Faculty Bibliography

In high-risk or inoperable patients with severe symptomatic aortic stenosis, transcatheter aortic valve implantation (TAVI) is a proven alternative to standard (i.e., medical) therapy or surgical aortic valve replacement. Concerns have been raised, however, about patients who survive the procedure but have short subsequent survival. The aim of this study was therefore to identify correlates of early out-of-hospital mortality (EOHM) in patients who underwent successful TAVI, rendering TAVI potentially "futile." Patients who were discharged from the hospital and survived >30 days but <12 months after TAVI were identified (the EOHM group). Independent predictors of EOHM were explored, including patient-level factors and procedural nonfatal major complications (NFMCs). A sensitivity analysis was also performed, excluding patients with NFMCs. Among 485 patients who were discharged from the hospital and survived 30 days after TAVI, 101 (21%) were dead within 1 year. Independent predictors of EOHM included serum creatinine, liver disease, coagulopathy, mental status, body mass index, male gender, and Society of Thoracic Surgeons score. Although NFMCs were strongly associated with EOHM, patient-level risk factors for EOHM were similar between patients who did and those who did not experience NFMCs. Compared with standard therapy, TAVI patients with EOHM had similar 6-month 6-minute walk distances and functional classes, with higher rates of repeat hospitalization. In conclusion, in high-risk or inoperable patients who underwent TAVI and were discharged and alive at 30 days, EOHM was not infrequent and was determined largely by presenting characteristics and the occurrence of periprocedural NFMCs. Careful screening and minimization of NFMCs may maximize the benefit of TAVI.

BACKGROUND:Transcatheter aortic valve replacement (TAVR) is a less invasive option for treatment of high-risk patients with severe aortic stenosis. We sought to identify patients at high risk for poor outcome after TAVR using a novel definition of outcome that integrates quality of life with mortality. METHODS AND RESULTS/RESULTS:Among 2137 patients who underwent TAVR in the PARTNER (Placement of Aortic Transcatheter Valve) trial or its associated continued access registry, quality of life was assessed with the Kansas City Cardiomyopathy Questionnaire-Overall Summary Scale (KCCQ-OS; range 0-100, where a higher score equates to a better quality of life) at baseline and at 1, 6, and 12 months after TAVR. A poor 6-month outcome (defined as death, KCCQ-OS score <45, or ≥10-point decrease in KCCQ-OS score compared with baseline) occurred in 704 patients (33%). Using a split-sample design, we developed a multivariable model to identify a parsimonious set of covariates to identify patients at high risk for poor outcome. The model demonstrated moderate discrimination (c-index=0.66) and good calibration with the observed data, performed similarly in the separate validation cohort (c-index=0.64), and identified 211 patients (10% of the population) with a ≥50% likelihood of a poor outcome after TAVR. A second model that explored predictors of poor outcome at 1 year identified 1102 patients (52%) with ≥50% likelihood and 178 (8%) with ≥70% likelihood of a poor 1-year outcome after TAVR. CONCLUSIONS:Using a large, multicenter cohort, we have developed and validated predictive models that can identify patients at high risk for a poor outcome after TAVR. Although model discrimination was moderate, these models may help guide treatment choices and offer patients realistic expectations of outcomes based on their presenting characteristics. CLINICAL TRIAL REGISTRATION URL/BACKGROUND:http://www.clinicaltrials.gov. Unique identifier: NCT00530894.

Due to the aging and increasingly complex nature of our patients, frailty has become a high-priority theme in cardiovascular medicine. Despite the recognition of frailty as a pivotal element in the evaluation of older adults with cardiovascular disease (CVD), there has yet to be a road map to facilitate its adoption in routine clinical practice. Thus, we sought to synthesize the existing body of evidence and offer a perspective on how to integrate frailty into clinical practice. Frailty is a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors. Upward of 20 frailty assessment tools have been developed, with most tools revolving around the core phenotypic domains of frailty-slow walking speed, weakness, inactivity, exhaustion, and shrinking-as measured by physical performance tests and questionnaires. The prevalence of frailty ranges from 10% to 60%, depending on the CVD burden, as well as the tool and cutoff chosen to define frailty. Epidemiological studies have consistently demonstrated that frailty carries a relative risk of >2 for mortality and morbidity across a spectrum of stable CVD, acute coronary syndromes, heart failure, and surgical and transcatheter interventions. Frailty contributes valuable prognostic insights incremental to existing risk models and assists clinicians in defining optimal care pathways for their patients. Interventions designed to improve outcomes in frail elders with CVD such as multidisciplinary cardiac rehabilitation are being actively tested. Ultimately, frailty should not be viewed as a reason to withhold care but rather as a means of delivering it in a more patient-centered fashion.

In recent years, experience with transcatheter aortic valve implantation has led to improved outcomes in elderly patients with severe aortic stenosis (AS) who may not have previously been considered for intervention. These patients are often frail with significant comorbid conditions. As the prevalence of AS increases, there is a need for improved assessment parameters to determine the patients most likely to benefit from this novel procedure. This review discusses the diagnostic criteria for severe AS and the trials available to aid in the decision to refer for aortic valve procedures in the elderly.

