Zakeih Chaker

Sex Differences in the Utilization and Outcomes of Surgical Aortic Valve Replacement for Severe Aortic Stenosis

Background Studies assessing the differential impact of sex on outcomes of aortic valve replacement (AVR) yielded conflicting results. We sought to investigate sex‐related differences in AVR utilization, patient risk profile, and in‐hospital outcomes using the Nationwide Inpatient Sample. Methods and Results In total, 166 809 patients (63% male and 37% female) who underwent AVR between 2003 and 2014 were identified, and 48.5% had a concomitant cardiac surgery procedure. Compared with men, women were older and had more nonatherosclerotic comorbid conditions including hypertension, diabetes mellitus, obstructive pulmonary disease, atrial fibrillation/flutter, and anemia but fewer incidences of coronary and peripheral arterial disease and prior sternotomies. In‐hospital mortality was significantly higher in women (5.6% versus 4%, P<0.001). Propensity matching was performed to assess the impact of sex on the outcomes of isolated AVR and yielded 28 237 matched pairs of male and female participants. In the propensity‐matched groups, in‐hospital mortality was higher in women (3.3% versus 2.9%, P<0.001). Along with vascular complications and blood transfusion (6% versus 5.6%, P=0.027 and 40.4% versus 33.9%, P<0.001, respectively). Rates of stroke, permanent pacemaker implantation, and acute kidney injury requiring dialysis were similar (2.4% versus 2.4%, P=0.99; 6% versus 6.3%, P=0.15; and 1.4% versus 1.3%, P=0.14, respectively). Length of stay median and interquartile range were both similar between groups (7±6 days). Rates of nonhome discharge were higher among women (27.9% versus 19.6%, P<0.001). Conclusions Women have worse in‐hospital mortality following AVR compared with men. Coupled with the accumulating evidence suggesting higher magnitude of benefit of transcatheter AVR over AVR in women, women should perhaps be offered transcatheter AVR over AVR at a lower threshold than men.

Mechanical circulatory support in patients with severe aortic stenosis and left ventricular dysfunction undergoing percutaneous coronary intervention

Management of obstructive coronary artery disease in patients with aortic stenosis and severe left ventricular dysfunction is challenging. Mechanical circulatory support at the time of percutaneous coronary interventions may be necessary in these extreme‐risk patients. We present a case in which the TandemHeart was used to support a patient with severe aortic stenosis, severe protected left main and circumflex disease, and severe cardiomyopathy and review the literature on this subject.

Emergent Transcatheter Aortic Valve Replacement for the Treatment of Severe Aortic Stenosis Patients Presenting With Cardiogenic Shock or Cardiac Arrest; A Case Series

ABSTRACT Background: Patients with severe aortic stenosis (AS) often present acutely with decompensated heart failure, cardiogenic shock or cardiac arrest requiring immediate intervention. Transcatheter aortic valve replacement (TAVR) has been effectively utilized to treat such patients. However, data on emergent TAVR remain scarce. Methods: We report a cases series of consecutive patients who underwent emergent TAVR between July 2016 and December 2017 at our institution. We describe the patients’ characteristics, the rational for intervention, procedural details, and mid-term outcomes. Results: Nine patients underwent emergent TAVR during the study’s period. Mean age was 80.6 ± 9.9, 44% were males, mean left ventricular ejection fraction was 42.8 ± 19.1. The rational for emergent intervention was cardiogenic shock in 6 (67%), cardiac arrest in 2 (22%), and both in 1 (11%). Mean transaortic valve gradient was 49.8 ± 20.4 mmHg. The mean time from event to TAVR time was 9.9 hours (range 2–14). Balloon aortic valvuloplasty was utilized pre-TAVR in four patients (44%), and peri-procedural percutaneous assist devices were used in three patients (33%). Sapien S3 was the most used valve (89%). Procedural success was achieved in 100%, and 8/9 patients (89%) survived to discharge. All surviving patients were alive and in class I/II New York Heart Association (NYHA) symptom category both at 1 month and a mean follow-up of 8.4 ± 3.7 months. Conclusions: TAVR may provide a feasible and effective treatment for patients with decompensated AS requiring emergent intervention. Further studies are needed to identify the optimal algorithm for the management of these patients.

