RESUMO
OBJECTIVES: To summarize the published data of combined transcatheter aortic and mitral valve intervention (CTAMVI). BACKGROUND: CTAMVI, a combination of either transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve-in-valve (TAViV) and transcatheter mitral valve replacement (TMVR), transcatheter mitral valve-in-valve/valve-in-ring (TMViV/ViR), or percutaneous mitral valve repair (PMVR) is an attractive alternative in high-surgical risk patients with combined aortic and mitral valve disease. However, its procedural details and clinical outcomes have not been well described. METHODS: We performed a systematic review of all the published articles from PUBMED and EMBASE. RESULTS: A total of 37 studies with 60 patients were included. The indication for CTAMVI was high or inoperable surgical risk and symptomatic severe aortic stenosis (92%) or severe aortic regurgitation (8%) combined with moderate to severe/severe mitral stenosis (30%) or moderate/severe mitral regurgitation (65%) or both (5%). In majority of the cases, aortic valve intervention was performed prior to the mitral valve. Mortality rate were 25% for TAVR + TMVR (range 42 days to 10 months), 17% for TAVR + TMViV/ViR (range 13 days to 6 months), 0% for TAViV + TMViV/ViR (range 6-365 days), and 15% for TAVR/ViV + PMVR (range 17 days to 419 days). Significant (more than moderate) paravalvular regurgitation post-procedure was rare. CONCLUSIONS: CTAMVI appears to confer reasonable clinical outcome. Further large study is warranted to clarify the optimal strategy, procedural details and clinical outcomes in the future.
Assuntos
Valva Aórtica/cirurgia , Cateterismo Cardíaco , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Valva Mitral/cirurgia , Substituição da Valva Aórtica Transcateter , Adulto , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Feminino , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/fisiopatologia , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Desenho de Prótese , Recuperação de Função Fisiológica , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/instrumentação , Resultado do TratamentoRESUMO
BACKGROUND: Transcatheter aortic valve replacement (TAVR) is typically performed under general anesthesia (GA). However, there is increasing data supporting the safety of performing TAVR under local anesthesia/conscious sedation (LA). We performed a meta-analysis to gain better understanding of the safety and efficacy of LA versus GA in patients with severe aortic stenosis undergoing TAVR. METHODS AND RESULTS: We comprehensively searched EMBASE, PubMed, and Web of Science. Effect sizes were summarized using risk ratios (RRs) difference of the mean (DM), and 95% CIs (confidence intervals) for dichotomous and continuous variables respectively. Twenty-six studies and 10,572 patients were included in the meta-analysis. The use of LA for TAVR was associated with lower overall 30-day mortality (RR, 0.73; 95% CI, 0.57-0.93; P = 0.01), use of inotropic/vasopressor drugs (RR, 0.45; 95% CI, 0.28-0.72; P < 0.001), hospital length of stay (LOS) (DM, -2.09; 95% CI, -3.02 to -1.16; P < 0.001), intensive care unit LOS (DM, -0.18; 95% CI, -0.31 to -0.04; P = 0.01), procedure time (DM, -25.02; 95% CI, -32.70 to -17.35; P < 0.001); and fluoroscopy time (DM, -1.63; 95% CI, -3.02 to -0.24; P = 0.02). No differences were observed between LA and GA for stroke, cardiovascular mortality, myocardial infarction, permanent pacemaker implantation, acute kidney injury, paravalvular leak, vascular complications, major bleeding, procedural success, conduction abnormalities, and annular rupture. CONCLUSION: Our meta-analysis suggests that use of LA for TAVR is associated with a lower 30-day mortality, shorter procedure time, fluoroscopy time, ICU LOS, hospital length of stay, and reduced need for inotropic support.
