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Interactive Cardiovascular and Thoracic... Oct 2017Most recent studies have proposed the paradoxical benefits of obesity in surgical populations. For patients who underwent transcatheter aortic valve implantation (TAVI)... (Meta-Analysis)
Meta-Analysis Review
Most recent studies have proposed the paradoxical benefits of obesity in surgical populations. For patients who underwent transcatheter aortic valve implantation (TAVI) for aortic stenosis, the prognostic roles of obesity and high body mass index remain controversial. Therefore, the objective of this meta-analysis was to evaluate whether the 'obesity paradox' exists in patients undergoing TAVI. We searched in PubMed and EMBASE to identify the eligible articles. Odds ratios and hazard ratios with the corresponding 95% confidence intervals (CI) were adopted for synthesizing short-term and long-term survival outcomes, respectively. The level of heterogeneity and the publication bias between studies were also estimated. Finally, there were 16 studies with 12 330 patients who met the eligibility criteria and who were thus included in this review. When body mass index was analysed as a continuous variable, each increase of 1 kg/m2 was significantly associated with the lower 30-day mortality rate (odds ratio = 0.95; 95% CI = 0.93-0.97; P < 0.001) and better long-term overall survival (hazard ratio = 0.96; 95% CI = 0.94-0.97; P < 0.001) for patients undergoing TAVI. The obese patients had a significantly lower risk of 30-day mortality after TAVI than did normal patients (odds ratio = 0.69; 95% CI = 0.50-0.95; P = 0.024). Further analyses indicated that the obesity could be predictive of more favourable long-term overall survival of TAVI (hazard ratio = 0.84; 95% CI = 0.72-0.97; P = 0.021). However, we found no difference in procedural complications between the obese and normal patients. In conclusion, higher body mass index and obesity seem to have protective benefits on both short-term and long-term survival of TAVI patients. Current evidence suggests that the 'obesity paradox' may really exist in TAVI.
Topics: Aortic Valve Stenosis; Body Mass Index; Female; Humans; Obesity; Prognosis; Risk Factors; Survival Rate; Transcatheter Aortic Valve Replacement
PubMed: 28962502
DOI: 10.1093/icvts/ivx191 -
Annals of Palliative Medicine Jul 2021Transcatheter aortic valve replacement (TAVR) has been increasingly used in all levels of risk patients, which is less invasive and has fewer complications. However, the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Transcatheter aortic valve replacement (TAVR) has been increasingly used in all levels of risk patients, which is less invasive and has fewer complications. However, the benefits of transcatheter and surgical methods of aortic valve replacement remain controversial for aortic stenosis (AS) patients with advanced chronic kidney disease (stage 3-5).
METHODS
We comprehensively searched PubMed, Embase, the Cochrane Library, and the International Clinical Trials Registry Platform (ICTRP) from January 2000 to October 2020 and performed a systematic review to evaluate the two techniques. Two investigators independently conducted the literature searches, study eligibility assessment, and data extraction in duplicate.
RESULTS
Compared to surgical aortic valve replacement (SAVR), TAVR had lower risk of in-hospital mortality [odds ratio (OR): 0.53; 95% confidence interval (CI): 0.36-0.78; P=0.001], lower stroke rate (OR: 0.68; 95% CI: 0.47-0.96; P=0.03), lower risk of acute kidney injury (AKI) (OR: 0.42; 95% CI: 0.34-0.52; P<0.00001) and AKI requiring dialysis (OR: 0.65; 95% CI: 0.58-0.73; P<0.00001), lower rate of bleeding (OR: 0.35; 95% CI: 0.31-0.38; P<0.00001) and blood transfusion (OR: 0.41; 95% CI: 0.32-0.52; P<0.00001), lower infection rate (OR: 0.23; 95% CI: 0.13-0.38; P<0.00001), lower risk of atrial fibrillation (AF) (OR: 0.37; 95% CI: 0.17-0.79; P=0.01) and cardiac tamponade (OR: 0.53; 95% CI: 0.37-0.75; P=0.0003), shorter ICU stay [weighted mean difference (WMD): -2.55; 95% CI: -4.13 to -0.98; P=0.002] and hospital stay (WMD: -7.06; 95% CI: -8.41 to -5.71; P<0.00001).
