RESUMEN
OBJECTIVES: To investigate the association of the CharlsonComorbidity Index (CCI) with clinical outcomes after transcatheter aortic valve implantation (TAVI). BACKGROUND: Patients undergoing TAVI have high comorbid burden; however, there is limited evidence of its impact on clinical outcomes. METHODS: Data from 1887 patients from the UK, Canada, Spain, Switzerland and Italy were collected between 2007 and 2016. The association of CCI with 30-day mortality, Valve Academic Research Consortium-2 (VARC-2) composite early safety, long-term survival and length of stay (LoS) was calculated using logistic regression and Cox proportional hazard models, as a whole cohort and at a country level, through a two-stage individual participant data (IPD) random effect meta-analysis. RESULTS: Most (60%) of patients had a CCI ≥3. A weak correlation was found between the total CCI and four different preoperative risks scores (ρ=0.16 to 0.29), and approximately 50% of patients classed as low risk from four risk prediction models still presented with a CCI ≥3. Per-unit increases in total CCI were not associated with increased odds of 30-day mortality (OR 1.09, 95% CI 0.96 to 1.24) or VARC-2 early safety (OR 1.04, 95% CI 0.96 to 1.14) but were associated with increased hazard of long-term mortality (HR 1.10, 95% CI 1.05 to 1.16). The two-stage IPD meta-analysis indicated that CCI was not associated with LoS (HR 0.97, 95% CI 0.93 to 1.02). CONCLUSION: In this multicentre international study, patients undergoing TAVI had significant comorbid burden. We found a weak correlation between the CCI and well-established preoperative risks scores. The CCI had a moderate association with long-term mortality up to 5 years post-TAVI.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Prótesis Valvulares Cardíacas , Medición de Riesgo/métodos , Reemplazo de la Válvula Aórtica Transcatéter , Adulto , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/epidemiología , Canadá/epidemiología , Comorbilidad/tendencias , Femenino , Estudios de Seguimiento , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Sistema de Registros , Factores de Riesgo , Índice de Severidad de la Enfermedad , España/epidemiología , Suiza/epidemiología , Factores de Tiempo , Adulto JovenRESUMEN
OBJECTIVES: Surgical aortic valve replacement (SAVR) for the treatment of in very old patients with severe aortic stenosis is associated with a high risk of morbidity and mortality. Transcatheter aortic valve implantation (TAVI) has become the preferred alternative. Therefore, we sought to evaluate outcomes in very old patients who underwent SAVR versus TAVI. METHODS: A total of 169 consecutive patients aged ≥85 years underwent TAVI (n = 68) or SAVR (n = 101). A propensity score adjustment was used to compare outcomes including cost analysis. RESULTS: The propensity score generated 40 pairs of patients with similar baseline characteristics. The TAVI group experienced atrioventricular block (37.5% vs 5%, P < 0.01) more frequently, a longer stay in the intensive care unit (median 5 days, range 1-35 vs median 2 days, range 1-6, P < 0.01) but a lower rate of new-onset atrial fibrillation (15% vs 47.5%, P < 0.01). The 30-day mortality rate was similar in the unmatched and matched cohorts (8.8% vs 5.0%, P = 0.32; 10% vs 7.5%, P = 0.69). One, 3- and 5-year overall survival rates (80% vs 90%, 56% vs 79%, 37% vs 71%, P < 0.01) and freedom from major adverse cardiac and cardiovascular events (72% vs 90%, 46% vs 76%, 17% vs 68%, P < 0.01) were lower in the TAVI group. An overall cost analysis indicated that TAVI was more expensive (2084 vs 19 891). CONCLUSIONS: In patients 85 years and older, SAVR seems to offer good short- and mid-term clinical outcomes compared to TAVI. Advanced age alone would not be an indication for TAVI in old-old patients.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Complicaciones Posoperatorias/epidemiología , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Factores de Edad , Anciano de 80 o más Años , Femenino , Anciano Frágil , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Incidencia , Italia/epidemiología , Masculino , Puntaje de Propensión , Factores de Riesgo , Tasa de Supervivencia/tendenciasRESUMEN
OBJECTIVES: Major trauma is a leading cause of death, particularly among young patients. New strategies in management are needed to improve poor outcomes in cases of severe trauma. Extracorporeal life support (ECLS) has proven to be effective in acute cardiopulmonary failure of different causes, even when conventional therapies fail. We report our initial experience with ECLS as a rescue therapy in severely polytraumatized patients in a refractory clinical setting. This study identifies the pre-ECLS characteristics of patients to predict the appropriateness of ECLS treatment. METHODS: From December 2008 to May 2012, 375 patients with polytrauma were treated in the Careggi Teaching Hospital, a tertiary-level referral trauma center. Our ECLS team was alerted on 30 patients and applied ECLS in 18 adult patients with trauma. We adopted venoarterial ECLS in 14 patients with cardiopulmonary failure with refractory shock and venovenous ECLS in 4 patients with isolated refractory acute respiratory failure. RESULTS: ECLS was initiated at a mean of 359.176 ± 216.606 (145-950) minutes from trauma. In 4 patients, the ECLS treatment failed because of an incapability to maintain adequate ECLS flow and perfusion. In 14 patients, efficiently supported by ECLS, the cardiac index, mean arterial pressure, blood lactate concentration, arterial oxygen tension, arterial carbon dioxide tension, and pH showed significant improvement, with normal values reached at 3.5 ± 1.5 hours. CONCLUSIONS: From our data, ECLS seems to be a valuable option to resuscitate patients with severe trauma when conventional therapies are insufficient. ECLS is safe, feasible, and effective in providing hemodynamic support and blood gas exchange.