RESUMEN
BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been developed to treat symptomatic aortic stenosis in patients deemed too high risk for open-heart surgery. To address this complex population, an interdisciplinary heart team approach was proposed. AIM: Present the short- and mid-term outcomes of the first 100 patients in the Royal Prince Alfred Hospital multidisciplinary TAVI programme. METHODS: Single-centre registry. Baseline and procedural data were prospectively recorded. Outcomes were recorded according to Valve Academic Research Consortium - version 2 guidelines. RESULTS: All patients underwent a comprehensive interdisciplinary pre-procedural evaluation. Sixty-eight transfemoral and 32 transapical implantations were performed. Mean age was 82 (±8.9) years old with an average logistic EuroSCORE of 33. Although 13 procedures had major complications, there was no intraprocedural mortality. During the first month, 9% of patients were re-admitted due to heart failure and 13% had a permanent pacemaker implanted. A 3% 30-day and 8% follow-up (mean 17 months) mortalities were recorded. While no significant differences in the rate of complications were found between the first and second half of the experience, all cases of mortality within 30 days (n = 3) occurred in the initial half. Sustained haemodynamic results were obtained with TAVI (immediate mean aortic valve gradient reduction from 47 to 9 mmHg; 1-year echocardiographic gradient 9.9 mmHg, with no moderate or severe aortic regurgitation). CONCLUSION: Excellent results can be achieved with TAVI in very high-risk patients at an Australian institution. A comprehensive evaluation based on a heart team can overcome most of the difficulties imposed by this challenging population.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Aortografía , Ecocardiografía , Anciano Frágil/estadística & datos numéricos , Comunicación Interdisciplinaria , Reemplazo de la Válvula Aórtica Transcatéter , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/fisiopatología , Australia/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Grupo de Atención al Paciente , Guías de Práctica Clínica como Asunto , Evaluación de Programas y Proyectos de Salud , Estudios Prospectivos , Sistema de Registros , Tasa de Supervivencia , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Resultado del TratamientoRESUMEN
AIMS/HYPOTHESIS: Bilirubin has antioxidant and anti-inflammatory activities. Previous studies demonstrated that higher bilirubin levels were associated with reduced prevalence of peripheral arterial disease (PAD). However, the relationship between bilirubin and lower-limb amputation, a consequence of PAD, is currently unknown. We hypothesised that, in patients with type 2 diabetes, bilirubin concentrations may inversely associate with lower-limb amputation. METHODS: The relationship between baseline plasma total bilirubin levels and amputation events was analysed in 9,795 type 2 diabetic patients from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study. The analysis plan was pre-specified. Lower-limb amputation was adjudicated blinded to treatment allocation. Relevant clinical and biochemical data were available for analyses. Amputation was a pre-specified tertiary endpoint. RESULTS: Bilirubin concentrations were significantly inversely associated with lower-limb amputation, with a greater than threefold risk gradient across levels. Individuals with lower bilirubin concentrations had a higher risk for first amputation (HR 1.38 per 5 µmol/l decrease in bilirubin concentration, 95% CI 1.07, 1.79, p = 0.013). The same association persisted after adjustment for baseline variables, including age, height, smoking status, γ-glutamyltransferase level, HbA1c, trial treatment allocation (placebo vs fenofibrate), as well as previous PAD, non-PAD cardiovascular disease, amputation or diabetic skin ulcer, neuropathy, nephropathy and diabetic retinopathy (HR 1.38 per 5 µmol/l decrease in bilirubin concentration, 95% CI 1.05, 1.81, p = 0.019). CONCLUSIONS/INTERPRETATION: Our results identify a significant inverse relationship between bilirubin levels and total lower-limb amputation, driven by major amputation. Our data raise the hypothesis that bilirubin may protect against amputation in type 2 diabetes.
Asunto(s)
Amputación Quirúrgica , Bilirrubina/sangre , Complicaciones de la Diabetes/diagnóstico , Diabetes Mellitus Tipo 2/sangre , Fenofibrato/uso terapéutico , Extremidad Inferior/patología , Anciano , Antioxidantes/farmacología , Bilirrubina/metabolismo , Biomarcadores/metabolismo , Estudios de Cohortes , Diabetes Mellitus Tipo 2/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo , Factores Sexuales , Resultado del TratamientoAsunto(s)
Antihipertensivos/uso terapéutico , Endotelio Vascular/fisiopatología , Sulfonamidas/uso terapéutico , Acetilcolina/uso terapéutico , Anciano , Arginina/uso terapéutico , Bosentán , Endotelio Vascular/diagnóstico por imagen , Endotelio Vascular/efectos de los fármacos , Hipertensión Pulmonar Primaria Familiar , Femenino , Humanos , Hipertensión Pulmonar/diagnóstico por imagen , Hipertensión Pulmonar/tratamiento farmacológico , Pulmón/diagnóstico por imagen , Pulmón/efectos de los fármacos , Masculino , Persona de Mediana Edad , Nitroprusiato/uso terapéutico , Arteria Pulmonar/diagnóstico por imagen , Arteria Pulmonar/efectos de los fármacos , Arteria Pulmonar/fisiopatología , Ultrasonografía , omega-N-Metilarginina/uso terapéuticoRESUMEN
The propensity of glucocorticoids to produce hyperglycaemia, hypertension, dyslipidaemia, and central obesity has long been a cause for concern among physicians regarding possible adverse cardiovascular events. Should heart failure be added to this list of concerns?