Early outcomes following transatrial transcatheter mitral valve replacement in patients with severe mitral annular calcification.

OBJECTIVE: Implantation of a transcatheter valve-in-mitral annular calcification (ViMAC) has emerged as an alternative to traditional surgical mitral valve (MV) replacement. Previous studies evaluating ViMAC aggregated transseptal, transapical, and transatrial forms of the procedure, leaving uncertainty about each technique's advantages and disadvantages. Thus, we sought to evaluate clinical outcomes specifically for transatrial ViMAC from the largest multicenter registry to-date. METHODS: Patients with symptomatic MV dysfunction and severe MAC who underwent ViMAC were enrolled from 12 centers across the United States and Europe. Clinical characteristics, procedural details, and clinical outcomes were abstracted from the electronic record. The primary end point was all-cause mortality. RESULTS: We analyzed 126 patients who underwent ViMAC (median age 76 years [interquartile range {IQR}, 70-82 years], 28.6% female, median Society of Thoracic Surgeons score 6.8% [IQR, 4.0-11.4], and median follow-up 89 days [IQR, 16-383.5]). Sixty-one (48.4%) had isolated mitral stenosis, 25 (19.8%) had isolated mitral regurgitation (MR), and 40 (31.7%) had mixed MV disease. Technical success was achieved in 119 (94.4%) patients. Thirty (23.8%) patients underwent concurrent septal myectomy, and 8 (6.3%) patients experienced left ventricular outflow tract obstruction (7/8 did not undergo myectomy). Five (4.2%) patients of 118 with postprocedure echocardiograms had greater than mild paravalvular leak. Thirty-day and 1-year all-cause mortality occurred in 16 and 33 patients, respectively. In multivariable models, moderate or greater MR at baseline was associated with increased risk of 1-year mortality (hazard ratio, 2.31; 95% confidence interval, 1.07-4.99, P = .03). CONCLUSIONS: Transatrial ViMAC is safe and feasible in this selected, male-predominant cohort. Patients with significant MR may derive less benefit from ViMAC than patients with mitral stenosis only.

A Comprehensive Appraisal of Risk Prediction Models for Cardiogenic Shock.

ABSTRACT: Despite advances in early revascularization, percutaneous hemodynamic support platforms, and systems of care, cardiogenic shock (CS) remains associated with a mortality rate higher than 50%. Several risk stratification models have been derived since the 1990 s to identify patients at high risk of adverse outcomes. Still, limited information is available on the differences between scoring systems and their relative applicability to both acute myocardial infarction and advanced decompensated heart failure CS. Thus, we reviewed the similarities, differences, and limitations of published CS risk prediction models and herein discuss their suitability to the contemporary management of CS care.

In-hospital outcomes of transcatheter versus surgical mitral valve repair in patients with chronic liver disease.

BACKGROUND: Mitral valve transcatheter edge-to-edge repair (TEER) using MitraClip is a treatment option for patients with moderate to severe mitral regurgitation who are not surgical candidate. Liver cirrhosis is associated with higher operative morbidity and mortality; however, it is not part of preoperative risk assessments calculators. We sought to evaluate the in-hospital outcomes in TEER and surgical mitral valve repair (SMVR) in liver cirrhosis. METHODS: National Inpatient Database from 2013 to 2017 was used to obtain all patients with cirrhosis who underwent TEER or SMVR using ICD-9-CM and ICD-10-CM codes. The primary outcome is to compare inpatient mortality between TEER and SMVR. Secondary outcomes were assessed including length of stay (LOS) and rate of complications including cardiogenic shock, blood transfusion and prolonged ventilation. RESULTS: A total of 875 patients with cirrhosis who underwent TEER (n = 123) or SMVR (n = 752) were identified in our analysis. Patients with TEER had significantly higher comorbidities such as congestive heart failure, coronary artery disease and chronic obstructive pulmonary disease. In-hospital mortality was lower in TEER group (8.2% vs 16%, P = .04). TEER was associated with lower rates of blood transfusion (30.3% vs 61.2%, P = .02) and reduced rates of prolonged mechanical ventilation (1.2% vs 17.2%, P = .042). In multivariate regression analysis, both blood transfusion and prolonged mechanical ventilation were significant predictors of mortality in liver cirrhosis. CONCLUSIONS: TEER was associated with lower rate of in-hospital mortality, LOS, blood transfusion and prolonged mechanical ventilation in cirrhosis patients. TEER can be considered as a viable option for cirrhosis patient with severe mitral regurgitation.

Outcomes of MitraClip Placement in Patients With Liver Cirrhosis.

