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JACC. Advances May 2024Persistent left ventricular hypertrophy after transcatheter aortic valve replacement (TAVR) has been associated with poor outcomes. Angiotensin-converting enzyme...
BACKGROUND
Persistent left ventricular hypertrophy after transcatheter aortic valve replacement (TAVR) has been associated with poor outcomes. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), due to their favorable effects on ventricular remodeling, have been hypothesized to improve outcomes post-TAVR, yet there are no recommendations regarding their use.
OBJECTIVES
This study aimed to compare the outcomes of patients receiving ACEIs/ARBs with those not receiving ACEIs/ARBs after TAVR.
METHODS
We performed a literature search on PubMed and Cochrane Library until June 14, 2023, and included all studies comparing clinical outcomes between patients given ACEIs/ARBs and those not given ACEIs/ARBs after TAVR. All-cause mortality was the primary outcome. We used a random effects model with appropriate corrections to calculate relative risk (RR) and CIs, with all analyses carried out using R v4.0.3.
RESULTS
We included ten studies on the use of ACEIs/ARBs post-TAVR. Patients on ACEIs/ARBs had lower risk of all-cause mortality (RR: 0.74, 95% CI: 0.65-0.86, I = 62%, chi-square < 0.01), cardiovascular mortality (RR: 0.70, 95% CI: 0.56-0.88, I = 0%, chi-square = 0.54), and new-onset atrial fibrillation (RR: 0.71, 95% CI: 0.52-0.96, I = 0%, chi-square = 0.59). Patients on ACEIs/ARBs had a similar risk of myocardial infarction, heart failure, stroke, new permanent pacemaker implantation, acute kidney injury, major bleeding, vascular complications, aortic regurgitation, and mitral regurgitation.
CONCLUSIONS
We found that patients receiving ACEIs/ARBs had a lower risk of all-cause mortality, cardiovascular mortality, and new-onset atrial fibrillation. Risk of other outcomes was similar to patients not receiving ACEIs/ARBs. Randomized clinical trials are needed to explore the benefits of ACEIs/ARBs post-TAVR, so that definitive guidelines can be developed.
PubMed: 38939627
DOI: 10.1016/j.jacadv.2024.100927 -
JACC. Advances Feb 2024
PubMed: 38939396
DOI: 10.1016/j.jacadv.2023.100760 -
JACC. Advances Feb 2024A blood multimarker approach may be useful to enhance risk stratification in patients undergoing TAVI.
BACKGROUND
A blood multimarker approach may be useful to enhance risk stratification in patients undergoing TAVI.
OBJECTIVES
The objective of this study was to determine the prognostic value of multiple blood biomarkers in transcatheter aortic valve implantation (TAVI) patients.
METHODS
In this prospective study, several blood biomarkers of cardiovascular function, inflammation, and renal function were measured in 362 patients who underwent TAVI. The cohort was divided into 3 groups according to the number of elevated blood biomarkers (ie, ≥ median value for the whole cohort) for each patient before the procedure. Survival analyses were conducted to evaluate the association between blood biomarkers and risk of adverse event following TAVI.
RESULTS
During a median follow-up of 2.5 (IQR: 1.9-3.2) years, 34 (9.4%) patients were rehospitalized for heart failure, 99 (27%) patients died, and 113 (31.2%) met the composite endpoint of all-cause mortality or heart failure rehospitalization. Compared to patients with 0 to 3 elevated biomarkers (referent group), those with 4 to 7 and 8 to 9 elevated biomarkers had a higher risk of all-cause mortality (HR: 1.54 [95% CI: 0.84-2.80], = 0.16, and HR: 2.81 [95% CI: 1.53-5.15], < 0.001, respectively) and of the composite endpoint (HR: 1.65 [95% CI: 0.95-2.84], = 0.07, and HR: 2.67 [95% CI: 1.52-4.70] < 0.001, respectively). Moreover, adding the number of elevated blood biomarkers into the clinical multivariable model provided significant incremental predictive value for all-cause mortality (Net Reclassification Index = 0.71, < 0.001).
CONCLUSIONS
An increasing number of elevated blood biomarkers is associated with higher risks of adverse clinical outcomes following TAVI. The blood multimarker approach may be helpful to enhance risk stratification in TAVI patients.
PubMed: 38939373
DOI: 10.1016/j.jacadv.2023.100761 -
ACG Case Reports Journal Jul 2024ST segment elevations (STEs) on an electrocardiogram (EKG) gravitate immediate attention to the heart. However, these EKG changes can sometimes be the result of...
