STS Score Research Articles

P292 “CAN MIXED REALITY IMPROVE THE RESULTS OF TAVI?”

Abstract Background and Aim: Although the rate of TAVI–related complications has consistently reduced during the last decade, vascular complications still occur, and can be serious. Mixed reality (MR) can be defined as a three–dimensional real world simulation allowing the user to directly interact with it. The present study was designed to explore the potential of MR in facilitating the vascular access and navigation with large–bore devices. Methods 3D holograms were generated from the CT’s of 20 TAVI patients (age 81.2±6.8 years, STS score 5.1±2.1) and made available to 2 surgeons in training. Different layers were generated: Skin, Arterial tree, and Calcium. A needle simulator was also available. The vascular puncture was echo guided. 2 percutaneous suture system were used to secure the hemostasys. Results All the procedures were carried out through the planned access. In 2 patients intravascular lythoplasty was used. There were no vascular complications, and procedural success was 100%. A single puncture was necessary to obtain vascular access in 19/20 patients and in 2 cases the echo was not used, and the operator decided to switch to angio–guided puncture due to the bad quality of the echo images that were in contrast with MR. Conclusion MR can be used to predict the optimal puncture site for TAVI. The interactive 3D holograms can be used to identify relevant repere on the skin and to reduce the rate of vascular complications and could become a powerful tool for procedural planning, training and remote proctoring.

One-Year and Five-Year Outcomes of Transcatheter Aortic Valve Replacement or Surgical Aortic Valve Replacement in a Taiwanese Elderly Population.

The aim of our study was to provide real-world data on outcomes for elderly Taiwanese patients who underwent transcatheter aortic valve replacement or surgical aortic valve replacement in different risk groups. From March 2011 through December 2021, 177 patients with severe aortic stenosis who were ≥70 years old and had undergone TAVI (transcatheter aortic valve implantation) or SAVR (surgical aortic valve replacement) in a single center were divided by STS score (<4%, 4-8% and >8%) into three different groups. Then, we compared their clinical characteristics, operative complications, and all-cause mortality. In all risk groups, there were no significant differences in in-hospital mortality, or 1-year and 5-year mortality between patients in the TAVI and SAVR groups. In all risk groups, patients in the TAVI group had shorter hospital stay and higher rate of paravalvular leakage than the SAVR group. After univariate analysis, BMI (body mass index) < 20 was a risk factor for higher 1-year and 5-year mortality. In the multivariate analysis, acute kidney injury was an independent factor for predicting worse outcomes in terms of 1-year and 5-year mortality. Taiwan elderly patients in all risk groups did not have significant differences in mortality rates between the TAVI and the SAVR group. However, the TAVI group had shorter hospital stay and higher rate of paravalvular leakage in all risk groups.

Analysis of therapeutic decision-making process and prognosis in patients referred to the Valvular Heart Team for management of mitral regurgitation

Due to the aging of the population and the diversification of treatment options, finding the right treatment for the right patient becomes a challenge, especially in patients with mitral regurgitation (MR), which is a heterogenous and complex disease, with numerous etiologies. Aims of this study are to describe the profile of patients referred to the Valvular Heart Team (VHT) for management of mitral regurgitation, to highlight the selection process and the main factors guiding allocation for different treatment options, to assess clinical outcomes after treatment. All patients with mitral regurgitation referred to the VHT between January 1st, 2014, and April 30th, 2021, in University Hospital of Tours, were included. MR patients referred to our VHT were, mostly, old (mean: 74.2 years), symptomatic (96%), at high or intermediate risk according to “European Society of Cardiology” criteria (44%). Most of them had comorbidities, 34% had LVEF < 50% and 70% a severe primary MR. In 81% of cases, invasive management was decided (surgery [44%], percutaneous edge- to-edge mitral repair [TEER] [35%], transcatheter mitral valve replacement [1.6%]) and in 19% of cases, medical treatment was decided. Distribution of treatments changed significantly (P < 0.01) over time, with a progressive increase in TEER. History of cardiac surgery (P = 0.015), EuroScore II > 4% (P = 0.012), STS score > 8% (P = 0.037), frailty according to the Katz index (P = 0.029), LVEF < 50% (P < 0.001), TAPSE < 15 mm (P < 0,01) secondary MR (P < 0.001) and leaflets calcifications (P = 0.027) were the main factors significantly associated with the choice of a conservative treatment. In 86% of cases, VHT decisions could be implemented. VHT is a centerpiece in the current management of patients with MR, it opts and more and more, for percutaneous treatments. The organization and the smooth running of VHT meetings will be a real issue in the future, with the increase in patients referred and we will have to find solutions (Fig. 1).

