Logistic EuroSCORE Research Articles

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>0.001). RE group on average had longer ICU stay and total hospital stay (p>0.001). RE group had significantly higher 30-day mortality 23.4% (vs. 6.3% p<0.001) and long term mortality 37% (vs. 22.9% log rank <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 <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<0.001). However, reopening in itself was a significant predictor of in hospital mortality (p<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.

A new risk-score model to predict in-hospital mortality after isolated tricuspid valve surgery for severe tricuspid regurgitation

Isolated tricuspid valve surgery (ITVS) is reputed to be a high-risk surgery, but in-hospital mortality is markedly variable. This study sought to develop a dedicated risk score model to predict the outcome of patients after ITVS for severe tricuspid regurgitation (TR). All consecutive adult patients who underwent an ITVS for severe TR at 12 French centers between 2007 and 2017 were included. We derived and internally validated a scoring system to predict in-hospital mortality using multivariable logistic regression and bootstrapping with 1000 re-samples. We identified 466 patients (60 ± 16 years, 49% female, functional TR in 49%). In-hospital mortality rate was 10%. The final risk score ranged from 0 to 12 points and included 8 parameters: age ≥ 70 years, New-York Heart Association class III-IV, right-sided heart failure signs, daily dose of furosemide ≥ 125 mg, glomerular filtration rate < 30 ml/min, elevated bilirubin, left-ventricular ejection fraction < 60% and moderate/severe right-ventricular dysfunction. TR mechanism was not an independent predictor of outcome. Observed and predicted in-hospital mortality rates increased from 0% to 60% and from 1% to 65% respectively as score increased from 0 up to ≥ 9 points. Apparent and bias-corrected areas under the receiver operating characteristic curves were 0.81 and 0.75 respectively, much higher than the logistic EuroSCORE (0.67) or EuroSCORE II (0.63). We proposed an accurate dedicated risk-score model based on eight easy to ascertain parameters to inform patients and physicians regarding the risk of ITVS and guide the clinical decision-making process of patients with severe TR, especially as transcatheter therapies are emerging.

Analysis of risk scores to predict mortality in patients undergoing cardiac surgery for infectious endocarditis at the Ibn Rochd university hospital in Casablanca, Morocco

Risk scores are available for use in daily clinical practice, but knowing which one to choose is always fraught with pitfalls. To assess The logistic scores of EuroSCORE, EuroSCORE II and the specific scores of infectious endocarditis (IE) STS-IE, PALSUSE, AEPEI, EndoSCORE and RISK-E, as predictors of hospital mortality in patients undergoing cardiac surgery at the IBN ROCHD University Hospital in CASABLANCA,Morocco. Retrospective cohort study including all patients aged ≥ 18 years who underwent active CARDIAC surgery for EI in the study centre from 2015 to 2020. Scores were assessed by calibration (observed/expected mortality ratio [O/E]) and by discrimination (area below the ROC [AUC] curve). A P < 0.05 was considered statistically significant. A total of 157 patients were included. Overall hospital mortality was 29.0% (95% CI: 20.4 to 37.6%). The best O/E mortality ratio was obtained by the PALSUSE score (1.01, 95% CI: 0.70–1.42), followed by the logistic EuroSCORE (1.3, 95% CI: 0.92–1.87). The EuroSCORE logistics had the highest discriminating power (AUC 0.77), which was significantly higher than EuroSCORE II ( P –0.03), STS-IE ( P –0.03), PALSUSE ( P –0.03), AEPEI ( P –0.03) and RISK-E ( P –0.02). Despite the availability of recent EI-specific scores, and given the trade-off between indices, EuroSCORE Logistics appeared to be the best predictor of mortality risk in our cohort, taking a calibration (mortality ratio O/E: 1.3) and discrimination (AUC 0.77). Local validation of IE-specific scores is needed to better assess preoperative surgical risk.

Accuracy of the Logistic EuroSCORE in Predicting Long-Term Survival Following Isolated Aortic Valve Replacement

Objective: To assess the ability of the logistic EuroSCORE to predict long- term mortality of patients undergoing isolated Surgical Aortic Valve Replacement (SAVR). Methods: A retrospective review of all patients undergoing SAVR between September 1999, and March 2018 was done. Results: 2018 patients were eligible for inclusion in the study. Patients were grouped according to risk: low (n = 506), intermediate (n = 609), and high-risk (n = 903) depending on their logistic EuroSCORE values. The 30-day mortality of the low- risk group was 0.47%. The one-, five-, 10-, 15-, and 20-year mortality was 1.66%, 4.9%, 14.9%, 24.3%, and 43.8%, respectively. Intermediate-risk group 30-day mortality was 0.66%. The one-, five-, 10-, 15-, and 20-year mortality was 3.28%, 11.9%, 32%, 54.8%, and 82.6%, respectively. The 30-day mortality of the high- risk group was 3.99%. The one-, five-, 10-, 15-, and 20-year mortality was 8.2%, 27%, 55.4%, 78.6%, and 87%, respectively. Conclusion: Our results confirm that the lES is accurate in predicting long-term mortality outcomes of SAVR. This real-world data provides evidence of the potential usefulness of the EuroSCORE to help the heart team and patients decide on appropriate interventions for aortic stenosis.