Assuntos
Anestesia Geral , Anestesia Local , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/efeitos adversos , Anestesia Geral/mortalidade , Anestesia Local/efeitos adversos , Anestesia Local/mortalidade , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Feminino , Humanos , Tempo de Internação , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias/terapia , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do TratamentoRESUMO
AIMS: In an effort to minimize periprocedural stroke risk, increasingly, electrophysiological (EP) procedures are being performed on anticoagulation. The decrease in stroke has been accompanied by an increase in potentially devastating vascular access complications. Ultrasound guidance for femoral vein cannulation reduces complications in other applications. The aim of this study is to determine the utility of real-time two-dimensional (2D) ultrasound guidance for femoral vein cannulation in EP. METHODS AND RESULTS: A comprehensive literature search of Medline, Embase, Google Scholar, and the Cochrane Central Register of Controlled Trials was performed. Five years of conference abstracts from the Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society were reviewed. Two independent reviewers identified trials comparing ultrasound-guided with standard cannulation in EP procedures. Data were extracted on study design, study size, operator and patient characteristics, use of anticoagulation, vascular complication rates, first-pass success rate, and inadvertent arterial puncture. Four trials, with a total of 4065 subjects, were included in the review, with 1848 subjects in the ultrasound group and 2217 subjects in the palpation group. Ultrasound guidance for femoral vein cannulation was associated with a 60% reduction of major vascular bleeding (relative risk, 0.40; 95% confidence interval, 0.28-0.91). Additionally, there was a 66% reduction in minor vascular complications (relative risk, 0.34; 95% confidence interval, 0.15-0.78). CONCLUSION: The use of real-time 2D ultrasound guidance for femoral vein cannulation decreases access-related bleeding rates and life-threatening vascular complications.
Assuntos
Cateterismo Venoso Central/estatística & dados numéricos , Cateterismo/estatística & dados numéricos , Técnicas Eletrofisiológicas Cardíacas/estatística & dados numéricos , Veia Femoral/diagnóstico por imagem , Hemorragia/epidemiologia , Ultrassonografia de Intervenção/estatística & dados numéricos , Doenças Vasculares/epidemiologia , Cateterismo Cardíaco/estatística & dados numéricos , Feminino , Humanos , Masculino , Prevalência , Fatores de RiscoRESUMO
BACKGROUND: The transfemoral (TF) approach has become the preferred approach for transcatheter aortic valve replacement (TAVR) because of its low risk profile. However, the relative safety of the percutaneous approach (PC) compared to surgical cut-down (SC) remains unclear. Our aim was to compare the outcomes between PC versus SC access in patients undergoing TF-TAVR using a meta-analysis. METHODS: We conducted a systematic electronic database search for studies reporting major and minor vascular complications (VC), major and minor bleeding, and perioperative all-cause mortality, in PC versus SC TF-TAVR cases. Complications were reported based on the Valve Academic Research Consortium criteria. A random-effects model was used to calculate odds ratios and 95% confidence intervals. RESULTS: Eight observational cohort studies and one randomized control trial (2513 patients in PC and 1767 patients in SC) were included in the analysis. Major and minor VC, as well as bleeding complications, were comparable between the two approaches. The need for surgical intervention for VC was comparable between PC and SC. There was no difference in perioperative all-cause mortality. CONCLUSIONS: PC and SC have similar safety profiles and outcomes when used appropriately in selected patients.
Assuntos
Substituição da Valva Aórtica Transcateter/métodos , Estudos de Coortes , Hemorragia/epidemiologia , Humanos , Estudos Observacionais como Assunto , Complicações Pós-Operatórias/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Doenças Vasculares/epidemiologiaRESUMO
PURPOSE: Left atrial appendage (LAA) flow velocity has not been extensively studied in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to assess the impact of TAVI on LAA flow velocity. METHODS: Medical records of consecutive TAVI recipients were reviewed retrospectively. Patients with persistent atrial fibrillation were excluded. LAA velocities were measured before and after TAVI by transesophageal echocardiography. RESULTS: Sixty-one patients were included. Mean LAA emptying (EV) and filling (FV) flow velocity before TAVI were 33 ± 16 cm/s and 31 ± 14 cm/s, respectively. They increased to 37 ± 20 (p = 0.0036) and 33 ± 13 cm/s (p = 0.047) after TAVI in the whole population sample, but not in patients with normal flow AS. In low-flow, low-gradient (LFLG) AS patients, EV and FV increased from 36 ± 22 to 47 ± 30 cm/s (p < 0.01), and from 29 ± 12 to 40 ± 15 cm/s (p < 0.01), respectively, after TAVI. There was no difference between normal flow and LFLG AS patients in the number of patients who achieved EV ≥ 40 cm/s post-TAVI (35% versus 47%, p = 0.54, respectively). CONCLUSIONS: LAA EV and FV were low prior to TAVI and increased significantly after TAVI only in patients with LFLG AS. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:375-382, 2016.
