Impact of Chronic Kidney Disease on Outcomes in Transcatheter Aortic Valve Implantation

INTRODUCTION@#Chronic kidney disease (CKD) is a significant comorbidity in aortic stenosis (AS) patients. We examined the impact of baseline CKD, postoperative acute kidney injury (AKI) and CKD progression on clinical outcomes in patients who underwent transcatheter aortic valve implantation (TAVI).@*MATERIALS AND METHODS@#Consecutive patients with severe AS who underwent TAVI were classified into CKD stages 1-2 (≥60 mL/min/1.72m), 3 (30-59 mL/min/1.73m) and 4-5 (<30 mL/min/1.73m or dialysis) based on estimated glomerular filtration rate (eGFR). Primary outcome was mortality and secondary outcomes included 1-year echocardiographic data on aortic valve area (AVA), mean pressure gradient (MPG) and aortic regurgitation (AR).@*RESULTS@#A total of 216 patients were included. Higher eGFR was associated with lower overall mortality (adjusted hazards ratio [AHR] 0.981, 95% confidence interval [CI] 0.968-0.993, = 0.002). CKD 4-5 were associated with significantly higher mortality from non-cardiovascular causes ( <0.05). Patients with CKD 3-5 had higher incidence of moderate AR than those with CKD 1-2 ( = 0.010); no difference in AVA and MPG was seen. AKI patients had higher mortality ( = 0.008), but the effect was attenuated on multivariate analysis (AHR 1.823, 95% CI 0.977-3.403, = 0.059). Patients with CKD progression also had significantly higher mortality (AHR 2.969, 95% CI 1.373-6.420, = 0.006).@*CONCLUSION@#CKD in severe AS patients undergoing TAVI portends significantly higher mortality and morbidity. Renal disease progression impacts negatively on outcomes and identifies a challenging subgroup of patients for optimal management.

Percutaneous transcatheter aortic valve implantation for degenerated surgical bioprostheses: the first case series in Asia with one-year follow-up

<p><b>INTRODUCTION</b>Percutaneous transcatheter aortic valve implantation (TAVI) has become an established therapy for inoperable and high-surgical-risk patients with severe aortic stenosis. Although TAVI in patients with degenerated surgical aortic bioprostheses (i.e. valve-in-valve TAVI) is increasingly reported in Western studies, such data is lacking in Asian patients. We describe the initial experience of valve-in-valve TAVI in Asia.</p><p><b>METHODS</b>Eight patients who underwent valve-in-valve TAVI due to degenerated aortic bioprostheses were enrolled. The mechanism of bioprosthetic valve failure was stenotic, regurgitation or mixed. All procedures were performed via transfemoral arterial access, using the self-expanding CoreValve prosthesis or balloon-expandable SAPIEN XT prosthesis.</p><p><b>RESULTS</b>The mean age of the patients was 71.6 ± 13.2 years and five were male. Mean duration to surgical bioprosthesis degeneration was 10.2 ± 4.1 years. Valve-in-valve TAVI was successfully performed in all patients. CoreValve and SAPIEN XT prostheses were used in six and two patients, respectively. There were no deaths, strokes or permanent pacemaker requirement at 30 days, with one noncardiac mortality at one year. All patients experienced New York Heart Association functional class improvement. Post-procedure mean pressure gradients were 20 ± 11 mmHg and 22 ± 8 mmHg at 30 days and one year, respectively. Residual aortic regurgitation (AR) of more than mild severity occurred in one patient at 30 days. At one year, only one patient had mild residual AR.</p><p><b>CONCLUSION</b>In our experience of valve-in-valve TAVI, procedural success was achieved in all patients without adverse events at 30 days. Good clinical and haemodynamic outcomes were sustained at one year.</p>

Impact of Direct Cardiovascular Laboratory Activation by Emergency Physicians on False-Positive Activation Rates

