Christian Hengstenberg

Incidence and outcomes of emergent cardiac surgery during transfemoral transcatheter aortic valve implantation (TAVI): insights from the European Registry on Emergent Cardiac Surgery during TAVI (EuRECS-TAVI)

AimsnLife-threatening complications occur during transcatheter aortic valve implantation (TAVI) which can require emergent cardiac surgery (ECS). Risks and outcomes of patients needing ECS during or immediately after TAVI are still unclear.nnnMethods and resultsnIncidence, risk factors, management, and outcomes of patients requiring ECS during transfemoral (TF)-TAVI were analysed from a contemporary real-world multicentre registry. Between 2013 and 2016, 27xa0760 patients underwent TF-TAVI in 79 centres. Of these, 212 (0.76%) patients required ECS (age 82.4u2009±u20096.3u2009years, 67.5% females, logistic EuroSCORE: 17.1%, STS-score 5.8%). The risk of ECS declined from 2013 (1.07%) to 2014 (0.70%) but remained stable since. Annual TF-TAVI numbers have more than doubled from 2013 to 2016. Leading causes for ECS were left ventricular perforation by the guidewire (28.3%) and annular rupture (21.2%). Immediate procedural mortality (<72u2009h) of TF-TAVI patients requiring ECS was 34.6%. Overall in-hospital mortality was 46.0%, and highest in case of annular rupture (62%). Independent predictors of in-hospital mortality following ECS were ageu2009>u200985u2009years [odds ratio (OR) 1.87, 95% confidence interval (95% CI) (1.02-3.45), Pu2009=u20090.044], annular rupture [OR 1.96, 95% CI (0.94-4.10), Pu2009=u20090.060], and immediate ECS [OR 3.12, 95% CI (1.07-9.11), Pu2009=u20090.037]. One year of survival of the 114 patients surviving the in-hospital period was only 40.4%.nnnConclusionnBetween 2014 and 2016, the need for ECS remained stable around 0.7%. Left ventricular guidewire perforation and annular rupture were the most frequent causes, accounting for almost half of ECS cases. Half of the patients could be salvaged by ECS-nevertheless, 1 year of all-cause mortality was high even in those ECS patients surviving the in-hospital period.

Conscious Sedation Versus General Anesthesia in Transcatheter Aortic Valve Replacement: The German Aortic Valve Registry

OBJECTIVESnThe aims of this study were to report on the use of local anesthesia or conscious sedation (LACS) and general anesthesia in transcatheter aortic valve replacement and to analyze the impact on outcome.nnnBACKGROUNDnTranscatheter aortic valve replacement can be performed in LACS or general anesthesia. Potential benefits of LACS, such as faster procedures and shorter hospital stays, need to be balanced with safety.nnnMETHODSnA total of 16,543 patients from the German Aortic Valve Registry from 2011 to 2014 were analyzed, and propensity-matched analyses were performed to correct for potential selection bias.nnnRESULTSnLACS was used in 49% of patients (8,121 of 16,543). In hospital, LACS was associated with lower rates of low-output syndrome, respiratory failure, delirium, cardiopulmonary resuscitation, and death. There was no difference in paravalvular leakage (II+) between LACS and general anesthesia in the entire population (5% vs. 4.8%; pxa0= 0.76) or in the matched population (3.9% vs. 4.9%, pxa0= 0.13). The risk for prolonged intensive care unit stay (≥3 days) was significantly reduced with LACS (odds ratio: 0.82; 95% confidence interval [CI]: 0.73 to 0.92; pxa0= 0.001). Thirty-day mortality was lower with LACS in the entire population (3.5% vs. 4.9%; hazard ratio [HR]: 0.72; 95% CI: 0.60 to 0.86; pxa0< 0.001) and in the matched population (2.8% vs. 4.6%; HR: 0.6; 95% CI: 0.45 to 0.8; pxa0< 0.001). However, no differences in 1-year mortality between both groups in the entire population (16.5% vs. 16.9%; HR: 0.93; 95% CI: 0.85 to 1.02; pxa0= 0.140) and in the propensity-matched population (14.1% vs. 15.5%; HR: 0.90; 95% CI: 0.78 to 1.03; pxa0= 0.130) were observed.nnnCONCLUSIONSnUse of LACS in transcatheter aortic valve replacement is safe, with fewer post-procedural complications and lower early mortality, suggesting its broad application.

