Logistic EuroSCORE Research Articles

Clinical outcomes of left main percutaneous coronary intervention in elderly patients at a long-term follow-up

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The progressive aging of the population leads to higher prevalence of ischemic heart disease with an increased left main coronary artery (LMCA) disease. Elderly patients (>75 years) represent an unfavorable subgroup because of their fragility, the frequent presence of multiple comorbidities associated and their especially high rate of surgical risk. Purpose The main objective of this study was to evaluate the efficacy and safety of percutaneous coronary interventions (PCI) in LMCA disease at 14 years follow-up in the elderly. Methods We prospectively included 217 consecutive patients (80.3 ± 2.4 years, 68.7% male) with LMCA disease treated with PCI between June 2006 and June 2020. We evaluated the occurrence of major adverse cardiovascular events (MACE) defined as cardiac death, non-fatal myocardial infarction, target lesion revascularization (TLR) and stent thrombosis after 14 years clinical follow-up (median 56 months). Results 48.4% of patients had stable coronary disease and 51.6% acute coronary syndrome (42.4% Non-STEMI and 9.2% STEMI). 43.3% were diabetic patients and 45.9% presented moderate-severe left ventricular systolic dysfunction. Mean logistic EuroSCORE was 10.4% and 47.5% of lesions with Syntax score ≥ 32. LMCA bifurcation was affected in 78.8% of cases and the most frequently bifurcation technique employed was "provisional stenting" in 64.1% of cases. Second-generation drug eluting stent was used in 97.6% of cases. The intraprocedural complication rate was 4.5% with one death. During follow-up, MACE rate at 14 years was 19.9% (14.7% cardiac death, 3.2% non-fatal myocardial infarction, 4.1% TLR and thrombosis rate 0.5%). There were significant differences in the occurrence of MACE in patients with moderate-severe ventricular systolic dysfunction (p=0.01 OR 3.92; IC 95% de 1.26-8.57). Conclusions Left main PCI in elderly patients with high surgical risk provide very favourable results with a low rate of immediate complications in the procedure and a low rate of cardiac adverse events at a very long-term follow-up. However, patients with ventricular dysfunction have poor prognosis.

Real-world clinical outcomes of left main percutaneous coronary intervention in diabetic patients at a long-term follow-up

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Coronary artery disease in diabetic patients has more aggressivity and tends to be a more complex disease characterized by small, diffuse, calcified, multivessel involvement that it presents higher in-stent restenosis rates after percutaneous coronary intervention (PCI). Besides, left main coronary artery (LMCA) disease has poor prognosis and it usually associates more severe lesions in other coronary arteries. Currently, the PCI in LMCA disease in these patients is controversial. Purpose The main objective of this study was to evaluate the efficacy and safety of PCI in LMCA disease in diabetic patients at a 14-year follow-up. Methods We prospectively included 228 consecutive patients (71 ± 11 years, 70.2% male) with LMCA disease treated with PCI between June 2006 and June 2020. We evaluated the occurrence of major adverse cardiovascular events (MACE) defined as cardiac death, nonfatal myocardial infarction, target lesion revascularization (TLR) and stent thrombosis after a 14-year clinical follow-up (median 66 months). Results 53.1% of patients had stable coronary disease and 46.9% acute coronary syndrome (42.1% Non-STEMI and 4.8% STEMI). 40.3% of patients presented moderate-severe left ventricular systolic dysfunction. 63.6% had LMCA and ≥ 2 vessels disease and 43% had a SYNTAX score ≥ 33. Mean Logistic Euroscore was 7.2%. The most frequent bifurcation technique employed in LMCA was "provisional stenting" in 65.4% and zotarolimus-eluting stent was used in 75.8% of cases. Angiographic success rate was 99.6% and complication rate intra-procedure was 3.1% without intraoperative death. During follow-up, MACE rate at 14 years was 19.8% (14.4% of cardiac death, 6.6% of nonfatal myocardial infarction, 5.7% of TLR and thrombosis rate 0.4%). Higher MACE rate was significantly associated to left ventricular systolic dysfunction (p=0.04) and chronic kidney insufficiency (p=0.02). 22.2% of patients had angiographic follow-up. Conclusions PCI on LMCA in diabetic patients is safe and effective, with low complication rate and a low rate of long-term follow-up events. Left ventricular systolic dysfunction and chronic kidney insufficiency showed a significantly worse outcome.