DISCUSSION
TAVR is a safe, efficient, and feasible technique for AS patients with advanced CKD and probably a better solution for its advantage in reducing in-hospital mortality, postoperative complications, ICU, and hospital stay.
Topics: Aortic Valve; Aortic Valve Stenosis; Humans; Postoperative Complications; Renal Insufficiency, Chronic; Risk Factors; Transcatheter Aortic Valve Replacement; Treatment Outcome
PubMed: 34263628
DOI: 10.21037/apm-21-758 -
The Journal of Heart Valve Disease Nov 2009It has not yet been established whether multi-slice computed tomography (MSCT) is reliable for the quantification of aortic valve area (AVA) in patients with aortic... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND AND AIM OF THE STUDY
It has not yet been established whether multi-slice computed tomography (MSCT) is reliable for the quantification of aortic valve area (AVA) in patients with aortic valve stenosis (AVS) and simultaneously for assessment of the coronary anatomy. The study aim, via a systematic literature review and meta-analysis, was to explore whether MSCT is a reliable method for AVA quantification, and simultaneously to assess the coronary anatomy in patients with AVS.
METHODS
A comprehensive systematic literature search and meta-analysis was conducted that included 14 studies totaling 470 patients. The meta-analysis was carried out to examine the reliability of MSCT compared to transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). Seven studies including 266 patients with AVS were also eligible for a secondary analysis to compare the accuracy of MSCT with invasive coronary angiography.
RESULTS
The AVA was measured by MSCT and TTE in all 14 studies, and by TEE in four studies. The results of the meta-analyses showed that planimetry by MSCT overestimated the AVA, with a bias of 0.08 (95% CI 0.04, 0.13) cm2) (p = 0.0001) compared to TTE. The MSCT measurement was concordant with planimetry by TEE, with a small bias of -0.02 (95% CI -0.16, 0.11) cm2 (p = 0.71). MSCT, when compared to invasive angiography for the detection of significant coronary stenosis, showed sensitivity, specificity and diagnostic odds ratio of 95.5% (95% CI 88-99), 81% (95% CI 75-86)%, and 53 (95% CI 19-147), respectively.
CONCLUSION
MSCT is a reliable method for the quantification of AVA, and represents a promising technique for the combined evaluation of aortic valve morphology and coronary artery disease.
Topics: Angiography; Aortic Valve Stenosis; Echocardiography; Humans; Tomography, X-Ray Computed
PubMed: 20099712
DOI: No ID Found -
Current Vascular Pharmacology 2019Hypertension (HT) is an important risk factor for cardiovascular disease and might precipitate pathology of the aortic valve.
BACKGROUND
Hypertension (HT) is an important risk factor for cardiovascular disease and might precipitate pathology of the aortic valve.
OBJECTIVE
To investigate the association of HT with aortic dysfunction (including both aortic regurgitation and stenosis) and the impact of antihypertensive treatment on the natural course of underlying aortic disease.
METHODS
We performed a systematic review of the literature for all relevant articles assessing the correlation between HT and phenotype of aortic disease.
RESULTS
Co-existence of HT with aortic stenosis and aortic regurgitation is highly prevalent in hypertensive patients and predicts a worse prognosis. Certain antihypertensive agents may improve haemodynamic parameters (aortic jet velocity, aortic regurgitation volume) and remodeling of the left ventricle, but there is no strong evidence of benefit regarding clinical outcomes. Renin-angiotensin system inhibitors, among other vasodilators, are well-tolerated in aortic stenosis.
