oxygen therapry (LTOT) in patients treated with transcatheter aortic valve replacement (TAVR). Methods: We compared in-hospital and intermediate TAVR outcomes in 150 patients requiring LTOT (home O2 cohort) with 2,313 non-home O2 patients. Results: Home O2 patients were younger, and had more comorbidities including chronic obstructive pulmonary disease (COPD), diabetes, carotid artery disease, lower forced expiratory volume (FEV1) (50.3±21.1% vs. 75.0±24.7%, P < 0.001), and lower diffusion capacity (DLCO, 48.6±19.2% vs. 74.6±22.4%, P < 0.001). These differences represented higher baseline Society of Thoracic Surgeons (STS) risk score (15.5±10.2% vs. 9.3±7.0%, P < 0.001) and lower pre-procedure Kansas City Cardiomyopathy Questionnaire (KCCQ-12) scores (32.5 ± 22.2 vs. 49.1 ± 25.4, P < 0.001). The home O2 cohort required higher use of alternative TAVR vascular access (24.0% vs. 12.8%, P = 0.002) and general anesthesia (51.3% vs. 36.0%, P < 0.001). Compared to non-home O2 patients, home O2 patients showed increased in-hospital mortality (5.3% vs. 1.6%, P = 0.001), procedural cardiac arrest (4.7% vs. 1.0%, P < 0.001), and postoperative atrial fibrillation (4.0% vs. 1.5%, P = 0.013). At 1-year follow-up, the home O2 cohort had a higher all-cause mortality (17.3% vs. 7.5%, P < 0.001) and lower KCCQ-12 scores (69.5 ± 23.8 vs. 82.1 ± 19.4, P < 0.001). Kaplan-Meir analysis revealed a lower survival rate in the home O2 cohort with an overall mean (95% confidence interval (CI)) survival time of 6.2 (5.9 - 6.5) years (P < 0.001). Conclusion: Home O2 patients represent a high-risk TAVR cohort with increased in-hospital morbidity and mortality, less improvement in 1-year KCCQ-12, and increased mortality at intermediate follow-up.

Postapproval Community Hospital Experience in the United States with Left Atrial Appendage Closure Device (Watchman).

BACKGROUND: To review the procedural safety and postimplantation complications of Watchman device implanted at 2 community hospitals for primary prevention of systemic embolization in patients with nonvalvular atrial fibrillation (NVAF) who were not candidates for long-term oral anticoagulation (OAC). METHODS: This was a retrospective case series of 48 patients carried out in 2 community hospitals in the United States. Patients with NVAF who had a CHADS2 higher than 2 or CHADS2VASc2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack [TIA] or thromboembolism, vascular disease, age 65-74 years, and female gender) score of 3 or higher and were not candidates for long-term OAC. These patients were selected for implantation of Watchman device. They were followed up at 45 days, 6 months, 9 months, and 12 months after implantation of Watchman device to assess for complications involving the device and to determine if anticoagulation could be discontinued at the 45 days follow-up. They were monitored for any systemic thromboembolism while off anticoagulation. RESULTS: The success rate of device implantation was 98% (48 of 49). Only a single patient could not get Watchman implantation because of unfavorable left atrial appendage anatomy. Access-related and device implantation-related complications were zero (0%). At 45 days follow-up and end of follow-up duration, the rate of thrombus formation on the Watchman device was 4% (2 of 48). One patient had TIA after warfarin discontinuation. CONCLUSION: With improved procedural technique and well-trained operators, Watchman implantation is feasible in a community hospital also.

Do All Patients with Atrial Fibrillation Need Long-Term Anticoagulation?

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide with an estimated number of 2.7-6.1 million cases in the United States (US) alone. The incidence of AF is expected to increase 2.5 fold over the next 50 years in the US. The management of AF is complex and includes mainly three aspects; restoration of sinus rhythm, control of ventricular rate and prevention of systemic thromboembolism. AF as a cause of systemic embolization has been well known for many years, and majority of patients are on oral anticoagulants (OACs) to prevent this. Many times, a patient may not be in AF chronically, nor is the AF burden (the amount of time patient is in AF out of the total monitored time) calculated. We present three cases of new onset transient AF triggered by temporary stressors. We were able to restore normal sinus rhythm (NSR) with chemical cardioversion. As per 2014 American College of Cardiology (ACC)/American Heart Association (AHA) recommendations, we started all three patients on OACs based on CHA2DS2VASc score ≥2. However, the patients refused long term OACs after restoration of NSR and correction of the temporary enticing stressors. In any case, the decision to start OACs would have had its own risks. Here we describe how antiarrhythmic drugs were used to maintain NSR, all while they were continuously monitored to determine the need to continue OACs.