Acute Kidney Injury Following Transcatheter Edge-to-Edge Mitral Valve Repair: A Systematic Review and Meta-Analysis

BackgroundAim of this study was to perform a systematic review a meta-analysis of the literature in order to identify predictors of acute kidney injury (AKI) in patients with mitral regurgitation (MR) undergoing transcatheter edge-to-edge repair (TEER) and assess its effect on in-hospital outcomes and mortality. Although iodinated contrast is not typically used in TEER, these patients are still at risk for developing AKI.MethodsStudies reporting on the effect of incident AKI on mortality following TEER for MR were included. Random-effects meta-analysis was performed, comparing clinical outcomes between the patients with or without incident AKI.ResultsSix studies including a total of 2057 patients (377 AKI and 1680 No-AKI) were included and analyzed. AKI was significantly associated with 30-day mortality after TEER (Odds ratio (OR): 8.06; 95% CI: 3.20, 20.30, p < 0.01; I² = 18.4%) and all-cause mortality over a mean follow-up time of 30 months (Hazard ratio (HR): 2.48; 95% CI: 1.89, 3.24, p < 0.01; I² = 23.7%). AKI after TEER was associated with prolonged hospitalization (Mean difference (in days): 1.41; 95% CI: 0.52, 2.31, p < 0.01; I² = 82.4%). Stage 4 chronic kidney disease (CKD), device failure and history of chronic obstructive pulmonary disease (COPD) were significant predictors of AKI following TEER (CKD stage 4: OR: 2.38; 95% CI: 1.18, 4.78, p = 0.02; I² = 0.0%; Device failure: OR: 3.15; 95% CI: 1.94, 5.12, p < 0.01; I² = 0.0%; COPD: OR: 1.92; 95% CI: 1.16, 3.17; I² = 26.7%).ConclusionsOur findings highlight the renal vulnerability of the TEER population to renal injury and the associated deterioration in clinical outcomes and survival.     

Prosthetic Valve Endocarditis in Patients Undergoing TAVR Compared to SAVR: A Systematic Review and Meta-Analysis

BackgroundThe risk of prosthetic valve endocarditis (PVE) in patients who underwent transcatheter aortic valve replacement (TAVR) is presumed to be high.MethodsElectronic databases were searched to identify articles comparing the rate of PVE in post-TAVR and post-surgical aortic valve replacement (SAVR) patients. Pooled adjusted odds ratio (OR) was computed using a random-effects model.ResultsA total of 19 studies consisting of 84,288 patients, were identified. There was no significant difference in the odds of PVE between patients undergoing TAVR and SAVR, at 30-day (OR 0.62, 95% confidence interval (CI) 0.20–1.92, p = 0.41), 1-year (OR 0.99 95% CI 0.89–1.11, p = 0.84), 2-year (OR 1.02 95% CI 0.68–1.54, p = 0.92) and 5-year (OR 1.03 95% CI 0.80–1.33, p = 0.81). A subgroup sensitivity analysis also showed no significant inter-group differences in the rate of PVE at all time points, when stratified by the study design (clinical trial vs. observational), type of TAVR valves used (self-expanding bioprosthetic valves vs. balloon expanded bioprosthetic valves) and surgical risk of patients (high vs. intermediate vs. low). There was no heterogeneity (I2 = 0%) in the outcomes of the included studies at 30-day, 1-year and 2-year, while the heterogeneity in studies at 5-year was minimal (I2 = 22%).ConclusionsIn comparison to SAVR, both short and long-term risk of prosthetic valve endocarditis appears to be identical in patients undergoing TAVR. This risk is unaffected by the type of valve, duration of follow-up, study design and surgical risk of the patients.     