Contemporary outcomes of isolated bioprothestic mitral valve replacement for mitral regurgitation

Background Early experience with transcatheter mitral valve replacement (TMVR) highlighted several investigational challenges related to this novel therapy. Conclusive randomised clinical trials in the field may, therefore, be years ahead. In the interim, contemporary outcomes of isolated surgical bioprosthetic mitral valve replacement (MVR) can be used as a benchmark for the emerging TMVR therapies. Methods We used the nationwide inpatient sample to examine recent trends and outcomes of surgical bioprosthetic MVR for mitral regurgitation (isolated and combined). Results 21 007 patients who had bioprosthetic MVR between 2003 and 2014 were included. Of those, 30% had isolated MVR and 70% had concomitant cardiac surgical procedure(s). In patients who underwent isolated bioprothestic MVR, mean age was 68±13, and females were the majority (58.4%). Most of these procedures were performed at teaching institutions (71.3%) and during an elective admission (64%). In-hospital mortality improved during the study period (7.8% in 2003 to 4.7% in 2014, p trend=0.016). Postoperative morbidities were common; permanent pacemaker 11.7%, stroke 2.4%, new dialysis 4.9% and blood transfusion 41.6%. Mean length of stay was 13±12 days, and 27.2% of patients were discharged to an intermediate care of rehabilitation facility. Cost of hospitalisation was

Management of Peridevice Leak Following Left Atrial Appendage Occlusion

62 443±50 997. Conclusions Isolated bioprosthetic MVR for mitral regurgitation is performed infrequently but is associated with significant in-hospital morbidity and mortality and cost in contemporary practice. These data are useful as benchmarks for the evolving TMVR therapies.

Meta-Analysis Comparing the Frequency of Stroke After Transcatheter Versus Surgical Aortic Valve Replacement

Residual leaks are not uncommon following percutaneous left atrial appendage occlusion (LAAO). There are currently no guidelines on the optimal management of these leaks, but life-long anticoagulation has been recommended in large persistent leaks. Percutaneous closure of peridevice leak is a viable

RACIAL DISPARITY IN AORTIC VALVE REPLACEMENT OUTCOMES: INSIGHT FROM NATIONAL INPATIENT SAMPLE

Stroke is one of the most feared complications of aortic valve replacement. Although the outcomes of transcatheter aortic valve implantation (TAVI) improved substantially over time, concerns remained about a potentially higher incidence of stroke with TAVI compared with surgical replacement (SAVR). However, comparative data are sparse. We performed a meta-analysis comparing the incidence of stroke among patients undergoing TAVI versus SAVR. Of the 5067 studies screened, 28 eligible studies (22 propensity-score matched studies and 6 randomized trials) were analyzed. Primary endpoints were 30-day stroke and disabling stroke. Secondary endpoints were 1-year stroke and disabling stroke. A total of 23,587 patients were included, of whom 47.27% underwent TAVI and 52.72% underwent SAVR. For each endpoint, pooled estimates of odds ratio (OR) with 95% confidence interval (CI) were calculated. The pooled estimates for stroke (2.7% vs 3.1%, OR 0.86; 95% CI 0.72 to 1.02; p=0.08) and disabling stroke (2.5% vs 2.9%, OR 0.96; 95% CI 0.57 to 1.62; p=0.89) were comparable following TAVI versus SAVR at 30 days. Similarly, the pooled estimates for stroke (5.0% vs 4.6%, OR 1.01; 95% CI 0.79 to 1.28; p=0.96) and disabling stroke (4.1% vs 4.5%, OR 0.92; 95% CI 0.92 to 1.39; p=0.71) were similar at 1 year. A sensitivity analysis including only RCTs yielded similar results. Our meta-analysis documents comparable rates of strokes and disabling strokes following TAVI or SAVR both at 30 days and 1 year.

TCT-278 Incidence, Characteristics and Management of Residual Peri-Device Leak after Percutaneous Left Atrial Appendage Occlusion

Introductions: The Society of Thoracic Surgeons’ risk score identifies the AA and Hispanic races as an independent risk factor for perioperative morbidity but not mortality in patients undergoing isolated AVR. We aim to investigate the effect of race on mortality and morbidity of AVR in a large