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Patient Selection for Percutaneous Aortic Valve Replacement
Abstracts
ered high risk for traditional surgical valve replacement. The self-expanding Medtronic CoreValveTM and balloon expandable Edwards SepianTM valve were used. We describe our experience in Waikato public hospital. Methods: Patients with comorbidities were reviewed by a team of cardiologists and cardiac surgeons with a consensus that surgical risk was excessive and TAVI was appropriate. Femoral and axillary artery access was used in 25 and 4 patients respectively. 18Fr and 22Fr–24Fr delivery sheaths were used for CV and EV respectively. Mean follow-up was 203 days. Results: 23 and 6 patients received CV and EV respectively. Mean age was 81 ± 7 [61–92 years] with 62% male. Procedural success was 100%. Median day to discharge was 5[4,9]. 4 patients who received Medtronic CoreValve required permanent pacemaker implantation. Peri-procedural strokes occurred in 3 patients with 1 major and 2 minor sequellae. Aortic regurgitation was ≤2 in all patients. NYHA class Aortic mean gradient (mmHg) Aortic valve area (cm2 ) Ejection fraction (%) Mitral regurgitation Pulmonary pressure
Baseline
1 month
6 months
12 months
3.1 ± 0.6 53 ± 17 0.7 ± 0.2 48 ± 17 1[1,2] 52 ± 17
1.2 ± 0.5 9±4 2.0 ± 0.5 59 ± 10 1[0.3,1] 40 ± 14
1.3 ± 0.6 9±4 2 ± 0.8 55 ± 12 0[0,1] 42 ± 12
1.5 ± 0.7 9±4 1.8 ± 0.8 56 ± 16 1[1,1] 45 ± 14
Predicted 30 day survival by logistic Euroscore and STS score was 75% and 94% respectively. Despite additional comorbidities not accounted for by this estimate actual 30day and 1 year survival was 100% and 94%. Conclusion: TAVI is feasible for patients with severe AS and high risk for surgery with favorable sustained 1 year outcome. doi:10.1016/j.hlc.2010.06.1005 339 Patient and Resident Understanding of the Benefits of Elective Percutaneous Coronary Intervention for Stable Coronary Artery Disease C. Broderick ∗ , P. Friend, H. Samardhi, D. Walters, O. Raffel The Prince Charles Hospital, Brisbane, Australia Introduction: Consenting patients for elective percutaneous coronary intervention (PCI) involves detailed information on the procedure’s associated risks. However, understanding its benefits is equally important. While PCI in patients with stable symptoms provides symptomatic benefits, it has not, with some exceptions, been proven to reduce the risk of acute myocardial infarction (MI) or confer long-term prognostic benefit. Methods: Forty patients with stable symptoms attending a pre-admission clinic were assessed using a standard questionnaire before and after seeing the resident obtaining consent. A separate questionnaire was completed
S143
by the residents. Both groups were surveyed about the intended benefits of having PCI. Results: Thirty-four (85%) patients were confident they understood the procedure’s benefits. All correctly believed it could relieve symptoms; however, 36 (90%) believed that any PCI would reduce their future risk of MI and 32 (80%) believed it would increase their life expectancy. Responses did not alter after the consenting process. Eight of the nine (89%) residents believed they had a good understanding of the PCI procedure and its intended benefits. However, 6 (67%) believed it reduced the risk of MI and increased life expectancy. Conclusions: Patients appear to have unrealistic expectations of the benefits of PCI in treating stable coronary disease. This was not altered by the consenting process, which reflects, as demonstrated in this study, a lack of understanding by residents of current evidence on the benefits of elective PCI. More emphasis needs to be placed on educating patients and residents on the benefits of PCI. doi:10.1016/j.hlc.2010.06.1006 340 Patient Selection for Percutaneous Aortic Valve Replacement K. Nowakowski 1,∗ , S. Gleeson 1 , D. Mullany 1 , C. Gough 1 , C. Aroney 2 , D. Walters 1 1 The
