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To examine the incidence and trends of peri-procedural complications after TAVR and their impact on resource utilization.The incidence of complications by type [acute kidney injury (AKI), permanent pacemaker (PPM), vascular, paravalvular leak, in-hospital mortality, others] was calculated for TAVR patients at a high-volume center between 2012 and 2018. Clinical data were matched with hospital-billing data of patients. Trends in high resource utilization (discharge to a rehabilitation facility or PLOS7 days) (HRU) and complication rates were assessed. Multivariable logistic regression models were used to determine predictors of HRU.Out of 1163 patients, 966 (83%) had no complications, others in 95 (8%), PPM in 56 (5%), AKI alone in 32 (3%), vascular in 31 (3%), in-hospital mortality in 28 (2%) and PVL in 10 (1%). A significant decreasing trend in the incidence of complications (29% vs 10%; p trend0.001) and HRU (75% vs 12%; p trend0.001) was observed between 2012 and 2018 respectively. Mean ± SD direct procedure cost of having a complication was $58,234 ± $24,568, was associated with an incremental cost of $10, 649 and a prolonged stay of 3-days. On multivariable logistic regression analysis, PPM, vascular complications, high STS risk score, NYHA class III/IV, frailty and ≥ moderate tricuspid regurgitation were significantly associated with HRU. TAVR year was protective against HRU.We established that, post-TAVR resource utilization and morbidity is high among frail and patients with higher STS risk scores. However, these rates decrease over time with experience.

Objective The transapical (TA) approach is an alternative access technique for transcatheter aortic valve replacement (TAVR) in patients with symptomatic aortic valve stenosis. The impact of prior coronary artery bypass graft (CABG) surgery and how it affects left ventricular function recovery is not well defined. Methods Patients who had TAVR at a single center between June 2012 and December 2016 were reviewed. High-risk patients who underwent the procedure via a TA approach were divided into 2 groups based on their history of CABG surgery. Postoperative outcomes were compared between groups. CABG/TA-TAVR patients were subdivided into 2 per baseline left ventricular ejection fraction (LVEF) Results Of 923 cases in total, 183 (19.8%) were performed via a TA approach. The mean ± SD Society of Thoracic Surgeons risk score of TA patients was 10.2 ± 4.6. Forty-nine (27%) had a surgical history of CABG. Overall all-cause mortality rates at 30 days, 1 year, and 2 years were similar for both groups ( P = 0.59, P = 0.64, P = 0.78). Subgrouping of CABG-TAVR patients ( n = 49) identified 24 patients (49%) with LVEF ≥50% vs. 25 (51%) with LVEF 2, P < 0.001; mean gradient: ∆: −38 mmHg, P < 0.001); LVEF 2, P < 0.001; MG: ∆: −31 mmHg, P < 0.001). Conclusions TA-TAVR can be safely performed with acceptable postoperative outcomes in patients with a history of CABG surgery. In those with reduced EF, significant improvements in LV and valve functions are seen at 1-year follow-up.

The study aims to investigate the incidence of immediate renal function improvement in renal dysfunction patients who had transcatheter aortic valve implantation (TAVI). TAVI patients with ≥ moderate reduced renal function [estimated GFR ≤ 60 ml/min/1.73 m2] at baseline were identified from a prospectively maintained database. Patients were divided into 3 groups based on percent change [(discharge eGFR − baseline eGFR/baseline GFR) × 100] in eGFR post-TAVR. Improvement ≥ 10%, no change, Decline ≥ 10%. Multivariable logistic regression was performed to identify factors that predicted improvement/decline in GFR postprocedure. Out of 677 patients, 359 (53%) had eGFR ≤ 60 ml/min/1.73 m2. Of these, 188 (52%) had an improvement in eGFR ≥ 10%, 125 (34%) had no change and 48 (14%) observed decline ≥ 10%. All groups had similar proportions of females and age was comparable in patient groups. Patients in whom a decline in eGFR was observed had significantly higher Society of thoracic Surgeons scores (10.7 vs 8.2 vs 8.2; p = 0.007) and incidence of liver disease (6% vs, 0% vs 2%; p = 0.014) than the no-change or improved groups respectively. On multivariable analysis, independent predictors of decline/improvement in eGFR were being female, low left ventricular ejection fraction and baseline liver dysfunction. In conclusion, over half of patients with compromised renal function who underwent TAVI experience an immediate improvement in kidney function post-TAVI. Being female, baseline liver dysfunction and a low left ventricular ejection fraction is associated with an immediate decline in eGFR.

