Neil Moat

Long-term outcomes after transcatheter aortic valve implantation in high-risk patients with severe aortic stenosis: the U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) Registry.

OBJECTIVESnThe objective was to define the characteristics of a real-world patient population treated with transcatheter aortic valve implantation (TAVI), regardless of technology or access route, and to evaluate their clinical outcome over the mid to long term.nnnBACKGROUNDnAlthough a substantial body of data exists in relation to early clinical outcomes after TAVI, there are few data on outcomes beyond 1 year in any notable number of patients.nnnMETHODSnThe U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) Registry was established to report outcomes of all TAVI procedures performed within the United Kingdom. Data were collected prospectively on 870 patients undergoing 877 TAVI procedures up until December 31, 2009. Mortality tracking was achieved in 100% of patients with mortality status reported as of December 2010.nnnRESULTSnSurvival at 30 days was 92.9%, and it was 78.6% and 73.7% at 1 year and 2 years, respectively. There was a marked attrition in survival between 30 days and 1 year. In a univariate model, survival was significantly adversely affected by renal dysfunction, the presence of coronary artery disease, and a nontransfemoral approach; whereas left ventricular function (ejection fraction <30%), the presence of moderate/severe aortic regurgitation, and chronic obstructive pulmonary disease remained the only independent predictors of mortality in the multivariate model.nnnCONCLUSIONSnMidterm to long-term survival after TAVI was encouraging in this high-risk patient population, although a substantial proportion of patients died within the first year.

Inadequacy of existing clinical prediction models for predicting mortality after transcatheter aortic valve implantation

Background The performance of emerging transcatheter aortic valve implantation (TAVI) clinical prediction models (CPMs) in national TAVI cohorts distinct from those where they have been derived is unknown. This study aimed to investigate the performance of the German Aortic Valve, FRANCE‐2, OBSERVANT and American College of Cardiology (ACC) TAVI CPMs compared with the performance of historic cardiac CPMs such as the EuroSCORE and STS‐PROM, in a large national TAVI registry. Methods The calibration and discrimination of each CPM were analyzed in 6676 patients from the UK TAVI registry, as a whole cohort and across several subgroups. Strata included gender, diabetes status, access route, and valve type. Furthermore, the amount of agreement in risk classification between each of the considered CPMs was analyzed at an individual patient level. Results The observed 30‐day mortality rate was 5.4%. In the whole cohort, the majority of CPMs over‐estimated the risk of 30‐day mortality, although the mean ACC score (5.2%) approximately matched the observed mortality rate. The areas under ROC curve were between 0.57 for OBSERVANT and 0.64 for ACC. Risk classification agreement was low across all models, with Fleisss kappa values between 0.17 and 0.50. Conclusions Although the FRANCE‐2 and ACC models outperformed all other CPMs, the performance of current TAVI‐CPMs was low when applied to an independent cohort of TAVI patients. Hence, TAVI specific CPMs need to be derived outside populations previously used for model derivation, either by adapting existing CPMs or developing new risk scores in large national registries.

Transatlantic editorial on transcatheter aortic valve replacement

From the Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, Ga; Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, NY; Department of Cardiology, Mayo Clinic, Rochester, Minn; Division of Cardiothoracic Surgery, Department of Surgery, Washington University; Department of Cardiology, University Hospital Santa Maria, University of Lisbon, Lisbon, Portugal; Department of Cardiac Surgery, Stanford University, Palo Alto, Calif; Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec; Department of Cardiac Surgery, Leipzig Heart Center, Leipzig; Clinic for Cardiac Surgery Karlsruhe; National Institute Health Research Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Harefield National Health Service Foundation Trust, London, United Kingdom; Department of Cardiovascular Surgery, Heart Centre Freiburg University, Freiburg, Germany; Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo; and Division of Cardiovascular Surgery, Peter Munk Cardiovascular Center, Toronto General Research Institute, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada. Dr Beyersdorf is the Editor of the European Journal of Cardiothoracic Surgery. Dr Patterson is the Editor of Annals of Thoracic Surgery. Dr Weisel is Editor of the Journal of Thoracic and Cardiovascular Surgery. This article has been co-published with permission in The Journal of Thoracic and Cardiovascular Surgery, The Annals of Thoracic Surgery, and European Journal of Cardio-Thoracic Surgery. Received for publication Jan 12, 2017; revisions received March 10, 2017; accepted for publication March 11, 2017. Address for reprints: Vinod H. Thourani, MD, Emory Hospital Midtown, 550 Peachtree St, 6th Floor Medical Office Tower, Atlanta, GA 30308 (E-mail: vthoura@emory.edu). J Thorac Cardiovasc Surg 2017;154:7-21 0022-5223/

