Packed red blood cell transfusion associates with acute kidney injury after transcatheter aortic valve replacement.

BACKGROUND: Acute kidney injury after cardiac surgery significantly associates with morbidity and mortality. Despite not requiring cardiopulmonary bypass, transcatheter aortic valve replacement patients have an incidence of post-procedural acute kidney injury similar to patients who undergo open surgical aortic valve replacement. Packed red blood cell transfusion has been associated with morbidity and mortality after cardiac surgery. We hypothesized that packed red blood cell transfusion independently associates with acute kidney injury after transcatheter aortic valve replacement, after accounting for other risk factors. METHODS: This is a single-center retrospective cohort study of 116 patients undergoing transcatheter aortic valve replacement. Post-transcatheter aortic valve replacement acute kidney injury was defined by Kidney Disease: Improving Global Outcomes serum creatinine-based criteria. Univariate comparisons between patients with and without post-transcatheter aortic valve replacement acute kidney injury were made for clinical characteristics. Multivariable logistic regression was used to assess independent association of packed red blood cell transfusion with post-transcatheter aortic valve replacement acute kidney injury (adjusting for pre-procedural renal function and other important clinical parameters). RESULTS: Acute kidney injury occurred in 20 (17.2%) subjects. Total number of packed red blood cells transfused independently associated with post-procedure acute kidney injury (OR = 1.67 per unit, 95% CI 1.13-2.47, P = 0.01) after adjusting for pre-procedure estimated glomerular filtration rate (OR = 0.97 per ml/min/1.73m2, 95% CI 0.94-1.00, P = 0.05), nadir hemoglobin (OR = 0.88 per g/dL increase, CI 0.61-1.27, P = 0.50), and post-procedure maximum number of concurrent inotropes and vasopressors (OR = 2.09 per inotrope or vasopressor, 95% CI 1.19-3.67, P = 0.01). CONCLUSION: Packed red blood cell transfusion, along with post-procedure use of inotropes and vasopressors, independently associate with acute kidney injury after transcatheter aortic valve replacement. Further studies are needed to elucidate the pathobiology underlying these associations.

Redo Surgical Aortic Valve Replacement After Prior Transcatheter Versus Surgical Aortic Valve Replacement.

BACKGROUND: Aortic stenosis treatment should consider risks and benefits for lifetime management. Although the feasibility of redo transcatheter aortic valve replacement (TAVR) remains unclear, concerns are emerging regarding reoperation after TAVR. OBJECTIVES: The authors sought to define comparative risk of surgical aortic valve replacement (SAVR) after prior TAVR or SAVR. METHODS: Data on patients undergoing bioprosthetic SAVR after TAVR and/or SAVR were extracted from the Society of Thoracic Surgeons Database (2011-2021). Overall and isolated SAVR cohorts were analyzed. The primary outcome was operative mortality. Risk adjustment using hierarchical logistic regression as well as propensity score matching for isolated SAVR cases were performed. RESULTS: Of 31,106 SAVR patients, 1,126 had prior TAVR (TAVR-SAVR), 674 had prior SAVR and TAVR (SAVR-TAVR-SAVR), and 29,306 had prior SAVR (SAVR-SAVR). Yearly rates of TAVR-SAVR and SAVR-TAVR-SAVR increased over time, whereas SAVR-SAVR was stable. The TAVR-SAVR patients were older, with higher acuity, and with greater comorbidities than other cohorts. The unadjusted operative mortality was highest in the TAVR-SAVR group (17% vs 12% vs 9%, respectively; P < 0.001). Compared with SAVR-SAVR, risk-adjusted operative mortality was significantly higher for TAVR-SAVR (OR: 1.53; P = 0.004), but not SAVR-TAVR-SAVR (OR: 1.02; P = 0.927). After propensity score matching, operative mortality of isolated SAVR was 1.74 times higher for TAVR-SAVR than SAVR-SAVR patients (P = 0.020). CONCLUSIONS: The number of post-TAVR reoperations is increasing and represent a high-risk population. Yet even in isolated SAVR cases, SAVR after TAVR is independently associated with increased risk of mortality. Patients with life expectancy beyond a TAVR valve and unsuitable anatomy for redo-TAVR should consider a SAVR-first approach.

