Association Between Patient Survival and Clinician Variability in Treatment Rates for Aortic Valve Stenosis

Background Patients with symptomatic severe aortic stenosis (ssAS) have a high mortality risk and compromised quality of life. Surgical/transcatheter aortic valve replacement (AVR) is a Class I recommendation, but it is unclear if this recommendation is uniformly applied. We determined the impact of managing cardiologists on the likelihood of ssAS treatment. Methods and Results Using natural language processing of Optum electronic health records, we identified 26 438 patients with newly diagnosed ssAS (2011–2016). Multilevel, multivariable Fine‐Gray competing risk models clustered by cardiologists were used to determine the impact of cardiologists on the likelihood of 1‐year AVR treatment. Within 1 year of diagnosis, 35.6% of patients with ssAS received an AVR; however, rates varied widely among managing cardiologists (0%, lowest quartile; 100%, highest quartile [median, 29.6%; 25th–75th percentiles, 13.3%–47.0%]). The odds of receiving AVR varied >2‐fold depending on the cardiologist (median odds ratio for AVR, 2.25; 95% CI, 2.14–2.36). Compared with patients with ssAS of cardiologists with the highest treatment rates, those treated by cardiologists with the lowest AVR rates experienced significantly higher 1‐year mortality (lowest quartile, adjusted hazard ratio, 1.22, 95% CI, 1.13–1.33). Conclusions Overall AVR rates for ssAS were low, highlighting a potential challenge for ssAS management in the United States. Cardiologist AVR use varied substantially; patients treated by cardiologists with lower AVR rates had higher mortality rates than those treated by cardiologists with higher AVR rates.

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Survival, Functional Capacity and Quality of Life after Transcatheter Aortic Valve Implantation: Present Considerations and Future Perspectives

Romanian Journal of Cardiology ◽

10.47803/rjc.2021.31.2.319 ◽

2021 ◽

Vol 31 (2) ◽

pp. 319-325

Author(s):

Crina-Ioana RADULESCU ◽

Dan DELEANU ◽

Ovidiu CHIONCEL

Keyword(s):

Quality Of Life ◽

Aortic Valve ◽

Transcatheter Aortic Valve Implantation ◽

Severe Aortic Stenosis ◽

Transcatheter Aortic Valve ◽

Age Related ◽

Aortic Valve Implantation ◽

Valve Implantation ◽

The Impact

Severe aortic stenosis (AS) is the most common valvular heart disease, with an increasing prevalence due to age-related degenerative modifi cations of the valve. Once AS becomes symptomatic, the survival of patients is significantly reduced with an annual mortality rate of 25%. Depending on surgical risk, anatomical and technical aspects, and the patient’s option, correction can be made either by surgical valve replacement (SAVR) or by transcatheter aortic valve implantation (TAVI). Although aortic valve implantation brings relief of symptoms, there is little data on the quality of life (QoL) of patients undergoing TAVI and the factors that directly influence it. Even if age and comorbidities are known modifiers of survival, there is no specific tool to assess the impact of AS and to determine the appropriate treatment strategy.

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IMPULSE: the impact of gender on the presentation and management of aortic stenosis across Europe

Open Heart ◽

10.1136/openhrt-2020-001443 ◽

2021 ◽

Vol 8 (1) ◽

pp. e001443

Author(s):

Richard Paul Steeds ◽

David Messika-Zeitoun ◽

Jeetendra Thambyrajah ◽

Antonio Serra ◽

Eberhard Schulz ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Severe Aortic Stenosis ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Surgical Aortic Valve Replacement ◽