Prince Charles Hospital, Australia Spirit Northside Private Hospital, Australia
2 Holy
Introduction: Percutaneous Aortic Valve Replacement (PAVR) is an emerging technique that is considered in selected high-risk patients with severe Aortic Stenosis whom might otherwise be deemed unfit for surgical valve replacement. Methods: Our database tracked 79 consecutive patients referred for PAVR. We noted the specialist responsible for the referral. Patient variables including age, functional class, co-morbidities, echocardiographic findings, and anatomical factors were assessed. The treatment modality chosen was identified and outcome assessed. Results: Mean age 84 years, Female 57%, Aortic valve area (AVA) 0.8 cm2 , Mean Gradient 50 mmHg, NYHA class 2.8, Euroscore 14, LVEF 57%. The referral originated from a cardiologist in 55%, a surgeon in 34%, and general practitioner in 11%. Patient preference for percutaneous replacement occurred in 20%. Of the total group 15% were assessed as suitable to proceed to surgical AVR (SAVR). 40% referrals progressed to successful PAVR, achieving an AVA 2.3 cm2 , NYHA 1.5. The mortality rate was 3%, less than that observed for conservative management (5%). 41% of referrals were considered not eligible for PAVR, 11% of these have since undergone SAVR, achieving an AVA 1.7 cm2 , NYHA 1.5 and no mortality. Most of the GPbased referrals (71%) were unsuitable for PAVR. Conclusion: Careful consideration of multiple factors and collaboration between cardiologists and cardiothoracic surgeons is essential to optimise the treatment approach. Increased education about and broadened
ABSTRACTS
Heart, Lung and Circulation 2010;19S:S1–S268
S144
Heart, Lung and Circulation 2010;19S:S1–S268
Abstracts
ABSTRACTS
inclusion criteria for PAVR may expose this effective innovation to more patients.
342
doi:10.1016/j.hlc.2010.06.1007
M. Liang 1,∗ , A. Puri 1 , J. Pasupati 1 , G. Devlin 1
341 Percutaneous Coronary Intervention in Elderly Australians; Initial and 1-Year Results from a National Multi-Centre Registry D. Eccleston ∗ , T. Rafter, S. Worthley, P. Muhlmann, M. Horrigan, G. Holt
Sage, M.
Heart Care Group, Australia Background: Few data exist regarding the outcomes of elderly (>75 years) patients undergoing PCI in Australia. Despite increasing rates of intervention in older patients, they are underrepresented in clinical trials. This study aimed to report procedural and clinical outcomes of elderly patients from a new multi-centre Australian registry. Methods: We prospectively enrolled consecutive patients aged >75 (n = 216) and ≤75 (n = 719) undergoing PCI to 1296 lesions at 6 Australian private hospitals from November 2008 to February 2010. We compared baseline data and in-hospital, 30 day and 1-year outcomes between these groups. Results: Elderly patients were less likely than younger patients to smoke (3.7% vs 10.9%, p = 0.002) or have a family history of coronary artery disease (41.0% vs 52.2%, p = 0.005) however had more heart failure symptoms (NYHA 3/4, 23.7% vs 16.7%, p = 0.006), presented more often with acute coronary syndromes (42.7% vs 35.4%, p = 0.04) and had a trend to more urgent procedures (23.6% vs 17.7%, p = 0.05). Outcomes %
>75 (n = 719)
≤75 (n = 216)
p
Lesion type B2/C Procedural success Aspirin Statins
49.3 96.9 97.3 90.3
33.5 96.3 99.6 94.8
<0.001 ns <0.01 0.04
MACEa In-hospital 30 day, 12 month
3.5 10.1 21.8
1.5 6.2 22.9
ns ns ns
a
MACE = death, MI, recurrent angina, urgent revascularisation, stroke.
Conclusion: PCI in elderly patients in Australia produces results comparable to those from international registries. Despite presenting more often with acute coronary syndromes, initial and long-term results of PCI in older patients are equivalent to those in younger patients. doi:10.1016/j.hlc.2010.06.1008
Percutaneous Coronary Intervention in the Very Elderly Liang 2 , S.
Pilkington 1 , S.