CONCLUSION
Several lines of evidence support a detrimental association between HT and aortic valve disease. Therefore, HT should be promptly treated in aortic valvulopathy. Despite conventional wisdom, specific vasodilators can be used with caution in aortic stenosis.
Topics: Antihypertensive Agents; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Arterial Pressure; Humans; Hypertension; Prevalence; Recovery of Function; Risk Factors; Treatment Outcome
PubMed: 29295699
DOI: 10.2174/1570161116666180101165306 -
Open Heart Jan 2024A quarter of patients with severe aortic stenosis (AS) were asymptomatic, and only a third of them survived at the end of 4 years. Only a select subset of these patients... (Meta-Analysis)
Meta-Analysis
Systematic review and meta-analysis of early aortic valve replacement versus conservative therapy in patients with asymptomatic aortic valve stenosis with preserved left ventricle systolic function.
BACKGROUND
A quarter of patients with severe aortic stenosis (AS) were asymptomatic, and only a third of them survived at the end of 4 years. Only a select subset of these patients was recommended for aortic valve replacement (AVR) by the current American College of Cardiology/American Heart Association guidelines. We intended to study the effect of early AVR (eAVR) in this subset of asymptomatic patients with preserved left ventricle function.
METHODS AND RESULTS
We searched PubMed and Embase for randomised and observational studies comparing the effect of eAVR versus conservative therapy in patients with severe, asymptomatic AS and normal left ventricular function. The primary outcome was all-cause mortality. The secondary outcomes were composite major adverse cardiac events (MACE) (study defined), myocardial infarction (MI), stroke, cardiac death, sudden death, the development of symptoms, heart failure hospitalisations and major bleeding. We used GRADEPro to assess the certainty of the evidence. In the randomised controlled trial (RCT) only analysis, we found no significant difference in all-cause mortality between the early aortic intervention group versus the conservative arm (CA) (incidence rate ratio, IRR (CI): 0.5 (0.2 to 1.1), I=31%, p=0.09). However, in the overall cohort, we found mortality benefit for eAVR over CA (IRR (CI): 0.4 (0.3 to 0.7), I=84%, p<0.01). There were significantly lower MACE, cardiac death, sudden death, development of symptoms and heart failure hospitalisations in the eAVR group. We noticed no difference in MI, stroke and major bleeding.
CONCLUSION
We conclude that there is no reduction in all-cause mortality in the eAVR arm in patients with asymptomatic AS with preserved ejection fraction. However, eAVR reduces heart failure related hospitalisations and death or heart failure hospitalisations.
PROSPERO REGISTRATION NUMBER
CRD42022306132.
Topics: Humans; Aortic Valve; Aortic Valve Stenosis; Conservative Treatment; Death, Sudden, Cardiac; Heart Failure; Hemorrhage; Myocardial Infarction; Stroke; United States; Ventricular Function, Left; Heart Valve Prosthesis Implantation; Transcatheter Aortic Valve Replacement
PubMed: 38191233
DOI: 10.1136/openhrt-2023-002511 -
Journal of the American Heart... Apr 2021Background The optimal threshold of left ventricular ejection fraction (LVEF) that should prompt aortic valve replacement (AVR) in asymptomatic patients with... (Meta-Analysis)
Meta-Analysis
Background The optimal threshold of left ventricular ejection fraction (LVEF) that should prompt aortic valve replacement (AVR) in asymptomatic patients with high-gradient severe aortic stenosis (AS) is controversial. The aim of this study was to assess the relationship between LVEF and mortality benefit in comparing early AVR versus watchful waiting in asymptomatic patients with severe AS. Methods and Results MEDLINE, Embase, Web of Science, and Google Scholar were searched for observational studies and randomized controlled trials on adults with asymptomatic severe AS. Severe AS was defined by a peak aortic velocity ≥4 m/s and/or mean aortic valve gradient ≥40 mm Hg and/or calculated aortic valve area <1.0 cm or an indexed valve area <0.6 cm. Studies comparing AVR with conservative management were included and meta-analysis on all-cause mortality was performed. Ten eligible studies were identified with a total of 3332 patients. In 5 observational studies comparing early AVR versus watchful waiting, our meta-analysis showed early AVR was associated with lower mortality with a hazard ratio (HR) of 0.41 (CI, 0.23-0.71; <0.01). In 4 observational studies comparing AVR versus no AVR, our meta-analysis showed AVR was associated with lower mortality with a HR of 0.31 (CI, 0.17-0.58; <0.001). In a meta-regression analysis pooling all 10 studies, there was no statistically significant correlation between study mean LVEF and the size of mortality benefit of AVR (=0.83). Conclusions Among asymptomatic patients with high-gradient severe AS, AVR was associated with a mortality benefit across the spectrum of LVEF. Our study calls into question the need of an LVEF threshold for recommending AVR in this patient population.
