Left atrial functional assessment and mortality in patients with severe aortic stenosis with sinus rhythm

Abstract Background Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence keeps growing. While other risk factors in severe AS are well documented, little is known about the prognostic value of left atrial (LA) function in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up. Methods We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up. Results A total of 408 patients were included in the analysis, with a median follow-up time of 45 months (interquartile range 54 months). 57.9% of patients underwent AVR and 44.9% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.845, 95%CI 0.81–0.88, P < 0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF < 37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (HR 13.91, 95%CI 6.20–31.19, P < 0.001 and HR 3.40, 95%CI 1.57–7.37, P = 0.002, respectively). After adjustment for AVR, excess risk of LAEF < 37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (HR 11.71, 95%CI 5.20–26.40, P < 0.001 and HR 3.59, 95%CI 1.65–7.78, P = 0.001, respectively). Conclusions In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.

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Left atrial functional assessment and mortality in patients with severe aortic stenosis with sinus rhythm

10.21203/rs.3.rs-52491/v2 ◽

2020 ◽

Author(s):

João Ferreira ◽

Valdirene Gonçalves ◽

Patrícia Marques-Alves ◽

Rui Martins ◽

Sílvia Monteiro ◽

...

Keyword(s):

Aortic Valve ◽

Left Atrial ◽

Primary Outcome ◽

Severe Aortic Stenosis ◽

Heart Team ◽

Pump Function ◽

Volumetric Assessment ◽

All Cause Mortality ◽

Echocardiography Laboratory

Abstract Background: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence keeps growing. While other risk factors in severe AS are well documented, little is known about the prognostic value of left atrial (LA) function in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up. Methods: We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up. Results: A total of 408 patients were included in the analysis, with a median follow-up time of 45 months (interquartile range 54 months). 57.9% of patients underwent AVR and 44.9% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.845, 95%CI 0.81-0.88, P <0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF <37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (HR 13.91, 95%CI 6.20-31.19, P <0.001 and HR 3.40, 95%CI 1.57-7.37, P =0.002, respectively). After adjustment for AVR, excess risk of LAEF <37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (HR 11.71, 95%CI 5.20-26.40, P <0.001 and HR 3.59, 95%CI 1.65-7.78, P =0.001, respectively). Conclusions: In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.

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Left Atrial Functional Assessment and Mortality in Patients with Severe Aortic Stenosis

10.21203/rs.3.rs-52491/v1 ◽

2020 ◽

Author(s):

João Ferreira ◽

Valdirene Gonçalves ◽

Patrícia Marques-Alves ◽

Rui Martins ◽

Sílvia Monteiro ◽

...

Keyword(s):

Aortic Valve ◽

Left Atrial ◽

Primary Outcome ◽

Severe Aortic Stenosis ◽

Hazard Ratio ◽

Heart Team ◽

Pump Function ◽

Volumetric Assessment ◽

All Cause Mortality

Abstract Background: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence is growing. While other risk factors in severe AS are well documented, less is known about the association between left atrial (LA) function and prognosis in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up.Methods: We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up.Results: A total of 451 patients were included in the analysis, with a median follow-up time of 73 months (interquartile range 44.5). 55.8% of patients underwent AVR and 45.5% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.840, 95% CI 0.803-0.872, p<0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF <37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (hazard ratio 19.04, 95% CI 8.30-43.67, P<0.001 and hazard ratio 4.09, 95% CI 1.85-9.06, p=0.001, respectively). After adjustment for AVR, excess risk of LAEF <37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (hazard ratio 13.95, 95% CI 5.98-32.54, P<0.001 and hazard ratio 3.97, 95% CI 1.80-8.78, P=0.001, respectively).Conclusions: In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.

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Left atrial functional assessment and mortality in patients with severe aortic stenosis

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa356.083 ◽

2021 ◽

Vol 22 (Supplement_1) ◽

Author(s):

J Ferreira ◽

V Goncalves ◽

P Marques ◽

R Martins ◽

S Monteiro ◽

...

