Propensity Matched Comparison of Clinical Outcome After Immediate Versus Staged Complete Revascularization in Patients With Acute Coronary Syndrome and Multivessel Disease

Complete revascularization (CR) in patients with acute coronary syndromes (ACS) and multivessel disease (MVD) improves clinical outcomes compared with culprit-only revascularization, but the optimal timing for non–culprit lesions treatment remains unclear. This study evaluated patients presenting with ACS and MVD admitted between January 2015 and September 2021 at the Erasmus University Medical Center. Clinical outcomes were compared between immediate and staged CR in terms of major adverse cardiac and cerebrovascular events (MACCEs), a composite of all-cause mortality, myocardial infarction, stroke, and any unplanned revascularization. A total of 1,400 patients presenting with ACS and MVD who underwent immediate or staged CR were included in this study. Using 1/many propensity score matching without replacement, 299 patients in the staged CR group were matched to 598 patients in the immediate CR group (mean 1:2 ratio), rendering a total of 897 patients for analysis. The median follow-up period was 648 days. MACCE rate was significantly higher in the staged CR group than in the immediate CR group (adjusted hazard ratio [95% confidence interval] 1.60 [1.05 to 2.45], p = 0.03). Furthermore, number of stents, stent length, and contrast usage were significantly greater in the staged revascularization group. Immediate CR was associated with less risk of MACCE than was staged CR. Staged CR required overall more contrast and stent material.</p

Patients with aortic stenosis referred for TAVI: treatment decision, in-hospital outcome and determinants of survival

Aims To assess treatment decision and outcome in patients referred for transcatheter aortic valve implantation (TAVI) in addition to predictive factors of mortality after TAVI. Methods Three-centre prospective observational study including 358 patients. Endpoints were defined according to the Valve Academic Research Consortium. Results Of the 358 patients referred for TAVI, TAVI was performed in 235 patients (65%), surgical aortic valve replacement (AVR) in 24 (7%) and medical therapy (MT) in 99 (28%). Reasons to decline TAVI in favour of AVR/MT were patient preference (29%), peripheral vascular disease (15%) and non-severe aortic stenosis (11%). The logistic EuroSCORE was significantly higher in patients who underwent TAVI and MT in comparison with those undergoing AVR (19 vs. 10%, p=0.007). At 30 days, all-cause mortality and the combined safety endpoint were 9 and 24% after TAVI and 8 and 25% after AVR, respectively. All-cause mortality was significantly lower in the TAVI group compared with the MT group at 6 months, 1 year and 2 years (12% vs. 22%, 21% vs. 33% and 31% vs. 55%, respectively, p<0.001). Multivariable analysis revealed that blood transfusion (HR: 1.19; 95% CI: 1.05-1.33), pre-existing renal failure (HR: 1.18; 95% CI: 1.06-1.33) and STS score (HR: 1.06; 95% CI: 1.02-1.10) were independent predictors of mortality at a median of 10 (IQR: 3-23) months after TAVI. Conclusions Approximately two-thirds of the patients referred for TAVI receive this treatment with gratifying short- and long-term survival. Another 7% underwent AVR. Prognosis is poor in patients who do not receive valve replacement therapy

Incidence, determinants and consequences of delirium in older patients after transcatheter aortic valve implantation

Background: delirium is an event leading to negative health outcomes and increased mortality in patients. The aim of this study is to investigate the incidence, determinants and consequences of post-operative delirium (POD) in older patients undergoing transcatheter aortic valve implantation (TAVI). Methods: The TAVI Care and Cure program is a prospective, observational registry in patients referred for TAVI at Erasmus University Medical Centre. The presence of delirium was evaluated by daily clinical assessment by a geriatrician pre- and up to 3 days post-TAVI. Mortality data were obtained from the Dutch Civil Registry. Results: A total of 543 patients underwent TAVI between January 2014 and December 2017. Overall, the incidence of POD was 14% (75/543 patients) but declined from 18% in 2014 to 7% in 2017 (P = 0.009). Patients who developed POD were older (81.9 ± 5.8 versus 78.6 ± 8.3 years, P < 0.001), had higher prevalence of renal dysfunction and prior stroke (54% versus 40%, P = 0.02; 31% versus 18%, P = 0.01) and were more often frail (32% versus 25%, P = 0.02). From a procedural perspective, general anesthesia (odds ratios (OR), 2.31; 95% CI, 1.40–3.83; P = 0.001), non-transfemoral access (OR, 2.37; 95% CI, 1.20–4.70; P = 0.01) and longer procedural time (OR, 1.01; 95% CI, 1.01–1.02; P < 0.001) were significantly associated with POD. One-year survival rate was 68% among patients who had suffered a POD and was 85% in patients without a POD (hazard ratio’s 1.8 (95% CI 1.01–3.10), P = 0.045). Conclusion: POD frequently occurs after TAVI and is associated with increased mortality. It might be speculated that patient selection and the minimalistic approach of TAVI may reduce the frequency of delirium