Aortic stenosis in chronic kidney disease: challenges in diagnosis and treatment.

Chronic kidney disease (CKD) is becoming increasingly common and is associated with development and rapid progression of aortic stenosis (AS). Patients with AS and CKD have higher mortality rates than those with AS of similar severity and normal kidney function. The diagnosis of severe AS in patients with CKD is often challenging due to alterations in haemodynamics and heart structure, and integration of data from multiple imaging modalities may be required. When indicated, the definitive treatment for severe AS is aortic valve replacement. Patients with CKD are candidates for bioprosthetic valve replacement (surgical or transcatheter aortic valve implantation) or mechanical valve replacement. However, for patients with CKD, lifetime management is complex, as patients with CKD have a higher competing risk of bioprosthetic structural valve deterioration, bleeding in the setting of systemic anticoagulation and mortality related to CKD itself. The involvement of a heart-kidney multidisciplinary team in the care of patients with CKD and severe AS is ideal to navigate the complexities of diagnosis and management decisions.

Renal Function-Based Contrast Threshold Predicts Kidney Injury in Transcatheter Aortic Valve Replacement.

Background: Acute kidney injury (AKI) after contrast-guided interventions is associated with adverse outcomes, but the role of contrast in the context of renal function is less well described for patients undergoing transcatheter aortic valve replacement (TAVR). Methods: Patients from the Michigan TAVR registry between January 2016 and December 2019 were included. AKI was defined using Valve Academic Research Consortium 2 definitions. An integer cut point for the ratio of contrast volume (CV) to renal function (estimated glomerular filtration rate [eGFR]) as a predictor of AKI was calculated. Results: Of 7112 cases, AKI occurred in 629 (8.8%) patients. Unadjusted mortality was higher among patients with AKI (32.5% vs 9.0%, P â€‹< â€‹.0001). AKI remained significantly associated with the risk of mortality after multivariable adjustment (hazard ratio = 4.50, P â€‹< â€‹.001). Procedural characteristics associated with AKI included CV/eGFR >2 (adjusted odds ratio [aOR] = 1.36, P = .003, 95% CI = 1.10-1.67), CV/eGFR >3 (aOR = 1.38, P â€‹= â€‹.009, 95% CI = 1.09-1.77), and use of general anesthesia (aOR = 1.67, P â€‹< â€‹.0001, 95% CI = 1.38-2.03). Conclusions: CV in the context of renal function administrated during TAVR is a robust tool to predict AKI. AKI after TAVR is associated with an increased risk of mortality. Incorporation of thresholds of >2× and > 3× eGFR into procedural planning should be considered as a quality initiative.

Cardiac tamponade after superior vena cava stenting.

Superior vena cava (SVC) syndrome results from the blockage of venous blood flow through the SVC, which is caused by either internal obstruction (eg, thrombus) or external compression (eg, thoracic malignancy and infection).1 While thrombus-related SVC syndrome is rising in prevalence, malignancy still accounts for the majority of cases.1 Regardless of cause, SVC syndrome is characterised by facial swelling and plethora, headache and dyspnoea.2 Although venous stenting has become standard of care for treatment of acute SVC syndrome, stent placement presents multiple risks including SVC rupture and cardiac tamponade. In these cases, a high index of suspicion and prompt action are required to avoid an often fatal outcome. Here, we present the case of a patient with cardiac tamponade and subsequent cardiac arrest after SVC stent placement.

Women's Representation in Interventional Cardiology.

This study discusses women's representation in interventional cardiology.

Sex Differences in Outcomes Following Percutaneous Coronary Intervention According to Age.

