Transcatheter Mitral Valve Repair-Beyond the EVEREST and COAPT Criteria.

Transcatheter mitral valve repair (TMVr) has emerged as a safe and effective alternative to conventional surgery in patients with primary and secondary mitral regurgitation, especially those at high surgical risk. This review summarises alternative indications for TMVr outside of the traditional criteria derived from the major randomised trials and focusses on less common mitral valve anatomies such as commissural prolapse and bileaflet prolapse, patients with mitral annuloplasty rings, as well as acutely unwell patients with papillary muscle rupture and/or cardiogenic shock. Specific technical challenges involved in treating such patient groups are summarised and described.

Aortic valve replacement rates in Australia from 2004 to 2019.

BACKGROUND: Several surgical and percutaneous treatments are available for patients with aortic valve disease. AIM: To establish whether trends in aortic valve replacements (AVR) in Australia reflect recent evidence. METHODS: Using the Australian Institute of Health and Welfare data, this study calculated all AVR and balloon aortic valvuloplasty (BAV) procedures conducted in all Australian hospitals from 2004 to 2019. Linear regression analysis was performed to determine whether age-adjusted rates had changed over the study period. RESULTS: There were 80 883 AVR performed. Of these, 66% were men and 64% were aged >70 years. Absolute rates of AVR increased from 3631 to 7277 with a significant 22% age-adjusted rise seen (1.9% increase per year (+0.26 per 100 000 per year; 95% confidence interval 0.19-0.34); P < 0.001). This trend was more pronounced in men than women and in those aged >80 years (+0.23 per 100 000 per year; P < 0.001). Proportion of mechanical AVR implanted fell from 38.4% to 8.6% (P < 0.001). A total of 2683 transcatheter aortic valve implantation (TAVI) procedures was performed in 2019, representing a 52% annual increase from 2014. BAV increased from 66 procedures in 2004 to 862 in 2019. CONCLUSION: Rates of AVR have increased significantly over the past 16 years, particularly in the elderly. Despite international guideline recommendations, fewer mechanical AVR are being used in younger cohorts. The uptake in TAVI rates might reflect evidence that suggests it is a safe alternative, at least in the medium term. BAV has also seen a resurgence during this time period.

A State-of-the-Art Review: The Percutaneous Treatment of Highly Calcified Lesions.

Coronary artery calcification is prevalent in coronary heart disease with its progression being predictive of future adverse cardiac events. Its presence is considered to be a marker of interventional procedural complexity. Several adjunctive percutaneous coronary intervention tools, such as modifying balloons, atherectomy devices and intravascular lithotripsy, now exist to successfully treat calcified lesions. In this state-of-the-art review, a step-wise progression of strategies is described to modify coronary plaque, from well-recognised techniques to techniques that should only be considered when standard manoeuvres have proven unsuccessful. Technology has advanced greatly over the past few decades and we discuss how future technologies might shape percutaneous intervention.

Cardiac Myeloid Sarcoma: A 1-kg Heart.

A 53-year-old man with a background of acute myelomonocytic leukemia in remission presented with pleurisy. Repeat transthoracic echocardiography over several weeks revealed thickening left ventricular walls and decreasing systolic function. He died of decompensated heart failure due to cardiac myeloid sarcoma, with autopsy revealing an enlarged heart weighing >1 kg. (Level of Difficulty: Intermediate.).

Ultrathin-strut biodegradable polymer versus durable polymer drug-eluting stents: a meta-analysis.

OBJECTIVES: Determine whether an ultrathin biodegradable polymer sirolimus-eluting stent ('Orsiro'-BP-SES) has clinical benefits over second-generation durable polymer drug-eluting stents (DP-DES). METHODS: We conducted a prospective systematic review and meta-analysis of randomised clinical trials comparing Orsiro BP-SES against DP-DES (PROSPERO Registration: CRD42019147136). The primary outcome was target lesion failure (TLF): composite of cardiac death, target vessel myocardial infarction (TVMI) and clinically indicated target lesion revascularisation (TLR)) evaluated at the longest available follow-up. RESULTS: Nine trials randomised 11 302 patients to either Orsiro BP-SES or DP-DES. At mean weighted follow-up of 2.8 years, the primary outcome (TLF) occurred in 501 of 6089 (8.2%) participants with BP-SES compared with 495 of 5213 (9.5%) participants with DP-DES. This equates to an absolute risk reduction of 1.3% in TLF in favour of Orsiro BP-SES (OR 0.82; 95% CI 0.69 to 0.98; p=0.03). This was driven by a reduction in TVMI (OR 0.80; 95% CI 0.65 to 0.98; p=0.03). There were no significant differences in other clinical endpoints: cardiac death, TLR and stent thrombosis. CONCLUSION: The Orsiro BP-SES shows promising clinical outcomes in patients undergoing percutaneous coronary intervention compared with contemporary second-generation DES at a short to medium term follow-up. More research is warranted to evaluate performance over a longer follow-up period and in different clinical and lesion subsets.