Assuntos
Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/cirurgia , Apêndice Atrial/fisiopatologia , Apêndice Atrial/cirurgia , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Apêndice Atrial/diagnóstico por imagem , Velocidade do Fluxo Sanguíneo/fisiologia , Ecocardiografia Transesofagiana/métodos , Feminino , Humanos , Masculino , Estudos RetrospectivosRESUMO
BACKGROUND: Ventricular septal defects (VSD) are rarely reported as a complication following transcatheter aortic valve replacement (TAVR). We sought to characterise the patients, clinical management, and outcomes regarding this rare phenomenon. METHODS: Relevant articles were identified by a systematic search of MEDLINE and EMBASE databases from January, 2002 to September, 2015. RESULTS: A total of 18 case reports, including 20 patients, were identified. The median age was 83 years and six were male. Twelve were performed by trans-femoral approach. Pre-dilation was performed in 12 patients and post-dilation in four. Balloon expandable valves were used in the majority (85%) of cases. The clinical presentation varied from asymptomatic to progressive heart failure. The timing of the diagnosis also varied significantly from immediately post valve implantation to one year afterwards. There were two cases of Gerbode-type defect while the rest were inter-ventricular defects. The location was mostly membranous or perimembranous (79%) and adjacent to the valve landing zone. A total of seven interventions (one open surgery and six percutaneous closure) were performed. Four patients died during the same hospital admission. Sixteen survived past discharge (range 12 days to two years). CONCLUSIONS: Ventricular septal defects post-TAVR were seen more with balloon expandable valves and with pre-dilation or post-dilation. Percutaneous treatment of the VSD was preferred over open cardiac surgery given the high surgical risk in this patient population. Some, but not all, patients survived TAVR and VSD and had a good prognosis for both patient groups with or without VSD closure.
Assuntos
Comunicação Interventricular/etiologia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Feminino , Comunicação Interventricular/epidemiologia , Humanos , Doença Iatrogênica , MasculinoRESUMO
Since its advent in 1991, endovascular aortic aneurysm repair (EVAR) has become a mainstay of treatment for abdominal aortic aneurysms (AAA). Studies such as the comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR 1) trial, have demonstrated the effectiveness of EVAR in reducing perioperative mortality. Technological improvements in graft design and delivery account for an increasing utilization of endovascular repair. Newer branch and fenestrated graft designs have allowed for treatment of patients with complex aortic anatomy that previously could not be treated with EVAR. Endovascular repair, while dominant, is unlikely to eliminate the need for open repair or to relegate open surgery for AAA to historical interest only. The unprecedented adoption of EVAR has led to complications and modes of failure that were not seen with open repair. The rate of failure is markedly increased when endografts are used outside of the instructions for use (IFU). The long-term durability of fenestrated and investigational branch devices remains to be established. The demand for an endovascular approach by patients and the willingness of physicians to place endografts outside the anatomic IFU criteria may have resulted in the pendulum swinging too far away from open surgical management. The consequence of reduced open aortic surgeries is a concern for both patient care as well as training for vascular surgery fellows. Vascular surgery training programs will require innovative changes in training to assure that vascular surgery trainees will have the requisite skill and experience required to competently perform open surgical repair on what will undoubtedly be some of the most complex aortic pathology.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Cirúrgicos Vasculares/tendências , Aneurisma da Aorta Abdominal/economia , Implante de Prótese Vascular/métodos , Educação de Pós-Graduação em Medicina/tendências , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/métodos , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Stents , Procedimentos Cirúrgicos Vasculares/educaçãoRESUMO
BACKGROUND: Compliance with guidelines for treating patients with peripheral artery disease (PAD) lags compliance for treating patients with coronary artery disease. We assessed the gap between guidelines and practice for patients with PAD who underwent lower extremity revascularization (LER) at our institution from 2007 to 2010. METHODS: Quality of care (QoC) was calculated by measuring provider performance on four indicators (antiplatelet therapy, dyslipidemia management, control of hypertension, and diabetes) derived from the ACCF/AHA PAD guidelines. The QoC score was calculated at the time of admission and at time of discharge for each patient, and reflects the proportion of indicated treatments received. RESULTS: Patients (n = 734, mean age 70±11, female 51%) were followed for a mean of 2.0±1.4 years (range 0-5.7) following LER. The indication for LER was claudication (24.8%), rest pain (16.7%), and tissue loss (58.4%). The percentage of patients with a perfect QoC score increased significantly during hospital admission (11% to 21%, p < 0.001). Significant multivariate predictors of perfect QoC score included race/ethnicity, Charlson score, severity of LE ischemia, and observation period (admission, discharge). Multivariate analysis demonstrated that age>75 years, heart failure, chronic kidney disease, rest pain, and tissue loss-but not compliance with four guideline-based therapies-were associated with decreased freedom from the composite endpoint of major amputation, repeat revascularization, and death. CONCLUSIONS: Although adherence to guidelines improved over time, we found a significant gap between guidelines and practice for this cohort of patients at increased risk for adverse cardiovascular events.
