Search

Aims: A considerable proportion of candidates for transcatheter aortic valve implantation (TAVI) have underlying heart failure (HF) with preserved ejection fraction (HFpEF), which can be challenging for diagnosis because significant valvular heart disease should be excluded before diagnosing HFpEF. This study investigated the long‐term prognostic value of the pre‐procedural H2FPEF score in patients with preserved ejection fraction (EF) undergoing TAVI. Methods and results: Patients who underwent TAVI between October 2013 and May 2017 were enrolled from the Optimized CathEter vAlvular iNtervention–Transcatheter Aortic Valve Implantation Japanese multicentre registry. After excluding 914 patients, 1674 patients with preserved EF ≥ 50% (median age: 85 years, 72% female) were selected for calculation of the H2FPEF score and were dichotomized into two groups: the low H2FPEF score [0–5 points; n = 1399 (83.6%)] group and the high H2FPEF score [6–9 points; n = 275 (16.4%)] group. Patients with high H2FPEF scores were associated with a higher prevalence of New York Heart Association Functional Class III/IV (59.3% vs. 43.7%, P < 0.001), diabetes (24.4% vs. 18.5%, P = 0.03), and paradoxical low‐flow, low‐gradient aortic stenosis (15.9% vs. 6.2%, P < 0.001). These patients showed worse prognoses than those with low H2FPEF scores regarding the cumulative 2 year all‐cause mortality (26.3% vs. 15.5%, log‐rank P < 0.001), cardiovascular mortality (10.5% vs. 5.4%, log‐rank P < 0.001), HF hospitalization (16.2% vs. 6.7%, log‐rank P < 0.001), and the composite endpoint of cardiovascular mortality and HF hospitalization (23.8% vs. 10.8%, log‐rank P < 0.001). After adjustment for several confounders, the high H2FPEF scores were independently associated with increased risk for all‐cause mortality [adjusted hazard ratio (HR), 1.48; 95% confidence interval (CI), 1.09–2.00; P = 0.011] and for the composite endpoint of cardiovascular mortality and HF hospitalization (adjusted HR, 1.95; 95% CI, 1.38–2.74; P < 0.001). Subgroup analysis confirmed the excess risk of high H2FPEF scores relative to low H2FPEF scores for the composite endpoint of cardiovascular mortality and HF hospitalization increased with a lower Society of Thoracic Surgeons (STS) score (STS score <8%: adjusted HR, 2.40; 95% CI, 1.50–3.85; P < 0.001; STS score ≥8%: adjusted HR, 1.34; 95% CI, 0.79–2.28; P = 0.28; Pinteraction = 0.030). Conclusions: The H2FPEF score is useful for predicting long‐term adverse outcomes after TAVI, including all‐cause mortality, cardiovascular mortality, and HF hospitalization for patients with preserved EF. More aggressive interventions targeting HFpEF in addition to the TAVI procedure might be relevant in patients with high H2FPEF scores, particularly in those with a lower surgical risk. [ABSTRACT FROM AUTHOR]

