Kazuki Mizutani

Relation of Aortic Arch Complex Plaques to Risk of Cerebral Infarction in Patients With Aortic Stenosis

Aortic stenosis (AS) and systemic atherosclerosis have been shown to be closely related. We evaluated the prevalence of aortic arch plaques and their possible association with the risk of cerebral infarction in patients with severe AS. Transesophageal echocardiography was performed in 116 patients with severe AS (55 men, mean age 71 ± 7 years, mean aortic valve area 0.68 ± 0.15 cm(2)) who were scheduled for aortic valve replacement. The presence, thickness, and morphology of the aortic arch plaques were evaluated using transesophageal echocardiography. Cerebral infarcts (chronic cerebral infarction and cerebral infarction after cardiac catheterization and aortic valve replacement) were assessed in all patients. Compared to age- and gender-matched control subjects, the patients with severe AS had a significantly greater prevalence of aortic arch plaques (74% vs 41%; p <0.0001) and complex arch plaques such as large plaques (≥4 mm), ulcerated plaques, or mobile plaques (30% vs 10%; p = 0.004). Multivariate logistic analyses showed that the presence of complex arch plaques was independently associated with cerebral infarction in patients with AS after adjusting for traditional atherosclerotic risk factors and coronary artery disease (odds ratio 8.46, 95% confidence interval 2.38 to 30.12; p = 0.001). In conclusion, the results from the present study showed that there is a greater prevalence of aortic arch plaques in patients with AS and that the presence of complex plaques is independently associated with cerebral infarction in these patients. Therefore, the identification of complex arch plaques using transesophageal echocardiography is important for risk stratification of cerebrovascular events in patients with severe AS.

Gait speed can predict advanced clinical outcomes in patients who undergo transcatheter aortic valve replacement insights from a Japanese multicenter registry

Background— Gait speed reflects an important factor of frailty and is associated with an increased risk of late mortality in patients with cardiac disease. This study sought to assess the prognostic value of gait speed in elderly patients who underwent transcatheter aortic valve replacement. Methods and Results— We investigated the 5-m or 15-feet gait speed (m/sec) in 1256 patients who underwent transcatheter aortic valve implantation using data from the OCEAN-TAVI Japanese multicenter registry (Optimized Catheter Valvular Intervention–Transcatheter Aortic Valve Implantation). Baseline characteristics, procedural outcomes, and all-cause mortality were compared among groups defined by differential gait speed classification: model 1, normal (>0.83 m/sec; n=563; 44.8%), slow (0.5–0.83 m/sec; n=429; 34.2%), slowest (<0.83 m/sec; n=205; 16.3%), unable to walk (n=48; 3.8%); and model 2, classification and regression tree survival model indicating the threshold of gait speed as 0.385 m/sec (>0.385 m/sec; n=1080 versus ⩽0.385 m/sec; n=117). The cumulative 1-year mortality rate showed significant differences in the classical gait speed groups in model 1 (7.6%, 6.6%, 18.2%, and 40.7%, respectively; P<0.001) and survival classification and regression tree group in model 2 (7.7% versus 21.9%; P<0.001). The slowest walkers and those unable to walk demonstrated independent associations with increased midterm mortality after adjustment for several confounding factors (hazard ratio, 1.83, 4.28; 95% confidence interval, 1.03–3.26, 2.22–8.72; P=0.039, <0.001, respectively). Gait speed <0.385 m/sec determined by classification and regression tree also independently associated with worse prognosis (hazard ratio, 2.40; 95% confidence interval, 1.75–5.88; P=0.001). Conclusions— Gait speed using both traditional and specific classification is useful as a potential marker for predicting vulnerable patients associated with adverse clinical outcomes after transcatheter aortic valve replacement.

Improving Outcomes of Witnessed Out‐of‐Hospital Cardiac Arrest After Implementation of International Liaison Committee on Resuscitation 2010 Consensus: A Nationwide Prospective Observational Population‐Based Study