Assuntos
Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Qualidade da Assistência à Saúde , Procedimentos Cirúrgicos Vasculares/métodos , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Análise de Variância , Angiografia/métodos , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/mortalidade , Arteriopatias Oclusivas/cirurgia , Estudos de Coortes , Feminino , Seguimentos , Fidelidade a Diretrizes , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/etiologia , Estimativa de Kaplan-Meier , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Guias de Prática Clínica como Assunto , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Atherosclerotic carotid artery disease remains an important cause of cerebrovascular ischemic disease. We present a patient with residual stenosis of the distal internal carotid artery following carotid endarterectomy that was treated with stenting. The case highlights the potential complimentary benefits of carotid endarterectomy and carotid stenting.
Assuntos
Angioplastia com Balão/instrumentação , Artéria Carótida Interna/cirurgia , Estenose das Carótidas/terapia , Endarterectomia das Carótidas , Stents , Idoso , Artéria Carótida Interna/diagnóstico por imagem , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/cirurgia , Constrição Patológica , Humanos , Masculino , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Severe stenosis of the common carotid artery (CCA), while uncommon, is associated with increased risk of transient ischemic attack and stroke. To date, no validated duplex ultrasound criteria have been established for grading the severity of CCA stenosis. The goal of this study was to use receiver-operating curve (ROC) analysis with computed tomographic angiography as the reference standard to establish duplex ultrasound criteria for diagnosing >or=50% CCA stenosis. METHODS: The study cohort included 64 patients (42 men, 22 women) with a mean age of 65 +/- 12 years (range, 16-89 years) who had CCA peak systolic velocity (PSV) >or=150 cm/sec and underwent computed tomographic angiography (CTA) of the cervical and intracerebral vessels within 1 month of the duplex examination. One study was excluded because the CTA was technically inadequate, whereas another was excluded because the patient underwent bilateral CCA stenting. The CCA ipsilateral to any of the following was excluded from the analysis: innominate artery occlusion (n = 1), previous stenting of the ICA or CCA (n = 7), carotid endarterectomy (n = 1), or carotid-to-carotid bypass (n = 1). Thus, the data set included 62 patients and 115 vessels. Bland-Altman analysis was used to examine the agreement between two measures of luminal reduction measured by CTA: percent diameter stenosis and percent area stenosis. Receiver operating characteristic (ROC) analysis was used to determine optimal PSV and EDV thresholds for diagnosing >or=50% CCA stenosis. RESULTS: Severity of CCA stenosis was <50% in 76 vessels, 50%-59% in eight, 60%-69% in eight, 70%-79% in nine, 80%-89% in three, 90%-99% in five, and occluded in six. Duplex ultrasonography identified six of six (100%) patients with 100% CCA occlusion by CTA. Bland-Altman analysis showed poor agreement between percent stenosis determined by vessel diameter compared with percent stenosis determined by reduction in lumen area. Therefore, subsequent analysis was performed using percent stenosis by area. ROC analysis of different PSV thresholds for detecting stenosis >or=50% showed that >182 cm/sec was the most accurate with a sensitivity of 64% and specificity of 88% (P < .0001). Sensitivity, specificity, and accuracy of carotid duplex were higher when the stenosis was located in the mid or distal aspects of the CCA (sensitivity 76%, specificity 89%, area under curve 0.84, P < .001) than in the intrathoracic and proximal segment of the artery (P = NS). ROC analysis of different EDV thresholds for detecting CCA stenosis >or=50% showed that >30 cm/sec was the most accurate with a sensitivity of 54% and a specificity of 74% (P < .0239). CONCLUSIONS: Duplex ultrasonography is highly sensitive, specific, and accurate for detecting CCA lesions in the mid and distal CCA. Use of peak systolic velocity may lead to improved detection of CCA disease and initiation of appropriate therapy to reduce the risk of stroke.