Ventricular Ejection Fraction ◽

Patient Profile ◽

Transcatheter Aortic Valve ◽

The Impact

AimsThere is an increasing awareness of gender-related differences in patients with severe aortic stenosis and their outcomes after surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI).MethodsData from the IMPULSE registry were analysed. Patients with severe aortic stenosis (AS) were enrolled between March 2015 and April 2017 and stratified by gender. A subgroup analysis was performed to assess the impact of age.ResultsOverall, 2171 patients were enrolled, and 48.0% were female. Women were characterised by a higher rate of renal impairment (31.7 vs 23.3%; p<0.001), were at higher surgical risk (EuroSCORE II: 4.5 vs 3.6%; p=0.001) and more often in a critical preoperative state (7.0vs 4.2%; p=0.003). Men had an increased rate of previous cardiac surgery (9.4 vs 4.7%; p<0.001) and a reduced left ventricular ejection fraction (4.9 vs 1.3%; p<0.001). Concomitant mitral and tricuspid valve disease was substantially more common among women. Symptoms were highly prevalent in both women and men (83.6 vs 77.3%; p<0.001). AVR was planned in 1379 cases. Women were more frequently scheduled to undergo TAVI (49.3 vs 41.0%; p<0.001) and less frequently for SAVR (20.3 vs 27.5%; p<0.001).ConclusionsThe present data show that female patients with severe AS have a distinct patient profile and are managed in a different way to males. Gender-based differences in the management of patients with severe AS need to be taken into account more systematically to improve outcomes, especially for women.

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Prognosis of persistent mitral regurgitation in patients undergoing transcatheter aortic valve replacement

Clinical Research in Cardiology ◽

10.1007/s00392-020-01618-9 ◽

2020 ◽

Vol 109 (10) ◽

pp. 1261-1270 ◽

Cited By ~ 1

Author(s):

Victor Mauri ◽

Maria I. Körber ◽

Elmar Kuhn ◽

Tobias Schmidt ◽

Christian Frerker ◽

...

Keyword(s):

Aortic Valve ◽

Mitral Regurgitation ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Severe Aortic Stenosis ◽

Transcatheter Aortic Valve ◽

The Impact

Abstract Objective The objective of this study was to assess imaging predictors of mitral regurgitation (MR) improvement and to evaluate the impact of MR regression on long-term outcome in patients undergoing transcatheter aortic valve replacement (TAVR). Background Concomitant MR is a frequent finding in patients with severe aortic stenosis but usually left untreated at the time of TAVR. Methods Mitral regurgitation was graded by transthoracic echocardiography before and after TAVR in 677 consecutive patients with severe aortic stenosis. 2-year mortality was related to the degree of baseline and discharge MR. Morphological echo analysis was performed to determine predictors of MR improvement. Results 15.2% of patients presented with baseline MR ≥ 3 +, which was associated with a significantly decreased 2-year survival (57.7% vs. 74.4%, P < 0.001). MR improved in 50% of patients following TAVR, with 44% regressing to MR ≤ 2 +. MR improvement to ≤ 2 + was associated with significantly better survival compared to patients with persistent MR ≥ 3 +. Baseline parameters including non-severe baseline MR, the extent of mitral annular calcification and large annular dimension (≥ 32 mm) predicted the likelihood of an improvement to MR ≤ 2 +. A score based on these parameters selected groups with differing probability of MR ≤ 2 + post TAVR ranging from 10.5 to 94.4% (AUC 0.816; P < 0.001), and was predictive for 2-year mortality. Conclusion Unresolved severe MR is a critical determinant of long term mortality following TAVR. Persistence of severe MR following TAVR can be predicted using selected parameters derived from TTE-imaging. These data call for close follow up and additional mitral valve treatment in this subgroup. Graphic abstract Factors associated with MR persistence or regression after TAVR

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Risk of Coronary Obstruction and Feasibility of Coronary Access After Repeat Transcatheter Aortic Valve Replacement With the Self-Expanding Evolut Valve

Circulation Cardiovascular Interventions ◽

10.1161/circinterventions.120.009496 ◽

2020 ◽

Vol 13 (12) ◽

Cited By ~ 1

Author(s):

Brian J. Forrestal ◽

Brian C. Case ◽

Charan Yerasi ◽

Corey Shea ◽

Rebecca Torguson ◽

...

Keyword(s):

Computed Tomography ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Severe Aortic Stenosis ◽