Clinical results at a long-term follow-up of percutaneous coronary intervention in ostial left main coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Left main coronary ostial lesions are notable for being found more commonly among middle-aged women with fewer conventional coronary artery risk factors and for lower long-term patency of internal thoracic grafts. Isolated ostial left main coronary artery (LMCA) disease is involved in the 18% of lesions and have a management approach do well either with percutaneous coronary intervention (PCI) or cardiac surgery. Continuous improvement in the devices and the emergence of better drug-eluting stents (DES) has improved the results of PCI in these high-risk lesions. Purpose The main objective of this study was to evaluate the efficacy and safety of PCI in ostial LMCA disease at a 14-year follow-up. Methods We prospectively included 109 consecutive patients (72± 12 years, 72.5% male) with ostial LMCA disease treated with PCI between June 2006 and June 2020. We evaluated the presence of major adverse cardiovascular events (MACE) defined as cardiac death, non-fatal myocardial infarction, target lesion revascularization (TLR) and stent thrombosis after a 14-year clinical follow-up (median 63.6 months). Results 55.9% had stable coronary disease and 44.1% had acute coronary syndrome (35.9% Non-STEMI and 8.2% STEMI). 45% were diabetic patients and 36.6% presented moderate-severe left ventricular systolic dysfunction. The mean logistic EuroSCORE was 8.1 % and SYNTAX score was ≥ 23 in 72.5% of the patients. We implanted second-generation DES in the 83.5% of patients (76% zotarolimus-eluting stent) and post-dilatation was performed in the 68.8%. The angiographic success rate was 99%. Complication rate in the procedure was 5.5% without intra-procedure deaths. During follow-up, MACE rate at 14 years was 18.3% (13.7% of cardiac death, 4.6% of nonfatal myocardial infarction, 7.3% of TLR and thrombosis rate of 0.9%). 24.2% of patients had an angiographic follow-up. Conclusions In spite of high surgical risk, complex coronary anatomy and older aged patients, PCI in ostial LMCA disease is safe and effective with a low rate of major cardiovascular events at long-term follow-up.

Surgical aortic valve replacement for low-gradient aortic stenosis.

Low-gradient aortic stenosis is a challenging entity that needs accurate preoperative evaluation. For this high-risk patient population, ad hoc predictive scores are not available and profile risk is currently revealed by the EuroSCOREs. Aims of this study are to verify the suitability of the ES II as predictor of mortality in low-gradient aortic stenosis and to analyse the role of surgery as a treatment. From June 2013 to August 2019, 414 patients underwent surgical aortic valve replacement for low-gradient aortic stenosis. Mean age was 75.78 ± 6.77 years and 190 were women. The prognostic value of Logistic EuroSCORE and EuroSCORE II were compared by receiver-operating characteristics (ROC) curve analysis. In-hospital, 30-day and 1-year mortality rates were respectively 3.4, 2.9 and 4.8% (14, 12 and 20 patients over 414). In-hospital mortality risk calculated by the Additive EuroSCORE was 7.2 ± 2.7%, by the Logistic EuroSCORE was 9 ± 5.2% and by the ES II was 4.13 ± 2.56%. The prognostic values of the EuroSCORE II and of the EuroSCORE were analysed in a ROC curve analysis for the prediction of in-hospital mortality [area under the curve (AUC): 0.62 vs. 0.58], 30-day mortality (AUC: 0.63 vs. 0.64) and 1-year mortality (AUC: 0.79 vs. 0.65). Both scores did not show significant differences with the only exception of 1-year mortality, for which EuroSCORE II had a better predictive ability than the Logistic EuroSCORE (P < 0.05). In low-gradient aortic stenosis undergoing surgery, the EuroSCORE II is a strong predictor of 1-year mortality.

Surgical repair of post-infarction ventricular free-wall rupture in the Netherlands: data from a nationwide registry.

Ventricular free-wall rupture (VFWR) is an infrequent but catastrophic complication of acute myocardial infarction (AMI). Most reports about outcome after surgical treatment are single-center experiences. We examined the early and mid-term outcomes after surgical repair of post-AMI VFWR using the Netherlands Heart Registration (NHR) database. We included data from NHR patients (>18 years old) who underwent surgery for post-AMI VFWR between 2014 and 2019. The primary end-point was in-hospital mortality. Secondary outcomes included postoperative complications and mid-term survival. The study included 148 patients (54.7% male, mean age 66.5±11.1 years). Critical preoperative status was found in 62.6% of subjects. In-hospital mortality was 31.1% (46 of 148). Multivariable analysis identified female sex [odds ratio (OR), 5.49; 95% confidence interval (CI): 2.24-13.46] and critical preoperative status (OR, 4.06; 95% CI: 1.36-12.13) as independent predictors of in-hospital mortality. The overall median postoperative follow-up was 2.2 (interquartile range, 0.7-3.8) years. Overall survival rates at three and five years were 58.9% and 55.7%, respectively. Among hospital survivors, only 15 (14.7%) patients died during follow-up, with a five-year survival rate of 80.8%. In-hospital mortality after surgical repair of post-AMI VFWR is considerable. Female sex and preoperative critical status are independent predictors of early postoperative (in-hospital) death. Logistic EuroSCORE I can reliably predict in-hospital mortality (optimal cut-off >33%). Mid-term follow-up of patients surviving in-hospital course shows excellent results.