INTRODUCTION: Liver cirrhosis is associated with increased morbidity and mortality. Many preoperative risk assessment tools do not take into account the presence or degree of liver cirrhosis prior to surgery. Over recent years, percutaneous mitral valve repair using MitraClip has emerged as an option for patients at high risk of surgical intervention. However, the safety, efficacy and outcomes of this procedure in patients with liver cirrhosis have not yet been evaluated. METHODS: This is a retrospective cohort study using the 2013-2017 National Inpatient Sample database of adults who were hospitalized for MitraClip repair of mitral valve. All patients were divided into patients with cirrhosis and those without cirrhosis. The primary outcome was all-cause mortality in patient with cirrhosis who underwent MitraClip. The secondary outcomes were to assess length of stay (LOS) and total hospital cost per year in cirrhotic patients compared to non-cirrhotic patients. RESULTS: In-hospital mortality was higher in cirrhosis group compared to non-cirrhosis however not statistically significant (8.1% vs 3.2%, OR: 2.59 [95% CI: 0.47-14.28, p-value 0.27). Additionally, neither of the secondary outcomes, LOS and total cost, were found to be statistically significant. However, the incidence of cardiogenic shock was significantly higher in the cirrhosis group 13.3% versus 3.9% (p-value 0.032). CONCLUSION: Patients with liver cirrhosis who underwent MitraClip repair of MV were at higher risk of developing cardiogenic shock, without any significant increase in in-hospital mortality, LOS or total cost. However, this study showed a trend toward higher rates of mortality, requirement of blood transfusion, mechanical ventilation, length of stay, and cost of care in cirrhosis patients.

Systematic Review of COVID-19 Related Myocarditis: Insights on Management and Outcome.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also referred to as COVID-19, was declared a pandemic by the World Health Organization in March 2020. The manifestations of COVID-19 are widely variable and range from asymptomatic infection to multi-organ failure and death. Like other viral illnesses, acute myocarditis has been reported to be associated with COVID-19 infection. However, guidelines for the diagnosis of COVID-19 myocarditis have not been established. METHODS: Using a combination of search terms in the PubMed/Medline, Ovid Medline and the Cochrane Library databases and manual searches on Google Scholar and the bibliographies of articles identified, we reviewed all cases reported in the English language citing myocarditis associated with COVID-19 infection. RESULTS: Fourteen records comprising a total of fourteen cases that report myocarditis/myopericarditis secondary to COVID-19 infection were identified. There was a male predominance (58%), with the median age of the cases described being 50.4 years. The majority of patients did not have a previously identified comorbid condition (50%), but of those with a past medical history, hypertension was most prevalent (33%). Electrocardiogram findings were variable, and troponin was elevated in 91% of cases. Echocardiography was performed in 83% of cases reduced function was identified in 60%. Endotracheal intubation was performed in the majority of cases. Glucocorticoids were most commonly used in treatment of myocarditis (58%). Majority of patients survived to discharge (81%) and 85% of those that received steroids survived to discharge. CONCLUSION: Guidelines for diagnosis and management of COVID-19 myocarditis have not been established and our knowledge on management is rapidly changing. The use of glucocorticoids and other agents including IL-6 inhibitors, IVIG and colchicine in COVID-19 myocarditis is debatable. In our review, there appears to be favorable outcomes related to myocarditis treated with steroid therapy. However, until larger scale studies are conducted, treatment approaches have to be made on an individualized case-by-case basis.

A novel technique to manage transcatheter aortic valve embolization.

We report a case of a 69-year-old male who was planned for a transcatheter aortic valve replacement (TAVR) with a 26 mm Sapien 3 Valve (Edwards Lifesciences, Irvine, California) for the treatment of symptomatic severe aortic stenosis. During rapid ventricular pacing and implantation of the TAVR valve, there was a loss of pacing capture and subsequent embolization of the valve into the aortic arch. Retrieval of the embolized valve was attempted unsuccessfully using several techniques. Finally, by using a 34 mm Evolut R Valve (Medtronic, Minneapolis, Minnesota), we were able to secure the embolized valve in the transverse segment of the aortic arch without compromising the branch vessels. To our knowledge, this is the first reported case of using a valve-in-valve approach to fixate an embolized valve in the transverse aorta.

Iatrogenic atrial septal defect following the MitraClip procedure: A state-of-the-art review.

