- Email: [email protected]
Balloon Aortic Valvuloplasty (BAV) for Severe Symptomatic Aortic Stenosis (AS) in the Current ERA
S26
Heart, Lung and Circulation 2010;19S:S1–S35
Abstracts
ABSTRACTS
>10 ng/L below this (“10/10 criteria”) and (3) at least one level >14 ng/L and a change of 20% above 53 ng/L or 50% below this (“White” criteria1 ). Results: In comparison to 4th generation testing, the “7,10” and “10,10” change criteria showed improved clinical sensitivity and the same or improved clinical specificity for the diagnosis of myocardial infarction. The “White” criteria showed decreased clinical sensitivity but better specificity. Criterion used
Sensitivity (95% CI)
Specificity (95% CI)
TnT (4th generation) “7,10” criteria for hsTnT “10,10” criteria for hsTnT “White” criteria for hsTnT
92.86 (80.99–97.54) 95.24 (84.21–98.68) 95.24 (84.21–98.68) 90.48 (77.93–96.23)
91.51 (84.65–95.47) 91.51 (84.65–95.47) 92.45 (85.81–96.13) 95.28 (89.43–97.97)
Conclusion: The use of the hsTnT assay has the potential to improve clinical sensitivity and specificity in the diagnosis of myocardial infarction. Conflict of interest: Unrestricted grant for the study from Roche Diagnostics NZ Ltd.1 Prof Harvey White, personal communication. 1 Prof
temporary pacing wire requiring urgent surgical correction. The hemodynamic and clinical outcomes for the successful patients are summarized in the table below. One patient died during follow-up at day 166 due to neurodegenerative disorder. One patient required pacemaker insertion due to worsening interventricular conduction.
Pre-procedural, n=9 Post-procedural, n=9 6-month follow-up, n = 8 Long-term follow-up, n = 8 (avg13 + 6 months) ∗
54 TRANSCORONARY ETHANOL SEPTAL ABLATION FOR HYPERTROPHIC OBSTRCTIVE CARDIOMYOPATHY: INITIAL EXPERIENCE AT WAIKATO HOSPITAL S Pasupati ∗ , M Liang Waikato Hospital, Hamilton, New Zealand Background: Hypertrophic obstructive cardiomyopathy (HOCM) is a common cardiac inheritable disorder associated with dyspnoea, angina, syncope and sudden cardiac death. Surgical myectomy was considered as the goldstandard management of symptomatic HOCM refractory to medical therapy, however, transcoronary ethanol septal ablation (TESA) has emerged as an attractive alternative percutaneous technique. We report our initial experience with TESA. Methods: All patients with HOCM who had TESA in Waikato Hospital (Hamilton, New Zealand) were included. Patient’s baseline characteristics, procedural success and complications and all-cause mortality were recorded. Pre/post-TESA hemodynamics was assessed by left ventricular outflow tract gradient (LVOT; mm Hg). Functional status was assessed using New York Heart Association (NYHA) classes for dyspnoea; Canadian Cardiovascular Society Classes (CCSC) for angina and presence of syncope. Results: Ten patients, 30% males, were referred between October 2007 to October 2009 for TESA. Nine (90%) patients had successful procedure with itraprocedural LVOT gradient drop from 95 ± 48 mmHg to 29 ± 33 mmHg. The mean alcohol volume used was 2.9 + 1.6 mls. One patient required repeat ablation at 4 months. The procedural failure was due to cardiac tamponade from the
CCSC
Syncope
LVOT
MR*
Mortality
3±1
2±1
44%
108 [104,115]
2±2
N/A
1±0
1±0
0%
43 [20,63]
1±1
0%
1±0
1±0
0%
23 [16,32]
1±1
11%
1±0
1±0
0%
N/A
N/A
11%
MR – mitral regurgitation.
Conclusion: TESA is an attractive alternative to surgical myectomy. It is safe, with high procedural success in reliving symptoms with favourable long-term outcome.