Severe, Reversible Pulmonary Hypertension From Giant Pedunculated Left Atrial Myxoma.

A 77-year-old woman with obstructive sleep apnea presented with a 3-week history of leg swelling and dyspnea on exertion. She had a dry cough and lost 10 kg over the past 2 years. Examination revealed elevated jugular venous pressure, reduced air entry in the left lower-lung field, and pedal edema. Imaging with chest computed tomography revealed a giant pedunculated left atrial myxoma to be the cause of her severe pulmonary hypertension, which was reversible with treatment.

A New Era for Rotational Atherectomy: An Australian Perspective.

BACKGROUND: Rotational atherectomy (RA) has been used in percutaneous coronary intervention (PCI) for 30 years. With advances in technology, this observational study looks at how rates of RA have changed over the past decade in Australia in relation to PCI and coronary artery bypass graft (CABG) rates. METHODS: Retrospective analysis of RA, PCI, and CABG rates per Australian state from Australian Government Department of Human Services' data on Medicare items from 2007 to 2017 was carried out. RESULTS: There were 149 RA procedures in 2007, increasing to 452 in 2017. Rotational atherectomy accounted for 0.67% of PCI procedures in 2007, increasing to 1.48% in 2018 (+0.81%, 95% confidence interval [CI] = [0.64%-0.91%]; P < .001). Most of this increase has come from procedures in New South Wales (441% increase). Australian PCI rate increased from 22 301 to 30 480. Rate of CABG decreased from 5418 to 5206. CONCLUSIONS: From 2007 to 2017, rates of RA trebled in Australia. This is despite stable rates of PCI and a fall in rates of CABG. There are several clinical explanations for this trend.

Delayed diagnosis of right-sided valve endocarditis causing recurrent pulmonary abscesses: a case report.

BACKGROUND: Pulmonary valve infective endocarditis is a rare diagnosis that is usually associated with immunocompromised states or structurally abnormal hearts. It is unusual for it to occur in structurally normal hearts or to cause recurrent symptoms after targeted antibiotics. Although guidelines suggest follow-up with repeat echocardiography and inflammatory marker surveillance, this case demonstrates that these are not always useful investigations, and instead imaging of the chest may be more appropriate. CASE PRESENTATION: We describe a case of a 74-year-old man who presented with respiratory symptoms and was originally misdiagnosed with pneumonia but later found to have a large pulmonary valve vegetation caused by Streptococcus mitis. Despite initially responding to antibiotic therapy, the vegetation continued to cause pulmonary emboli and cavitating lung abscesses months later, necessitating pulmonary valve replacement. CONCLUSIONS: This case demonstrates that pulmonary valve endocarditis can present atypically with recurrent respiratory symptoms, and in such cases, echocardiography should be considered to investigate for right-sided infective endocarditis. In addition, despite correct treatment, with normalization of inflammatory markers and improvement in vegetation size, infective endocarditis can continue to cause systemic symptoms. Finally, clinicians should consider chest computed tomography routinely as part of right-sided infective endocarditis follow-up.

Severe Dilatation of Coronary Artery Ostium Complicating Sinus of Valsalva Aneurysm: Differential Diagnosis and Review of the Literature.

Coronary artery dilatation may be due to various aetiologies including congenital anomalies, atherosclerotic coronary disease, and Kawasakis disease. We describe a case characterised by apparent severe dilatation of the right coronary artery ostium in an asymptomatic male. Subsequent imaging and surgical intervention documented the presence of a sinus of Valsalva aneurysm extending into the ostium of the right coronary artery. This represents an unusual manifestation of a sinus of Valsalva aneurysm. The underlying pathophysiology, differential diagnosis, role of surgical management, and outcomes are discussed.

Assessing the burden of pregnancy-associated malaria under changing transmission settings.

BACKGROUND: The clinical presentation of pregnancy-associated malaria, or PAM, depends crucially on the particular epidemiological settings. This can potentially lead to an underestimation of its overall burden on the female population, especially in regions prone to epidemic outbreaks and where malaria transmission is generally low. METHODS: Here, by re-examining historical data, it is demonstrated how excess female mortality can be used to evaluate the burden of PAM. A simple mathematical model is then developed to highlight the contrasting signatures of PAM within the endemicity spectrum and to show how PAM is influenced by the intensity and stability of transmission. RESULTS: Both the data and the model show that maternal malaria has a huge impact on the female population. This is particularly pronounced in low-transmission settings during epidemic outbreaks where excess female mortality/morbidity can by far exceed that of a similar endemic setting. CONCLUSION: The results presented here call for active intervention measures not only in highly endemic regions but also, or in particular, in areas where malaria transmission is low and seasonal.