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1.
Am Heart J ; 234: 111-121, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33453161

RESUMO

BACKGROUND: Among patients with severe aortic stenosis (AS), there are limited data on aortic valve replacement (AVR), reasons for nonreceipt and mortality by race. METHODS: Utilizing the Duke Echocardiography Laboratory Database, we analyzed data from 110,711 patients who underwent echocardiography at Duke University Medical Center between 1999 and 2013. We identified 1,111 patients with severe AS who met ≥1 of 3 criteria for AVR: ejection fraction ≤50%, diagnosis of heart failure, or need for coronary artery bypass surgery. Logistic regression models were used to assess the association between race, AVR and 1-year mortality. χ2 testing was used to assess potential racial differences in reasons for AVR nonreceipt. RESULTS: Among the 1,111 patients (143 AA and 968 CA) eligible for AVR, AA were more often women, had more diabetes, renal insufficiency, aortic regurgitation and left ventricular hypertrophy. CA were more often smokers, had more ischemic heart disease, hyperlipidemia and higher median income levels. There were no racial differences in surgical risk utilizing logistic euroSCORES. Relative to CA, AA had lower rates of AVR (adjusted odds ratio 0.46, 95% CI 0.3-0.71, P < .001) yet similar 1-year mortality (aHR 0.81, 95% CI 0.57-1.17, P = .262). There were no significant differences in reasons for AVR nonreceipt. CONCLUSIONS: We identified 143 African Americans (AA) and 968 Caucasian Americans(CA) with severe AS who met prespecified criteria for AVR.. AA relative to CA were more often women, had more diabetes, renal insufficiency, and left ventricular hypertrophy, however had less tobacco use, ischemic heart disease, hyperlipidemia and lower median income levels. Among patients with severe AS, AA relative to CA had lower rates of AVR (adjusted odds ratio 0.46, 95% CI 0.3-0.71, P < .001) without significant differences in reasons for AVR nonreceipt and similar 1-year mortality.


Assuntos
Afro-Americanos/estatística & dados numéricos , Estenose da Valva Aórtica/cirurgia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/etnologia , Estenose da Valva Aórtica/mortalidade , Distribuição de Qui-Quadrado , Ponte de Artéria Coronária/estatística & dados numéricos , Diabetes Mellitus/epidemiologia , Ecocardiografia , Feminino , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Hiperlipidemias/epidemiologia , Hipertrofia Ventricular Esquerda/epidemiologia , Renda , Modelos Logísticos , Masculino , Isquemia Miocárdica/epidemiologia , Insuficiência Renal/epidemiologia , Fatores Sexuais , Volume Sistólico , Tabagismo/epidemiologia , Estados Unidos/epidemiologia , Estados Unidos/etnologia
2.
J Thorac Cardiovasc Surg ; 161(3): 920-932, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33478837

RESUMO

OBJECTIVE: Sutureless aortic valves are a novel option for aortic valve replacement. We sought to demonstrate noninferiority of sutureless versus standard bioprostheses in severe symptomatic aortic stenosis. METHODS: The Perceval Sutureless Implant Versus Standard-Aortic Valve Replacement is a prospective, randomized, adaptive, open-label trial. Patients were randomized (March 2016 to September 2018) to aortic valve replacement with a sutureless or stented valve using conventional or minimally invasive approach. Primary outcome was freedom from major adverse cerebral and cardiovascular events (composite of all-cause death, myocardial infarction, stroke, or valve reintervention) at 1 year. RESULTS: At 47 centers (12 countries), 910 patients were randomized to sutureless (n = 453) or conventional stented (n = 457) valves; mean ages were 75.4 ± 5.6 and 75.0 ± 6.1 years, and 50.1% and 44.9% were female, respectively. Mean ± standard deviation Society of Thoracic Surgeons scores were 2.4 ± 1.7 and 2.1 ± 1.3, and a ministernotomy approach was used in 50.4% and 47.3%, respectively. Concomitant procedures were performed with similar rates in both groups. Noninferiority was demonstrated for major adverse cerebral and cardiovascular events at 1 year, whereas aortic valve hemodynamics improved equally in both groups. Use of sutureless valves significantly reduced surgical times (mean extracorporeal circulation times: 71.0 ± 34.1 minutes vs 87.8 ± 33.9 minutes; mean crossclamp times: 48.5 ± 24.7 vs 65.2 ± 23.6; both P < .0001), but resulted in a higher rate of pacemaker implantation (11.1% vs 3.6% at 1 year). Incidences of perivalvular and central leak were similar. CONCLUSIONS: Sutureless valves were noninferior to stented valves with respect to major adverse cerebral and cardiovascular events at 1 year in patients undergoing aortic valve replacement (alone or with coronary artery bypass grafting). This suggests that sutureless valves should be considered as part of a comprehensive valve program.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Bioprótese , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Procedimentos Cirúrgicos sem Sutura , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Estudos Prospectivos , Desenho de Prótese , Reoperação , Índice de Gravidade de Doença , Procedimentos Cirúrgicos sem Sutura/efeitos adversos , Procedimentos Cirúrgicos sem Sutura/mortalidade , Fatores de Tempo , Resultado do Tratamento
4.
J Am Coll Cardiol ; 76(25): 2940-2951, 2020 12 22.
Artigo em Inglês | MEDLINE | ID: mdl-33334422