1 Department of Cardiology, Waikato Hospital, Hamilton, New Zealand 2 Department of Medicine, Middlemore Hospital, Auckland, New Zealand
Background: There is increasing demand for percutaneous coronary intervention (PCI) in patients ≥ 80 years old as the population ages and life-expectancy increases. Outcomes in these patients, peri-procedural and longer term, are less predictable than in younger patients. We report our experience with consecutive interventions in patients ≥80 years old in the last 3 years and provide the survival and major adverse cardiac and cerebrovascular events-(MACCE)free outcome data. Methods: 105 consecutive PCI in 95 patients were performed from May 2006 to August 2009 in patients over 80 years. All patients who had successful or unsuccessful procedure were included in the retrospective analysis. Results Mean age is 83 ± 3 years, (58% male). Mean follow up was 14 ± 11 months (maximum follow up is 3 years). The indications for PCI included 29% unstable angina, 43% NSTEMI, 18% STEMI and 10% stable angina. PCI was unsuccessful in 3%. Bare-metal stents were used in 58% of cases, drug-eluting stents in 30% and combination of stents in 6%, balloon only in 3%. The MACCE rate during follow up was 29%, including 6% MI, 9% repeated revascularization, 5% CVA, 15% Death. The Kaplan–Meier 2-year survival and MACCE-free survival for all octogenarian interventions is 84% and 68% respectively. Conclusion: Our study showed that, in the very elderly without immediate major life-threatening co-morbidity, PCI can be performed with a high expectation of procedural success and a favourable 2-year survival. However, 1 in 3 patients present with an adverse cardiac or cerebrovascular event during follow up. doi:10.1016/j.hlc.2010.06.1009 343 Percutaneous Device Closure Utilising the Premere Patent Foramen Ovale Occluder R. Hatton 1,∗ , K. Ng 2 , P. Hayes 1 , R. Bhagwandeen 1 , N. Collins 1 , R. Jayasinghe 2 1 John 2 Gold
Hunter Hospital, Australia Coast Health Services, Australia
Introduction: Percutaneous device closure of patent foramen ovale (PFO) is a therapeutic option in patients with cryptogenic stroke and migraine with a number of devices available for defect closure. We evaluated the clinical characteristics, procedural data and intermediate outcome of those patients undergoing percutaneous device closure using the Premere (St Jude Medical) PFO occluder; these were compared to patients receiving
ered high risk for traditional surgical valve replacement. The self-expanding Medtronic CoreValveTM and balloon expandable Edwards SepianTM valve were used. We describe our experience in Waikato public hospital. Methods: Patients with comorbidities were reviewed by a team of cardiologists and cardiac surgeons with a consensus that surgical risk was excessive and TAVI was appropriate. Femoral and axillary artery access was used in 25 and 4 patients respectively. 18Fr and 22Fr–24Fr delivery sheaths were used for CV and EV respectively. Mean follow-up was 203 days. Results: 23 and 6 patients received CV and EV respectively. Mean age was 81 ± 7 [61–92 years] with 62% male. Procedural success was 100%. Median day to discharge was 5[4,9]. 4 patients who received Medtronic CoreValve required permanent pacemaker implantation. Peri-procedural strokes occurred in 3 patients with 1 major and 2 minor sequellae. Aortic regurgitation was ≤2 in all patients. NYHA class Aortic mean gradient (mmHg) Aortic valve area (cm2 ) Ejection fraction (%) Mitral regurgitation Pulmonary pressure
Baseline
1 month
6 months
12 months
3.1 ± 0.6 53 ± 17 0.7 ± 0.2 48 ± 17 1[1,2] 52 ± 17
1.2 ± 0.5 9±4 2.0 ± 0.5 59 ± 10 1[0.3,1] 40 ± 14
1.3 ± 0.6 9±4 2 ± 0.8 55 ± 12 0[0,1] 42 ± 12
1.5 ± 0.7 9±4 1.8 ± 0.8 56 ± 16 1[1,1] 45 ± 14