Results and insights after 413 TAVI procedures performed by cardiac surgeons on their own.

Current evidence on transcatheter aortic valve implantation (TAVI) has been generated exclusively by cardiology studies and no operative data from cardiac surgeons are available. Here, we describe the development of our TAVI programme and report the results of transfemoral (TF) TAVI done by cardiac surgeons on their own. This study included all the TAVI procedures on native valve performed at Cardiac Surgery Unit, Ospedali Riuniti di Ancona, during the period October 2018 to July 2022. Relevant prospectively collected preoperative, intraprocedural and postoperative data were retrieved from the Institutional database. A total of 413 patients were included in the study. Mean patients' age was 82 years and among them 44% (180/413) were male. STS score was 3.1% (2.2-4.4). Eighty patients underwent transapical TAVI and 333 patients had a TF approach. We progressively moved from transapical TAVI towards TF procedures that are now routinely performed on conscious sedation and using a fully percutaneous approach. After TF TAVI, 30-day mortality rate was 1%, cerebral stroke occurred in 2% of the cases, permanent pacemaker implantation was necessary in 23% of the patients and in 6% of the cases there was a moderate/severe degree of aortic regurgitation. There was no association between operators performing TAVI and 30-day mortality. The acquisition of catheter-based skills and an adequate training allowed cardiac surgeons to perform on their own awake and fully percutaneous TF TAVI with similar results when compared with major randomized clinical trials and registries' experiences.

B-55 | Impact of Baseline Tricuspid Regurgitation on Health Status and Clinical Outcomes After Transcatheter Aortic Valve Replacement: Insights from the STS/ACC TVT Registry

Tricuspid regurgitation (TR) is associated with worse clinical outcomes after TAVR. Little is known about the association between TR and health status outcomes after TAVR. Health status was assessed with the Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OS) in patients enrolled in the STS/ACC TVT Registry who underwent isolated TAVR between Jan 2019-Jun 2021. Multivariable logistic and cox regression models were used to evaluate the association of TR with being alive and well and clinical outcomes (deaths and readmission) respectively at 1 year. We included 130,097 patients who underwent TAVR (mean age 79.2±8.3 years, STS score 5.3±4.6%, 56.2% men, 13.1% moderate TR, 2.3% severe TR). Mean baseline KCCQ-OS was significantly lower in patients with severe vs moderate vs none/trace/mild TR (39.4±24.2 vs 45.2±24.7 vs 51.3±25.3; p<0.0001). Greater baseline TR was also associated with lower KCCQ-OS at 30 days and 1 year (Figure A). Compared with patients with none/trace/mild TR, moderate, and severe TR had lower odds of being alive and well at 1 year after TAVR [adjOR 0.79 (0.74-0.85); adjOR 0.81 (0.70-0.94), respectively; Figure B]. Further, moderate, and severe TR were both associated with higher mortality [adjHR 1.24 (1.15-1.34); adjHR 1.65 (1.46-1.86)], and readmission [adjHR 1.07 (1.01-1.12); adjHR 1.11 (1.01-1.21)] at 1 year in comparison with none/trace/mild TR (Figure C). The presence of baseline moderate or severe TR is associated with worse health status and clinical outcomes after TAVR. Future studies should focus on whether treatment of baseline TR improves outcomes among TAVR recipients.