Aims: This study investigated the prognostic value of plasma volume status (PVS) in patients who underwent transcatheter aortic valve replacement (TAVR). Methods and results: Plasma volume status was calculated in 2588 patients who underwent TAVR using data from the Japanese multicentre registry. All‐cause mortality and heart failure hospitalization (HFH) within 2 years of TAVR were compared among the PVS quartiles (Q1, PVS < 5.5%; Q2, PVS 5.5–13.5%; Q3, PVS 13.5–21.0%; and Q4, PVS ≥ 21.0%). Subgroups were stratified by the PVS cut‐off value combined with the New York Heart Association (NYHA) class as follows: low PVS with NYHA I/II (n = 959), low PVS with NYHA III/IV (n = 845), high PVS with NYHA I/II (n = 308), and high PVS with NYHA III/IV (n = 476). The cumulative all‐cause mortality and HFH within 2 years of TAVR significantly increased with increasing PVS quartiles [8.5%, 16.8%, 19.2%, and 27.0% (P < 0.001) and 5.8%, 8.7%, 10.3%, and 12.9% (P < 0.001), respectively]. The high‐PVS group regardless of the NYHA class had a higher all‐cause mortality and HFH [9.6%, 18.2%, 24.5%, and 30.4% (P < 0.001) and 6.1%, 10.4%, 14.1%, and 11.3% (P < 0.001)]. In a Cox regression multivariate analysis, the PVS values of Q3 and Q4 had independently increased all‐cause mortality [hazard ratio (HR), 1.50 and 1.64 (P = 0.017 and P = 0.008), respectively], and Q4 had independently increased HFH (HR, 1.98, P = 0.005). The low PVS with NYHA III/IV, high PVS with NYHA I/II, and high PVS with NYHA III/IV also had significantly increased all‐cause mortality [HR, 1.45, 1.73, and 1.86 (P = 0.006, P = 0.002, and P < 0.001), respectively] and HFH [HR, 1.52, 2.21, and 1.70 (P = 0.049, P = 0.002, and P = 0.031), respectively]. Conclusions: Plasma volume status is useful for predicting all‐cause mortality and HFH after TAVR. [ABSTRACT FROM AUTHOR]

Background: Preprocedural clinical predictors of the successful maintenance of sinus rhythm may contribute to optimal treatment strategies for atrial fibrillation (AF). The CAAP‐AF score, a novel simple tool scored as 0‐13 points (including six independent variables) has been proposed to predict long‐term freedom from AF after catheter ablation. To clarify its reproducibility, we examined the CAAP‐AF score's predictive performance and then created subgroups to best predict AF recurrence by using a machine learning algorithm. Methods: We studied 583 consecutive patients who underwent initial AF catheter ablation at our institute (median CAAP‐AF score, 5; age, 66 ± 10 years old; female, 28.3%; coronary artery disease, 10.8%; left atrial diameter, 39.9 ± 6.6 mm; number of antiarrhythmic drugs failed, 0.4 ± 0.6; nonparoxysmal AF, 45.3%). All were systematically followed up with an endpoint of atrial tachyarrhythmia recurrence after the last ablation procedure. Results: During the 1.8 ± 1.2‐year follow‐up, 157 patients had atrial tachyarrhythmia recurrence. Repeated procedures were performed (n = 115). Arrhythmia recurrence after the last session occurred in 69 patients. We created Kaplan‐Meier curves for freedom from AF after final AF ablation for ranges of CAAP‐AF scores; these confirmed the original study results. The machine learning using Classification and Regression Trees divided the patients into three categories by the risk score: low (score ≤5), intermediate (score 6‐8), and high (score ≥9). Conclusions: The CAAP‐AF score was useful to stratify the atrial tachyarrhythmia recurrence risk in AF patients undergoing catheter ablation into three categories. The score should be considered when deciding whether to perform AF ablation in clinical practice. [ABSTRACT FROM AUTHOR]

Background Anticoagulation therapy with the vitamin K antagonist (VKA) warfarin has been demonstrated to reduce thromboembolic risk after electrical cardioversion (ECV). However, data concerning ECV with non-VKA oral anticoagulants (NOACs) is limited. The objective of this study was to determine the efficacy and safety of NOACs in patients undergoing ECV in a real-world clinical practice at a single center in Japan. Methods We retrospectively analyzed the data of 406 consecutive patients who underwent ECV for atrial fibrillation (AF) or flutter under anticoagulation with one of the three NOACs ( n =149) or with a VKA ( n =257). Results The CHADS2 and HAS-BLED scores were significantly higher in the VKA group, whereas the NOACs group had a tendency toward greater spontaneous echo contrast grades. After ECV, ischemic stroke occurred in three patients of the VKA group and one patient in the NOAC group, all of whom had persistent AF, indicating no significant difference in the thromboembolic event rate within 30 days following ECV. No other thromboembolic events, major bleeding, or death occurred in either group. Among the NOAC and VKA patients in whom we newly introduced an oral anticoagulant to perform ECV, the number of days leading to ECV was significantly lesser for the NOAC patients. Conclusion NOACs may be used as an alternative to VKAs for ECV and may allow prompt ECV in clinical practices. [ABSTRACT FROM AUTHOR]

