Transcatheter Tricuspid Valve Intervention for the Treatment of Tricuspid Regurgitation with TriClip: All You Need to Know.

Severe tricuspid regurgitation (TR) is a common pathology in the daily practice of a cardiologist. This disease entity is associated with significant morbidity and mortality if left untreated. Classically, surgical repair or replacement were the only therapeutic options present and were often not performed due to high postprocedural mortality. Transcatheter tricuspid valve intervention has emerged as a novel and effective therapeutic option for the treatment of significant TR. Several devices have been developed with different mechanisms of action. In this review, we will provide an overview of transcatheter edge-to-edge repair of TR using the TriClip device (Abbott, Santa Clara, CA, USA).

Managing endothelial dysfunction in COVID-19 with statins, beta blockers, nicorandil, and oral supplements: A pilot, double-blind, placebo-controlled, randomized clinical trial.

Coronavirus disease 2019 (COVID-19) is associated with endothelial dysfunction. Pharmacologically targeting the different mechanisms of endothelial dysfunction may improve clinical outcomes and lead to reduced morbidity and mortality. In this pilot, double-blind, placebo-controlled, randomized clinical trial, we assigned patients who were admitted to the hospital with mild, moderate, or severe COVID-19 infection to receive, on top of optimal medical therapy, either an endothelial protocol consisting of (Nicorandil, L-arginine, folate, Nebivolol, and atorvastatin) or placebo for up to 14 days. The primary outcome was time to recovery, measured by an eight category ordinal scale and defined by the time to being discharged from the hospital or hospitalized for infection-control or other nonmedical reasons. Secondary outcomes included the composite outcome of intensive care unit (ICU) admission or the need for mechanical ventilation, all-cause mortality, and the occurrence of side effects. Of 42 randomized patients, 37 were included in the primary analysis. The mean age of the patients was 57 years; the mean body mass index of study participants was 29.14. History of hypertension was present in 27% of the patients, obesity in 45%, and diabetes mellitus in 21.6%. The median (interquartile range) time to recovery was not significantly different between the endothelial protocol group (6 [4-12] days) and the placebo group (6 [5-8] days; p value = 0.854). Furthermore, there were no statistically significant differences in the need for mechanical ventilation or ICU admission, all-cause mortality, or the occurrence of side effects between the endothelial protocol group and the placebo group. Among patients hospitalized with mild, moderate, or severe COVID-19 infection, targeting endothelial dysfunction by administering Nicorandil, L-arginine, Folate, Nebivolol, and Atorvastatin on top of optimal medical therapy did not decrease time to recovery. Based on this study's findings, targeting endothelial dysfunction did not result in a clinically significant improvement in outcome and, as such, larger trials targeting this pathway are not recommended.

Transcatheter tricuspid valve intervention techniques and procedural steps for the treatment of tricuspid regurgitation: a review of the literature.

Severe tricuspid regurgitation (TR) is an undertreated common pathology associated with significant morbidity and mortality. Classically, surgical repair or valve replacement were the only therapeutic options and are associated with up to 10% postprocedural mortality. Transcatheter tricuspid valve interventions are a novel and effective therapeutic option for the treatment of significant TR. Several devices have been developed with different mechanisms of action. They are classified as annuloplasty devices, replacement devices, caval valve implantation and coaptation devices. In this review, we provide a step-by-step description of the procedural steps and techniques of every device along with video support.

Combined anticoagulant and antiplatelet therapy is associated with an improved outcome in hospitalised patients with COVID-19: a propensity matched cohort study.