Transfermoral transcatheter aortic valve implantation using self-expanding Allegra bioprosthesis: One-year single-center outcomes.

BackgroundThe NAUTILUS study aimed to evaluate the safety and performance of the Allegra bioprosthesis in high-risk recipients undergoing transcatheter aortic valve implantation and previously reported 30-day outcomes. In the current investigation 1-year results of the trial are presented.MethodsTwenty-seven recipients with severe, symptomatic aortic valve stenosis at high surgical risk, who underwent treatment using the next-generation self-expanding Allegra via transfemoral approach were prospectively enrolled. Clinical endpoints assessed were: mortality, stroke, permanent pacemaker implantation, New York Heart Association class and re-hospitalizations. Prosthetic valve performance evaluation comprised of: mean gradient, effective orifice area and paravalvular leak.ResultsPatients were elderly (82.8 ± 4.2 years) and predominantly female (n = 19, 70.4%). All of them were deemed to be at high surgical risk with a mean logistic EuroSCORE of 12.5 ± 6.7. The bioprosthesis was successfully implanted in 92.6% of the cases (n = 25). At 1-year, all-cause mortality was 12.0% (n = 3) and stroke was 4.0% (n = 1). Three (12%) of patients developed complete atrioventricular block and received permanent pacemakers. 84% of patients were in New York Heart Association class II or lower. Need for subsequent hospitalization arose in 48% patients. The echocardiographic assessment confirmed an acceptable hemodynamic profile of the Allegra with low mean transprosthetic gradient (9.5 ± 3.4 mmHg), absence of severe paravalvular leak and a 20%-presence of moderate paravalvular leak.ConclusionsThe current follow-up observation study shows that the Allegra was associated with a satisfactory safety profile and hemodynamic performance at 1-year after implantation.

Use and Outcomes of Acute Treatment Strategies in Patients with Severe Aortic Valve Stenosis.

Background:This study aimed to evaluate the acute treatment of patients with severe aortic valve stenosis in Germany.Methods and Results:Three treatment strategies in 11,027 patients acutely admitted due to aortic valve stenosis were compared from 2014 until 2018 using German nationwide records: The annual number of transcatheter aortic valve replacement (TAVR) procedures (1,294 to 1,827) and balloon valvuloplasty (BV only) procedures (170 to 233) in patients acutely admitted increased, but surgical aortic valve replacement (SAVR) procedures decreased (426 to 316). In comparison to BV only patients (mean age 81.3; EuroSCORE 23.2) SAVR patients were younger and at lower logistic EuroSCORE (mean age 66.9; EuroSCORE 9.4). Patients treated with TAVR were at comparable age and operative risk (mean age 81.3; EuroSCORE 24.4) as those patients treated with BV only. Primary outcome was in-hospital mortality. Reimbursement was considered secondary outcome. After risk adjustment using multivariable logistic and linear regression analyses, SAVR (OR 0.26 [96%CI 0.16;0.45], p < 0.001) and TAVR (OR 0.38 [0.29;0.49], p < 0.001) were associated with lower risk for mortality compared to BV only. Compared to BV only, hospitalization costs of patients undergoing SAVR were reduced by €5,578 ([95%CI €8,023; €3,133], p < 0.001). TAVR procedures were associated with higher hospitalization costs than BV only (risk-adjusted difference €4,143 [€2,330; €5,926], p < 0.001).Conclusions:BV only was associated with a substantially increased risk of in-hospital mortality in acute patients. We conclude that a definitive aortic valve replacement should be preferred as primary treatment in patients with severe aortic valve stenosis causing an acute admission.

In-hospital outcomes of patients undergoing concomitant aortic and mitral valve replacement in Germany

OBJECTIVESTo evaluate in-hospital outcomes of concomitant mitral valve replacement (MVR) in patients undergoing conventional aortic valve replacement due to aortic stenosis in a nationwide cohort.METHODSAdministrative data from all patients with aortic stenosis undergoing conventional aortic and concomitant MVR (reason for MVR not specified) between 2017 and 2018 in Germany were analysed.RESULTSA total of 2597 patients with a preoperative logistic EuroScore of 9.81 (standard deviation: 8.56) were identified. In-hospital mortality was 6.8%. An in-hospital stroke occurred in 3.4%, acute kidney injury in 16.3%, prolonged mechanical ventilation of more than 48 h in 16.3%, postoperative delirium in 15.8% and postoperative pacemaker implantation in 7.6% of the patients. Mean hospital stay was 16.5 (standard deviation: 12.1) days. Age [odds ratio (OR): 1.03; P = 0.019], New York Heart Association class III or IV (OR: 1.63; P = 0.012), previous cardiac surgery (OR: 2.85, P = 0.002), peripheral vascular disease (OR: 2.01, P = 0.031), pulmonary hypertension (OR: 1.63, P = 0.042) and impaired renal function (glomerular filtration rate <15, OR: 3.58, P = 0.001; glomerular filtration rate <30, OR: 2.51, P = 0.037) were identified as independent predictors for in-hospital mortality.CONCLUSIONSIn this nationwide analysis, concomitant aortic and MVR was associated with acceptable in-hospital mortality, morbidity and length of in-hospital stay. The regression analyses may help to identify high-risk patients and further optimize treatment strategies.