COMPARISON OF FREQUENTLY USED RISK SCORING SYSTEMS IN PATIENTS WHICH WAS PERFORMED OPEN HEART SURGERY BY THE COUNCIL DECISION AND DETERMINING THE MOST SUITABLE RISK SCORING SYSTEM FOR OUR PATIENT POPULATION

Objective: In this study, we compared the Türkskor risk scoring system, which we have used for many years in our clinic, with other risk scoring systems.&#x0D; Methods: A retrospective review of 267 patients we presented to the council before open heart surgery was performed in the Cardiovascular Surgery Clinic of Dr Siyami Ersek Training and Research Hospital in 2013-2014. The efficiency of Türkskor, standard EuroSCORE, logistics EuroSCORE and EuroSCORE II, calculated with the preoperative parameters of the patients, in predicting the actual mortality was compared with the ROC analysis.&#x0D; Results: When the whole patient population was evaluated, the mean Türkscore value was 6.05±3.46, the mean standard EuroSCORE value was 6.09±2.85, the mean logistic EuroSCORE value was 7.72±7.81, and the mean EuroSCORE II value was 3.75±5.49. The total mortality was 44 (44/267 %16,5). The efficiencies of Türkskor, Standard, logistic EuroSCORE and EuroSCORE II in determining mortality in all patient groups were compared with the ROC curve. With these results, the area under the curve was AUC: 0.729 %95 CI: 0.640-0.817 for Türkskor, AUC: 0.710 %95 CI: 0.618-0.803 for Standard EuroSCORE , AUC: 0.715 %95 CI: 0.623-0.807 for Logistic EuroSCORE and AUC:0.730 95% CI: 0.639-0.822 for EuroSCORE 2 were calculated . When compared in all risk groups, Türkskor, Standard EuroSCORE, logistic Euroscore Euroscore II were found to be similar in predicting mortality (p&gt;0.05).&#x0D; Conclusions: Türkskor, Standard EuroSCORE, logistics EuroSCORE and EuroSCORE II are similarly successful in predicting mortality for all patient groups.

Early- and mid-term outcomes of reinterventions for aortic bioprosthesis failure.

The aim of this study was to evaluate early- and mid-term results of our actual practice embedding redo aortic valve replacement and transcatheter procedures for aortic bioprosthetic failure. Data for aortic valve reinterventions (redo surgical aortic valve replacement, isolated redo aortic valve replacement, and valve-in-valve transcatheter aortic valve implantation, transcatheter valve-in-valve procedure) were collected (2010-2019). Logistic regression analysis was performed to identify predictors favouring the choice of transcatheter against redo surgery. Cox analysis was used to study the association of preoperative variables with survival. Survival probabilities were calculated with Kaplan-Meier analysis and compared using a log-rank test. A total of 125 patients were included (redo surgical aortic valve replacement: 84 patients, valve-in-valve transcatheter aortic valve implantation: 41 patients). Median age was 74 [63-80] years, 58% of the patients were male and the median logistic EuroSCORE was 15 [8-26] %. There was no early mortality. Eighteen patients (redo surgical aortic valve replacement: 15, valve-in-valve transcatheter aortic valve implantation: 3) sustained at least one postoperative complication. At pre-discharge transthoracic echocardiogram, valve-in-valve transcatheter aortic valve implantation had significantly higher trans-prosthetic gradients (mean gradient: valve-in-valve transcatheter aortic valve implantation 18 mmHg vs. redo surgical aortic valve replacement 14 mmHg, p < 0.001). Overall survival probabilities were 94% and 73% at 1 year and 5 years, respectively. Previous coronary artery bypass surgery operation and age were independently associated with lower survival probabilities during the follow-up. Redo surgical aortic valve replacement and valve-in-valve transcatheter aortic valve implantation are both safe and effective for aortic bioprosthetic failure. Further valve-in-valve data are needed to determine the haemodynamic performance of transcatheter prostheses and its impact on long-term outcomes.

Comorbidities may offset expected improved survival after transcatheter aortic valve replacement.