BACKGROUND: COVID-19 is a respiratory disease that results in a prothrombotic state manifesting as thrombotic, microthrombotic and thromboembolic events. As a result, several antithrombotic modalities have been implicated in the treatment of this disease. This study aimed to identify if therapeutic anticoagulation (TAC) or concurrent use of antiplatelet and anticoagulants was associated with an improved outcome in this patient population. METHODS: A retrospective observational cohort study of adult patients admitted to a single university hospital for COVID-19 infection was performed. The primary outcome was a composite of in-hospital mortality, intensive care unit (ICU) admission or the need for mechanical ventilation. The secondary outcomes were each of the components of the primary outcome, in-hospital mortality, ICU admission, or the need for mechanical ventilation. RESULTS: 242 patients were included in the study and divided into four subgroups: Therapeutic anticoagulation (TAC), prophylactic anticoagulation+antiplatelet (PACAP), TAC+antiplatelet (TACAP) and prophylactic anticoagulation (PAC) which was the reference for comparison. Multivariable Cox regression analysis and propensity matching were done and showed when compared with PAC, TACAP and TAC were associated with less in-hospital all-cause mortality with an adjusted HR (aHR) of 0.113 (95% CI 0.028 to 0.449) and 0.126 (95% CI 0.028 to 0.528), respectively. The number needed to treat in both subgroups was 11. Furthermore, PACAP was associated with a reduced risk of invasive mechanical ventilation with an aHR of 0.07 (95% CI 0.014 to 0.351). However, the was no statistically significant difference in the occurrence of major or minor bleeds, ICU admission or the composite outcome of in-hospital mortality, ICU admission or the need for mechanical ventilation. CONCLUSION: The use of combined anticoagulant and antiplatelet agents or TAC alone in hospitalised patients with COVID-19 was associated with a better outcome in comparison to PAC alone without an increase in the risk of major and minor bleeds. Sufficiently powered randomised controlled trials are needed to further evaluate the safety and efficacy of combining antiplatelet and anticoagulants agents or using TAC in the management of patients with COVID-19 infection.

Role of combining anticoagulant and antiplatelet agents in COVID-19 treatment: a rapid review.

Although primarily affecting the respiratory system, COVID-19 causes multiple organ damage. One of its grave consequences is a prothrombotic state that manifests as thrombotic, microthrombotic and thromboembolic events. Therefore, understanding the effect of antiplatelet and anticoagulation therapy in the context of COVID-19 treatment is important. The aim of this rapid review was to highlight the role of thrombosis in COVID-19 and to provide new insights on the use of antithrombotic therapy in its management. A rapid systematic review was performed using preferred reporting items for systematic reviews. Papers published in English on antithrombotic agent use and COVID-19 complications were eligible. Results showed that the use of anticoagulants increased survival and reduced thromboembolic events in patients. However, despite the use of anticoagulants, patients still suffered thrombotic events likely due to heparin resistance. Data on antiplatelet use in combination with anticoagulants in the setting of COVID-19 are quite scarce. Current side effects of anticoagulation therapy emphasise the need to update treatment guidelines. In this rapid review, we address a possible modulatory role of antiplatelet and anticoagulant combination against COVID-19 pathogenesis. This combination may be an effective form of adjuvant therapy against COVID-19 infection. However, further studies are needed to elucidate potential risks and benefits associated with this combination.

Immediate and long-term results of percutaneous mitral commissurotomy: up to 15 years.

PURPOSE: To evaluate immediate and long-term clinical results of percutaneous mitral commissurotomy (PMC) in patients with severe mitral stenosis. METHODS: In a retrospective study, data were included from 317 patients over 18 years of age (mean age 45) who had been treated for mitral stenosis between January 1993 and March 2015 with PMC using the Inoue balloon technique. Immediate results: Valvular function improved as evidenced by an increase in mitral valve area from 1.01 ± 0.24 cm2 to 2 ± 0.31 cm2 (P < 0.001) and a decrease in mean mitral gradient from 13.64 ± 6.03 mm Hg to 5.40 ± 2.49 mm Hg. Long-term follow-up: At 5-15 years (mean 10.2 years, Inter-quartile range 8.25), 105 (33.1%) of the 317 patients were available for follow-up, 95 living patients and 10 deceased. Of the deceased, average time from PMC to death was 8 years. Results were strongly significant showing that age at the time of PMC and surface area before the procedure were the best predictors of survival at 15 years follow-up, showing significance values of P = 0.022 and P = 0.001, respectively. CONCLUSIONS: PMC using the Inoue balloon technique improves morbidity and long-term mortality rates in patients with severe mitral stenosis. Lower Wilkins score and NYHA class at baseline were not found to be significant predictors of mortality in older patients (age > 45). Overall, 65 (61.9%) had survived at 5-15 years follow-up without further cardiac intervention.

