Amos Levi

Urgent Transcatheter Aortic Valve Implantation in Patients With Severe Aortic Stenosis and Acute Heart Failure: Procedural and 30-Day Outcomes.

BACKGROUND Transcatheter aortic valve implantation (TAVI) is recommended for patients with severe symptomatic aortic stenosis (AS) who are at prohibitive/high risk for surgical aortic valve replacement (SAVR). Patients with severe AS may experience acute decompensated heart failure (HF) that is resistant to medical therapy. We report our TAVI experience in treating patients with unstable AS who require urgent intervention for their aortic valve disease. METHODS Patients were restrictively included in the urgent TAVI registry if they were admitted with acute refractory and persistent HF despite medical therapy and had TAVI performed during the same hospital stay. All others were included in the elective TAVI group. RESULTS Between November 2008 and April 2015, 410 consecutive patients underwent TAVI at our centre-27 (6.6%) urgently. Patients operated on urgently were more likely to be frail and carry higher SAVR mortality risk based on The Society of Thoracic Surgeons Predicted Risk of Mortality/logistic EuroSCORE (LES) measures. Pulmonary edema was the most common clinical presentation. Preprocedural assessment used fewer imaging modalities, yet implantation success remained high and reached 96.3% using an additional valve (valve-within-valve) required in 3 patients, with no difference in periprocedural complications according to the Valve Academic Research Consortium-2 definitions. Although 30-day functional capacity was reduced, patients had similar 30-day mortality and major adverse cardiovascular event rates compared with patients who underwent elective TAVI. CONCLUSIONS Short-term outcome after urgent TAVI appears to be reasonable. For patients with severe AS who experience acute decompensated HF that is recalcitrant to optimal medical therapy and who are at high risk with SAVR, urgent TAVI may be a viable treatment strategy. Larger prospective studies and data on long-term outcomes are needed.

Assessment of a Possible Link Between Hyperhomocysteinemia and Hyperuricemia

Background/Aim Hyperhomocysteinemia and hyperuricemia are both considered risk factors for coronary artery disease. However, the relationship between the 2 has not yet been thoroughly investigated. This study aimed to evaluate this relationship more closely. Material and Methods This study is a retrospective cross-sectional analysis of data from a screening center in Israel assessing 16,477 subjects, within an age range of 20 to 80 years. Results The mean age of the study sample was 46 years, and 68% were males. Hyperuricemia was found in 24.9% and 14.6% of subjects with elevated and normal homocysteine serum levels, respectively (P < 0.001). A positive association was found between homocysteine serum levels and uric acid serum levels. Compared with subjects with normal homocysteine serum levels, those with hyperhomocysteinemia had an odds ratio (OR) for hyperuricemia of 1.7 (95% confidence interval [CI], 1.5–1.9) and 1.6 (95% CI, 1.1–2.5) for males and females, respectively. After multivariate adjustment for age, hypertension, body mass index, estimated glomerular filtration rate, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and thiazide use, the association remained significant in males (OR, 1.5; 95% CI, 1.3–1.7; P < 0.001) but not in females (OR, 0.9; 95% CI, 0.6–1.6; P = 0.82). Conclusions This large cohort showed a significant association between hyperhomocysteinemia and hyperuricemia. Sex differences were observed. This study suggests that accelerated atherosclerosis may be a consequence of the combined effect of these 2 factors.

The Frequency and Prognostic Impact of Fever Following Transcatheter Aortic Valve Implantation

Objectives: This study sought to explore the frequency and prognostic implications of infectious and noninfectious fever following transcatheter aortic valve implantation (TAVI). Methods: We performed a retrospective cohort study including 194 consecutive patients who underwent TAVI at our institution. We identified and characterized all patients who developed fever within the first 72 h following the procedure. We determined the etiology of the fevers (infectious vs. noninfectious) and assessed their impact on in-hospital complications and 1-year mortality. Results: Following TAVI, 65 (33.5%) patients had fever (mean age 83.7 ± 3.8 years, 70.2% female). An infectious etiology was evident in only 17 of the 65 patients (26.1%) with fever, mainly due to pneumonia (52.9%) and a urinary tract infection (41.2%). No significant difference was observed in baseline characteristics, the mean fever temperature/duration, or signs of inflammatory response between infectious and noninfectious fevers. The mean hospital duration was longer (7 ± 4.8 days vs. 4.7 ± 2.4 days, p = 0.01) among patients with an infectious fever; however, fever had no impact on the 1-year mortality rate (5.9 and 4.5%, respectively, p = 0.71). Conclusions: Our study demonstrates that, although fever was a common phenomenon after TAVI, it represented an infectious complication only in a minority of cases. Nevertheless, fever, infectious or not, had no impact on the 1-year mortality rate following TAVI.

Incidence, predictors, and outcomes of failed primary percutaneous coronary intervention: a 10-year contemporary experience.