Última generación de prótesis percutáneas expandibles con balón y autoexpandibles en la estenosis aórtica bicúspide: estudio TRITON

Introduction and objectivesNo comparisons have been published yet regarding the newest iteration of balloon- and self-expandable transcatheter heart valves for the treatment of bicuspid aortic valve (BAV) stenosis. MethodsMulticenter registry of consecutive patients with severe BAV stenosis treated with balloon-expandable transcatheter heart valves (Myval and SAPIEN 3 Ultra, S3U) or self-expanding Evolut PRO+(EP+). TriMatch analysis was carried out to minimize the impact of baseline differences. The primary endpoint of the study was 30-day device success, and the secondary endpoints were the composite and individual components of early safety at 30 days. ResultsA total of 360 patients (age 76.6±7.6 years, 71.9% males) were included: 122 Myval (33.9%), 129 S3U (35.8%), and 109 EP+(30.3%). The mean STS score was 3.6±1.9%. There were no cases of coronary artery occlusion, annulus rupture, aortic dissection, or procedural death. The primary endpoint of device success at 30 days was significantly higher in the Myval group (Myval: 100%; S3U: 87.5%; and EP+: 81.3%), mainly due to higher residual aortic gradients with S3U and greater≥moderate aortic regurgitation (AR) with EP+. No significant differences were found in the unadjusted rate of pacemaker implantation. ConclusionsIn patients with BAV stenosis deemed unsuitable for surgery, Myval, S3U and EP+showed similar safety but balloon-expandable Myval had better gradients than S3U, and both balloon-expandable devices had lower residual AR than EP+, suggesting that, taking into consideration the patient-specific risks, any of these devices can be selected with optimal outcomes.Full English text available from:www.revespcardiol.org/en

Clinical outcomes of the ACURATEneo2transcatheter heart valve: a prospective, multicenter, observational, post-market surveillance study.

The next-generation ACURATE neo2 transcatheter aortic valve was designed for simplified implantation and to mitigate the risk of paravalvular leak (PVL) compared to the earlier device. To collect clinical outcomes and device performance data, including echocardiography and 4-dimensional computed tomography (4D-CT) data, with the ACURATE neo2 transcatheter heart valve in patients with severe aortic stenosis (AS). ACURATE neo2 PMCF is a single-arm, multicentre study of patients with severe AS treated in routine clinical practice. The primary safety endpoint was all-cause mortality at 30-days. The primary imaging endpoint was hypo-attenuated leaflet thickening (HALT), measured by core laboratory-adjudicated 4D-CT at 30 days. Secondary endpoints included VARC safety endpoints, procedural success, and evaluation of valve performance via core laboratory-adjudicated echocardiography. The study enrolled 250 patients at 18 European centres (mean age: 80.8 years; 63.6% female; mean STS score: 2.9±2.0%); 246 (98.4%) were successfully treated with ACURATE neo2. The 30-day rates for mortality and disabling stroke were 0.8% and 0%, respectively. The new permanent pacemaker implantation rate was 6.5%. HALT >50% was present in 9.3% of patients at 30 days. Valve haemodynamics improved from baseline to 30 days (mean aortic valve gradient: from 47.6±14.5 mmHg to 8.6±3.9 mmHg; mean aortic valve area: from 0.7±0.2 cm2 to 1.6±0.4 cm2). At 30 days, PVL was evaluated as none/trace in 79.2% of patients, mild in 18.9%, moderate in 1.9%, and severe in 0%. The study results support the safety and efficacy of TAVI with ACURATE neo2 in patients in routine clinical practice.

E-41 | Role of Cerebral Embolic Protection With Transcatheter Aortic Valve Replacement: An Updated Meta-Analysis of Randomized Controlled Trials

The role of cerebral embolic protection (CEP) in patients undergoing transcatheter aortic valve replacement (TAVR remains a topic of debate despite multiple randomized controlled trials (RCTs). Recently, the PROTECTED TAVR trial was published. The current meta-analysis aimed to aggregate RCTs that examined all available forms of CEP devices to date. PubMed, Cochrane Central, and EMBASE were searched for RCTs comparing CEP versus no CEP in patients undergoing TAVR. The primary outcome was 30-day stroke. The secondary outcome was 30-day all-cause mortality. Search and reporting were according to PRISMA guidelines. Random effects model with DL tau estimator were used for pooled effect. Heterogeneity was assessed using I2 test. All analyses were performed by R studio. Six studies with a total of 3621 patients (CEP n= 1874, no CEP n= 1747) met our inclusion criteria (mean age 79.5 years, 58.6% male, average STS score 3.76). CEP was not associated with a significant reduction of stroke at 30 days (Relative risk RR: 0.75; 95% CI: 0.52, 1.08; P= 0.12; Absolute Risk Difference ARD: -0.75%; 95% CI: -1.8%, 0.3%). No difference in 30-day all-cause mortality with CEP vs no CEP use, RR: 0.93; 95% CI: 0.41, 2.11; P= 0.86. No change in pooled estimate when limiting analysis to trials that utilized Sentinel device. In this meta-analysis of all RCTs to date, use of CEP devices in patients undergoing TAVR was not associated with a significant reduction in 30-day stroke or all-cause mortality.