Evaluation of prophylactic dosages of Enoxaparin in non-surgical elderly patients with renal impairment.

BACKGROUND: Thromboprophylaxis dosing strategies using enoxaparin in elderly patients with renal disease are limited, while dose adjustments or monitoring of anti-Xa levels are recommended. We sought to evaluate the efficacy and safety of enoxaparin 20 mg versus 30 mg subcutaneously daily by comparing anti-Xa levels, thrombosis and bleeding. METHODS: We conducted a prospective, single-blinded, single-center randomized clinical trial including non-surgical patients, 70 years of age or older, with renal disease requiring thromboprophylaxis. Patients were randomized to receive either 20 mg or 30 mg of enoxaparin. The primary endpoint was peak anti-Xa levels on day 3. Secondary endpoints included trough anti-Xa levels on day 3, achievement of within range prophylactic target peak anti-Xa levels and the occurrence of hemorrhage, thrombosis, thrombocytopenia or hyperkalemia during hospitalization. RESULTS: Thirty-two patients were recruited and sixteen patients were randomized to each arm. Mean peak anti-Xa level was significantly higher in 30 mg arm (n = 13) compared to the 20 mg arm (n = 11) 0.26 ± 0.11, 95%CI (0.18-0.34), versus 0.14 ± 0.09, 95CI (0.08-0.19) UI/ml, respectively; p = 0.004. Mean trough anti-Xa level was higher in 30 mg arm (n = 10) compared to the 20 mg arm (n = 16), 0.06 ± 0.03, 95CI (0.04-0.08) versus 0.03 ± 0.03, 95CI (0.01-0.05) UI/ml, respectively; p = 0.044. Bleeding events reported in the 30 mg arm were one retroperitoneal bleed requiring multiple transfusions, and in the 20 mg arm one hematuria. No thrombotic events were reported. CONCLUSION: Peak anti-Xa levels provided by enoxaparin 20 mg were lower than the desired range for thromboprophylaxis in comparison to enoxaparin 30 mg. TRIAL REGISTRATION: The trial was retrospectively registered on ClinicalTrials.gov identifier: NCT03158792 . Registered: May 18, 2017.

Assessment of bleeding in chronic liver disease and coagulopathy using the IMPROVE bleeding criteria.

BACKGROUND: In this study, the authors utilized the IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) bleeding definition to explore the safety profile of pharmacologic venous thromboembolism (VTE) prophylaxis in patients with chronic liver disease (CLD) and concurrent coagulopathy (INR ≥1.5). METHODS: A retrospective study was conducted on 193 adult patient admissions with a diagnosis of CLD and INR ≥1.5 not due to therapeutic anticoagulation. Patients were stratified based on their receipt of pharmacological thromboprophylaxis or not during hospitalization. The rates of overall bleeding, defined as the composite of major bleeding and clinically relevant non-major bleeding; major bleeding; and clinically relevant non-major bleeding, within 14 days of admission were evaluated. Secondary endpoints included the rates of thrombosis and mortality. RESULTS: The composite of overall bleeding occurred in 17.6% of the admissions. More patients in the group not receiving pharmacological thromboprophylaxis had overall bleeding (18.5% vs 10%), major bleeding (13.3% vs 10%), and clinically relevant non-major bleeding (14.5% vs 5%), with overlapping 95% CI. When stratified per pharmacological thromboprophylaxis status, IMPROVE bleeding risk score (BRS) ≥ 7 was associated with higher rates of overall bleeding, major bleeding, and clinically relevant non-major bleeding as compared to IMPROVE BRS <7, whether patients received or did not receive pharmacological thromboprophylaxis. The overall incidence of in-hospital mortality among our study population was 15.5%. Receiving pharmacological thromboprophylaxis was markedly associated with higher in-hospital mortality (OR = 16.58, 95% CI = 4.47-61.45). CONCLUSION: This study shows that the IMPROVE BRS calculated on admission may serve as a guide for omission of thromboprophylaxis in advanced CLD.