Harvey White, personal communication.
doi:10.1016/j.hlc.2010.04.054
NYHA
Conflict of interest: None. doi:10.1016/j.hlc.2010.04.055 55 BALLOON AORTIC VALVULOPLASTY (BAV) FOR SEVERE SYMPTOMATIC AORTIC STENOSIS (AS) IN THE CURRENT ERA S Pasupati ∗ , M Liang Waikato Hospital, Hamilton, New Zealand Background: BAV fell out of favour due to poor survival benefit, perceived procedural complexity and the need for repeat procedure in short duration. It has been used as a bridge to aortic valve replacement (AVR) or transcatheter aortic valve insertion (TAVI) and as a palliative procedure for patients who have been denied valve replacement. Method: Procedures were done under local anaesthesia with rapid pacing during BAV. Balloon size was 100–120% of aortic annulus with Cristal balloon (Balt, Montmorency, France) used as first line. Echocardiogram was performed at 24–48 h post BAV. Results: In the last 25 months 46 BAV were done in 49 patients. 17 proceeded to TAVI with 1 receiving an AVR. Mean age was 81 years. Mean Logistic Euroscore was 30%. 94% were done using a [20–28 mm] single balloon. 18% received a concomitant coronary intervention. Aortic mean gradient and valve area improved from 52 ± 16 mm Hg to 31 ± 10 mm Hg, 0.7 ± 0.2 cm2 to 1.0 ± 0.24 cm2 respectively. 68% of patients with impaired ejection fraction, improvement post BAV(32 ± 7% to 40 ± 10%). Mitral regurgitation improved from 1.5 ± 1.1 to 1.2 ± 1.2. 9–12Fr sheaths were used with 2% vascular complications. There was 1 periprocedural stroke. Admissions in 6months improved from 2 ± 1 to 0 ± 1. There were no intra-procedural deaths with 1 and 12 month survival of
89% and 82% respectively. One year survival for bridged procedures vs. isolated BAV was 100% and 69% respectively. Conclusion: In the current era BAV can be performed with low procedural complications and acceptable one year survival in both patients bridged for surgery and treated palliatively for symptoms.
Abstracts
S27
58 LEFT VENTRICULAR HYPERTROPHY AND MORTALITY IN PATIENTS WITH ASYMPTOMATIC SEVERE AORTIC STENOSIS S Perera 1,∗ , N Wijesinghe 2 , V Pera 1 , S Pasupati 1 , G Devlin 1 1 Waikato
Conflict of interest: None. doi:10.1016/j.hlc.2010.04.057 57 WHAT FACTORS INFLUENCE HEALTHCARE PROFESSIONALS’ DECISION TO REFER PATIENTS TO CARDIAC REHABILITATION PHASE II PROGRAMMES? K Patrick South Canterbury DHB, Timaru, New Zealand Chronic conditions such as cardiovascular disease (CVD) result in 46% of death and disability world wide. Cardiac rehabilitation phase II programmes are designed as a secondary prevention course for people with CVD and have been shown to be effective in reducing cardiac morbidity and mortality. Attendance rates are poor internationally and have been linked to failure to refer and failure to attend. The aim of this literature review was to explore the failure to refer. A systematic review of the literature was conducted following the Joanna Briggs Institute (JBI) model for searching, critiquing and reviewing papers. An inclusion and exclusion criteria was developed with search strategy. Meta-synthesis of the extracted data produced three main categories, patient characteristics, healthcare professional characteristics and healthcare systems. It was that the found groups least likely to be referred to cardiac rehabilitation phase II programmes were women, older people (>65 years), those who experienced multiple cardiac events, those with co-morbidities and ethnic minorities. Referral rates were also linked to specialty area of practice. Cardiologists and cardiovascular surgeons were more likely to refer than primary care physicians. The characteristics of the healthcare systems that impacted on failure to refer were the lack of a clear referral pathway, and poor communication between referrers and cardiac rehabilitation programme coordinators. Cardiac rehabilitation has been shown to improve health outcomes for patients with CVD; however, the research shows referral rates are low. To improve understanding of referral failure, further research is warranted in New Zealand for a culturally relevant perspective. doi:10.1016/j.hlc.2010.04.058