RESUMO

BACKGROUND: Few studies have evaluated if diastolic function could predict outcomes in patients with aortic stenosis. OBJECTIVES: The authors aimed to assess the association between diastolic dysfunction (DD) and outcomes in patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). METHODS: Baseline, 30-day, and 1- and 2-year transthoracic echocardiograms from the PARTNER (Placement of Aortic Transcatheter Valves) 2 SAPIEN 3 registry were analyzed by a consortium of core laboratories and divided into the American Society of Echocardiography DD groups. RESULTS: Among the 1,750 included, 682 (54.4%) had grade 1 DD, 352 (28.1%) had grade 2 DD, 168 (13.4%) had grade 3 DD, and 51 (4.1%) had indeterminate DD grade. Incremental baseline grades of DD were associated with an increase in combined 1- and 2-year cardiovascular (CV) death/rehospitalization (all p < 0.002) and all-cause death at 2 years (p = 0.01) but not at 1 year. Improvement in DD grade/grade 1 DD at 30 days post-TAVR was seen in 70.8% patients. Patients with improvement in ≥1 grade of DD/grade 1 DD had reduced 1-year CV death/rehospitalization (p < 0.001) and increased 2-year survival (p = 0.01). Baseline grade 3 DD was a predictor of 1-year CV death/rehospitalization (hazard ratio: 2.73; 95% confidence interval: 1.07 to 6.98; p = 0.04). Improvement in DD grade/grade 1 DD at 30 days was protective for 1-year CV death/rehospitalizations (hazard ratio: 0.39; 95% confidence interval: 0.19 to 0.83; p = 0.01). CONCLUSIONS: In the PARTNER 2 SAPIEN 3 registry, baseline DD was a predictor of up to 2 years clinical outcomes in patients who underwent TAVR. Improvement in DD grade at 30 days was associated with improvement in short-term clinical outcomes. (The PARTNER II Trial: Placement of AoRTic TraNscathetER Valves II - PARTNER II - PARTNERII - S3 Intermediate [PARTNERII S3i]; NCT03222128; PARTNER II Trial: Placement of AoRTic TraNscathetER Valves II - High Risk and Nested Registry 7 [PII S3HR/NR7]; NCT03222141).


Assuntos
Estenose da Valva Aórtica , Insuficiência Cardíaca Diastólica , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/cirurgia , Canadá , Ecocardiografia/métodos , Ecocardiografia/estatística & dados numéricos , Feminino , Insuficiência Cardíaca Diastólica/diagnóstico , Insuficiência Cardíaca Diastólica/etiologia , Insuficiência Cardíaca Diastólica/fisiopatologia , Humanos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/fisiopatologia , Prognóstico , Análise de Sobrevida , Substituição da Valva Aórtica Transcateter/métodos , Estados Unidos
8.
PLoS One ; 15(9): e0238953, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32915895

