Transcatheter Aortic Valve Implantation in Mixed Aortic Valve Disease: A Multicenter Study.

Mixed aortic valve disease (MAVD), defined by the concurrent presence of aortic stenosis (AS) and insufficiency is frequently seen in patients who have undergone transcatheter aortic valve implantation (TAVI). However, studies comparing the outcomes of TAVI in MAVD versus isolated AS have demonstrated conflicting results. Therefore, we aim to assess the outcomes of TAVI in patients with MAVD in comparison with those with isolated severe AS. Patients who underwent native valve TAVI for severe AS at 3 tertiary care academic centers between January 2012 and December 2020 were included and categorized into 3 groups based on concomitant aortic insufficiency (AI) as follows: group 1, no AI; group 2, mild AI; and group 3, moderate to severe AI. Outcomes of interest included all-cause mortality and all-cause readmission rates at 30 days and 1 year. Other outcomes include bleeding, stroke, vascular complications, and the incidence of paravalvular leak at 30 days after the procedure. Of the 1,588 patients who underwent TAVI during the study period, 775 patients (49%) had isolated AS, 606 (38%) had mild AI, and 207 (13%) had moderate to severe AI. Society of Thoracic Surgeons risk scores were significantly different among the 3 groups (5% in group 1, 5.5% in group 2, and 6% in group 3, p = 0.003). Balloon-expandable valves were used in about 2/3 of the population. No statistically significant differences in 30-day or 1-year all-cause mortality and all-cause readmission rates were noted among the 3 groups. Post-TAVI paravalvular leak at follow-up was significantly lower in group 1 (2.3%) and group 2 (2%) compared with group 3 (5.6%) (p = 0.01). In summary, TAVI in MAVD is associated with comparable outcomes at 1 year compared with patients with isolated severe AS.

Transcatheter vacuum aspiration of valvular and lead related infective endocarditis.

BACKGROUND: Transcatheter aspiration is utilized for removal of thrombi and vegetations in inoperable patients and high-risk surgical candidates where medical therapy alone is unlikely to achieve desired outcome. A number of case reports and series have been published since the introduction of AngioVac system (AngioDynamics Inc., Latham, NY) in 2012 where this technology was used in the treatment of endocarditis. However, there is a lack of consolidated data reporting on patient selection, safety and outcomes. METHODS: PubMed and Google Scholar databases were queried for publications reporting cases where transcatheter aspiration was used for endocarditis vegetation debulking or removal. Data on patient characteristics, outcomes and complications from select reports were extracted and systematically reviewed. RESULTS: Data from 11 publications with 232 patients were included in the final analyses. Of these, 124 had lead vegetation aspiration, 105 had valvular vegetation aspiration, and 3 had both lead as well as valvular vegetation aspiration. Among the 105 valvular endocarditis cases, 102 (97 %) patients had right sided vegetation removal. Patients with valvular endocarditis were younger (mean age 35 years) vs. patients with lead vegetations (mean age 66 years). Among the valvular endocarditis cases, there was a 50-85 % reduction in vegetation size, 14 % had worsening valvular regurgitation, 8 % had persistent bacteremia and 37 % required blood transfusion. Surgical valve repair or replacement was subsequently performed in 3 % and in-hospital mortality was 11 %. Among patients with lead infection, procedural success rate was reported at 86 %, 2 % had vascular complications and in-hospital mortality was 6 %. Persistent bacteremia, renal failure requiring hemodialysis, and clinically significant pulmonary embolism occurred in about 1 % each. CONCLUSIONS: Transcatheter aspiration of vegetations in infective endocarditis has acceptable success rates in vegetation debulking as well as rates of morbidity or mortality. Large prospective multi-center studies are warranted to determine predictors of complications, thus helping identify suitable patients.

Impact of sex on in-hospital mortality and 90-day readmissions in patients undergoing transcatheter mitral valve replacement (TMVR): Analysis from the nationwide readmission database.

OBJECTIVES: To evaluate sex differences in in-hospital mortality and 90-day readmission rates among patients undergoing transcatheter mitral valve replacement (TMVR) in the United States of America. BACKGROUND: Women have higher rates of mortality and rehospitalization than men following many cardiac procedures. TMVR has grown as an alternative to mitral valve surgery for patients at high surgical risk. The rates of TMVR mortality and rehospitalization by sex are unknown. METHODS: We analyzed the Nationwide Readmissions Database (NRD) from 2016 to 2019 to identify hospitalizations for TMVR. Sex differences in in-hospital mortality and 90-day readmissions were determined using logistic regression models. RESULTS: Between 2016 and 2019, 4109 hospitalizations for TMVR were identified, comprised of 1758 (42.8%) men and 2351 (57.2%) women. The median age was 74 years for both men and women. There was no significant difference in in-hospital mortality during index hospitalization (6.51% vs. 6.69%; p = 0.852) and all-cause 90-day readmission (28.19% vs. 29.59%; p = 0.563) between men and women. Across the study period, trend analysis did not reveal a significant change in in-hospital mortality (men p = 0.087, women p = 0.194) or 90-day readmission rates (men p = 0.569, women p = 0.454). CONCLUSIONS: In patients undergoing TMVR, in-hospital mortality and 90-day readmissions are similar between men and women. Between 2016 and 2019, TMVR in-hospital mortality and 90-day readmission rates remained unchanged. Further research is necessary to confirm these findings.

