Albumin Is Predictive of 1-Year Mortality After Transcatheter Aortic Valve Replacement.

BACKGROUND: A validated model for predicting 1-year outcomes after transcatheter aortic valve replacement (TAVR) does not exist. TAVR-specific risk models may benefit from frailty markers, and sarcopenia may represent an objective frailty marker. This study assessed the predictive ability of sarcopenia and frailty markers on 1-year mortality after TAVR. METHODS: We evaluated 470 patients undergoing TAVR at a single center. Frailty was assessed using four markers: gait speed, hand grip strength, serum albumin, and Katz activities of daily living. Sarcopenia was measured as the cross-sectional psoas muscle area on pre-TAVR computed tomography. Performance of four models incorporating The Society of Thoracic Surgeons Predicted Risk of Mortality, frailty, or sarcopenia metrics, or both, for predicting 1-year mortality was assessed with area under the curve, Hosmer-Lemeshow statistics, and calibration plots. RESULTS: A total of 63 deaths (13.4%) deaths occurred by 1 year. The Society of Thoracic Surgeons Predicted Risk of Mortality alone was poorly predictive of 1-year mortality (area under the curve, 0.52; 95% confidence interval, 0.42 to 0.68). Only the model including sarcopenia and all frailty markers (area under the curve, 0.61; 95% confidence interval, 0.53 to 0.68) significantly improved predictive ability compared with The Society of Thoracic Surgeons Predicted Risk of Mortality alone (p = 0.05). Albumin was the only frailty marker significantly associated with increased risk for 1-year mortality (p = 0.03). Psoas muscle area, as a surrogate for sarcopenia, was not significantly associated with increased risk for 1-year mortality. CONCLUSIONS: Most of the commonly used pre-TAVR risk assessments are poorly predictive of 1-year mortality. Albumin was the only frailty marker that was associated with higher mortality. Future studies should investigate whether optimization of nutritional status can improve outcomes after TAVR.

Description of a Method to Obtain Complete One-Year Follow-Up in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.

The Centers for Medicare and Medicaid Services National Coverage Determination requires centers performing transcatheter aortic valve implantation (TAVI) to report clinical outcomes up to 1 year. Many sites encounter challenges in obtaining complete 1-year follow-up. We report our process to address this challenge. A multidisciplinary process involving clinical personnel, data and quality managers, and research coordinators was initiated to collect TAVI data at baseline, 30 days, and 1 year. This process included (1) planned clinical follow-up of all patients at 30 days and 1 year; (2) query of health-care system-wide integrated data warehouse (IDW) to ascertain last date of clinical contact within the system for all patients; (3) online obituary search, cross-referencing for unique patient identifiers to determine if mortality occurred in remaining unknown patients; and (4) phone calls to remaining unknown patients or patients' families. Between January 2012 and December 2016, 744 patients underwent TAVI. All 744 patients were eligible for 30-day follow-up and 546 were eligible for 1-year follow-up. At routine clinical follow-up of 22 of 744 (3%) patients at 30 days and 180 of 546 (33%) patients at 1 year had unknown survival status. The integrated data warehouse query confirmed status-alive for an additional 1 of 22 patients at 30 days (55%) and 91 of 180 patients at 1 year (51%). Obituaries were identified for 23 of 180 additional patients at 1 year (13%). Phone contact identified the remaining unknown patients at 30 days and 1 year, resulting in 100% known survival status for patients at 30 days (744 of 744) and at 1 year (546 of 546). In conclusion, using a comprehensive approach, we were able to determine survival status in 100% of patients who underwent TAVI.

Balloon aortic valvuloplasty to improve candidacy of patients evaluated for transcatheter aortic valve replacement.

OBJECTIVES: Evaluate the role of balloon aortic valvuloplasty (BAV) in improving candidacy of patients for transcatheter aortic valve replacement (TAVR). BACKGROUND: Patients who are not candidates for TAVR may undergo BAV to improve functional and clinical status. METHODS: 117 inoperable or high-risk patients with critical aortic stenosis underwent BAV as a bridge-to-decision for TAVR. Frailty measures including gait speed, serum albumin, hand grip, activities of daily living (ADL); and NYHA functional class before and after BAV were compared. RESULTS: Mean age was 81.6 ± 8.5 years and the mean Society of Thoracic Surgeons predicted risk of mortality was 9.57 ± 5.51, with 19/117 (16.2%) patients non-ambulatory. There was no significant change in mean GS post-BAV, but all non-ambulatory patients completed GS testing at follow-up. Albumin and hand grip did not change after BAV, but there was a significant improvement in mean ADL score (4.85 ± 1.41 baseline to 5.20 ± 1.17, P = 0.021). The number of patients with Class IV congestive heart failure (CHF) was significantly lower post BAV (71/117 [60.7%] baseline versus 18/117 [15.4%], P = 0.008). 78/117 (66.7%) of patients were referred to definitive valve therapy after BAV. CONCLUSIONS: When evaluating frailty measures post BAV, we saw no significant improvement in mean GS, however, we observed a significant improvement in non-ambulatory patients and ADL scores. We also describe improved Class IV CHF symptoms. With this improved health status, the majority of patients underwent subsequent valve therapy, demonstrating that BAV may improve candidacy of patients for TAVR.