ObjectivesOur aim was to compare available transcatheter aortic valve replacement (TAVR) valves using direct and indirect evidence from randomized controlled trials (RCT).BackgroundTAVR is now an established treatment for majority of patients with severe aortic stenosis. However, there is limited data comparing various valves.MethodsWe performed a systematic search of electronic databases for RCT comparing a TAVR valve to a valve or surgery. A Bayesian network meta-analysis was performed to compile evidence from both direct and indirect comparisons at 30 days and at one year.ResultsTwelve studies with 10,307 patients eligible for TAVR met the criteria and were included. Self-expanding valve CoreValve type (SEV_C) is associated with higher risk of pacemaker implantation and use of >1 valve, SEV Accurate type (SEV_A) is associated with higher risk of ≥ moderate aortic regurgitation (AR) and death, and mechanically expandable valve (MEV) is associated with lower risk of ≥ moderate AR but higher risk of pacemaker at 30 days, SEV_C and MEV were associated with higher pacemaker rates compared balloon expandable valve (BEV) at 1 year. There is no difference among the valves in stroke at 30 days and 1 year.ConclusionsAt 30 days, BEV was superior on one or more outcomes of mortality, pacemaker implantation, >1 valve implantation, and ≥ moderate AR compared to other valves except the higher rate ≥?moderate AR compared to MEV. At one year, BEV was associated with lower odds of pacemaker implantation compared to SEV_C and MEV but not different on other end points.

Background Patients undergoing transcatheter aortic valve replacement (TAVR) are likely to be discharged to a location other than home. We aimed to determine the association between preoperative risk factors and non-home discharge after TAVR. Methods Patients discharged alive after TAVR at three centers were identified from a prospectively maintained database randomly divided into 80% derivation and 20% validation cohorts. Logistic regression models were fit to identify preoperative factors associated with non-home discharge in the derivation cohort. Multivariable models were developed and a nomogram based risk-scoring system was developed for use in preoperative counseling. Results Between June 2012 and December 2018, a total of 1, 163 patients had TAVR at three centers. Thirty-seven patients who died before discharge were excluded. Of the remaining 1, 126 patients (97%) who were discharged alive, the incidence of non-home discharge was 25.6% (n = 289). The patient population was randomly divided into the 80% (n = 900) derivation cohort and 20% (n = 226) validation cohort. Mean ± SD age of the study population was 83 ± 8 years. In multivariable analysis, factors that were significantly associated with non-home discharge were extreme age, female sex, higher STS scores, use of general anesthesia, elective procedures, chronic liver disease, non-transfemoral approach and postoperative complications. The unbiased estimate of the C-index was 0.81 and the model had excellent calibration. Conclusions One out of every four patients undergoing TAVR is discharged to a location other than home. Identification of preoperative factors associated with non-home discharge can assist patient counseling and postoperative disposition planning.