ST segment elevations (STEs) on an electrocardiogram (EKG) gravitate immediate attention to the heart. However, these EKG changes can sometimes be the result of noncardiac pathologies. Here, we present an interesting case of small bowel obstruction (SBO) masquerading as an inferior wall myocardial infarction. A 77-year-old woman with a history of aortic stenosis status postsurgical aortic valve replacement presented with chest pain. Workup revealed elevated high-sensitivity troponins and STE in the inferior leads. She subsequently underwent a left heart catheterization, which showed no critical plaques or stenosis. Persistent abdominal pain prompted further evaluation with a computed tomography scan of the abdomen, which demonstrated evidence of SBO. Conservative treatment with bowel decompression resulted in symptom improvement and complete resolution of the STEs on a follow-up EKG. This case underscores the importance of considering noncardiac etiologies, such as SBO, in the differential diagnosis of STE on EKG for accurate diagnosis and management.
PubMed: 38939350
DOI: 10.14309/crj.0000000000001412 -
JACC. Advances Jul 2023Transcatheter aortic valve implantation (TAVI) rates are lower among Black compared with White individuals. However, it is unclear whether racial residential...
BACKGROUND
Transcatheter aortic valve implantation (TAVI) rates are lower among Black compared with White individuals. However, it is unclear whether racial residential segregation, which remains common in the United States, contributes to observed disparities in TAVI rates.
OBJECTIVES
The purpose of this study was to evaluate the association between county-level racial segregation, and aortic stenosis (AS) diagnosis, management, and outcomes.
METHODS
We identified Black and White Medicare fee-for-service beneficiaries age ≥65 years living in metropolitan areas of the United States (2016-2019). Using the American Community Survey's Black-White residential segregation index, a measure of geographic racial distribution, we determined segregation in each beneficiary's county of residence. Using hierarchical modeling, we determined the association between racial segregation and rates of AS diagnosis, TAVI receipt, and 30-day clinical outcomes (mortality, readmission, stroke).
RESULTS
There were 29,264,075 beneficiaries, of whom 22% lived in a high-segregation county. Among Black beneficiaries, high-segregation county residence was associated with decreased rates of AS diagnosis (OR: 0.97; 95% CI: 0.96-0.98) and TAVI (OR: 0.89; 95% CI: 0.86-0.93) compared with low-segregation county residence. In contrast, among White beneficiaries, high-segregation county residence was associated with higher rates of AS diagnosis (OR: 1.02; 95% CI: 1.02-1.03) and no differences in TAVI (OR: 1.00; 95% CI: 0.99-1.00). Segregation and race were not independently associated with 30-day mortality.
CONCLUSIONS
Among Black Medicare fee-for-service beneficiaries, living in a high-segregation county was independently associated with decreased rates of AS diagnosis and TAVI, an association not seen among White beneficiaries. Residential racial segregation may contribute to racial disparities seen in AS care.
PubMed: 38939010
DOI: 10.1016/j.jacadv.2023.100415 -
JACC. Advances Jul 2023
PubMed: 38939002
DOI: 10.1016/j.jacadv.2023.100432 -
JACC. Advances Mar 2024Low stroke volume index <35 ml/m despite preserved ejection fraction (paradoxical low flow [PLF]) is associated with adverse outcomes in patients with aortic stenosis...
BACKGROUND
Low stroke volume index <35 ml/m despite preserved ejection fraction (paradoxical low flow [PLF]) is associated with adverse outcomes in patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). However, whether the risk associated with PLF is similar in both sexes is unknown.
OBJECTIVES
The purpose of this study was to analyze the risk associated with PLF in severe aortic stenosis for men and women randomized to TAVR or SAVR.
METHODS
Patients with ejection fraction ≥50% from the PARTNER (Placement of Aortic Transcatheter Valves) 2 and 3 trials were stratified by sex and treatment arm. The impact of PLF on the 2-year occurrence of the composite of death or heart failure hospitalization (primary endpoint) and of all-cause mortality alone (secondary endpoint) was analyzed. Analysis of variance was used to assess baseline differences between groups. Multivariate Cox regression analysis was used to identify predictors of the endpoint.
RESULTS
Out of 2,242 patients, PLF was present in 390 men and 239 women (30% vs 26%, = 0.06). PLF was associated with a higher rate of NYHA functional class III to IV dyspnea (60% vs 54%, < 0.001) and a higher prevalence of atrial fibrillation (39% vs 24%, < 0.001). PLF was a significant predictor of the primary endpoint among women undergoing SAVR in multivariate analysis (adjusted HR: 2.25 [95% CI: 1.14-4.43], = 0.02) but was not associated with a worse outcome in any of the other groups (all > 0.05).
