Benjamin D. Pollock M.S.P.H.

Sannino, A., S. Potluri, B. Pollock, G. Filardo, A. Gopal, R. C. Stoler, M. Szerlip, A. Chowdhury, M. J. Mack and P. A. Grayburn (2019). “Impact of Mitral Stenosis on Survival in Patients Undergoing Isolated Transcatheter Aortic Valve Implantation.” Am J Cardiol Jan 25. [Epub ahead of print].

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This study was performed to investigate the prevalence and impact on survival of baseline mitral stenosis (MS) in patients who underwent transcatheter aortic valve implantation (TAVI) due to the presence of severe symptomatic aortic stenosis. This retrospective study included 928 consecutive patients with severe, symptomatic aortic stenosis who underwent TAVI in 2 institutions, from January 2012 to August 2016. Mean follow-up was 40.8 +/- 13.9 months. Based on the mean mitral gradient (MMG) at baseline, 3 groups were identified: MMG <5 mm Hg (n=737, 81.7%); MMG >/=5 and <10 mm Hg (n=147, 16.3%); MMG >/=10 mm Hg (n=17, 1.9%). These latter were more frequently women, with a smaller body surface area, a higher prevalence of atrial fibrillation, chronic obstructive pulmonary disease, and previous history of coronary-artery bypass graft/percutaneous coronary intervention. At baseline, patients with MMG >/=10 mm Hg compared with >/=5 and <10 mm Hg and <5 mm Hg patients had a lower mitral valve area (2.4 +/- 0.94 vs 2.1 +/- 0.86 vs 1.5 +/- 0.44 cm(2)), a lower prevalence of MR >/=2+ (5.9% vs 28.6% and 15.6%, p <0.0001), a higher prevalence of severe mitral annular calcium (70.6% vs 45.6% and 13.0%, p <0.0001) and a higher systolic pulmonary arterial pressure (50.6 +/- 12.1 vs 47.2 +/- 14.5 and 41.6 +/- 14.4, p <0.0001). Despite the low prevalence of MMG >/=10 mm Hg, these patients had higher 5-year mortality compared with the other groups (adjusted hazard ratio 2.91, 95% confidence interval 1.17 to 7.20, p=0.02). In conclusion, severe calcific MS is uncommon in patients who underwent TAVI. Its presence is associated with higher long-term mortality whereas moderate MS is not.

Pollock, B. D., P. Stuchlik, E. W. Harville, K. T. Mills, W. Tang, W. Chen and L. A. Bazzano (2018). “Life course trajectories of cardiovascular risk: Impact on atherosclerotic and metabolic indicators.” Atherosclerosis 280: 21-27.

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BACKGROUND AND AIMS: In this analysis, we estimated population-level trajectory groups of life course cardiovascular risk to explore their impact on mid-life atherosclerotic and metabolic outcomes. METHODS: This prospective study followed n=1269 Bogalusa Heart participants, each with at least 4 study visits from childhood in 1973 through adulthood in 2016. We used discrete mixture modeling to determine trajectories of cardiovascular risk percentiles from childhood to adulthood. Outcomes included mid-life subclinical atherosclerotic measures [(carotid intima-media thickness (cIMT), pulse wave velocity (PWV)], metabolic indicators [(diabetes and body mass index (BMI)], and short physical performance battery (SPPB). RESULTS: Between the mean ages of 9.6-48.3 years, we estimated five distinct trajectory groups of life course cardiovascular risk (High-Low, High-High, Mid-Low, Low-Low, and Low-High). Adult metabolic and vascular outcomes were significantly determined by life course cardiovascular risk trajectory groups (all p<0.01). Those in the High-Low group had lower risks of diabetes (20% vs. 28%, respectively; p=.12) and lower BMIs (32.4kg/m(2)vs. 34.6kg/m(2); p=.06) than those who remained at high risk (High-High) throughout life. However, the High-Low group had better cIMT (0.89mm vs. 1.05mm; p<.0001) and PWV (7.8m/s vs. 8.2m/s; p=.03) than the High-High group. For all outcomes, those in the Low-Low group fared best. CONCLUSIONS: We found considerable movement between low- and high-relative cardiovascular risk strata over the life course. Children who improved their relative cardiovascular risk over the life course achieved better mid-life atherosclerotic health despite maintaining relatively poor metabolic health through adulthood.

Hebeler, K. R., H. Baumgarten, J. J. Squiers, J. Wooley, B. D. Pollock, C. Mahoney, G. Filardo, B. Lima and J. M. DiMaio (2018). “Albumin Is Predictive of 1-Year Mortality After Transcatheter Aortic Valve Replacement.” Ann Thorac Surg 106(5): 1302-1307.

