Utility of Routine Invasive Coronary Angiography Prior to Transcatheter Aortic Valve Replacement.

BACKGROUND/PURPOSE: Despite the high prevalence of coronary artery disease (CAD) in patients with severe aortic stenosis (AS), the optimal management of concomitant CAD, including revascularization before transcatheter aortic valve replacement (TAVR), remains controversial. Contemporary, real-world practice patterns have not yet been described. We aimed to characterize the burden of CAD in contemporary TAVR patients and evaluate revascularization practices at a high-volume center. METHODS/MATERIALS: We retrospectively analyzed all adult patients referred for TAVR at our center between January 2019 and January 2020. Presence of significant CAD and subsequent management were recorded. Presenting symptoms, use of non-invasive and invasive ischemia testing, and pre-TAVR computed tomography (CT) imaging were analyzed. RESULTS: A total of 394 patients with severe AS were referred for TAVR. Thirty-nine patients (9.9%) instead underwent surgery, of whom only 5 (1.3%) received coronary artery bypass grafting. Of the remaining 355 patients, 218 patients (61.4%) had insignificant CAD. Of the 137 patients (38.6%) with significant CAD, only 30 (8.5%) underwent percutaneous coronary intervention (PCI). Of these, less than half had anginal symptoms, a third had CAD in proximal segments, and a third underwent ischemia testing before PCI. Pre-TAVR CT accurately identified significant CAD in 28/30 patients (93.3%) who underwent PCI. CONCLUSIONS: Only 1 in 25 contemporary TAVR patients had significant CAD and angina requiring intervention, calling into question the utility of routine invasive coronary angiography before TAVR. A Heart Team approach integrating anginal symptoms, ischemia testing and possibly pre-TAVR CT is needed to guide the need, timing, and strategy of revascularization.

Admissions Rate and Timing of Revascularization in the United States in Patients With Non-ST-Elevation Myocardial Infarction.

Clinical trials have shown improved outcomes with an early invasive approach for non-ST-elevation myocardial infarction (NSTEMI). However, real-world data on clinical characteristics and outcomes based on time to revascularization are lacking. We aimed to analyze NSTEMI rates, revascularization timing, and mortality using the 2016 Nationwide Readmissions Database. We identify patients who underwent diagnostic angiography and subsequently received either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Finally, revascularization timing and mortality rates (in-hospital and 30-day) were extracted. Our analysis included 748,463 weighted NSTEMI hospitalizations in 2016. Of these hospitalizations, 50.3% (376,695) involved diagnostic angiography, with 34.1% (255,199) revascularized. Of revascularized patients, 77.6% (197,945) underwent PCI and 22.4% (57,254) underwent CABG. Patients with more comorbidities tended to have more delayed revascularization. PCI was most commonly performed on the day of admission (32.9%; 65,155). This differs from CABG, which was most commonly performed on day 3 after admission (13.7%; 7,823). The in-hospital mortality rate increased after day 1 for PCI patients and after day 4 for CABG patients, whereas 30-day in-hospital mortality for both populations increased as revascularization was delayed. Our study shows that patients undergoing early revascularization differ from those undergoing later revascularization. Mortality is generally high with delayed revascularization, as these are sicker patients. Randomized clinical trials are needed to evaluate whether very early revascularization (<90 minutes) is associated with improved long-term outcomes in high-risk patients.

MitraClip 30-Day Readmissions and Impact of Early Discharge: An Analysis from the Nationwide Readmissions Database 2016.

BACKGROUND/PURPOSE: Edge-to-edge mitral valve repair (MVR) using the MitraClip (Abbott Vascular, Santa Clara, CA), is now labeled for patients with degenerative and functional mitral regurgitation. Because this is a minimally invasive transcatheter procedure, patients are commonly discharged early post-procedure, yet rates and causes of early readmissions are unknown. This study aimed to evaluate underlying causes and trends of 30-day readmissions using the 2016 US Nationwide Readmissions Database (NRD) in patients discharged early after MVR with MitraClip. METHODS/MATERIALS: We identified all patients who received a MitraClip in 2016 and then identified a cohort of patients who were discharged early (<48 h). Next, any admission within 30 days of the index procedure was identified. RESULTS: Our analysis included 3858 MitraClip patients. The overall 30-day readmission rate was 13.5%. A total of 2341 patients (61%) were discharged early. The readmission rate among the early discharge cohort was 10.1% (233/2314). The readmission rate among the early discharge cohort was 10.1% (233/2314). The major causes of readmission were heart failure (27.5%), infections (15.5%), and postprocedural complications (6.9%). CONCLUSIONS: Early discharge post-MitraClip treatment is feasible, safe, and associated with low readmission rates as compared to all MitraClip procedures performed. Special considerations for early discharge should apply to postprocedural complications and patients with heart failure, the most common readmission causes, as these may require longer stays post-procedure. SUMMARY: This study aimed to evaluate underlying causes and trends of 30-day readmissions using the US Nationwide Readmissions Database (NRD) 2016 dataset in patients discharged early after mitral valve repair with MitraClip. The overall 30-day readmission rate during this period was 13.5%; the readmission rate among patients discharged early (<48 h) was 10.1%. Early discharge post-MitraClip treatment is feasible and safe and is associated with low readmission rates.