Abstract Objectives We sought to identify baseline demographics and procedural factors that might independently predict in‐hospital stroke following transcatheter aortic valve implantation (TAVI). Background Stroke is a recognized, albeit infrequent, complication of TAVI. Established predictors of procedure‐related in‐hospital stroke; however, remain poorly defined. Methods We conducted an observational cohort analysis of the multicenter UK TAVI registry. The primary outcome measure was the incidence of in‐hospital stroke. Results A total of 8,652 TAVI procedures were performed from 2007 to 2015. There were 205 in‐hospital strokes reported by participating centers equivalent to an overall stroke incidence of 2.4%. Univariate analysis showed that the implantation of balloon‐expandable valves caused significantly fewer strokes (balloon‐expandable 96/4,613 [2.08%] vs. self‐expandable 95/3,272 [2.90%]; p = .020). After multivariable analysis, prior cerebrovascular disease (CVD) (odds ratio [OR] 1.51, 95% confidence interval [CI 1.05–2.17]; p = .03), advanced age at time of operation (OR 1.02 [0.10–1.04]; p = .05), bailout coronary stenting (OR 5.94 [2.03–17.39]; p = .008), and earlier year of procedure (OR 0.93 [0.87–1.00]; p = .04) were associated with an increased in‐hospital stroke risk. There was a reduced stroke risk in those who had prior cardiac surgery (OR 0.62 [0.41–0.93]; p = .01) and a first‐generation balloon‐expandable valve implanted (OR 0.72 [0.53–0.97]; p = .03). In‐hospital stroke significantly increased 30‐day (OR 5.22 [3.49–7.81]; p < .001) and 1‐year mortality (OR 3.21 [2.15–4.78]; p < .001). Conclusions In‐hospital stroke after TAVI is associated with substantially increased early and late mortality. Factors independently associated with in‐hospital stroke were previous CVD, advanced age, no prior cardiac surgery, and deployment of a predominantly first‐generation self‐expandable transcatheter heart valve.
During Primary Percutaneous Coronary Intervention (PPCI) post ST-Segment Myocardial Infarction (STEMI), distal embolisation of thrombus may lead to failure to re-establish normal flow in the infarct-related artery. Manual thrombus aspiration has been shown to improve coronary perfusion as assessed by time to ST-segment resolution and myocardial blush grade. Evidence supporting the benefit of thrombus aspiration on clinical outcomes, however, is limited and inconsistent. We aimed to assess the impact of manual thrombectomy on mortality in patients presenting with STEMI across all PPCI centres in London over a 5 year period from 2007 until 2012.
Methods
This was an observational cohort study of 9935 consecutive patients with STEMI treated with PPCI between 2007 and 2012 at eight tertiary cardiac centres across London, UK. Patient9s details were recorded at the time of the procedure into the British Cardiac Intervention Society (BCIS) database. Outcome was assessed by all-cause mortality. Anonymous datasets from the eight centres were merged for analysis. The primary end-point was all-cause mortality at a median follow-up of 2.0 years (IQR range 1.1–3.1 years).
Results
Of the 9935 consecutive STEMI patients presenting for PPCI, 2859 had mechanical thrombectomy. Patients who had manual thrombectomy were significantly younger (average age 60.6 vs 62.9) and were less likely to have had a previous myocardial infarction (11.9% of thrombectomy patients vs 14.7% of non-thrombectomy patients). Patients receiving manual thromectomy were found to be significantly more likely to have had PPCI via a radial approach (33.1% in thrombectomy patients vs 19.9% in non-thromectomy patients). Procedural success (defined as TIMI 3 flow at the end of procedure) was found to be significantly more likely in patients receiving manual thrombectomy (89.5% vs 86.7%) (table 1). Patients with thrombectomy use had similar unadjusted all-cause mortality rates to those without thrombectomy use (12.7% vs 16.5%, p=NS) during the 5-year follow-up period (figure 1). After multivariable adjustment thrombectomy use was associated with significantly decreased mortality rates (HR: 0.82, 95% CI 0.68 to 0.9, p=0.04).
Conclusion
Mechanical thrombectomy use appears to be associated with improved outcome, in the form of decreased mortality, in this large observational trial.