Abstract 10487: Right Thoracotomy versus Conventional Median Sternotomy in Redo Cardiac Surgery: A 10-Year Single-Centre Experience

Introduction: Minimally invasive cardiac surgery (MICS) has been gaining popularity over conventional sternotomy due to reduced invasiveness. However, in redo cardiac surgery when the risks are higher due to adhesions, few studies compare long-term outcomes. Objective: We aim to compare the perioperative and long-term mortality and stroke/TIA rate in patients undergoing median sternotomy and right thoracotomy for redo cardiac surgery. Secondary outcomes were post-operative and total hospital stay, blood products used, return to theatre and new renal replacement therapy (RRT). Methods: We retrospectively analysed a cohort of 127 sternotomy patients and 29 right thoracotomy patients for redo cardiac surgery between 2010-2020. All patients underwent valve repair or replacement. Patients requiring concomitant cardiac procedures were included. Results: In-hospital and long-term follow-up were 100% and 98.1% complete and a maximum of 10.4 years. There were 52 deaths (33.3%) within the follow-up period. Perioperative mortality was 16.5% in sternotomy versus 3.45% in MICS, although this difference was insignificant after adjustment for logistic EuroSCORE (HR 0.38, [0.05-2.79]). In multivariate analysis, long-term mortality was significantly lower in MICS (HR 0.30 [0.10-0.85]). Adjusted Kaplan-Meier curves revealed lower long-term mortality in the MICS group (p&lt;0.0001). Differences in stroke/TIA rates were insignificant (odds ratio 3.23 [0.85-12.8]). There were significantly less RBC (p=0.0001) and total blood products (p=0.0032) used in the MICS group. All 12 patients who returned to theatre for bleeding complications were in the sternotomy group. Although mean post-operative and total hospital stay and new RRT were lower in the MICS group, these differences were insignificant. Conclusion: MICS for redo cardiac surgery is a safe and effective alternative to median sternotomy without compromising both short-term and long-term clinical outcomes.

Minimally invasive mitral valve reconstruction: Is it an "all-comers" procedure?

The debate on the usefulness of the minimally invasive approach in mitral valve surgery is still open. The aim of this study is to describe a single-center case series of all comers undergoing minimally invasive mitral valve reconstruction. From 2010 to 2019, all the data recorded in the medical records of 893 consecutive patients undergoing mitral valve reconstruction through a right mini-thoracotomy were retrospectively collected. All patients were contacted by telephone for remote evaluation and integration of echocardiographic information on surgical results. Mean age was 62.2 ± 14.5; 447 (50%) were female and mean log EuroSCORE was 2.5 ± 2.8%. At a mean follow-up of 4.1 ± 2.2 years (median 3.9), a total of 24 deaths (2.68%) were recorded. Twenty-four patients required rehospitalization for cardiac causes, 13 (1.4%) patients had at least moderate mitral insufficiency on follow-up echocardiography and, of these, seven patients underwent reoperation (0.8%). The cumulative hazard showed that 8.3% of patients experienced at least one event at 5 years. NYHA class improved significantly with 874 patients in NYHA class I, 13 in NYHA class II, 6 in NYHA class III, and 0 in NYHA class IV at last follow-up (p < .001 from baseline as reference point). In a high-volume center, mitral valve surgery using a minimally invasive approach is a feasible treatment option for all-comers and is associated with excellent results that are maintained at clinical and echocardiographic follow-up.

Cardiac surgery in older patients: hospital outcomes during a 15-year period from a complete national series.

OBJECTIVESThe objective was to review national trends in activity and hospital outcomes in older patients having cardiac surgery over a 15-year time period.METHODSData were collected prospectively and uploaded to the National Institute for Cardiovascular Outcomes Research electronically. Data were validated, cleaned and processed using reproducible algorithms. Mortality was death in hospital after index operation.RESULTSA total of 227 442 cardiac procedures were recorded in patients aged ≥70 years of which 46 354 were in those aged ≥80 years. Overall patients aged ≥70 years represented 43% of all adult cardiac surgery in the most recent study year. The annual proportion of surgery in patients ≥80 years increased from 4.1% to 10.8% between the first and last study years. There has been a significant linear increase in octogenarian valve [β 67.44, 95% confidence interval (CI) 55.04 to 79.83, P < 0.001] and coronary artery bypass graft surgery (β 32.53, 95% CI 6.16 to 58.90, P = 0.020) patients. In-hospital mortality reduced significantly for patients aged 70–79 years (β −0.17, 95% CI −0.20 to −0.13, P < 0.001) and all patients aged ≥80 (β −0.37, 95% CI −0.45 to −0.30, P < 0.001). The median length of hospital stay was 7 days for 70–79 and 9 days for ≥80 group, compared with 7 days for the whole cohort <70 years.CONCLUSIONSThis study represents the largest complete validated national dataset of cardiac surgery in the entire population of older patients. Octogenarians represent 11% of adult patients having cardiac surgery by the end of the study period, a three-fold increase from the start. In-hospital mortality in patients aged ≥80 years halved during study period to only 4% despite high logistic EuroSCORE of 15%. Cardiac surgery in octogenarians places a higher demand on resources, however, with an increased postoperative length of stay.

