Daily Cardiology Research Analysis
Long-term durability signals after TAVI show higher structural valve deterioration with balloon-expandable valves versus self-expandable systems, informing device selection and follow-up. A network meta-analysis supports complete revascularization (either at index or staged) over culprit-only PCI in ACS with multivessel disease. In a nationwide STEMI cohort, diabetes remained associated with substantially higher long-term mortality, but high-quality inpatient care attenuated risk, underscoring s
Summary
Long-term durability signals after TAVI show higher structural valve deterioration with balloon-expandable valves versus self-expandable systems, informing device selection and follow-up. A network meta-analysis supports complete revascularization (either at index or staged) over culprit-only PCI in ACS with multivessel disease. In a nationwide STEMI cohort, diabetes remained associated with substantially higher long-term mortality, but high-quality inpatient care attenuated risk, underscoring system-level improvement opportunities.
Research Themes
- Transcatheter aortic valve durability and structural valve deterioration
- Revascularization strategies in ACS with multivessel disease
- Diabetes-specific disparities and quality-of-care in STEMI outcomes
Selected Articles
1. 'Incidence and impact of structural valve deterioration following TAVI: a multicenter real-world study'.
In a multicenter real-world TAVI registry (n=2040), 8-year structural valve deterioration (SVD) was 13.3% overall, with balloon-expandable valves exhibiting a markedly higher SVD risk than self-expandable valves after IPTW adjustment. SVD was associated with increased heart failure rehospitalization and a trend toward higher cardiovascular mortality.
Impact: Provides long-term durability evidence across platforms and links SVD to clinical outcomes, guiding prosthesis selection and surveillance strategies in younger/low-risk TAVI populations.
Clinical Implications: When anticipating longer life expectancy, self-expandable platforms may be preferable to mitigate SVD risk; echocardiographic surveillance should be emphasized for early SVD detection to prevent HF rehospitalizations.
Key Findings
- Estimated 8-year incidence: SVD 13.3% (95% CI 9.8–18.0), BVF 11.5% (95% CI 8.9–14.8).
- After IPTW, balloon-expandable vs self-expandable valves had higher SVD (5.25% vs 1.19%; HR 10.25, 95% CI 3.79–27.71) and higher all-cause BVF (6.41% vs 3.2%; HR 2.10, 95% CI 1.27–3.47).
- SVD associated with increased HF rehospitalization (P=0.048) and a trend to higher cardiovascular mortality (P=0.06); no difference in a composite of CV death, HF rehospitalization, and valve reintervention by platform (P=0.46).
Methodological Strengths
- Large multicenter cohort with inverse probability treatment weighting to balance platforms
- Use of standardized VARC-3 echocardiographic SVD definitions and long follow-up
Limitations
- Observational design with potential residual confounding despite IPTW
- Device-generation heterogeneity across 2007–2020 and echo-based endpoints
Future Directions: Prospective comparative studies by contemporary valve generation and patient-risk strata; incorporation of CT-based structural biomarkers to refine SVD prediction and surveillance intervals.
AIMS: Valve durability becomes a major issue as transcatheter aortic valve implantation (TAVI) is expanding to populations with longer life expectancy. We sought to (i) determine the incidence of structural valve deterioration (SVD), (ii) compare the incidence of SVD between balloon-expandable (BE) and self-expandable (SE) valves, and (iii) analyse the impact of SVD. METHODS AND RESULTS: 2040 patients who underwent TAVI (2007-2020) from 9 centres were included. After inverse probability treatment weighting (IPTW), 1848 patients were selected (973 BE and 875 SE). SVD was defined using recent echocardiographic definitions according to VARC-3 criteria: Median follow-up was 4.2 (IQR: 2.5-5.7) years. The estimated incidence of SVD and bioprosthetic valve failure (BVF) at 8 years follow-up for the overall cohort were 13.3% [95% confidence interval (CI) 9.8-18%] and 11.5% (95% CI 8.9-14.8%), respectively. After IPTW and a median follow-up of 4 years, the risk of SVD (5.25% vs. 1.19%; HR 10.25, 95% CI 3.79-27.71, P < 0.001), and all-cause BVF (6.41% vs. 3.2%; HR 2.1, 95% CI 1.27-3.47 P = 0.004), was significantly higher for BE compared with SE recipients. Patients developing SVD had a trend towards a higher incidence of cardiovascular death (P = 0.06), as well as a significantly higher risk of heart failure rehospitalization (P = 0.048). After IPTW, there were no differences between BE and SE recipients in the combined endpoint of cardiovascular death, heart failure rehospitalization and valve reintervention (P = 0.46). CONCLUSION: In this real-world registry, the incidence of SVD at 8 years after TAVI was relatively low. The risk of SVD was higher among BE compared with SE valve recipients. SVD was associated with an increased risk of heart failure rehospitalization and a trend towards a higher risk of cardiovascular death.
2. Revascularization Strategies for Multivessel Disease in Acute Coronary Syndrome: Network Meta-analysis.
Across 20 studies, complete revascularization (index or staged) outperformed culprit-only PCI in ACS with multivessel disease, reducing repeat revascularization. Staged completeness lowered cardiac death, and index completeness lowered recurrent MI, without excess bleeding, CIN, stroke, or stent thrombosis.
Impact: Provides consolidated comparative effectiveness and safety evidence to guide revascularization strategy selection in ACS-MVD, a frequent and high-risk clinical scenario.