Topics: Aortic Valve Stenosis; Asymptomatic Diseases; Echocardiography; Global Health; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Incidence; Risk Assessment; Risk Factors; Severity of Illness Index; Stroke Volume; Survival Rate; Ventricular Function, Left
PubMed: 33787311
DOI: 10.1161/JAHA.120.020252 -
Open Heart 2020Patients with severe aortic stenosis and concomitant active cancer (AC) are considered high-risk patients and usually are not allowed to undergo surgical valve... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Patients 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 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% 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).
CONCLUSION
TAVR 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 NUMBER
CRD42019120416.
Topics: Aged; Aged, 80 and over; Aortic Valve Stenosis; Clinical Decision-Making; Female; Humans; Male; Neoplasm Staging; Neoplasms; Patient Selection; Risk Assessment; Risk Factors; Severity of Illness Index; Transcatheter Aortic Valve Replacement; Treatment Outcome
PubMed: 32201582
DOI: 10.1136/openhrt-2019-001131 -
Journal of Cardiovascular Medicine... Nov 2020The management of patients with severe but asymptomatic aortic stenosis is challenging. Evidence on early aortic valve replacement (AVR) versus symptom-driven... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The management of patients with severe but asymptomatic aortic stenosis is challenging. Evidence on early aortic valve replacement (AVR) versus symptom-driven intervention in these patients is unknown.
METHODS
Electronic databases were searched, articles comparing early-AVR with conservative management for severe aortic stenosis were identified. Pooled adjusted odds ratio (OR) was computed using a random-effect model to determine all-cause and cardiovascular mortality.
RESULTS
A total of eight studies consisting of 2201 patients were identified. Early-AVR was associated with lower all-cause mortality [OR 0.24, 95% confidence interval (CI) 0.13-0.45, P ≤ 0.00001] and cardiovascular mortality (OR 0.21, 95% CI 0.06-0.70, P = 0.01) compared with conservative management. The number needed to treat to prevent 1 all-cause and cardiovascular mortality was 4 and 9, respectively. The odds of all-cause mortality in a selected patient population undergoing surgical AVR (SAVR) (OR 0.16, 95% CI 0.09-0.29, P ≤ 0.00001) and SAVR or transcatheter AVR (TAVR) (OR 0.53, 95% CI 0.35-0.81, P = 0.003) were significantly lower compared with patients who are managed conservatively. A subgroup sensitivity analysis based on severe aortic stenosis (OR 0.24, 95% CI 0.11-0.52, P = 0.0004) versus very severe aortic stenosis (OR 0.20, 95% CI 0.08-0.51, P = 0.0008) also mirrored the findings of overall results.
CONCLUSION
Patients with asymptomatic aortic valve stenosis have lower odds of all-cause and cardiovascular mortality when managed with early-AVR compared with conservative management. However, because of significant heterogeneity in the classification of asymptomatic patients, large scale studies are required.