Background Patients undergoing transcatheter aortic valve replacement (TAVR) are likely to be discharged to a location other than home. We aimed to assess the association between discharge disposition after TAVR and patient survival at 1 year. Methods Patients admitted from home and survived till discharge after TAVR were divided into two groups based on discharge disposition (home discharge vs. non-home discharge). Pre-operative factors predicting the odds of not being discharged home were identified by using multivariable logistic regression analysis. Study patients were matched one-to-one via a propensity scoring method. Differences in procedural outcomes were compared. Survival of both unmatched and matched pairs was evaluated by using the Kaplan-Meier method with the Kleine-Moesch-Berger stratified log-rank test. Results Out of 1,160 TAVR patients, 851 were admitted from home and survived till discharge. The incidence non-home discharge was 19% (n = 159). Factors that were significantly associated with non-home discharge were older age, non-transfemoral approach, female sex, frailty status, history of chronic lung disease, pacemaker placement and insulin-dependent diabetes mellitus. One-to-one propensity score matching resulted in 141 patient pairs with similar age, operative risk, frailty and functional status. At 1-year follow-up, all-cause mortality rates were significantly higher in the non-home group than their home counterparts (18% vs. 3%, P = 0.006; stratified log rank test: P = 0.006). Conclusions A considerable number of TAVR patients are discharged to a location other than home after the procedure. Not being discharged home after TAVR is associated with a high mortality risk at 1 year.

Background The impact of frailty status on TAVR outcomes in nonagenarians is unknown. The present study aims to investigate the impact of frailty status on procedural outcomes and overall survival in nonagenarians after TAVR. Methods A frailty score (FS) was derived by using preoperative grip strength, gait speed, serum albumin, and daily activities. Patients were divided into two groups: Frail (FS ≥ 3/4) and Non-Frail (FS 90 years underwent full assessment for frailty status. There was a significant improvement in overall health status of non-frail patients (mean difference: 11.03, P = 0.032). Unadjusted 30-day and 2-year mortality rates were higher in the frail group than the non-frail group. (14% vs. 2% P = 0.059; 31% vs. 9% P = 0.018). Kaplan-Meier estimated all-cause mortality to be significantly higher in the frail group (log-rank test; P = 0.042). Frailty status was independently associated with increased mortality (hazard ratio: 1.84, 95% C.I: 1.06–3.17; P = 0.028) after TAVR. Conclusion Among nonagenarians selected to undergo TAVR for severe aortic stenosis, a considerable number are frail. Nonfrail patients report a significant improvement in overall health status in the short term. Worse frailty is strongly associated with diminished long-term survival. © 2017 Wiley Periodicals, Inc.

This study sought to describe a single center's experience with transcatheter mitral valve-in-valve (TM-ViV) implantation.Consecutive patients who had TM-ViV due to degenerative biological valve prosthesis at a single center during a 4-year period were identified from a prospectively maintained database. Operative outcomes were assessed both in-hospital and at 30 days. The primary outcome was in-hospital mortality. Secondary outcomes included valve function, functional status, and quality of life at follow-up.Mean (± standard deviation) patient age was 69 ± 12 years and all patients were high risk for redo surgery (STS risk score, 9.6 ± 6.2%). The primary mechanism of bioprosthetic valve failure was stenosis in 7 patients (47%) and regurgitation in 8 patients (53%). Mean duration between mitral valve replacement (MVR) and transcatheter MVR was 89 months (range, 66-72 months). Failed bioprosthetic valves were replaced with Sapien XT (n = 10; 67%), Sapien (n = 4; 26%), or Sapien S3 valves (n = 1; 7%) (all valves manufactured by Edwards Lifesciences). Procedural success was 100%. No intraoperative deaths were recorded. Postimplantation valve hemodynamics was satisfactory, with a significant improvement in mean valvular gradient (Δ = -12 mm Hg; P.001) and mitral valve area (Δ = 0.9 cm²; P.01). At 30-day follow-up, no reports of death, disabling stroke, or rehospitalization for cardiac reasons was recorded. Health status scores were available for 11 of the 15 study patients (73%). Except for 1 patient, significant improvements were seen for all components of the health assessment survey.TM-ViV for failing biological mitral prosthesis can be performed with minimal operative morbidity and acceptable mid-term clinical and hemodynamic outcomes.

