Age at menopause, extent of coronary artery disease and outcome among postmenopausal women with acute coronary syndromes

Background: Early menopause has been associated with increased cardiovascular mortality, but prospective studies investigating outcomes of postmenopausal women with acute coronary syndromes (ACS) in relation to menopausal age are lacking.Methods: We analyzed the 1-year outcome of 373 women with acute myocardial infarction enrolled in the Ladies ACS study. All patients underwent coronary angiography, with corelab analysis. Menopause questionnaires were administered during admission. Menopausal age below the median of the study population (50 years) was defined as "early menopause". The composite 1-year outcome included all-cause mortality, recurrent myocardial infarction and stroke.Results: The mean age at index ACS was 73 years (IQR 65-83) for women with early menopause, and 74 (IQR 6580) for those with late menopause. Patients with early menopause had more prevalent chronic kidney disease (12.8% vs 5.9%, p=0.03), whereas there were no differences in all other clinical characteristics, extent of coronary disease at angiography (as assessed by Gensini and SYNTAX scores), as well as interventional treatments. Within 1 year, women with late menopause had significantly better outcome as compared with those with early menopause (6.5% vs 15.3%, p=0.007). At logistic regression analysis, late menopause was independently associated with better outcome(OR 0.28; 95% CI 0.12-0.67; p=0.004). With each year's delay in the menopause the adjusted risk decreased by 12% (OR 0.88, 0.77-0.99, p=0.040).Conclusion: Despite comparable clinical and angiographic characteristics, women with late menopausal age experience better outcomes after an ACS as compared with those with early menopause. (c) 2018 Elsevier B.V. All rights reserved

How to solve difficult side branch access?

Safe guidewire placement in the main vessel (MV) and in the side branch (SB) does represent the key point for successful percutaneous coronary interventions (PCI) in bifurcated lesions. During bifurcation PCI, SB wiring is systematically performed as a first step and is often repeated ("rewiring") during the procedure in order to treat the SB after MV stenting. Wiring and rewiring are crucial phases of bifurcation PCI which require, in the most complex cases, specific operator experience. In the present paper, the classic SB wiring techniques necessary for routine bifurcation interventions (antegrade and pullback wiring technique) as well as "advanced" wiring techniques ("reverse wire" technique, Venture-facilitate wiring, MV balloon predilation or debulking) are described. Moreover, the rewiring technique is discussed in detail, with particular attention on the tips and tricks which may facilitate the achievement of optimal result with provisional stenting (pullback rewiring) and help manage bail out situations like acute SB flow impairment after MV stenting

Coronary Protection to Prevent Coronary Obstruction During TAVR: A Multicenter International Registry

Objectives: The aim of this study was to investigate the safety and efficacy of coronary protection by preventive coronary wiring and stenting across the coronary ostia in patients at high risk for coronary obstruction after transcatheter aortic valve replacement (TAVR). Background: Coronary obstruction following TAVR is a life-threatening complication with high procedural and short-term mortality. Methods: Data were collected retrospectively from a multicenter international registry between April 2011 and February 2019. Results: Among 236 patients undergoing coronary protection with preventive coronary wiring, 143 had eventually stents implanted across the coronary ostia after valve deployment. At 3-year follow-up, rates of cardiac death were 7.8% in patients receiving stents and 15.7% in those not receiving stents (adjusted hazard ratio: 0.42; 95% confidence interval: 0.14 to 1.28; p = 0.13). There were 2 definite stent thromboses (0.9%) in patients receiving stents, both occurring after TAVR in \u201cvalve-in-valve\u201d procedures. In patients not receiving stents, there were 4 delayed coronary occlusions (DCOs) (4.3%), occurring from 5 min to 6 h after wire removal. Three cases occurred in valve-in-valve procedures and 1 in a native aortic valve procedure. Distance between the virtual transcatheter valve and the protected coronary ostia <4 mm was present in 75.0% of patients with DCO compared with 30.4% of patients without DCO (p = 0.19). Conclusions: In patients undergoing TAVR at high risk for coronary obstruction, preventive stent implantation across the coronary ostia is associated with good mid-term survival rates and low rates of stent thrombosis. Patients undergoing coronary protection with wire only have a considerable risk for DCO

Different impact of sex on baseline characteristics and major periprocedural outcomes of transcatheter and surgical aortic valve interventions: results of the multicenter Italian OBSERVANT Registry