Background Acute myocardial infarction (AMI) infrequently occurs after acute stroke. The Heart-brain team approach has a potential to appropriately manage this poststroke cardiovascular complication. However, clinical outcomes of AMI complicating acute stroke (AMI-CAS) with the heart-brain team approach have not been characterized. The current study investigated cardiovascular outcomes in patients with AMI-CAS managed by a heart-brain team. Methods and Results We retrospectively analyzed 2390 patients with AMI at our institute (January 1, 2007-September 30, 2020). AMI-CAS was defined as the occurrence of AMI within 14 days after acute stroke. Major adverse cerebral/cardiovascular events (cardiac-cause death, nonfatal myocardial infarction, and nonfatal stroke) and major bleeding events were compared in subjects with  AMI-CAS and those without acute stroke. AMI-CAS was identified in 1.6% of the subjects. Most AMI-CASs (37/39=94.9%) presented ischemic stroke. Median duration of AMI from the onset of acute stroke was 2 days. Patients with AMI-CAS less frequently received primary percutaneous coronary intervention (43.6% versus 84.7%; P <0.001) and dual-antiplatelet therapy (38.5% versus 85.7%; P <0.001), and 33.3% of them did not receive any antithrombotic agents (versus 1.3%; P <0.001). During the observational period (median, 2.4 years [interquartile range, 1.1-4.4 years]), patients with AMI-CAS exhibited a greater likelihood of experiencing major adverse cerebral/cardiovascular events (hazard ratio [HR], 3.47 [95% CI, 1.99-6.05]; P <0.001) and major bleeding events (HR, 3.30 [95% CI, 1.34-8.10]; P =0.009). These relationships still existed even after adjusting for clinical characteristics and medication use (major adverse cerebral/cardiovascular event: HR, 1.87 [95% CI, 1.02-3.42]; P =0.04; major bleeding: HR, 2.67 [95% CI, 1.03-6.93]; P =0.04). Conclusions Under the heart-brain team approach, AMI-CAS was still a challenging disease, reflected by less adoption of primary percutaneous coronary intervention and antithrombotic therapies, with substantially elevated cardiovascular and major bleeding risks. Our findings underscore the need for a further refined approach to mitigate their ischemic/bleeding risks.

Background: Mortality following transcatheter aortic valve replacement (TAVR) in patients with post-procedural left ventricular systolic dysfunction remains high. We investigated clinical variables associating with worse clinical outcomes following TAVR in patients with systolic dysfunction., Methods: We retrospectively investigated 2588 patients with severe aortic stenosis who received TAVR and were enrolled in the optimized transcatheter valvular intervention (OCEAN-TAVI) multicenter registry (UMIN000020423). The association between the clinical variables following TAVR and 2-year cardiovascular mortality was investigated among those with post-TAVR left ventricular ejection fraction less than 50%., Results: A total of 298 patients (median 85 years old, 131 men) were included. The presence of moderate or greater tricuspid regurgitation following TAVR was independently associated with 2-year mortality (adjusted hazard ratio 3.41, 95% confidence interval 1.15-10.1), and significantly discriminated 2-year cardiovascular mortality (30% vs. 12%, p = 0.001). No patients with any improvement in tricuspid regurgitation had cardiovascular death., Conclusion: Following TAVR, the existence of significant tricuspid regurgitation was associated with cardiovascular mortality in patients with heart failure with reduced ejection fraction., (© 2021 Wiley Periodicals LLC.)