RESUMO

Whether the subtype of atrial fibrillation affects outcomes after transcatheter aortic valve replacement for aortic stenosis is unclear. The nationwide FinnValve registry included 2130 patients who underwent primary after transcatheter aortic valve replacement for aortic stenosis during 2008-2017. Altogether, 281 (13.2%) patients had pre-existing paroxysmal atrial fibrillation, 651 (30.6%) had pre-existing non-paroxysmal atrial fibrillation and 160 (7.5%) were diagnosed with new-onset atrial fibrillation during the index hospitalization. The median follow-up was 2.4 (interquartile range: 1.6-3.8) years. Paroxysmal atrial fibrillation did not affect 30-day or overall mortality (p-values >0.05). Non-paroxysmal atrial fibrillation demonstrated an increased risk of overall mortality (hazard ratio: 1.61, 95% confidence interval: 1.35-1.92; p<0.001), but not 30-day mortality (p = 0.084). New-onset atrial fibrillation demonstrated significantly increased 30-day mortality (hazard ratio: 2.76, 95% confidence interval: 1.25-6.09; p = 0.010) and overall mortality (hazard ratio: 1.68, 95% confidence interval: 1.29-2.19; p<0.001). The incidence of early or late stroke did not differ between atrial fibrillation subtypes (p-values >0.05). In conclusion, non-paroxysmal atrial fibrillation and new-onset atrial fibrillation are associated with increased mortality after transcatheter aortic valve replacement for aortic stenosis, whereas paroxysmal atrial fibrillation has no effect on mortality. These findings suggest that non-paroxysmal atrial fibrillation rather than paroxysmal atrial fibrillation may be associated with structural cardiac damage which is of prognostic significance in patients with aortic stenosis undergoing transcatheter aortic valve replacement.


Assuntos
Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/cirurgia , Fibrilação Atrial/classificação , Fibrilação Atrial/complicações , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Fibrilação Atrial/mortalidade , Estudos de Coortes , Feminino , Finlândia/epidemiologia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Prognóstico , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento
10.
Am J Cardiol ; 133: 89-97, 2020 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-32798043

RESUMO

Data regarding the longitudinal effect of catheter procedure-related acute kidney injury (AKI) on clinical outcomes are limited. This study aimed to assess the late adverse cardiorenal events of AKI following transcatheter aortic valve implantation (TAVI). A total of 2,518 patients who underwent TAVI, excluding in-hospital deaths, were enrolled from the Japanese multicenter registry. The definition of AKI was determined using the Valve Academic Research Consortium-2 criteria. The incidence, predictors, major adverse renal and cardiac events (MARCE), and all-cause mortality of AKI were evaluated. MARCE included readmission for renal and heart failure (HF), hemodialysis requirement, and cardiovascular-renal death during the follow-up period. The incidence of AKI was 9.7% in the entire cohort. The significant predictive factors of AKI were men, diabetes mellitus, hypertension, chronic kidney disease, low albumin, overdose of contrast media, nontransfemoral approach, transfusion, vascular complications, and new pacemaker implantation. The rates of HF readmission and future hemodialysis were significantly higher in patients with AKI than in those without AKI (19.7% vs 9.0%, p <0.001, 3.3% vs 0.4%, p <0.001, respectively). Cox regression multivariate analysis showed that AKI occurrence was an independent predictive factor for the incremental risk of both MARCE and late mortality up to 4 years (hazard ratio [HR] 1.59, 95% confidence interval [CI] 0.75 to 1.20, p <0.001, HR 2.18, 95% CI 1.70 to 2.79; p <0.001, respectively). In conclusion, AKI occurrence was significantly associated with late adverse cardiorenal events after TAVI. Adequate clinical management can be expected to reduce AKI-related late phase cardiorenal damage even after successful TAVI.