Assuntos
Artéria Carótida Primitiva/diagnóstico por imagem , Estenose Coronária/diagnóstico por imagem , Tomografia Computadorizada Espiral , Ultrassonografia Doppler Dupla , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estenose Coronária/complicações , Estenose Coronária/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Curva ROC , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Adulto JovemRESUMO
BACKGROUND: We analyzed the risk of adverse events following carotid angioplasty and stenting (CAS) in patients <80 years (group I) compared with those > or = 80 years of age (group II). METHODS: Prospective data from 224 patients who underwent 235 consecutive CAS procedures at three participating institutions were reviewed retrospectively. All subjects were enrolled in Food and Drug Administration-approved clinical trials of CAS in high-risk patients or in institutional protocols. Procedural details and angiographic morphology were reviewed in all cases. All patients underwent independent neurological evaluation at 24hr and 30 days following CAS. RESULTS: Mean age was 69.9 years in the younger cohort and 83.5 years in the older group. Embolic protection devices were successfully deployed in 97.5% of cases in group I compared with 98.7% in group II (p=nonsignificant [NS]). Procedural success, defined as <30% residual stenosis after CAS, was achieved in all cases. Mean hospital stay was similar in the two groups. Transient ischemia attacks occurred in 1.9% in group I and 1.3% in group II (p=NS). Within 30 days of CAS, the risk of minor or major stroke (p=NS) as well as the composite risk of stroke (minor or major) and death was 2.5% in group I and 3.8% in group II (p=NS). Multivariate logistic regression analysis showed that absence of hypertension (odds ratioi [OR]=0.38, p=0.0352) and chronic renal insufficiency (OR=2.62, p=0.0238) were significant predictors of the composite end point of stroke and all-cause mortality. Kaplan-Meier analysis revealed that survival and freedom from the combined end point of stroke and all-cause mortality were similar for patients in groups I and II. CONCLUSION: Octogenarians are not at increased risk of periprocedural adverse events following CAS compared to younger patients. Exclusion of high-risk patients from CAS based on age alone is unjustified.
Assuntos
Angioplastia/efeitos adversos , Angioplastia/instrumentação , Estenose das Carótidas/terapia , Stents , Acidente Vascular Cerebral/etiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Angioplastia/mortalidade , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Estimativa de Kaplan-Meier , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Exame Neurológico , Razão de Chances , Seleção de Pacientes , Radiografia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
Although relatively uncommon, isolated iliac artery aneurysms are associated with significant risk of rupture and death. Clinical presentation can be confusing and ultrasound or CT imaging is paramount in establishing the diagnosis and anatomical extent of disease. Important considerations prior to intervention include determination of proximal neck, involvement of the internal iliac artery, and status of the contralateral internal iliac artery. Endovascular repair has evolved as the first choice treatment option for patients with anatomically suitable iliac artery aneurysms. In uncommon circumstances when endovascular treatment may result in significant pelvic ischemia or the primary symptoms are related to extrinsic compression of adjacent structures, surgical repair may be the preferred option.
Assuntos
Aneurisma Roto/prevenção & controle , Embolização Terapêutica , Aneurisma Ilíaco/terapia , Procedimentos Cirúrgicos Vasculares , Aneurisma Roto/etiologia , Aneurisma Roto/patologia , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Progressão da Doença , Embolização Terapêutica/efeitos adversos , Humanos , Aneurisma Ilíaco/complicações , Aneurisma Ilíaco/etiologia , Aneurisma Ilíaco/patologia , Aneurisma Ilíaco/cirurgia , Ligadura , Procedimentos Cirúrgicos Minimamente Invasivos , Stents , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/instrumentaçãoRESUMO
AIMS: Patients with paradoxical low-flow severe aortic stenosis (PLF-AS) reportedly have higher left ventricular hydraulic load and more systolic strain dysfunction than patients with normal-flow aortic stenosis. This study investigates the relationship of systolic loading and strain to PLF-AS to further define its pathophysiology. METHODS: One hundred and twenty patients (age 79â±â12âyears, 37% men) with an indexed aortic valve area (AVAi) of 0.6âcm/m or less and an ejection fraction of 50% or higher were divided into two groups based on indexed stroke volume (SVi): PLF-AS, SVi ≤ 35âml/m, Nâ=â46; normal-flow aortic stenosis, SVi > 35âml/m, Nâ=â74). Valvular and arterial load were assessed using multiple measurements, and strain was assessed using speckle-tracking echocardiography. RESULTS: Patients with PLF-AS were found to have more valvular load (lower AVAi, Pâ=â0.028; lower energy loss coefficient, Pâ=â0.001), more arterial load [decreased arterial compliance and increased systemic vascular resistance (SVR), both Pâ<â0.001] and more total hydraulic load [increased valvuloarterial impedance (Zva), Pâ<â0.001]. Transvalvular gradients and arterial pressures were similar. Longitudinal strain was lower in PLF-AS (Pâ<â0.001), but circumferential and rotation strains were similar. On adjusted regression, AVAi, SVR and longitudinal strain were associated with PLF-AS [odds ratio (OR)â=â1.34, Pâ=â0.043; ORâ=â1.31, Pâ=â0.004; ORâ=â1.34, Pâ=â0.011, respectively]. When SVR and AVAi were replaced with Zva, longitudinal strain and Zva (ORâ=â1.38, Pâ=â0.015; ORâ=â1.33, Pâ<â0.001 for both, respectively) were associated with PLF-AS. CONCLUSION: Increased hydraulic load, from more severe valvular stenosis and increased vascular resistance, and longitudinal strain impairment are associated with PLF-AS and their interplay is likely fundamental to its pathophysiology.
Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Substituição da Valva Aórtica Transcateter/métodos , Resistência Vascular , Disfunção Ventricular Esquerda/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Pressão Arterial , Velocidade do Fluxo Sanguíneo , Comorbidade , Ecocardiografia , Feminino , Humanos , Modelos Logísticos , Masculino , Análise Multivariada , Estudos Retrospectivos , Índice de Gravidade de Doença , Remodelação VentricularRESUMO
We sought to determine the association of Life's Simple Seven (LSS) with peripheral artery disease (PAD) in African Americans. We performed a cross-sectional analysis of baseline data (2000-2004) from subjects participating in the Jackson Heart Study. African American men and women (N = 4403) age 35-84 years participated in the study. PAD was defined by an ankle-brachial index (ABI) of < 0.9. We assessed frequency of LSS (body mass index [BMI], blood pressure, total cholesterol, glucose, dietary habits, physical activity, and smoking) among participants with and without PAD. LSS variables were categorized as ideal, intermediate, or poor to indicate a participant's health status. Data were analyzed using logistic regression to assess the association of PAD with LSS. PAD was diagnosed in 113 participants (2.6%). The percentage of the cohort meeting criteria for ideal health for each of the seven LSS factors was: 14.2% for BMI, 17.1% for blood pressure, 38.0% for total cholesterol, 72.9% for glucose, 1.0% for dietary habits, 19.2% for physical activity, and 84.6% for smoking. Having ≥ 3 LSS variables within the category of poor health was associated with elevated odds for PAD (odds ratio (OR) 1.34, 95% CI 1.11-1.63) after adjusting for age. Among African American adults, LSS variables are associated with PAD. Further studies are needed to determine the association of LSS with PAD among other racial/ethnic groups.
RESUMO
The comparative outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in diabetes mellitus (DM) patients are scarce. We aimed to assess and compare the outcomes of TAVR versus SAVR in DM patients using the Nationwide Inpatient Sample database from 2011 to 2013. A complete case analysis was performed for the multivariate analysis and cases with missing data were excluded. The primary end point was in-patient all-cause mortality and secondary outcomes were perioperative complications. An estimated 5,719 TAVR procedures and 65,096 SAVR procedures were performed among DM patients in the United States between 2011 and 2013. TAVR patients were older (80 ± 8.1 vs 70 ± 10, p <0.001), majority of them were women (45% vs 38%, p <0.001), and predominantly white race (total of 80%). The adjusted odds ratio (OR) for the primary outcome was significantly lower in TAVR patients (2.8% vs 3.6%, OR 0.63, p = 0.02). TAVR patients were also at lower risk for bleeding requiring transfusions (13% vs 20%, OR 0.43, p <0.01), cardiac complications (6.1% vs 14%, OR 0.34, p <0.01), respiratory complications (1.2% vs 3.7%, OR 0.26, p <0.01), postoperative sepsis (1.7% vs 3.6%, OR 0.45, p = 0.03), and acute myocardial infarction (2.5% vs 2.9%, OR 0.62, p <0.01), compared with SAVR patients. Conversely, TAVR patients were at increased risk for vascular complications (5.7% vs 3.9%, OR 1.5, p <0.01) and new pacemaker implantation (10% vs 5.7%, OR 1.5, p <0.01). The mean hospitalization cost was lower for TAVR than SAVR ($58,878 vs $63,869, p = 0.003). Length of stay (median 6 vs 8 days, p <0.001) was shorter in TAVR patients. In conclusion, TAVR may result in better in-hospital outcome than SAVR in DM patients.