King's College Hospital, London, UK Correspondence to Dr Refai Showkathali, MBBS, MRCP, (UK), Department of Cardiology, King's College Hospital, Denmark Hill, London SE5 9RS, UK Tel: +20 3299 9000; e-mail: [email protected] Received 6 July, 2013 Revised 20 August, 2013 Accepted 06 October, 2013
Following a technically successful procedure, it is the post-procedural care of the patient that will often dictate both short- and long-term outcomes. Post-procedural care involves close monitoring of the patient for early complications, which may be secondary to the procedure itself or the presenting complaint. Immediate complications following percutaneous coronary intervention (PCI) may occur due to bleeding, most commonly at the access site, or due to early cardiac complications, often related to technical issues during the procedure. Non-cardiac complications, such as the development of contrast nephropathy, will become apparent in the hours or days following the initial procedure. Prompt and accurate identification of post-procedural complications is essential if they are to be managed effectively, and identification of the ‘at risk’ patient may also facilitate early identification of problems when they do occur. Complication rates are higher in patients with acute coronary syndromes, often exacerbated by aggressive antithrombotic regimens, and also in older patients with comorbid conditions. The type of care and length of stay will also vary according to the clinical context and needs to be carefully considered once the PCI has been performed. Following discharge, the longer-term management of residual coronary disease and recurrent ischaemia along with appropriate secondary prevention may all affect longer-term outcome. This chapter will examine the issues surrounding the immediate and longer-term care of the patient following PCI.
ArrestRitesh Kanyal, Dhruv Sarma, Nilesh Pareek, Rafal Dworakowski, Narbeh Melikian, Ian Webb, Ajay Shah, Philip MacCarthy, Jonathan Byrne.
Background
Left ventricular systolic dysfunction (LVSD) is common after out of hospital cardiac arrest (OOHCA) and can manifest as global or regional change. PurposeWe evaluated the extent of global and regional LVSD and its association with coronary artery disease (CAD) and outcome in those undergoing coronary angiography after OOHCA.
Methods
619 patients with OOHCA were admitted at our centre between 1st May 2012 and 31st December 2017. After excluding 237 for having a non-cardiac aetiology/prior neurological disability, so 398 patients were included. Rates of cardiogenic shock and extent of CAD, as classified by the SYNTAX score were measured. The primary endpoint was 12-month mortality. Patients with incomplete data were excluded from the analysis.
Results
Two hundred and sixty-six patients (median age 62 [53-71] 76.3% male) underwent both trans-thoracic wchocardiography and coronary angiography on arrival and were included in the final analysis. 81.6% had ventricular fibrillation, 83.5% were witnessed and 51.9% occurred at residence. Ninety-six patients (36%) had significant LVSD (Left Ventricular Ejection Fraction [LVEF] <40%) and 139 (52.2%) patients had regional wall motion abnormalities (RWMAs) on arrival. Patients were classified into 4 groups (Group A: LVEF<40%/Global, Group B: LVEF<40%/RWMA, Group C: LVEF≥40%/Global and Group D: LVEF≥40%/RWMA) with frequencies of 10.9%, 25,2%, 41.4% and 22.6%). Patients in Group D had the shortest low-flow times and lowest rates of epinephrine administration, with most favourable metabolic status on arrival, based on lactate and creatinine values. In Groups B and D (RWMAs), patients were significantly more likely to have a post-ROSC ECG demonstrating ST elevation/LBBB and absence of epinephrine administration during resuscitation with shorter low flow times. Extent of CAD was similar between the four groups. From patients with LVEF≥40%, patients in Group C had substantially lower SYNTAX scores than compared with Group D (0.5 vs 13.5, p<0.001). However, both Group B and C (RWMA) groups had highest rates of culprit lesions compared with matched global groups which was reflected in higher PCI rates (figure 2 and table 3). The primary endpoint of 12-month mortality was lowest in Group D and highest in the Group A group. A similar effect was observed for poor neurological outcome and 30-day mortality. Patients with regional LVSD had significantly improved survival at 12 months compared with those with global LVSD (70.5% vs 48.3%, p<0.001) vs 51). Those in Group D had highest survival at 12 months, while this was similar for Groups B and C and lowest in Group A (figure 1). Cardiac aetiology death was significantly higher in those with LVEF<40% compared to those with LVEF≥40% (70.5% vs 48.3%, p<0.001).
Conclusions
Patients with significant LVEF <40% have higher rates of cardiogenic shock and mortality which was driven by cardiac aetiology death, while presence of RWMAs are associated with a higher rate of culprit coronary lesions and improved outcome
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)