Assuntos
Lesão Renal Aguda/epidemiologia , Estenose da Valva Aórtica/cirurgia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/terapia , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/mortalidade , Feminino , Humanos , Incidência , Japão , Masculino , Sistema de Registros , Diálise Renal , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo
11.
Am J Cardiol ; 133: 105-115, 2020 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-32811649

RESUMO

Scarce data exist on clinical features and prognosis of patients with severe aortic stenosis (AS), concomitant with left ventricular obstruction (LVO). We aimed to evaluate the prevalence, characteristics, and outcomes in patients with severe AS and LVO undergoing transcatheter aortic valve implantation (TAVI). Consecutive patients with severe AS undergoing TAVI between January 2013 to December 2017 at our institution were included. Significant LVO was defined as resting peak left ventricular (LV) systolic gradient ≥30 mm Hg on pre-TAVI echocardiography. We analyzed the primary composite outcome of all-cause mortality and rehospitalization for heart failure (HHF) at 1-year in patients with LVO and those without LVO in the overall and propensity-matched populations. Among 1,729 patients who underwent TAVI, significant LVO was observed in 31 (1.8%) patients. This group was more likely to be female, had smaller aortic annulus and LV cavity, and received a smaller size of the transcatheter heart valve. The most common phenotype of LV hypertrophy causing LVO was concentric LV hypertrophy (58%), and mid-LV obstruction was more common than LV outflow tract obstruction (77% vs 23%, respectively). After adjustment for baseline differences, the primary outcome was not significantly different between patients with LVO and those without LVO (15% vs 16%, respectively; hazard ratio: 0.83; 95% confidence interval: 0.19 to 3.72; p = 0.809). In conclusion, in patients undergoing TAVI, concomitant LVO was relatively uncommon and occurred more often at mid-LV. The presence of pre-TAVI LVO was not associated with worse outcomes defined as increase all-cause mortality or HHF at 1-year.


Assuntos
Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/cirurgia , Insuficiência Cardíaca/epidemiologia , Substituição da Valva Aórtica Transcateter , Obstrução do Fluxo Ventricular Externo/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Feminino , Insuficiência Cardíaca/diagnóstico , Hospitalização , Humanos , Masculino , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento , Obstrução do Fluxo Ventricular Externo/complicações , Obstrução do Fluxo Ventricular Externo/diagnóstico
12.
Am J Cardiol ; 133: 98-104, 2020 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-32843145

RESUMO

Previous studies indicate that women who underwentwho underwent transcatheter aortic valve implantation (TAVI) have poorer 30-day outcomes compared with men. However, the effect of gender as a prognostic factor for long-term outcomes following TAVI remains unclear. Between 2008 and 2018, all patients (n = 683) who underwent TAVI in 2 centres in Melbourne, Australia were prospectively included in a registry. The primary end-point was long-term mortality. The secondary end points were Valve Academic Research Consortium-2 (VARC-2) in-hospital complications and mortality at 30-days and 1-year. Of 683 patients, 328 (48%) were women. Women had a higher mean STS-PROM score (5.2 ± 3.1 vs 4.6 ± 3.5, p < 0.001) but less co-morbidities than men. Women had a significantly higher in-hospital bleeding rates (3.3% vs 1.0%, Odds Ratio 4.21, 95% confidence interval [CI] 1.16 to15.25, p = 0.027) and higher 30-day mortality (2.4% vs 0.3%, hazard ratio [HR] 8.75, 95% CI 1.09 to 69.6, p = 0.040) than men. Other VARC-2 outcomes were similar between genders. Overall mortality rate was 36% (246) over a median follow up of 2.7 (interquartile rang [IQR] 1.7 to 4.2) years. Median time to death was 5.3 (95% CI 4.7 to 5.7) years. One-year mortality was similar between genders (8.3% vs 7.8%), as was long-term mortality (HR = 0.91, 95% CI 0.71 to 1.17, p = 0.38). On multivariable analysis, female gender was an independent predictor for 1-year mortality (HR = 2.33, 95% CI 1.11 to 4.92, p = 0.026), but not long-term mortality (HR = 0.78, 95% CI 0.54 to 1.14, p = 0.20). In the women only cohort, STS-PROM was the only independent predictor of long-term mortality (HR 1.88, 95% CI 1.42 to 2.48, p < 0.001). In conclusion, women had higher rates of peri-procedural major bleeding and 30-day mortality following TAVI. However, long-term outcomes were similar between genders.