Novel United Kingdom prognostic model for 30-day mortality following transcatheter aortic valve implantation

36.00 Copyright 2017 Jointly between The American Association for Thoracic Surgery, the European Association for Cardio-Thoracic Surgery, and the Society for Thoracic Surgeons. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jtcvs.2017.03.047 The treatment of aortic stenosis is changing rapidly, and sharing ideas from across the Atlantic will help us provide the most optimal care for our patients.

Transatlantic Editorial on Transcatheter Aortic Valve Replacement

Objective Existing clinical prediction models (CPM) for short-term mortality after transcatheter aortic valve implantation (TAVI) have limited applicability in the UK due to moderate predictive performance and inconsistent recording practices across registries. The aim of this study was to derive a UK-TAVI CPM to predict 30-day mortality risk for benchmarking purposes. Methods A two-step modelling strategy was undertaken: first, data from the UK-TAVI Registry between 2009 and 2014 were used to develop a multivariable logistic regression CPM using backwards stepwise regression. Second, model-updating techniques were applied using the 2013–2014 data, thereby leveraging new approaches to include frailty and to ensure the model was reflective of contemporary practice. Internal validation was performed by bootstrapping to estimate in-sample optimism-corrected performance. Results Between 2009 and 2014, up to 6339 patients were included across 34 centres in the UK-TAVI Registry (mean age, 81.3; 2927 female (46.2%)). The observed 30-day mortality rate was 5.14%. The final UK-TAVI CPM included 15 risk factors, which included two variables associated with frailty. After correction for in-sample optimism, the model was well calibrated, with a calibration intercept of 0.02 (95% CI −0.17 to 0.20) and calibration slope of 0.79 (95% CI 0.55 to 1.03). The area under the receiver operating characteristic curve, after adjustment for in-sample optimism, was 0.66. Conclusion The UK-TAVI CPM demonstrated strong calibration and moderate discrimination in UK-TAVI patients. This model shows potential for benchmarking, but even the inclusion of frailty did not overcome the need for more wide-ranging data and other outcomes might usefully be explored.

‘Porcelain aorta’: a proposed definition and classification of ascending aortic calcification

From the Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, Ga; Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, NY; Department of Cardiology, Mayo Clinic, Rochester, Minn; Division of Cardiothoracic Surgery, Department of Surgery, Washington University; Department of Cardiology, University Hospital Santa Maria, University of Lisbon, Lisbon, Portugal; Department of Cardiac Surgery, Stanford University, Palo Alto, Calif; Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec; Department of Cardiac Surgery, Leipzig Heart Center, Leipzig; Clinic for Cardiac Surgery Karlsruhe; National Institute Health Research Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Harefield National Health Service Foundation Trust, London, United Kingdom; Department of Cardiovascular Surgery, Heart Centre Freiburg University, Freiburg, Germany; Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo; and Division of Cardiovascular Surgery, Peter Munk Cardiovascular Center, Toronto General Research Institute, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada. Dr Beyersdorf is the Editor of the European Journal of Cardiothoracic Surgery. Dr Patterson is the Editor of Annals of Thoracic Surgery. Dr Weisel is Editor of the Journal of Thoracic and Cardiovascular Surgery. This article has been co-published with permission in The Journal of Thoracic and Cardiovascular Surgery, The Annals of Thoracic Surgery, and European Journal of Cardio-Thoracic Surgery. Received for publication Jan 12, 2017; revisions received March 10, 2017; accepted for publication March 11, 2017. Address for reprints: Vinod H. Thourani, MD, Emory Hospital Midtown, 550 Peachtree St, 6th Floor Medical Office Tower, Atlanta, GA 30308 (E-mail: vthoura@emory.edu). J Thorac Cardiovasc Surg 2017;154:7-21 0022-5223/