Right Ventricular Contraction Patterns in Patients Undergoing Transcatheter Tricuspid Valve Repair for Severe Tricuspid Regurgitation

ObjectivesThis study investigated patterns of right ventricular (RV) contraction by using cardiac magnetic resonance (CMR) imaging in patients undergoing transcatheter tricuspid valve repair (TTVR).BackgroundThe role of RV function in patients with severe tricuspid regurgitation undergoing TTVR is poorly understood.MethodsGlobal RV dysfunction was defined as CMR-derived RV ejection fraction (RVEF) ≤45% and longitudinal RV dysfunction was defined as tricuspid annular plane systolic excursion (TAPSE) <17 mm on echocardiography. Patients were stratified into 3 types of RV contraction: type I, TAPSE ≥17 and RVEF >45%; type II, TAPSE <17 and RVEF >45%; and type III, TAPSE <17 and RVEF ≤45%. CMR feature tracking was performed to assess longitudinal and circumferential RV strain. The primary outcome was a composite of all-cause mortality or first heart failure hospitalization.ResultsOf 79 patients (median age 79 years, 51% female), 18 (23%) presented with global and 40 (51%) presented with longitudinal RV dysfunction. The composite outcome occurred in 22 patients (median follow-up 362 days). Global RV dysfunction but not longitudinal RV dysfunction (hazard ratio: 6.62; 95% confidence interval: 2.77-15.77; and hazard ratio: 1.30; 95% confidence interval: 0.55-3.08, respectively) was associated with the composite outcome. Compared with type I RV contraction, patients with type II RV contraction exhibited increased circumferential strain, with a preservation of RVEF despite diminished longitudinal strain. Patients with type III RV contraction exhibited both diminished longitudinal and circumferential strain, resulting in an impaired RVEF. Patients with type III RV contraction showed the worst survival (P < 0.001).ConclusionsGlobal RV dysfunction is a predictor of outcomes among TTVR patients. Tricuspid regurgitation patients can be stratified into 3 types of RV contraction, in which a loss of longitudinal function can be compensated by increasing circumferential function, preserving RVEF and favorable outcomes.     

National Trends and Outcomes of Tricuspid Valve Surgery with Concomitant Mitral Valve Surgery: Results From a Ten-year Analysis of the National Inpatient Sample Database

According to an estimate, 20% of patients with heart valve disease have multivalve involvement necessitating combined valve surgery. There is a dearth of data about the clinical outcomes of patients with combined mitral and tricuspid valve disease who go through tricuspid valve surgery with concomitant mitral valve replacement or repair. We utilized National Inpatient Sample (NIS) between January 1, 2004, and December 31, 2014, to analyze the outcomes of patients who underwent tricuspid valve surgery with either mitral valve replacement or repair. We identified 21,141 weighted hospitalizations for combined TVS with MVr (TVS/MVr) or TVS with MVR (TVS/MVR). The overall inpatient mortality in the TVS/MVR cohort was higher than in the TVS/MVr cohort (7.36% vs 5.33%, P < 0.01). There was a trend toward decreased mortality over the years in the TVS/MVr cohort (P = 0.04) while mortality remained unchanged in the TVS/MVR cohort (P = 0.88). Overall, the TVS/MVr cohort had better clinical outcomes profile compared with TVS/MVR cohort.     

Safety and Efficacy of Colchicine in Patients With Coronary Artery Disease: A Systematic Review and Meta-Analysis

