Among 674 patients, focal LV scar was common (51 percent of patients), and was more commonly noninfarct pattern (33 percent) than infarct pattern (18 percent). Men were more likely to have infarct, as were those with larger ventricles and those with larger mass and lower ejection fraction (EF).

After a median follow-up of 3.6 years, 21.5 percent of patients died (10.4 percent from cardiovascular causes). Using Cox regression, three independent predictors of mortality emerged: age (hazard ratio [HR], 1.5 per 10 years; p=0.009), Society of Thoracic Surgeons (STS) score (HR, 1.1; p=0.007) and scar presence (HR, 2.4; p=0.001).

For each 1 percent of the myocardium scarred, there was an 11 percent increased hazard of mortality. Similar results were found for cardiovascular death, with added predictors of female sex and reduced LVEF. Results were generally similar when patients who underwent SAVR vs. TAVR were analyzed separately.

“Our findings suggest that scar burden might be used to optimize the timing of surgical intervention, with half of patients demonstrating irreversible scar, and a consequent doubling of post-operative medium-term mortality,” the authors write.

Musa TA, Treibel TA, Vassiliou VS, et al. Circulation 2018; Jul 12:[Epub ahead of print].

RETURN TO TOP.

The study found a high prevalence of TR among patients undergoing TAVR, with more than 80 percent having at least mild TR and more than 24 percent having at least moderate TR. Of the 34,576 patients, 19.6 percent (n=6,772) had no TR; 56.1 percent (n=19,393) had mild TR; 19.3 percent (n=6,687) had moderate TR; and 5 percent (n=1,724) had severe TR.

The primary outcome of observed-to-expected in-hospital mortality ratio increased based on TR severity and peaked among those with severe TR. Overall in-hospital mortality was 4.5 percent, with the lowest rate in patients with mild TR (3.9 percent) and the highest rate in patients with severe TR (7.6 percent).

In addition, patients with severe TR had the highest mortality rate at 30 days (11.3 percent), six months (26.8 percent) and one year (34.2 percent). Secondary outcomes of the length of intensive care unit and overall stays also increased incrementally based on TR severity.

The authors note “there was a significant interaction between left ventricle ejection fraction (LVEF) and TR in that severe TR was independently associated with risk-adjusted increased mortality and heart failure readmission for patients with LVEF greater than 30 percent.” Future research should investigate whether these patients would have better outcomes with SAVR.

McCarthy et al., conclude that the effectiveness of TAVR in patients with aortic stenosis and severe TR warrants further research, particularly for lower-risk patients.

McCarthy FH, Vemulapalli S, Li Z, et al. Ann Thorac Surg 2018;105:1121–28.

RETURN TO TOP.

According to the results, 22 percent of patients had carotid artery disease at the time of the TAVR procedure – 17.2 percent had moderate carotid artery disease, 3.2 percent had severe carotid artery disease and 1.6 percent had occlusive carotid artery disease. Patients with carotid artery disease at baseline were more likely to have a history of hypertension, diabetes, stroke or myocardial infarction.

After one year, the primary endpoint of incidence of stroke in patients with and without carotid artery disease, respectively, was 4.5 vs. 4.1 percent. A secondary endpoint of all-cause mortality was 21.5 vs. 19.9 percent, respectively.

Although patients with carotid artery disease had higher cumulative incidence rates of stroke and mortality at 30 days and one year, these differences were not significant after adjusting for patient characteristics.

The researchers conclude that although stroke continues to be a complication in post-TAVR patients, the study suggests that “post-TAVR stroke seems to be because of mechanisms other than carotid artery disease.” Moving forward, their research could be “helpful in focusing attention toward other stroke reduction strategies.”

Kochar A, Li Z, Harrison JK, et al. Circ Cardiovasc Interv 2018;11:e006322.

RETURN TO TOP.

The mean age of the 727 TAVR and 431 SAVR patients was 81 years. Nine percent were classified as malnourished and 33 percent as at-risk for malnutrition. Worse nutritional scores were correlated with worse frailty scores (r=0.31). Unadjusted mortality at one year was higher in malnourished patients than in those with normal nutritional status (28 vs. 10 percent; p<0.01).

Variables independently associated with mortality at one year, after multivariable adjustment, were malnutrition (odds ratio [OR], 1.08 per point decrease in scale); frailty (OR, 1.14 per point decrease in scale); Society of Thoracic Surgeons-Predicted Risk of Mortality (STS-PROM) score (OR, 1.10 per percent); and TAVR (vs. SAVR) procedure (OR, 1.63).

According to the authors, this is the first study to systematically screen for malnutrition and demonstrate it predicts poor outcomes after TAVR and SAVR. They write the findings demonstrate: 1) screening for malnutrition is easy; 2) malnutrition is a risk factor for mid-term mortality and to a lesser extent short-term mortality and major morbidity post procedure; and 3) risk associated with malnutrition persists even after adjusting for physical function and other potential confounders.

The study raises the question of whether pre- and postoperative interventions should be recommended in malnourished cardiac patients to improve postoperative outcomes, they add. Clinical trials are needed to validate the beneficial clinical impact of targeted nutritional interventions in malnourished or at-risk older adults undergoing TAVR or SAVR.

Goldfarb M, Lauck S, Webb JG, et al. Circulation 2018;Jul 5:[Epub ahead of print].

RETURN TO TOP.

Stroke or death within 30 days after revascularization occurred in 158 (7.2 percent) CAS patients and in 84 (3.7 percent) CEA patients. Stroke or death within one year occurred in 248 (11.4 percent) CAS patients and in 163 (7.2 percent) CEA patients.

C statistics for the four short-term outcome models after CAS ranged from 0.55 to 0.64 for the primary outcome in the validation population and were consistently lower than the corresponding C statistics in the development cohorts. The calibration curves of all four models deviated from the ideal calibration slope for patients within the highest risk categories.

For the 19 short-term outcome models after CEA, C statistics ranged from 0.49 to 0.60, indicating poor discriminative performance. The models were unable to distinguish between patients with a low or high risk of the outcome. In the seven long-term models for CAS or CEA, C statistics ranged from 0.59 to 0.67 and were clearly higher compared with those of the short-term outcome models.

According to the authors, differences in study population characteristics between the development cohorts and the validation population may have contributed to the poor external performance of most models. Another reason for the poor external performance could be that clinicians have already identified the high-risk patients for CAS or CEA and have avoided treating these patients.

The authors do not recommend any of the studied models in clinical practice. “Further external validation of existing prediction models or development of new prediction models – preferably in a more heterogeneous study population with sufficient information on predictors and outcomes – is needed to accurately estimate risks after CAS or CEA in individual patients with carotid stenosis,” they write.

Volkers EJ, Algra A, Kappelle LJ, et al. Stroke 2018;49:1880-85.

RETURN TO TOP.