ABSTRACT
Background: Treatment of symptomatic mitral valve stenosis in severe mitral annular calcification is a surgical challenge. Transcatheter options include transfemoral transcatheter mitral valve replacement (TMVR), which poses its own risks, the most significant is left ventricular outflow tract (LVOT) obstruction. Transatrial hybrid TMVR optimizes advantages of both traditional open-heart surgery and transcatheter valve replacement. Methods: Retrospective review of seven high-risk patients (deemed ineligible for traditional surgery) undergoing transatrial implantation of a SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA) in the mitral position for severe symptomatic mitral stenosis. Laceration of the Anterior Mitral leaflets to Prevent Outflow ObstructioN procedure was not considered due to heavy leaflet calcifications. Results: Seven patients treated consecutively from June 2020 to July 2021 were included in this analysis. Mean age was 77 years;six were females, one was male. Average STS score was 9.8. Three patients had New York Heart Association (NYHA) class IV heart failure. Mean left ventricular ejection fraction was 62%. Dominant mitral valve pathology included mitral stenosis in all patients. Mean mitral valve gradient was 12 mmHg. All patients had circumferential annular calcification except one, who had predominantly anterior calcification. All patients received the Edwards SAPIEN 3 valve and had anterior leaflet resection. Surgical approach was at the discretion of the attending cardiac surgeon. Mean cardiopulmonary bypass time was 85 minutes;mean cross-clamp time was 36 minutes. No anchoring felt was used. Technical success was 100%, with no device embolization. There was no clinically significant LVOT obstruction. There were two deaths: one occurred during index hospitalization due to worsening heart failure secondary to torrential tricuspid regurgitation, and the second was 2 months later due to COVID-19 infection. Conclusion: Surgical hybrid transatrial TMVR for patients at high surgical risk is technically feasible with high procedure success. A relatively shorter cardiac ischemic duration, direct visualization and resection of the anterior mitral leaflet can allow for safe TMVR without risk of LVOT obstruction.
ABSTRACT
Background: Measures taken to mitigate the spread of coronavirus disease 2019 (COVID-19) have been correlated to a decline in the number of patients seeking medical care for emergency cardiovascular illness. Here we evaluate the impact of a state-wide lockdown on ST-elevation myocardial infarction (STEMI) care. Purpose: The purpose of this study is to help understand the impact of COVID-related lockdowns on STEMI interventions. Methods: All consecutive adult patients admitted with an acute STEMI diagnosis and percutaneous intervention (PCI) performed between January 17, 2020, and July 14, 2020, at five sites across our health care network, were included in this study. Patient demographics, medical history and procedure details were collected retrospectively from electronic medical records. Data were segregated according to date into pre-lockdown, lockdown (March 17 to May 13, 2020) and post-lockdown groups. Results: A total of 225 patients formed the study cohort. Median age was 62 (IQR: 53-71) years. Patients were predominantly male (n=154, 68%), white (n=208, 92%), hypertensive (n=139, 61%) and dyslipidemic (n=135, 60%). The average weekly rate of STEMI PCIs performed pre-lockdown decreased by 40% during the lockdown from 10.9 to 6.5 PCIs per week (p<0.05). Door-to-balloon (D2B) times increased from 42 (IQR: 28-68) min pre-lockdown to 53 (IQR: 40-72) min during the lockdown (p=0.01). No significant differences were observed in in-hospital mortality or cardiac troponin measurements within 24 h of procedure between the three groups. Conclusion: Adverse effects of COVID-19-related lockdowns on acute STEMI care include a decrease in PCI volumes and prolonged D2B times. Our results provide valuable data-driven criteria to help inform patient decisions to seek care and to find ways to protect healthcare workers without compromising timely critical intervention.