Life Expectancy After Surgical Aortic Valve Replacement

BackgroundSurgical risk, age, perceived life expectancy, and valve durability influence the choice between surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation. The contemporaneous life expectancy after SAVR, in relation to surgical risk and age, is unknown. ObjectivesThe purpose of this study was to determine median survival time in relation to surgical risk and chronological age in SAVR patients. MethodsPatients ≥60 years with aortic stenosis who underwent isolated SAVR with a bioprosthesis (n = 8,353) were risk-stratified before surgery into low, intermediate, or high surgical risk using the logistic EuroSCORE (2001-2011) or EuroSCORE II (2012-2017) and divided into age groups. Median survival time and cumulative 5-year mortality were estimated with Kaplan-Meier curves. Cox regression analysis was used to further determine the importance of age. ResultsThere were 7,123 (85.1%) low-risk patients, 942 (11.3%) intermediate-risk patients, and 288 (3.5%) high-risk patients. Median survival time was 10.9 years (95% confidence interval: 10.6-11.2 years) in low-risk, 7.3 years (7.0-7.9 years) in intermediate-risk, and 5.8 years (5.4-6.5 years) in high-risk patients. The 5-year cumulative mortality was 16.5% (15.5%-17.4%), 30.7% (27.5%-33.7%), and 43.0% (36.8%-48.7%), respectively. In low-risk patients, median survival time ranged from 16.2 years in patients aged 60 to 64 years to 6.1 years in patients aged ≥85 years. Age was associated with 5-year mortality only in low-risk patients (interaction P < 0.001). ConclusionsEighty-five percent of SAVR patients receiving bioprostheses have low surgical risk. Estimated survival is substantial following SAVR, especially in younger, low-risk patients, which should be considered in Heart Team discussions.

Evidence-Based Determination of Cut-Off Points for Increased Cardiac-Surgery Mortality Risk With EuroSCORE II and STS: The Best-Performing Risk Scoring Models in a Single-Centre Australian Population

Risk scoring models (RSMs) are commonly used for estimation of postoperative-mortality risk in patients undergoing cardiac surgery, but their prediction accuracy may vary in different populations and clinical situations. The prognostic accuracies of some RSMs have not yet been fully evaluated in the Australian population. In this retrospective observational study, our aims were to assess the performance of four contemporary RSMs, to identify the best RSMs for prediction of postoperative-mortality in the single-centre cohort, and to determine a statistical threshold for classification of patients with increased or "higher" mortality risk. The study population included patients who underwent cardiac surgery at Liverpool Hospital between January 2013 and December 2014. Demographic information was collected, and mortality risks were estimated with the ES2 (EuroSCORE II), STS (Society of Thoracic Surgeons Score), AS (AusSCORE total) and ASMR (AusSCORE multi-risk) RSMs. (Additive EuroSCORE) (AES) and LES (logistic EuroSCORE) were included for historical interest. Discrimination, the ability to stratify patients between mortality and no mortality outcomes, and calibration, the comparison of risk score estimated and observed outcome in the population, were evaluated for each RSM, to determine their predictive accuracy in the study population. Discrimination was assessed by the AUC (area under the receiver operating characteristic curve), and acceptable calibration by the p-value greater than 0.05 for the Hosmer-Lemeshow (H-L) test. The best AUCs in contempory models were compared using the DeLong test. For ES2 and STS risk scores, cut-off points, or thresholds, for patients at increased risk of mortality were derived using Youden's J-statistics, calculated from sensitivity and specificity of models in predicting mortality. From a total study population of 898 patients, 738 had scores for all six RSMs. The three EuroSCORE risk models and Youden's J-statistics analysis included the total population. Of the models in contemporary use, ES2 had higher discrimination (AUC=0.850) in this population than ASMR (AUC=0.767, p=0.024) and AS (AUC=0.739) and non-significantly higher discrimination than STS (AUC=0.806, p=0.19). All contemporary models had acceptable calibration but the older LES (H-L p=0.024) did not. Estimated mortality was closest to observed mortality with the ES2 model. Both AES and LES over predicted mortality. The RSM with the highest discrimination in isolated coronary artery bypass graft surgery (CAGs) (AUC=0.847), isolated valves (AUC=0.830), and females (AUC=0.784) was the ES2 model. STS discrimination was highest in CAGs plus valve procedures (AUC 0.891), and males (STS AUC=0.891). Cut-off points for risk scores to define increased risk populations were 3.0% for ES2 and 1.7% for STS. Similar proportions of patients in each RSM (ES2-26% to STS-32%) were defined as higher risk by the model threshold score depending on type of procedure. Among RSMs in contemporary use, ES2 and STS showed the best discrimination and acceptable calibration. Caution is recommended in specific subgroups. Increased mortality risk score cut-off points could be identified for these two RSMs in this single-centre cohort.

Long-term results of coronary surgery with endoscopic vein harvesting.