B-43 | TAVR in End-Stage Renal Disease Patients: Long-Term Outcomes, Structural Valve Degeneration and Need for Aortic Valve Reintervention

ESRD patients are predisposed to the development of calcific aortic valve disease. Patients with ESRD were excluded from the clinical trials of TAVR, and hence long-term outcomes are not well established. We sought to describe the long-term outcomes, including incidence of structural valve degeneration (SVD) and re-intervention, in patients with ESRD undergoing TAVR at our institution. Retrospective registry of consecutive patients with ESRD who underwent TAVR for aortic stenosis at our institution (2012-present). Variables of interest included patient demographics, clinical and procedural characteristics. Outcomes assessed were in-hospital events, SVD, aortic re-intervention procedures, and standard MACE incidence at 30-days, 6-months, 1-year, and at annual follow-ups. Our study included 95 patients with ESRD who underwent TAVR. In-hospital events were notable for new permanent pacemaker placement (12.6%), cardiac arrest (5.3%), and mortality (6.3%). The long-term all-cause mortality was 47.4%, with survival time after TAVR of 596 days. The most common long-term MACE was MI (7.4%). Long-term SVD occurred in 25 cases (26.3%). Long-term re-intervention occurred in 3 cases (3.2%). In-hospital and long-term MACE were high; however, when looking at baseline STS scores, these rates were close to expected. SVD was elevated with over one-fourth of patients demonstrating some degree for degeneration; however, only 3.2% of patients required re-intervention. To the best of our knowledge, this is the only study characterizing long-term SVD and re-intervention rates in this population.

Comparison of a novel self-expanding transcatheter heart valve with two established devices for treatment of degenerated surgical aortic bioprostheses

AimsThis study was performed to compare haemodynamic properties of a novel transcatheter heart valve (THV) with two established valve technologies for treatment of failing surgical aortic bioprosthetic valves (SAV). The ALLEGRA THV has been recently described with a proven safety and performance profile.Methods and resultsThe study was designed as a retrospective, single-centre study investigating 112 patients (77.7 ± 7.1 years, 53.8% female, STS score 6.8 ± 5.8% and logEuroSCORE I 27.4 ± 16.1%) with failing SAV. Patients were treated with the ALLEGRA THV (NVT, n = 24), the CoreValve/EvolutR (MTD, n = 64) or the Edwards Sapien/Sapien XT/Sapien 3 (EDW, n = 24). Adverse events, haemodynamic outcomes and patient safety were analysed according to VARC-3 definitions. Overall procedural success was high (94.6%), even though 58.9% of the treated SAV were classified as small (true inner diameter < 21 mm). After treatment, the mean pressure gradient was significantly reduced (baseline: 33.7 ± 16.5 mmHg, discharge: 18.0 ± 7.1 mmHg), with a corresponding increase in effective orifice area (EOA). The complication rates did not differ in between groups. There was a trend to lower mean transvalvular gradients after implantation of self-expanding THV with supra-annular valve function, despite a higher frequency of smaller SAVs in the NVT and MTD group. Additionally, comparison between NVT and MTD revealed statistically lower transvalvular gradients (NVT 14.9 ± 5.0 mmHg, MTD 18.7 ± 7.5 mmHg, p = 0.0295) in a subgroup analysis.ConclusionsValve-in-valve (ViV) treatment of failing SAV with supra-annular design like the ALLEGRA THV resulted in favourable haemodynamic outcomes with similar low clinical event rates and may therefore be an interesting alternative for VIV TAVI.Graphical abstract

Preoperative risk modelling for oesophagectomy: A systematic review.