Assuntos
Estenose da Valva Aórtica/cirurgia , Complicações Pós-Operatórias/epidemiologia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/mortalidade , Austrália , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico , Sistema de Registros , Estudos Retrospectivos , Fatores Sexuais , Taxa de Sobrevida , Resultado do Tratamento
13.
Am J Cardiol ; 131: 67-73, 2020 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-32723557

RESUMO

The use of LDT may signify significant hemodynamic changes and left ventricular remodeling in severe aortic stenosis (AS). Therefore, we sought to determine whether loop diuretic therapy (LDT) is associated with adverse outcomes following transcatheter aortic valve implantation (TAVI) in patients with severe symptomatic AS. Subjects undergoing TAVI at a single institution from June 2008 to December 2017 were analyzed. LDT doses were normalized to oral furosemide daily equivalents. All outcomes were adjudicated using VARC2 criteria. Descriptive statistics, multivariate logistic regression, and propensity score matching were used. Of the 804 subjects studied, 48.3% were on pre-TAVI LDT with a mean dose of 51.1 mg furosemide dose-equivalents. Subjects on LDT were higher risk, frail patients with more co-morbidities including chronic kidney disease, coronary artery disease requiring prior bypass grafting, peripheral arterial disease, atrial fibrillation or flutter, and diabetes with more severe heart failure symptoms. Those on LDT also had worse left ventricular systolic function, lower transvalvular gradients, and markers of adverse left ventricular remodeling, including increased left ventricular mass index and higher rates of concentric and eccentric hypertrophy. On propensity-score matching, death within one year post-TAVI was borderline significantly higher in the pre-LDT as compared with no-LDT group (16.9% vs 10.4 %, p = 0.068). In conclusion, use of pre-TAVI LDT for severe symptomatic AS is associated with a trend towards worse 1-year mortality and is a marker of high-risk, frail individuals with advanced left ventricular remodeling.


Assuntos
Estenose da Valva Aórtica/cirurgia , Inibidores de Simportadores de Cloreto de Sódio e Potássio/uso terapêutico , Substituição da Valva Aórtica Transcateter , Remodelação Ventricular/efeitos dos fármacos , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Feminino , Idoso Fragilizado , Humanos , Masculino , Pontuação de Propensão , Medição de Risco , Taxa de Sobrevida
14.
Asian Cardiovasc Thorac Ann ; 28(9): 553-559, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32727206

RESUMO

BACKGROUND: Minimally invasive surgical approaches have gained popularity among patients and surgeons. The aim of this project was to assess the safety of initiating aortic valve replacement via an anterior right thoracotomy program. METHODS: Between May 2015 and May 2019, data of all isolated primary aortic valve replacements were extracted retrospectively from our prospectively collected database and categorized into conventional median sternotomy, hemisternotomy, and anterior right thoracotomy cases. In total, 661 patients underwent isolated primary aortic valve replacement, of whom 429 (65%) had a median sternotomy, 126 (19%) had a hemisternotomy, and 106 (16%) had an anterior right thoracotomy. Preoperative characteristics were similar in each of the three groups. Statistical testing of the surgical groups was undertaken using the chi-square test for categorical variables and one-way analysis of variance with Tukey post-hoc pairwise tests (where appropriate) for continuous variables, to identify differences between pairs of data. RESULTS: Cardiopulmonary bypass and crossclamp times were significantly longer in the anterior right thoracotomy group compared to the hemisternotomy and median sternotomy groups (p < 0.001). Blood loss was significantly less and hospital stay significantly shorter in the hemisternotomy group compared to median sternotomy group but not the anterior right thoracotomy group. Mortality, stroke, renal, gastrointestinal and respiratory complications showed no statistical differences. CONCLUSION: Surgical aortic valve replacement had a very low mortality and morbidity in our experience, and it is safe to start a minimal access program for aortic valve replacement.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca , Esternotomia , Toracotomia , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Competência Clínica , Bases de Dados Factuais , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Curva de Aprendizado , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Segurança do Paciente , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Esternotomia/efeitos adversos , Esternotomia/mortalidade , Toracotomia/efeitos adversos , Toracotomia/mortalidade , Fatores de Tempo , Resultado do Tratamento
15.
Am J Cardiol ; 131: 74-81, 2020 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-32718554