With an increase in number of patients undergoing percutaneous treatment of severe mitral regurgitation with MitraClip placement, the consequences of transseptal puncture resulting in iatrogenic atrial septal defects (iASDs) are being increasingly realized. Closure of iASDs following MitraClip therapy is not routinely performed, and no guidelines currently exist in managing this condition. While immediate hemodynamic and clinical compromise secondary to acute hypoxemia related to iASDs should be acutely managed with defect closure, the prevalence and consequences of long-term iASDs are still unclear. Some studies have cited a potential improvement in hemodynamic outcomes as a result of iASDs; while others report potential inferior and even fatal outcomes. In this state-of-the-art clinical review, we present the readers with the current data on the prevalence, outcomes, and potential management options of iASDs after MitraClip placement.

Capecitabine-Induced Takotsubo Cardiomyopathy: A Case Report.

INTRODUCTION: The medication 5-fluorouracil is known to cause cardiotoxic effects (with an incidence ranging from 5% to 18%), such as rhythm abnormalities and cardiomyopathies, including takotsubo cardiomyopathy. Capecitabine, an oral prodrug of 5-fluorouracil, has rarely been reported to cause cardiotoxic effects compared with its parent drug. CASE PRESENTATION: An 80-year-old woman presented to the hospital with chest pain after recent initiation of capecitabine use for anal cancer. Results of cardiac catheterization revealed moderate nonobstructive coronary disease. Overall, the findings were highly consistent with a clinical diagnosis of takotsubo cardiomyopathy. DISCUSSION: With the current increasing use of capecitabine, recognizing this agent as a potential risk factor for cardiac-related events is important.

Imaging in patients with severe mitral annular calcification: insights from a multicentre experience using transatrial balloon-expandable valve replacement.

AIMS: To investigate valve sizing and the haemodynamic relevance of the predicted left ventricular outflow tract (LVOT) in patients with mitral annular calcification (MAC) undergoing transatrial transcatheter valve implantation (THV). METHODS AND RESULTS: In total, 21 patients undergoing transatrial THV, multiplanar reconstruction (MPR), maximum intensity projection (MIP), and cubic spline interpolation (CSI) were compared for MA sizing during diastole. In addition, predicted neo-LVOT areas were measured in 18 patients and correlated with the post-procedural haemodynamic dimensions. The procedure was successful in all patients (100%). Concomitant aortic valve replacement was performed in eight patients (43%) (AVR group). Sizing using MPR and MIP yielded comparable results in terms of area, perimeter, and diameter, whereas the dimensions obtained with CSI were systematically smaller. The simulated mean systolic neo-LVOT area was 133.4 ± 64.2 mm2 with an anticipated relative LVOT area reduction (neo-LVOT area/LVOT area × 100) of 59.3 ± 14.7%. The systolic relative LVOT area reduction, but not the absolute neo-LVOT area, was found to predict the peak (r = 0.69; P = 0.002) and mean (r = 0.65; P = 0.004) post-operative aortic gradient in the overall population as well as separately in the AVR (peak: r = 0.91; P = 0.002/mean: r = 0.85; P = 0.002) and no-AVR (peak: r = 0.89; P = 0.003/mean: r = 0.72; P = 0.008) groups. CONCLUSION: In patients with severe MAC undergoing transatrial transcatheter valve implantation, MPR, and MIP yielded comparable annular dimensions, while values obtained with CSI tended to be systematically smaller. Mitral annular area and the average annular diameter appear to be reliable parameters for valve selection. Simulated relative LVOT reduction was found to predict the post-procedural aortic gradients.

Transatrial implantation of a transcatheter heart valve for severe mitral annular calcification.

OBJECTIVE: To assess the outcomes of transatrial implantation of a transcatheter heart valve (THV) for the treatment of mitral valve disease with severe mitral annular calcification (MAC). METHODS: Implantation of a balloon-expandable THV was performed on cardiopulmonary bypass via left atrial exposure in patients considered at risk for left ventricular outflow tract obstruction. The anterior mitral valve leaflet was systematically resected and pledgeted sutures were placed to enhance stability and reduce paravalvular leak. RESULTS: Twenty-six consecutive symptomatic patients with severe MAC (mean age, 78 ± 7 years; 92% female; mean Society of Thoracic Surgeons score, 9.4 ± 4.8) were included at 6 different centers. Two patients (8%) received an Edwards Sapien XT (Edwards Lifesciences, Irvine, Calif), and 24 (92%) an Edwards Sapien 3 bioprosthesis (Edwards Lifesciences). Concomitant aortic valve replacement was performed in 11 patients. Technical success according to the criteria of the Mitral Valve Academic Research Consortium was achieved in all patients. The mean transmitral gradient decreased from 10 ± 5 to 4 ± 2 mm Hg (P < .001) with trace or mild regurgitation in all patients. An elevated mean transaortic gradient (30 mm Hg) was observed in 1 patient (4%). Five patients died during hospital stay (19%) and 2 additional between discharge and 30 days (30-day mortality: 27%). Sustained functional improvement was observed in the remaining patients. CONCLUSIONS: Transatrial implantation of a THV for the treatment of MAC is associated with high technical success despite unfavorable anatomy. In this early experience of very high surgical risk patients, 30-day all-cause mortality was high. Patients at particular risk appear to be those with chronic kidney disease requiring multiple valve surgery.