Oesophageal cancer is a frequently observed and lethal malignancy worldwide. Surgical resection remains a realistic option for curative intent in the early stages of the disease. However, the decision to undertake oesophagectomy is significant as it exposes the patient to a substantial risk of morbidity and mortality. Therefore, appropriate patient selection, counselling and resource allocation is important. Many tools have been developed to aid surgeons in appropriate decision-making. To examine all multivariate risk models that use preoperative and intraoperative information and establish which have the most clinical utility. A systematic review of the MEDLINE, EMBASE and Cochrane databases was conducted from 2000-2020. The search terms applied were ((Oesophagectomy) AND (Risk OR predict OR model OR score) AND (Outcomes OR complications OR morbidity OR mortality OR length of stay OR anastomotic leak)). The applied inclusion criteria were articles assessing multivariate based tools using exclusively preoperatively available data to predict perioperative patient outcomes following oesophagectomy. The exclusion criteria were publications that described models requiring intra-operative or post-operative data and articles appraising only univariate predictors such as American Society of Anesthesiologists score, cardiopulmonary fitness or pre-operative sarcopenia. Articles that exclusively assessed distant outcomes such as long-term survival were excluded as were publications using cohorts mixed with other surgical procedures. The articles generated from each search were collated, processed and then reported in accordance with PRISMA guidelines. All risk models were appraised for clinical credibility, methodological quality, performance, validation, and clinical effectiveness. The initial search of composite databases yielded 8715 articles which reduced to 5827 following the deduplication process. After title and abstract screening, 197 potentially relevant texts were retrieved for detailed review. Twenty-seven published studies were ultimately included which examined twenty-one multivariate risk models utilising exclusively preoperative data. Most models examined were clinically credible and were constructed with sound methodological quality, but model performance was often insufficient to prognosticate patient outcomes. Three risk models were identified as being promising in predicting perioperative mortality, including the National Quality Improvement Project surgical risk calculator, revised STS score and the Takeuchi model. Two studies predicted perioperative major morbidity, including the predicting postoperative complications score and prognostic nutritional index-multivariate models. Many of these models require external validation and demonstration of clinical effectiveness. Whilst there are several promising models in predicting perioperative oesophagectomy outcomes, more research is needed to confirm their validity and demonstrate improved clinical outcomes with the adoption of these models.

Why Self-Care? Maintaining High Job Satisfaction Among Human Service Professionals

Human services professionals (HSPs) experiencing "secondary traumatic stress" (STS) are at higher risk for job burnout. This study is to examine STS, job satisfaction, and self-care strategies among HSPs. Research questions include (1) what traumatic events were experienced? (2) are STS and job satisfaction related? and (3) What self-care strategies do they use to cope with secondary traumatic stress? Using an online survey, 92 HSPs answered demographic questions and the secondary traumatic stress scale was used to assess the STS resulting from working with traumatized populations. Findings indicated that three STS subscales are negatively correlated to job satisfaction. Independent samples t-test indicated that the STS scores did differ between two different job satisfaction groups. Qualitative findings from 13 interviewees indicated that HSPs experience diverse work-related traumatic events with core themes such as emotionally and mentally taxing situation, a work-life imbalance, little time off and talk, open-dialogue in peer support, professional help, family support, self-care, and a lack of accessibility to resources. Although less diverse participants are study limitations, findings suggest understanding the impact of STS on job satisfaction and developing hands-on self-care strategies are needed.

Latest-iteration balloon- and self-expandable transcatheter valves for severe bicuspid aortic stenosis: the TRITON study

Introduction and objectivesNo comparisons have been published yet regarding the newest iteration of balloon- and self-expandable transcatheter heart valves for the treatment of bicuspid aortic valve (BAV) stenosis. MethodsMulticenter registry of consecutive patients with severe BAV stenosis treated with balloon-expandable transcatheter heart valves (Myval and SAPIEN 3 Ultra, S3U) or self-expanding Evolut PRO+(EP+). TriMatch analysis was carried out to minimize the impact of baseline differences. The primary endpoint of the study was 30-day device success, and the secondary endpoints were the composite and individual components of early safety at 30 days. ResultsA total of 360 patients (age 76.6±7.6 years, 71.9% males) were included: 122 Myval (33.9%), 129 S3U (35.8%), and 109 EP+(30.3%). The mean STS score was 3.6±1.9%. There were no cases of coronary artery occlusion, annulus rupture, aortic dissection, or procedural death. The primary endpoint of device success at 30 days was significantly higher in the Myval group (Myval: 100%; S3U: 87.5%; and EP+: 81.3%), mainly due to higher residual aortic gradients with S3U and greater≥moderate aortic regurgitation (AR) with EP+. No significant differences were found in the unadjusted rate of pacemaker implantation. ConclusionsIn patients with BAV stenosis deemed unsuitable for surgery, Myval, S3U and EP+showed similar safety but balloon-expandable Myval had better gradients than S3U, and both balloon-expandable devices had lower residual AR than EP+, suggesting that, taking into consideration the patient-specific risks, any of these devices can be selected with optimal outcomes.

