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      Predictors of Contrast Volume in Transcatheter Aortic Valve Replacement

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          Abstract

          Background: Contrast-induced acute kidney injury (CIAKI) is a frequent and serious complication of transcatheter aortic valve replacement (TAVR). The most important procedural risk factor for CIAKI is contrast volume. Objectives: Because contrast volume is a modifiable factor that directly predicts CIAKI, we sought to identify predictors of increased contrast volume in TAVR patients. Identification of such predictors may allow both prediction and mitigation of CIAKI risk following TAVR. Method: We retrospectively analyzed data from consecutive patients not on hemodialysis who underwent successful TAVR at a single US center from 2013 to 2018. Using multivariable linear regression modelling, we assessed the relationships between contrast volumes and 49 patient and procedural factors hypothesized to be potential predictors. Results: In 295 patients, we identified 17 factors that independently predicted contrast volume, 10 of which contributed 90% of the complete model’s r<sup>2</sup> value. Procedure year (suggesting a learning curve), aortic insufficiency, radiation dose, prior AVR, and previous pacemaker placement were statistically the most significant predictors of CIAKI. TAVR device and diabetes were notably not predictors. Conclusions: To predict and reduce contrast use in TAVR, patients at risk for increased contrast volume may be identified using the predictors elucidated in this study. For such patients, strategies for contrast reduction and renal protection may be employed.

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          Most cited references 5

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          Renal function-based contrast dosing predicts acute kidney injury following transcatheter aortic valve implantation.

          This study sought to assess whether the volume of contrast media (CM) influences the occurrence of acute kidney injury (AKI) following transcatheter aortic valve implantation (TAVI).
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            Acute kidney injury after transcatheter aortic valve implantation: incidence, predictors and impact on mortality.

            There is a paucity of data describing acute kidney injury (AKI) following transcatheter aortic valve implantation and its impact on mortality remains unknown. We therefore evaluate the incidence, predictors and impact of AKI following transcatheter aortic valve implantation. We searched MEDLINE for studies from 2008 to 2013, evaluating AKI after transcatheter aortic valve implantation. All studies were compared according to the incidence, predictors and impact of AKI following transcatheter aortic valve implantation. AKI was diagnosed according to the Valve Academic Research Consortium definition using the RIFLE criteria. Thirteen studies with more than 1900 patients were included. AKI occurred in 8.3-57% of the patients. The following factors were associated with AKI: blood transfusion; transapical access; preoperative creatinine concentration; peripheral vascular disease; hypertension; and procedural bleeding events. The 30-day mortality rate in patients with AKI ranged from 13.3% to 44.4% and was 2-6-fold higher than in patients without AKI. The amount of contrast agent used was not associated with the occurrence of AKI. AKI is a common complication, with an incidence of 8.3-57% following transcatheter aortic valve implantation. Patients with AKI had higher 30-day and late mortality rates. However, AKI was related to the amount of contrast volume used in only one study.
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              Acute kidney injury after aortic valve replacement: incidence, risk factors and outcomes.

              The occurrence of acute kidney injury (AKI) following aortic valve replacement (AVR) has very serious clinical implications and has therefore been the focus of several studies. The authors report the results of previous studies evaluating both transcatheter AVR (TAVR) and indirectly surgical AVR (SAVR) through looking at cardiopulmonary bypass (CPB) cardiac surgeries, and identify the incidence, predictors and outcomes of AKI following AVR. In most studies, AKI was defined using the Risk, Injury, Failure, Loss and End Stage, Valve Academic Research Consortium (modified Risk, Injury, Failure, Loss and End Stage) or Valve Academic Research Consortium-2 (Acute Kidney Injury Network) AKI classification criteria. Twelve studies including more than 90,000 patients undergoing cardiac surgery on CPB were considered as well as 26 studies with more than 6000 patients undergoing TAVR. Depending on the definition used, AKI occurred in 3.4-43% of SAVR cases with up to 2.5% requiring dialysis, and in 3.4-57% of TAVR cases. Factors identified as independent predictors of AKI were: baseline kidney failure, EUROSCORE, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, anemia, peripheral vascular disease, heart failure, surgical priority, CPB time, reoperation, use of intra-aortic balloon pump, need for re-exploration, contrast agent volume, transapical access, blood transfusion, postoperative thrombocytopenia, postoperative leukocytosis as well as demographic variables such as age and female gender. The 30-day mortality rate for patients with AKI following SAVR ranged from 5.5 to 46% and was 3- to 16-times higher than in those without AKI. Similarly, patients who developed AKI after TAVR had a mortality rate of 7.8-29%, which was two- to eight-times higher than those who did not suffer from AKI. AKI confers up to a fourfold increase in 1-year mortality. Finally, hospital length of stay was significantly increased in patients with AKI in both SAVR and TAVR groups, with increases up to 3- and 2.5-times, respectively.
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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2020
                September 2020
                02 July 2020
                : 145
                : 9
                : 608-610
                Affiliations
                aDivision of Cardiovascular Medicine, University of Nebraska Medical Center and Nebraska Medicine, Omaha, Nebraska, USA
                bSchool of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, USA
                cDivision of Cardiovascular Medicine, Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
                dDivision of Cardiovascular Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
                eDivision of Cardiovascular Medicine, Richard M. Ross Heart Hospital, The Ohio State University, Columbus, Ohio, USA
                Author notes
                *Andrew M. Goldsweig, Division of Cardiovascular Medicine, University of Nebraska Medical Center, 982265 Nebraska Medical Center, Omaha, NE 68198 (USA), andrew.goldsweig@unmc.edu
                Article
                507506 Cardiology 2020;145:608–610
                10.1159/000507506
                32615571
                © 2020 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 1, Pages: 3
                Categories
                Valvular Heart Disease: Short Communication

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