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BACKGROUND: A validated model for predicting 1-year outcomes after transcatheter aortic valve replacement (TAVR) does not exist. TAVR-specific risk models may benefit from frailty markers, and sarcopenia may represent an objective frailty marker. This study assessed the predictive ability of sarcopenia and frailty markers on 1-year mortality after TAVR. METHODS: We evaluated 470 patients undergoing TAVR at a single center. Frailty was assessed using four markers: gait speed, hand grip strength, serum albumin, and Katz activities of daily living. Sarcopenia was measured as the cross-sectional psoas muscle area on pre-TAVR computed tomography. Performance of four models incorporating The Society of Thoracic Surgeons Predicted Risk of Mortality, frailty, or sarcopenia metrics, or both, for predicting 1-year mortality was assessed with area under the curve, Hosmer-Lemeshow statistics, and calibration plots. RESULTS: A total of 63 deaths (13.4%) deaths occurred by 1 year. The Society of Thoracic Surgeons Predicted Risk of Mortality alone was poorly predictive of 1-year mortality (area under the curve, 0.52; 95% confidence interval, 0.42 to 0.68). Only the model including sarcopenia and all frailty markers (area under the curve, 0.61; 95% confidence interval, 0.53 to 0.68) significantly improved predictive ability compared with The Society of Thoracic Surgeons Predicted Risk of Mortality alone (p = 0.05). Albumin was the only frailty marker significantly associated with increased risk for 1-year mortality (p = 0.03). Psoas muscle area, as a surrogate for sarcopenia, was not significantly associated with increased risk for 1-year mortality. CONCLUSIONS: Most of the commonly used pre-TAVR risk assessments are poorly predictive of 1-year mortality. Albumin was the only frailty marker that was associated with higher mortality. Future studies should investigate whether optimization of nutritional status can improve outcomes after TAVR.

Hebeler, K. R., H. Baumgarten, J. J. Squiers, J. Wooley, B. D. Pollock, C. Mahoney, G. Filardo, B. Lima and J. M. DiMaio (2018). “Albumin Is Predictive of 1-Year Mortality After Transcatheter Aortic Valve Replacement.” Ann Thorac Surg Jul 23. [Epub ahead of print].

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BACKGROUND: A validated model for predicting 1-year outcomes after transcatheter aortic valve replacement (TAVR) does not exist. TAVR-specific risk models may benefit from frailty markers, and sarcopenia may represent an objective frailty marker. This study assessed the predictive ability of sarcopenia and frailty markers on 1-year mortality after TAVR. METHODS: We evaluated 470 patients undergoing TAVR at a single center. Frailty was assessed using 4 markers (gait speed, handgrip strength, serum albumin, and Katz activities of daily living). Sarcopenia was measured as the cross-sectional psoas muscle area on pre-TAVR computed tomography. Performance of four models incorporating Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM), frailty, and/or sarcopenia metrics for predicting 1-year mortality was assessed with area under the curve, Hosmer-Lemeshow statistics, and calibration plots. RESULTS: A total of 63 (13.4%) deaths occurred by 1-year. STS-PROM alone was poorly predictive of 1-year mortality (AUC 0.52, 95%CI: 0.42, 0.68). Only the model including both sarcopenia and all frailty markers (AUC 0.61, 95%CI: 0.53, 0.68) significantly improved predictive ability compared to STS-PROM alone (p = 0.05). Albumin was the only frailty marker significantly associated with increased risk for 1-year mortality (p=0.03). Psoas muscle area, as a surrogate for sarcopenia, was not significantly associated with increased risk for 1-year mortality. CONCLUSIONS: Most commonly used pre-TAVR risk assessments are poorly predictive of 1-year mortality. Albumin was the only frailty marker that was associated with higher mortality. Future studies should investigate whether optimization of nutritional status can improve outcomes following TAVR.

Arsalan, M., W. K. Kim, A. Van Linden, C. Liebetrau, B. D. Pollock, G. Filardo, M. Renker, H. Mollmann, M. Doss, U. Fischer-Rasokat, A. Skwara, C. W. Hamm and T. Walther (2018). “Predictors and outcome of conversion to cardiac surgery during transcatheter aortic valve implantation.” Eur J Cardiothorac Surg 54(2): 267-272.

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OBJECTIVES: Due to increasing clinical experience with transcatheter aortic valve implantation (TAVI) procedures, sophisticated imaging and advanced device technology, TAVI complication rates are low; however, patients requiring conversion to surgery are confronted with an increased mortality risk. In this retrospective study, we evaluated the predictors for conversion and the outcomes of these patients. METHODS: We analysed the records of all patients undergoing TAVI in our centre from 2011 to 2016 and focused on cases that required conversion to sternotomy. We investigated reasons and risk factors for conversion as well as 30-day and 1-year outcomes. RESULTS: During the study period, 32 (2.1%) of 1775 patients undergoing TAVI required immediate conversion to sternotomy. Annular rupture (5 of 32; 16%), device embolization (9 of 32; 28%) and pericardial tamponade (15 of 32; 47%) were the most common reasons for conversion. Usage of a self-expandable valve showed to be the only predictor for conversion (odds ratio 0.38, 95% confidence interval 0.16-0.90; P = 0.03). Survival at 30 days and 1 year was 56% and 41%, respectively. Patients who survived 30 days after conversion showed higher preoperative ejection fraction, shorter duration of surgery and shorter perfusion time. CONCLUSIONS: In this high-volume, single-centre experience, conversion to sternotomy during TAVI occurred in about 2%, with annular rupture, device embolization and pericardial tamponade being the most common causes. Complications requiring conversion showed to be unpredictable. However, in view of these life-threatening complications, the 30-day survival rate exceeding 50% emphasizes the importance of an experienced and well-attuned heart team providing immediate access to surgical bailout procedures.