Background Ventricular-arterial coupling predicts outcomes in patients with heart failure. The arterial elastance to end-systolic elastance ratio (Ea/Ees) is a noninvasively assessed index that reflects ventricular-arterial coupling. We aimed to determine the prognostic value of ventricular-arterial coupling assessed through Ea/Ees after transcatheter aortic valve replacement to predict clinical events. Methods and Results We retrieved data on 1378 patients (70% women) who underwent transcatheter aortic valve replacement between October 2013 and May 2017 from the OCEAN-TAVI (Optimized transCathEter vAlvular iNtervention) Japanese multicenter registry. We determined the association between Ea/Ees and the composite end point of hospitalization for heart failure and cardiovascular death by classifying the patients into quartiles based on Ea/Ees values (group 1: <0.326; group 2: 0.326-0.453; group 3: 0.453-0.666; and group 4: >0.666) during the midterm follow-up after transcatheter aortic valve replacement. During a median follow-up period of 736 days (interquartile range, 414-956), there were 247 (17.9%) all-cause deaths, 89 (6.5%) cardiovascular deaths, 130 (9.4%) hospitalizations for heart failure, and 199 (14.4%) composite events of hospitalization for heart failure and cardiovascular death. The incidence of the composite end point was significantly higher in group 2 (hazard ratio [HR], 1.76; 95% CI, 1.08-2.87 [ P =0.024]), group 3 (HR, 2.43; 95% CI, 1.53-3.86 [ P <0.001]), and group 4 (HR, 2.89; 95% CI, 1.83-4.57 [ P <0.001]) than that in group 1. On adjusted multivariable Cox analysis, Ea/Ees was significantly associated with composite events (HR, 1.47 per 1-unit increase; 95% CI, 1.08-2.01 [ P =0.015]). Conclusions These findings suggest that a higher Ea/Ees at discharge after transcatheter aortic valve replacement is associated with adverse clinical outcomes during midterm follow-up. Registration URL: https://www.upload.umin.ac.jp/. Unique identifier: UMIN000020423.

Background In patients undergoing transcatheter aortic valve replacement (TAVR), those with small left ventricle (LV) may have an increased risk of poor outcomes, because small LV is associated with low-flow (LF), left ventricular hypertrophy. However, the impact of small LV on patients undergoing TAVR remains unknown. Methods and Results We examined 2584 patients who underwent TAVR between October 2013 and May 2017 using data from the Japanese multicenter registry. On the basis of the American Society of Echocardiography guidelines, small LV was defined as left ventricular end-diastolic dimension <42.0 mm for men or <37.8 mm for women. The 2-year clinical outcomes were compared between patients with and without small LV using multivariable Cox regression analyses and propensity score matching. Subgroup analyses by LF, left ventricular hypertrophy were performed. Of 2584 patients who underwent TAVR, 466 (18.0%) had small LV. Patients with small LV had smaller body size and less comorbidity, and were more likely to have LF status compared with those without. Small LV was associated with a higher 2-year all-cause (20.8% versus 14.3%; adjusted hazard ratio [HR],1.58 [95% CI, 1.20-2.09]; P =0.0013) and cardiovascular mortality (8.8% versus 5.5%; adjusted HR, 1.93 [95% CI, 1.25-2.98]; P =0.0028). Propensity score matching analysis showed consistent findings. In subgroup analyses, LF, left ventricular hypertrophy did not interact with small LV. Conclusions Small LV, determined by a simple echocardiographic parameter, was associated with poorer clinical outcomes after TAVR regardless of LF, left ventricular hypertrophy. LV size may be useful for assessing clinical outcomes after TAVR. Registration URL: https://www.umin.ac.jp/ctr/index.htm; Unique identifier: UMIN000020423.

Background Although transcatheter aortic valve replacement ( TAVR ) is the least invasive treatment for patients with symptomatic aortic stenosis, some patients hesitate to undergo the procedure. We investigated the clinical impact of treatment delay after patient refusal of TAVR . Methods and Results We used the Japanese OCEAN (Optimized Catheter valvular intervention) regsitry data of 1542 patients who underwent TAVR . Refusal was defined as at least 1 refusal of TAVR at the time of informed consent. Patients were separated into 2 groups: refusal (28/1542, 1.8%) and non-refusal (1514/1542, 98.2%). We compared the baseline characteristics, procedural outcomes, and mortality rates between the groups. Additionally, data on reasons for refusal and those leading to eventually undergoing TAVR were collected. Age, surgical risk scores, and frailty were higher in the refusal group than in the non-refusal group ( P<0.05 for all). Periprocedural complications did not differ between groups, whereas 30-day and cumulative 1-year mortality were significantly higher in the refusal group than in the non-refusal group (7.1% versus 1.3%, P=0.008 and 28.8% versus 10.3%, P=0.010, respectively). Multivariate Cox regression analysis revealed that TAVR refusal was an independent predictor of increased midterm mortality (hazard ratio: 3.37; 95% confidence interval: 1.52-7.48; P=0.003). The most common reason for refusal was fear (13/28, 46.4%), and the most common reason for changing their mind was worsening heart failure (21/28, 75.0%). All patients in the refusal group decided to undergo TAVR within 20 months (median: 5.5 months). Conclusions Refusing TAVR even once led to poorer prognosis; therefore, this fact should be clearly discussed when obtaining informed consent.

