Journal of Invasive Cardiology最新文献

Objectives: Severe aortic stenosis (AS) with a left ventricular ejection fraction (LVEF) of 50% to 54% is associated with worse outcomes than an LVEF greater than or equal to 55%. European guidelines consider aortic valve replacement (AVR) a Class IIa indication for asymptomatic patients with an LVEF of less than 55%, whereas American guidelines recommend AVR when the LVEF is less than 50%. The authors assessed outcomes of AVR vs conservative management in this range where guidelines differ.

Methods: A registry was created for individuals with severe high-gradient AS (AVA ≤ 1 cm²), an LVEF of 50% to 54%, and a mean gradient greater than or equal to 40 mm Hg from 2000 to 2022 using queries of transthoracic echocardiogram (TTE) reports. Only asymptomatic cases were included; time-zero was defined as the time of the index TTE, and both AVR (considered as a time-dependent covariate) and mortality could occur at any point after. Proportional hazard modeling assessed the AVR-mortality association, with subset analyses for individuals with AVAs of less than 0.9 cm² and less than or equal to 0.75 cm².

Results: Among 693 included individuals, 83 were asymptomatic at their index TTE. Of these, 38 (45.8%) underwent AVR within 2 years. After adjusting for immortal time, individuals with AVR had a trend toward decreased mortality (HR, 0.56; 95% CI, 0.31-1.01; P = .054). Among individuals with AVAs of less than 0.9 cm² and less than or equal to 0.75 cm², AVR was associated with improved survival (HR, 0.42; 95% CI, 0.21-0.84; P less tan .01 and HR, 0.33; 95% CI, 0.15-0.75; P less than .008, respectively).

Conclusions: AVR within 2 years was associated with improved survival among asymptomatic individuals with high-grade severe AS and an LVEF of 50% to 54%.

Objectives: Shared decision making regarding how to best manage atrial fibrillation (AF) includes the use and efficacy of catheter ablation (CA) as a treatment option. However, the long-term success rate for the procedure based on patients' baseline demographics and comorbidities remains unclear. The authors aimed to create a user-friendly predictive model to help provide an individualized risk score for long-term AF recurrence.

Methods: Ablation outcomes reported in the electronic medical records were documented from 3, 12, and 24 months, and last follow-up visit, which was an average of 42 months. Multivariate logistic regression was used to identify independent variables associated with AF recurrence. Based on respective coefficients, associated variables were used to create the ORACLE-AF (symptOmatic AF, race [White], AF type [persistent], cardioversion, late age > 70, early AF recurrence, asthma/COPD, heart failure) model. A k-1 machine learning model was used for validation, using an 80/20 development test cohort ratio.

Results: A total of 3440 patients (69.4 ± 10.2 years, 44% women) who received a de novo CA were included in the analysis. Forty-eight percent of patients had the primary composite outcome of AF recurrence by the end of the 42-month observation period. After analysis, the ORACLE-AF model was created with an area under the curve of 0.80.

Conclusions: Using machine learning, the authors created a predictive tool to allow for individualized risk prediction for long-term AF recurrence following CA. These findings highlight the need to consider risk factors not typically associated with long-term AF recurrence during the pre-ablation consultation.

Objectives: Transfemoral (TF) access for transcatheter aortic valve replacement (TAVR) may be challenging in patients with peripheral arterial disease (PAD). Alternative access through intra- and extrathoracic approaches can be performed. Recently, a facilitated TF access strategy, which involves the use of intravascular lithotripsy to optimize the iliofemoral arteries prior to TAVR, has been utilized. The aim of this study was to evaluate early outcomes of facilitated TF access compared to alternative access in patients with severe PAD.

Methods: Patients with severe PAD who underwent TAVR from 2021 to 2023 were included in the study and were divided into 2 groups: facilitated and alternative access. The primary endpoint was a composite of mortality, stroke, and vascular complications. Mortality was evaluated in-hospital and at 1-month follow-up.

Results: Of 150 TAVR patients with severe PAD, 24 underwent facilitated access. Baseline characteristics including age, Society of Thoracic Surgeons score, and mean gradients were similar between the 2 groups. The most common alternative access was transsubclavian, followed by transcarotid. Primary outcomes were numerically higher in the alternative access group (14% vs 8%); however, this did not reach statistical significance (P = .49). General anesthesia use and postoperative length of stay were higher in the alternative access group. Postoperative and 1-month mortalities were similar between the 2 groups.

Conclusions: Although the primary endpoint did not reach statistical significance, the numerical trend toward better outcomes in the facilitated TAVR group indicates a potential advantage. Large-scale prospective studies are required to determine the appropriate access strategy for TAVR in patients with severe PAD.