Background The International Liaison Committee on Resuscitation (ILCOR) periodically updates the consensus recommendations for cardiopulmonary resuscitation to improve the outcomes of out‐of‐hospital cardiac arrest (OHCA). However, little is known about the differences in outcomes of witnessed OHCA following the publication of the ILCOR 2010 and the ILCOR 2005 recommendations. Methods and Results We enrolled 241 990 adults who experienced witnessed OHCA between 2007 and 2013 from a prospective, nation‐wide, population‐based cohort database in Japan. We compared neurologically favorable 1‐month survival and 1‐month survival rates post‐OHCA by dividing the study period into 2 categories: the ILCOR 2005 period and ILCOR 2010 period. The associations between guideline periods and outcomes were estimated using multivariable logistic regression analysis and reported as adjusted odds ratio and 95% CI. Among 241 990 patients examined in this study, OHCA was witnessed in 44 706 patients (18%) by emergency medical service personnel and in 197 284 patients (82%) by citizens. Compared with the ILCOR 2005 period, the neurologically favorable 1‐month survival rate improved from 4.6% to 5.2% (adjusted odds ratio, 1.54; 95% CI, 1.42–1.67; P<0.001), and the 1‐month survival rate improved from 9.0% to 9.7% (adjusted odds ratio, 1.34; 95% CI, 1.27–1.42; P<0.001) in the ILCOR 2010 period. These improvements were also shown in patients receiving conventional versus compression‐only cardiopulmonary resuscitation. Conclusions Outcomes of witnessed OHCA were better in the ILCOR 2010 period than those in the ILCOR 2005 period. Our results can provide baseline data for many future prospective studies.

Elevation of B-type natriuretic peptide at discharge is associated with 2-year mortality after transcatheter aortic valve replacement in patients with severe aortic stenosis: Insights from a multicenter prospective OCEAN-TAVI (Optimized Transcatheter Valvular Intervention-Transcatheter Aortic Valve Implantation) registry

Background In this study, we sought to investigate the 2‐year prognostic impact of B‐type natriuretic peptide (BNP) levels at discharge, following transcatheter aortic valve replacement. Methods and Results We enrolled 1094 consecutive patients who underwent transcatheter aortic valve replacement between 2013 and 2016. Study patients were stratified into 2 groups according to survival classification and regression tree analysis (high versus low BNP groups). We evaluated the impact of high BNP on 2‐year mortality compared with that of low BNP using a multivariable Cox model, and assessed whether this stratification would improve predictive accuracy for determining 2‐year mortality by assessing time‐dependent net reclassification improvement and integrated discrimination improvement. The median age of patients was 85 years (quartile 82–88), and 29.2% of the study population were men. The median Society of Thoracic Surgeons score was 6.8 (4.7–9.5), and BNP at discharge was 186 (93–378) pg/mL. All‐cause mortality following discharge was 7.9% (95% CI, 5.8–9.9%) at 1 year and 15.4% (95% CI, 11.6–19.0%) at 2 years. The survival classification and regression tree analysis revealed that the discriminating BNP level to discern 2‐year mortality was 202 pg/mL, and that elevated BNP had a statistically significant impact on outcomes, with an adjusted hazard ratio of 2.28 (1.36–3.82, P=0.002). The time‐dependent net reclassification improvement (P=0.047) and integrated discrimination improvement (P=0.029) analysis revealed that the incorporation of BNP stratification with other clinical variables significantly improved predictive accuracy for 2‐year mortality. Conclusions Elevation of BNP at discharge is associated with 2‐year mortality after transcatheter aortic valve replacement.

Importance of Geriatric Nutritional Risk Index assessment in patients undergoing transcatheter aortic valve replacement

Background Nutritional condition is one marker of patients’ frailty. The Geriatric Nutritional Risk Index (GNRI) is a well‐known marker of nutritional status. This study sought to assess the clinical outcomes of GNRI after transcatheter aortic valve replacement (TAVR). Methods We evaluated the GNRI value of 1,613 patients who underwent TAVR using data from a Japanese multicenter registry. According to baseline GNRI, patients were classified into 3 groups: GNRI ≥92 (n = 1,085; 67.3%), GNRI 82‐92 (n = 396; 24.6%), and GNRI ≤82 (n = 132; 8.2%). Baseline characteristics, procedural outcomes, and cumulative mortality rates were compared. In addition, GNRI correlations with other frailty components (gait speed, grip strength, and Clinical Frailty Scale) and Society of Thoracic Surgeons (STS) score were also evaluated. Results Significantly increased mortality rates were observed across the 3 groups at 30 days (0.9%, 2.3%, and 6.8%, respectively; P < .001) and 1 year (6.5%, 16.4%, and 36.4%, respectively; P < .001). Both GNRI 82‐92 and GNRI ≤82 (as a reference for GNRI ≥92) were independently associated with increased midterm mortality in the Cox regression multivariate model (hazard ratio: 1.97, 3.60; 95% confidence interval: 1.37‐2.84, 2.30‐5.64; P < .001, P < .001, respectively). The GNRI value was significantly correlated with gait speed (Spearman &rgr; = −0.15, P < .001), grip strength (&rgr; = 0.25, P < .001), Clinical Frailty Scale (&rgr; = −0.24, P < .001), and STS score (&rgr; = −0.29, P < .001). Conclusions GNRI is related to both frailty components and the STS score and is an important surrogate marker for predicting worse clinical outcomes after TAVR. Assessment of the GNRI may be considered when deciding on TAVR.