Background: Despite the widespread use of transcatheter aortic valve implantation (TAVI), the role of sex on outcome after TAVI or surgical aortic valve replacement (AVR) has been poorly investigated. We investigated the impact of sex on outcome after TAVI or AVR. Methods: There were 2108 patients undergoing TAVI or AVR who were enrolled in the Italian Observational Multicenter Registry (OBSERVANT). Thirty-day mortality, major periprocedural morbidity, and transprosthetic gradients were stratified by sex according to interventions. Results: Female AVR patients showed a worse risk profile compared with male AVR patients, given the higher mean age, prevalence of frailty score of 2 or higher, New York Heart Association class of 3 or higher, lower body weight, and preoperative hemoglobin level (P ≤.02). Similarly, female TAVI patients had a different risk profile than male TAVI patients, given a higher age and a lower body weight and preoperative hemoglobin level (P ≤.005), but with a similar New York Heart Association class, frailty score, EuroSCORE (P = NS), a better left ventricular ejection fraction and a lower prevalence of left ventricular ejection fraction less than 30%, porcelain aorta, renal dysfunction, chronic obstructive pulmonary disease, arteriopathy, and previous cardiovascular surgery or percutaneous coronary intervention (P ≤.01). Women showed a smaller aortic annulus than men in both populations (P <.001). Female sex was an independent predictor in the AVR population for risk-Adjusted 30-day mortality (odds ratio [OR], 2.34; P =.043) and transfusions (OR, 1.47; P =.003), but not for risk-Adjusted acute myocardial infarction, stroke, vascular complications, permanent atrioventricular block (P = NS). Female sex was an independent predictor in the TAVI population for risk-Adjusted major vascular complications (OR, 2.92; P =.018) and transfusions (OR, 1.93; P =.003), but proved protective against moderate to severe postprocedural aortic insufficiency (P =.018). Conclusions: Female sex is a risk factor for mortality after aortic valve replacement, for major vascular complications after TAVI, and for transfusions after both approaches. Copyright © 2014 by The American Association for Thoracic Surgery

1-Year Outcomes After Transfemoral Transcatheter or Surgical Aortic Valve Replacement: Results From the Italian OBSERVANT Study.

Tamburino C, Barbanti M, D'Errigo P, Ranucci M, Onorati F, Covello RD, Santini F, Rosato S, Santoro G, Fusco D, Grossi C, Seccareccia F; OBSERVANT Research Group. Collaborators (209) Marra S, Marra S, D'Amico M, Gaita F, Moretti C, De Benedictis M, Aranzulla T, Pistis G, Reale M, Bedogni F, Brambilla N, Ferrario M, Ferrero L, Vicinelli P, Colombo A, Chieffo A, Ferrari A, Inglese L, Casilli F, Ettori F, Frontini M, Antona C, Piccaluga E, Klugmann S, De Marco F, Tespili M, Saino A, Leonzi O, Rizzi A, Grisolia E, Franceschini Grisolia E, Isabella G, Fraccaro C, Bernardi G, Bisceglia T, Armellini I, Vischi M, Parodi E, Vignali L, Ardissimo D, Marzocchi A, Marrozzini C, Cremonesi A, Colombo F, Giannini C, Pierli C, Iadanza A, Santoro G, Meucci F, Berti S, Mariani M, Tomai F, Ghini A, Violini R, Confessore P, Crea F, Giubilato S, Sardella G, Mancone M, Ribichini F, Vassanelli C, Dandale R, Giudice P, Vigorito F, Liso A, Specchia L, Indolfi C, Spaccarotella C, Stabile A, Gandolfo C, Tamburino C, Ussia G, Comoglio C, Dyrda O, Rinaldi M, Salizzoni S, Micalizzi E, Grossi C, Di Gregorio O, Scoti P, Costa R, Casabona R, Del Ponte S, Panisi P, Spira G, Troise G, Messina A, Viganò M, Aiello M, Alfieri O, Denti P, Menicanti L, Agnelli B, Donatelli F, Muneretto C, Frontini M, Rambaldini M, Frontini M, Gamba A, Tasca G, Ferrazzi P, Terzi A, Antona C, Gelpi G, Martinelli L, Bruschi G, Graffigna AC, Mazzucco A, Pappalardo A, Gatti G, Livi U, Pompei E, Coppola R, Gucciardo M, Parodi E, Albertini A, Caprili L, Ghidoni I, Gabbieri D, La Marra M, Aquino T, Gherli T, Policlinico S, Di Bartolomeo R, Savini C, Popoff G, Innocenti D, Bortolotti U, Pratali S, Stefano P, Blanzola C, Glauber M, Cerillo A, Chiaramonti F, Pardini A, Fioriello F, Torracca L, Rescigno G, De Paulis R, Nardella S, Musumeci F, Luzi G, Possati G, Bonalumi G, Covino E, Pollari F, Sinatra R, Roscitano A, Chiariello L, Nardi P, Lonobile T, Baldascino F, Di Benedetto G, Mastrogiovanni G, Piazza L, Marmo J, Vosa C, De Amicis V, Speziale G, Visicchio G, Spirito R, Gregorini R, Specchia L, Villani M, Pano MA, Bortone A, De Luca Tupputi Schinosa L, De Cillis E, Gaeta R, Di Natale M, Cassese M, Antonazzo A, Argano V, Santaniello E, Patanè L, Gentile M, Tribastone S, Follis F, Montalbano G, Pilato M, Stringi V, Patanè F, Salamone G, Ruvolo G, Pisano C, Mignosa C, Bivona A, Cirio EM, Lixi G, Seccareccia F, D'Errigo P, Rosato S, Maraschini A, Badoni G, Tamburino C, Santoro G, Santini F, Grossi C, Ranucci M, Covello RD, Fusco D, Onorato F, De Palma R, Scandotto S, Orlando A, Copello F, Borgia P, Marchetta F, Porcu R. BACKGROUND: There is a paucity of prospective and controlled data on the comparative effectiveness of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in a real-world setting. OBJECTIVES: This analysis aims to describe 1-year clinical outcomes of a large series of propensity-matched patients who underwent SAVR and transfemoral TAVR. METHODS: The OBSERVANT (Observational Study of Effectiveness of SAVR-TAVI Procedures for Severe Aortic Stenosis Treatment) trial is an observational prospective multicenter cohort study that enrolled patients with aortic stenosis (AS) who underwent SAVR or TAVR. The propensity score method was applied to select 2 groups with similar baseline characteristics. All outcomes were adjudicated through a linkage with administrative databases. The primary endpoints of this analysis were death from any cause and major adverse cardiac and cerebrovascular events (MACCE) at 1 year. RESULTS: The unadjusted enrolled population (N = 7,618) included 5,707 SAVR patients and 1,911 TAVR patients. The matched population had a total of 1,300 patients (650 per group). The propensity score method generated a low-intermediate risk population (mean logistic EuroSCORE 1: 10.2 ± 9.2% vs. 9.5 ± 7.1%, SAVR vs. transfemoral TAVR; p = 0.104). At 1 year, the rate of death from any cause was 13.6% in the surgical group and 13.8% in the transcatheter group (hazard ratio [HR]: 0.99; 95% confidence interval [CI]: 0.72 to 1.35; p = 0.936). Similarly, there were no significant differences in the rates of MACCE, which were 17.6% in the surgical group and 18.2% in the transcatheter group (HR: 1.03; 95% CI: 0.78 to 1.36; p = 0.831). The cumulative incidence of cerebrovascular events, and rehospitalization due to cardiac reasons and acute heart failure was similar in both groups at 1 year. CONCLUSIONS: The results suggest that SAVR and transfemoral TAVR have comparable mortality, MACCE, and rates of rehospitalization due to cardiac reasons at 1 year. These data need to be confirmed in longer term and dedicated ongoing randomized trial