Hospital, Hamilton, New Zealand of Interventional Cardiology and Research, St Paul’s Hospital, Vancouver, BC, Canada
2 Department
Background: In patients with severe aortic stenosis (AS), conservative management is recommended in the absence of symptoms. Aortic valve replacement may however be considered in asymptomatic patients with high risk features which may include severe left ventricular hypertrophy (LVH). Our aim was to study the relationship between LVH and mortality in asymptomatic patients with severe AS. Method: Retrospectively studied 117 consecutive patients with severe AS (at least 1 echocardiographic parameters of valve area <1 cm2 , maximum velocity >4 m/s and mean pressure gradient >40 mmHg) diagnosed by echocardiography between January 2005 and April 2006 at Waikato Hospital. Results: Thirty-four patients with asymptomatic severe AS were identified and divided into 2 groups according to the severity of LVH. Group 1: No/Mild LVH (septal thickness = <1.4 cm) and Group 2: Moderate/Severe LVH (septal thickness >1.4 cm). Group 1 and Group 2 patients had 56% and 88% hypertensive patients respectively. Number of patients
Age (years ± SD)
Males (%)
Median F/U (days (Q1, Q3))
Mortality (%)
Group 1
18
79.5 ± 17.1
39%
33%
Group 2
16
85.1 ± 3.4
50%
1011 (828, 1097) 1025 (346, 1136)
63%
We noted only a trend to increase in mortality in patients with moderate or severe LVH (p = 0.09). Conclusion: There was no significant association between mortality and degree of LVH among asymptomatic patients with severe AS. doi:10.1016/j.hlc.2010.04.059
ABSTRACTS
Heart, Lung and Circulation 2010;19S:S1–S35
Heart, Lung and Circulation 2010;19S:S1–S35
Abstracts
ABSTRACTS
>10 ng/L below this (“10/10 criteria”) and (3) at least one level >14 ng/L and a change of 20% above 53 ng/L or 50% below this (“White” criteria1 ). Results: In comparison to 4th generation testing, the “7,10” and “10,10” change criteria showed improved clinical sensitivity and the same or improved clinical specificity for the diagnosis of myocardial infarction. The “White” criteria showed decreased clinical sensitivity but better specificity. Criterion used
Sensitivity (95% CI)
Specificity (95% CI)
TnT (4th generation) “7,10” criteria for hsTnT “10,10” criteria for hsTnT “White” criteria for hsTnT
92.86 (80.99–97.54) 95.24 (84.21–98.68) 95.24 (84.21–98.68) 90.48 (77.93–96.23)
91.51 (84.65–95.47) 91.51 (84.65–95.47) 92.45 (85.81–96.13) 95.28 (89.43–97.97)
Conclusion: The use of the hsTnT assay has the potential to improve clinical sensitivity and specificity in the diagnosis of myocardial infarction. Conflict of interest: Unrestricted grant for the study from Roche Diagnostics NZ Ltd.1 Prof Harvey White, personal communication. 1 Prof
temporary pacing wire requiring urgent surgical correction. The hemodynamic and clinical outcomes for the successful patients are summarized in the table below. One patient died during follow-up at day 166 due to neurodegenerative disorder. One patient required pacemaker insertion due to worsening interventricular conduction.
