Transcatheter aortic valve replacement in elderly population. Do we have reliable scores to predict prognosis?

Abstract Background Aortic stenosis (AS) is the most common valvulopathy in the western world and its prevalence is rising due to an ageing population. Transcatheter aortic valve replacement (TAVR) is the procedure of choice for severe AS in intermediate and high-risk patients and for very elderly population. Geriatric evaluation can be crucial to identify those subjects in which TAVR will not provide a prognosis benefit. Purpose The aims of this study were to compare clinical outcomes of patients that were evaluated by a Heart Team and were treated with conservative treatment or by TAVR and to identify geriatric scales that could predict worse prognosis during follow-up. Methods From November 2015 to April 2019, 154 consecutive patients with severe aortic stenosis assessed for suitability of TAVR were included in the analysis. A complete geriatric evaluation were performed at inclusion. Results Seventy-six patients (51%, median age 82.9±0.7) were allocated to medical treatment (MT) and the remainder (n=78, 49%, median age 83.7±0.6) to TAVR. Median follow up period was 17.8±13.8 months. Basal and echocardiographic features were similar in both groups except for Euroscore and geriatric evaluation (table 1). In a multivariate analysis including treatment and geriatric scales, conservative treatment was an independent predictor of all-cause and cardiovascular mortality (HR 3.92, 95% CI 1.47–10.48, p=0.015 and HR 4.12, 95% CI 0.98–17.28, p=0.0023 respectively). TAVR was also a protective factor for cardiovascular hospitalizations (OR 0.21, 95% CI 0.08–0.52, p&amp;lt;0.001). A Lawton scale score &amp;lt;4 was associated with a higher cardiovascular mortality (HR 9.97, 95% CI 1.18–84.42, p=0.0023) and cardiovascular hospitalizations (OR 3.5, 95% CI 1.30–9.43 p&amp;lt;0.0001). None of the other scores were associated to outcomes. Conclusion TAVR confers a survival benefit in the elderly population with severe aortic stenosis compared to conservative treatment. Lawton scale could be a useful tool to identify high risk patients with poorer prognosis during follow-up independently of the therapy performed. Funding Acknowledgement Type of funding source: None </jats:sec

Opportunistic infections and AIDS malignancies early after initiating combination antiretroviral therapy in high-income countries

Background: There is little information on the incidence of AIDS-defining events which have been reported in the literature to be associated with immune reconstitution inflammatory syndrome (IRIS) after combined antiretroviral therapy (cART) initiation. These events include tuberculosis, mycobacterium avium complex (MAC), cytomegalovirus (CMV) retinitis, progressive multifocal leukoencephalopathy (PML), herpes simplex virus (HSV), Kaposi sarcoma, non-Hodgkin lymphoma (NHL), cryptococcosis and candidiasis. Methods: We identified individuals in the HIV-CAUSAL Collaboration, which includes data from six European countries and the US, who were HIV-positive between 1996 and 2013, antiretroviral therapy naive, aged at least 18 years, hadCD4+ cell count and HIV-RNA measurements and had been AIDS-free for at least 1 month between those measurements and the start of follow-up. For each AIDS-defining event, we estimated the hazard ratio for no cART versus less than 3 and at least 3 months since cART initiation, adjusting for time-varying CD4+ cell count and HIV-RNA via inverse probability weighting. Results: Out of 96 562 eligible individuals (78% men) with median (interquantile range) follow-up of 31 [13,65] months, 55 144 initiated cART. The number of cases varied between 898 for tuberculosis and 113 for PML. Compared with non-cART initiation, the hazard ratio (95% confidence intervals) up to 3 months after cART initiation were 1.21 (0.90-1.63) for tuberculosis, 2.61 (1.05-6.49) for MAC, 1.17 (0.34-4.08) for CMV retinitis, 1.18 (0.62-2.26) for PML, 1.21 (0.83-1.75) for HSV, 1.18 (0.87-1.58) for Kaposi sarcoma, 1.56 (0.82-2.95) for NHL, 1.11 (0.56-2.18) for cryptococcosis and 0.77 (0.40-1.49) for candidiasis. Conclusion: With the potential exception of mycobacterial infections, unmasking IRIS does not appear to be a common complication of cART initiation in high-income countries. © 2014 Wolters Kluwer Health | Lippincott Williams &amp; Wilkins

Human immunodeficiency virus continuum of care in 11 european union countries at the end of 2016 overall and by key population: Have we made progress?

Background. High uptake of antiretroviral treatment (ART) is essential to reduce human immunodeficiency virus (HIV) transmission and related mortality; however, gaps in care exist. We aimed to construct the continuum of HIV care (CoC) in 2016 in 11 European Union (EU) countries, overall and by key population and sex. To estimate progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, we compared 2016 to 2013 estimates for the same countries, representing 73% of the population in the region. Methods. A CoC with the following 4 stages was constructed: number of people living with HIV (PLHIV); proportion of PLHIV diagnosed; proportion of those diagnosed who ever initiated ART; and proportion of those ever treated who achieved viral suppression at their last visit. Results. We estimated that 87% of PLHIV were diagnosed; 92% of those diagnosed had ever initiated ART; and 91% of those ever on ART, or 73% of all PLHIV, were virally suppressed. Corresponding figures for men having sex with men were: 86%, 93%, 93%, 74%; for people who inject drugs: 94%, 88%, 85%, 70%; and for heterosexuals: 86%, 92%, 91%, 72%. The proportion suppressed of all PLHIV ranged from 59% to 86% across countries. Conclusions. The EU is close to the 90-90-90 target and achieved the UNAIDS target of 73% of all PLHIV virally suppressed, significant progress since 2013 when 60% of all PLHIV were virally suppressed. Strengthening of testing programs and treatment support, along with prevention interventions, are needed to achieve HIV epidemic control