The purpose of this study is to assess the impact of frailty index comprised of commonly used frailty metrics on outcomes following transcatheter aortic valve replacement (TAVR) outcomes, including mortality, length of stay, and discharge destination.Retrospective data collection was performed for 342 consecutive patients who underwent TAVR at a single center from May 15, 2012, to September 17, 2015. Frailty index score was calculated using 15-ft walk test, Katz activities of daily living, preoperative serum albumin, and dominant handgrip strength. Patients were given a frailty score from 0/4 to 4/4, with higher scores indicating greater levels of frailty. There were 27 patients (8%) in 0/4, 82 patients (24%) in 1/4, 129 patients (38%) in 2/4, 73 patients (21%) in 3/4, and 31 patients (9%) in 4/4 frailty group. Multivariate cox, logistic, and linear regression analyses showed that patients with frailty score of 3/4 or 4/4 had increased all-cause mortality (P = .015 and P.001) and were more likely to be discharged to an acute care facility (P = .083 and P = .001). 4/4 frail patients had increased post-operative length of stay (P = .014) when compared to less frail patients. Individual components of the frailty score were also independent predictors of all-cause mortality. Median survival in 4/4 frail patients was 7 months.Frailty index comprised of commonly used frailty metrics and its components are independent predictors of poor post-TAVR outcomes. There is a stepwise increase in mortality and post-TAVR length of stay with increasing frailty with dismal prognosis in extremely frail patients.

The study aim was to investigate the relationship between postoperative morbidity after transcatheter aortic valve replacement (TAVR) and short-term patient-reported health status, using the Kansas City Cardiomyopathy Questionnaire (KCCQ).The association between 30-day post-procedure changes in patient-reported heath status and post-TAVR outcomes was examined. Patients were stratified into three groups based on observed changes in KCCQ-Overall scores (OS): Group A, increase in KCCQ-OS ≥10 points; Group B, KCCQ-OS scores10 points; and Group C, decline in KCCQ-OS ≥10 points. Variation components of KCCQ scores were determined using paired t-tests. Postoperative morbidity was investigated. Multivariable logistic regression was used to identify pre-procedural factors associated with an increase or decline in KCCQ-OS at 30 days.A total of 223 patients with complete baseline and postoperative 30-day KCCQ responses was studied. At the 30-day follow up there was a significant change in baseline mean KCCQ-OS for all patients (mean difference 14.1; p0.0001). Improvement in KCCQ-OS ≥10 was observed in 130 patients (58%), 64 patients (29%) had no change, and 29 patients (13%) had a decline in KCCQ-OS ≥10. The incidence of acute kidney injury (AKI), permanent pacemaker (PPM) placement and new-onset arrhythmia (NOA) was higher in group C than in groups A and B: AKI, 11%, 0%, 0%; p0.001; PPM, 21%, 4%, 6%; p = 0.004; and NOA, 21%, 5%, 8%, p = 0.026. Independent predictors of decline in KCCQ scores after TAVR were PPM requirement (estimate: 0.76 CI 0.22, 1.29; p = 0.005) and NYHA functional class (III/IV) (estimate: -0.41 CI -0.71, 0.10; p = 0.009).TAVR patients experienced an improvement in health status after the procedure, but for a smaller proportion their health status worsened. Patients who experience perioperative complications may have a decline in their health status after the procedure in the short term.

Tricuspid valve regurgitation (TR) is often not taken into consideration in the prognostication of patients undergoing transcatheter aortic valve replacement (TAVR). Accordingly, its impact on such patients remains relatively poorly defined. The study aim was to explore the effect of TR and parameters of right ventricular (RV) function on outcomes in patients undergoing TAVR.Baseline demographic and echocardiographic data were collected for 460 consecutive patients undergoing TAVR at the authors' institution between 2012 and 2015. A retrospective analysis was performed to determine the association of TR with all-cause mortality in these patients. The primary endpoint was 30-day rate of all-cause mortality and/or hospital re-admission.Among 460 patients included in the study analysis there were 25 deaths and 40 re-admissions. Univariate analysis showed that a higher Society of Thoracic Surgeons (STS) score, severe preoperative mitral and tricuspid regurgitation were associated with statistically significant higher 30-day mortality and/or re-admission rates. On multivariate analysis, STS score (OR 1.07, 95% CI 1.012-1.126), moderate TR (OR 3.24, 95% CI 1.52-6.87) and severe TR (OR 2.5, 95% CI 1.04-6.04) were identified as significant independent predictors of all-cause mortality.The severity of TR is a strong independent parameter predictive of death at 30 days. Therefore, parameters of RV function such as TR should be incorporated into predictive models for patients undergoing TAVR.

