Shmuel Banai

Neutrophil/lymphocyte ratio is related to the severity of coronary artery disease and clinical outcome in patients undergoing angiography

BACKGROUNDnWhite blood cell count is an independent predictor of cardiovascular events and mortality. Neutrophil/lymphocyte ratio (NLR) is a biomarker that can single out individuals at risk for vascular events.nnnOBJECTIVEnTo evaluate whether NLR adds additional information beyond that provided by conventional risk factors and biomarkers for coronary artery disease (CAD) severity and adverse outcome, in a large cohort of consecutive patients referred for coronary angiography.nnnMATERIALS AND METHODSnNLR was computed from the absolute values of neutrophils and lymphocytes from the complete blood count of 3005 consecutive patients undergoing coronary angiography for various indications. CAD severity was determined by an interventional cardiologist unaware of the study aims. The association between NLR and CAD severity was assessed by logistic regression and the association between NLR and 3-years outcome were analyzed using Cox regression models, adjusting for potential clinical, metabolic, and inflammatory confounders.nnnRESULTSnThe cohort was divided into 3 groups according to the NLR value (<2, 2-3, and >3). NLR was independently associated with CAD severity and it contributed significantly to the regression models. Patients with NLR >3 had more advanced obstructive CAD (OR = 2.45, CI 95% 1.76-3.42, p < 0.001) and worse prognosis, with a higher rate of major CVD events during up to 3 years of follow-up (HR = 1.55, CI 95% 1.09-2.2, p = 0.01).nnnCONCLUSIONnNeutrophil/lymphocyte ratio is independently associated with CAD severity and 3-years outcome. NLR value appears additive to conventional risk factors and commonly used biomarkers.

Percutaneous Transcatheter Mitral Valve Replacement An Overview of Devices in Preclinical and Early Clinical Evaluation

Mitral regurgitation (MR) is one of the most prevalent valvular heart diseases in Western countries. The current estimated prevalence of moderate and severe MR in the United States is 2 to 2.5 million, and it is expected that this number will rise to 5 million by 2030.1 Surgical intervention is recommended for symptomatic severe MR or asymptomatic severe MR with left ventricular (LV) dysfunction.2 Treatment of degenerative MR has evolved from mitral valve (MV) replacement to MV repair because of superior long-term outcomes after repair.2–4 For functional MR, however, the benefit over MV replacement is less certain.5 In addition, minimally invasive MV surgery has become a well-established and increasingly used option for managing patients with MV pathology.6nnAlthough surgery remains the gold standard treatment for significant MR, MV surgery is deferred in a large number of patients because of high surgical risk.7 The decrease in the prevalence of rheumatic valve disease, in combination with an increased life expectancy, has led to a high prevalence of degenerative MR. As a consequence, patients are older and present with comorbidities that increase operative mortality and morbidity risks.8 In octogenarians, there has been reported a mortality and morbidity rate of 17.0% and 35.5%, respectively, following MV surgery.9 This results in denial or nonreferral for surgery in a large group of patients with significant MR—the Euro Heart Survey revealed that up to 50% of patients hospitalized with symptomatic severe MR are not referred for MV surgery, mainly because of advanced age, comorbidities, and LV dysfunction. In patients aged ≥80 years, surgical treatment was performed in only 15% compared to 60% in patients aged ≤70 years.8,10nnThe observation that a significant number of patients are not referred for MV surgery and the desire …

Hemodynamic Impact and Outcome of Permanent Pacemaker Implantation Following Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) frequently requires postprocedural permanent pacemaker (PPM) implantation. We evaluated clinical and hemodynamic impact of PPM after TAVI. Clinical and echocardiographic data were retrospectively analyzed in 230 consecutive patients who underwent TAVI and echocardiography at baseline and after 6 months. Echocardiographic parameters included left ventricular ejection fraction (LVEF), left ventricular (LV) stroke volume, early mitral velocity/annulus velocity ratio (E/e), right ventricular index of myocardial performance, systolic pulmonary artery pressure (SPAP), and aortic, mitral, and tricuspid regurgitation grades. Clinical outcomes included 2-year survival and cardiovascular and PPM-related event-free survival. The Medtronic CoreValve and Edwards Sapien prosthesis were used in 201 and 29 patients, respectively. PPM was required in 58 patients (25.4%). Two-year and event-free survival rates were similar between patients with and without PPM. At 6 months, patients with PPM demonstrated attenuated improvement in LVEF (-0.9 ± 8.7% vs 2.3 ± 10.8%, respectively, p = 0.03) and LV stroke volume (-2 ± 16 vs 4 ± 10 ml/m(2), respectively, p = 0.015), a trend toward smaller reduction in systolic pulmonary artery pressure (-1 ± 12 vs -6 ± 10 mm Hg, respectively, p = 0.09), and deterioration of right ventricular index of myocardial performance (-3 ± 17% vs 5 ± 26%, respectively, p = 0.05). The differences in post-TAVI aortic, mitral, and tricuspid regurgitation grades were insignificant. In conclusion, PPM implantation after TAVI is associated with reduced LVEF and impaired LV unloading. However, this unfavorable hemodynamic response does not affect the 2-year clinical outcome. The maintenance of clinical benefit appears to be driven by TAVI-related recovery of LV and right ventricular performance that mitigates unfavorable impact of PPM.