RESUMO

Up to a quarter of vascular complications during transcatheter aortic valve implantation (TAVI) result from secondary access via the femoral artery (FA). The radial artery (RA) is increasingly used as an alternative to the FA for secondary access in TAVI. Limited data exist on the outcomes of RA secondary access versus FA secondary access. We therefore conducted a systematic review and meta-analysis comparing secondary access sites. PubMed, EMBASE, Scopus, Cochrane library and CINAHL were searched systematically for studies comparing RA and FA as secondary access sites for TAVI. Primary outcomes of interest were vascular complications and major bleeding. Secondary outcomes included all-cause mortality, stroke and myocardial infarction (MI). Risk ratio (RR), standardized mean difference and corresponding 95% confidence intervals (CI) were calculated using a random effects model. Six observational studies comprising 6,373 patients (RA: 1,514, FA: 4,859) met inclusion criteria. Secondary access was utilized for aortography during valve deployment and to manage primary access site complications. Procedural characteristics were similar in both groups. RA was associated with a lower risk of major bleeding (RR: 0.51, 95% CI: 0.40 to 0.64, p <0.00001). No statistically significant difference was observed in the incidence of overall vascular complications, however, the risk of major vascular complications was lower with RA (RR: 0.45, 95% CI: 0.32 to 0.63, p <0.00001). The incidence of stroke and all-cause mortality was lower in RA, whereas no difference was observed in the risk of MI. In conclusion, our meta-analysis suggests that RA secondary access is associated with better outcomes for TAVI than FA.


Assuntos
Estenose da Valva Aórtica/cirurgia , Artéria Femoral , Artéria Radial , Substituição da Valva Aórtica Transcateter , Estenose da Valva Aórtica/mortalidade , Humanos , Complicações Pós-Operatórias/mortalidade , Fatores de Risco
16.
J Card Surg ; 35(10): 2627-2632, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32720442

RESUMO

BACKGROUND: Surgical aortic valve replacement (sAVR) is the ultimate therapy for severe aortic stenosis (AS) in suitable patients. Prognostic factors of sAVR are great interest in recent studies. Frontal QRS-T angle (fQRSTa) is a novel marker of ventricular repolarization abnormalities. In this study, we aimed to investigate the prognostic value of fQRSTa in patients with severe symptomatic AS undergoing sAVR. METHODS: A total of 372 patients with severe degenerative AS who underwent successful sAVR were included in this retrospective study. Then, patients were divided into two groups: patients with narrow fQRSTa (≤90°) as group 1 and wide fQRSTa (>90°) as group 2. Perioperative and postoperative clinical evaluation and time of death were recorded from all subjects. RESULTS: The incidence of total mortality was higher in patients with wider fQRSTa (13.8% [15]; 4.9% [9], P = .013) compared to patients with narrow fQRSTa. In multivariate logistic regression analysis, advanced age (odds ratio [OR] = 1.054; 95% confidence interval [CI] = 1.004-1.106; P = .034), dyspnea (OR = 7.687; 95% CI = 2.296-25.729; P = .001), lower efection fraction (OR = 0.924; 95% CI = 0.884-0.966; P = .001), in-hospital duration (OR = 1.051; 95% CI = 1.016-1.088; P = .004) and wider fQRSTa (OR = 4.029; 95% CI = 1.383-11.740; P = .011) were found to be independent predictors of mortality. Additionally, a Kaplan-Meier survival analysis also revealed that long-term survival was found to be significantly decreased in patients with wider fQRSTa (log-rank P = .014). CONCLUSION: fQRSTa was related with poor prognosis in patients with AS undergoing sAVR. fQRSTa was also an independent predictor of mortality in this population.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Eletrocardiografia , Implante de Prótese de Valva Cardíaca/métodos , Ventrículos do Coração/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Feminino , Implante de Prótese de Valva Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do Tratamento
17.
Prog Cardiovasc Dis ; 63(4): 482-487, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32592707