Keyword(s):

Aortic Valve ◽

Left Atrial ◽

Primary Outcome ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Heart Team ◽

Aortic Valve Area ◽

Ventricular Ejection Fraction ◽

All Cause Mortality

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe. Both symptoms and systolic dysfunction can appear late in the course of the disease, being often synonym of irreversible damage to the myocardium when found. Thus, there is a necessity to find other sensitive markers present at an earlier stage of the disease. Purpose Our primary aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up. Methods We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated all 3 left atrial (LA) functional phases (reservoir, conduit and pump) by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and own patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up. Results After exclusion criteria, a total of 451 patients were included in the analysis (aged 74 ±11years, 54% male) and were followed during a median period of 73 months (interquartile range 44.5). A total of 55.8% of patients underwent AVR and 45,5% of patients registered the primary outcome. Left atrial emptying fraction (LAEF) was the best LA functional parameter in discriminating primary outcome (AUC 0.840, p < 0.001), even when compared to left ventricular ejection fraction, aortic valve area, aortic mean pressure gradient and aortic Vmax. Patients in the lower tercile of LAEF were older, had greater comorbidities, had greater AS severity, with greater degree of diastolic disfunction. After adjustment for clinical and demographic variables, cumulative survival of patients with LAEF <37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (adjusted HR 19.04, 95% CI 8.30-43.67, P < 0.001 and adjusted HR 4.09, 95% CI 1.85-9.06, P = 0.001). Survival was also higher in patients with LAEF 37 to 53% when compared to patients with LAEF <37% (adjusted HR 0.22, 95% CI 0.13-0.37, P < 0.001). All associations remained true after adjustment for AVR (LAEF <37% versus LAEF 37 to 53% and LAEF ≥54%, respectively, adjusted HR 3.97, 95% CI 1.80-8.78, P = 0.001 and adjusted HR 13.95, 95% CI 5.98-32.54, P < 0.001, respectively) Conclusion(s) In patients with a first diagnosis of severe AS in hospital setting, LA function assessed by volumetric parameters is an independent predictor of all-cause mortality. Compared to classical severity parameters, different LA functional parameters were found to be more potent predictors of death. These data can be useful in clinical practice for risk stratification and therefore for decision of timing for AVR. Abstract Figure. Survival of patients stratified by group

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Effect of persistence of left ventricular hypertrophy and left atrial dilatation after aortic valve replacement on early outcomes and survival: a prospective study

International Surgery Journal ◽

10.18203/2349-2902.isj20194442 ◽

2019 ◽

Vol 6 (10) ◽

pp. 3786

Author(s):

Hari Krishna Murthy P. ◽

Abha Chandra

Keyword(s):

Aortic Valve ◽

Left Ventricular Hypertrophy ◽

Aortic Stenosis ◽

Left Atrial ◽

Ventricular Hypertrophy ◽

Severe Aortic Stenosis ◽

Left Ventricular ◽

Significant Difference ◽

A Prospective Study

Background: The objective of the study was to evaluate the early outcomes and survival in patients with severe aortic stenosis associated with concentric left ventricular hypertrophy following aortic valve replacement.Methods: This is a prospective study done at SVIMS, Tirupati, from June 2014 to September 2015 evaluating out comes and survival in patients undergoing primary isolated aortic valve replacement (AVR) for severe aortic stenosis, severe aortic stenosis with mild aortic regurgitation and severe aortic stenosis with moderate aortic regurgitation.Results: A total of 40 cases 26 males and 14 females aged 18 to 60 years (mean age, 48.5±13.4 years) underwent elective AVR. Left ventricular end diastolic diameter (p=0.008) at 6 months, a statistically highly significant difference in left ventricular mass preoperatively, at discharge, at 3rd and 6th month follow up. The difference in mean left ventricular mass index (LVMI) had declined from 244.425 to 141.100 at 6 months, showing a statistically highly significant difference in LVMI preop, at discharge, at 3rd month and at 6th month follow up.Conclusions: Patients with preoperative increase in LVMI, with large left atrial diameter carries a strong predictor of postoperative mortality for patients undergoing aortic valve surgery. We also conclude that there will be significant regression of LVMI following successful AVR. But, the decrease in LVMI is maximum during early three months and it is minimal though significant in the later course of follow up.

