Timing and Outcomes of Percutaneous Coronary Intervention in Patients Who Underwent Transcatheter Aortic Valve Implantation.
- 作者列表："Ochiai T","Yoon SH","Flint N","Sharma R","Chakravarty T","Kaewkes D","Patel V","Nakamura M","Cheng W","Makkar R
:Limited data exist regarding the timing of percutaneous coronary intervention (PCI) in patients with coronary artery disease who underwent transcatheter aortic valve implantation (TAVI). We aimed to investigate clinical outcomes of patients who underwent TAVI and planned PCI according to the timing of PCI in relation to the TAVI. Consecutive patients with severe aortic stenosis who underwent TAVI with planned PCI between January 2013 and November 2017 were included. Patients were divided according to the timing of PCI. The primary end point was major adverse cardiac and cerebrovascular events, defined as a composite of all-cause death, myocardial infarction, unplanned revascularization, and stroke. Among 1,756 patients who underwent TAVI, 258 patients underwent planned PCI either before TAVI (n = 143, 55.4%), concomitantly with TAVI (n = 77, 29.8%), or after TAVI (n = 38, 14.7%). All patients in the post-TAVI PCI group were treated using balloon-expandable valves, and neither hemodynamic instability during TAVI nor PCI-related complications were observed. In a multivariable analysis, the timing of PCI was not associated with 2-year major adverse cardiac and cerebrovascular events rate (concomitant vs pre-TAVI, hazard ratio [HR]: 0.92; 95% confidence interval [CI]: 0.52 to 1.66; p = 0.79; post- vs pre-TAVI, HR: 0.45; 95% CI: 0.18 to 1.16; p = 0.10). In conclusion, there were no significant differences in terms of mid-term outcomes among pre-TAVI, concomitant, and post-TAVI PCI groups when the timing of PCI was carefully selected by heart team.
: 关于接受经导管主动脉瓣植入术 (TAVI) 的冠心病患者经皮冠状动脉介入治疗 (PCI) 时机的数据有限。我们旨在研究根据与TAVI相关的PCI时机接受TAVI和计划PCI的患者的临床结局。纳入2013年1月至2017年11月期间接受TAVI并计划行PCI的重度主动脉瓣狭窄患者。根据PCI的时机对患者进行分组。主要终点是主要的心脏和脑血管不良事件，定义为全因死亡、心肌梗死、非计划血运重建和卒中的复合事件.在1,756例接受TAVI的患者中，258例患者在TAVI前 (n = 143，55.4%)，同时接受TAVI (n = 29.8%) 或TAVI后 (n = 14.7%) 接受了计划的PCI。TAVI PCI术后组所有患者均使用球囊扩张瓣膜治疗，未观察到TAVI期间血流动力学不稳定及PCI相关并发症。在一项多变量分析中，PCI的时间与2年主要心脏和脑血管不良事件发生率无关 (合并与TAVI前相比，风险比 [HR]: 0.92; 95% 置信区间 [CI]: 0.52至1.66; P = 0.79; TAVI后与TAVI前比较，HR: 0.45; 95% CI: 0.18 ~ 1.16;p = 0.10).总之，当心脏团队仔细选择PCI的时机时，TAVI前、伴随和TAVI后PCI组在中期结局方面没有显著差异。
METHODS::Relapsing polychondritis is a rare multi-system disease characterized by inflammation in cartilaginous structures and other connective tissues. Cardiovascular complications occur in 10-51% of the patients. We report a case of concomitant aortic valve replacement, mitral valve replacement, and coronary artery bypass grafting in a patient with relapsing polychondritis. A 71-year-old female with relapsing polychondritis on prednisolone (5 mg/day) for 15 years presented at our hospital for further evaluation of valvular disease. Severe aortic stenosis and severe mitral regurgitation were diagnosed. We performed aortic and mitral valve replacement. During surgery, we found connective tissue surrounding the intima of the sinus of Valsalva and stenosis of the right coronary artery ostium, which was not noted on preoperative coronary angiography. We removed the tissue and performed bypass grafting to the right coronary artery. Postoperative recovery was uneventful, and she was discharged 27 days after surgery.
METHODS:BACKGROUND:The effect of significant mitral regurgitation (MR) on outcomes after continuous flow left ventricular assist device (cfLVAD) implantation remains unclear. METHODS:We performed a retrospective review of prospectively collected data from 159 patients with preoperative severe MR who underwent cfLVAD implantation (2003-2017). Two-step cluster analysis using the log-likelihood distance for post-cfLVAD implantation parameters, which included right ventricular (RV) dysfunction, MR severity, and tricuspid regurgitation (TR) severity. Post-cfLVAD implantation echocardiographic parameters were obtained within the first month. RESULTS:Cluster analysis resulted in 3 groups. Group 1 (n = 67) had mild or less MR with moderate-severe RV dysfunction (RVD). Group 2 (n = 43) had moderate-severe MR with moderate-severe RVD. Group 3 (n = 49) had moderate MR with mild RVD. Group 2 had the largest proportion with Interagency Registry for Mechanically Assisted Circulatory Support score of 1 (30.2%) and 2 (41.9%). They were more likely to undergo temporary mechanical circulatory support (18.6%) and tricuspid valve procedure (62.8%). Group 2 had the highest rate of stroke (30.2%; P = .02), hemolysis (39.5%; P = .01), device thrombosis (30%; P = .01), and worst survival (46.5%; P = .01). Survival at 5 years for groups 1, 2, and 3 were 56.0%, 17.6%, and 55.8%. Regression analysis of the entire population showed that greater MR severity after cfLVAD was associated with RV failure (P < .05; odds ratio, 1.6) and RV assist device use (P = .09; odds ratio, 1.6). After excluding tricuspid valve repairs, MR severity had a positive correlation with TR severity (R = 0.33; P < .01). CONCLUSIONS:After cfLVAD implantation, moderate-severe MR and RVD predicted RV failure. Patients with preoperative moderate-severe MR and TR coupled with moderate-severe RVD might benefit the most from mitral and tricuspid valve intervention.
METHODS:BACKGROUND:Among elderly with severe aortic stenosis (AS), Comprehensive Geriatric Assessment (CGA) originally contributed to address to transcatheter aortic valve implantation (TAVI) patients not suitable to surgical aortic valve replacement(SAVR). Nevertheless, TAVI has recently been proposed also in lower surgical risk patients. AIMS:To evaluate predictors of TAVI procedure and clinical outcomes among these patients. METHODS:For each patient ≥ 65 years with severe AS referring to our Cardiac Surgery Division, CGA was performed, including functional and cognitive status, comorbidity burden, frailty, nutritional status, gait speed, hand-grip strength and number of medications. Surgical risk was evaluated according to the Society of Thoracic Surgeons (STS) score (low-risk < 4%). Post-procedural outcomes (30-day survival and post-procedural complications) were obtained by medical records and a one-year follow-up assessed survival, and functional and cognitive performance. RESULTS:Among 154 subjects (mean age 82.9 years), 52 were at low-risk according to STS score. 32 patients were addressed to TAVI, 20 to SAVR. Variables significantly associated with TAVI-approach were lower gait speed (p 0.030) and higher number of medications (p 0.015). Short and long-term outcomes did not differ between groups. DISCUSSION:Among CGA variables, gait speed and number of medications were associated with the decision to perform TAVI instead of SAVR, even in patients at low surgical risk. 30-day and one-year survival and one-year functional and cognitive decline were similar between groups, despite a relevant prevalence of frailty in the TAVI group. CONCLUSIONS:We suggest that gait speed and number of medications should be considered in selecting appropriate candidates to TAVI among low surgical risk patients.