Achieving low-density lipoprotein cholesterol treatment goals among dyslipidemic individuals in the Levant: the CEntralized Pan-Levant survey on tHE Undertreatment of hypercholeSterolemia (CEPHEUS) study.

BACKGROUND: Several studies that evaluated achieving lipid goals have demonstrated an undertreatment of dyslipidemia. We evaluated the use and efficacy of lipid-lowering agents (LLAs) in reducing low-density lipoprotein cholesterol (LDL-C) to recommended levels in the Levant region. DESIGN AND METHODS: A multi-center, cross-sectional survey enrolled 1002 dyslipidemic patients (August 2010 - January 2011) on LLAs for ≥3 months. Collection of data and blood samples was done over one visit. Physicians and patients filled out questionnaires pertaining to dyslipidemia diagnosis and treatment. LDL-C target levels were defined according to international guidelines. RESULTS: The full analysis set included 992 patients. Mean age was 58.0 ± 11.6 years (41% women, 65.7% diabetics and 51.5% had history of coronary heart disease). LLAs were prescribed for primary prevention or secondary prevention or familial hypercholesterolemia in 45.8% and 52.8% and 1.4% of patients; respectively. Overall, 64.0% and 56.8% of the patients attained their LDL-C goal recommended by the NCEP ATP III and TJETF guidelines, respectively. According to the 2004 NCEP ATP III updated guidelines, about 24.8% of the very high risk group attained their LDL goal of ≤70 mg/dL. Smoking, diabetes, metabolic syndrome, history of cardiovascular disease, increased waist circumference, and elevated pre-treatment LDL-C level were all associated with not reaching LDL-C goals. CONCLUSIONS: Although the study cohort was a relatively high risk group and might not be representative of the general population, we found that about 60% of enrolled individuals achieved the LDL-C treatment goals and 24.8% of the very high risk group achieved the recommended LDL-C targets of ≤70 mg/dl; national strategies and aggressive awareness campaigns to effectively control lipid levels to recommended target levels, especially in the high risk groups, are urgently needed.

An unusual complication of coronary angiography: bidirectional dissection of the right coronary artery and the ascending aorta.

Iatrogenic aortocoronary dissection is a rare but devastating complication of percutaneous coronary interventions. The authors present the case of a 45 years old woman admitted for anginal chest pain. She underwent coronary angiography and developed complete anterograde dissection of the right coronary artery simultaneously with retrograde extensive propagation to the ascending aorta. Failure to attempt stenting because of altered hemodynamics and intractable chest pain prompted an emergent bypass surgery with treatment of the aortic dissection. Causes and modalities of treatment of iatrogenic aortocoronary dissections are discussed.

Myocardial perfusion in patients with a totally occluded left anterior descending coronary artery reinjected by a normal right coronary artery: the role of collateral circulation.

In this article, myocardial perfusion in patients with a totally occluded left anterior descending artery reinjected by a normal right coronary artery is assessed using stress single photon emission computed tomography (SPECT). In all, 20 patients, with a totally occluded left anterior descending artery reinjected by normal right coronary artery, underwent myocardial single photon emission computed tomography imaging within 60 days of angiography. All patients had abnormal perfusion single photon emission computed tomography results and 70% had reversible defects. Perfusion defects at rest were present in 75% of patients, with perinecrotic residual ischemia in 45% of patients whereas for 30% of patients, no viable myocardium was detected in the collateral-dependent segments. In all, 25% of patients had no resting perfusion defects but all are presented with stress-induced ischemia. Collaterals are not protective against stress-induced ischemia, but they can preserve myocardial viability. This conclusion is highly supported by the presence of residual ischemia in the collateral-dependent segments.

The appropriateness of use of coronary angiography in Lebanon: implications for health policy.