AimsAfter transcatheter aortic valve replacement (TAVR), cardiovascular and non-cardiovascular comorbidities may offset the survival benefit from the procedure. We aimed to describe the relationships between that benefit and patient comorbidities.Methods and resultsThe study pooled two European cohorts of patients with severe aortic stenosis (AS-pooled): one with patients who underwent (cohort of AS patients treated by TAVR, N = 233) and another with patients who did not undergo TAVR (cohort of AS patients treated medically; N = 291). The investigators collected the following: calcification prognostic impact (CAPRI) and Charlson scores for cardiovascular and non-cardiovascular comorbidities, activities of daily living (ADL)/instrumental activities of daily living (IADL) scores for frailty as well as routine Society of Thoracic Surgeons (STS) score and Logistic Euroscore. Unlike ADL/IADL scores, CAPRI and Charlson scores were found to be independent predictors of 1-year all-cause death in the AS-pooled cohort, with and without adjustment for STS score or Logistic Euroscore; they were thus retained to define a three-level prognostic scale (good, intermediate, and poor). The survival benefit from TAVR—vs. no TAVR—was stratified according to these three prognosis categories. The beneficial effect of TAVR on 1-year all-cause death was significant in patients with good and intermediate prognosis, hazard ratio (95% confidence interval): 0.36 (0.18; 0.72) and 0.32 (0.15; 0.67). That effect was reduced and not statistically significant in patient with poor prognosis [0.65 (0.22; 1.88)].ConclusionThe study showed that, beyond a given comorbidity burden (as assessed by CAPRI and Charlson scores), the probability of death within a year was high and poorly reduced by TAVR. This indicates the futility of TAVR in patients in the poor prognosis category.

Risk stratification using growth differentiation factor 15 in patients undergoing transcatheter aortic valve implantation.

Growth differentiation factor 15 (GDF15) shows potential predictive value in various cardiac conditions. We investigated relationships between GDF15 and clinical or procedural outcomes in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) in order to propose clinically useful predictive risk stratification model. This prospective single-center registry enrolled 88 consecutive patients with severe symptomatic aortic stenosis treated with TAVI. Clinical parameters were collected and biomarkers including GDF-15 were measured within 24 h before TAVI. All relevant clinical outcomes according to the Valve Academic Research Consortium-2 were collected over the follow-up period. The cohort included 52.3% of females. The mean age of study participants was 81 years; the mean Society of Thoracic Surgeons (STS) score and logistic EuroSCORE were 3.6% and 15.4%, respectively. The mortality over the entire follow-up period was 10.2%; no death was observed within the first 30 days following TAVI. Univariate analysis showed significant associations between GDF15 and mortality (P=0.0006), bleeding (P=0.0416) and acute kidney injury (P=0.0399). A standard multivariate logistic regression model showed GDF-15 as the only significant predictor of mortality (P=0.003); the odds ratio corresponding to an increase in GDF15 of 1000 pg/mL was 1.22. However, incremental predictive value was not observed when the STS score was combined with GDF15 in this predictive model. Based on our observations, preprocedural elevated GDF15 levels are associated with increased mortality and demonstrate their additional value in predicting adverse clinical outcomes in a TAVI population.

C-Reactive Protein to Albumin Ratio in Patients Undergoing Transcatheter Aortic Valve Replacement

ObjectiveTo evaluate whether the serum C-reactive protein to albumin ratio (CAR) could be used for risk stratification of patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS). Patients and MethodsFrailty is a predictor of poor outcomes in patients undergoing AS interventions. The CAR reflects key components of frailty (systemic inflammation and nutrition) and could potentially be implemented into assessment and management strategies for patients with AS. From March 1, 2010, through February 29, 2020, 1836 patients were prospectively enrolled in an observational TAVR database. Patients (prospective development cohort, n=763) were grouped into CAR quartiles to compare the upper quartile (CAR Q4) with the lower quartiles (CAR Q1-3). Primary end point was all-cause mortality. Results were verified in an independent retrospective cohort (n=1403). ResultsThe CAR Q4 had a higher prevalence of impaired left ventricular function, atrial fibrillation, diabetes, and cerebrovascular disease and a higher median logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) vs CAR Q1-3. After median follow-up of 15.0 months, all-cause mortality was significantly higher in CAR Q4 vs CAR Q1-3 (P<.001). In multivariable analyses, risk factors for all-cause mortality were CAR Q4 (>0.1632; hazard ratio, 1.45; 95% confidence interval, 1.05 to 2.00; P=.03), N-terminal pro–B-type natriuretic peptide Q4 (>3230 pg/mL [to convert to ng/L, multiply by 1), high-sensitivity troponin T Q4 (>0.0395 ng/mL [to convert to μg/L, multiply by 1]), above-median logistic EuroSCORE (16.1%), myocardial infarction, Acute Kidney Injury Network stage 3, and life-threatening bleeding. ConclusionElevated CAR was associated with increased risk of all-cause mortality in patients undergoing transfemoral TAVR. The CAR, a simple, objective tool to assess frailty, could be incorporated into assessing patients with AS being considered for TAVR.

