Briasoulis, Αlexandros

AbstractBackgroundTo assess the impact of post transcatheter aortic valve implantation (TAVI) mild paravalvular regurgitation (PVR) on mortality. More than moderate PVR after TAVI has decreased with the advent of new‐generation prosthetic valves. However, mild PVR remains common and its clinical impact has been inconsistent. We aimed to assess the impact of mild PVR through meta‐analysis.Methods and ResultsA systematic literature search was conducted through PUBMED and EMBSE. Manuscripts that reported hazard ratio (HR) with 95% confidence interval (CI) for clinical outcome of interest (all‐cause and cardiac mortality) has been included. Random‐effects model was used for calculation of HR. A total of 25 articles including total of 21,018 patients were finally included for quantitative synthesis (meta‐analysis). Our pooled analysis demonstrated higher all‐cause mortality in patients with mild PVR compared to none/trivial PVR (HR 1.26, 95%CI 1.11–1.43, I2=45%, p < 0.001) (follow up duration range 6 months to 5 years). Significant heterogeneity among studies was observed (p for heterogeneity = 0.005). Egger's test showed no evidence of publication bias. Cardiovascular mortality was increased in patients with mild PVR compared with none/trivial PVR (HR 1.28, 95%CI 1.05–1.57, I2=8%, p = 0.02) (follow up duration range 1–3 years).ConclusionsMild PVR was associated with increased all‐cause and cardiovascular mortality after TAVI. Whether further interventions in mild PVR is of benefit, has yet to be determined.

BackgroundThere is lack of evidence of the impact of varying season on heart failure (HF) hospitalization outcomes in the U.S.HypothesisHF hospitalization outcomes exhibit significant seasonal variation in the U.S.MethodsUsing data from the National Inpatient Sample (2011‐2013), seasonal variation was classified based on meteorological classification of Northern Hemisphere–Spring, Summer, Fall, & Winter–and analysis was conducted via multivariable‐adjusted mixed‐effect model.ResultsAn estimated 2.8 million adults were hospitalized for HF in the U.S. from 2011 to 2013. Of all hospitalizations, admissions were highest in Winter (27%), followed by Spring (26%), Fall (24%), and Summer (23%). The overall mortality rate was 3.1%. Compared with Spring, there was significantly lower mortality in Summer (odds ratio [OR]: 0.95, 95% CI: 0.91‐0.99) and Fall (OR: 0.94, 95% CI: 0.89‐0.98), but the highest mortality was in Winter (OR: 1.06, 95% CI: 1.02‐1.11). In addition, mean length of stay and median cost of hospitalization were highest in Winter (5.3 days, USD7459, respectively) and lowest in Summer (5.1 days, USD7181, respectively). However, age and sex differences existed (e.g. seasonal variation in inpatient mortality was only significant for patients age ≥65 years, and, comparedwith the Spring season, males had higher risk of inpatient mortality in Winter (OR: 1.10, 95% CI: 1.04‐1.17) and females had lower risk of inpatient mortality in Summer (OR: 0.94, 95% CI: 0.88‐1.00) and Fall (OR: 0.92, 95% CI: 0.87‐0.98).ConclusionsAmong HF patients in the U.S., hospitalization outcomes were worse in Winter but better in Summer.

AbstractObjectivesTo summarize the published data of combined transcatheter aortic and mitral valve intervention (CTAMVI).BackgroundCTAMVI, a combination of either transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve‐in‐valve (TAViV) and transcatheter mitral valve replacement (TMVR), transcatheter mitral valve‐in‐valve/valve‐in‐ring (TMViV/ViR), or percutaneous mitral valve repair (PMVR) is an attractive alternative in high‐surgical risk patients with combined aortic and mitral valve disease. However, its procedural details and clinical outcomes have not been well described.MethodsWe performed a systematic review of all the published articles from PUBMED and EMBASE.ResultsA total of 37 studies with 60 patients were included. The indication for CTAMVI was high or inoperable surgical risk and symptomatic severe aortic stenosis (92%) or severe aortic regurgitation (8%) combined with moderate to severe/severe mitral stenosis (30%) or moderate/severe mitral regurgitation (65%) or both (5%). In majority of the cases, aortic valve intervention was performed prior to the mitral valve. Mortality rate were 25% for TAVR + TMVR (range 42 days to 10 months), 17% for TAVR + TMViV/ViR (range 13 days to 6 months), 0% for TAViV + TMViV/ViR (range 6–365 days), and 15% for TAVR/ViV + PMVR (range 17 days to 419 days). Significant (more than moderate) paravalvular regurgitation post‐procedure was rare.ConclusionsCTAMVI appears to confer reasonable clinical outcome. Further large study is warranted to clarify the optimal strategy, procedural details and clinical outcomes in the future.