Feasibility, safety, and patient satisfaction of same-day discharge following peripheral arterial interventions: A randomized controlled study.

OBJECTIVE: To assess feasibility, safety, and patient satisfaction of same-day discharge (SD) following peripheral arterial interventions. BACKGROUND: Although diagnostic angiography is routinely performed as a same-day procedure, same-day percutaneous trans-luminal angioplasty is less common. Because there is very low incidence of peri-procedural complications after 4 hr, discharge after this window is possible provided the patient is able to ambulate and has necessary social support. To-date, safety and patient satisfaction related to SD has not been studied systematically in this population. METHOD: After providing informed consent, patients undergoing out-patient peripheral arterial interventions in a single institution between 2011 and 2015 were randomized to usual care (overnight stay, OS) or SD following successful interventions. Patient satisfaction, complications, and readmission status was ascertained by blinded telephone interviewers at 48-72 hr and 10 days post-procedure. RESULTS: A total of 24 patients consented. Of these, 5 (21.7%) failed screening, leaving 19 patients for randomization to control (n = 10) and experimental group (n = 9) conditions. The SD group experienced zero complications, however their Likert scale rating scores were significantly lower than OS for perceived level of safety (P = 0.02) and likelihood of having the procedure again (P = 0.004). CONCLUSION: This small, single-center randomized study found that among carefully selected peripheral arterial interventions, SD may be feasible and safe. However, patient satisfaction and perceived safety were significantly lower among SD compared to the OS condition. Larger prospective studies are warranted to confirm these findings.

A novel approach to extraction of a large thrombus on the intraventricular guide-wire during transcatheter aortic valve replacement.

For appropriate patients with severe symptomatic aortic stenosis with a prohibitively high surgical risk, trans-catheter aortic valve replacement (TAVR) is now established as a viable option. Thrombosis on the intra-ventricular guide-wire during TAVR is a recognized complication (Wiper et al., Cardiovasc Revasc Med 2014). There is an obvious potential for embolization with particular concern for stroke in this situation. We describe a case in which a >1cm thrombus was noted on the intra-ventricular guide-wire by trans-esophageal echocardiogram (TEE) during a TAVR procedure. Balloon aortic valvuloplasty was still performed and an Edwards Sapien valve was deployed. After valve deployment a multi-purpose guiding catheter was advanced with continuous suction. The guide-wire and thrombus were withdrawn inside the guiding catheter. The guide-wire and catheter were removed as a single unit, allowing the thrombus to be safely retrieved. We believe that this is a novel technique of aspiration thrombectomy in this potentially hazardous clinical circumstance. As our experience with TAVR increases, so does our experience with the complications. In the PARTNER trial there was a higher rate of neurological events in TAVR patients than those who had open aortic valve replacement (Smith et al. N Engl J Med 2011;364:2187-2198.). This may be related to peri-procedural formation of thrombus and subsequent embolization. We report a case where a large guide-wire thrombus identified during TAVR was successfully removed using a novel approach, preventing a potentially major stroke in this high-risk patient. © 2015 Wiley Periodicals, Inc.

Acquired Aorto-Right Ventricular Fistula following Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement (TAVR) techniques are rapidly evolving, and results of published trials suggest that TAVR is emerging as the standard of care in certain patient subsets and a viable alternative to surgery in others. As TAVR is a relatively new procedure and continues to gain its acceptance, rare procedural complications will continue to appear. Our case is about an 89-year-old male with extensive past medical history who presented with progressive exertional dyspnea and angina secondary to severe aortic stenosis. Patient got TAVR and his postoperative course was complicated by complete heart block, aorto-RV fistula, and ventricular septal defect (VSD) formation as a complication of TAVR. To the best of our knowledge, this is the third reported case of aorto-RV fistula following TAVR as a procedural complication but the first one to show three complications all together in one patient.

Optimal use of left ventriculography at the time of cardiac catheterization: a consensus statement from the Society for Cardiovascular Angiography and Interventions.