Medical Versus Invasive Management of Non-ST Segment Elevation Myocardial Infarction in Diabetes Mellitus.

INTRODUCTION: While management guidelines clearly indicate treatment algorithms for ST-segment elevation myocardial infarction, evidence behind treatment of other forms of acute coronary syndrome among diabetic patients has been inconclusive. This study examines diabetic patients with non ST-segment elevation myocardial infarction (NSTEMI) who were subsequently treated conservatively or with an invasive approach. METHODS: Diabetic patients admitted to our health network with NSTEMI between January 2013-2018 were identified. Data collected included demographics, treatment, survival, recurrence of myocardial infarction (MI), stroke and additional revascularization procedures. Historical data including comorbid factors present at time of NSTEMI and history of revascularization procedures were also collected. RESULTS: A total of 357 patients met exclusion criteria. 172 were treated medically and 185 with PCI. A total of 78 deaths occurred over the five year observation period. 48 patients who were treated medically died while 30 patients treated with PCI died. After initial medical management, nine patients went on to require PCI while 19 patients treated with PCI required additional PCI. Recurrence of MI occurred in 19.8 % in medically managed patients and 18.6 % in patients who underwent PCI. Multivariable analysis was completed with the Kaplan-Meier method to estimate the survival function and Cox proportional-hazard models to investigate association between the variables and survival time. CONCLUSIONS: In this single center study, diabetic patients treated with PCI had lower rates of all-cause mortality over the five-year study period compared to medical management. There was no difference in stroke events, recurrent MI, or revascularization between the two groups although patients from the PCI group showed a trend towards higher risk for repeat interventions. Treatment selection bias remains the major limitation of this study and thus, the results of the comparison of therapeutic choices should be viewed as hypothesis generating.

Multivessel vs. culprit-vessel only percutaneous coronary interventions in acute myocardial infarction and cardiogenic shock: a systematic review and meta-analysis of prospective randomized and retrospective studies.

AIMS: Studies comparing outcomes of multivessel (MV) vs. culprit-vessel (CV) only percutaneous coronary intervention (PCI) during index cardiac catheterization in patients presenting with acute myocardial infarction (MI) and cardiogenic shock (CS) have reported conflicting results. In this systematic review we aim to investigate outcomes with MV vs. CV-only revascularization strategies in patients with acute MI and CS. METHODS AND RESULTS: PubMed, Google Scholar, CINAHL and Cochrane databases were queried for studies comparing MV vs. CV PCI in patients with acute MI and CS. Data were extracted and pooled by means of random effects model. Primary outcome was early all-cause mortality (up to 30 days), while the secondary outcomes included late all-cause mortality (mean, 11.4 months), stroke, new renal replacement therapy, reinfarction, repeat revascularization, and bleeding. Pooled odds ratio (OR), 95% confidence intervals (CIs), and number needed to harm (NNH) were calculated. A total of 16 studies enrolling 75 431 patients were included. The MV PCI was associated with higher risk of early mortality [OR 1.17, 95% CI (1.00-1.35); P = 0.04; NNH = 62], stroke [1.15 (1.03-1.29); P = 0.01; NNH = 351], and new renal replacement therapy [1.33 (1.06-1.67); P = 0.01; NNH = 61]; and with lower risk of repeat revascularization [0.61 (0.41-0.89); P = 0.01] when compared with CV PCI. No significant difference was observed in late-term mortality [1.02 (0.84-1.25); P = 0.84], risk of reinfarction [1.13 (0.94-1.35); P = 0.18], or bleeding [1.21 (0.94-1.55); P = 0.13] between groups. CONCLUSION: Among patients with acute MI and CS, MV PCI during index cardiac catheterization was associated with higher risk of early mortality, stroke, and renal replacement therapy.

Comparative efficacy and safety of adenosine and regadenoson for assessment of fractional flow reserve: A systematic review and meta-analysis.