Relative survival after transcatheter aortic valve implantation: How do patients undergoing transcatheter aortic valve implantation fare relative to the general population?

36.00 Copyright 2017 Jointly between The American Association for Thoracic Surgery, the European Association for Cardio-Thoracic Surgery, and the Society for Thoracic Surgeons. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jtcvs.2017.03.047 The treatment of aortic stenosis is changing rapidly, and sharing ideas from across the Atlantic will help us provide the most optimal care for our patients.

Seminars in thoracic and cardiovascular surgery: Roundtable discussion on TAVR

Introduction ‘Porcelain aorta’ is listed in the second consensus document of the Valve Academic Research Consortium as a risk factor in aortic valve replacement. However, the extent of circumferential involvement is poorly defined with great variability in reported incidence. We present a simple, reproducible classification to describe the extent of aortic calcification and thus appropriately define ‘porcelain aorta’, aiding clinical decision-making and registry data collection. Methods 175 consecutive CT aortograms were reviewed. The aorta was divided into three sections, and each section divided into quadrants. These were individually scored using a 5-point scale (0—no calcification, 5—complete contiguous calcification). Results for each quadrant were summated for each segment to provide an indication of the distribution of calcification. Results Only one patient (0.6%) had a ‘true’ porcelain aorta, defined as contiguous calcification across all quadrants at any aortic level. Intraobserver and interobserver variation was excellent for the ascending aorta (K=0.85–0.88 and 0.81–0.96, respectively) while the interobserver variation in the transverse arch was good at 0.75. Conclusions Our data suggest the incidence of ‘true’ porcelain aorta may be significantly lower than reported in the literature. The predominance of calcification within the anterior wall of the proximal ascending aorta and the superior wall of the transverse arch may be clinically important. Application of this quick, simple and reproducible grading system, with no requirement for advanced software, may provide a tool to support accurate assessment of focal aortic calcification and its relationship to subsequent procedural risk.

Influence of Gender on Clinical Outcomes Following Transcatheter Aortic Valve Implantation from the UK Transcatheter Aortic Valve Implantation Registry and the National Institute for Cardiovascular Outcomes Research

Background Transcatheter aortic valve implantation (TAVI) is indicated for patients with aortic stenosis who are intermediate‐high surgical risk. Although all‐cause mortality rates after TAVI are established, survival attributable to the procedure is unclear because of competing causes of mortality. The aim was to report relative survival (RS) after TAVI, which accounts for background mortality risks in a matched general population. Methods and Results National cohort data (n=6420) from the 2007 to 2014 UK TAVI registry were matched by age, sex, and year to mortality rates for England and Wales (population, 57.9 million). The Ederer II method related observed patient survival to that expected from the matched general population. We modelled RS using a flexible parametric approach that modelled the log cumulative hazard using restricted cubic splines. RS of the TAVI cohort was 95.4%, 90.2%, and 83.8% at 30 days, 1 year, and 3 years, respectively. By 1‐year follow‐up, mortality hazards in the >85 years age group were not significantly different from those of the matched general population; by 3 years, survival rates were comparable. The flexible parametric RS model indicated that increasing age was associated with significantly lower excess hazards after the procedure; for example, by 2 years, a 5‐year increase in age was associated with 20% lower excess mortality over the general population. Conclusions RS after TAVI was high, and survival rates in those aged >85 years approximated those of a matched general population within 3 years. High rates of RS indicate that patients selected for TAVI tolerate the risks of the procedure well.