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Heart Team for Optimal Management of Patients with Severe Aortic Stenosis—Long-Term Outcomes and Quality of Life from Tertiary Cardiovascular Care Center

Journal of Clinical Medicine ◽

10.3390/jcm10225408 ◽

2021 ◽

Vol 10 (22) ◽

pp. 5408

Author(s):

Szymon Jonik ◽

Michał Marchel ◽

Ewa Pędzich-Placha ◽

Zenon Huczek ◽

Janusz Kochman ◽

...

Keyword(s):

Quality Of Life ◽

Aortic Valve ◽

Aortic Stenosis ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Severe Aortic Stenosis ◽

Heart Team ◽

Secondary Endpoints

Background: This retrospective study was proposed to investigate outcomes of patients with severe aortic stenosis (AS) after implementation of various treatment strategies following dedicated Heart Team (HT) decisions. Methods: Primary and secondary endpoints and quality of life during a median follow-up of 866 days of patients with severe AS qualified after HT discussion to: optimal medical treatment (OMT) alone, OMT and transcather aortic valve replacement (TAVR) or OMT and surgical aortic valve replacement (SAVR) were evaluated. As the primary endpoint composite of all-cause mortality, non-fatal disabling strokes and non-fatal rehospitalizations for AS were considered, while other clinical outcomes were determined as secondary endpoints. Results: From 2016 to 2019, 176 HT meetings were held, and a total of 482 participants with severe AS and completely implemented HT decisions (OMT, TAVR and SAVR for 79, 318 and 85, respectively) were included in the final analysis. SAVR and TAVR were found to be superior to OMT for primary and all secondary endpoints (p < 0.05). Comparing interventional strategies only, TAVR was associated with reduced risk of acute kidney injury, new onset of atrial fibrillation and major bleeding, while the superiority of SAVR for major vascular complications and need for permanent pacemaker implantation was observed (p < 0.05). The quality of life assessed at the end of follow-up was significantly better for patients who underwent TAVR or SAVR than in OMT-group (p < 0.05). Conclusions: We demonstrated that after careful implementation of HT decisions interventional strategies compared to OMT only provide superior outcomes and quality of life for patients with AS.

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P1795Impact of severe aortic stenosis treatment strategy in low-risk patients: a propensity matched analysis of surgical aortic valve replacement versus transcatheter aortic valve implantation

European Heart Journal ◽

10.1093/eurheartj/ehz748.0547 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

C Brizido ◽

M Madeira ◽

J Brito ◽

R C Teles ◽

M Goncalves ◽

...

Keyword(s):

