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Objective: The influence of left ventricular (LV) dysfunction on survival of patients with severe aortic stenosis is poorly characterized. Few data are available about preoperative predictors of cardiac mortality and LV function recovery after aortic valve replacement of such patients. The aim of our study was to examine the outcome and the preoperative predictors of postoperative cardiac death and of LV function recovery in these patients. Methods: We evaluated 85 consecutive patients with severe aortic stenosis (aortic valve area <1 cm2) and severe depression of LV ejection fraction (EF) <35% at cardiac catheterization. Among them, 52 underwent aortic valve replacement and they were compared to patients who were not operated on. All patients had a mean clinical follow-up of 53 months and 94% of them had a mean echocardiographic follow-up of 14 months after aortic valve replacement. Results: The mean baseline characteristics included: LVEF 28±6%, peak-to-peak transvalvular gradient 51±29 mmHg, aortic valve area 0.63±0.25 cm2. Thirty-three patients did not undergo aortic valve replacement: 32 of them died within 3 years. Fifty-two patients underwent aortic valve replacement and 16 had a concomitant coronary bypass surgery. In-hospital mortality was 8%. Postoperative NYHA functional class changed from 2.84±0.67 to 1.43±0.44 (P<0.001) and LVEF from 29±6% to 43±10% (P<0.001). At follow-up 10 patients died of heart disease. By multivariate analysis, preoperative LV end-systolic volume index (ESVI) was the only covariate of cardiac death (LVESVI/10 ml/m2, OR 1.3, CI 1.1–1.8, P<0.028). By using a receiver operating characteristic curve, LVESVI≤90 ml/m2 was the best cut-off value (sensitivity and specificity 78%) to fit with a better survival (93% vs. 63%, P<0.01) and with LVEF recovery after aortic valve replacement (EF improved by 15±10% vs. 8±5%, P<0.001). Conclusions: Despite LV dysfunction, aortic valve replacement appears to change drastically the natural history of severe aortic stenosis. Preoperative LV levels predict different postoperative survival rate and LVEF recovery. [Copyright &y& Elsevier]

Background: Concerns still exist regarding long-term results and freedom from valve-related adverse events in transcatheter aortic valve implantation (TAVI). The aim of this single-center retrospective study was to assess intermediate-term (up to 5-year) clinical and hemodynamic outcomes in patients undergoing TAVI., Methods: From 2007 through 2013, 338 consecutive patients underwent TAVI at our institution. Preoperative variables were defined according to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) definitions, and outcomes were reported according to the Valve Academic Research Consortium (VARC)-2 definitions. Multivariate logistic regression analysis was performed to identify independent predictors of mortality at follow-up., Results: transfemoral (TF) and transapical (TA) TAVI were performed in 233 (69%) and 105 (31%) patients, respectively. All-cause 30-day mortality was 4.4%, with no differences between TA and TF procedures. Thirty-day cardiovascular death, stroke, and myocardial infarction were not different between groups. The acute kidney injury (AKI) rate was higher in the TA group (30.5% versus 11.2%; p < 0.001). Access-related complications were more frequent in the TF group (36.1% versus 11.4%; p < 0.001). Mean follow-up was 22.3 ± 17.8 months (range, 1-74 months). Overall survival rates at 1, 3, and 5 years were 85.5% ± 2.1%, 69.9% ± 3.2%, and 61% ± 4.3%, respectively. Independent predictors of all-cause mortality at follow-up were previous myocardial infarction (odds ratio [OR], 2.7), any grade of paravalvular leak (PVL) (OR, 2.5), and AKI (OR, 3.1). Mean gradient and effective orifice area at follow-up were 10.7 ± 12.0 mm Hg and 1.1 ± 0.9 cm(2)/m(2), respectively., Conclusions: Our data show that TAVI has good early and intermediate-term clinical and hemodynamic outcomes in high-risk or inoperable patients with severe symptomatic aortic valve stenosis. PVL of any grade has a significant impact on survival., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The time-to-treatment is a critical determinant of outcome after acute myocardial infarction. We investigated the relationship between the primary angioplasty (PCI)-related time delay and the benefit of PCI over thrombolytic therapy (TT), considering the time elapsing from symptom onset in 21 randomized trials comparing PCI to TT., Methods: PCI-related time delay was calculated as the median of the "door-to-balloon" time minus the median of the "door-to-needle" time. The survival benefit was defined as the difference between 30-day mortality after TT and after PCI. The relationships between time delay and benefit were assessed by linear regression., Results: PCI-related time delay ranged from 7 to 104 min. Linear regression showed that at a PCI-related delay of 75 min, PCI and TT yielded equivalent reductions in mortality (p = 0.03). When the trials with the longest and shortest delays were excluded, the benefit of PCI over TT was nullified after a delay of 62 min, and every additional 10-min delay produced a 1.1% increase in mortality (p = 0.01). When trials with a symptom duration < 6 hours (median 130 min) were considered, PCI-related delay still correlated with an absolute risk reduction in 30-day mortality with a time to equipoise of 57 min (p = 0.03). Lack of correlation (p = 0.85) was observed in trials enrolling patients within 12 hours of symptom onset (median 185 min)., Conclusions: Our analysis suggests that PCI-related delay substantially modifies the benefit of PCI over TT, particularly in case of patients presenting early following symptom onset.