Background In this study, we aimed to evaluate early and longterm outcomes of both isolated or concomitant coronary artery bypass grafting with the endoscopic vein harvesting technique. Methods Between November 2012 and May 2017, a total of 324 patients (259 males, 65 females; mean age: 63.2±9.8 years; range, 36 to 91 years) who underwent coronary artery bypass grafting, with or without concomitant procedures, using the endoscopic vein harvesting technique were retrospectively analyzed. Early postoperative outcomes and long-term follow-up data of the patients, such as cardiovascular or cerebral events, cardiac reinterventions, and the images of coronary angiography were recorded. Results Median logistic EuroSCORE and in hospital mortality was 3.99 (0.8-81) vs. 0 .9% f or i solated c oronary surgery and 13.34 (1.5-76.4) vs. 1.5% for concomitant procedures. The long-term data could be obtained in 288 patients with a median of 59.6 (7-90) months of follow-up. During this period, 22 (7.6%) patients underwent coronary angiography for control or treatment, 12 (4.2%) patients needed revascularization, and none of the patients underwent redo coronary surgery. Conclusion Our study results suggest that the endoscopic vein harvesting technique during coronary artery bypass grafting is safe in experienced hands.

Impact of gender on long-term prognosis after transcatheter edge-to-edge repair for mitral regurgitation

Abstract Background A symptomatic and prognostic benefit by Transcatheter edge-to-edge repair (TEER) for mitral regurgitation (MR) has been proven. A variety of individual factors including female sex has been suggested to be associated with adverse outcome in cardio-surgical procedures. Purpose While gender is factored in common risk factor models for adverse outcome, evidence on sex-specific differences in long-term outcome after TEER for MR is limited. We aimed to investigate the impact of gender on prognosis in a large monocentric cohort with long-term follow-up. Methods We analyzed survival stratified for gender after successful isolated edge-to-edge repair of MR in the period between 06/2010 and 03/2018 (exclusion of combined forms of TMVR) in a monocentric retrospective cohort by performing survival analyses and cox regression analyses. Results Consecutively, 627 patients (47.0% females, 57.4% functional MR; survival status was available in 96.7%) entered the study and were followed for a median follow-up period of 462 days [IQR 142–945 days]. Survival rates were 97.6% at discharge, 75.7% after 1, 54.5% after 3, 37.6% after 5 and 21.7% after 7 years. Risk score as calculated by the Logistic Euroscore I did not differ significantly between females and males (at baseline: 25.0 [IQR 18.0/34.8] vs. 27.0 [18.4/40.1]%, p=0.093) and no relevant differences were found for in-hospital (2.0 vs. 2.7%, p=0.613), 30 days (4.8 vs. 6.5%, p=0.473) and 1-year mortality (27.0 vs. 25.3%, p=0.675). At the time of procedure, women were older (79.9 [IQR 75.6/84.4] vs. 78.3 [72.9/83.4] years, p&amp;lt;0.001), were less often affected by coronary artery disease (53.1% vs. 75.0% p&amp;lt;0.001), diabetes mellitus (23.7% vs. 31.3%, p=0.040) and impaired left ventricular function (44.5±12.9% vs. 38.9±13.4%, p&amp;lt;0.001). Regarding long-term survival, women had a better prognosis after MR-therapy, especially in functional etiology: e.g., 4-year survival in FMR 65.7 vs. 35.7%, p=0.006 (Figure 1). Remarkably, female sex was associated with a lower risk for long-term mortality in the Cox-regression models, especially in the FMR subgroup (total cohort: univariate HR 0.81 [0.62–1.04], p=0.101; FMR: univariate HR 0.68 [0.49–0.96], p=0.028). Conclusion In our cohort of patients undergoing TEER for MR, we found no evidence for an impaired short- and mid-term prognosis for female patients. In contrary and not as indicated by Logistic Euroscore, female sex was associated with better long-term survival in comparison to men despite higher median age, which might be partly explained by a slightly more favorable cardiovascular risk profile. Funding Acknowledgement Type of funding sources: None. Figure 1

Insights on clinical outcomes in according to age in patients undergoing Transcatheter Aortic Valve Replacement