Pre-procedural, n=9 Post-procedural, n=9 6-month follow-up, n = 8 Long-term follow-up, n = 8 (avg13 + 6 months) ∗
54 TRANSCORONARY ETHANOL SEPTAL ABLATION FOR HYPERTROPHIC OBSTRCTIVE CARDIOMYOPATHY: INITIAL EXPERIENCE AT WAIKATO HOSPITAL S Pasupati ∗ , M Liang Waikato Hospital, Hamilton, New Zealand Background: Hypertrophic obstructive cardiomyopathy (HOCM) is a common cardiac inheritable disorder associated with dyspnoea, angina, syncope and sudden cardiac death. Surgical myectomy was considered as the goldstandard management of symptomatic HOCM refractory to medical therapy, however, transcoronary ethanol septal ablation (TESA) has emerged as an attractive alternative percutaneous technique. We report our initial experience with TESA. Methods: All patients with HOCM who had TESA in Waikato Hospital (Hamilton, New Zealand) were included. Patient’s baseline characteristics, procedural success and complications and all-cause mortality were recorded. Pre/post-TESA hemodynamics was assessed by left ventricular outflow tract gradient (LVOT; mm Hg). Functional status was assessed using New York Heart Association (NYHA) classes for dyspnoea; Canadian Cardiovascular Society Classes (CCSC) for angina and presence of syncope. Results: Ten patients, 30% males, were referred between October 2007 to October 2009 for TESA. Nine (90%) patients had successful procedure with itraprocedural LVOT gradient drop from 95 ± 48 mmHg to 29 ± 33 mmHg. The mean alcohol volume used was 2.9 + 1.6 mls. One patient required repeat ablation at 4 months. The procedural failure was due to cardiac tamponade from the
CCSC
Syncope
LVOT
MR*
Mortality
3±1
2±1
44%
108 [104,115]
2±2
N/A
1±0
1±0
0%
43 [20,63]
1±1
0%
1±0
1±0
0%
23 [16,32]
1±1
11%
1±0
1±0
0%
N/A
N/A
11%
MR – mitral regurgitation.
Conclusion: TESA is an attractive alternative to surgical myectomy. It is safe, with high procedural success in reliving symptoms with favourable long-term outcome.
Harvey White, personal communication.
doi:10.1016/j.hlc.2010.04.054
NYHA
Conflict of interest: None. doi:10.1016/j.hlc.2010.04.055 55 BALLOON AORTIC VALVULOPLASTY (BAV) FOR SEVERE SYMPTOMATIC AORTIC STENOSIS (AS) IN THE CURRENT ERA S Pasupati ∗ , M Liang Waikato Hospital, Hamilton, New Zealand Background: BAV fell out of favour due to poor survival benefit, perceived procedural complexity and the need for repeat procedure in short duration. It has been used as a bridge to aortic valve replacement (AVR) or transcatheter aortic valve insertion (TAVI) and as a palliative procedure for patients who have been denied valve replacement. Method: Procedures were done under local anaesthesia with rapid pacing during BAV. Balloon size was 100–120% of aortic annulus with Cristal balloon (Balt, Montmorency, France) used as first line. Echocardiogram was performed at 24–48 h post BAV. Results: In the last 25 months 46 BAV were done in 49 patients. 17 proceeded to TAVI with 1 receiving an AVR. Mean age was 81 years. Mean Logistic Euroscore was 30%. 94% were done using a [20–28 mm] single balloon. 18% received a concomitant coronary intervention. Aortic mean gradient and valve area improved from 52 ± 16 mm Hg to 31 ± 10 mm Hg, 0.7 ± 0.2 cm2 to 1.0 ± 0.24 cm2 respectively. 68% of patients with impaired ejection fraction, improvement post BAV(32 ± 7% to 40 ± 10%). Mitral regurgitation improved from 1.5 ± 1.1 to 1.2 ± 1.2. 9–12Fr sheaths were used with 2% vascular complications. There was 1 periprocedural stroke. Admissions in 6months improved from 2 ± 1 to 0 ± 1. There were no intra-procedural deaths with 1 and 12 month survival of
89% and 82% respectively. One year survival for bridged procedures vs. isolated BAV was 100% and 69% respectively. Conclusion: In the current era BAV can be performed with low procedural complications and acceptable one year survival in both patients bridged for surgery and treated palliatively for symptoms.