The axillary artery is an alternative, large-caliber vessel that can be utilized in the presence of hostile aortoiliac segments. It can accommodate sheaths up to 18 Fr and is infrequently affected by atherosclerosis.

This study sought to determine predictors of advanced conduction disturbances requiring late (≥ 30-days) permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR). A prospectively maintained TAVR database was queried to identify all patients who had TAVR at a high

RAASi use is common in patients with AS and has some, albeit inconsistent, evidence of contrast-induced nephropathy reduction. We aimed to investigate the effects of RAAS agents on post-operative AKI in aging patients undergoing TAVR. Patients who had TAVR at a single center were retrospectively

Previous studies have identified polypharmacy as a potential risk factor for hospital readmission. We aimed to assess the overall impact of the number of discharge medications on hospital readmission after transcatheter aortic valve replacement (TAVR). The number of discharge medications of

When untreated, Aortic stenosis (AS) patients with renal dysfunction report dismal prognosis. The study aims to investigate operative outcomes in renal dysfunction patients who had transcatheter aortic valve replacement. (TAVR) TAVR patients with ≥ moderately reduced renal function [estimated

Valve-in-valve transcatheter aortic valve replacement (VIV TAVR) can result in high residual gradients that are associated with increased mortality. Bioprosthetic valve fracture (BVF) has been shown to improve residual gradients following VIV TAVR; however, factors influencing the results of BVF have not been studied.BVF was performed in 75 patients at 21 centers. Hierarchical multiple linear regression was performed to identify variables that were associated with lower final transvalvular gradient.Surgical valves with a median true internal diameter of 18.5 mm (interquartile range, 17.0-20.5 mm) were treated with VIV TAVR in conjunction with BVF using balloon-expandable (n = 43) or self-expanding (n = 32) transcatheter heart valves with a median size of 23 mm (interquartile range, 23-23 mm). There were no aortic root disruptions, coronary occlusions, or new pacemakers; in-hospital or 30-day mortality was 2.6% (2 out of 75). Final mean transvalvular gradient was 9.2 ± 6.3 mm Hg, but was significantly lower when BVF was performed after VIV TAVR compared with BVF first (8.1 ± 4.8 mm Hg vs 16.9 ± 10.1 mm Hg; P .001). After adjusting for timing of BVF (ie, before or after VIV TAVR), transcatheter heart valve size/type, surgical valve mode of failure, true internal diameter, and baseline gradient and BVF balloon size, performing BVF after VIV TAVR (P .001) and using a larger BVF balloon (P = .038) were the only independent predictors of lower final mean gradient.BVF can be performed safely and results in reduced residual transvalvular gradients. Performing BVF after VIV TAVR and using larger balloon appears to achieve the best hemodynamic results.