AbstractBackgroundEvidence suggests that medical service offerings vary by hospital teaching status. However, little is known about how these translate to patient outcomes. We therefore sought to evaluate this gap in knowledge in patients undergoing Transcatheter aortic valve replacement (TAVR) in the United States.MethodsThis study was conducted using the National Inpatient Sample (NIS) in the United States from 2011 to 2014. Teaching status was classified, as teaching vs. nonteaching and endpoints were clinical outcomes, length of stay and cost. Procedure‐related complications were identified via ICD‐9 coding and analysis was performed via mixed effect model.ResultsAn estimated 33,790 TAVR procedures were performed in the U.S between 2011 and 2014, out of which 89.3% were in teaching hospitals. Mean (SD) age was 81.4 (8.5) and 47% were females. There was no significant difference between teaching versus nonteaching hospitals in regards to the primary outcome of in‐hospital mortality and secondary outcomes of several cardiovascular and other end points except for a high rates of acute kidney injury (AKI) (OR: 1.34 [95% CI, 1.04–1.72]) and lower rate for use of mechanical circulatory support devices in teaching vs. nonteaching centers. The mean length of stay was significantly higher in teaching hospitals (7.7 days) vs. nonteaching hospitals (6.8 days) (P = 0.002) and so was the median cost of hospitalization (USD 50,814 vs. USD 48, 787, P = 0.02) for teaching vs. nonteaching centers.ConclusionMost TAVR related short‐term outcomes including all cause in‐hospital mortality are about the same in teaching and nonteaching hospitals. However, AKI, length of hospital stay and TAVR related cost were significantly higher in teaching than nonteaching hospitals. There was more use of mechanical circulatory support in nonteaching than teaching hospitals.

BACKGROUNDThere is a concerted push for adopting a minimalist strategy with emphasis on early hospital discharge for patients undergoing Transcatheter aortic valve implantation (TAVI). However, studies on discharge patterns and predictors of early discharge (≤3 days post‐TAVI) are sparse, in the United States.METHODSWe analyzed using Healthcare Utilization Project, Nationwide Inpatient Sample database, 2011‐2012. A total of 7321 TAVI procedures were identified. We compared in‐hospital outcomes between early and late discharge cohorts, and determined the predictors of early discharge. Correlation of costs and post‐TAVI length of stay was also performed.RESULTSEarly discharge rate post‐TAVI was about 21% in the United States, in 2011‐2012. Overall mean age was 81 years. In‐hospital adverse outcomes post‐TAVI were higher in late discharge cohort (P < 0.001). Mean length of stay post‐TAVI (7.7 days vs 2.6 days) and costs ($208 752 vs $157 663) were significantly higher in late discharge than early discharge cohort. Females, bleeding, blood transfusions, stroke, permanent pacemakers, mechanical circulatory support, acute kidney injury were associated with significantly lower adjusted odds for early discharge. Transfemoral TAVI approach, prior aortic valvuloplasty, and procedure year 2012 were associated with significantly higher odds for early discharge. We observed positive correlation between costs of hospitalization and post‐TAVI length of stay (R = 0.58; P < 0.001).CONCLUSIONSFemales, bleeding, blood transfusions, stroke, permanent pacemakers, mechanical circulatory support devices, renal failure were associated with lower odds for early discharge. Transfemoral approach and prior aortic valvuloplasty increased the likelihood for early discharge. Post‐TAVI length of stay was associated with significantly higher hospitalization costs.