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This study provides 2-year data from the PARTNER trial, in which patients with aortic stenosis received transcatheter aortic-valve replacement (TAVR) or surgical replacement. Overall mortality was similar, but paravalvular leak increased mortality in the TAVR group. Aortic stenosis is associated with high mortality after the appearance of cardiac symptoms. 1 Nevertheless, many patients do not undergo surgical aortic-valve replacement owing to real or perceived increased risks associated with surgery. 2 – 5 Transcatheter aortic-valve replacement (TAVR) has emerged as an alternative therapy in high-risk patients with aortic stenosis. 6 – 10 Observational registries from various countries have reported 1-month and 1-year outcomes after TAVR, 11 – 14 but there are limited long-term follow-up data. 15 The Placement of Aortic Transcatheter Valves (PARTNER) trial was a randomized trial comparing TAVR with standard-of-care therapies in high-risk patients with aortic stenosis. One-year mortality outcomes from PARTNER showed . . .

Produced by senescent cells, the senescence-associated secretory phenotype (SASP) is a potential driver of age-related dysfunction. We tested whether circulating concentrations of SASP proteins reflect age and medical risk in humans. We first screened senescent endothelial cells, fibroblasts, preadipocytes, epithelial cells, and myoblasts to identify candidates for human profiling. We then tested associations between circulating SASP proteins and clinical data from individuals throughout the life span and older adults undergoing surgery for prevalent but distinct age-related diseases. A community-based sample of people aged 20–90 years (retrospective cross-sectional) was studied to test associations between circulating SASP factors and chronological age. A subset of this cohort aged 60–90 years and separate cohorts of older adults undergoing surgery for severe aortic stenosis (prospective longitudinal) or ovarian cancer (prospective case-control) were studied to assess relationships between circulating concentrations of SASP proteins and biological age (determined by the accumulation of age-related health deficits) and/or postsurgical outcomes. We showed that SASP proteins were positively associated with age, frailty, and adverse postsurgery outcomes. A panel of 7 SASP factors composed of growth differentiation factor 15 (GDF15), TNF receptor superfamily member 6 (FAS), osteopontin (OPN), TNF receptor 1 (TNFR1), ACTIVIN A, chemokine (C-C motif) ligand 3 (CCL3), and IL-15 predicted adverse events markedly better than a single SASP protein or age. Our findings suggest that the circulating SASP may serve as a clinically useful candidate biomarker of age-related health and a powerful tool for interventional human studies.

The prognostic implications of several baseline preprocedural variables in patients with severe native valve aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) are unclear. The goal of this study was to determine the impact of reduced stroke volume index (SVI), low gradient (LG), and reduced ejection fraction (EF) on all-cause mortality. We searched MEDLINE, CENTRAL, EMBASE, Web of Science, and Scopus through October 13, 2014. We evaluated the association between low SVI (<35 ml/m2), LG (<40 mm Hg), and low EF (<50% and <30%) on 1-year all-cause mortality. We pooled results across studies using the random-effects model. We included 16 studies at moderate risk of bias enrolling 7,673 patients with severe AS who underwent TAVI. Low EF was associated with increased 1-year mortality after TAVI compared to preserved EF (for EF <30%, hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.19 to 2.16, I2 = 32%; and for EF <50%, HR 1.52, 95% CI 1.31 to 1.76, I2 = 17%). LG was associated with increased mortality after TAVI compared to high mean gradient (≥40 mm Hg; HR 1.60, 95% CI 1.30 to 1.97, I2 = 36%). Low SVI was associated with increased mortality after TAVI compared to normal SVI (HR 1.59, 95% CI 1.23 to 2.05, I2 = 27%). In conclusion, low SVI, LG, and low EF are each associated with higher mortality after TAVI. These findings highlight the importance of including these variables into TAVI risk algorithms and will better inform shared decision-making before TAVI.