Abstracts
S27
58 LEFT VENTRICULAR HYPERTROPHY AND MORTALITY IN PATIENTS WITH ASYMPTOMATIC SEVERE AORTIC STENOSIS S Perera 1,∗ , N Wijesinghe 2 , V Pera 1 , S Pasupati 1 , G Devlin 1 1 Waikato
Conflict of interest: None. doi:10.1016/j.hlc.2010.04.057 57 WHAT FACTORS INFLUENCE HEALTHCARE PROFESSIONALS’ DECISION TO REFER PATIENTS TO CARDIAC REHABILITATION PHASE II PROGRAMMES? K Patrick South Canterbury DHB, Timaru, New Zealand Chronic conditions such as cardiovascular disease (CVD) result in 46% of death and disability world wide. Cardiac rehabilitation phase II programmes are designed as a secondary prevention course for people with CVD and have been shown to be effective in reducing cardiac morbidity and mortality. Attendance rates are poor internationally and have been linked to failure to refer and failure to attend. The aim of this literature review was to explore the failure to refer. A systematic review of the literature was conducted following the Joanna Briggs Institute (JBI) model for searching, critiquing and reviewing papers. An inclusion and exclusion criteria was developed with search strategy. Meta-synthesis of the extracted data produced three main categories, patient characteristics, healthcare professional characteristics and healthcare systems. It was that the found groups least likely to be referred to cardiac rehabilitation phase II programmes were women, older people (>65 years), those who experienced multiple cardiac events, those with co-morbidities and ethnic minorities. Referral rates were also linked to specialty area of practice. Cardiologists and cardiovascular surgeons were more likely to refer than primary care physicians. The characteristics of the healthcare systems that impacted on failure to refer were the lack of a clear referral pathway, and poor communication between referrers and cardiac rehabilitation programme coordinators. Cardiac rehabilitation has been shown to improve health outcomes for patients with CVD; however, the research shows referral rates are low. To improve understanding of referral failure, further research is warranted in New Zealand for a culturally relevant perspective. doi:10.1016/j.hlc.2010.04.058
Hospital, Hamilton, New Zealand of Interventional Cardiology and Research, St Paul’s Hospital, Vancouver, BC, Canada
2 Department
Background: In patients with severe aortic stenosis (AS), conservative management is recommended in the absence of symptoms. Aortic valve replacement may however be considered in asymptomatic patients with high risk features which may include severe left ventricular hypertrophy (LVH). Our aim was to study the relationship between LVH and mortality in asymptomatic patients with severe AS. Method: Retrospectively studied 117 consecutive patients with severe AS (at least 1 echocardiographic parameters of valve area <1 cm2 , maximum velocity >4 m/s and mean pressure gradient >40 mmHg) diagnosed by echocardiography between January 2005 and April 2006 at Waikato Hospital. Results: Thirty-four patients with asymptomatic severe AS were identified and divided into 2 groups according to the severity of LVH. Group 1: No/Mild LVH (septal thickness = <1.4 cm) and Group 2: Moderate/Severe LVH (septal thickness >1.4 cm). Group 1 and Group 2 patients had 56% and 88% hypertensive patients respectively. Number of patients
Age (years ± SD)
Males (%)
Median F/U (days (Q1, Q3))
Mortality (%)
Group 1
18
79.5 ± 17.1
39%
33%
Group 2
16
85.1 ± 3.4
50%
1011 (828, 1097) 1025 (346, 1136)
63%
We noted only a trend to increase in mortality in patients with moderate or severe LVH (p = 0.09). Conclusion: There was no significant association between mortality and degree of LVH among asymptomatic patients with severe AS. doi:10.1016/j.hlc.2010.04.059
ABSTRACTS
Heart, Lung and Circulation 2010;19S:S1–S35