Echocardiographic parameters predicting acute hemodynamically significant mitral regurgitation during transfemoral transcatheter aortic valve replacement

Alteration in mitral valve morphology resulting from retrograde stiff wire entanglement sometimes causes hemodynamically significant acute mitral regurgitation (MR) during transfemoral transcatheter aortic valve replacement (TAVR). Little is known about the echocardiographic parameters related to hemodynamically significant acute MR.

Intravascular findings of fibromuscular dysplasia on optical coherence tomography

We present the case of a 29-year-old woman with right renal artery stenosis caused by fibromuscular dysplasia (FMD) who underwent optical coherence tomography (OCT)-guided percutaneous transluminal renal angioplasty. Using OCT, we could clearly observe intimal fibroplasia and medial hyperplasia that was indicative of FMD. Based on diagnosis of FMD by OCT, this patient was treated with plain old balloon angioplasty that resulted in adequate luminal opening without intimal dissection confirmed on final angiography and OCT. <Learning objective: Fibromuscular dysplasia (FMD) is most often diagnosed based on its characteristic appearance on angiography but it is insufficient. Although pathological examination is needed for definite diagnosis, it is not realistic. Therefore, it is important to assess the detailed intravascular findings of culprit and non-culprit lesions in FMD with optical coherence tomography.>.

Arterial inflow line equipped with a side arm for circulatory support and catheter insertion during transcatheter aortic valve implantation for limited vascular access

Transcatheter aortic valve implantation was performed on a 78-year-old patient. Elective circulatory support with cardiopulmonary bypass was planned because of left ventricular function impairment and hemodynamic instability. Limited vascular access was due to a severe atherosclerotic aorta distal to the origin of the left carotid artery. The right arm was the only safe vascular access site. However, at least 2 vascular access sites for angiographic catheter and inflow of circulatory support were required. An arterial inflow line equipped with a side arm was developed to enable single access to the right axillary artery to be used for the above purposes.

Risk stratification using lean body mass in patients undergoing transcatheter aortic valve replacement

The prognostic impact of skeletal muscle mass, assessed using lean body mass (LBM), remain unclear in patients who underwent transcatheter aortic valve replacement (TAVR). The aim of this study to assess prognostic impact of LBM on mortality after TAVR.

Is elevation of N-terminal pro-B-type natriuretic peptide at discharge associated with 2-year composite endpoint of all-cause mortality and heart failure hospitalisation after transcatheter aortic valve implantation? Insights from a multicentre prospective OCEAN-TAVI registry in Japan

Objectives The aim of this study was to investigate the 2-year prognostic impact of N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels at discharge following transcatheter aortic valve implantation (TAVI). Design Multicentre prospective observational study. Settings Seven institutions from multicentre, observational registry of symptomatic patients with severe aortic stenosis who undergo TAVI. Participants We enrolled 500 consecutive patients who underwent TAVI with measurements of NT-proBNP at discharge between 2013 and 2016. Study patients were stratified into two groups according to survival classification and regression tree (CART) analysis: high versus low NT-proBNP groups. Interventions The impact of high NT-proBNP on a 2-year composite endpoint consisting of all-cause mortality and heart failure hospitalisation was evaluated using a multivariable Cox model. Results Median age was 86 years (quartile 82–89), and 24.2% of the study population were men. Median Society of Thoracic Surgeon score was 7.1 (5.1–9.8), and NT-proBNP at discharge was 1381 (653–3136) pg/mL. The composite endpoint incidence was 13.0% (95% CI 9.5% to 16.3%) at 1 year and 22.3% (95% CI 16.1%–27.9%) at 2 years. The survival CART analysis revealed that the NT-proBNP level required to discern the 2-year composite endpoint was 4288 pg/mL. Elevated NT-proBNP had a statistically significant impact on outcomes, with adjusted HR of 2.21 (95% CI 1.21 to 4.04, p=0.010), and with a significant sex difference (P for interaction=0.003). Conclusion Elevation of NT-proBNP at discharge is associated with higher incidence of the 2-year composite endpoint after TAVI. Trial registration number 000020423