RESUMO
BACKGROUND: Whether patients with reduced left ventricular function present worse outcome after transcatheter aortic valve implantation (TAVI) is controversial. The aim of this study was to assess the impact of baseline severe impairment of left ventricular ejection fraction (LVEF) on mortality after TAVI. METHODS: Six-hundred-forty-nine patients with aortic stenosis underwent TAVI with the CoreValve system (92.8%) or the Edwards SAPIEN valve system (7.2%). Baseline LVEF was measured by the echocardiographic Simpson method. The impact of LVEF ≤ 30% on mortality was assessed by Cox regression. RESULTS: Patients with LVEF ≤ 30% (n = 63), as compared to those with LVEF > 30% (n = 586), had a higher prevalence of NHYA class > 2 (P < 0.001) and presented with a higher Euroscore (P < 0.001). Procedural success was similar in both groups (98.4% vs. 97.2%, P = 1). After a median follow-up of 436 days (25(th)-75(th) percentile, 357-737 days), all-cause mortality [23.8% vs. 23.7%, P = 0.87, hazard ratios (HR): 0.96, 95% confidence intervals (CI): 0.56-1.63] and cardiac mortality (19.1% vs. 17.6%, P = 0.89, HR: 1.04, 95% CI: 0.57-1.90) were similar in patients with LVEF ≤ 30% as compared to those with LVEF > 30%. Thirty-day all-cause mortality was not significantly different between the two groups (11.1% vs. 6.3%, P = 0.14, HR: 1.81, 95% CI: 0.81-4.06). Patients with LVEF ≤ 30% had a trend toward higher risk of 30-day cardiac mortality (11.1% vs. 5.3%; P = 0.06, HR: 2.16, 95% CI: 0.95-4.90), which disappeared after multivariable adjustment (P = 0.22). CONCLUSIONS: Baseline severe impairment of LVEF is not a predictor of increased short-term and mid-term mortality after TAVI. Selected patients with severe impairment of left ventricular function should not be denied TAVI.
RESUMO
The rate of percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction varies between European countries, as does total mortality as a result of acute myocardial infarction. These differences arise partly because of differences between countries in the time delay from symptom onset to first medical contact, and from first medical contact to reperfusion with thrombolysis or PCI. The European Society of Cardiology guidelines emphasize the importance of early reperfusion therapy. There are, however, often logistical delays in transport of the patient, in diagnosis of myocardial infarction and in preparation of medical teams to be available to perform PCI. Studies have shown that door-to-balloon time may improve with an integrated approach coordinating systems, procedures and institutions, and steps such as including prehospital triage and prehospital electrocardiogram transmission can dramatically reduce door-to-balloon time. Early transfer to PCI is associated with fewer ischaemic complications.