Emergency extracorporeal membrane oxygenation in transcatheter aortic valve implantation: A two-center experience of incidence, outcome and temporal trends from 2010 to 2015

Although the incidence of periprocedural complications has decreased in transcatheter aortic valve implantation (TAVI), life‐threatening complications occur and emergency veno‐arterial extracorporeal membrane oxygenation (vaECMO) can provide immediate circulatory stabilization. We report our two‐center experience of vaECMO during life‐threatening complications in TAVI.

Cardiac Magnetic Resonance T1 Mapping in Cardiac Amyloidosis

In cardiac amyloidosis (CA), extracellular deposition of amyloid fibrils within the myocardium significantly expands the extracellular volume (ECV). Affected patients develop severe heart failure and face a dismal prognosis. Cardiac magnetic resonance (CMR) T1 mapping allows ECV measurement [(1)][1

Papillary Muscle Dyssynchrony-Mediated Functional Mitral Regurgitation: Mechanistic Insights and Modulation by Cardiac Resynchronization

OBJECTIVESnThis study sought to define interpapillary muscle dyssynchrony as a major contributing factor in functional mitral regurgitation (FMR) and prove the reversibility of FMR by interpapillary muscle resynchronization.nnnBACKGROUNDnMechanistic features of FMR include papillary muscle displacement due to left ventricular remodeling. Intraventricular conduction delay might further augment this condition by introducing interpapillary muscle dyssynchrony.nnnMETHODSnWe enrolled 269 chronic heart failure with reduced ejection fraction patients with conduction delay and comprehensively assessed dyssynchrony by complementary echocardiographic techniques covering the entire spectrum of dyssynchrony.nnnRESULTSnPatients with severe FMR had markedly increased interpapillary longitudinal dyssynchrony [160 ms (interquartile range [IQR]: 120 to 200 ms])] compared with those with moderate (70 ms [IQR: 40 to 110 ms]), no, or mild FMR (60 ms [IQR: 30 to 100 ms]; pxa0< 0.001). Increased interpapillary muscle dyssynchrony was correlated with regurgitant volume (rxa0= 0.50; pxa0< 0.001) and vena contracta width (rxa0= 0.49; pxa0< 0.001). Restoration of longitudinal papillary muscle synchronicity by cardiac resynchronization therapy was correlated with FMR regression, as reflected by the reduction in regurgitant volume (rxa0= 0.46; pxa0< 0.001) and vena contracta width (rxa0= 0.58; pxa0< 0.001). Conversely, the improvement of FMR was associated with improved interpapillary radial (pxa0= 0.006) and longitudinal (pxa0< 0.001) dyssynchrony. The improvement of dyssynchrony-mediated FMR signified a better prognosis compared with no improvement in FMR during the 8-year follow-up period even after comprehensive adjustment by a bootstrap-selected confounder model (adjusted hazard ratio: 0.41; 95% confidence interval: 0.18 to 0.91; pxa0= 0.028). The results remained virtually unchanged after adjustment for left bundle branch block.nnnCONCLUSIONSnIntraventricular dyssynchrony introduces unequal contraction by papillary muscle bearing walls, which has an adverse effect on FMR. Cardiac resynchronization therapy can effectively restore interpapillary balance and thus create a less tented leaflet configuration, resulting in a clinically meaningful reduction of FMR. The restoration of papillary muscle synchronicity in dyssynchrony-mediated FMR translates into a significantly better prognosis.