BACKGROUND: Adenosine is a coronary hyperemic agent used to measure invasive fractional flow reserve (FFR) of intermediate severity coronary stenosis. AIM: To compare FFR assessment using adenosine with an alternate hyperemic agent, regadenoson. METHODS: PubMed, Google Scholar, CINAHL and Cochrane databases were queried for studies comparing adenosine and regadenoson for assessment of FFR. Data on FFR, correlation coefficient and adverse events from the selected studies were extracted and analyzed by means of random effects model. Two tailed P-value less than 0.05 was considered significant. Heterogeneity was assessed using I 2 test. RESULTS: Five studies with 248 patients were included in the final analysis. All included patients and coronary lesions underwent FFR assessment using both adenosine and regadenoson. There was no significant mean difference between FFR measurement by the two agents [odds ratio (OR) = -0.00; 95% confidence interval (CI): (-0.02)-0.01, P = 0.88]. The cumulative correlation coefficient was 0.98 (0.96-0.99, P < 0.01). Three of five studies reported time to FFR with cumulative results favoring regadenoson (mean difference 34.31 s; 25.14-43.48 s, P < 0.01). Risk of adverse events was higher with adenosine compared to regadenoson (OR = 2.39; 95%CI: 1.22-4.67, P = 0.01), which most commonly included bradycardia and hypotension. Vast majority of the adverse events associated with both agents were transient. CONCLUSION: The performance of regadenoson in inducing maximal hyperemia was comparable to that of adenosine. There was excellent correlation between the FFR measurements by both the agents. The use of adenosine, was however associated with higher risk of adverse events and longer time to FFR compared to regadenoson.

In-Hospital Weight Loss and Outcomes in Patients With Heart Failure.

BACKGROUND: Acute decompensation of heart failure (HF) is often marked by fluid retention, and weight loss is a marker of successful diuresis. We examined the relationship between in-hospital weight loss and post-discharge outcomes in patients with HF. METHODS: We conducted a propensity score-matched study of 8830 patients hospitalized for decompensated HF in the Medicare-linked Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry, in which 4415 patients in the weight-loss group and 4415 patients in the no-weight-loss group were balanced on 75 baseline characteristics. We defined weight loss as an admission-to-discharge weight loss of 1-30 kilograms, and we defined no weight loss as a weight gain or loss of < 1 kilogram. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with weight loss were estimated. RESULTS: Patients had a mean age of 78 years, 57% were women, and 11% were African American. The median weight loss in the weight-loss group was 3.6 (interquartile range, 2.0-6.0) kilograms. HRs and 95% CIs for 30-day all-cause mortality, all-cause readmission and HF readmission associated with weight loss were 0.75 (0.63-0.90), 0.90 (0.83-0.99) and 0.83 (0.72-0.96), respectively. Respective 60-day HRs (95% CIs) were 0.80 (0.70-0.92), 0.91 (0.85-0.98) and 0.88 (0.79-0.98). These associations were attenuated and lost significance during 6 months of follow-up. CONCLUSIONS: Among older patients hospitalized for decompensated HF, in-hospital weight loss was associated with a lower risk of mortality and hospital readmission. These findings suggest that in-hospital weight loss, a marker of successful diuresis and decongestion, is also a marker of improved clinical outcomes.

Ischemic and Bleeding Outcomes of Potent P2Y12 Inhibitor Antiplatelet Agents Versus Clopidogrel in Elderly Patients With Acute Coronary Syndrome: A Meta-Analysis of Randomized Trials.

BACKGROUND: The role of P2Y12 inhibition in acute coronary syndrome (ACS) has been well described in literature. However, the agent of choice is less clear among elderly patients (>65 years) who are at increased risk of bleeding. This meta-analysis was designed to investigate the efficacy and safety of potent P2Y12 inhibitors vs. clopidogrel in this population. METHODS AND RESULTS: PubMed, Cochrane Central Register of Clinical Trials, EMBASE, and ClinicalTrial.gov (inception through February 25, 2021) were searched for randomized studies comparing potent oral P2Y12 inhibitors to clopidogrel in elderly population presenting with ACS. Study endpoints included major adverse cardiac events (MACE), major bleeding, all-cause mortality, cardiovascular mortality, myocardial infarction, and stroke. Hazard ratios (HRs) with 95% confidence intervals (CIs) were computed and p<0.05 was considered significant. Eight randomized studies with a total 10,081 patients were included in the final analysis. At mean follow up of 26 months, there were no significant differences between potent oral P2Y12 inhibitors and clopidogrel in MACE (HR 0.97, 95% CI [0.82-1.15]; p=0.73), all-cause mortality (HR 0.91, 95% CI [0.75-1.10]; p=1.00), MI (HR 0.95, 95% CI [0.78-1.17]; p=0.64), and stroke (HR 1.24, 95% CI [0.82-1.86]; p=0.31). However, potent oral P2Y12 inhibitors were associated with a reduction in cardiovascular mortality (HR 0.82, 95% CI [0.68-0.98]; p=0.03), and an increase in major bleeding events (HR 1.32, 95% CI [1.09-1.59]; p<0.01). CONCLUSION: In comparison with clopidogrel, the use of potent oral P2Y12 inhibitors in elderly patients with ACS, is associated with a reduction in the risk of cardiovascular mortality with increased risk of bleeding events and no significant change in MACE outcomes.

