Israel Barbash

Outcome of myocardial infarction in patients treated with aspirin is enhanced by pre-hospital administration.

Objective: Reducing time to reperfusion therapy is one of the goals in the management of acute myocardial infarction (AMI). We assessed the association between timing of aspirin administration and outcome of patients with AMI. Patients: We studied 922 consecutive AMI patients with ST-segment elevation in Killip class I–III on admission. Patients were divided into two groups based upon the timing of emergency aspirin administration: before (early aspirin users) or after (late aspirin users) hospital admission. Results: Early aspirin users (n = 338; 37%) were younger, less likely to be women, and more likely to smoke (p < 0.006) than late users (n = 584; 63%). Other baseline and clinical characteristics were similar. Early aspirin users were more likely to be treated with thrombolysis or primary percutaneous transluminal coronary angioplasty. Compared with late users, early aspirin users had significantly lower in-hospital complications and lower mortality rates at 7 (2.4 vs. 7.3%, p = 0.002) and 30 days (4.9 vs. 11.1%, p = 0.001). By multivariate adjustment, pre-hospital aspirin was an independent determinant of survival at 7 (odds ratio 0.43; 95% confidence interval 0.18–0.92) and at 30 days (odds ratio, 0.60; 95% confidence interval 0.32–1.08). Survival benefit associated with aspirin persisted for subgroups treated or not with reperfusion therapy. Conclusions: Outcome of AMI patients treated with aspirin is improved by pre-hospital administration.Our findings suggest that emergency pre-hospital aspirin might facilitate early reperfusion.

Timing of aspirin administration as a determinant of survival of patients with acute myocardial infarction treated with thrombolysis.

Unlike thrombolytic agents, there are conflicting data regarding the time-dependent effect of aspirin treatment on outcome in acute myocardial infarction (AMI). We sought to evaluate the impact of timing of aspirin administration (before vs after thrombolysis) on mortality of patients with AMI. Our study included 1,200 patients with ST elevation AMI treated with thrombolysis. Early (n = 364) versus late (n = 836) users were defined as those receiving emergency aspirin before versus after initiation of thrombolysis, respectively. Time (median) from symptom onset to initiation of aspirin treatment was significantly shorter in early versus late users (1.6 vs 3.5 hours; p <0.001). There were no significant differences between the 2 groups with respect to baseline clinical characteristics. Early aspirin users were more likely to develop reischemia, to be treated with beta blockers, to be referred to coronary angiography, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery. Early users experienced lower mortality at 7 days (2.5% vs 6.0%, p = 0.01), 30 days (3.3% vs 7.3%, p = 0.008), and 1 year (5.0% vs 10.6%, p = 0.002) than late users. This survival benefit persisted for patients with and without previous aspirin therapy or revascularization and after adjustment for baseline characteristics and therapies at 7 days (odds ratio 0.36, 95% confidence interval 0.15 to 0.79), at 30 days (odds ratio 0.39, 95% confidence interval 0.17 to 0.82), and at 1 year (odds ratio 0.41, 95% confidence interval 0.21 to 0.74). Our study proposes a time-dependent benefit from aspirin in patients with AMI treated with thrombolysis.

Inverse Relationship Between Membranous Septal Length and the Risk of Atrioventricular Block in Patients Undergoing Transcatheter Aortic Valve Implantation.

OBJECTIVESnThis study sought to examine whether imaging of the atrioventricular (AV) membranous septum (MS) by computed tomography (CT) can be used to identify patient-specific anatomic risk of high-degree AV block and permanent pacemaker (PPM) implantation before transcatheter aortic valve implantation (TAVI) with self-expandable valves.nnnBACKGROUNDnMS length represents an anatomic surrogate of the distance between the aortic annulus and the bundle of His and may therefore be inversely related to the risk of conduction system abnormalities after TAVI.nnnMETHODSnSeventy-three consecutive patients with severe aortic stenosis underwent contrast-enhanced CT before TAVI. The aortic annulus, aortic valve, and AV junction were assessed, and MS length was measured in the coronal view.nnnRESULTSnIn 13 patients (18%), high-degree AV block developed, and 21 patients (29%) received a PPM. Multivariable logistic regression analysis revealed MS length as the most powerful pre-procedural independent predictor of high-degree AV block (odds ratio [OR]: 1.35, 95% confidence interval [CI]: 1.1 to 1.7, p = 0.01) and PPM implantation (OR: 1.43, 95% CI: 1.1 to 1.8, p = 0.002). When taking into account pre- and post-procedural parameters, the difference between MS length and implantation depth emerged as the most powerful independent predictor of high-degree AV block (OR: 1.4, 95% CI: 1.2 to 1.7, p < 0.001), whereas the difference between MS length and implantation depth and calcification in the basal septum were the most powerful independent predictors of PPM implantation (OR: 1.39, 95% CI: 1.2 to 1.7, p < 0.001 and OR: 4.9, 95% CI: 1.2 to 20.5, p = 0.03; respectively).nnnCONCLUSIONSnShort MS, insufficient difference between MS length and implantation depth, and the presence of calcification in the basal septum, factors that may all facilitate mechanical compression of the conduction tissue by the implanted valve, predict conduction abnormalities after TAVI with self-expandable valves. CT assessment of membranous septal anatomy provides unique pre-procedural information about the patient-specific propensity for the risk of AV block.