Predicted 30 day survival by logistic Euroscore and STS score was 75% and 94% respectively. Despite additional comorbidities not accounted for by this estimate actual 30day and 1 year survival was 100% and 94%. Conclusion: TAVI is feasible for patients with severe AS and high risk for surgery with favorable sustained 1 year outcome. doi:10.1016/j.hlc.2010.06.1005 339 Patient and Resident Understanding of the Benefits of Elective Percutaneous Coronary Intervention for Stable Coronary Artery Disease C. Broderick ∗ , P. Friend, H. Samardhi, D. Walters, O. Raffel The Prince Charles Hospital, Brisbane, Australia Introduction: Consenting patients for elective percutaneous coronary intervention (PCI) involves detailed information on the procedure’s associated risks. However, understanding its benefits is equally important. While PCI in patients with stable symptoms provides symptomatic benefits, it has not, with some exceptions, been proven to reduce the risk of acute myocardial infarction (MI) or confer long-term prognostic benefit. Methods: Forty patients with stable symptoms attending a pre-admission clinic were assessed using a standard questionnaire before and after seeing the resident obtaining consent. A separate questionnaire was completed
S143
by the residents. Both groups were surveyed about the intended benefits of having PCI. Results: Thirty-four (85%) patients were confident they understood the procedure’s benefits. All correctly believed it could relieve symptoms; however, 36 (90%) believed that any PCI would reduce their future risk of MI and 32 (80%) believed it would increase their life expectancy. Responses did not alter after the consenting process. Eight of the nine (89%) residents believed they had a good understanding of the PCI procedure and its intended benefits. However, 6 (67%) believed it reduced the risk of MI and increased life expectancy. Conclusions: Patients appear to have unrealistic expectations of the benefits of PCI in treating stable coronary disease. This was not altered by the consenting process, which reflects, as demonstrated in this study, a lack of understanding by residents of current evidence on the benefits of elective PCI. More emphasis needs to be placed on educating patients and residents on the benefits of PCI. doi:10.1016/j.hlc.2010.06.1006 340 Patient Selection for Percutaneous Aortic Valve Replacement K. Nowakowski 1,∗ , S. Gleeson 1 , D. Mullany 1 , C. Gough 1 , C. Aroney 2 , D. Walters 1 1 The
Prince Charles Hospital, Australia Spirit Northside Private Hospital, Australia
2 Holy
Introduction: Percutaneous Aortic Valve Replacement (PAVR) is an emerging technique that is considered in selected high-risk patients with severe Aortic Stenosis whom might otherwise be deemed unfit for surgical valve replacement. Methods: Our database tracked 79 consecutive patients referred for PAVR. We noted the specialist responsible for the referral. Patient variables including age, functional class, co-morbidities, echocardiographic findings, and anatomical factors were assessed. The treatment modality chosen was identified and outcome assessed. Results: Mean age 84 years, Female 57%, Aortic valve area (AVA) 0.8 cm2 , Mean Gradient 50 mmHg, NYHA class 2.8, Euroscore 14, LVEF 57%. The referral originated from a cardiologist in 55%, a surgeon in 34%, and general practitioner in 11%. Patient preference for percutaneous replacement occurred in 20%. Of the total group 15% were assessed as suitable to proceed to surgical AVR (SAVR). 40% referrals progressed to successful PAVR, achieving an AVA 2.3 cm2 , NYHA 1.5. The mortality rate was 3%, less than that observed for conservative management (5%). 41% of referrals were considered not eligible for PAVR, 11% of these have since undergone SAVR, achieving an AVA 1.7 cm2 , NYHA 1.5 and no mortality. Most of the GPbased referrals (71%) were unsuitable for PAVR. Conclusion: Careful consideration of multiple factors and collaboration between cardiologists and cardiothoracic surgeons is essential to optimise the treatment approach. Increased education about and broadened
ABSTRACTS
Heart, Lung and Circulation 2010;19S:S1–S268
S144
Heart, Lung and Circulation 2010;19S:S1–S268
Abstracts
ABSTRACTS
inclusion criteria for PAVR may expose this effective innovation to more patients.
342
doi:10.1016/j.hlc.2010.06.1007
M. Liang 1,∗ , A. Puri 1 , J. Pasupati 1 , G. Devlin 1
341 Percutaneous Coronary Intervention in Elderly Australians; Initial and 1-Year Results from a National Multi-Centre Registry D. Eccleston ∗ , T. Rafter, S. Worthley, P. Muhlmann, M. Horrigan, G. Holt
Sage, M.