Clinical Implications: Favor complete revascularization (either at index or staged) when feasible in ACS with multivessel disease, tailoring timing to patient stability and anatomy without anticipating added bleeding or renal risk.
Key Findings
- Complete index procedure (CIP) and complete staged procedure (CSP) each reduced the need for future revascularization versus culprit-only PCI.
- CSP was associated with lower cardiac death, whereas CIP was associated with fewer recurrent myocardial infarctions.
- No significant differences in bleeding, contrast-induced nephropathy, stroke, or stent thrombosis between complete and culprit-only strategies.
Methodological Strengths
- Network meta-analysis enabling indirect and direct comparisons across three strategies
- Evaluation of both efficacy (death, MI, revascularization) and safety outcomes
Limitations
- Heterogeneity across included studies and potential inconsistency inherent to network meta-analysis
- Variability in ACS definitions, timing of staged procedures, and adjunctive medical therapy
Future Directions: Head-to-head randomized trials comparing index vs staged completeness in contemporary practice, with patient-centered endpoints and cost-effectiveness analyses.
BACKGROUND: The optimal revascularization strategy for patients with acute coronary syndrome (ACS) and multivessel disease (MVD) remains debated. This study compares the efficacy and safety of different revascularization strategies in these patients. METHODS: We included 20 studies comparing staged, complete, and culprit-only (CO) revascularization strategies in patients with ACS and MVD. We divided the revascularization strategies into 3 distinct strategies: CO, complete index procedure (CIP), and complete staged procedure (CSP). We then compared CIP and CSP with CO. Outcomes studied are all-cause mortality, cardiac death, recurrent myocardial infarction (MI), need for revascularization, bleeding, contrast-induced nephropathy (CIN), stroke, bleeding, and stent thrombosis. RESULTS: Compared with the CO group, both the CIP group (relative risk [RR], 0.42; 95% CI, 0.26-0.69; CONCLUSIONS: Our findings support complete revascularization (CIP or CSP) over CO for patients with ACS and MVD. Both CIP and CSP are associated with lower needs for future revascularization. CSP was associated with lower cardiac deaths. CIP was associated with fewer recurrent MI. Additionally, both strategies were safe with no differences noted in bleeding, CIN, stroke, and stent thrombosis.
3. Association of quality of care and long-term mortality risk for individuals presenting with ST-segment myocardial infarction (STEMI) by diabetes mellitus status: A nationwide cohort study.
In 283,658 UK STEMI patients, diabetes was associated with less timely reperfusion and higher long-term mortality (HR ~1.5 up to 10 years). High inpatient quality-of-care (OBQI) significantly reduced mortality in both diabetic and non-diabetic patients, highlighting modifiable system-level factors.
Impact: Defines diabetes-related disparities in STEMI care and outcomes at national scale and demonstrates that excellence in inpatient care mitigates risk, informing quality-improvement priorities.
Clinical Implications: Prioritize door-to-balloon targets and equitable access to PCI for diabetic STEMI patients; implement robust quality programs (eg, OBQI-linked processes) to reduce mortality disparities.
Key Findings
- Diabetes associated with less frequent PCI (60% vs 63%) and lower achievement of DTB <60 min (69% vs 75%) and <120 min (89% vs 92%).
- Adjusted all-cause mortality higher in diabetes at 30 days (HR 1.49, 95% CI 1.44–1.54) and up to 10 years (HR 1.54, 95% CI 1.52–1.57).
- Excellent inpatient care (high OBQI) reduced mortality (Diabetes HR 0.56, 95% CI 0.50–0.64; No diabetes HR 0.62, 95% CI 0.58–0.67).
Methodological Strengths
- Very large national registry linked to mortality data with long-term follow-up
- Use of opportunity-based quality metrics (OBQI) to quantify care quality
Limitations
- Observational design with potential residual confounding and time-era effects
- Limited granularity on outpatient care, medication adherence, and socioeconomic factors
Future Directions: Implement and evaluate targeted STEMI process bundles for diabetic patients (eg, rapid triage, cath-lab activation) and assess equity-focused interventions to close care gaps.
AIMS: This study aimed to assess how diabetes influences the quality of care and longer-term outcomes in contemporary STEMI cohorts. METHODS: We analysed 283,658 adults hospitalised with STEMI from the United Kingdom Myocardial Ischaemia National Audit Project (MINAP) registry between 2005 and 2019. This was linked with Office of National Statistics data to provide out of hospital mortality outcomes. We compared longer-term outcomes depending on diabetes status and assessed the effect of quality of care using the opportunity-based quality-indicator score (OBQI). RESULTS: Individuals with diabetes were older (median age 68.7 vs. 65.5), underwent percutaneous coronary intervention less frequently (60 % vs. 63 %) and were less likely to achieve a door-to-balloon time of < 60 min (69 % vs. 75 %) or < 120 min (89 % vs. 92 %). Their adjusted all-cause mortality risk was higher during follow-up, from 30 days (HR: 1.49, CI: 1.44-1.54), to up to 10 years of follow up (HR: 1.54, CI: 1.52-1.57), compared to individuals without diabetes. Excellent inpatient care was associated with lower mortality rates within individuals with diabetes (Diabetes: HR 0.56, CI: 0.50-0.64, No diabetes: HR 0.62, CI: 0.58-0.67). CONCLUSIONS: Individuals with diabetes have a higher risk of long-term mortality after STEMI. They experience delays in angiography and receive lower quality inpatient care.