Aortic Valve ◽

Treatment Strategy ◽

Severe Aortic Stenosis ◽

Nyha Class ◽

Low Risk ◽

Transcatheter Aortic Valve ◽

All Cause Mortality ◽

Risk Patients ◽

Valve Implantation

Abstract Introduction Recent studies suggest that transcatheter aortic valve implantation (TAVI) benefits might extend to lower risk patients. Our goal was to compare the impact of treatment strategy in mortality and peri-procedural complications in a low-risk severe aortic stenosis population. Methods Single-center retrospective study which screened patients undergoing intervention from June/2009 to July/2016 (682 isolated aortic valve replacement patients) and from June/2009 to July/2017 (400 TAVI patients). Low-risk was defined as EuroScore II <4% for single non-CABG procedure. After excluding patients with EuroScore II ≥4%, previous cardiac surgery and/or undergoing pre-treatment PCI, 544 AVR and 119 TAVI patients were included. TAVI patients were propensity score paired in a 1:1 ratio with a group of AVR patients, matched by age, NYHA class, diabetes mellitus, COPD, atrial fibrillation, creatinine clearance and LVEF <50% (mean standardized difference <10% for matching variables). All patients completed at least 1 year of follow-up. Outcomes were adjudicated according to VARC2 criteria. Results A total of 158 patients (79 AVR and 79 TAVI) were matched (mean age 79±6 years, 79 men). Median EuroScore II was 2.3% (IQR 1.6–3.0%), 46% were in NYHA class ≥3 and 91% had preserved ejection fraction. Main comorbidities were hypertension (n=105, 67%), diabetes mellitus (n=48, 30%), COPD (n=35, 22%) and coronary artery disease (n=30, 19%). Most patients had at least mild renal function impairment and median creatinine clearance was 58 ml/min (IQR 43–62 ml/min). The 30-day mortality was 2.5% (n=2 in each group) and there were no differences in in-hospital complications. During a median follow-up of 3.8 years (IQR 2.1–6.1), 67 deaths occurred (39 on the AVR group and 28 on the TAVI group), and treatment strategy did not influence all-cause mortality (HR 0.97, 95% CI 0.60–1.60, log rank p=0.92) - figure 1. By multivariate analysis, need for dialysis during hospitalization remained the only independent predictor of all-cause mortality (adjusted HR 6.40, 95% CI 1.57–28.14, p=0.01). Figure 1 Conclusion In this low-risk matched population, treatment strategy did not influence mortality neither complications. Older age, higher NYHA class and renal impairment were the main contributors to the predicted surgical risk. These results suggest that both options are safe for low-risk patients, even though Heart Team remains essential to contemplate other variables that might alter patient management.

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Transcatheter aortic valve replacement in patients with severe aortic stenosis and active cancer: a systematic review and meta-analysis

European Heart Journal ◽

10.1093/ehjci/ehaa946.3256 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Bendary ◽

A.R Ramzy ◽

M.B Bendary ◽

M.S Salem

Keyword(s):

Aortic Valve ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Severe Aortic Stenosis ◽

Meta Analysis ◽

Cancer Stage ◽

Transcatheter Aortic Valve ◽

All Cause Mortality ◽

Active Cancer

Abstract Background Patients with severe aortic stenosis (AS) and concomitant active cancer (AC) are considered high-risk patients and usually are not allowed to undergo surgical valve replacement. Transcatheter aortic valve replacement (TAVR) may be an attractive option for them; however, little is known about the outcomes of TAVR in this subset of complex patients. Methods and results In this meta-analysis, Medline, Cochrane Library and Scopus databases were searched (anytime up to April 2019) for studies evaluating the outcomes of TAVR in patients with or without AC. We assessed pooled estimates (with their 95% confidence intervals [CIs]) of the risk ratio (RR) for the all-cause mortality at the 30-day and 1-year follow-ups, a 4-point safety outcome (any bleeding, stroke, need for a pacemaker and acute kidney injury) and a 2-point efficacy outcome (device success and residual mean gradient [mean difference]). Three studies (5162 patients) were included. Of those patients, a total of 368 patients (7.1%) had AC. Apart from a significantly higher need for a postprocedural pacemaker (RR 1.29, 95% CI: 1.06–1.58, P=0.01), TAVR in AC patients resulted in similar outcomes for safety and efficacy at the 30-day follow-up compared to those without AC. Patients with AC experienced similar rates of the all-cause mortality at the 30-day follow-up compared to those without (RR 0.92, 95% CI: 0.53 to 1.59, P=0.76); however, the all-cause mortality was significantly higher in patients with AC at the 1-year follow-up (RR 1.71, 95% CI: 1.26 to 2.33, P=0.0006). This mortality difference was independent of cancer stage (advanced or limited) at the 30-day follow-up but not at the 1-year follow-up; only patients with limited cancer stages showed similar all-cause mortality rates compared to those without cancer at the 1-year follow-up (RR 1.22, 95% CI: 0.79 to 1.91, P=0.37). Conclusion TAVR in patients with AC is associated with similar 30-day and potentially worse 1-year outcomes compared to those in patients without AC. The 1-year all-cause mortality appears to be dependent on the cancer stage. Involving a specialized oncologist who usually considers cancer stage in the decision-making process and applying additional preoperative scores such as frailty indices might refine the risk assessment process among these patients. All-cause mortality (cancer vs no) Funding Acknowledgement Type of funding source: None