BackgroundGiven current evidence, the use of colchicine for the prevention of adverse cardiovascular events in patients with coronary artery disease (CAD) remains controversial.MethodsMultiple databases were queried to identify studies comparing the safety and efficacy of colchicine in patients with acute coronary syndrome (ACS) or stable angina. The relative risk (RR) of major adverse cardiovascular events (MACE) and gastrointestinal (GI) adverse events were calculated using a random-effect model.ResultsSix clinical trials comprising a total of 5820 patients were identified. The pooled RR of MACE (0.64, 95% confidence interval (CI) 0.36–1.14, p = 0.13), ACS (0.62, 95% CI 0.27–1.41, p = 0.25), cardiac arrest (0.74, 95% CI 0.26–2.14, p = 0.58), stent restenosis (0.71, 95% CI 0.41–1.23, p = 0.22) and mortality (0.95, 95% CI 0.63–1.42, p = 0.79) with colchicine was not significantly different from placebo or control groups. The overall RR of revascularization (0.53, 95% CI 0.34–0.83, p = 0.005) and stroke (0.26, 95% CI 0.11–0.62, p = 0.002) was significantly lower while the net RR of GI adverse events was significantly higher (HR 2.66, 95% CI 1.21–5.87, p = 0.02) in the colchicine group. Propensity matched cohort, sensitivity and subgroup analysis based on adjusted MACE and dosages of colchicine all mirrored the overall results.ConclusionIn patients with CAD presenting with an acute coronary syndrome or stable angina, colchicine might offer no significant reduction in MACE and could potentially be harmful due to a significantly higher risk of GI-related adverse events.     

Mitral Valve Repair for Anterior/Bi-leaflet Versus Posterior Leaflet Degenerative Mitral Valve Disease: A Systematic Review and Meta-analysis

Mitral valve repair (MVr) secondary to degenerative anterior/bi-leaflet mitral valve disease is more challenging than posterior leaflet repair. However, conclusive evidence is needed to make decisions based on the outcomes rather than technical difficulties. This meta-analysis compares anterior/bi-leaflet MVr with isolated posterior leaflet repair in patients with mitral regurgitation (MR) due to degenerative mitral valve disease. The outcomes of interest were long-term (≥ 5 years) survival and freedom from re-operation and moderate-to-severe MR. Meta-analysis of 10 studies showed that there was no significant difference in long-term survival (risk ratio, RR: 1.00; 95% confidence interval, 95% CI 0.96-1.04), freedom from moderate-to-severe MR (RR: 0.95; 95% CI 0.87-1.03), and freedom from re-operation (RR: 0.96; 95% CI 0.90-1.02) between anterior/bi-leaflet MVr and posterior leaflet repair. As outcomes of anterior/bilateral repair were comparable with those of isolated posterior leaflet repair, our findings do not support the inclination towards replacement over repair for MR caused by anterior/bilateral degenerative mitral disease.     

Outcomes After Transcatheter Aortic Valve Replacement in Bicuspid Versus Tricuspid Anatomy: A Systematic Review and Meta-Analysis

ObjectivesThe aim of this study was to compare the feasibility, safety, and clinical outcomes of transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) versus tricuspid aortic valve (TAV) stenosis.BackgroundAt present, limited observational data exist supporting TAVR in the context of bicuspid anatomy.MethodsPrimary endpoints were 1-year survival and device success. Secondary endpoints included moderate to severe paravalvular leak (PVL) and a composite endpoint of periprocedural complications; incidence rates of individual procedural endpoints were also explored individually.ResultsIn the main analysis, 17 studies and 181,433 patients undergoing TAVR were included, of whom 6,669 (0.27%) had BAV. A secondary analysis of 7,071 matched subjects with similar baseline characteristics was also performed. Device success and 1-year survival rates were similar between subjects with BAV and those with TAV (97% vs 94% [P = 0.55] and 91.3% vs 90.8% [P = 0.22], respectively). In patients with BAV, a trend toward a higher risk for periprocedural complications was observed in our main analysis (risk ratio [RR]: 1.12; 95% CI: 0.99-1.27; P = 0.07) but not in the matched population secondary analysis (RR: 1.00; 95% CI: 0.81-1.24; P = 0.99). The risk for moderate to severe PVL was higher in subjects with BAV (RR: 1.42; 95% CI: 1.29-1.58; P < 0.0001) as well as the incidence of cerebral ischemic events (2.4% vs 1.6%; P = 0.015) and of annular rupture (0.3% vs 0.02%; P = 0.014) in matched subjects.ConclusionsTAVR is a feasible option among selected patients with BAV anatomy, but the higher rates of moderate to severe PVL, annular rupture, and cerebral ischemic events observed in the BAV group warrant caution and further evidence.