Assuntos
Diabetes Mellitus/epidemiologia , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Substituição da Valva Aórtica Transcateter/estatística & dados numéricos , Injúria Renal Aguda/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/estatística & dados numéricos , Bases de Dados Factuais , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Implante de Prótese de Valva Cardíaca/economia , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Infarto do Miocárdio/epidemiologia , Marca-Passo Artificial/estatística & dados numéricos , Sepse/epidemiologia , Substituição da Valva Aórtica Transcateter/economia , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: This study sought to determine the association of chronic kidney disease (CKD) with in-hospital outcomes of transcatheter aortic valve replacement (TAVR). BACKGROUND: CKD is a known independent risk factor for worse outcomes after surgical aortic valve replacement (SAVR). However, data on outcomes of patients with CKD undergoing TAVR are limited, especially in those on chronic dialysis. METHODS: The authors used data from the 2012 to 2014 National Inpatient Sample database to identify all patients ≥18 years of age who underwent TAVR. International Classification of Diseases-Ninth Revision-Clinical Modification codes were used to identify patients with no CKD, CKD (without chronic dialysis), or end-stage renal disease (ESRD) on long-term dialysis. Multivariable logistic regression models were constructed using generalized estimating equations to examine in-hospital outcomes. RESULTS: Of 41,025 patients undergoing TAVR from 2012 to 2014, 25,585 (62.4%) had no CKD, 13,750 (33.5%) had CKD, and 1,690 (4.1%) had ESRD. Compared with patients with no CKD, in-hospital mortality was significantly higher in patients with CKD or ESRD (3.8% vs. 4.5% vs. 8.3%; adjusted odds ratio [no CKD as reference]: 1.39 [95% confidence interval: 1.24 to 1.55] for CKD and 2.58 [95% confidence interval: 2.09 to 3.13] for ESRD). Patients with CKD or ESRD had a higher incidence of major adverse cardiovascular events (composite of death, myocardial infarction, or stroke), net adverse cardiovascular events (composite of major adverse cardiovascular events, major bleeding, or vascular complications), and pacemaker implantation compared with patients without CKD. Acute kidney injury (AKI) and AKI requiring dialysis were associated with several-fold higher risk-adjusted in-hospital mortality in patients in the no CKD and CKD groups. Moreover, the incidence of AKI and AKI requiring dialysis did not decline during the study period. CONCLUSIONS: Patients with CKD or ESRD have worse in-hospital outcomes after TAVR. AKI is associated with higher in-hospital mortality in patients undergoing TAVR and the incidence of AKI has not declined over the years.
Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Falência Renal Crônica/fisiopatologia , Rim/fisiopatologia , Insuficiência Renal Crônica/fisiopatologia , Substituição da Valva Aórtica Transcateter , Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/fisiopatologia , Injúria Renal Aguda/terapia , 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 , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/mortalidade , Falência Renal Crônica/terapia , Modelos Lineares , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Diálise Renal , Insuficiência Renal Crônica/diagnóstico , Insuficiência Renal Crônica/mortalidade , Insuficiência Renal Crônica/terapia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
We queried the National Inpatient Sample database from 2012 to 2014 to identify all patients aged ≥18 years undergoing transcatheter aortic valve implantation (TAVI) in the United States. Regional differences in TAVI utilization, in-hospital mortality, and health-care resource use were analyzed. Of 41,025 TAVI procedures in the United States between 2012 and 2014, 10,390 were performed in the Northeast, 9,090 in the Midwest, 14,095 in the South, and 7,450 in the West. Overall, the number of TAVI implants per million adults increased from 24.8 in 2012 to 63.2 in 2014. The utilization of TAVI increased during the study period in all 4 geographic regions, with the number of implants per million adults being highest in the Northeast, followed by the Midwest, South, and West, respectively. Overall in-hospital mortality was 4.2%. Compared with the Northeast, risk-adjusted in-hospital mortality was higher in the Midwest (adjusted odds ratio [aOR] 1.26 [1.07 to 1.48]) and the South (aOR 1.61 [1.40 to 1.85]) and similar in the West (aOR 1.00 [0.84 to 1.18]). Average length of stay was shorter in all other regions compared with the Northeast. Among patients surviving to discharge, disposition to a skilled nursing facility or home health care was most common in the Northeast, whereas home discharge was most common in the West. Average hospital costs were highest in the West. In conclusion, we observed significant regional differences in TAVI utilization, in-hospital mortality, and health-care resource use in the United States. The findings of our study may have important policy implications and should provide an impetus to understand the source of this regional variation.