The United States ◽

The Self ◽

Transcatheter Aortic Valve ◽

Coronary Obstruction

Background: The supra-annular leaflet position and tall stent frame of the self-expanding Evolut PRO or Evolut PRO+ transcatheter heart valves (THVs) may cause coronary occlusion during transcatheter aortic valve replacement (TAVR)-in-TAVR and present challenges for future coronary access. We sought to evaluate the risk of TAVR-in-TAVR with Evolut PRO or Evolut PRO+ THVs and the feasibility of future coronary access. Methods: The CoreValve Evolut PRO Prospective Registry (EPROMPT; NCT03423459) prospectively enrolled patients with symptomatic severe aortic stenosis to undergo TAVR using a commercially available latest generation self-expanding THV at 2 centers in the United States. Computed tomography was performed 30 days after TAVR, which we used to simulate TAVR-in-TAVR with a second Evolut PRO or Evolut PRO+ THV and evaluate for risk of coronary obstruction and feasibility of future coronary access. Results: Eighty-one patients enrolled with interpretable computed tomography are reported herein. Computed tomography simulation predicted sinus of Valsalva sequestration and resultant coronary obstruction during future TAVR-in-TAVR in up to 23% of patients. Computed tomography simulation predicted that the position of the pinned THV leaflets would hinder future coronary access in up to 78% of patients after TAVR-in-TAVR. Conclusions: Further THV design improvements and leaflet modification strategies are needed to mitigate the risk of coronary obstruction during TAVR-in-TAVR with self-expanding THVs and to facilitate future coronary access. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03423459.

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The impact of transcatheter aortic valve implantation on quality of life: A mixed methods study

Heart & Lung ◽

10.1016/j.hrtlng.2017.08.005 ◽

2017 ◽

Vol 46 (6) ◽

pp. 432-438 ◽

Cited By ~ 5

Author(s):

Felicity Astin ◽

Judith Horrocks ◽

Jim McLenachan ◽

Daniel J. Blackman ◽

John Stephenson ◽

...

Keyword(s):

Quality Of Life ◽

Mixed Methods ◽

Aortic Valve ◽

Transcatheter Aortic Valve Implantation ◽

Mixed Methods Study ◽

Transcatheter Aortic Valve ◽

Aortic Valve Implantation ◽

Valve Implantation ◽

The Impact

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Impact of Pre-procedural Cerebrovascular Events on Clinical Outcomes After Transcatheter Aortic Valve Implantation in Patients with Severe Aortic Stenosis

Current Pharmaceutical Design ◽

10.2174/1381612824666180219145229 ◽

2018 ◽

Vol 24 (5) ◽

pp. 641-646

Author(s):

Agata Wiktorowicz ◽

Pawel Kleczynski ◽

Artur Dziewierz ◽

Tomasz Tokarek ◽

Danuta Sorysz ◽

...

Keyword(s):

Aortic Valve ◽

Transcatheter Aortic Valve Implantation ◽

Severe Aortic Stenosis ◽

Vascular Events ◽

Transcatheter Aortic Valve ◽

All Cause Mortality ◽

History Of ◽

Aortic Valve Implantation ◽

Valve Implantation ◽

The Impact

Background: Transcatheter aortic valve implantation (TAVI) is an increasingly common treatment of symptomatic severe aortic valve stenosis (AS). Thus, it is reasonable to carefully investigate the impact of individual clinical factors on outcomes after TAVI. Objectives: We aimed to investigate the impact of the previous cerebro-vascular events (CVEs) on outcomes of patients with severe AS undergoing TAVI. Methods: A total of 148 consecutive patients scheduled for TAVI were included and stratified as with and without a history of CVEs (stroke or transient ischemic attack). Frailty features were also assessed. The primary endpoint was a 12-month all-cause mortality. Results: Seventeen (11.5%) patients had a history of CVEs (the CVE group). At 30 days and 12 months, all-cause mortality was higher in the CVE group [30-day: 5 (29.4%) vs. 7 (5.3%); p=0.005; 12-month: 9 (52.9%) vs. 13 (9.9%); p=0.001]. Similarly, at the longest available follow-up, mortality was higher in the CVE group [10 (58.8%) vs. 23 (17.6%); p=0.001]. Similar rates of other complications after TAVI were noted, apart from inhospital acute kidney injury (AKI) grade 3 [3 (17.6%) vs. 5 (3.8%); p=0.049] and blood transfusions [9 (52.9%) vs. 35 (26.7%); p=0.026]. Results of 5MWT and Katz index assessment indicated a greater level of frailty in the CVE group. There were no differences in subsequent events including CVEs, bleeding, myocardial infarction, and new-onset of atrial fibrillation (AF) at 12 months between the groups. Conclusion: We showed that a history of CVEs in patients with severe AS undergoing TAVI is associated with a higher long-term mortality.

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