Direct Stenting versus Conventional Stenting in Patients with ST-Segment Elevation Myocardial Infarction—A COMPARE CRUSH Sub-Study

Background: Direct stenting (DS) compared with conventional stenting (CS) after balloon predilatation may reduce distal embolization during percutaneous coronary intervention (PCI), thereby improving tissue reperfusion. In contrast, DS may increase the risk of stent underexpansion and target lesion failure. Methods:In this sub-study of the randomized COMPARE CRUSH trial (NCT03296540), we reviewed the efficacy of DS versus CS in a cohort of contemporary, pretreated ST-segment elevation myocardial infarction (STEMI) patients undergoing primary PCI. We compared DS versus CS, assessing (1) stent diameter in the culprit lesion, (2) thrombolysis in myocardial infarction (TIMI) flow in the infarct-related artery post-PCI and complete ST-segment resolution (STR) one-hour post-PCI, and (3) target lesion failure at one year. For proportional variables, propensity score weighting was applied to account for potential treatment selection bias. Results: This prespecified sub-study included 446 patients, of whom 189 (42%) were treated with DS. Stent diameters were comparable between groups (3.2 ± 0.5 vs. 3.2 ± 0.5 mm, p = 0.17). Post-PCI TIMI 3 flow and complete STR post-PCI rates were similar between groups (DS 93% vs. CS 90%, adjusted OR 1.16 [95% CI, 0.56–2.39], p = 0.69, and DS 72% vs. CS 58%, adjusted OR 1.29 [95% CI 0.77–2.16], p = 0.34, respectively). Moreover, target lesion failure rates at one year were comparable (DS 2% vs. 1%, adjusted OR 2.93 [95% CI 0.52–16.49], p = 0.22). Conclusion:In this contemporary pretreated STEMI cohort, we found no difference in early myocardial reperfusion outcomes between DS and CS. Moreover, DS seemed comparable to CS in terms of stent diameter and one-year vessel patency.</p

Impact of frailty on health-related quality of life 1 year after transcatheter aortic valve implantation

Background: Transcatheter aortic valve implantation (TAVI) brings symptom relief and improvement in health-related quality of life (HRQoL) in the majority of patients treated for symptomatic, severe aortic stenosis. However, there is a substantial group of patients that do not benefit from TAVI. The aim of this study is to investigate the impact of frailty on HRQoL 1 year after TAVI. Methods: The TAVI Care & Cure Program is an ongoing, prospective, observational study including patients referred for TAVI to our institution. A comprehensive geriatric assessment was performed to evaluate existence of frailty using the Erasmus Frailty Score (EFS). HRQoL was assessed using the EQ-5D-5 L at baseline and 1 year after TAVI. Results: 239 patients underwent TAVI and completed HRQoL assessment 1 year after TAVI. Seventy (29.3%) patients were classified as frail (EFS ≥ 3). In non-frail patients, the EQ-5D-5 L index did not change (0.71(± 0.22) to 0.68(± 0.33) points, P = 0.22); in frail patients, the EQ-5D-5 L index decreased from 0.55(±0.26) to 0.44 points (±0.33) (P = 0.022). Frailty was an independent predictor of deteriorated HRQoL 1 year after TAVI (OR 2.24, 95% CI 1.07–4.70, P = 0.003). In frail patients, the absence of peripheral artery disease (OR 0.17, 95% 0.05–0.50, P = 0.001) and renal dysfunction (OR 0.13, 95% CI 0.04–0.41, P = <0.001) at baseline was associated with improved HRQoL 1 year after TAVI. Conclusion: Frailty is associated with deterioration of HRQoL 1 year after TAVI. Notably, HRQoL did improve in frail patients with no peripheral arterial disease or renal impairment at baseline