CONCLUSIONS
In women with PLF, TAVR may improve outcomes compared to SAVR. PLF appears to have less impact on outcomes in men.
PubMed: 38938841
DOI: 10.1016/j.jacadv.2024.100853 -
JACC. Advances Mar 2024FAV is offered to fetuses with severe aortic valve stenosis and evolving hypoplastic left heart syndrome. An inferential analysis of TS and SAE in a large series has not...
BACKGROUND
FAV is offered to fetuses with severe aortic valve stenosis and evolving hypoplastic left heart syndrome. An inferential analysis of TS and SAE in a large series has not been reported.
OBJECTIVES
The purpose of this study was to determine factors associated with fetal aortic valvuloplasty (FAV) technical success (TS) and serious adverse events (SAEs).
METHODS
Retrospective, single-center, cohort analysis of attempted FAV from March 1, 2000, to December 31, 2020. The primary outcome was the TS of FAV, and the secondary outcome was the presence of an SAE.
RESULTS
A total of 165 FAVs were attempted in 163 patients with a median gestational age of 24.6 weeks (IQR: 22.9-27.1 weeks). FAV TS was 85% (141/165) and was higher in the 2010 to 2020 era (94% [85/90] vs 75% [56/75]; < 0.001). Pre-FAV echocardiographic left ventricle (LV) long axis dimension z-score >-0.10 ( < 0.001) and higher LV ejection fraction ( = 0.037) were independently associated with a higher odds of TS. There were 117 SAEs in 67 attempted FAVs (41%), 13 of which were fetal deaths (7.9%). By classification and regression tree analysis, gestational age <21 weeks or in older fetuses, a procedure time of ≥39.6 minutes was associated with higher SAE rate. In the multivariable logistic regression model correcting for gestational age, fetuses with an LV end-diastolic volume <4.09 mL had an age-adjusted OR of 4.71 (95% CI: 1.67-13.29; = 0.004) for experiencing an SAE.
CONCLUSIONS
TS of FAV has improved over time, and failure is associated with smaller fetal left heart sizes. SAEs are common and are associated with smaller left hearts and longer procedure times.
PubMed: 38938833
DOI: 10.1016/j.jacadv.2024.100835 -
JACC. Advances Mar 2024
PubMed: 38938827
DOI: 10.1016/j.jacadv.2024.100826 -
JACC. Advances Mar 2024International guidelines recommend aortic valve replacement (AVR) as Class I triggers in high-gradient severe aortic stenosis (HGSAS) patients with symptoms and/or left...
BACKGROUND
International guidelines recommend aortic valve replacement (AVR) as Class I triggers in high-gradient severe aortic stenosis (HGSAS) patients with symptoms and/or left ventricular ejection fraction (LVEF) <50%. The association between waiting for these triggers and postoperative survival penalty is poorly studied.
OBJECTIVES
The purpose of this study was to examine the impact of guideline-based Class I triggers on long-term postoperative survival in HGSAS patients.
METHODS
2,030 patients operated for HGSAS were included and classified as follows: no Class I triggers (no symptoms and LVEF >50%, n = 853), symptoms with LVEF >50% (n = 965), or LVEF <50% regardless of symptoms (n = 212). Survival was compared after matching (inverse probability weighting) for clinical differences. Restricted mean survival time was analyzed to quantify lifetime loss.
RESULTS
Ten-year survival was better without any Class I trigger than with symptoms or LVEF <50% (67.1% ± 3% vs 56.4% ± 3% vs 53.1% ± 7%, respectively, < 0.001). Adjusted death risks increased significantly in operated patients with symptoms (HR: 1.45 [95% CI: 1.15-1.82]) or LVEF <50% (HR: 1.47 [95% CI: 1.05-2.06]) than in those without Class I triggers. Performing AVR with LVEF >60% produced similar outcomes to that of the general population, whereas operated patients with LVEF <60% was associated with a 10-year postoperative survival penalty. Furthermore, according to restricted mean survival time analyses, operating on symptomatic patients or with LVEF <60% led to 8.3- and 11.4-month survival losses, respectively, after 10 years, compared with operated asymptomatic patients with a LVEF >60%.
CONCLUSIONS
Guideline-based Class I triggers for AVR in HGSAS have profound consequences on long-term postoperative survival, suggesting that HGSAS patients should undergo AVR before trigger onset. Operating on patients with LVEF <60% is already associated with a 10-year postoperative survival penalty questioning the need for an EF threshold recommending AVR in HGSAS patients.
PubMed: 38938822
DOI: 10.1016/j.jacadv.2024.100830