Surgical outcomes and optimal approach to treatment of aortic valve endocarditis with aortic root abscess.

ObjectivesTo evaluate the impact of aortic root abscess (ARA) on the postoperative outcomes of surgically managed infective endocarditis (IE) and to inform optimal surgical approach.MethodsBetween 2009 and 2020, 143 consecutive patients who underwent surgical management for aortic‐valve IE were included in a retrospective cohort study. Multivariable and propensity‐weighted analyses were used to adjust for demographic imbalances between those without (n = 93; NARA) and with an ARA (n = 50). Additionally, empirical subgroup analysis appraised the two most used surgical techniques; patch reconstruction (PR) and aortic root replacement (ARR).ResultsDemographic characteristics were similar between ARA and NARA except for logistic EuroSCORE, previous valve surgery, and multivalvular infection. In‐hospital mortality was 8% and 12% in NARA and ARA, respectively (p = .38), with mortality rates consistently nonsignificantly higher in ARA across all time periods. The overall reoperation rate was also higher in ARA (27% vs. 14%; p = .09) and ARA was shown to be associated with late reoperation (odds ratio [OR] = 2.74; 95% confidence interval [CI] = 1.18–6.36). Patients treated with an ARR showed a 16% increase in late mortality when compared with PR (40% vs. 24%; p = .27) and a 17% lower reoperation rate (14% vs. 31%; p = .24). Propensity‐weighted analysis identified ARR as a significant protective factor for reoperation (hazard ratio = 0.05; 95% CI = 0.01–0.34).ConclusionsThe presence of an ARA in aortic valve endocarditis was not associated with significantly higher early and late mortality but is linked with a higher reoperation rate at our institution. ARR in ARA is protective from reoperation so should be considered best practice in this setting.

Transcatheter aortic valve implantation: The road to a minimalist “stent-like” procedure

Since the first-in-man implantation of a transcatheter aortic stented valve in April 2002 in Rouen, the procedure has expanded worldwide. In our centre, all transfemoral procedures have been performed using local anaesthesia without transoesophageal echocardiographic monitoring. To report our experience of transfemoral arterial transcatheter aortic valve implantation (TAVI) over the last 2 decades, following the evolution of devices, practices and indications. Between 2002 and 2021, 2097 consecutive patients had a TAVI procedure in our centre. Among them, 1780 underwent transfemoral arterial aortic valve implantation, and were subdivided into three groups according to the time period: before 2009; 2009-2014; and 2014-2021. Median age was 85 years, and remained unchanged over time. The mean logistic EuroSCORE gradually decreased over time (28% before 2009 vs 15% for 2009-2014 vs 11% since 2014; P<0.001). Predilatation was performed almost systematically before 2009 (93%), but was rarely performed in the last period (14%; P<0.001). Thirty-day all-cause mortality decreased over time, and was only 1.4% in 2021. Length of stay decreased considerably, with a median duration of only 2 days after the procedure, and>70% of patients were discharged home within 72hours. Similarly, procedural duration, X-ray time and contrast volume decreased over time. Transfemoral aortic valve implantation, performed as a minimalist "stent-like" procedure using only local anaesthesia, is feasible in the vast majority of patients, with excellent outcomes.

Stroke after transcatheter aortic valve replacement: A severe complication with low predictability.

We aimed to describe stroke and transient ischemic attacks (TIAs) after transcatheter aortic valve replacement (TAVR) and to identify associated risk factors. Stroke/TIA after TAVR is a major complication. A total of 1919 concomitant patients underwent TAVR in a single center from 2007 to 2017. Pre-, intra-, and postprocedural data were collected prospectively in a database and analyzed retrospectively. Stroke and TIA were documented according to the Valve Academic Research Consortium-II criteria. Logistic regression was used to determine risk factors for stroke after TAVR. Mean age was 79.5 ± 6.8 years, mean logistic EuroScore was 17.6% ± 12.8%, and 51.8% (n = 994) of the patients were female. Stroke/TIA occurred in 76 patients (3.9%), 1.9% were disabling, and 1.6% nondisabling. The predominant type of stroke were territorial ischemic lesions (82.4%), with primary bleeding in 4.4% and border zone infarctions in 4.4%. Left-sided lesions were more common (45.6% left sided vs. 25% right sided) and 13.2% of the lesions were bilateral (4.4% no finding and 11.8% missing data). In multivariate logistic regression, prior stroke (odds ratio [OR] = 1.83, p = 0.046) and initial experience (first 300 TAVR implanted at our center) were identified as independent risk factors for stroke/TIA during the first 30 days (OR = 1.95, p = 0.045). Overall, the occurrence of stroke had a highly significant impact on a 30-day mortality (13.2% vs. 4.9% in patients without stroke (p = 0.005). Stroke within the first 30 days after TAVR severely impairs 30-day survival. We identified prior stroke and initial experience as significant independent risk factors for the occurrence of stroke after TAVR.