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P6477Preoperative renal injury and multi-elevated biomarkers are associated with adverse outcomes in patients with severe aortic stenosis undergoing surgical valve replacement

European Heart Journal ◽

10.1093/eurheartj/ehz746.1068 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

R Spampinato ◽

R Bochen ◽

G Stoeger ◽

F Sieg ◽

T Noack ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Valve Replacement ◽

Renal Injury ◽

Severe Aortic Stenosis ◽

Adverse Outcomes ◽

Amino Terminal ◽

All Cause Mortality

Abstract Background The presence of early stages of renal injury (AKI) and biomarkers has been associated with adverse outcomes in cardiac surgery. Purpose We aimed to determine whether preoperative AKI is associated with long-term all-cause mortality in patients with severe aortic stenosis (AS) undergoing surgical aortic valve replacement (SAVR) and if the combination of AKI with multi-elevated biomarkers (Amino-terminal pro-B-type natriuretic peptide, BNP; high-sensitivity cardiac troponin T, hsTNT; and C reactive protein, CRP) has a better prognostic utility. Method From a prospective registry of patients with AS referred for SAVR, 560 participants (68±8.8 years; 329 men) were retrospectively included when echocardiograms, serum creatinine and biomarkers were available within 30-days before surgery. Kaplan-Meier (KM) curves for all-cause mortality were created for groups of patients based on the presence of AKI, defined as a stage I or more according to the Acute Kidney Injury Network classification. To further describe the utility of multi-elevated biomarkers, 4 groups were created and the KM-curves and c-statistics evaluated. Mean follow-up was 737±410 days and 30 (5.4%) patients died. Results Patients with preoperative AKI (n=68) were significantly older (70±7.6 vs. 67±8.9 years, p=0.02), more likely to have hypertension, diabetes, a worse functional class (NYHA III-IV: 59% vs. 36%, p<0.001), worse glomerular filtration rate (60±20 vs. 81±26, p<0.001), an elevation of multiple biomarkers (hsTNT, BNP, and CRP), and a higher logistic-EuroScore (3.8±2.8 vs. 3.0±2.2, p=0.04). But there were no differences in the incidence of coronary artery disease, LVEF (57±10 vs. 59±11%), aortic valve area index, or in surgical characteristics. Those patients with AKI exhibited higher 3-year all-cause mortality (11.7% vs. 5.7%, p=0.04). Interestingly, the combination of AKI with 3 elevated biomarkers was associated with a more than fourfold increase in 3-year all-cause mortality (47.5% vs. 4.3%, p<0.0001), and the c-statistics (AUC 0.599 vs 0.710, p<0.001) suggested a better prediction for long-term death. Figure 1 Conclusions This study demonstrates an adverse association of preoperative AKI with survival following SAVR, which was accentuated when combined with multi-elevated biomarkers, suggesting the need for less invasive strategies and/or closer postoperative follow–up in such patients.

