Transcatheter Aortic Valve Replacement Outcomes in End-Stage Renal Disease Patients on Hemodialysis Requiring Midodrine.

Background: Patients with dialysis-dependent end-stage renal disease (ESRD) taking midodrine may be at high risk for poor outcomes following transcatheter aortic valve replacement (TAVR). We evaluated dialysis-dependent ESRD patients taking midodrine. Methods: We conducted a retrospective analysis of non-clinical trial TAVR patients from February 2012 to December 2020 from 11 facilities in a Western US health system. Patient groups included ESRD patients on midodrine before TAVR (ESRD [+M]), ESRD patients without midodrine (ESRD [-M]), and non-ESRD patients. The endpoints of 30-day and 1-year mortality were represented by Kaplan-Meier survival estimator and compared by log-rank test. Results: Forty-five ESRD (+M), 216 ESRD (-M), and 6898 non-ESRD patients were included. ESRD patients had more comorbid conditions, despite no significant difference in predicted Society of Thoracic Surgeons mortality risk between ESRD (+M) and ESRD (-M) (8.7% vs. 9.2%, p = 0.491). Thirty-day mortality was significantly higher for ESRD (+M) patients vs. ESRD (-M) patients (20.1% vs. 5.6%, p = 0.001) and for ESRD (+M) vs. non-ESRD patients (2.5%, p < 0.001). One-year mortality trended higher for ESRD (+M) vs. ESRD (-M) patients (41.9% vs. 29.8%, p = 0.07), and was significantly higher for ESRD (+M) vs. non-ESRD patients (10.7%, p < 0.001). Compared to ESRD (-M), ESRD (+M) patients had a higher incidence of 30-day stroke (6.7% vs. 1.4%, p = 0.033), 30-day vascular complications (6.7% vs. 0.9%, p = 0.011), and a lower rate of discharge to home (62.2% vs. 84.7%, p < 0.001). In contrast, ESRD (-M) patients had no significant differences from non-ESRD patients for these outcomes. Conclusions: Our experience suggests ESRD patients on midodrine are a higher acuity population with worse survival after TAVR, compared to ESRD patients not on midodrine. These findings may help with risk stratification for ESRD patients undergoing TAVR.

Safety and efficiency of percutaneous coronary intervention using a standardised optical coherence tomography workflow.

BACKGROUND: While intravascular imaging guidance during percutaneous coronary intervention (PCI) improves outcomes, routine intravascular imaging usage remains low, in part due to perceived inefficiency and safety concerns.  Aims: The LightLab (LL) Initiative was designed to evaluate whether implementing a standardised optical coherence tomography (OCT) workflow impacts PCI safety metrics and procedural efficiency. METHODS: In this multicentre, prospective, observational study, PCI procedural data were collected over 2 years from 45 physicians at 17 US centres. OCT-guided PCI incorporating the LL workflow (N=264), a structured algorithm using routine pre- and post-PCI OCT imaging, was compared with baseline angiography-only PCI (angio) (N=428). Propensity score analysis identified 207 matched procedures. Outcomes included procedure time, radiation exposure, contrast volume, device utilisation, and treatment strategy. RESULTS: Compared with angiography alone, LL workflow OCT-guided PCI increased the median procedural time by 9 minutes but reduced vessel preparation time (2 min LL workflow vs 3 min angio; p<0.001) and resulted in less unplanned additional treatment (4% LL workflow vs 10% angio; p=0.01). With LL workflow OCT guidance, fewer cineangiography views were needed compared to angiography guidance, leading to decreased radiation exposure (1,133 mGy LL workflow vs 1,269 mGy angio; p=0.02), with no difference in contrast utilisation between groups (p=0.28). Furthermore, LL workflow OCT guidance resulted in fewer predilatation balloons and stents being used, more direct stent placement, and greater stent post-dilatation than angiography-guided PCI. CONCLUSIONS: The incorporation of a standardised pre- and post-PCI OCT imaging workflow improves procedural efficiency and safety metrics, at a cost of a modestly longer procedure time.

