Maciej Bagienski

Impact of frailty on mortality after transcatheter aortic valve implantation

Background We sought to investigate the relation between frailty indices and 12‐month mortality after transcatheter aortic valve implantation (TAVI). Methods We included 101 consecutive patients with severe aortic stenosis who have undergone TAVI. Frailty indices according to Valve Academic Research Consortium‐2 recommendations (5‐m walk test [5MWT] and hand grip strength) as well as other available scales of frailty (Katz index, Elderly Mobility Scale [EMS], Canadian Study of Health and Aging [CSHA] scale, Identification of Seniors at Risk [ISAR] scale) were assessed at baseline. The primary endpoint was 12‐month all‐cause mortality. Results Twelve‐month all‐cause mortality was 17.8%. According to 5MWT, 17.8% were frail; hand grip test: 6.9%; Katz index: 17.8%; EMS: 7.9%; CSHA scale: 16.9%; and ISAR scale: 52.5%. Associations between frailty indices and 12‐month all‐cause mortality after TAVI were significant in Cox regression analysis (frail vs not frail, presented as hazard ratio[95%CI] adjusted for logistic EuroSCORE): for 5MWT, 72.38 (15.95‐328.44); for EMS, 23.39 (6.89‐79.34); for CSHA scale, 53.97 (14.67‐198.53); for Katz index, 21.69 (6.89‐68.25); for hand grip strength, 51.54 (12.98‐204.74); and for ISAR scale, 15.94 (2.10‐120.74). Similarly, such relationship was confirmed when 5MWT, EMS, and CSHA were used as continuous variables (hazard ratio [95%CI] adjusted for logistic EuroSCORE: for 5MWT per 1‐second increase, 2.55 [1.94‐3.37]; for EMS per 1‐point decrease, 2.90 (1.99‐4.21); and for CSHA per 1‐point increase, 3.13 [2.17‐4.53]). Conclusions Our study confirmed a strong predictive ability of most of the proposed frailty indices for 12‐month mortality after TAVI. For patients scheduled for TAVI, the use of frailty indices, which are easy and quick to assess on clinical basis but with strong performance, for example, 5MWT, EMS, or hand grip test, may be advocated.

Short- and intermediate-term improvement of patient quality of life after transcatheter aortic valve implantation: a single-centre study

BACKGROUND Transcatheter aortic valve implantation (TAVI) is a treatment option for elderly high-risk patients with symptomatic severe aortic stenosis. Improvement of quality of life (QoL) is a relevant issue in this group of patients. AIM To assess changes in QoL after TAVI. METHODS Forty patients who underwent TAVI in our institution were included in this QoL study. All subjects were screened for TAVI in a standard fashion, including QoL assessment with the EQoL (EQ-5D-3L). The pre- and postprocedural scores obtained up to a 12-month follow-up were assessed. RESULTS Median of logistic EuroScore I was 21.5% (13.5-26.75%), and Society of Thoracic Surgeons score was 5.5% (4.0-10.75%). Comparison of baseline values with follow-up data at one, six and 12 months after TAVI showed significant improvement of QoL (p < 0.001). Visual Analogue Scale score (VAS score) was assessed. There was an incremental increase in VAS score during follow-up (p < 0.001). Median of six-minute walk test distance at baseline was 200 m (IQR 150-300) and 325 m (IQR 250-400) 12 months after TAVI (p < 0.001). CONCLUSIONS TAVI provides improved QoL and effectively relieves symptoms.

Early- and mid-term outcomes after transcatheter aortic valve implantation. Data from a single-center registry

Introduction Transcatheter aortic valve implantation (TAVI) is a less invasive treatment option for elderly, high-risk patients with symptomatic severe aortic stenosis (AS) than aortic valve replacement. More importantly, TAVI improves survival and quality of life as compared to medical treatment in inoperable patients. Aim To assess early- and mid-term clinical outcomes after TAVI. Material and methods All consecutive high-risk patients with severe symptomatic AS undergoing TAVI from November 2008 to August 2014 were enrolled. The clinical and procedural characteristics, as well as clinical outcomes including mortality during 12-month follow-up, were assessed. Results A total of 101 consecutive patients underwent TAVI for native aortic valve stenosis (100%). Patients were elderly, with a median age of 81.0 (76.0–84.0) years, 60.4% were female and 83.2% presented with NYHA III/IV. Median baseline EuroSCORE I and STS scores were 14.0 (10.0–22.5)% and 12.0 (5.0–24.0)%, respectively. The main periprocedural and in-hospital complications were minor vascular complications, bleeding requiring blood transfusions, and the need for a permanent pacemaker. In-hospital, 30-day, 6-month and 12-month mortality rates were 6.9%, 10.9%, 15.8% and 17.8%, respectively. Conclusions A mortality rate of < 20% after 12 months seems acceptable given the high-risk population enrolled.