<p><b>INTRODUCTION</b>Door-to-balloon (DTB) time is critical to ST elevation myocardial infarction (STEMI) patients' survival. Although DTB time is reduced with direct cardiovascular laboratory (CVL) activation by emergency physicians, concerns regarding false-positive activation remain. We evaluate false-positive rates before and after direct CVL activation and factors associated with false-positive activations.</p><p><b>MATERIALS AND METHODS</b>This is a retrospective single centre study of all emergency CVL activation 3 years before and after introduction of direct activation in July 2007. False-positive activation is defined as either: 1) absence of culprit vessel with coronary artery thrombus or ulceration, or 2) presence of chronic total occlusion of culprit vessel, with no cardiac biomarker elevations and no regional wall abnormalities. All false-positive cases were verified by reviewing their coronary angiograms and patient records.</p><p><b>RESULTS</b>A total of 1809 subjects were recruited; 84 (4.64%) identified as false-positives. Incidence of false-positive before and after direct activation was 4.1% and 5.1% respectively, which was not significant (P = 0.315). In multivariate logistic regression analysis, factors associated with false-positive were: female (odds ratio (OR): 2.104 [1.247-3.548], P = 0.005), absence of chest pain (OR: 5.369 [3.024-9.531], P <0.0001) and presence of only left bundle branch block (LBBB) as indication for activation (OR: 65.691 [19.870-217.179], P <0.0001).</p><p><b>CONCLUSION</b>Improvement in DTB time with direct CVL activation by emergency physicians is not associated with increased false-positive activations. Factors associated with false-positive, especially lack of chest pain or LBBB, can be taken into account to optimise STEMI management.</p>

Complete atrioventricular block complicating acute anterior myocardial infarction can be reversed with acute coronary angioplasty

<p><b>INTRODUCTION</b>A retrospective case series of acute anterior myocardial infarction (MI) patients complicated by complete atrioventricular block (AVB) treated with acute percutaneous transluminal coronary angioplasty (PTCA).</p><p><b>CLINICAL PICTURE</b>Eight patients with anterior MI and complete AVB underwent acute PTCA between 2000 and 2005. Mean onset of complete AVB was 16.6 +/- 16.9 hours from chest pain onset.</p><p><b>TREATMENT</b>All patients underwent successful PTCA to the left anterior descending artery.</p><p><b>OUTCOME</b>Complete AVB resolved with PTCA in 88%; mean time of resolution was 89 +/- 144 minutes after revascularisation. One patient had permanent pacemaker implanted at Day 12 after developing an 8-second ventricular standstill during hospitalisation but not pacing-dependent on follow-up. The rhythm on discharge for the other surviving patients was normal sinus rhythm.</p><p><b>CONCLUSION</b>This case series suggests that complete AVB complicating anterior MI is reversible with acute PTCA and survivors are not at increased risk of recurrent AVB. Nevertheless, this condition is associated with extensive myocardial damage and high mortality during the acute hospitalisation was not improved with correction of AVB with temporary pacing.</p>

Late complications following tetralogy of Fallot repair: the need for long-term follow-up

<p><b>INTRODUCTION</b>We report a series of operated tetralogy of Fallot (TOF) patients focusing on complications and outcomes.</p><p><b>MATERIALS AND METHODS</b>Data from TOF patients seen at our centre's adult congenital heart disease clinic was analysed.</p><p><b>RESULTS</b>There were 21 patients: the mean age was 32.2 +/- 12.4 years; the age at first operation was 9.0 +/- 7.9 years; the mean postoperative follow-up duration was 23.5 +/- 12.1 years; and the current New York Heart Association (NYHA) status: I, 82%; II, 4%; III, 14%. Fourteen patients had complete operative notes. All these patients underwent total TOF correction; 2 had staged aortopulmonary shunt with total correction at a mean of 3.2 years later, pulmonary artery patch augmentation in 8 patients and pulmonary valvotomy in 8 patients. Three patients required pulmonary valve homograft replacement for severe pulmonary regurgitation (PR) at 13, 28 and 36 years after the initial corrective operation.</p><p><b>CURRENT INVESTIGATIONS</b>RBBB on ECG (91%), QRS duration 137 +/- 29 ms. Echocardiography showed dilated right ventricular end-diastolic (RVED) diameters (3.2 +/- 0.8 cm); severe PR (67%), residual right ventricular outflow tract obstruction (RVOTO) (42%) and VSD patch leakage (9%). Cardiac magnetic resonance (CMR) (8 patients) showed dilated RVED volumes 252.6 +/- 93.8 mL, indexed RV volume 165.7 +/- 34.8 mL; RV systolic function was preserved in most patients with a RV ejection fraction of 49.5 +/- 5.7%. One patient had atrial tachycardia and another had frequent non-sustained ventricular tachycardia that required radiofrequency ablation.</p><p><b>CONCLUSION</b>Patients with TOF who had full corrective surgery during childhood are now surviving into adulthood. Many challenges arising from complications in the postoperative period remain. It is imperative that adult TOF patients should have regular followup to monitor development and subsequent management of these complications.</p>