Role of aortic valve replacement in moderate aortic stenosis: a 10-year outcomes study.

OBJECTIVE: Patients with moderate aortic stenosis (AS) exhibit high morbidity and mortality. Limited evidence exists on the role of aortic valve replacement (AVR) in this patient population. To investigate the benefit of AVR in moderate AS on survival and left ventricular function. METHODS: In a retrospective cohort study, patients with moderate AS between 2008 and 2016 were selected from the Cleveland Clinic echocardiography database and followed until 2018. Patients were classified as receiving AVR or managed medically (clinical surveillance). All-cause and cardiovascular mortality were assessed by survival analyses. Temporal haemodynamic and structural changes were assessed with longitudinal analyses using linear mixed effects models. RESULTS: We included 1421 patients (mean age, 75.3±5.4 years and 39.9% women) followed over a median duration of 6 years. Patients in the AVR group had lower risk of all-cause (adjusted HR (aHR)=0.51, 95% CI: 0.34 to 0.77; p=0.001) and cardiovascular mortality (aHR=0.50, 95% CI: 0.31 to 0.80; p=0.004) compared with those in the clinical surveillance group irrespective of sex, receipt of other open-heart surgeries and underlying malignancy. These findings were seen only in those with preserved left ventricular ejection fraction (LVEF) ≥50%. Further, patients in the AVR group had a significant trend towards an increase in LVEF and a decrease in right ventricular systolic pressure compared with those in the clinical surveillance group. CONCLUSIONS: In patients with moderate AS, AVR was associated with favourable clinical outcomes and left ventricular remodelling.

Evaluating troponin elevation in patients with chronic kidney disease and suspected acute coronary syndrome.

Many patients with chronic kidney disease have chronically elevated cardiac troponin levels, and if they present with symptoms suggesting an acute coronary syndrome, it is often difficult to determine if this is the correct diagnosis. This article briefly reviews the major challenges in diagnosing acute coronary syndrome in patients with chronic kidney disease, describes the mechanisms and prognostic significance of troponin elevation in chronic kidney disease, and provides a diagnostic algorithm to risk-stratify patients with chronic kidney disease who have troponin elevation and suspected acute coronary syndrome.

Clinical outcomes following tricuspid transcatheter edge-to-edge repair with PASCAL: A meta-analysis.

BACKGROUND: Patients with severe tricuspid regurgitation (TR) exhibit high morbidity and mortality. Tricuspid transcatheter edge-to-edge repair (T-TEER) is a rapidly evolving strategy to address the unmet clinical need of severe TR therapies. OBJECTIVE: Organize the current body of evidence on outcomes following use of the PASCAL (Edwards Lifesciences) system for T-TEER. METHODS: For this meta-analysis, we searched the MEDLINE/PubMed, Embase, and Cochrane databases for keywords ["tricuspid"] and ["transcatheter" or "edge-to-edge"] and ["PASCAL" or "leaflet repair" or "valve repair"] from the database inception until January 11, 2023. Primary outcomes of interest were procedural success, mortality, New York Heart Association (NYHA) functional class, 6-min walking distance (6MWD), and TR severity. RESULTS: A total of 549 patients undergoing PASCAL or PASCAL Ace T-TEER were included. The mean age ranged from 71.0 to 80.3 years, with 25.0 to 63.6% females. The follow-up duration ranged from 30 days to 1 year. The success rate was 83.5% (409/490). There was improvement in symptoms based on NYHA classification (at 1- to 6-months; NYHA ≥3 RR 0.27 [95% CI 0.19-0.39]; p < 0.001) and 6MWD (at 1-month; 50.96 [95% CI 32.34-69.59]; p < 0.001) post-procedure. On imaging, there was improvement in TR severity post-procedure (at 1- to 12-months; ≥ severe TR 0.21 [95% CI 0.14-0.31]; p < 0.001), which remained significant with each study removed. CONCLUSION: PASCAL for T-TEER is associated with high procedural success rates along with improvements in NYHA functional class, TR severity, 6MWD, and patient-reported outcomes.

Immune checkpoint inhibitor induced myocarditis, myasthenia gravis, and myositis: A single-center case series.

BACKGROUND: Immune checkpoint inhibitors can result in overlap syndrome comprised of myasthenia gravis, myositis and myocarditis. However, the mortality predictors have not been clearly delineated. METHODS: We examined the characteristics of 11 patients diagnosed with overlap syndrome at Cleveland Clinic. All the available clinical, diagnostic, biochemical and disease specific factors were examined. Clinical predictors of increased mortality were using student t-test for parametric data and Wilcoxon-signed rank testing for nonparametric data. RESULTS: Seven patients out of eleven patients were alive during the analysis. Our study did confirm that troponins were indicator of early demise. However, study showed that elevated creatinine, BUN, and decreased hemoglobin were also observed in patients who met early demise. Unlike previously published studies, elevated NT Pro-BNP and reduced left ventricular ejection fraction were not a seen in this study. However, there were higher incidence of electrical abnormalities in deceased patients when compared to alive. CONCLUSION: Our study is first to examine various clinical parameters of overlap syndrome that might be predictive of mortality. This study confirms troponin as possible predictor and adds elevated creatinine, BUN and reduced hemoglobin as possible early biomarkers in deceased patients. The analysis showed that reduced LVEF was not a seen in deceased patients.

Heart Failure Drug Class Effects on 30-Day Readmission Rates in Patients with Heart Failure with Preserved Ejection Fraction: A Retrospective Single Center Study.

Background: The pharmacologic management of heart failure with preserved ejection fraction (HFpEF) involves far fewer options with demonstrated additional benefit. Therefore, we examined the effect of combination of multiple classes of HF medication in the 30-day hospital readmission in patients with HFpEF. Methods: All adult patients discharged with a diagnosis of HFpEF and a left ventricular ejection fraction (LVEF) of ≥ 50% reported during the admission or within the previous six months from our institution were retrospectively studied for a 30-day hospital readmission risk. Individual as well as combination drug therapy at the time of hospital discharge were evaluated using Pearson chi2 test and multivariate logistic regression. Results: The overall 30-day readmission rate in this HFpEF cohort of 445 discharges was 29%. Therapy with loop diuretics (p = 0.011), loop diuretics and angiotensin receptor blocker (p = 0.043) and loop diuretics and beta blockers (p = 0.049) were associated with a lower risk of 30-day hospital readmission. Multivariate logistic regression revealed only loop diuretics to be associated with a lower risk of hospital readmission in patients with HFpEF (OR 0.59; 95% CI, 0.39-0.90; p = 0.013). Conclusions: Our study revealed that loop diuretics at discharge decreases early readmission in patients with HFpEF. Further, our study highlights the implication of a lack of guidelines and treatment challenges in HFpEF patients and emphasizes the importance of a conservative approach in preventing early readmission in patients with HFpEF.