BackgroundLimited contemporary data exist regarding the incidence, predictors, and outcomes of failure of primary percutaneous coronary intervention (PCI) in the treatment of ST-segment elevation myocardial infarction (STEMI). Materials and methodsIn this registry-based retrospective cohort study, all consecutive unselected patients (n=1725) who were hospitalized for STEMI and underwent primary PCI from January 2001 to December 2010 were included. PCI failure was defined as a final diameter stenosis greater than 30% or postdilatation Thrombolysis in Myocardial Infarction (TIMI) flow grade of 2 or less. We examined the predictors and survival among patients who failed primary PCI. ResultsThe overall PCI failure rate was 5.4% (94 of 1725 procedures). After adjusting for prespecified baseline characteristics, independent predictors of PCI failure included age greater than 65 years (P=0.02), procedure date between 2001 and 2005 (P=0.05), night-time PCI (P=0.008), calcific lesion (P=0.008), and lower preprocedural TIMI flow grade (P=0.006). Failed PCI was associated with a 1-year mortality rate of 22% as compared with 4.2% in the successful PCI group (P<0.001). Conservative medical management was preferred in the majority of patients with failed PCI (n=78, 83%). Patients who underwent emergent surgery (n=11), conservative management (n=78), and redo PCI (n=5) experienced 30-day mortality rates of 27, 16, and 0%, respectively. ConclusionPrimary PCI failure in the setting of STEMI is not rare. It is associated with high-risk patient-related and angiographic-related characteristics. Primary PCI failure is associated with early and late mortality.

Effect of vitamin D on endothelial progenitor cells function

Background Endothelial progenitor cells (EPCs) are a population of bone marrow-derived cells, which have an important role in the process of endothelialization and vascular repair following injury. Impairment of EPCs, which occurs in patients with diabetes, was shown to be related to endothelial dysfunction, coronary artery disease (CAD) and adverse clinical outcomes. Recent evidence has shown that calcitriol, the active hormone of vitamin D, has a favorable impact on the endothelium and cardiovascular system. There is limited data on the effect of vitamin D on EPCs function. Aim To examine the in vitro effects of Calcitriol on EPCs from healthy subjects and patients with diabetes. Methods Fifty-one patients with type 2 diabetes (60±11 years, 40% women, HbA1C: 9.1±0.8%) and 23 healthy volunteers were recruited. EPCs were isolated and cultured with and without calcitriol. The capacity of the cells to form colony-forming units (CFUs), their viability (measured by MTT assay), KLF-10 levels and angiogenic markers were evaluated after 1 week of culture. Results In diabetic patients, EPC CFUs and cell viability were higher in EPCs exposed to calcitriol vs. EPCs not exposed to calcitriol [EPC CFUs: 1.25 (IQR 1.0–2.0) vs. 0.5 (IQR 0.5–1.9), p < 0.001; MTT:0.62 (IQR 0.44–0.93) vs. 0.52 (IQR 0.31–0.62), p = 0.001]. KLF-10 levels tended to be higher in EPCs exposed to vitamin D, with no differences in angiopoietic markers. In healthy subjects, calcitriol supplementation also resulted in higher cell viability [MTT: 0.23 (IQR 0.11–0.46) vs. 0.19 (0.09–0.39), p = 0.04], but without differences in CFU count or angiopoietic markers. Conclusion In patients with diabetes mellitus, in vitro vitamin D supplementation improved EPCs capacity to form colonies and viability. Further studies regarding the mechanisms by which vitamin D exerts its effect are required.

Temporal trends in percutaneous coronary interventions thru the drug eluting stent era: Insights from 18,641 procedures performed over 12‐year period

The last decade, regarded as the DES era in PCI, has witnessed significant advances in the management of coronary disease. We aimed to assess temporal trends in the practice and outcome of percutaneous coronary intervention (PCI) during the drug eluting stent (DES) era.

Usefulness of the CHA2DS2-VASc Score to Predict Outcome in Patients Who Underwent Transcatheter Aortic Valve Implantation

Risk assessment for transcatheter aortic valve implantation (TAVI) patients remains challenging, especially in elderly and high-risk candidates. Although several risk factors contribute to increased morbidity and mortality after TAVI, simple risk scores for routine use are lacking. Applying the CHA2DS2-VASC (congestive heart failure, hypertension, age ≥ 75 years, diabetes, prior stroke, vascular disease, age 65-74 years, sex [female] category) score as a novel risk stratification tool for conditions other than atrial fibrillation and stroke prevention has been previously examined; however, its usefulness in a population of patients with aortic stenosis after TAVI has not been established. Thus, we investigated 633 consecutive patients who underwent TAVI between November 2008 and May 2017, and calculated the CHA2DS2-VASC score. Patients were stratified according to their CHA2DS2-VASC score into 3 categories (0 to 3, 4 to 6, 7 to 9), and the association between CHA2DS2-VASC score and 1-year clinical outcomes (stroke, all-cause mortality, and combined outcome of stroke or mortality) was evaluated. We found that both stroke and mortality at 1 year were significantly more frequent with increasing CHA2DS2-VASC score (p = 0.012 and p = 0.025, respectively). Each single-point rise in CHA2DS2-VASC score was associated with a 38% increase in the 1-year combined outcome of mortality or stroke (p = 0.022; C index 0.615). In conclusion, CHA2DS2-VASC score can be used as a simple and effective tool to predict 1-year clinical outcomes including death and stroke in patients who underwent TAVI.