Assuntos
Estenose da Valva Aórtica/cirurgia , Recursos em Saúde/estatística & dados numéricos , Custos Hospitalares , Pacientes Internados , Substituição da Valva Aórtica Transcateter/métodos , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/economia , Estenose da Valva Aórtica/mortalidade , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Alta do Paciente/tendências , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/economia , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: Patients undergoing transcatheter aortic valve replacement (TAVR) often have spontaneous echocardiographic contrast (SEC) observed in the left atrium (LA). Mid-term prognosis of patients with SEC following TAVR is not well studied. We assessed the impact of SEC on outcomes after TAVR. METHODS: Medical records of 93 consecutive patients who underwent TAVR at a single center were reviewed retrospectively. The primary endpoint was defined as the composite of a cardioembolic event, death from any cause, and admission for decompensated heart failure within 3 months of TAVR. RESULTS: After excluding 3 patients who had procedural complications, 90 patients were included in the study. The mean age was 81 ± 8 years old and 50% were male. There were 12 patients with SEC in the LA (group 1) and 78 patients without SEC in the LA (group 2) during the TAVR procedure. Atrial fibrillation was more common in group 1 (50% vs 13%, respectively; P=.01) and diabetes was more common in group 2 (17% vs 53%, respectively; P=.03). The primary endpoint occurred in 22 patients (24%) and occurred more in group 1 (58% vs 19%, respectively; P<.01). On regression analysis, after adjusting for sex and STS score, SEC had a hazard ratio (HR) of 5.02 (95% confidence interval [CI], 1.96-12.9; P<.001) and STS ≥15 had an HR of 6.37 (95% CI, 2.02-20.1; P=.01). On survival analysis, group 1 had lower event-free survival compared with group 2 (log-rank P=.01). CONCLUSION: SEC during TAVR procedure is a negative prognostic marker for death, cardioembolic events, or admission for decompensated heart failure in the first 3 months post procedure.
Assuntos
Estenose da Valva Aórtica , Ecocardiografia/métodos , Átrios do Coração , Insuficiência Cardíaca Diastólica , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/cirurgia , Feminino , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/fisiopatologia , Insuficiência Cardíaca Diastólica/diagnóstico , Insuficiência Cardíaca Diastólica/etiologia , Insuficiência Cardíaca Diastólica/fisiopatologia , Humanos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to surgical aortic-valve replacement (SAVR) for patients with severe symptomatic aortic stenosis (AS) who are at high operative risk. We sought to determine the long-term (≥1year follow-up) safety and efficacy TAVR compared with SAVR in patients with severe AS. METHODS: A comprehensive search of PubMed, EMBASE, Cochrane Central Register of Controlled Trials, conference proceedings, and relevant Web sites from inception through 10 April 2016. RESULTS: Fifty studies enrolling 44,247 patients met the inclusion criteria. The mean duration follow-up was 21.4months. No difference was found in long-term all-cause mortality (risk ratios (RR), 1.06; 95% confidence interval (CI) 0.91-1.22). There was a significant difference favoring TAVR in the incidence of stroke (RR, 0.82; 95% CI 0.71-0.94), atrial fibrillation (RR, 0.43; 95% CI 0.33-0.54), acute kidney injury (RR, 0.70; 95% CI 0.53-0.92), and major bleeding (RR, 0.57; 95% CI 0.40-0.81). TAVR had significant higher incidence of vascular complications (RR, 2.90; 95% CI 1.87-4.49), aortic regurgitation (RR, 7.00; 95% CI 5.27-9.30), and pacemaker implantation (PPM) (RR, 2.02; 95% CI 1.51-2.68). TAVR demonstrated significantly lower stroke risk compared to SAVR in high-risk patients (RR, 1.49; 95% CI 1.06-2.10); no differences in PPM implantation were observed in intermediate-risk patients (RR, 1.68; 95% CI 0.94-3.00). In a meta-regression analysis, the effect of TAVR baseline clinical features did not affect the long-term all-cause mortality outcome. CONCLUSION: TAVR and SAVR showed similar long-term survival in patients with severe AS; with important differences in treatment-associated morbidity.