BACKGROUND: Lebanon, characterized by a free-market health care system, has one of the highest reported per capita rates of cardiac catheterization facilities and coronary angiographies in the world. The aim of this study is to evaluate the appropriateness of performance of coronary angiography procedures in Lebanon. METHODS: Data derived from the 2004 Lebanese Interventional Coronary Registry (LICOR) included 5418 patients aged 30 years and older who had not undergone prior percutaneous coronary intervention or coronary artery bypass grafting. Appropriateness was evaluated based on the Class I indications of the ACC/AHA guidelines for coronary angiography. FINDINGS: The overall rate of appropriate procedures was 54.7% (95% CI 53.3-56.0%). Appropriateness varied significantly by gender and across administrative regions. Compared with females, males were more likely to be referred appropriately for coronary angiography (OR = 1.28, 95% CI = 1.15-1.44). Appropriateness was lowest (OR = 0.89, 95% CI = 0.71-1.12) in the region where the per capita density of cardiac catheterization labs increased by six-fold in the latter 2 years. The majority of the patients (84.3%) were not evaluated by any of the non-invasive tests prior to angiography, with only 10.8%, 4% and 1.5% of the patients referred for an exercise stress test, stress echocardiography and thallium stress tests, respectively. DISCUSSION: Findings indicate a high rate of procedures conducted without appropriate indications and a low utilization rate of pre-interventional non-invasive testing. This may be attributed to three factors: a surplus of catheterization facilities in certain regions, the insignificant cost gradient between non-invasive testing and coronary angiography, and the wide case-based reimbursement of coronary angiography, unlike non-invasive testing, by public insurance schemes.

Noninvasive assessment of coronary flow reserve in the left anterior descending artery by transthoracic echocardiography before and after stenting.

BACKGROUND: Noninvasive assessment of coronary flow reserve in the left anterior descending artery (LAD) by transthoracic Doppler echocardiography (TTDE) has been already validated as a new method for determining the degree of stenosis over the proximal flow. OBJECTIVES: The aim of the study is to determine, by TTDE, the feasibility and the value of the coronary flow reserve (CFR) (defined as the maximal increase in coronary blood flow above its basal pressure for a given perfusion pressure when coronary circulation is maximally dilated) in the mid-to-distal LAD before and after percutaneous angioplasty and to demonstrate the early recovery of microvascular tone immediately after stenting. METHODS: The study population consisted of 36 patients with significant isolated LAD stenosis (70-90%) identified by coronary angiography. CFR was recorded in the mid-to-distal LAD at rest and during hyperemia obtained after adenosine intravenous infusion before and after stenting. RESULTS: Adequate visualization of the LAD was obtained in 25 out of 36 patients (70%). At rest the mean CFR was 1.5132 +/- 0.33 (1.1-2.58). However, after stenting the mean CFR was significantly higher: 2.18 +/- 0.55 (1.3-3.8), with P <0.01. CONCLUSIONS: CFR can be easily determined by TTE in approximately 70% of patients. Noninvasive Doppler echocardiography shows impaired CFR in patients with LAD disease. After stenting CFR is restored, demonstrating early recovery of microvascular tone. These results are comparable to those published in the same conditions. Larger series with a long-term follow-up may allow identifying patients at high risk for restenosis after stenting.

Evaluation of Tc-99m tetrofosmin scan for coronary artery disease diagnosis.

Detection of myocardial perfusion abnormalities using Tc-99m tetrofosmin was evaluated for sensitivity and specificity compared to coronary angiography. Between January 1996 and January 1998, exercise stress tests and myocardial scintigraphy were performed in 58 patients, followed by coronary angiography within 2 months. There were 48 males and 10 females, aged 33 to 72 years (mean, 57 years). The sensitivity and specificity of exercise stress tests were 64% and 68%, respectively, while the sensitivity and specificity of Tc-99m tetrofosmin scans were 88% and 75%, respectively, compared to angiography. For Tc-99m tetrofosmin scans, the sensitivity was 78% for the left anterior descending artery, 66% for the left circumflex artery, and 76% for the right coronary artery; specificity was 74% for the left anterior descending artery, 90% for the left circumflex artery, and 75% for the right coronary artery. It was concluded that Tc-99m tetrofosmin allowed high-quality myocardial perfusion imaging with results comparable to those obtained using thallium-201 chloride.