BACKGROUND: Women <50 years of age with coronary artery disease may represent a group at higher risk for recurrent ischemic events after percutaneous coronary intervention (PCI); however, no long-term, multicenter outcomes assessment exists in this population. METHODS AND RESULTS: Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated the association of sex and age on cardiovascular-related outcomes in 10,963 patients (3797 women, 394 <50 years) undergoing PCI and followed for 5 years. Death, myocardial infarction, coronary artery bypass graft surgery, and repeat PCI were primary outcomes comprising major adverse cardiovascular events. Although procedural success rates were similar by sex, the cumulative rate of major adverse cardiovascular events at 1 year was higher in young women (27.8 versus 19.9%; P=0.003), driven largely by higher rates of repeat revascularizations for target vessel or target lesion failure (coronary artery bypass graft surgery: 8.9% versus 3.9%, P<0.001, adjusted hazard ratio 2.4, 95% confidence interval 1.5-4.0; PCI: 19.0% versus 13.0%, P=0.005, adjusted hazard ratio 1.6, 95% confidence interval 1.2-2.2). At 5 years, young women remained at higher risk for repeat procedures (coronary artery bypass graft surgery: 10.7% versus 6.8%, P=0.04, adjusted hazard ratio 1.71, 95% confidence interval 1.01-2.88; repeat PCI [target vessel]: 19.7% versus 11.8%, P=0.002, adjusted hazard ratio 1.8, 95% confidence interval 1.24-2.82). Compared with older women, younger women remained at increased risk of major adverse cardiovascular events, whereas all outcome rates were similar in older women and men. CONCLUSIONS: Young women, despite having less severe angiographic coronary artery disease, have an increased risk of target vessel and target lesion failure. The causes of this difference deserve further investigation. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00005677.

Amplatzer vascular plug IV for occlusion of pulmonary arteriovenous malformations in a patient with cryptogenic stroke.

Paradoxical embolism resulting in cryptogenic stroke has received much attention recently, with the primary focus on patent foramen ovale (PFO). However, it is essential to be vigilant in the search for other causes of paradoxical embolic events, such as pulmonary arteriovenous malformations (PAVM). We describe successful closure of pulmonary AVM with a St Jude Medical (Plymouth, MN) Amplatzer™ vascular plug IV. The newer AVP-IV devices can be used for successful embolization of tortuous pulmonary AVM in remote locations where use of other traditional devices may be technically challenging.

Characterization of a novel symptom of advanced heart failure: bendopnea.

OBJECTIVES: This study sought to examine the frequency and hemodynamic correlates of shortness of breath when bending forward, a symptom we have termed "bendopnea." BACKGROUND: Many heart failure patients describe bendopnea such as when putting on their shoes. This symptom has not previously been characterized. METHODS: We conducted a prospective study of 102 subjects with systolic heart failure referred for right-heart catheterization. Time to onset of bendopnea was measured prior to catheterization. Forty-six subjects also underwent hemodynamic assessment when sitting and bending. Hemodynamic profiles were assigned on the basis of whether pulmonary capillary wedge pressure (PCWP) was ≥ 22 mm Hg and cardiac index (CI) was ≤ 2.2 l/min/m(2). RESULTS: Bendopnea was present in 29 of 102 (28%) subjects with median (25th, 75th percentiles) time to onset of 8 (7, 11) seconds. Subjects with bendopnea had higher supine right atrial pressure (RAP) (p = 0.001) and PCWP (p = 0.0004) than those without bendopnea but similar CI (p = 0.2). RAP and PCWP increased comparably in subjects with and without bendopnea when bending, but CI did not change. In those with, versus without, bendopnea, there was more than a 3-fold higher frequency of a supine hemodynamic profile consisting of elevated PCWP with low CI (55% vs. 16%, respectively, p < 0.001) but no association with a profile of elevated PCWP with normal CI (p = 0.95). CONCLUSIONS: Bendopnea is mediated via a further increase in filling pressures during bending when filling pressures are already high, particularly if CI is reduced. Awareness of bendopnea should improve noninvasive assessment of hemodynamics in subjects with heart failure.

Temporal trends in the use of drug-eluting stents for approved and off-label indications: a longitudinal analysis of a large multicenter percutaneous coronary intervention registry.

