Seiji Kano

Impact of the Clinical Frailty Scale on Outcomes After Transcatheter Aortic Valve Replacement

Background: The semiquantitative Clinical Frailty Scale (CFS) is a simple tool to assess patients’ frailty and has been shown to correlate with mortality in elderly patients even when evaluated by nongeriatricians. The aim of the current study was to determine the prognostic value of CFS in patients who underwent transcatheter aortic valve replacement. Methods: We utilized the OCEAN (Optimized Catheter Valvular Intervention) Japanese multicenter registry to review data of 1215 patients who underwent transcatheter aortic valve replacement. Patients were categorized into 5 groups based on the CFS stages: CFS 1-3, CFS 4, CFS 5, CFS 6, and CFS ≥7. We subsequently evaluated the relationship between CFS grading and other indicators of frailty, including body mass index, serum albumin, gait speed, and mean hand grip. We also assessed differences in baseline characteristics, procedural outcomes, and early and midterm mortality among the 5 groups. Results: Patient distribution into the 5 CFS groups was as follows: 38.0% (CFS 1-3), 32.9% (CFS4), 15.1% (CFS 5), 10.0% (CFS 6), and 4.0% (CFS ≥7). The CFS grade showed significant correlation with body mass index (Spearman’s &rgr;=−0.077, P=0.007), albumin (&rgr;=−0.22, P<0.001), gait speed (&rgr;=−0.28, P<0.001), and grip strength (&rgr;=−0.26, P<0.001). Cumulative 1-year mortality increased with increasing CFS stage (7.2%, 8.6%. 15.7%, 16.9%, 44.1%, P<0.001). In a Cox regression multivariate analysis, the CFS (per 1 category increase) was an independent predictive factor of increased late cumulative mortality risk (hazard ratio, 1.28; 95% confidence interval, 1.10–1.49; P<0.001). Conclusions: In addition to reflecting the degree of frailty, the CFS was a useful marker for predicting late mortality in an elderly transcatheter aortic valve replacement cohort.

Impact of preparatory coronary protection in patients at high anatomical risk of acute coronary obstruction during transcatheter aortic valve implantation.

BACKGROUND This study aimed to assess the effectiveness of preparatory coronary protection (CP) in patients considered at high risk of acute coronary obstruction (ACO) after transcatheter aortic valve implantation (TAVI). METHODS The Optimized CathEter vAlvular iNtervention (OCEAN-TAVI) Japanese multicenter registry enrolled 666 consecutive patients. All patients were assessed by preprocedural multidetector computed tomography. CP using a guide wire with or without a balloon was prospectively performed according to the following criteria: 1) coronary height length from the annulus <10mm, 2) evidence of ACO during balloon aortic valvuloplasty with simultaneous aortic injection, and 3) shallow valsalva or bulky calcification on the leaflet. The incidence of ACO and other procedural outcomes were compared between the CP and non-CP groups. RESULTS CP was performed in 14.1% of all patients (94/666). ACO had an incidence of 1.5% (10/666) and mainly occurred in women (70%) and the left coronary artery (70%). The ACO rate was significantly higher in the CP group than in the non-CP group (7.4% [7/94] vs. 0.5% [3/572]; p<0.001), although notably 30% of ACO were occurred in non-CP group. All 10 ACO cases were successfully treated by catheter intervention, although periprocedural myocardial injury occurred in 42.9% of patients with CP group and 33.3% of those without CP group. Mortality and other periprocedural complications did not significantly differ between the 2 groups. CONCLUSION The preparatory CP strategy was feasible for the management of ACO during TAVI, but the complication of ACO was difficult to predict completely.

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.

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.

Rates of future hemodialysis risk and beneficial outcomes for patients with chronic kidney disease undergoing recanalization of chronic total occlusion

BACKGROUND This study aimed to assess the prognosis and deleterious effects of chronic kidney disease (CKD) on future renal function, in patients who had undergone chronic total occlusion-percutaneous coronary intervention (CTO-PCI). METHODS The treatment effects were studied in 739 patients who underwent CTO-PCI. The patients were divided into 3 groups according to estimated glomerular filtration rate (eGFR): non-CKD (eGFR≥60ml/min/1.73m(2), n=562), CKD-1 (45≤eGFR<60ml/min/1.73m(2), n=90), and CKD-2 (eGFR<45ml/min/1.73m(2), n=87). Future hemodialysis (HD) rates and the prevalence of acute kidney injury (AKI) except for 45 patients undergoing regular HD, and other clinical and prognostic outcomes were compared between the 3 groups. RESULTS Procedural success rates showed trends toward lower prevalence across the 3 groups (89.5%, 84.4%, and 81.6%, p=0.060). The prevalence of AKI significantly differed between the 3 groups (4.6%, 8.9%, and 16.7%, p=0.001), whereas no patients were introduced to regular HD at discharge. During a median follow-up period of 51.2±28.9months, newly required HD significantly differed between the 3 groups (0.7%, 0%, and 7.1%, p<0.001). When compared with unsuccessful CTO-PCI, successful CTO-PCI was found to improve cardiovascular mortality in the non-CKD and CKD-1 (Log-rank test: p=0.025, p=0.024, respectively) and to improve both cardiovascular and all-cause mortality in the CKD-2 (Log-rank test: p=0.027, p=0.0022, respectively). CONCLUSIONS Although CTO-PCI for patients with advanced CKD was associated with a high risk of future HD introduction, not directly owing to CTO-PCI and AKI, successful treatment of CTO might contribute to better survival benefit regardless of the presence or absence of CKD.