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Transcatheter aortic valve replacement in patients with severe aortic stenosis and active cancer: a systematic review and meta-analysis

Open Heart ◽

10.1136/openhrt-2019-001131 ◽

2020 ◽

Vol 7 (1) ◽

pp. e001131 ◽

Cited By ~ 3

Author(s):

Ahmed Bendary ◽

Ahmed Ramzy ◽

Mohamed Bendary ◽

Mohamed Salem

Keyword(s):

Aortic Valve ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Severe Aortic Stenosis ◽

Meta Analysis ◽

Cancer Stage ◽

Transcatheter Aortic Valve ◽

All Cause Mortality ◽

Active Cancer

BackgroundPatients with severe aortic stenosis and concomitant active cancer (AC) are considered high-risk patients and usually are not allowed to undergo surgical valve replacement. Transcatheter aortic valve replacement (TAVR) may be an attractive option for them; however, little is known about the outcomes of TAVR in this subset of complex patients.Methods and resultsIn this meta-analysis, Medline, Cochrane Library and Scopus databases were searched (anytime up to April 2019) for studies evaluating the outcomes of TAVR in patients with or without AC. We assessed pooled estimates (with their 95% CIs) of the risk ratio (RR) for the all-cause mortality at the 30-day and 1-year follow-ups, a 4-point safety outcome (any bleeding, stroke, need for a pacemaker and acute kidney injury) and a 2-point efficacy outcome (device success and residual mean gradient (mean difference)). Three studies (5162 patients) were included. Of those patients, a total of 368 (7.1%) had AC. Apart from a significantly higher need for a postprocedural pacemaker (RR 1.29, 95% CI 1.06 to 1.58, p=0.01), TAVR in patients with AC resulted in similar outcomes for safety and efficacy at the 30-day follow-up compared with those without AC. Patients with AC experienced similar rates of the all-cause mortality at the 30-day follow-up compared with those without (RR 0.92, 95% CI 0.53 to 1.59, p=0.76); however, the all-cause mortality was significantly higher in patients with AC at the 1-year follow-up (RR 1.71, 95% CI 1.26 to 2.33, p=0.0006). This mortality difference was independent of cancer stage (advanced or limited) at the 30-day follow-up but not at the 1-year follow-up; only patients with limited cancer stages showed similar all-cause mortality rates compared with those without cancer at the 1-year follow-up (RR 1.22, 95% CI 0.79 to 1.91, p=0.37).ConclusionTAVR in patients with AC is associated with similar 30-day and potentially worse 1-year outcomes compared with those in patients without AC. The 1-year all-cause mortality appears to be dependent on the cancer stage. Involving a specialised oncologist who usually considers cancer stage in the decision-making process and applying additional preoperative scores such as frailty indices might refine the risk assessment process among these patients.PROSPERO registration numberCRD42019120416.

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Aortic Valve Disease and Associated Complex CAD: The Interventional Approach

Journal of Clinical Medicine ◽

10.3390/jcm10050946 ◽

2021 ◽

Vol 10 (5) ◽

pp. 946

Author(s):

Federico Marin ◽

Roberto Scarsini ◽

Rafail A. Kotronias ◽

Dimitrios Terentes Printzios ◽

Matthew K. Burrage ◽

...

Keyword(s):

Aortic Valve ◽

Severe Aortic Stenosis ◽

Myocardial Revascularization ◽

Coronary Intervention ◽

Hemodynamic Instability ◽

Bleeding Complications ◽

Diagnostic Tools ◽

Heart Team ◽

Complex Anatomy ◽

Increased Risk

Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis (AS). The management of CAD is a central aspect of the work-up of patients undergoing transcatheter aortic valve implantation (TAVI), but few data are available on this field and the best percutaneous coronary intervention (PCI) practice is yet to be determined. A major challenge is the ability to elucidate the severity of bystander coronary stenosis independently of the severity of aortic valve stenosis and subsequent impact on blood flow. The prognostic role of CAD in patients undergoing TAVI is being still debated and the benefits and the best timing of PCI in this context are currently under evaluation. Additionally, PCI in the setting of advanced AS poses some technical challenges, due to the complex anatomy, risk of hemodynamic instability, and the increased risk of bleeding complications. This review aims to provide a comprehensive synthesis of the available literature on myocardial revascularization in patients with severe AS undergoing TAVI. This work can assist the Heart Team in individualizing decisions about myocardial revascularization, taking into account available diagnostic tools as well as the risks and benefits.

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