Long-term fate of patients discharged to extended care facilities after cardiovascular surgery.

BACKGROUND: The Society of Thoracic Surgeons predictive algorithms can be used to help patients understand the risks in having a surgical procedure. However, elderly patients are frequently more concerned about the quality of their remaining life and whether they will return home. Currently, we have no predictors of which patients are likely to return to independent living after surgery. We followed patients discharged home or to an extended care facility to determine which patients were most likely to return home and be alive at one year. METHODS: This single-hospital, retrospective study followed 590 cardiac surgery patients (January 2008 to December 2009) for at least 1 year after discharge. Follow-up data were collected by contacting facilities, patients, and families, and Social Security Death Index searches. RESULTS: At hospital discharge, 84.4% went home, 3.7% to rehab, 7.5% to skilled nursing facilities (SNF), and 4.4% to a long-term acute care facility (LTAC). Predictors for facility discharge include increasing age, female, dialysis, emergent status, procedures other than CAB, preoperative stroke, and moderate to severe tricuspid insufficiency. The most significant predictors of dying or still being in a facility at 1 year include being on dialysis, right heart failure, and having chronic lung disease. Considering perioperative complications, requiring prolonged ventilation decreases the odds of being home and alive at 1 year by 67%: one-year survival at home, 95.4%; rehabilitation, 63.6%; SNF, 52.3%; and LTAC, 30.8%. CONCLUSIONS: Many patients discharged to extended care do not return to their previous lifestyle; only 30.8% of those requiring care in a LTAC facility are alive at home at 1 year.

Long-term monitoring after surgical ablation for atrial fibrillation: how much is enough?

INTRODUCTION: Evaluating and comparing the success of surgical ablation techniques in the treatment of atrial fibrillation is complicated by clinicians' use of varying techniques to measure the burden of atrial fibrillation after ablation. Intuitively, one would expect longer monitoring to be more accurate, picking up atrial fibrillation events occurring at a low rate, but how long is long enough? This study compared rates of normal sinus rhythm recorded after atrial fibrillation ablation in a cohort of patients monitored for a range of durations. METHODS: Two hundred fifty-four patients (50.4% paroxysmal) underwent surgical ablation for treatment of atrial fibrillation. All patients were monitored at 6 months with both electrocardiography and either an event monitor or implanted pacemaker device that could be interrogated. Event monitoring and pacemaker data were analyzed for rhythm at 24 hours, 7 days, and 14 days; pacemaker data were also analyzed at 3 months. RESULTS: In the overall group, we found that rates of normal sinus rhythm detected were greatest with electrocardiography (91.7%) and decreased significantly at each of the longer durations (88.2% at 24 hours, 82.7% at 7 days, 81.1% at 14 days). Pacemaker data from a subset of patients revealed minimal or no statistically significant changes from 7 days to 3 months. Results were consistent across types of atrial fibrillation. CONCLUSIONS: These findings suggest that rhythm measurements in patients with atrial fibrillation differ according to the measurement duration used. We recommend longer-term monitoring, with 7 days providing both good accuracy and good patient compliance.

Totally thorascopic surgical ablation of persistent AF and long-standing persistent atrial fibrillation using the "Dallas" lesion set.

Minimally invasive surgery consisting of bipolar radiofrequency pulmonary vein (PV) isolation and limited ganglionated plexus ablation is effective in eliminating atrial fibrillation (AF) in patients with paroxysmal AF but is less effective in those with persistent AF or long-standing persistent AF. The purpose of this study was examine the results of minimally invasive surgery incorporating an additional set of radiofrequency ablation lines replicating a left-sided Cox maze III procedure. Thirty patients with persistent AF (n = 10) or long-standing persistent AF (n = 20) underwent minimally invasive surgery with an extended lesion set and PV isolation for a minimum follow-up of 6 months. Linear lesions were created at the roof line, at the anterior line, and between the roof line and the left atrial appendage. All patients underwent limited ganglionated plexus ablation and left atrial appendage excision as well as PV isolation verification. Block across the roof and anterior lines was confirmed in 29 (96.6%) of the 30 patients. Follow-up included 2-week event monitoring with auto-trigger in 21 patients, pacemaker interrogation in 8, and ECG in 1 who was in AF and refused longer-term monitoring. No operative mortality or major morbidity occurred. At 6 months, 24 (80%) of the 30 patients were free of AF: 15 (75%) with long-standing persistent AF and 9 (90%) with persistent AF. Among the six failures, burden of AF was low: one had 1 episode >15 seconds, two had 4 episodes, one had 6 episodes, one had >50 episodes, and one had AF on ECG and refused further monitoring. Early results of minimally invasive surgery with a new extended linear lesion set suggest increased efficacy over PV isolation and limited ganglionated plexus ablation in patients with persistent AF or long-standing persistent AF.