Within the first 30 days, 34 patients with TAVR and 38 patients with SAVR had died. More patients who underwent SAVR had worsening RV function (n=156; 24.7 percent) than who had TAVR (n=62; 8.3 percent). Fewer SAVR (n=26; 4.1 percent) than TAVR (n=47; 6.3 percent) patients had improved RV function at 30 days. In patients who developed worsening RV function, moderate or severe TR was more common, along with dilated RV. The development of moderate or severe RV dysfunction from baseline normal RV function conferred the worst prognosis.

“Combined with other investigations and future studies, these results have implications regarding which intermediate risk patients may benefit from TAVR or SAVR,” the authors write. “In addition, these results prompt the question of whether medical, surgical, and percutaneous treatment of concomitant TR can preserve RV function. Most importantly, clinicians should recognize that patients with normal baseline RV function who develop moderate or severe dysfunction after AVR are at especially high risk.”

Cremer PC, Zhang Y, Alu M, et al. Eur Heart J 2018;May 8:[Epub ahead of print].

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There were 75,782 patients in the database who had cardiac surgery and were included in the analyses. The average age was 66 years and 29 percent were women; 34 percent had pre-existing AFib and close to 6 percent underwent concurrent LAAO. Patients who had LAAO were more likely to have a history of AFib, valve surgery (vs. CABG) and use oral anticoagulants prior to surgery.

A total of 8,590 patients were included in the propensity matched cohort and they had similar baseline sociodemographic, medical and procedure characteristics.

LAAO was associated with a reduced risk of stroke (hazard ratio [HR], 0.73) and mortality (HR, 0.71), but a higher risk of developing AFib. The rate ratio for AFib-related outpatient visits was 1.17 and for AFib-related hospitalization it was 1.13. In patients with prior AFib who underwent LAAO, the stroke and mortality findings were similar with the larger cohort.

In the subgroup of patients without a history of AFib, LAAO was not associated with a decreased risk of stroke (HR, 0.95) or reduced mortality (HR, 0.92). However, there was no significant interaction between AFib and LAAO, suggesting that the larger cohort findings also apply to patients with AFib. The findings from multiple sensitivity analyses did not alter the primary results.

“Among patients undergoing cardiac surgery, concurrent surgical LAAO, compared with no surgical LAAO, was associated with reduced risk of subsequent stroke and all-cause mortality,” the authors conclude. “Further research, including from randomized clinical trials, is needed to more definitively determine the role of surgical LAAO.”

Yao X, Gersh BJ, Holmes DR, et al. JAMA 2018;319:2116-26.

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Study population included 1,193 adult patients >18 years treated with coronary stent and DAPT from July 2012 through June 2014. Mean patient age was 63 years, 68 percent were men and 21 percent were African American. Of the study participants, 53.8 percent presented with acute coronary syndrome (ACS), 26 percent were on chronic P2Y12 inhibitor therapy at admission and 40 percent had bleeding risk factor(s).

Genotype testing was performed in 72.8 percent of patients: 66.6 percent genotyped during index admission and 6.2 percent genotyped during prior admission. Results showed that 30.2 percent were intermediate (27.5 percent) or poor (2.8 percent) metabolizers. Significant predictors of CYP2C19 genotype testing during index admission included ACS, left anterior descending stent or left main coronary stent. Chronic P2Y12 therapy on admission was negatively associated with genotype testing.

In the entire study population, clopidogrel was ordered in 69.4 percent, prasugrel in 30.6 percent and ticagrelor in 3.3 percent. In intermediate and poor metabolizers combined, 28.3 percent were treated with clopidogrel, 59.9 percent with prasugrel and 11.8 percent with ticagrelor. Prasugrel or ticagrelor was used in 83.3 percent of poor metabolizers; 69.5 percent of intermediate metabolizers; 23.6 percent of normal, rapid, or ultrarapid metabolizers; and in 11.1 percent in whom no genotype was available.

Intermediate or poor metabolizer phenotype was a significant independent predictor of prasugrel or ticagrelor therapy or for a change to prasugrel/ticagrelor after index PCI. Use of prasugrel or ticagrelor was significantly associated with ACS, left anterior descending stent or prasugrel/ticagrelor use on admission. Clopidogrel selection was significantly associated with chronic clopidogrel use at admission and with higher bleeding risk.

During follow-up, 11.9 percent experienced major adverse cardiac and cerebrovascular events (MACCE) and 3.8 percent experienced significant bleeding event. Intermediate and poor metabolizers treated with clopidogrel demonstrated a significantly higher risk of MACCE (26.5 percent; adjusted hazard ratio 4.65; p<0.001) than did intermediate and poor metabolizers treated with prasugrel or ticagrelor. The highest risk of MACCE (45.2 percent; adjusted hazard ratio 10.0; p<0.001) occurred in intermediate and poor metabolizers with ACS who were treated with clopidogrel. The risk of significant bleed was not associated with phenotype or antiplatelet therapy.

Four six-month time periods were evaluated. In the first six months, 88 percent were genotyped; this dropped to 61-65 percent during the next 12 months and increased to 78 percent during the final period. Treatment with prasugrel or ticagrelor in intermediate or poor metabolizers was initially 83 percent; it was sustained at 78.2 percent for the second six months, dropped to 53.8 percent during the third six months and increased to 68.1 percent for the final six months.

The authors write, “Taken together, these data illustrate that implementing a CYP2C19-guided antiplatelet therapy algorithm is feasible, sustainable, and associated with better clinical outcomes in real-world clinical practice but challenging to maintain at a consistently high level of fidelity.”

“Given the increasing number of institutions that seek to clinically implement genotype-guided antiplatelet therapy, our results offer insight into the feasibility, sustainability, and clinical impact of using a CYP2C19 genotyping strategy to optimize P2Y12 inhibitor selection in PCI patients,” they conclude.

Lee CR, Sriramoju VB, Cervantes A, et al. Circ Genom Precis Med 2018; April 3:[Epub ahead of print].

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