Abstract Transcatheter Aortic Valve Replacement (TAVR) is considered the treatment in patients older or at high or intermediate risk. Results form contemporary randomized trials in low-risk patients will likely broaden the indication of TAVR, but the data regarding long-term are limited by older population. The aim of this study was to evaluate the survival and the factors predicting mortality after TAVR in according to age. Methods From April 2008 to December 2019, the self-expandable and balloon-expandable prostheses were was implanted in 765 patients with symptomatic severe aortic stenosis with deemed high risk on base to age, &amp;lt;80 years and ≥80 years old. The rate of acute complications was defined by the combined endpoint of death, vascular complications, myocardial infarction, majopr bleeding or stroke. Results The mean age in patients &amp;lt;80 compared with ≥80 years, was 73.69±6.5 vs. 83.4±2.1 years and the logistic EuroSCORE and STS score were 15.9±11% vs. 18±11%, 4.8±3 vs. 6.3±4, p&amp;gt;0.001, respectively In-hospital mortality was 4% vs. 3.4%, p=0.404, and the rate of acute complications was 19.6 vs. 16.5%, p=0.168. The late mortality (beyond 30 days) was 36.9 vs. 35.2%, p=0.352. When compared in both groups, there were no differences for the presence of threatening bleeding 3.4% vs. 3.2% (HR = 1.028 [IC95% 0.722–1.463], p=0.516), myocardial infarction 4% vs. 2.5% (HR = 1.263 [IC95% 0.814–1.960], p=0.167), stroke 8% vs. 9.1% (HR = 1.149 [IC95% 0.686–1.925], p=0.347) and acute kidney innjury 14.1% vs. 19.1% (HR=0.1.14 [IC95% 0.969–2.141], p=0.071) and there was difference in between groups in hospitalizations for heart failure 14.6% vs. 7.9% (HR = 1.398 [IC95% 1.075–1.817], p=0.008 Survival at 1, 3, and 5were similar in both groups (88% vs. 89.5%, 73.3 vs. 78.2%, 58.8 vs. 62.6%, log Rank 0.992, p=0.319), respectively, after a mean follow-up of 42.3±27 months. The main predictors of cumulative mortality in young patients were: Charlson index [HR 1.18 (95% CI 1.06–1.30), p=0.001], Acute Kidney Injury [HR 2.21 (95% CI 1.42–3.47), p=0.001], Left ventricular ejection fraction [HR 1.02 (95% CI 1.009–1.035), p=0,001], and protective factor was a higher Karnosfky index [HR 0.98 (95% CI 0.97–0.99) p=0.006]. And in older patients were: Frailty [HR 1.67 (95% CI 1.13–2.47), p=0.010], COPD [HR 2.09 (95% CI 1.41–2.91), p=0,001], Stroke [HR 3.01 (95% CI 1.54–5.89), p=0.001] Charlson index [HR 1.14 (95% CI 1.02–1.27), p=0.015], Acute Kidney Injury [HR 1.57 (95% CI 1.06–2.32), p=0.001. Conclusions TAVR is associated with low complications rate in young and older patients. Survival during follow-up was similar in both groups, but the predictive factors of mortality differ, with greater impact on the comorbidtiy in the elderly patients Funding Acknowledgement Type of funding sources: None.

Percutaneous bioprosthetic aortic valve durability: results a single center after ten years of follow-up ago

Abstract The durability of transcatheter heart valves and long-term clinical outcomes are unknown. The aim of this study was to evaluate clinical and hemodynamic outcomes 10 years after Transcatheter Aortic Valve Implantation (TAVI). Methods Between April 2008 and December 2011, 230 patients underwent TAVI for the treatment of severe symptomatic aortic stenosis with the auto-expandable prosthesis. Results The mean age, logistic EuroSCORE and STS score were 79.3±6.4 years, 19.8±13% and 6.8±5% respectively. Mean aortic valve gradient decreased from 49.8±15 mm Hg to 8.6±3.8 mmHg after TAVI, to 11.1±9 mm Hg at 5 years, and 25.7±12 mmHg at 7 years (p for post-TAVI trend 0.03). Mean aortic valve area increased from 0.63±0.16 cm2 to 1.57±0.3cm2 after TAVI to 1.48±0.2 at 5 years and 0.87±0.3 cm2 at 7 years (p for post-TAVI trend 0.01). Mean left ventricular ejection fraction increased from 61.1±15% to 65.5±11% after TAVI, to 58.2±17% at 5 years and 57.2±8% at 7 years (p for post-TAVI trend 0.001). The total mortality after a mean of 53±34 months was 73% and 34.4% was cardiovascular mortality. Survival rates at 1 to 10 years were at 86%, 75.4%, 64.9%, 59.6%, 52.6%, 33.1%, 24.9%, 20.7%, 10.4% and 10.4% respectively. Only 4 patients had severe prosthetic valve dysfunction (severe stenosis and moderate-severe transvalvular regurgitation). Median survival time after TAVI was 6 years (95% confidence interval [CI]: 5.89 to 6.28), and the risk of death was significantly increased in patients with frailty (adjusted hazard ratio [HR]: 1.874; 95% CI: 1.028 to 3.418), p=0.040, Charlson index [HR=1.212 (95% CI: 1.094–1.341), p&amp;lt;0.001], and age [HR=1.03; (95% CI: 1.001–1.062), p=0.049]. Conclusions In our center, the transcatheter aortic valve implantation in patients at high surgical risk, presented favourable clinical outcomes and hemodynamic performance after ten years of follow-up. Funding Acknowledgement Type of funding sources: None.