The impact of frailty status on TAVR outcomes in nonagenarians is unknown. The present study aims to investigate the impact of frailty status on procedural outcomes and overall survival in nonagenarians after TAVR.A frailty score (FS) was derived by using preoperative grip strength, gait speed, serum albumin, and daily activities. Patients were divided into two groups: Frail (FS ≥ 3/4) and Non-Frail (FS3/4). Health status was assessed using the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ). Baseline demographic and clinical characteristics were compared in both groups. The effect of frailty status on outcomes was investigated. Cox regression analyses were performed to determine predictors of overall all-cause mortality. Kaplan-Meier survival curves were used to estimate survival.Seventy-five patients90 years underwent full assessment for frailty status. There was a significant improvement in overall health status of non-frail patients (mean difference: 11.03, P = 0.032). Unadjusted 30-day and 2-year mortality rates were higher in the frail group than the non-frail group. (14% vs. 2% P = 0.059; 31% vs. 9% P = 0.018). Kaplan-Meier estimated all-cause mortality to be significantly higher in the frail group (log-rank test; P = 0.042). Frailty status was independently associated with increased mortality (hazard ratio: 1.84, 95% C.I: 1.06-3.17; P = 0.028) after TAVR.Among nonagenarians selected to undergo TAVR for severe aortic stenosis, a considerable number are frail. Nonfrail patients report a significant improvement in overall health status in the short term. Worse frailty is strongly associated with diminished long-term survival. © 2017 Wiley Periodicals, Inc.

Recent advances in transcatheter aortic valve replacement (TAVR) have led to the adoption of the technology in patients with lower surgical risk. The present study aims to analyze direct costs associated with TAVR in patients with different pre-operative risks. Data were drawn from a prospectively

The present study aimed to determine (i) the effect of post-transcatheter aortic valve replacement (TAVR) complications rates (CR) on direct procedure costs and resource utilization (RU) and (ii) impact of operator experience on trends in CR and RU. Clinical data were matched with hospital-billing

Patients undergoing transcatheter aortic valve replacement (TAVR) are likely to be discharged to a location other than home. We aimed to determine the association between preoperative risk factors and non-home discharge. Patients admitted from home and discharged alive after TAVR at a single center

Background: With high resolution live 3-D TEE and 4-D dynamic cardiac CT, anatomic aortic valve area can be directly traced without geometric assumptions and flow calculations. We hypothesize that direct planimetry of AVA either by 3-D TEE or cardiac CT provides a reliable measurement of anatomic

Mechanical rotational atherectomy with the Rotablator is widely used for percutaneous coronary revascularization, but the ideal debulking strategy remains unknown. The purpose of this study was to compare the immediate and late results after Rotablator using two treatment strategies: Large burrs (burr/artery ratio of0.7) to achieve maximal debulking (lesion debulking strategy) or small burrs (burr/artery ratioor = 0.7) to modify lesion compliance (lesion modification strategy). Two hundred twenty-two patients at six centers were prospectively enrolled in this study and randomly assigned to large (n = 104 patients with 118 lesions) or small (n = 118 patients with 136 lesions) burrs. The primary endpoint was final diameter stenosis at the end of the procedure, and secondary endpoints included inhospital angiographic and clinical complications, and target lesion revascularization at 6 months. Baseline demographic and angiographic characteristics were similar. There were no differences in procedural success, the extent of immediate lumen enlargement, inhospital ischemic complications, or late target vessel revascularization. However, compared with small burrs, patients randomized to large burrs were more likely to experience serious angiographic complications (5.1% vs. 12.7%, P0.05) immediately after atherectomy. This study suggests that a routine lesion modification strategy employing small burrs (burr/artery ratioor = 0.7) achieves similar immediate lumen enlargement and late target vessel revascularization compared with a more aggressive debulking strategy (burr/artery ratio0.7), but with fewer angiographic complications.

The coronary lesions in 164 patients who underwent 194 PTCA procedures were analyzed in an effort to define if there were morphological characteristics that would predict thrombotic problems following percutaneous transluminal angioplasty (PTCA). Patients with smooth and concentric or eccentric lesions rarely had difficulty at PTCA, whereas those with filling defects or with eccentric and irregular lesions frequently had postprocedure thrombi. Total occlusions were amenable to angioplasty when there was lesion staining present, but the success rate was significantly less in patients in whom there was no staining. These findings suggest that the acute outcome of PTCA can be predicted on the basis of the morphology of coronary lesions on preprocedure angiography.