Heart Care Group, Australia Background: Few data exist regarding the outcomes of elderly (>75 years) patients undergoing PCI in Australia. Despite increasing rates of intervention in older patients, they are underrepresented in clinical trials. This study aimed to report procedural and clinical outcomes of elderly patients from a new multi-centre Australian registry. Methods: We prospectively enrolled consecutive patients aged >75 (n = 216) and ≤75 (n = 719) undergoing PCI to 1296 lesions at 6 Australian private hospitals from November 2008 to February 2010. We compared baseline data and in-hospital, 30 day and 1-year outcomes between these groups. Results: Elderly patients were less likely than younger patients to smoke (3.7% vs 10.9%, p = 0.002) or have a family history of coronary artery disease (41.0% vs 52.2%, p = 0.005) however had more heart failure symptoms (NYHA 3/4, 23.7% vs 16.7%, p = 0.006), presented more often with acute coronary syndromes (42.7% vs 35.4%, p = 0.04) and had a trend to more urgent procedures (23.6% vs 17.7%, p = 0.05). Outcomes %
>75 (n = 719)
≤75 (n = 216)
p
Lesion type B2/C Procedural success Aspirin Statins
49.3 96.9 97.3 90.3
33.5 96.3 99.6 94.8
<0.001 ns <0.01 0.04
MACEa In-hospital 30 day, 12 month
3.5 10.1 21.8
1.5 6.2 22.9
ns ns ns
a
MACE = death, MI, recurrent angina, urgent revascularisation, stroke.
Conclusion: PCI in elderly patients in Australia produces results comparable to those from international registries. Despite presenting more often with acute coronary syndromes, initial and long-term results of PCI in older patients are equivalent to those in younger patients. doi:10.1016/j.hlc.2010.06.1008
Percutaneous Coronary Intervention in the Very Elderly Liang 2 , S.
Pilkington 1 , S.
1 Department of Cardiology, Waikato Hospital, Hamilton, New Zealand 2 Department of Medicine, Middlemore Hospital, Auckland, New Zealand
Background: There is increasing demand for percutaneous coronary intervention (PCI) in patients ≥ 80 years old as the population ages and life-expectancy increases. Outcomes in these patients, peri-procedural and longer term, are less predictable than in younger patients. We report our experience with consecutive interventions in patients ≥80 years old in the last 3 years and provide the survival and major adverse cardiac and cerebrovascular events-(MACCE)free outcome data. Methods: 105 consecutive PCI in 95 patients were performed from May 2006 to August 2009 in patients over 80 years. All patients who had successful or unsuccessful procedure were included in the retrospective analysis. Results Mean age is 83 ± 3 years, (58% male). Mean follow up was 14 ± 11 months (maximum follow up is 3 years). The indications for PCI included 29% unstable angina, 43% NSTEMI, 18% STEMI and 10% stable angina. PCI was unsuccessful in 3%. Bare-metal stents were used in 58% of cases, drug-eluting stents in 30% and combination of stents in 6%, balloon only in 3%. The MACCE rate during follow up was 29%, including 6% MI, 9% repeated revascularization, 5% CVA, 15% Death. The Kaplan–Meier 2-year survival and MACCE-free survival for all octogenarian interventions is 84% and 68% respectively. Conclusion: Our study showed that, in the very elderly without immediate major life-threatening co-morbidity, PCI can be performed with a high expectation of procedural success and a favourable 2-year survival. However, 1 in 3 patients present with an adverse cardiac or cerebrovascular event during follow up. doi:10.1016/j.hlc.2010.06.1009 343 Percutaneous Device Closure Utilising the Premere Patent Foramen Ovale Occluder R. Hatton 1,∗ , K. Ng 2 , P. Hayes 1 , R. Bhagwandeen 1 , N. Collins 1 , R. Jayasinghe 2 1 John 2 Gold
Hunter Hospital, Australia Coast Health Services, Australia
Introduction: Percutaneous device closure of patent foramen ovale (PFO) is a therapeutic option in patients with cryptogenic stroke and migraine with a number of devices available for defect closure. We evaluated the clinical characteristics, procedural data and intermediate outcome of those patients undergoing percutaneous device closure using the Premere (St Jude Medical) PFO occluder; these were compared to patients receiving