Predictors of in-hospital mortality, 20-year survival and reflection on risk scoring in patients with impaired left ventricular function undergoing isolated coronary artery bypass grafting

Abstract Background Impaired left ventricular ejection fraction (LVEF) is a risk factor for mortality in patients undergoing coronary artery bypass grafting (CABG). Limited data is available on survival after 5 years and sensitivity of preoperative risk scoring systems in this high-risk population. Purpose To investigate in-hospital mortality, 20-year survival, predictors of early and late mortality and sensitivity of available risk-scoring systems in a large population with moderate to poor baseline LVEF and undergoing isolated CABG. Methods Patients presenting with moderate to poor LVEF and undergoing isolated CABG between 1996 and 2015 were selected for the purpose of this study. LVEF was defined moderate if between 30–39% and poor if &amp;lt;30%. Data collection was prospective and retrospectively analysed. Early and long-term mortality was derived from the NHS National Mortality Tracking system. Exclusion criteria included reoperations and combined procedures only. Patients undergoing urgent and emergency CABG procedures were included. Key outcome measures included 30-day health outcome, long-term survival, impact of incomplete revascularization (IC) and off-pump coronary artery bypass (OPCAB) surgery, independent predictors of poor in-hospital outcome and long-term mortality and reliability of Euroscore in predicting mortality in this high-risk population. Comparative analysis was conducted with Student t-test or Mann-whithney test fro numerical variable and Chi-Square for categorical variables. Survival were compared and reported using Log rank test and Kaplan Meier methods. A Cox Proportional Hazard model was developed to identify risk factors for long term mortality. Results 5016 patients with reduced LVEF were identifiedL1024 (20.4%) with poor and 3992 (79.6%) with moderate LVEF. After excluding reoperations and combined procedures, the final sample consisted of 3867 patients. Average age was68 years, 83% were male, 40% had NYHA IV; 12.5% of patients received IC and 44% underwent OPCAB surgery. 30-day mortality was 4.4%, stroke 1.4% and renal failure requiring dialysis of 2.9%. Survival at 1, 5, 10 and 20 years was 91.1%, 76.7%, 55.1% and 22.1% respectively (Figure). OPCAB surgery was not associated with long-term mortality. Independent predictors of late mortality as shown in Table. Additive Euroscore and Logistic Euroscore appeared to overestimate mortality in this patient population (AUC 0.78). Conclusions In patients with reduced LVEF the use of CABG is associated with low rates of in-hospital mortality, key post-operative complications and excellent long-term survival. Incomplete revascularization but not OPCAB surgery are surgical predictors of long-term mortality. Euroscore appears to overestimate the risk of mortality in this population. Funding Acknowledgement Type of funding sources: None. Cox Hazard Ratio Table

Long-term outcomes in patients undergoing transcatheter aortic valve implantation: insights on clinical outcomes and prognostic markers from a large cohort of patients

Abstract Transcatheter Aortic valve Replacement (TAVR) has emerged as paradigm shift in the treatment of patients with severe symptomatic aortic stenosis. Clinical and performance data on long-term TAVR are still limited. The aim of this study was to determine the survival and the factors predicting mortality after TAVR with the first and second generation of prostheses. Methods From April 2008 to December 2019, the auto-expandible prostheses were implanted in 765 patients with symptomatic severe aortic stenosis with deemed high risk. The first generation prostheses included CoreValve and Accutrak System and the second prostheses included Evolut R and Pro. Results The mean age was 79.4±6.6 years. The logistic EuroSCORE and STS score were 17.1±11% and 5.7±3.9%, respectively. The implantation success rate was 98.87%. In-hospital mortality was 3.7%, and the combined endpoint of death, vascular complications, myocardial infarction or stroke had a rate of 15.1%. The clinical outcomes in according to prosthesis generation were, for pacemaker requirement (CoreValve vs. Accutrak system vs. Evolut R vs. and Evolut pro) 35.3% vs. 26.1% vs. 14.3% vs. 14%, p=0.001; and the paravalvular aortic regurgitation, were: none 28% vs. 44.8% vs. 43.3% vs. 58; mild 40% vs. 32.3% vs. 30.8% vs. 35.2%; moderate 32% vs. 20.3 vs. 23.9% vs. 5.7%; severe 0% vs. 2.6% vs. 0% vs. 1.1, p 0.001 The late mortality (beyond 30 days) was 35.9%. Survival at 1, 3, 5, 7 and 9 years were 88.9%, 76.1%, 61.1%, 44% and 32.6% respectively, after a mean follow-up of 42.3±27 months. The NYHA functional class improved from 3.1±0.6 to 1.77±0.7 in the follow-up. At 5 years, 5 patients had severe prosthetic valve dysfunction (severe stenosis and moderate transvalvular regurgitation The predictors of cumulative mortality were: Charlson index [HR 1.25 (95% CI 1.077–1.461), p=0.004], Readmision Heart Failure [HR 3.02 (95% CI 1.554–5.879), p=0.001], stroke post-TAVR [HR 3.472 (95% CI 1.115–10.53), p=0.032], residual aortic regurgitation [HR 1.45 (95% CI 1.093–1.934), p=0,010], and severe pulmonary hypertension [HR −0.983 (95% CI 0.645–0.423) p=0.032]. Conclusions TAVR is associated with significant survival benefit throughout 3.09 years of follow-up. Survival during follow-up depends particularly among patients with associated comorbidities and cardiac markers such as aortic regurgitation or pulmonary hypertension Funding Acknowledgement Type of funding sources: None.