BACKGROUND: We sought to examine the temporal variations in the rate of both bare-metal stent (BMS) and drug-eluting stent (DES) use for off-label indications after the reports of an increased risk of very late stent thrombosis in patients with DES at the 2006 meeting of the European Society of Cardiology (ESC). HYPOTHESIS: To determine whether the decrease in use of DES has affected both on and off-label indications. METHODS: The study cohort included patients undergoing coronary intervention in a large regional registry, the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). Patient demographic and clinical characteristics for patients with DES in the third quarter of 2006 (pre-ESC) were compared to those from the fourth quarter of 2008 (post-guideline changes). Use of DES for off-label indications, such as ST-segment elevation myocardial infarction (STEMI), in-stent restenosis (ISR), and saphenous vein graft (SVG) interventions, were evaluated. RESULTS: The overall deployment of DES fell sharply from 83% pre-ESC to a plateau of 58% in the first quarter of 2008. This corresponded to a rise in BMS use, while angioplasty procedures stayed the same. The STEMI subgroup showed the most dramatic change, from 78% to only 36%. Off-label use in SVGs showed a similar trend, from 74% to 43%. Drug-eluting stent deployment for ISR was less affected, though it also fell 25% (from 79%-56%). CONCLUSIONS: The use of DES has fallen dramatically from June 2006 to December 2008, particularly for nonapproved indications. Our study provides a real-world assessment of contemporary change in DES use in response to the presentation of negative observational studies.

Evaluation of patients with severe symptomatic aortic stenosis who do not undergo aortic valve replacement: the potential role of subjectively overestimated operative risk.

BACKGROUND: Some patients with severe symptomatic aortic stenosis (AS) do not undergo aortic valve replacement (AVR) despite demonstrated symptomatic and survival advantages and despite unequivocal guideline recommendations for surgical evaluation. METHODS AND RESULTS: In 3 large tertiary care institutions (university, Veterans Affairs, and private practice) in Washtenaw County, Mich, patients were identified with unrefuted echocardiography/Doppler evidence of severe AS during calendar year 2005. Medical records were retrospectively reviewed for symptoms, referral for AVR, calculated operative risk for AVR, and rationale as to why patients did not undergo valve replacement. Of 369 patients with severe AS, 191 (52%) did not undergo AVR. Of these, 126 (66%, 34% of total) had symptoms consistent with AS. The most common reasons cited for absent intervention were comorbidities with high operative risk (61 patients [48%]), patent refusal (24 patients [19%]), and symptoms unrelated to AS (24 patients [19%]). Operated patients had a lower Society of Thoracic Surgery-calculated perioperative mortality risk than unoperated patients (1.8% [interquartile range, 1.0 to 3.0%] versus 2.7% [interquartile range, 1.6 to 5.5%], P<0.001). However, 28 (24%) of 126 unoperated symptomatic patients had a calculated perioperative risk less than the median risk for patients who underwent AVR. Only 57 (30%) of 191 unoperated patients were evaluated by a cardiac surgeon. There were similar rates of intervention across practice settings, and similar rates of unoperated patients despite symptoms and low operative risk. CONCLUSIONS: One third of patients with severe AS are symptomatic but do not undergo AVR, with similar findings in multiple practice environments. For most unoperated patients, objectively calculated operative risks did not appear prohibitive. Despite this, a minority of unoperated patients were referred for surgical consultation. Some patients with severe symptomatic AS may be inappropriately denied access to potentially life-saving therapy.

High prevalence of false chordae tendinae in patients without left ventricular tachycardia.

BACKGROUND: Left ventricular (LV) false chordae tendinae (false chords) have been implicated as a source of idiopathic left (IL) ventricular tachycardia (VT). However, it is unknown whether pretest bias contributes to an apparent association with disease. The purpose of this study was to determine the prevalence of false chords on direct inspection of the LV endocardium. METHODS: In a prospective series, 75 hearts were examined to identify and characterize false chords, including 20 specimens examined at autopsy and 55 consecutive patients undergoing mitral valve surgery. Medical records were reviewed for history of VT, including ILVT. RESULTS: Of 75 patients whose hearts were studied, none had a history of ILVT and only 5 had a history of any VT. False chords were present in 34 of 75 (45%) hearts, including 13 of 20 (65%) at postmortem and 21 of 55 (38%) examined at surgery (P = 0.07). The prevalence of false chords was not different among patients with (3 of 5 [60%]) versus those without (31 of 70 [44% p = 0.65]) a history of VT (P = 0.65). CONCLUSIONS: In this prospective anatomic series, the prevalence of LV false chords on autopsy and surgical inspection was approximately 45% among patients without ILVT. Previously reported associations of false chords with ILVT likely underestimated the prevalence of false chords in a normal population.