Extreme late-phase observation using coronary angioscopy until 7 years after sirolimus-eluting stent implantation.

BackgroundLittle is known about the very late-phase morphological vessel characteristics within the sirolimus-eluting stent (SES). Methods and resultsWe assessed a total of 12 patients with 15 SES implantations who underwent repeat angiographic and angioscopic procedures after 5 and 7 years. The degree of neointimal stent coverage (NSC) was classified as follows: grade 0, uncovered struts; grade 1, visible struts through a thin neointima; or grade 2, invisible struts with complete neointimal coverage. The maximum and minimum NSC grades were evaluated and the existence of in-stent thrombus was also recorded for all patients. The prevalence of a maximum NSC grade of 2 increased and that of a minimum NSC grade of 0 decreased, although there was no significant difference in prevalence between 5 and 7 years. One of four in-stent thrombus identified at 5 years had disappeared from 5 to 7 years and a new thrombus was found in another patient at 7 years. Thus, the incidence of in-stent thrombus did not change from 5 to 7 years. In one case, a thrombus was observed inside the angiographic aneurysmal change, but none of the thrombi were related to adverse events. ConclusionThis angioscopic study reported gradual arterial repair and continuous delayed healing associated with subclinical thrombus formation 7 years after SES deployment.

Recurrent Takotsubo cardiomyopathy with variable left ventricular obstruction and morphologies.

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 60-year-old woman presenting with chest pain with elevated troponin T had different patterns of electrocardiogram and left ventricular (LV) morphologies associated with Takotsubo cardiomyopathy. Each coronary angiography was

Sex-Specific Grip Strength After Transcatheter Aortic Valve Replacement in Elderly Patients

Hand-dominant grip strength is a simple marker that reflects frailty associated with incremental risks for late mortality. However, the prognostic value and optimal threshold of grip strength are not fully validated in elderly patients who undergo transcatheter aortic valve replacement (TAVR). The

The incidence, predictive factors and prognosis of acute pulmonary complications after transcatheter aortic valve implantation

OBJECTIVES Although acute pulmonary complications (APCs), such as the exacerbation of pulmonary disease (PD) or a newly developed pulmonary event, are thought to be catastrophic after invasive therapy, little is known about the occurrence of APCs after transcatheter aortic valve implantation (TAVI). This study aims to clarify the incidence, predictive factors and impact of APCs on prognosis after TAVI. METHODS We identified 749 patients who underwent TAVI, using data from the Optimized CathEter vAlvular iNtervention (OCEAN-TAVI) Japanese multicentre registry. APCs were defined as exacerbation of a comorbidity or newly developed PD during hospitalization. Patients were divided into 2 groups: an APC group (1.5%, 11/749) and a non-APC group (98.5%, 738/749). Clinical and prognostic outcomes were compared, and predictive factors for APCs were assessed. RESULTS Procedure-related death did not differ between the groups (0.4% vs 0.0%, P = 1.00), although 30-day mortality was significantly higher in the APC group than in the non-APC group (27.3% vs 1.6%, P = 0.001) and the difference in cumulative 1-year mortality increased further (72.7% vs 8.6%, log-rank test: P < 0.001). In particular, concomitant PD and transapical (TA) approach were identified as predictors of APCs after TAVI [univariable odds ratio (uOR) = 24.2, 95% confidence interval (CI) = 3.08-189.9, P = 0.002; uOR = 3.69, 95% CI = 1.11-12.3, P = 0.033, respectively]. CONCLUSIONS Although rare, the occurrence of APCs after TAVI was associated with extremely poor prognosis. Patients undergoing TAVI with concomitant PD and/or TA require careful consideration to avoid the risk of APCs.

Usefulness of routine aortic valve calcium score measurement for risk stratification of aortic stenosis and coronary artery disease in patients scheduled cardiac multislice computed tomography

Objectives This study sought to investigate the clinical utility of aortic valve calcium score (AVCS) determined by using cardiac multislice computed tomography (MSCT). Methods Data of 1315 consecutive patients who underwent both conventional echocardiography and MSCT were reviewed. Degree of aortic stenosis (AS) was assessed according to mean pressure gradient (mPG) measured by echocardiography. Extent of coronary artery disease (CAD) derived by MSCT also was evaluated in 1173 patients who did not undergo prior coronary treatment. Both AVCS and coronary calcium score (CCS) were defined by Agatston units (AU) according to MSCT findings. Results A total of 613 of 1315 patients were defined as AVCS positive (mean, 100 AU [range, 31.0–380.0 AU]). AVCS showed significant correlations with mPG (Spearmans ρ = 0.81, p < 0.001), and CCS (ρ = 0.53, p < 0.001). Differential adequate cut-off values of AVCS were proved for predicting severe AS with mPG ≥ 40 mmHg (1596.5 AU; AUC, 0.88; sensitivity, 89.7%; specificity, 77.0%), and for predicting moderate AS with mPG ≥ 20 mmHg (886.5 AU; area under the curve [AUC], 0.91; sensitivity, 92.4%; specificity, 78.3%). Mean AVCS was higher with increased extent of CAD (none, 0 AU [range, 0–30 AU]; single vessel, 8.5 AU [range, 0–104 AU]; multivessel, 142 AU [range, 10–525 AU]; p < 0.001). The optimal cut-off value of AVCS for predicting multivessel disease was 49 AU (AUC, 0.77; sensitivity, 68.8%; specificity, 78.0%). Conclusions AVCS might be a surrogate marker not only for AS grading but also for CAD progression. Therefore, routine AVCS assessment could be useful for risk stratification.