Relationship between homocysteine and intraocular pressure in men and women: A population-based study.

AbstractThe relationship between homocysteine levels and glaucoma has been questioned in previous studies without conclusive results. In the current study, we assessed the relationship between homocysteine levels and intraocular pressure which is one of the main factors in the development of glaucoma in men and women.A retrospective cross-sectional analysis of a database from a screening center in Israel which assessed 11,850 subjects, within an age range 20 to 80 years. The relationship between homocysteine and intraocular pressure has been investigated by comparing intraocular pressure in subjects with elevated and normal homocysteine and by comparing homocysteine levels in subjects with elevated and normal intraocular pressure. In addition, we compared the levels of homocysteine in subjects with and without a confirmed diagnosis of glaucoma.The mean IOP (±SD) in subjects with normal homocysteine levels(⩽15 &mgr;mol/L) was 13.2 ± 2.3 mm Hg and 13.4 ± 2.4 mm Hg in those with high homocysteine levels (>15 &mgr;mol/L) (P < 0.008, 95% confidence interval [CI] 0.3–0.09).Nonetheless, after multivariate adjustment for age, gender, vitamin B12, and folic acid statistical significance was no longer demonstrated (P = 0.37). Mean homocysteine levels (±SD) in subjects with normal intraocular pressure of ⩽ 21 mm Hg was 11.7 ± 5.5 &mgr;mol/L and 12.09 ± 3.43 &mgr;mol/L in those with elevated intraocular pressure (P = 0.4, 95%CI 1.1–1.8). Mean homocysteine levels (±SD) in subjects with glaucoma were 11.2 ± 3.5 &mgr;mol/L compared to 11.7 ± 5.5 &mgr;mol/L in subjects without glaucoma and normal intraocular pressure ⩽ 21 mm Hg (P = 0.4, 95% CI 1.2–2.1).The current study displays no clinical correlation between the homocysteine level and the intraocular pressure. Homocysteine may not be used as a predictive parameter to recognize those subjects prone to develop elevated intraocular pressure.

The association of central venous catheter placement timing with infection rates in patients with acute leukemia

BACKGROUND Timing of central venous catheter (CVC) insertion among patients with acute leukemia is debatable. Early insertion increases convenience, but might increase infection rates. METHODS We assessed retrospectively the rate of central line-associated bloodstream infections (CLABSI) according to CVC time of insertion in patients with acute leukemia admitted for induction or salvage therapy. The study was conducted in the Hematology Department of a Tertiary hospital in Israel between 2007 and 2011. Early CVC placement was defined as CVC inserted during the first week of induction therapy. CLABSI rate was documented between the seventh day of induction therapy to 30 days after its completion. RESULTS A total of 127 patients were included. Acute myeloid leukemia was the most common diagnosis (103 patients, 80.5%). Late CVC placement was associated with CLABSI after adjustment to the Charlson comorbidity index (OR 3.4, 95% CI 1.1-10.45), p=0.03. CONCLUSION Delaying CVC placement in adult patients with acute leukemia may be associated with higher rate of CLABSI in the early period after induction therapy.

Iliofemoral artery lumen volume assessment with three dimensional multi-detector computed tomography and vascular complication risk in transfemoral transcatheter aortic valve replacement

BACKGROUND Transfemoral Transcatheter Aortic Valve Replacement (TAVR) carries a risk of Vascular Complications (VCs) at the access site. The currently used measures for assessing the risk for VCs are not accurate enough, and sometimes fail to predict them. We therefore aimed to examine whether Iliofemoral artery lumen volume (IFV) assessment with 3-dimensional computed tomography (CT) predicts VCs after transfemoral TAVR. METHODS We identified 45/560 trans-femoral TAVR patients with VC, then performed nearest neighbor 1:1 matching for patients with no VC, matching for age, sex, TAVR year, valve size and type, closure-device, sheath size and peripheral vascular disease. IFV, minimal diameter, tortuosity, and calcification were measured, and their diagnostic performance assessed. RESULTS The final analysis included 45 patients with and 45 patients without VCs. The two groups were well balanced. For all patients, median IFV was 8.65 ml (IQR 6.5-11.95). IFV was lower in patients with VC compared to patients without VC: 7.10 ml (IQR 5.4-9.0) vs. 10.10 ml (IQR 8.3-13.3), p < 0.001. VC risk had marginal association with iliofemoral artery minimal diameter (p = 0.06) and no association with tortuosity or calcification. Compared with other measurements, IFV had the most favorable receiver operating curve for the prediction of VC, with an area under the curve (AUC) of 0.78. CONCLUSION IFV measurement using 3-dimensional CT is significantly associated with VCs in transfemoral TAVR patients and might be superior to currently accepted parameters. IFV should be further studied among extended cohorts of TAVR treated patients as a novel tool for VC risk assessment prior to transfemoral TAVR.