Safety and efficacy of the INC bioprosthetic heart valve in humans.

Heart valve bioprostheses are the gold standard for aortic valve surgical replacement in selected patients. To evaluate the safety and efficacy of the National Institute of Cardiology (INC) bioprosthetic heart valve in humans. Single-center study that included 341 patients who underwent single surgical aortic valve replacement with INC heart valve. 318 implants were performed de novo (93%) and 23 as redo surgery (7%); STS scores were 1.4 and 1.8%, and follow-up was for 42 and 46 months, respectively. There were no differences in clinical complications or pacemaker implantation rate. Both groups maintained a normal LVEF. Overall improvement in functional class was observed, with worsening only in two patients of the de novo group. INC prosthesis dysfunction requiring surgical reintervention was observed in eight patients (4.65%) of the de novo group vs. one patient in the redo group. The INC heart valve is efficacious and safe, and is associated with a low rate of complications and functional class improvement during long-term follow-up. Prospective, comparative studies of this valve are required.

Presence of Moderate or Severe Regurgitation after Transcatheter Aortic Valve Implant with the Cusp Overlap Strategy

Background: The aim of this study is to whether higher transcatheter aortic valve implantation (TAVI) with self-expandable valves using the right and left cusp overlap strategy (Cusp Overlap, COVL) is associated with a lower incidence of moderate or severe paravalvular regurgitation (PVR), compared with the conventional strategy (CON). Methods: A total of 206 consecutive patients undergoing TAVI with self-expandable valves between August 2019 and May2022 were analyzed. The CON technique was used in the first 101 patients (49%) and COVL was used in 105 (51%). The primary endpoint (PEP) was the presence of moderate or severe paravalvular regurgitation at 30 days. Results: There were no clinical differences between the groups in terms of mean age, sex or comorbidities, except for a trend towards more patients with diabetes and previous percutaneous coronary intervention in the COVL group. The STS score was greater in the COVL group (6.9 ± 2.2 vs. 5.8 ± 2.4 in the CON group; p = 0.01). There was no difference in the PEP at 30 days with 2% incidence of moderate PVR in the CON group and 0.9% in the COVL group, and none of them presented severe PVR. There were no differences in mortality, myocardial infarction, coronary artery obstruction, stroke, major bleeding or vascular complications. The need for permanent pacemaker was lower with the COVL strategy (6.7% vs. 17.8%, p = 0.01) and a new left bundle branch block occurred in 5.7% vs. 12.9% (p = 0.07). Conclusions: In this single-center series, the strategy of high transcatheter aortic valve implantation using the COVL strategy showed no difference in the presence of moderate or severe regurgitation compared with the conventional strategy, with no differences in complications, and was associated with a lower need for definitive pacemaker and with a trend towards lower incidence of left bundle branch block at 30 days.

Dedicated Next Day Discharge Post Minimalist TAVI: The Tasmanian Experience.