Background: Hypothyroidism has been shown to contribute to enhanced atrial arrhythmogenesis, resulting in atrial fibrillation (AF) development in animal models and clinical populations. We aimed to elucidate whether high thyroid-stimulating hormone (TSH) levels are related to outcomes of catheter ablation of AF., Methods and Results: Of 477 consecutive patients who underwent first-time pulmonary vein isolation-based radiofrequency catheter ablation of AF, 456 with TSH above the lower limit of the normal range (age, 65.5±9.9 years; men, 73.9%; paroxysmal AF, 56.8%) were analyzed for this study. Atrial tachyarrhythmia recurrence for 3 years was compared across groups with hypothyroidism (n=23) and TSH quartile groups with euthyroidism (normal-range TSH levels, n=433). Atrial tachyarrhythmia recurrence occurred in 179 patients (39%) after the first session. Patients with hypothyroidism had increased recurrence compared with patients with normal TSH levels (crude hazard ratio, 3.14 after the last session; P =0.001). When focusing on patients with normal TSH levels, recurrence-free survivals after both the first and last sessions were significantly reduced in euthyroid patients with the highest quartile of TSH levels (quartile 4) compared with others (quartiles 1-3). Cox regression analysis identified high TSH levels as an independent predictor of atrial tachyarrhythmia recurrence after both the first (adjusted hazard ratio, 1.51; P =0.018) and last (adjusted hazard ratio, 1.86; P =0.023) sessions. The difference was more pronounced in patients with paroxysmal AF than in those with nonparoxysmal AF., Conclusions: Not only hypothyroidism but also high-normal TSH levels may be an independent predictor of atrial tachyarrhythmia recurrence after catheter ablation of AF., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: In this study, we sought to investigate the 2-year prognostic impact of B-type natriuretic peptide (BNP) levels at discharge, following transcatheter aortic valve replacement., Methods and Results: We enrolled 1094 consecutive patients who underwent transcatheter aortic valve replacement between 2013 and 2016. Study patients were stratified into 2 groups according to survival classification and regression tree analysis (high versus low BNP groups). We evaluated the impact of high BNP on 2-year mortality compared with that of low BNP using a multivariable Cox model, and assessed whether this stratification would improve predictive accuracy for determining 2-year mortality by assessing time-dependent net reclassification improvement and integrated discrimination improvement. The median age of patients was 85 years (quartile 82-88), and 29.2% of the study population were men. The median Society of Thoracic Surgeons score was 6.8 (4.7-9.5), and BNP at discharge was 186 (93-378) pg/mL. All-cause mortality following discharge was 7.9% (95% CI, 5.8-9.9%) at 1 year and 15.4% (95% CI, 11.6-19.0%) at 2 years. The survival classification and regression tree analysis revealed that the discriminating BNP level to discern 2-year mortality was 202 pg/mL, and that elevated BNP had a statistically significant impact on outcomes, with an adjusted hazard ratio of 2.28 (1.36-3.82, P =0.002). The time-dependent net reclassification improvement ( P =0.047) and integrated discrimination improvement ( P =0.029) analysis revealed that the incorporation of BNP stratification with other clinical variables significantly improved predictive accuracy for 2-year mortality., Conclusions: Elevation of BNP at discharge is associated with 2-year mortality after transcatheter aortic valve replacement., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)