Blood urea nitrogen has additive value beyond estimated glomerular filtration rate for prediction of long-term mortality in patients with acute myocardial infarction

OBJECTIVESnBlood urea nitrogen (BUN) has been shown to independently predict short- and intermediate-term outcomes in patients with acute myocardial infarction (AMI). We aimed to assess the additive predictive value of BUN beyond estimated glomerular filtration rate (eGFR) in AMI patients with an 8.6-year follow-up.nnnMETHODSnThis retrospective, observational single-centre study included 1332 consecutive AMI patients (median age 64u202fyears, 58.4% male). BUN, creatinine and eGFR were determined at hospital admission.nnnRESULTSnDuring a median follow-up of 8.6u202fyears (interquartile range [IQR] 4.0-11.6), 408 patients (30.6%) experienced the study endpoint of cardiovascular mortality. BUN (median 17.0u202fmg/dL [IQR 13.5-22.7]) was a significant predictor of cardiovascular mortality in univariate Cox regression (hazard ratio (HR) per 1 standard deviation increase 2.10, 95% confidence interval [CI] 1.94-2.28, pu202f<u202f.001). This association remained significant after multivariable adjustment for demographics, clinical variables and eGFR (adjusted HR 1.52 [CI 1.16-2.00, pu202f=u202f.003]). The association between BUN and outcome was more pronounced in patients with eGFR >60u202fmL/min/1.73m2 (HR 2.81 [CI 2.20-3.58, pu202f<u202f.001]). The discriminatory abilities (Harrells C-statistic) for BUN, eGFR and creatinine were 0.75, 0.76 and 0.67, respectively. The addition of BUN to eGFR significantly improved the C-statistic (0.78, p for comparisonu202f=u202f0.017), net reclassification (23.7%, pu202f<u202f.001) and integrated discrimination (2.9%, pu202f<u202f.001).nnnCONCLUSIONSnCirculating BUN on admission is an independent predictor of long-term cardiovascular mortality in AMI patients and adds predictive power beyond eGFR. BUN reflects not only kidney function, but also acute haemodynamic and neurohumoral alterations during AMI, and may help to identify high-risk patients.

EdoxabaN Versus standard of care and theIr effectS on clinical outcomes in pAtients havinG undergonE Transcatheter Aortic Valve Implantation in Atrial Fibrillation—Rationale and design of the ENVISAGE-TAVI AF trial

&NA; Transcatheter aortic valve implantation, also called transcatheter aortic valve replacement (TAVR), is the treatment of choice for patients with severe aortic stenosis and intermediate to high operative risk. A significant portion of TAVR patients have atrial fibrillation (AF) requiring chronic oral anticoagulation. In moderate‐ to high‐risk AF patients, the direct factor Xa inhibitor edoxaban is noninferior to vitamin K antagonists (VKAs) for prevention of stroke or systemic embolism with less bleeding and cardiovascular deaths. ENVISAGE‐TAVI AF (NCT02943785) is a multinational, multicenter, prospective, randomized, open‐label, blinded end point evaluation study comparing edoxaban to VKA‐based therapy in approximately 1,400 patients with an indication for chronic oral anticoagulation after successful transfemoral TAVR. The coprimary end points are to assess the differential effects of the 2 treatments (a) on net adverse clinical events (the composite of all‐cause death, myocardial infarction, ischemic stroke, systemic thromboembolism, valve thrombosis, and major bleeding events) and (b) on major bleeding. Twelve hours to 5 days after successful TAVR, patients will be randomized to 60 mg daily oral edoxaban or any VKA (international normalized ratio: 2.0‐3.0 or 1.6‐2.6 [numbers inclusive] in Japan if age ≥ 70 years). Antiplatelet therapy may be administered per physicians discretion. Randomization will be stratified by edoxaban dose reduction (per local label). Treatment duration will be up to 36 months. The study is powered (80%) to detect noninferiority (margin for the hazard ratio: 1.38) for the composite primary end points, followed by superiority testing.