Association Between Blood Transfusions and 12-Month Mortality After Transcatheter Aortic Valve Implantation

Blood transfusions are considered as an important predictor of adverse outcome in patients with severe aortic (AS) undergoing transcatheter aortic valve implantation (TAVI). We sought to investigate the association between blood transfusions and mortality after TAVI. We enrolled 101 consecutive patients with severe AS undergoing TAVI. Patients who required transfusion were defined as patients in whom at least one unit of packed red blood cells (PRBCs) was transfused in the perioperative period. Twelve-month outcomes were assessed based on Valve Academic Research Consortium definitions. A total of 28 (27.7%) patients required blood transfusion after TAVI. Baseline characteristics of the patients with and without a transfusion were similar. Median amount of PRBCs was 2 (interquartile range, 2-4). Twelvemonth all-cause mortality was higher in patients with than without a blood transfusion (39.3% versus 9.6%; P = 0.001). Importantly, the need for a blood transfusion after TAVI was an independent predictor of higher mortality rates after 12 months (hazard ratio (HR) 2.84 95%CI (1.06-7.63); P = 0.039; (HR for incomplete coronary revascularization 10.86, 95%CI 3.72-31.73; P < 0.001; HR for a history of stroke/TIA 3.93, 95%CI 1.39-11.07; P < 0.001). The duration of inhospital stay was longer in patients requiring transfusion (16.0 (14.0-22.0) versus 7.0 (7.0-11.5) days; P = 0.014). In conclusion, blood transfusions after TAVI were associated with higher mortality rates after 12 months, longer in-hospital stay, and were identified as an independent predictor of impaired clinical outcome.

Twelve-Month Quality of Life Improvement and All-Cause Mortality in Elderly Patients Undergoing Transcatheter Aortic Valve Replacement:

Purpose Restoration of quality of life (QoL) and improvement of clinical outcomes is crucial in elderly patients undergoing transcatheter aortic valve implantation (TAVI). We sought to evaluate changes in QoL and all-cause mortality 12 months after TAVI. Methods A total of 101 patients who underwent TAVI were included. Patients were followed for 12 months. QoL was assessed at baseline and at 1, 6 and 12 months after TAVI using EQ-5D-3L with a visual analog scale (VAS). Results Patients who reported some problems with mobility at baseline showed better mobility after 12 months (p = 0.001). On the other hand, those who reported issues with self-care, usual activity or pain did not show significant improvement (p = 0.41; p = 0.12; p = 0.27, respectively). Patients reporting anxiety at baseline improved 12 months later (p = 0.003). VAS score showed an incremental increase during follow-up (p<0.001). Transfemoral access was associated with higher VAS score values after 1 month (median (IQR): 65.0 (50.0–75.0) vs. 54.0 (50.0–60.0); p = 0.019) but not after 12 months (70.0 (62.5–80.0) vs. 67.5 (55.0–70.0); p = 0.07) as compared to non-transfemoral access. In multivariable regression analysis, only age and the presence of coronary chronic total occlusion were independently associated with VAS score at 12 months. In-hospital, 1-, 6- and 12-month mortality rates were 6.9%, 10.9%, 15.8 and 17.8%, respectively. Conclusions TAVI provides improved QoL with relatively good clinical outcomes. However, not all components of QoL may be improved. Patients treated with transfemoral access might have better QoL than those who had non-transfemoral access, especially early after TAVI.

Incidence of Postoperative Delirium and Its Impact on Outcomes After Transcatheter Aortic Valve Implantation

There are limited data on the occurrence of postoperative delirium after transcatheter aortic valve implantation (TAVI). We sought to investigate the incidence of delirium after TAVI and its impact on clinical outcomes. A total of 148 consecutive patients who underwent TAVI were enrolled. Of these patients, 141 patients survived hospital stay. The incidence of delirium was assessed in these patients for the first 4 days after the index procedure. The patients were divided into 2 groups based on the presence of delirium. Baseline characteristics, procedural and long-term outcomes, and frailty and quality-of-life indexes were compared among the groups. Of the 141 patients analyzed, 29 patients developed delirium. The transapical access was more common in patients with delirium (51.7% vs 8.9%, p <0.001). A greater median contrast volume load in the delirium group was noted (75 vs 100 ml, p = 0.001). Significantly more patients with delirium were considered as frail before TAVI. Thirty-day and 12-month all-cause mortality rates were higher in the delirium group (0.0% vs 17.2%, p <0.001; and 3.6% vs 37.9%, p <0.001, respectively). Differences in mortality were significant even after adjustment for baseline characteristics. The quality of life at 12 months, assessed by the 3-level version of the EuroQol 5-dimensional questionnaire, was similar in both groups. Despite a relatively minimally invasive character of TAVI as compared with surgery, some patients experience delirium after TAVI. Importantly, the occurrence of delirium after TAVI may help to identify patients with worse short- and long-term outcomes.