The rationale to perform left ventriculography at the time of cardiac catheterization has been little studied. The technique and frequency of use of left ventriculography vary by geographic regions, institutions, and individuals. Despite the recent publication of guidelines and appropriate use criteria for coronary angiography, revascularization, and noninvasive imaging, to date there have been no specific guidelines on the performance of left ventriculography. When left ventriculography is performed, proper technique must be used to generate high quality data which can direct patient management. The decision to perform left ventriculography in place of, or in addition to, other forms of ventricular assessment should be made taking into account the clinical context and the type of information each study provides. This paper attempts to show the role of left ventriculography at the time of coronary angiography or left heart catheterization. The recommendations in this document are not formal guidelines but are based on the consensus of this writing group. These recommendations should be tested through clinical research studies. Until such studies are performed, the writing group believes that adoption of these recommendations will lead to a more standardized application of ventriculography and improve the quality of care provided to cardiac patients. © 2014 Wiley Periodicals, Inc.

Aortic valve fibroelastoma presenting with myocardial infarction.

Fibroelastoma is a rare, benign cardiac tumor. It is the second most common primary cardiac tumor and the most common primary cardiac valvular tumor. Nonvalvular endocardial location is rare and may be difficult to differentiate from thrombus and myxoma. Fibroelastoma consists of a small, highly papillary, pedunculated, and avascular tumor which is covered by a single layer of endothelium. It contains fine elastic fibrils arranged in whorls in a hyaline stroma. Fibroelastoma is mostly found incidentally at the time of echocardiography, cardiac catheterization, surgery, or autopsy. Symptomatic patients present with various clinical presentations, mainly cardiovascular in nature.

Preventing serious sequelae after an acute coronary syndrome: the consequences of thrombosis versus bleeding with antiplatelet therapy.

Acute coronary syndrome (ACS) is associated with a persistent prothrombotic state, placing patients at high risk of subsequent ischemic events. Guidelines recommend the use of dual antiplatelet therapy with aspirin + a thienopyridine (clopidogrel) for at least a year after ACS in most patients, except those who undergo coronary artery bypass grafting. Clinical studies demonstrate that this strategy significantly reduces the risk of ischemic events at the expense of a small increase in the risk of bleeding. Physicians must balance the risk of bleeding against the benefit of ischemia prevention, bearing in mind that ischemic events are generally more common than major bleeding and often associated with more catastrophic consequences or ongoing morbidity. The relationship between bleeding and mortality is complicated by the fact that many risk factors for bleeding are also those for mortality and that bleeding may lead to discontinuation of antiplatelet therapy, thereby increasing the risk for an ischemic event. Data suggest that physicians tend to overestimate the risk of bleeding and underestimate the risk of ischemia. Careful patient selection and thorough patient education are the keys to managing antiplatelet therapy after ACS, especially as newer more potent antiplatelet agents, such as prasugrel, become available.

Fatal pheochromocytoma crisis precipitated by dobutamine stress echocardiography.

The safety of dobutamine stress echocardiography (DSE) has been demonstrated in multiple studies with a major complication rate of <1%. Specifically, ventricular tachycardia during DSE has a reported incidence of 0.3%, and has been bound to be of no prognostic significance in patients without obstructive coronary artery disease. We report a unique case of fatal pheochromocytoma crisis precipitated by DSE in a patient with heretofore unknown adrenal disease. We are once again reminded that no diagnostic modality is absolutely without risk; however, minimal they might be.

Morphology and location of restenosis following bare metal coronary stenting.

Restenosis following bare metal coronary stenting is common. The location and characteristics of restenotic lesions in patients who have undergone coronary stent implantation is not well described. The purpose of this study was to determine the location, type and temporal distribution of stent-related restenosis. We reviewed the clinical and angiographic characteristics of 203 consecutive patients with stent-related restenosis undergoing a repeat clinically-indicated coronary angiogram, 30 days to 1 year after the index procedure. All lesions within 10 mm of the proximal and distal margins of the stent were included in the analysis. An angiographic classification was developed based on lesion location. Class I lesions were those occurring within the stent, and Class II comprised those lesions occurring within 10 mm of the proximal and distal stent edge. We classified a total of 234 stent-related restenosis lesions. Class I lesions were found in 52% of patients, and Class II in 48%. Three-fifths of the patients who developed new lesions at a stent edge presented 1-3 months following the initial procedure, which was significantly earlier than other lesion types (p < 0.001). A substantial number of patients undergoing repeat angiography after stent placement have lesions proximate, but peripheral, to the stent. This may limit the effectiveness of stent-based efforts to reduce restenosis. The time interval between coronary stenting and symptom recurrence appears to vary according to lesion location.