Transcatheter Aortic Valve Replacement for Severe Aortic Regurgitation in Patients With a Left Ventricular Assist Device.

BACKGROUND: There are limited invasive treatment options for patients with end-stage heart failure and left ventricular assist device (LVAD) who develop severe aortic valve regurgitation (AR). One option for such patients is transcatheter aortic valve replacement (TAVR). There are limited data on outcomes of patients with LVAD who receive TAVR for severe AR. We present a series of 4 consecutive patients with LVAD who underwent TAVR for severe AR. METHODS AND RESULTS: This is a retrospective chart review of 4 consecutive patients with LVAD who underwent TAVR for severe AR. All 4 patients underwent TAVR with a 34-mm self-expanding valve (Medtronic). One patient received a 29-mm balloon-expandable valve (Edwards Lifesciences) within the self-expanding valve (SEV) to postdilate the SEV and minimize paravalvular leak (PVL). All 4 procedures were technically successful. The patient who received rescue valve-in-valve TAVR continued to have persistent mild to moderate PVL. CONCLUSION: Although technically challenging, TAVR is a feasible option for carefully selected LVAD patients with severe AR. Procedural issues to consider include oversizing the transcatheter heart valve (THV) while being cognizant of the risks of annular rupture and valve dislocation, anticipating and avoiding ventricular migration of the THV and being ready to postdilate the THV if necessary, to limit hemodynamically significant PVL.

The Carotid Artery as a Preferred Alternative Access Route for Transcatheter Aortic Valve Replacement.

BACKGROUND: In high-risk patients with severe aortic stenosis, transfemoral (TF) access for transcatheter aortic valve replacement (TAVR) is the preferred access route but is not always feasible. Compared with other alternative access routes, transcarotid (TC) access is often overlooked by many valvular heart teams. METHODS: We report our single-center experience of all patients undergoing TC (n = 25), transapical (TA) (n = 12), or TF (n = 100; limited to most recent cases) TAVR over a 1.5 year period. In-hospital and 30-day outcomes were retrospectively compared between groups using the Kruskal-Wallis and Wilcoxon rank sum tests. RESULTS: TAVR was successfully performed through the left or right carotid artery in all 25 patients. Procedurally, TC and TF procedures were faster than TA procedures (p < 0.001), and patients who underwent TC and TF procedures had shorter intensive care unit (ICU) hours (p = 0.05), ventilator hours (p < 0.001), and length of stay (LOS) (p = 0.01) compared to patients who underwent a TA procedure. No patients who underwent a TC procedure had in-hospital stroke, transient ischemic attack (TIA), or myocardial infarction (MI). One patient who underwent a TC procedure had a TIA by 30-day follow-up, which was not significantly different from the TF (2 patients) or TA groups (0 patients; p = 0.75). In-hospital mortality rates were the same between TC (1 patient) and TF (1 patient) procedures but were significantly greater for TA procedures (2 patients; p = 0.009). Thirty-day mortality rates were low and did not differ between the groups. CONCLUSIONS: In our US community hospital setting, TC-TAVR is a safe alternative to TF-TAVR in appropriate patients and has evolved to be our alternative access route of choice if TF access is not feasible.

Plasma and dietary magnesium and risk of sudden cardiac death in women.