To assess the safety, feasibility and independent predictors of next day discharge (NDD) in patients undergoing minimalist transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) in a real-world Australian population. This single centre study reviewed 135 consecutive patients who underwent minimalist transfemoral TAVI from June 2020 to February 2022. Baseline demographics, procedural characteristic and outcomes were obtained. All patients were assessed by the local protocol for NDD. Patients were then divided into two groups: those who achieved next day discharge (NDD) and those requiring >1 overnight hospital stay. Univariate, bivariate and stepwise multivariate logistic regression modelling was used to identify the predictors of successful next day discharge. The mean age of the cohort was 82.9±5.7 years with 62.3% patients male, the average STS score was 4.1±2.4. All 135 patients underwent a successful transfemoral TAVI procedure, with 131 (97%) receiving a balloon-expandable valve. Ninety-seven (97) (71.9%) patients achieved NDD. Thirty (30)-day outcomes were excellent with a 30-day mortality of 0.7%, transient ischaemic attack/cardiovascular accident (TIA/CVA) 1.5%, major vascular complication 1.5% and 11.4% need for permanent pacemaker (PPM). In patients not achieving NDD, the average length of stay (LOS) was 3.0 days. Baseline characteristics demonstrated pre-existing first degree atrioventricular (AV) block and right bundle branch block (RBBB) as statistically significant negative predictors of NDD on univariate analysis. Next day discharge was achievable in only 50% of patients who suffered any minor or major procedural complication (15/30). Stepwise multivariate logistic regression modelling demonstrated female gender (OR 3.094, 95% CI 1.141-8.391, p=0.026), smaller aortic valve area (AVA) (OR 48.265, 95% CI 2.269-102.6, p=0.013), the presence of diabetes mellitus (OR 0.594, 95% CI 0.356-0.991, p=0.046) and a longer procedure time (OR 0.960, 95% CI 0.935-0.986, p=0.002) as statistically significant negative predictors of NDD. In addition, there was no difference in 30-day readmission rates between the NDD and non-NDD cohort (7.2% vs 10.5%, p=0.386). Next day discharge is safe and feasible in almost three quarters of patients undergoing minimalist TAVI for severe AS in a predominantly balloon expandable valve cohort, with a very low rate of 30-day readmission. NDD provides advantages for hospital efficiency and improved cost-effectiveness. Female gender, smaller AVA, the presence of diabetes mellitus and a longer procedure time were independent negative predictors of successful NDD.

The Utility of Risk Scores in Postcardiotomy Extracorporeal Membrane Oxygenation.

The use of a venoarterial extracorporeal membrane oxygenation (ECMO) in the postcardiotomy shock setting (PC-ECMO) can be life-saving. Risk stratification for patients under PC-ECMO is currently challenging. The aim of this study was to assess the discriminatory ability of the different available risk scores for mortality in PC-ECMO patients. Patients aged >18years undergoing coronary artery bypass, valve surgery, or a combination of these procedures and implanted an ECMO for postcardiotomy shock between January 2017 and June 2022 in a single ELSO registered center were retrospectively included. The STS, Euroscore II, SAVE, modified SAVE, APACHE II, and VIS scores were compared for their discriminatory ability concerning weaning and 30-day survival. During the study period, 7342 patients underwent coronary bypass or valve surgery, of whom 109 patients with PC-ECMO were included in the analysis. The Euroscore II and STS scores were not associated significantly with 30-day mortality, whereas the SAVE, the modified SAVE, APACHE II, and VIS scores significantly predicted 30-day mortality. The SAVE and the modified SAVE scores showed moderate discrimination ability with AUCs of 0.672 and 0.695, while the APACHE and VIS scores had a satisfactory discriminatory ability with AUCs of 0.727 and 0.844, respectively. Currently used risk scores for PC-ECMO patients do not provide satisfactory predictions for weaning and survival. VIS at the 24th hour can be a valuable parameter for risk analysis and prospective studies can investigate novel PC-ECMO risk scoring systems.

Prognostic value of longitudinal assessment of inflammatory and nutritional status in patients undergoing valvular heart surgery