Sex differences in aortic root and vascular anatomy in patients undergoing transcatheter aortic valve implantation: A computed-tomographic study

BACKGROUNDnVery little data exist on the impact of sex on aortic and arterial anatomy as relevant for transcatheter aortic valve implantation (TAVI).nnnOBJECTIVEnTo investigate whether patients with severe aortic stenosis (AS) referred for TAVI display sex-specific differences in aortic root and ilio-femoral artery size.nnnMETHODSnIn 506 patients referred for pre-procedural CT evaluation before TAVI we performed a detailed assessment of aortic root anatomy: size of the annulus and the sinus of Valsalva (SoV), diameter of the sino-tubular junction (STJ), and distance of the coronary artery ostia to the aortic annulus plane; we also determined the dimensions of aorta, subclavian, and ilio-femoral arteries.nnnRESULTSnWomen had significantly smaller aortic root dimensions (annulus mean diameter: 22.9xa0±xa02.2xa0mm vs. 25.7xa0±xa02.7xa0mm, SoV mean diameter: 31.8xa0±xa04.2xa0mm vs. 36.3xa0±xa03.8xa0mm, STJ mean diameter: 26.3xa0±xa03.4xa0mm vs. 29.8xa0±xa04.2xa0mm) and lower left and right coronary artery ostia take-off (12.3xa0±xa02.4 vs. 14.1xa0±xa02.9xa0mm; 14.8xa0±xa02.6 vs. 17.1xa0±xa03.2xa0mm, respectively) than men (Pxa0<xa00.001 for all), even after adjustment for their smaller body surface area (BSA) and height. Dimensions of the ascending aorta, subclavian and ilio-femoral arteries were also significantly smaller in women, but not when adjusted for BSA.nnnCONCLUSIONSnWomen with severe AS had smaller aortic root dimensions even after correcting for their smaller body size and height, reflecting a sex-specific difference. In contrast, sex-related differences in aortic, subclavian, and ilio-femoral dimensions were fully explained by the smaller BSA of women.

Impact of Renal Dysfunction on Results of Transcatheter Aortic Valve Replacement Outcomes in a Large Multicenter Cohort

Patients with advanced chronic renal dysfunction were excluded from randomized trials of transcatheter aortic valve replacement (TAVR). The potential impact of chronic renal disease on TAVR prognosis is not fully understood. We aim to evaluate outcomes within a large cohort of patients who underwent TAVR distinguished by renal function. Baseline characteristics, procedural data, and clinical follow-up findings were collected from 10 high-volume TAVR centers in Europe, Israel, and Japan. Data were analyzed according to renal function. Patients (nxa0= 1,204) were divided into 4 groups according to pre-TAVR-estimated glomerular filtration rate (eGFR): group I (eGFR >60), nxa0= 288 (female 45%), group II (eGFR 31 to 60), nxa0= 452 (female 61%), group III (eGFR ≤30), nxa0= 398 (female 61%), and group IV (dialysis), nxa0= 66 (female 31%). Mean Society of Thoracic Surgeons score was higher in patients with lower preprocedural eGFR. All-cause mortality at 1 year was higher in patients with lower eGFR (9.0%, 12.1%, 24.3%, and 24.2% for group I, II, III, and IV, respectively, p <0.001). Multivariate analysis demonstrated that eGFR ≤30, but not eGFR 31 to 60, was associated with increased risk of death (odds ratio 3), bleeding (odds ratio 5.2), and device implantation failure (hazard ratio 2.28). For each 10 ml/min decrease in eGFR, there was an associated relative increase in the risk of death (35%; p <0.001), cardiovascular death (14%; pxa0= 0.018), major bleeding 35% (p <0.001), and transcatheter valve failure (16%; pxa0= 0.007). Renal dysfunction was not associated with stroke or need for pacemaker implantation. In conclusion, among patients who underwent TAVR, baseline renal dysfunction is an important independent predictor of morbidity and mortality.