Incidence of Prosthesis-Patient Mismatch in Valve-in-Valve with a Supra-Annular Valve.

Transcatheter aortic valve replacement (TAVR) for a degenerated surgical bioprosthesis (valve-in-valve [ViV]) has become an established procedure. Elevated gradients and patient-prosthesis mismatch (PPM) have previously been reported in mixed TAVR cohorts. We analyzed our single-center experience using the third-generation self-expanding Medtronic Evolut R prosthesis, with an emphasis on the incidence and outcomes of PPM. This is a retrospective analysis of prospectively collected data from our TAVR database. Intraprocedural and intrahospital outcomes are reported. Eighty-six patients underwent ViV-TAVR with the Evolut R prosthesis. Mean age was 75.5 ± 9.5 years, 64% were males. The mean log EuroScore was 21.6 ± 15.7%. The mean time between initial surgical valve implantation and ViV-TAVR was 8.8 ± 3.2 years. The mean true internal diameter of the implanted surgical valves was 20.9 ± 2.2 mm. Post-AVR, 60% had no PPM, 34% had moderate PPM, and 6% had severe PPM. After ViV-TAVR, 33% had no PPM, 29% had moderate, and 39% had severe PPM. After implantation, the mean transvalvular gradient was reduced significantly from 36.4 ± 15.2 to 15.5 ± 9.1 mm Hg (p < 0.001). No patient had more than mild aortic regurgitation after ViV-TAVR. No conversion to surgery was necessary. Estimated Kaplan-Meier survival at 1 year for all patients was 87.4%. One-year survival showed no significant difference according to post-ViV PPM groups (p = 0.356). ViV-TAVR using a supra-annular valve resulted in low procedural and in-hospital complication rates. However, moderate or severe PPM was common, with no influence on short-term survival. PPM may not be a suitable factor to predict survival after ViV-TAVR.

Surgical Treatment of Patients With Infective Endocarditis After Transcatheter Aortic Valve Implantation

BackgroundThe optimal treatment of patients developing infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) is uncertain. ObjectivesThe goal of this study was to investigate the clinical characteristics and outcomes of patients with TAVI-IE treated with cardiac surgery and antibiotics (IE-CS) compared with patients treated with antibiotics alone (IE-AB). MethodsCrude and inverse probability of treatment weighting analyses were applied for the treatment effect of cardiac surgery vs medical therapy on 1-year all-cause mortality in patients with definite TAVI-IE. The study used data from the Infectious Endocarditis after TAVI International Registry. ResultsAmong 584 patients, 111 patients (19%) were treated with IE-CS and 473 patients (81%) with IE-AB. Compared with IE-AB, IE-CS was not associated with a lower in-hospital mortality (HRunadj: 0.85; 95% CI: 0.58-1.25) and 1-year all-cause mortality (HRunadj: 0.88; 95% CI: 0.64-1.22) in the crude cohort. After adjusting for selection and immortal time bias, IE-CS compared with IE-AB was also not associated with lower mortality rates for in-hospital mortality (HRadj: 0.92; 95% CI: 0.80-1.05) and 1-year all-cause mortality (HRadj: 0.95; 95% CI: 0.84-1.07). Results remained similar when patients with and without TAVI prosthesis involvement were analyzed separately. Predictors for in-hospital and 1-year all-cause mortality included logistic EuroSCORE I, Staphylococcus aureus, acute renal failure, persistent bacteremia, and septic shock. ConclusionsIn this registry, the majority of patients with TAVI-IE were treated with antibiotics alone. Cardiac surgery was not associated with an improved all-cause in-hospital or 1-year mortality. The high mortality of patients with TAVI-IE was strongly linked to patients’ characteristics, pathogen, and IE-related complications.

Early and long-term outcomes of re-sternotomy for aortic valve replacement with patent coronary artery grafts.