We report the spectrum of aortic involvement in patients with giant cell arteritis (GCA) following review of medical records of 4,006 patients including those with imaging studies. A total of 1,450 patients (36%) had a confirmed diagnosis of GCA. Of these, 974 had aortic imaging. Of the 974 patients with imaging, 435 (45%) had an identified aortopathy. The most common aortopathy was aneurysm/dilation (69%). Overall, an annual aneurysmal growth rate of 1.5 mm/y was calculated. In patients with aneurysm/dilation, aortic dissection occurred in 18 patients (6%), and these patients had a significantly higher aneurysmal growth rate compared with those without dissection (4.5 vs 1.4 mm/y, p = 0.005). The median size of the aorta at the time of dissection was 51 mm, with 7 (39%) occurring with a maximal aortic aneurysm/dilation <50 mm. In conclusion, our findings indicate higher aneurysmal growth rate in GCA compared with that reported for degenerative aortic disease. Moreover, patients who develop dissection had a significantly higher growth rate than those without dissection with over a third of these patients suffering dissection at a caliber <50 mm.

This study aimed to examine the association between renal recovery status at hospital discharge after acute kidney injury (AKI) and long-term mortality following transcatheter aortic valve replacement (TAVR). We screened all adult patients who survived to hospital discharge after TAVR for aortic stenosis at a quaternary referral medical center from January 1, 2008, through June 30, 2014. An AKI was defined as an increase in serum creatinine level of 0.3 mg/dL or a relative increase of 50% from baseline. Renal outcome at the time of discharge was evaluated by comparing the discharge serum creatinine level to the baseline level. Complete renal recovery was defined as no AKI at discharge, whereas partial renal recovery was defined as AKI without a need for renal replacement therapy at discharge. No renal recovery was defined as a need for renal replacement therapy at discharge. The study included 374 patients. Ninty-eight (26%) patients developed AKI during hospitalization: 55 (56%) had complete recovery; 39 (40%), partial recovery; and 4 (4%), no recovery. AKI development was significantly associated with increased risk of 2-year mortality (hazard ratio [HR], 2.20 [95% CI, 1.37-3.49]). For patients with AKI, the 2-year mortality rate for complete recovery was 34%; for partial recovery, 43%; and for no recovery, 75%; compared with 20% for patients without AKI (P < .001). In adjusted analysis, complete recovery (HR, 1.87 [95% CI, 1.03-3.23]); partial recovery (HR, 2.65 [95% CI, 1.40-4.71]) and no recovery (HR, 10.95 [95% CI, 2.59-31.49]) after AKI vs no AKI were significantly associated with increased risk of 2-year mortality. The mortality rate increased for all patients with AKI undergoing TAVR. A reverse correlation existed for progressively higher risk of death and the extent of AKI recovery.

To determine whether surgical pericardiectomy is a safe and effective alternative to medical management for chronic relapsing pericarditis. Retrospective review of 184 patients presenting to the Mayo Clinic in Rochester, Minnesota, from January 1, 1994, through December 31, 2005, with persistent relapsing pericarditis identified 58 patients who had a pericardiectomy after failed medical management and 126 patients who continued with medical treatment only. The primary outcome variables were in-hospital postoperative mortality or major morbidity, all-cause death, time to relapse, and medication use. Mean ± SD follow-up was 5.5±3.5 years in the surgical group and 5.4±4.4 years in the medical treatment group. At baseline, patients in the surgical group had higher mean relapses (6.9 vs 5.5; P=.01), were more likely to be taking colchicine (43.1% [n=25] vs 18.3% [n=23]; P=.002) and corticosteroids (70.7% [n=41] vs 42.1% [n=53]; P<.001), and were more likely to have undergone a prior pericardiotomy (27.6% [n=16] vs 11.1% [n=14]; P=.003) than the medical treatment group. Perioperative mortality (0%) and major morbidity (3%; n=2) were minimal. Kaplan-Meier analysis revealed no differences in all-cause death at follow-up (P=.26); however, the surgical group had a markedly decreased relapse rate compared with the medical treatment group (P=.009). Medication use was notably reduced after pericardiectomy. In patients with chronic relapsing pericarditis in whom medical management has failed, surgical pericardiectomy is a safe and effective method of relieving symptoms.