Coronary CT angiography for the detection of coronary artery stenosis in patients referred for transcatheter aortic valve replacement

BACKGROUNDnCoronary CT has become the foremost noninvasive imaging modality for detecting coronary stenoses in patients with suspected coronary artery disease. Nevertheless, little is known about its performance in patients undergoing transcatheter aortic valve replacement (TAVR).nnnOBJECTIVEnThis study investigates the diagnostic performance of coronary CT angiography in patients referred for TAVR.nnnMETHODSnOne hundred and fifteen consecutive patients with severe aortic stenosis underwent CT angiography with retrospective electrocardiography triggered acquisition and an iterative reconstruction algorithm, of whom 23 (20%) had prior coronary artery bypass graft (CABG) surgery. Diagnostic accuracy of CT for detecting significant coronary stenosis (≥ 50% luminal diameter stenosis in segments ≥ 2 mm) in the left main, proximal, or middle segments of coronary arteries and bypass grafts was compared with that of invasive coronary angiography.nnnRESULTSnIn the overall study population, the sensitivity, specificity, and positive and negative predictive value of CT angiography for the detection of coronary segment or bypass graft lesions were 96% (47 of 49), 73% (48 of 66), 72% (47 of 65), and 96% (48 of 50), respectively. The per-patient diagnostic yield of CT angiography was consistent among patients without prior CABG (93% [28 of 30], 73% [45 of 62], 62% [28 of 45], and 96% [45 of 47], respectively) and among patients with prior CABG (100% [19 of 19], 75% [3 of 4], 95% [19 of 20], and 100% [3 of 3], respectively).nnnCONCLUSIONnAmong patients referred for TAVR, coronary CT angiography with retrospective gating and iterative reconstruction may allow detection of significant stenosis in the proximal or middle segments of coronary arteries and could permit the evaluation of patients after bypass grafts.

Usefulness of pre- versus postadmission cardiogenic shock during acute myocardial infarction in predicting survival☆

pigments: biliverdin and bilirubin. Methods Enzymol 1990;186:301–309. 6. Neuzil J, Stocker R. Bilirubin attenuates radical-mediated damage to serum albumin. FEBS Lett 1993;331:281–284. 7. Cao G, Alessio HM, Cutler RG. Oxygen-radical absorbance capacity assay for antioxidants. Free Radic Biol Med 1993;14:303–311. 8. Farrera JA, Jauma A, Ribo JM, Peire MA, Parellada PP, Roques-Choua S, Bienvenue E, Seta P. The antioxidant role of bile pigments evaluated by chemical tests. Bioorg Med Chem 1994;2:181–185. 9. Wu TW, Fung KP, Yang CC. Unconjugated bilirubin inhibits the oxidation of human low-density lipoprotein better than trolox. Life Sci 1994;54:P477–P481. 10. Wu TW, Carey D, Wu J, Sugiyama H. The cytoprotective effects of bilirubin and biliverdin on rat hepatocytes and human erythrocytes and the impact of albumin. Biochem Cell Biol 1991;69:828–834. 11. Wu TW, Wu J, Li RK, Mickle D, Carey D. Albumin-bound bilirubins protect human ventricular myocytes against oxyradical damage. Biochem Cell Biol 1991;69:683–688. 12. Neuzil J, Stocker R. Free and albumin-bound bilirubin are efficient coantioxidants for alpha-tocopherol, inhibiting plasma and low density lipoprotein lipid peroxidation. J Biol Chem 1994;269:16712–16719. 13. Hopkins PN, Wu LL, Hunt SC, James BC, Vincent GM, Williams RR. Higher serum bilirubin is associated with decreased risk for early familial coronary artery disease. Arterioscler Thromb Vasc Biol 1996;16:250–255. 14. Levinson SS. Relationship between bilirubin, apolipoprotein B, and coronary artery disease. Ann Clin Lab Sci 1997;27:185–92. 15. Schwertner HA, Jackson WG, Tolan G. Association of low serum concentration of bilirubin with increased risk of coronary artery disease. Clin Chem 1994;40:18–23. 16. Kannel WB, Feinleib M, McNamara PM, Garrison RJ, Castelli WP. An investigation of coronary heart disease in families. The Framingham Offspring Study. Am J Epidemiol 1979;110:281–290. 17. Gordon T, Kannel WB. Premature mortality from coronary heart disease: the Framingham Study. JAMA 1971;215:1617–1625. 18. Abell LL, Levy BB, Brodie BB, Kendall FE. A simplified method or estimation of total cholesterol in serum and demonstration of its specificity. J Biol Chem 1952;195:357–366. 19. Wu TW, Fung KP, Wu J, Yang CC, Weisel RD. Antioxidant of human low density lipoprotein by unconjugated and conjugated bilirubins. Biochem Pharmacol 1996;51:859–862.