Impact of Coronary Artery Disease Burden on 12-Month Mortality of Patients After Transcatheter Aortic Valve Implantation

OBJECTIVES The aim of the study was to compare 12-month mortality rate of patients with and without complete coronary revascularization before transcatheter aortic valve implantation (TAVI). BACKGROUND There are limited data on the impact of coronary artery disease burden in patients with severe aortic stenosis undergoing TAVI. METHODS One hundred and one consecutive patients undergoing TAVI were enrolled. Of them 16 (15.8%) had an incomplete coronary revascularization. The primary endpoint was 12-month all-cause mortality. RESULTS Twelve-month all-cause mortality was higher in patients with incomplete coronary revascularization than in patients with complete coronary revascularization or without significant lesions (75.0% vs 7.1%; P < 0.001). Importantly, incomplete coronary revascularization was an independent predictor of higher mortality rate after 12 months (hazard ratio (HR) for incomplete coronary revascularization 10.86, 95% CI 3.72-31.73; P < 0.001; HR for a history of stroke/TIA 3.93, 95% confidence interval (CI) 1.39-11.07; P < 0.001; HR for blood transfusion 2.84 95% CI (1.06-7.63); P = 0.039). In 9 of 16 (56.3%) patients, incomplete revascularization was related to the presence of chronic total occlusions (CTO). Patients with CTO had an increased mortality rate after 12 months (55.6% vs 14.1%; P = 0.008) as compared to patients without the CTO. CONCLUSIONS Incomplete coronary revascularization and a history of stroke or TIA may be independent predictors of all-cause mortality in patients undergoing TAVI. However, further studies are recommended to confirm the results, especially in terms of the impact of CTO presence on long-term mortality after TAVI.

Usefulness of Psoas Muscle Area and Volume and Frailty Scoring to Predict Outcomes After Transcatheter Aortic Valve Implantation

Numerous scales were implemented for frailty assessment. However, limited evidence and recommendations for frailty tools for everyday clinical practice in patients who underwent transcatheter aortic valve implantation (TAVI) exist. Thus, we aimed to determine the long-term predictive value of different frailty scores and objective assessment of sarcopenia by imaging techniques in patients after TAVI. Frailty indexes according to Valve Academic Research Consortium-2 (VARC-2) recommendations, as well as other available scales of frailty, were assessed at baseline. Sarcopenia was evaluated with psoas muscle area (PSA) and psoas muscle volume (PSV) using computed tomography (CT) scans. The primary end point was 12-month all-cause mortality. We enrolled 153 patients who underwent TAVI with analyzable CT scans and complete frailty data. The median of PSA normalized for body surface area was 2,581.1 (2,214.9 to 2,654.9) mm2/m2, and the median of normalized PSV was 338.8 (288.1-365.6) cc/m2. At 12 months, all-cause mortality and new-onset atrial fibrillation were highest in the lowest tertile of normalized PSA. In the receiver operating characteristic analysis, all the tested frailty indexes, as well as PSA and PSV, were good predictors of 12-month all-cause mortality after TAVI with the highest area under the curve value for PSA and PSV normalized for body surface area. In conclusion, normalized PSA and PSV values are strong predictors of long-term mortality after TAVI. CT evaluation of psoas muscles could be incorporated to preprocedural comprehensive clinical models used for prediction of outcomes in patients scheduled for TAVI.

Acute myocardial infarction in a patient with chronic renal failure and endocarditis

We report a case of a 55 year-old female with chronic renal failure who received routine haemodialysis and suffered from acute myocardial infarction of inferior wall. Based on coronary angiogram, transoesophageal echocardiography, and autopsy,coronary embolisation with vegetations in the course of infective endocarditis was identified as a rare cause of ST-segment elevation myocardial infarction.

Sex-related differences in clinical outcomes and quality of life after transcatheter aortic valve implantation for severe aortic stenosis

Introduction There are inconsistent data on the sex-related differences in clinical outcomes and quality of life (QoL) after transcatheter aortic valve implantation (TAVI). Aim We sought to investigate sex-related differences in procedural, clinical and QoL outcomes of TAVI. Material and methods A total of 101 consecutive patients undergoing TAVI were enrolled. Patients were stratified by gender. Baseline characteristics, procedural and long-term clinical outcomes as well as frailty and QoL indices (EQ-5D-3L questionnaire) were compared between women and men. Results Women represented 60.4% of the study population. Periprocedural risk measured with the Logistic EuroSCORE and STS scale was similar for women and men. There were no differences in 30-day or 12-month all-cause mortality between groups (women vs. men: 9.8% vs. 12.5%; age-adjusted odds ratio (OR) (95% CI): 1.38 (0.39–4.94); 13.1% vs. 25.0%; age-adjusted OR (95% CI): 2.51 (0.87–7.25)). Men were at higher risk of new onset atrial fibrillation at follow-up (1.6% vs. 17.5%; age-adjusted OR (95% CI): 14.61 (1.68–127.37)). In multivariable Cox regression analysis, a history of stroke/transient ischemic attack (TIA) (hazard ratio (HR)) (95% CI): 3.93 (1.39–11.07) and blood transfusion (HR (95% CI): 2.84 (1.06–7.63)) were identified as independent factors affecting 12-month mortality. No differences in QoL parameters were noted. Conclusions The TAVI can be considered as an effective and safe treatment in high-risk patients with severe aortic stenosis, regardless of gender.