BACKGROUND:Many acute coronary syndrome (ACS; myocardial infarction and unstable angina) patients are rehospitalized within 30 days of discharge, and recent US health policy initiatives have tied hospital Medicare reimbursement to 30-day readmission rates. Patient-perceived psychological stress is thought to impact prognosis after ACS. A recently offered "posthospital syndrome" model of 30-day readmissions posits that the stress level at the time of the index hospitalization itself may increase 30-day risk for readmission in ACS patients. We tested whether self-reported stress in the days surrounding the ACS hospitalization was associated with increased risk for readmission within 30 days. METHODS:A mean of 8.5 days after discharge, 342 consecutively hospitalized ACS patients reported on how often they felt stress during the past two weeks. Readmission within 30 days of hospital discharge for any cause was determined by follow-up telephone calls to patients and confirmed by hospital records. RESULTS:Overall, 40 (11.7%) participants were readmitted within 30 days, and 22 (6.4%) reported high stress. Readmission within 30 days was more common in patients with high stress (5 admissions, 23%) than in patients with low stress (35 admissions, 11%). After adjustment for demographic and clinical factors, as well as depression, high stress was associated with a 3-fold increased risk of 30-day readmission (HR = 3.21, 95% CI = 1.13, 9.10). CONCLUSIONS:Previous research has shown that stress in the days surrounding a hospitalization can mark long-term cardiovascular risk, but this is the first study to test a hypothesis of the posthospital syndrome model of early readmission. Further research is needed to confirm the association between stress and readmission risk, and to identify the processes of hospitalization that could be modified to both reduce the stress experienced and that would also be effective for reducing readmissions.

BACKGROUND:The effect of preoperative mitral regurgitation (MR) on clinical outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) is controversial. This study sought to examine the impact of moderate and severe MR on outcomes after TAVR and surgical aortic valve replacement (SAVR). METHODS AND RESULTS/RESULTS:Data were drawn from the randomized Placement of Aortic Transcatheter Valve (PARTNER) Trial cohort A patients with severe, symptomatic aortic stenosis undergoing either TAVR (n=331) or SAVR (n=299). Both TAVR and SAVR patients were dichotomized according to the degree of preoperative MR (moderate/severe versus none/mild). At baseline, moderate or severe MR was reported in 65 TAVR patients (19.6%) and 63 SAVR patients (21.2%). At 30 days, among survivors who had isolated SAVR/TAVR, moderate/severe MR had improved in 25 SAVR patients (69.4%) and 30 TAVR patients (57.7%), was unchanged in 10 SAVR patients (27.8%) and 19 TAVR patients (36.5%), and worsened in 1 SAVR patient (2.8%) and 4 TAVR patients (5.8%; all P=NS). Mortality at 2 years was higher in SAVR patients with moderate or severe MR than in those with mild or less MR (49.8% versus 28.1%; adjusted hazard ratio, 1.73; 95% confidence interval, 1.01-2.96; P=0.04). In contrast, MR severity at baseline did not affect mortality in TAVR patients (37.0% versus 32.7%, moderate/severe versus none/mild; hazard ratio, 1.14; 95% confidence interval, 0.72-1.78; P=0.58; P for interaction=0.05). CONCLUSIONS:Both TAVR and SAVR were associated with a significant early improvement in MR in survivors. However, moderate or severe MR at baseline was associated with increased 2-year mortality after SAVR but not after TAVR. TAVR may be a reasonable option in selected patients with combined aortic and mitral valve disease. CLINICAL TRIAL REGISTRATION URL/BACKGROUND:http://www.clinicaltrials.gov. Unique identifier: NCT00530894.

BACKGROUND:The diagnosis of cardiac amyloidosis often requires a right heart catheterization with an endomyocardial biopsy. Although the central hemodynamics of the three main types of cardiac amyloidosis (AL, ATTRm, ATTRwt) have previously been described, the prognostic significance of these variables have not been fully explored. OBJECTIVE:To compare the right heart catheterization variables between the three sub-groups of AL, ATTRm and ATTRwt, and describe if any of these variables are of prognostic significance. METHODS:We conducted a retrospective cohort analysis of patients with biopsy confirmed cardiac amyloidosis between 1997 and 2011. Central hemodynamics as well as baseline clinical and laboratory characteristics were collected at the time of diagnosis. The prognostic significance of the central hemodynamics was evaluated. The internal review board of our institution approved the study. RESULTS:Patients with ATTR and AL cardiac amyloidosis had similar central hemodynamic profiles of high filling pressures and low cardiac output with the exception of ATTR having higher pulmonary artery systolic pressure and pulmonary vascular resistance. Right atrial pressure (RAP), pulmonary artery diastolic pressure, pulmonary capillary wedge pressure and pulmonary artery saturation were individual predictors of death or heart transplantation (p < 0.05). However, when each was added to RAP they did not increase the predictive value compared to RAP alone. CONCLUSION/CONCLUSIONS:The central hemodynamics of ATTR and AL amyloidosis were found to be similar and RAP emerged as the main predictor of transplant-free survival.