Higher Neutrophil/Lymphocyte Ratio Is Related to Lower Ejection Fraction and Higher Long-term All-Cause Mortality in ST-Elevation Myocardial Infarction Patients

BACKGROUNDnNeutrophil/lymphocyte ratio (NLR) is a novel biomarker that can single out individuals at risk for vascular events. We assessed whether NLR provides additive prognostic value in patients with ST-elevation myocardial infarction (STEMI).nnnMETHODSnNLR was computed from the absolute values of neutrophils and lymphocytes from the complete blood count of patients who underwent primary coronary angioplasty for STEMI. The cohort was divided into 2 groups according to NLR (NLR ≥ 6.5%, NLR < 6.5%) using χ(2) automatic interaction detection. The association between NLR and in-hospital clinical complications and left ventricular ejection fraction (EF) was assessed using logistic regression. The association between NLR, 30-day and 5-year all-cause mortality were analyzed using Cox regression models, adjusting for potential clinical, metabolic, and inflammatory confounders.nnnRESULTSnIn a group of 538 consecutive STEMI patients, high NLR (NLR ≥ 6.5%) was independently associated with increased 30-day and 5-years mortality rates (odds ratio, 15.8; 95% confidence interval, 1.6-154; Pxa0= 0.018; and hazard ratio, 2.2; 95% confidence interval, 1.04-4.8; Pxa0= 0.039, respectively). High NLR was also independently associated with lower EF (49 ± 8 vs 46 ± 8; P < 0.001) and fewer hospital complications.nnnCONCLUSIONSnIn patients presenting with STEMI, high NLR was independently associated with lower EF, fewer hospital complications, and higher mortality rates up to 5 years. NLR value appears additive to conventional risk factors and commonly used biomarkers.

Comparison of early and late outcomes of TAVI alone compared to TAVI plus PCI in aortic stenosis patients with and without coronary artery disease

To assess the safety and effectiveness of performing percutaneous coronary intervention (PCI) before transcatheter aortic valve implantation (TAVI).

Vascular complications after transcatheter aortic valve implantation and their association with mortality reevaluated by the valve academic research consortium definitions.

Vascular complications (VC) after transcatheter aortic valve implantation (TAVI) are reported using various criteria and several access site approaches. We aimed to describe them in a solely percutaneous transfemoral TAVI approach and their association with survival using both the updated Valve Academic Research Consortium (VARC)-2 criteria and the former VARC-1 criteria. From March 2009 to September 2013, 403 consecutive patients at a mean age (±SD) of 83 ± 6 years underwent percutaneous transfemoral TAVI. VC were defined by both VARC-1 and VARC-2 criteria and analyzed separately. Cox proportional hazard ratio models for all-cause mortality were adjusted separately as defined by each criteria. VARC-1-defined and VARC-2-defined VC occurred in 71 (18%) and 78 (19%) patients, respectively, with 15 (4%) and 33 (8%) defined as major VC. The difference in frequency of major and minor VC was mainly driven by VARC-2 implementation of major bleeding events. With either VARC definition, patients with minor VC had similar mortality and complications rates as those patients without VC. In multivariate analyses, referenced to patients with minor or no VC, only VARC-1-defined major VC were significantly associated with increased mortality (hazard ratio 3.52; confidence interval 1.5 to 8.4; pxa0= 0.005), whereas VARC-2-defined major VC werexa0found to be only marginally significant (hazard ratio 1.9; confidence interval 0.9 to 3.9; pxa0= 0.08). In conclusion, the implementation of the VARC-2 criteria resulted in a higher rate ofxa0reported major VC after TAVI compared with VARC-1 criteria, mainly by the inclusion ofxa0major bleeding events and a reduced association with patient mortality.