Topics: Aged; Aged, 80 and over; Aortic Valve; Aortic Valve Stenosis; Asymptomatic Diseases; Conservative Treatment; Early Medical Intervention; Female; Humans; Male; Middle Aged; Risk Assessment; Risk Factors; Severity of Illness Index; Time Factors; Transcatheter Aortic Valve Replacement; Treatment Outcome; Watchful Waiting
PubMed: 32925391
DOI: 10.2459/JCM.0000000000001110 -
Open Heart May 2022The management of severe aortic stenosis mandates consideration of aortic valve intervention for symptomatic patients. However, for asymptomatic patients with severe... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
The management of severe aortic stenosis mandates consideration of aortic valve intervention for symptomatic patients. However, for asymptomatic patients with severe aortic stenosis, recent randomised trials supported earlier intervention. We conducted a systematic review and meta-analysis to evaluate all the available data comparing the two management strategies.
METHODS
PubMed, Cochrane and Web of Science databases were systematically searched from inception until 10 January 2022. The search key terms were 'asymptomatic', 'severe aortic stenosis' and 'intervention'.
RESULTS
Meta-analysis of two published randomised trials, AVATAR and RECOVERY, included 302 patients and showed that early intervention resulted in 55% reduction in all-cause mortality (HR=0.45, 95% CI 0.24 to 0.86; I 0%) and 79% reduction in risk of hospitalisation for heart failure (HR=0.21, 95% CI 0.05 to 0.96; I 15%). There was no difference in risk of cardiovascular death between the two groups (HR=0.36, 95% CI 0.03 to 3.78; I 78%). Additionally, meta-analysis of eight observational studies showed improved mortality in patients treated with early intervention (HR=0.38, 95% CI 0.26 to 0.56; I 77%).
CONCLUSION
This meta-analysis provides evidence that, in patients with severe asymptomatic aortic stenosis, early intervention reduces all-cause mortality and improves outcomes compared with conservative management. While this is very encouraging, further randomised controlled studies are needed to draw firm conclusions and identify the optimal timing of intervention.
PROSPERO REGISTRATION NUMBER
CRD42022301037.
Topics: Aortic Valve; Aortic Valve Stenosis; Conservative Treatment; Heart Failure; Humans; Transcatheter Aortic Valve Replacement
PubMed: 35581008
DOI: 10.1136/openhrt-2022-001982 -
Journal of Clinical Neuroscience :... Sep 2018Aortic valve calcification (AVC) is common among aged population and reported to be associated with the risk of stroke. However, the conclusions are inconsistent among... (Meta-Analysis)
Meta-Analysis Review
Aortic valve calcification (AVC) is common among aged population and reported to be associated with the risk of stroke. However, the conclusions are inconsistent among studies. We performed a rigorous meta-analysis to unravel the AVC-stroke relationship. Embase, PubMed and Cochrane library were retrieved for related cohort studies investigating the correlations between AVC and risk of stroke. The language was limited to English. We selected risk ratio (RR) and 95% confidence intervals (CIs) as the effect size. Random-effects model was used in the data synthesis. A total of 7 cohort studies were identified in our meta-analysis with 21,395 participants and 1025 strokes. We detected statistically significant correlation between AVC and stroke (RR, 1.20; 95% CI, 1.02-1.40, P = 0.02) with low heterogeneity (I = 6.9%, P = 0.375). Statistically significant results were detected only in the subgroup of "+" degree of adjustment (P = 0.04). Therefore, a definite relationship between AVC and risk of stroke couldn't be decided based on current available data, and more large scale prospective studies were needed to verify the AVC-stroke relationship.
Topics: Aged; Aortic Valve; Aortic Valve Stenosis; Calcinosis; Female; Humans; Middle Aged; Prospective Studies; Risk Factors; Stroke
PubMed: 30041902
DOI: 10.1016/j.jocn.2018.07.016