BACKGROUND: Magnesium has antiarrhythmic properties in cellular and experimental models; however, its relation to sudden cardiac death (SCD) risk is unclear. OBJECTIVE: We prospectively examined the association between magnesium, as measured in diet and plasma, and risk of SCD. DESIGN: The analysis was conducted within the Nurses' Health Study. The association for magnesium intake was examined prospectively in 88,375 women who were free of disease in 1980. Information on magnesium intake, other nutrients, and lifestyle factors was updated every 2-4 y through questionnaires, and 505 cases of sudden or arrhythmic death were documented over 26 y of follow-up. For plasma magnesium, a nested case-control analysis including 99 SCD cases and 291 controls matched for age, ethnicity, smoking, and presence of cardiovascular disease was performed. RESULTS: After multivariable adjustment for confounders and potential intermediaries, the relative risk of SCD was significantly lower in women in the highest quartile compared with those in the lowest quartile of dietary (relative risk: 0.63; 95% CI: 0.44, 0.91) and plasma (relative risk: 0.23; 95% CI: 0.09, 0.60) magnesium. The linear inverse relation with SCD was strongest for plasma magnesium (P for trend = 0.003), in which each 0.25-mg/dL (1 SD) increment in plasma magnesium was associated with a 41% (95% CI: 15%, 58%) lower risk of SCD. CONCLUSIONS: In this prospective cohort of women, higher plasma concentrations and dietary magnesium intakes were associated with lower risks of SCD. If the observed association is causal, interventions directed at increasing dietary or plasma magnesium might lower the risk of SCD.

Amino-terminal pro-B-type natriuretic peptide and high-sensitivity C-reactive protein as predictors of sudden cardiac death among women.

BACKGROUND: Plasma concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) have been found to predict risk of sudden cardiac death (SCD) in patients with known cardiac disease, and C-reactive protein levels have been found to predict risk among apparently healthy men. However, there are no data on SCD risk prediction for either of these markers in a population of women unselected on the basis of cardiovascular disease. METHODS AND RESULTS: In a prospective, nested, case-control analysis within the 121,700-participant Nurses' Health Study, 99 cases of definite or probable SCD were identified and matched to 294 controls. In multivariable models that adjusted for coronary heart disease risk factors, glomerular filtration rate, and other biomarkers, the trend across quartiles approached significance for NT-proBNP (rate ratio=2.37 for comparison of the highest and lowest quartile; P for trend=0.05) but not for high-sensitivity C-reactive protein (P for trend=0.60). When examined continuously, both NT-proBNP and high-sensitivity C-reactive protein were significantly associated with SCD risk in age- and fasting-adjusted models (P for linear trend=0.04 and 0.03). Adjustment for coronary heart disease risk factors and other biomarkers strengthened the relationship with NT-proBNP and SCD (relative risk for 1-SD increment=1.49; 95% confidence interval, 1.09 to 2.05; P=0.01) but eliminated the relationship with high-sensitivity C-reactive protein (P=0.34). Women with NT-proBNP levels above the prespecified cut point of 389 pg/mL were at a markedly increased risk of SCD in both models (rate ratio=5.68; 95% confidence interval, 1.78 to 18.2; P=0.003). CONCLUSIONS: In this population of women, baseline levels of NT-proBNP were associated with subsequent risk of SCD. If this association is confirmed in larger prospectively studied populations, these findings might provide another useful marker contributing to efforts to screen and prevent SCD among women.

Unusual causes of intermittent claudication: popliteal artery entrapment syndrome, cystic adventitial disease, fibromuscular dysplasia, and endofibrosis.

In the general population, vascular causes of exercise-induced limb discomfort are most often the result of peripheral artery disease (PAD) due to atherosclerosis. However, several other clinical entities can often mimic the symptoms of atherosclerotic PAD of the lower extremities, particularly among younger patients with fewer risk factors for atherosclerosis, who often are more athletically fit than patients with PAD. Treatment for these entities often requires percutaneous or surgical intervention. This article reviews four uncommon vascular causes of exercise-induced limb discomfort: popliteal artery entrapment syndrome, cystic adventitial disease of the popliteal artery, fibromuscular dysplasia of the lower-extremity arteries, and endofibrosis of the iliac artery.

A novel technique for 14 French arteriotomy closure after percutaneous aortic valvuloplasty using two Mynx closure devices.

Management of large bore arterial access sites often represents a challenge during interventional procedures, and usually requires prolonged manual compression, though suture-mediated closure techniques have been described. We report our experience in using the Mynx vascular closure device to close a 14 French femoral arteriotomy in two patients undergoing percutaneous balloon aortic valvuloplasty.