Frailty is a common condition in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). The aim of this systematic review was to assess the impact of frailty status on acute kidney injury (AKI) and mortality after TAVR. A systematic literature search was conducted using MEDLINE, EMBASE, and Cochrane databases from the inception through November 2016. The protocol for this study is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42016052350). Studies that reported odds ratios, relative risks or hazard ratios comparing the risk of AKI after TAVR in frail vs. non-frail patients were included. Mortality risk was evaluated among the studies that reported AKI-related outcomes. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. Eight cohort studies with a total of 10,498 patients were identified and included in the meta-analysis. The pooled RR of AKI after TAVR among the frail patients was 1.19 (95% CI 0.97-1.46, I2 = 0), compared with non-frail patients. When the meta-analysis was restricted only to studies with standardized AKI diagnosis according to Valve Academic Research Consortium (VARC)-2 criteria, the pooled RRs of AKI in frail patients was 1.16 (95% CI 0.91-1.47, I2 = 0). Within the selected studies, frailty status was significantly associated with increased mortality (RR 2.01; 95% CI 1.44-2.80, I2 = 58). The findings from our study suggest no significant association between frailty status and AKI after TAVR. However, frailty status is associated with mortality after TAVR and may aid appropriate patient selection for TAVR.

To assess long-term survival with repeat coronary artery bypass grafting (RCABG) or percutaneous coronary intervention (PCI) in patients with previous CABG. From January 1, 2000, through December 31, 2013, 1612 Mayo Clinic patients underwent RCABG (n=215) or PCI (n=1397) after previous CABG. The RCABG cohort was grouped by use of saphenous vein grafts only (n=75), or with additional arterial grafts (n=140); the PCI cohort by, bare metal stents (BMS; n=628), or drug-eluting stents (DES; n=769), and by the treated target into native coronary artery (n=943), bypass grafts only (n=338), or both (n=116). Multivariable regression and propensity score analysis (n=280 matched patients) were used. In multivariable analysis, the 30-day mortality was increased in RCABG versus PCI patients (hazard ratio [HR], 5.32; 95%CI, 2.34-12.08; P<.001), but overall survival after 30 days improved with RCABG (HR, 0.72; 95% CI, 0.55-0.94; P=.01). Internal mammary arteries were used in 61% (129 of 215) of previous CABG patients and improved survival (HR, 0.82; 95% CI, 0.69-0.98; P=.03). Patients treated with drug-eluting stent had better 10-year survival (HR, 0.74; 95% CI, 0.59-0.91; P=.001) than those with bare metal stent alone. In matched patients, RCABG had improved late survival over PCI: 48% vs 33% (HR, 0.57; 95% CI, 0.35-0.91; P=.02). Compared with RCABG, patients with PCI involving bypass grafts (n=60) had increased late mortality (HR, 1.62; 95% CI, 1.10-2.37; P=.01), whereas those having PCI of native coronary arteries (n=80) did not (HR, 1.09; 95% CI, 0.75-1.59; P=.65). RCABG is associated with improved long-term survival after previous CABG, especially compared with PCI involving bypass grafts.

Intermediate-risk patients with aortic stenosis were randomly assigned to undergo either transcatheter or surgical aortic-valve replacement. At 5 years, there was no significant difference between the two groups in the incidence of death or disabling stroke. The incidence of aortic regurgitation was higher with transcatheter AVR.

In a randomized trial involving more than 2000 patients, transcatheter aortic-valve replacement was noninferior to surgical replacement in the primary end point of death from any cause or disabling stroke at 2 years. Transcatheter aortic-valve replacement (TAVR) is a new therapy for patients with severe aortic stenosis who are not candidates for surgery 1 , 2 or who are at high risk for complications due to surgery. 3 , 4 The acceptance of the use of TAVR in high-risk patients was based on evidence from clinical trials 5 , 6 that used early-generation TAVR devices; these procedures were associated with considerable procedure-related complications. 7 – 9 Recently, increased operator experience and enhanced transcatheter valve systems have led to a worldwide trend to use TAVR in patients who are at low or intermediate risk. 10 – 12 This trend has been evaluated in small . . .