Atrial Fibrillation, Stroke, and Mortality Rates After Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) is considered a suitable treatment for patients with severe symptomatic aortic stenosis and high operative risk. Our aim was to evaluate the effect of preprocedural and new-onset atrial fibrillation (NOAF) on mortality and stroke in patients who underwent TAVI. We performed a single-center study of 380 consecutive patients enrolled to a TAVI registry. NOAF was defined as postprocedural atrial fibrillation (AF) occurring within 30xa0days after the procedure. Patients were followed up for a mean of 528 ± 364xa0days. During follow-up, 19 (5%) new episodes of stroke occurred, of whom 6 and 18 cases occurred within 30xa0days and 1 year, respectively. Overall mortality during the follow-up was 68 (20%), of those 12 and 58 patients died within 30xa0days and 1xa0year, respectively. NOAF occurred in 31 (8.2%) patients and was not associated with higher stroke or mortality rates at 30xa0days or 1 year of follow-up. Notably, compared with patients without previous AF, patients with previous AF at baseline had increased rates of stroke and mortality at 1-year follow-up (2.1% vs 9.6%, pxa0= 0.01, and 8.2% vs 34.9%, p <0.01; respectively). In multivariate analysis, AF at baseline but not NOAF was a significant predictor of mortality throughout the follow-up period (HR 2.2, 95% confidence interval 1.3 to 3.8, pxa0= 0.003, and HR 1.5, 95% confidence interval 0.5 to 4.1, pxa0= 0.390, respectively). In conclusion, previous AF at baseline but not NOAF significantly increases stroke and mortality rates after TAVI. The inclusion of AF into future TAVI risk stratification scores should be strongly considered.

The Obesity Paradox in Patients Undergoing Transcatheter Aortic Valve Implantation

Obesity is a major risk factor for cardiovascular morbidity and mortality. A considerable number of studies, however, showed better outcomes for overweight patients undergoing cardiovascular interventions—the so called obesity paradox.

Admission glucose, fasting glucose, HbA1c levels and the SYNTAX score in non-diabetic patients undergoing coronary angiography

BackgroundPre-diabetic state is a major risk factor for the development of diabetes and cardiovascular events. Admission glucose, fasting glucose and HbA1c levels have an effect on prognosis in patients with pre-diabetes and in non-diabetic individuals. The aim of the present study was to investigate which of the following glucometabolic markers (admission glucose, fasting glucose and HbA1c levels) is correlated with the severity of coronary artery disease (CAD) in non-diabetic patients.MethodsCAD severity according to SYNTAX score was prospectively evaluated in 226 non-diabetic patients hospitalized with myocardial infarction or stable angina and underwent coronary angiography. Glucose intolerance was assessed by serum admission glucose, fasting glucose and HbA1c levels. Logistic regression analysis was used to evaluate which glucometabolic factor has the strongest correlation with CAD severity.ResultsHbA1c was the only glucometabolic factor associated with SYNTAX score above 22 (ORxa0=xa03.03, CI 95xa0% 1.03–8.9, pxa0=xa00.04). HbA1c was also significantly associated with CAD severity in subgroup analysis (MI and stable angina).ConclusionsIn non-diabetic patients with myocardial infarction or stable angina, HbA1c levels correlate with CAD severity as measured by the SYNTAX score. No correlation was found between admission glucose or fasting glucose levels and CAD severity.

Impact of Estimated Glomerular Filtration Rate on Vascular Disease Extent and Adverse Cardiovascular Events in Patients Without Chronic Kidney Disease

BACKGROUNDnEstimated glomerular filtration rate (eGFR) predicts major adverse cardiovascular events (MACE) in patients with chronic kidney disease (CKD), though the effect of eGFR on MACE and vascular disease extent among individuals with normal or mildly impaired renal function requires definition. Our aim was to examine the prognostic implications of eGFR and its effect on atherosclerosis burden in individuals without CKD undergoing vascular imaging studies.nnnMETHODSnThe study enrolled 2746 consecutive patients undergoing clinically-driven coronary angiography who had an eGFR > 60 mL/min/1.73 m(2) and no history of CKD. Same-day carotid duplex results were available for 317 patients. Patients were followed for up to 3 years for the occurrence of all-cause mortality, myocardial infarction, and stroke.nnnRESULTSnAfter adjustment for potential clinical and biochemical confounders, eGFR was found to be independently associated with coronary artery disease extent in the entire study population and among patients with normal renal function (nxa0= 1170; eGFR > 90 mL/min/1.73 m(2)): odds ratio (OR)xa0= 1.16 (95% confidence interval [CI], 1.09-1.24) and ORxa0= 1.25 (95% CI, 1.11-1.4) per 10 mL/min decrements in eGFR, respectively. Similarly, eGFR was independently associated with carotid artery stenosis in the entire cohort (OR, 1.86 [95% CI, 1.12-3.1]). By Cox regression analysis, eGFR was an independent predictor of the composite MACE end point (hazard ratio, 1.16 [95% CI, 1.04-1.28]), and all-cause mortality (hazard ratio, 1.38 [95% CI, 1.19-1.60]).nnnCONCLUSIONSneGFR is an independent predictor of atherosclerotic vascular disease extent and MACE rates in patients with normal or mildly impaired renal function.