The aim was to evaluate early and long-term outcomes of re-sternotomy for aortic valve replacement (AVR) with previous patent coronary artery grafts. Data for re-sternotomy for AVRs (group 1 isolated AVR, group 2 AVR with concomitant procedure) were collected (2000-2019). Logistic regression analysis was performed to identify predictors of in-hospital mortality and postoperative composite outcome (in-hospital death, transient ischemic attack/stroke, renal failure requiring new hemofiltration, deep sternal wound infection, re-exploration for bleeding/tamponade and length of stay >30 days). Survival curves were compared using log-rank test Cox proportion hazards model was used for predictors of long-term survival. Total 178 patients were included (groups 1-90 patients, group 2-88 patients). Mean age was 75 ± 4 years and mean log EuroSCORE was 17 ± 12% (15 ± 8% - group 1 vs. 19 ± 14% - group 2, p = 0.06). Mean follow-up was 6.3 ± 4.4 years. Cardiovascular injury occurred in 12%. Left internal mammary artery was most commonly injured. In-hospital mortality was 7.8% (5% - group 1 vs. 10.2% - group 2, p = 0.247). NYHA class III-IV, perioperative intra-aortic balloon pump and cardiovascular injury were independent predictors of in-hospital mortality (hazard ratio: 13.33, 95% confidence interval: 2.04-83.33, p = 0.007). Survival was significantly worse with cardiovascular injury at re-sternotomy up to 5 years (46% vs. 67%, p = 0.025) and postoperative complications (p = 0.023). Survival was significantly lower than age-matched first-time AVR and UK population. Long-term survival is significantly impaired by cardiovascular injury and perioperative complications of re-sternotomy.

Transcatheter aortic valve replacement – 10 years experience at Gottsegen György National Cardiovascular Center in Hungary

Transcatheter aortic valve implantation (TAVI) is an alternative treatment to surgical aortic valve replacement for elderly, high surgical risk patients. The aim of this study was to evaluate the short- and long-term outcomes of those 463 patients who underwent TAVI during the first 10 years in our TAVI program. We compare the first 200 patients' results with the further 263 patients' results. Between 11th November 2008 and 31st December 2018, 463 patients underwent TAVI. The average age of the patients was 79.6 years, the average logistic EuroSCORE was 19.0%, the average STS score was 5.2%. 72% of the patients were in NYHA III or IV stage before TAVI. 92% of TAVIs were performed from femoral arteries. Average mean gradient was 50.0 mmHg and aortic valve area was 0.55 cm2, respectively. In 2% of the cases, "valve-in-valve" intervention was performed because of the restenosis of former aortic valve prosthesis. 30-day mortality was 5.2% and the 1-year mortality was 16.4% after TAVI. Post-TAVI complications were evaluated according to the VARC-2 definitions. Major stroke occurred in 2.2% after TAVI. The most common complication was pacemaker implantation (19.9%), but their incidence was significantly reduced between the 2 groups (26.5% vs. 14.8% [p = 0.002]). The incidence of vascular access site complications was significantly higher between the 2 groups (10% vs. 20.2% [p = 0.016]), but it did not affect the mortality. Based on our results, TAVI is a safe alternative treatment for patients with severe, symptomatic aortic stenosis in our institute as well. Orv Hetil. 2022; 163(6): 229-235.

Male-Female Differences in Ascending Aortic Aneurysm Surgery: 25-Year Single Center Results

The aim of this study was to improve insight into male-female differences in patients undergoing ascending aortic aneurysm surgery. Consecutive patients that underwent ascending aortic aneurysm surgery between January 1991-December 2016 were retrospectively analyzed. Patient and procedural characteristics, 30-day mortality, and survival were compared between male and female patients. Multivariable Cox-regression analysis was performed to explore differences in factors associated with long-term mortality. Of 631 included patients, 36% were female patients. They were older (66 (55.9-72.9) vs 56 (44.1-67.3) years, p < 0.001), had a higher logistic EuroSCORE (12 (8-17) vs 8 (5-12), p < 0.001), and underwent concomitant arch surgery more often (74% vs 54%, p < 0.001). Aortic diameter (5.5 (5.0.6.5) vs 5.5 (5.0-6.0) cm, p=0.025) and Aortic Size Index (3.15 (2.80-3.65) vs 2.70 (2.42-3.00) cm/m2, p < 0.001) were larger in female patients. Early mortality was 0.9% in female patients and 2.0% in male patients (p=0.51). Adjusted 15-year survival was comparable between male and female patients. Multivariable Cox-regression did not identify an independent association between female sex and mortality. In males a larger aortic diameter (HR1.38 per centimeter increase, 95%-CI 1.03-1.85, p=0.003) was an independent factor associated with mortality, and in female patients a larger BSA (HR0.08 per 1kg/m2 increase, 95%-CI 0.01-0.49, p=0.007) was an independent risk-reducing factor. Female patients presented at older age and with more advanced disease. Increased awareness for ascending aortic pathology and timely referral may result in better preoperative profiles in female patients. This may improve outcomes after ascending aortic aneurysm surgery.