Abstract Funding Acknowledgements Type of funding sources: None. Background Novel strategies to improve the long-term risk stratification of valvular surgery are urgently needed as a result of the increasing prevalence of valvular heart diseases globally. Purpose This study aimed to evaluate the prognostic implications of longitudinal assessment of inflammatory and nutritional status in patients undergoing valvular surgery. Methods 1046 patients who underwent valvular surgery were stratified into three groups based on their inflammatory (neutrophil-to-lymphocyte ratio [NLR]) and nutritional status (prognostic nutritional index [PNI]): without inflammation and malnutrition (normal), inflammation or malnutrition alone (mild), and concomitant inflammation and malnutrition (severe). Optimal NLR and PNI thresholds for predicting all-cause mortality were determined using receiver-operating characteristic analysis. The endpoints were all-cause mortality, cardiovascular death and adverse events (composite of death and heart failure [HF] hospitalization). Results Over a median follow-up of 4.3 years (IQR: 2.6 to 6.4 years), 139 (13.3%) deaths and 148 (14.1%) HF hospitalizations occurred. Based on the optimal cut-off of NLR &amp;gt;4.06 (inflammation) and PNI &amp;lt;45.8 (malnutrition), 714 (68.3%), 214 (20.5%) and 118 (11.3%) patients were categorized into normal, mild and severe groups respectively. Compared with patients without inflammation and malnutrition, those with concomitant inflammation and malnutrition before surgery had the highest risk of all-cause mortality (hazard ratio [HR] 5.60, 95% confidence interval [CI] 3.66-8.57), cardiovascular death (subdistribution HR [SHR] 5.19, 95% CI 2.33-11.60) and adverse events (HR 3.14, 95% CI 2.25-4.38) (p&amp;lt;0.001 for all), adjusted for demographics, cardiovascular risk factors and diseases, medications, valvular surgeries and EuroSCORE II. Discriminatory improvement for predicting all-cause mortality was observed when baseline NLR and PNI were added to EuroSCORE II (C-statistic 0.77 vs 0.73, p=0.04; continuous net reclassification improvement [cNRI] 0.24, 95% CI 0.12-0.36, p=0.004; integrated discrimination improvement [IDI] 0.04, 95% CI 0.01-0.08, p=0.004) and STS score (C-statistic 0.78 vs 0.73, p=0.03; cNRI 0.16, 95% CI 0.06-0.32, p=0.002; IDI 0.02, 95% CI 0.000-0.049, p=0.048) respectively. 1 year following surgery (n=740), those with persistent concomitant inflammation and malnutrition experienced the highest risk of all-cause mortality (HR 8.82, 95% CI 4.21-18.49), cardiovascular death (SHR 12.63, 95% CI 3.85-41.39) and adverse events (HR 5.83, 95% CI 3.16-10.76) than those without (p&amp;lt;0.001 for all). Conclusion Concomitant inflammation and malnutrition is common and is strongly associated with mortality and HF in patients undergoing valvular surgery. Beyond conventional risk scores, assessments of inflammatory and nutritional status using NLR and PNI before and after surgery may provide additional prognostic value for long-term outcomes following valvular surgery.

External validation of the EuroSCORE II and the STS score for patients undergoing isolated coronary artery bypass grafting in Algeria

External validation of the EuroSCORE II and the STS score for patients undergoing isolated coronary artery bypass grafting in Algeria

Machine learning-based predictive risk models for 30-day and 1-year mortality in severe aortic stenosis patients undergoing transcatheter aortic valve implantation

BackgroundPredictive risk score for mortality plays an important role in the decision-making in patient selection and risk stratification for TAVI. Existing established predictive risk scores had poor discrimination performance in the prediction of mortality after the TAVI. ObjectivesThe present study aimed to develop machine learning-based predictive models for30-day and 1-year mortality in severe aortic stenosis patients undergoing TAVI. MethodsA total of 186 patients in a retrospective cohort study were analyzed. The models were fitted by a decision tree. Each model was tested in 100 iterations of 80:20 stratified random splitting into training/testing samples and 10-fold cross-validation. ResultsVariables that predict 30-day mortality are a set of factors driven mainly by height, chronic lung disease, STS score, preoperative LVEF, age, and preoperative LVOT VTI. Variables that predict 1-year mortality are a set of factors consisting of preoperative LVEF, STS score, heart rate, systolic blood pressure, home oxygen use, serum creatinine level, and preoperative LVOT Vmax. This decision tree-generated predictive models for 30-day and 1- year mortality provided the most precise accuracy of 0.97 and 0.90 with the AUC-ROC curves of 0.83 and 0.71 on 30-day and 1-year mortality on testing data and had better discrimination performance compared to the existing established TAVI predictive risk scores. ConclusionsThese machine learning models show excellent accuracy and have a better prediction for 30-day and 1-year mortality than the existing established TAVI predictive risk scores. A customized predictive model deems to be properly developed for better risk discrimination among cohorts.