Risk prediction in patients with classical Low-flow, low-gradient aortic stenosis undergoing TAVI

Abstract Background Patients with classical low-flow, low-gradient aortic stenosis (LFLG AS) undergoing transcatheter aortic valve implantation (TAVI) are known to suffer from poor prognosis. Risk prediction is difficult and predictors of outcome are scarce in this complex patient subset. Purpose This study aimed to develop a simple score system for risk prediction in patients with classical LFLG AS scheduled for TAVI including baseline clinical, echocardiographic and computed tomography (CT) parameters. Methods Among 9,150 patients undergoing TAVI (2008–2019) at five German centers, patients with classical LFLG AS were screened for availability of sufficient CT data for aortic valve calcification (AVC) quantification. Score variables were defined as all variables included into the best performing multivariable regression model. Score performance was assessed by Kaplan-Meier analysis for the endpoint of 1-year all-cause as well as c-index calculation. Results A total of 718 patients were included into the study. Predictors of all-cause mortality were male sex (HR 1.27 [0.98, 1.65], p=0.068), chronic obstructive pulmonary disease (HR 1.59 [1.21,2.08], p&amp;lt;0.001), atrial fibrillation (HR 1.33 [1.03,1.70], p=0.026), stroke volume index (HR 0.96 [0.94, 0.98], p&amp;lt;0.001), non-transfemoral access (HR 1.44 [1.09,1.91], p=0.011), pulmonary hypertension (HR 1.58 [1.20,2.08], p=0.0012) and low AVC density (HR 1.49 [1.16,1.90], p=0.0016). A score system was developed ranging from 0 points to 11 points. Kaplan-Meier analysis for low (0–2 points), moderate (3–6 points) and high score (&amp;gt;6 points) demonstrated 1-year mortality rates of 20.9%, 28.9% and 64.3% (p&amp;lt;0.001), respectively. C-index for prediction of 1-year mortality was 0.69 (95%-CI 0.65–0.84). The RELiEF TAVI score outperformed classical risk prediction models like the logistic euroSCORE (c-index 0.60 [95%-CI 0.51–0.72], p=0.013), the EuroSCORE II (c-index 0.57 [95%-CI 0.45–0.70], p=0.039) and the STS PROM (c-index 0.60 [0.48–0.70], p=0.035). Conclusions The RELiEF TAVI score is based on simple clinical, echocardiographic and CT parameters and might serve as a helpful tool for risk prediction in the vulnerable subset of patients with classical LFLG AS scheduled for TAVI. Funding Acknowledgement Type of funding sources: None. RELiEF TAVI Score

Percutaneous edge-to-edge therapy with PASCAL or MitraClip: a multicenter propensity score matched comparison

Abstract Background The MitraClip is the worldwide established transcatheter edge-to-edge repair system with over 100,000 treated patients. The recently approved PASCAL repair system is well adopted in the field of percutaneous mitral regurgitation (MR) treatment with growing acceptance both in mitral and tricuspid valves. The aim of this retrospective multicenter study was to compare the Edwards' PASCAL System with the Abbott MitraClip System in terms of procedural results and short-term outcome. Methods We retrospectively evaluated patient data of three high volume German centers that performed percutaneous edge to edge procedures either with the MitraClip or the PASCAL repair system. Primary endpoint was the amount of MR reduction. Secondary endpoints were residual MR at discharge, technical success, device success and 30-day mortality. Results Between 2018 and 2020 a total of 412 procedures were performed in the three centers. 216 cases were performed with the MitraClip compared to 196 procedures done with the PASCAL repair system. Patients were male in 55.6% of the cases (50.5% in the MitraClip cohort compared to 61.2% in the PASCAL cohort, p=0.028), mean Logistic Euro-Score II was 4.42 (3.58 in the MitraClip and 3.23 in the PASCAL cohort, p=0.038) and reduced LVEF beyond 45% was seen in 42.6% of the cases (49.5% in the MitraClip compared to 35.3% in the PASCAL cohort, p=0.004). Severe MR at baseline was seen in 98.5% in the MitraClip cohort compared to 98.6% in the PASCAL cohort, p=0.909). Mean number of implanted devices was 1.41±0.56 in the MitraClip cohort and 1.37±0.55 in the PASCAL cohort (p=0.401). Procedures were successfully conducted with both edge-to-edge systems (device success rate 93.2% in the MitraClip cohort and 94.0% in the PASCAL cohort, p=0.775), leading to comparably good results (final MR ≤2 in 94.4% with the MitraClip compared to 95.9% with the PASCAL system, p=0.448) and very good results (final MR ≤1 in 72.6% in the MitraClip compared to 79.5% in the PASCAL cohort, p=0.102). After propensity score matching for adjustment of major differences among the two treatment strategies (including age, gender, MR etiology, EROA, Severe MR (III and IV), reduced LVEF and Mitral Valve orifice area) the achieved mean MR reduction remains comparable (2.29±0.82 with the MitraClip compared to 2.46±0.82 with the PASCAL system, p=0.191). In multivariate regression analysis STS Score independently correlates with a very good final result while device choice did not show a significant impact in this cohort. Conclusion In this retrospective multicenter study both the MitraClip and PASCAL system performed excellent with comparable procedural success rates. Achieved final average reduction of MR Grade was 2.29±0.82 with the MitraClip and 2.46±0.82 with the PASCAL system. Funding Acknowledgement Type of funding sources: None.