Protected Percutaneous Coronary Intervention of Unprotected Left Main Using Impella Ventricular Assist Device Before Transcatheter Aortic Valve Implantation: A Single-Center Experience.

Transcatheter aortic valve implantation (TAVI) is nowadays the optimal therapeutic strategy in patients with severe aortic valve stenosis (AS). Consequently, percutaneous coronary intervention (PCI) of concomitant complex coronary artery disease (CAD) has increased in the last decade to optimize patients with severe AS before TAVI. Although the Impella ventricular assist device (Abiomed) was considered as a relative contraindication in patients with AS, its usage has demonstrated promising results in selected patients. All consecutive patients with severe AS who underwent staged approach with high-risk PCI of unprotected left main (ULM) using the Impella ventricular assist device before TAVI were retrospectively included. The primary endpoint was 30-day all-cause mortality, and secondary endpoints were peri-interventional mortality, vascular complication, and 30-day stroke rates. Due to the exploratory, observational intent of the study, no statistical analysis was performed. Twenty-one consecutive patients (14 men; age, 80 ± 6 years; log EuroScore, 17 ± 7; SYNTAX score, 27 ± 10) were included. All patients (21/21) survived to 30-day follow-up exam. Three patients (14%) had PCI of ULM and TAVI at the same session. Eighteen patients (86%) underwent TAVI in a staged approach after previous PCI (10 ± 10 days). No patient suffered from stroke up to 30-day follow-up. One patient (5%) developed Valve Academic Research Consortium-2 major vascular complication after PCI. TAVI was successfully performed in all patients. Temporary hemodynamic support with the Impella device during staged approach with high-risk protected PCI appears to be safe and technically feasible in patients with severe AS before undergoing TAVI.

The Impact of Re-Opening Post Cardiac Surgery on Short and Long- Term Outcomes: 11 Years Follow Up

Objective: Re opening immediately post major cardiac surgery is a problematic complication. Studies suggest bleeding and/or tamponade post cardiac surgery significantly affects in hospital mortality and length of stay. The primary objective of this study was to compare the short- and long-term outcomes of patients who were reopened with those who were not reopened (Control) following cardiac surgery using propensity matched analysis. Methods: In total, 7960 patients underwent cardiac surgery. 539 (6.8%) were reopened immediately post cardiac surgery for either bleeding or tamponade. Patients were propensity score matched (525 reopened versus 525 control) by age, gender, operative priority, preoperative arrhythmia, Ejection Fraction, Euroscores, logistic Euroscores, type of cardiac operation, Body Mass Index, bypass time and cross clamp times. Data were collected prospectively and follow up obtained to date on all patients. Statistical analysis was performed using IBM SPSS version 22. Results: The overall rate of re exploration was 6.8%. After propensity score matching the baseline demographics, pre-operative and intra operative variables were comparable between the two groups. Therefore, patients with similar risk profiles were compared between RE and Control group. Significantly higher rate of post-operative arrhythmias, myocardial infarctions, renal complications, wound infections, cerebrovascular accidentsm, ulatnisdystem failure were observed in the RE group compared to Control group (p&gt;0.001). RE group on average had longer ICU stay and total hospital stay (p&gt;0.001). RE group had significantly higher 30-day mortality 23.4% (vs. 6.3% p&lt;0.001) and long term mortality 37% (vs. 22.9% log rank &lt;0.001) compared to Control group. However, patients who were discharged alive had a comparable long-term survival 82.4% vs. 84.9% between the RE and Control group (log rank &lt;0.396). Significant predictors of reopening post cardiac operation were; poor left ventricular function, pre-operative Intra-Aortic Balloon Pump (IABP), and post-operative arrhythmias (p&lt;0.001). However, reopening in itself was a significant predictor of in hospital mortality (p&lt;0.001). Conclusion: Reopening for bleeding and/or Tamponade saves lives. However, in this propensity matched study we have shown that reopening is also associated with a significantly higher rate of post-operative complications; hospital stay, short- and long-term mortality compared to similar risk profile patients who were not reopened. Re opening post cardiac operation is an independent predictor of in hospital mortality. Meticulous haemostasis is required to reduce risk of bleeding/tamponade and prevent re opening post cardiac surgery.