1-Year Outcomes After Transfemoral Transcatheter or Surgical Aortic Valve Replacement: Results From the Italian OBSERVANT Study.

BACKGROUND: There is a paucity of prospective and controlled data on the comparative effectiveness of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in a real-world setting. OBJECTIVES: This analysis aims to describe 1-year clinical outcomes of a large series of propensity-matched patients who underwent SAVR and transfemoral TAVR. METHODS: The OBSERVANT (Observational Study of Effectiveness of SAVR-TAVI Procedures for Severe Aortic Stenosis Treatment) trial is an observational prospective multicenter cohort study that enrolled patients with aortic stenosis (AS) who underwent SAVR or TAVR. The propensity score method was applied to select 2 groups with similar baseline characteristics. All outcomes were adjudicated through a linkage with administrative databases. The primary endpoints of this analysis were death from any cause and major adverse cardiac and cerebrovascular events (MACCE) at 1 year. RESULTS: The unadjusted enrolled population (N = 7,618) included 5,707 SAVR patients and 1,911 TAVR patients. The matched population had a total of 1,300 patients (650 per group). The propensity score method generated a low-intermediate risk population (mean logistic EuroSCORE 1: 10.2 ± 9.2% vs. 9.5 ± 7.1%, SAVR vs. transfemoral TAVR; p = 0.104). At 1 year, the rate of death from any cause was 13.6% in the surgical group and 13.8% in the transcatheter group (hazard ratio [HR]: 0.99; 95% confidence interval [CI]: 0.72 to 1.35; p = 0.936). Similarly, there were no significant differences in the rates of MACCE, which were 17.6% in the surgical group and 18.2% in the transcatheter group (HR: 1.03; 95% CI: 0.78 to 1.36; p = 0.831). The cumulative incidence of cerebrovascular events, and rehospitalization due to cardiac reasons and acute heart failure was similar in both groups at 1 year. CONCLUSIONS: The results suggest that SAVR and transfemoral TAVR have comparable mortality, MACCE, and rates of rehospitalization due to cardiac reasons at 1 year. These data need to be confirmed in longer term and dedicated ongoing randomized trials