RESUMO

Bicuspid aortic valve (BAV) is the most common congenital cardiac abnormality in adults, and symptoms typically develops in adulthood. In the majority of cases, BAV disease progresses with age and surgical aortic valve replacement (AVR) is performed with excellent operative outcomes. Based on a series of randomized trials, transcatheter AVR (TAVR) has evolved from a novel technology to an established therapy for patients with symptomatic severe aortic stenosis (AS) regardless of risk profile. Despite exclusion of bicuspid anatomy from the randomized trials, an increasing number of patients with BAV-AS have been treated with TAVR. Recent observational studies showed the comparable outcomes of TAVR between bicuspid and tricuspid AS. However, worse outcomes in patients with unfavorable bicuspid anatomy such as calcified raphe plus excessive leaflet calcification have raised concerns for TAVR in younger and lower risk population. For the further expansion of TAVR toward BAV-AS population, we need randomized trials of TAVR in this population. Until then, previous registry data combined with computed tomographic-based anatomical assessment may guide the optimal therapy in patients with bicuspid anatomy.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/anormalidades , Doenças das Valvas Cardíacas/cirurgia , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/mortalidade , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/mortalidade , Humanos
18.
JACC Cardiovasc Interv ; 13(16): 1937-1944, 2020 08 24.
Artigo em Inglês | MEDLINE | ID: mdl-32484159

RESUMO

The novel coronavirus disease-2019 (COVID-19) pandemic has created uncertainty in the management of patients with severe aortic stenosis. This population experiences high mortality from delays in treatment of valve disease but is largely overlapping with the population of highest mortality from COVID-19. The authors present strategies for managing patients with severe aortic stenosis in the COVID-19 era. The authors suggest transitions to virtual assessments and consultation, careful pruning and planning of necessary testing, and fewer and shorter hospital admissions. These strategies center on minimizing patient exposure to COVID-19 and expenditure of human and health care resources without significant sacrifice to patient outcomes during this public health emergency. Areas of innovation to improve care during this time include increased use of wearable and remote devices to assess patient performance and vital signs, devices for facile cardiac assessment, and widespread use of clinical protocols for expedient discharge with virtual physical therapy and cardiac rehabilitation options.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Infecções por Coronavirus/complicações , Pandemias , Pneumonia Viral/complicações , Substituição da Valva Aórtica Transcateter/métodos , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/mortalidade , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Saúde Global , Mortalidade Hospitalar/tendências , Humanos , Pneumonia Viral/epidemiologia , Fatores de Risco
19.
Int J Cardiovasc Imaging ; 36(10): 1897-1905, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32556718

RESUMO

This study applies L-wave measurements of mid-diastolic trans-mitral flow. Although considered to be a marker of elevated filling pressure or delayed myocardial relaxation, its clinical and prognostic value is yet to be completely elucidated. It has been shown that transcatheter aortic valve replacement (TAVR) induces reverse remodeling and improves diastolic function and prognosis in patients with severe aortic stenosis (AS). Our purpose was to evaluate the prognostic value of L-wave following TAVR. We examined clinical and echocardiographic data of patients undergoing TAVR. L-Wave presence and velocity were recorded at baseline and at 1 month and 6 months following TAVR. The effect of the procedure on L-wave measurements and its impact on mortality and other clinical outcomes were analyzed. A total of 502 patients (mean age 82.58 ± 5.9) undergoing TAVR were included. Patients with baseline L-wave (n = 68, 12%) had a smaller stroke volume index by 5.7 ± 2.3 ml/m2 (p = 0.01) as compared to patients without L-wave at baseline. L-waves disappeared In 35% and 70% of patients at 1 month and at 6 months respectively. Baseline L-wave velocity was 34.8 ± 11.5 (cm/s) and decreased significantly at follow-up examinations. Patients with persistent L-wave following TAVR had higher 3-year adjusted mortality rates (HR 5.7, 95% CI 3.7-8.9, p < 0.001). Multivariate analysis of survival was also statistically significant (p < 0.001). TAVR induces L-wave disappearance and a decrease in L-wave velocity in patients with severe AS. L-wave persistence following TAVR is an independent risk factor for mortality.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Ecocardiografia Doppler de Pulso , Hemodinâmica , Substituição da Valva Aórtica Transcateter , Função Ventricular Esquerda , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Diástole , Feminino , Humanos , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento
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