Vascular complications in steroid treated patients undergoing transfemoral aortic valve implantation

To assess the rate of Vascular complications in steroid treated patients undergoing transfemoral aortic valve implantation (TAVI).

Balloon dilatation and outcome among patients undergoing trans-femoral aortic valve replacement

BACKGROUNDnBalloon pre-dilatation before transcatheter aortic valve replacement (TAVR) is performed at the discretion of the treating physician. Clinical data assessing the implications of this step on procedural outcomes are limited.nnnMETHODSnWe conducted a retrospective analysis of 1164 consecutive TAVR patients in the Israeli multicenter TAVR registry (Sheba, Rabin, and Tel Aviv Medical Centers) between the years 2008 and 2014. Patients were divided to those who underwent balloon pre-dilation (n=1026) versus those who did not (n=138).nnnRESULTSnRates of balloon pre-dilation decreased from 95% in 2008-2011 to 59% in 2014 (p for trend=0.002). Baseline characteristics between groups were similar except for more smoking (22% vs. 8%, p=0.008), less past CABG (18% vs. 26%, p=0.016), less diabetes mellitus (35% vs. 45%, p=0.01), and lower STS mortality scores (5.2±3.7 vs. 6.1±3.5, p=0.006) in the pre-dilatation group. The pre-dilation group included less patients with moderate to severely depressed LVEF (7% vs. 16%, p<0.001) and higher aortic peak gradients (76.9±22.7mmHg vs. 71.4±24.3mmHg, p=0.01). Stroke rates were comparable in both groups (2.5% vs. 3%, p=0.8), but pre-dilation was associated with lower rates of balloon post-dilatation (9% vs. 26%, p<0.001). On multivariate analysis, balloon pre-dilatation was not a predictor of device success or any post-procedural complications (p=0.07).nnnCONCLUSIONSnBalloon pre-dilatation was not associated with procedural adverse events and may decrease the need for balloon post-dilatation. The results of the present study support the current practice to perform liberally balloon pre-dilatation prior to valve implantation.

Predictors of 1-Year Mortality After Transcatheter Aortic Valve Implantation in Patients With and Without Advanced Chronic Kidney Disease

Advanced chronic kidney disease (CKD) is an independent predictor of mortality in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to identify predictors of 1-year mortality in patients after TAVI stratified by the presence or absence of advanced CKD (defined as estimated glomerular filtration rate ≤30u2009ml/min/1.73u2009m2 or permanent renal replacement therapy). Patients (nu2009=u20091204) from 10 centers in Europe, Japan, and Israel were included: 464 with and 740 without advanced CKD. Advanced CKD was associated with a 2-fold increase in the adjusted risk of 1-year all-cause death (pu2009<0.001), and a 1.9-fold increase in cardiovascular death (pu2009=u20090.016). Interaction-term analysis was used to identify and compare independent predictors of 1-year mortality in both groups. Impaired left ventricular ejection fraction and poor functional class were predictive of death in the advanced CKD group (odds ratio [OR] 2.27, pu2009=u20090.002 and OR 3.87, pu2009=u20090.003, respectively) but not in patients without advanced CKD (p for interactionu2009=u20090.035 and 0.039, respectively), whereas bleeding was a predictor of mortality in the nonadvanced CKD group (OR 3.2, pu2009=u20090.005) but not in advanced CKD (p for interactionu2009=u20090.006). Atrial fibrillation was associated with a 2.2-fold increase (pu2009=u20090.032) in the risk of cardiovascular death in the advanced CKD group but not in the absence of advanced CKD (p for interactionu2009=u20090.022). In conclusion, the coexistence of advanced CKD and either reduced left ventricular ejection fraction or poor functional class has an incremental effect on the risk of death after TAVI. In contrast, bleeding had a greater effect on risk of death in patients without advanced CKD.