Challenges in Implementing Evidence Based Cross-Disciplinary Therapies: Are Cardiovascular Specialists Ready to Claim SGLT-2 Inhibitors and GLP-1 Analogs?

Cardiovascular disease is a leading cause of morbidity, mortality and financial burden to the United States health system. A change in focus towards preventive medicine along with advances in pharmacologic and invasive therapies, has led to improved cardiac death rates. These benefits however, come with increased prevalence of heart failure and soaring readmission rates. Reducing burden of hospitalizations has therefore, been a focus of clinicians and researchers over the years. An improvement in clinical outcomes has been demonstrated in multiple trials investigating HF therapies, however, execution of guideline recommendations has been trailing. Over the past decade, 2 classes of hypoglycemic agents, the glucagon-like peptide-1 (GLP-1) receptor agonists and the sodium-glucose cotransporter 2 (SGLT-2) inhibitors have been recognized for their cardiovascular morbidity and mortality benefits. Studies have shown that there has been a steady increase in prescription rates of these medications, however, overall usage remains quite low. Various patient, physician and system-based factors have been identified that cause barriers to translation of trial data to real-world clinical outcomes. A strategy focused on physician and patient education, quality improvement, multi-disciplinary team approach, and patient centered care is essential to meet treatment goals.

Transcatheter aortic valve replacement in mixed aortic valve disease: a systematic review and meta-analysis.

BACKGROUND: Utilization of transcatheter aortic valve replacement (TAVR) has expanded from high-risk patients to intermediate- and select low-risk candidates with severe aortic stenosis (AS). TAVR is currently not indicated for patients with aortic insufficiency, and its outcomes in mixed aortic valve disease (MAVD) are unclear. METHODS: A systematic search of PubMed, Medline, CINHAL, and Cochrane databases was performed to identify studies comparing TAVR outcomes in patients with AS vs. MAVD. Primary outcomes included 30-day and late all-cause mortality, and paravalvular regurgitation (PVR). Secondary outcomes were major bleeding, vascular complications, device implantation success, permanent pacemaker, and stroke. Pooled odds ratios (OR) and 95% confidence intervals (CIs) were calculated using Der Simonian-Laird random-effects model. RESULTS: Six observational studies with 58 879 patients were included in the analysis. There was no significant difference in 30-day all-cause mortality [OR 1.03 (95% CI 0.92-1.15); P = 0.63], however, MAVD group had higher odds of moderate-to-severe PVR [1.81 (1.41-2.31); P < 0.01]. MAVD patients had lower odds of device implantation success [0.60 (0.40-0.91); P = 0.02] while other secondary outcomes were similar in the two groups. CONCLUSIONS: TAVR in MAVD is associated with increased odds of paravalvular regurgitation and lower odds of device implantation success when compared to severe aortic stenosis.

Major acute cardiovascular events in patients with inflammatory bowel disease.

BACKGROUND: Systemic inflammation and immune-mediated diseases have been associated with ischemic heart disease in addition to traditional risk factors. In this study, we investigate associations between inflammatory bowel disease (IBD) and acute cardiovascular events. METHODS: An observational study where patient data were extracted from our health system patient pool of 3 917 894. Propensity scores were calculated for all 15 292 patients (0.39%) with IBD to assemble a 1:1 matched cohort balanced for age, gender, race and known cardiovascular risk factors including hypertension, hyperlipidemia, diabetes mellitus and smoking (current and former). Secondary analyses were performed independently for 6658 patients with ulcerative colitis and 9406 patients with Crohn's disease. ICD-9 and ICD-10 codes were used to identify cardiovascular risk factors and outcomes. RESULTS: Matched patients (n = 30 584) had a mean age of 51 years, with 58% being women, and 63% Caucasian. During the median follow-up of 4.4 years, all-cause mortality was observed in 1.7 versus 1.2% of patients from IBD and non-IBD groups, respectively [hazard ratio, 1.31; 95% confidence interval (CI), 1.08-1.58; P = 0.005]. Combined outcome for myocardial infarction or cardiovascular mortality was noted in 2.3 and 2.1% from IBD and non-IBD groups, respectively (hazard ratio, 1.04; 95% CI, 0.90-1.21; P = 0.588), while hazard ratios for cardiovascular mortality, myocardial infarction and unstable angina were 1.04 (0.74-1.47; P = 0.833), 1.05 (0.89-1.23; P = 0.591) and 1.10 (0.83-1.46; P = 0.524), respectively. CONCLUSIONS: Among patients with IBD, incidence of acute coronary events did not show a statistically significant difference when compared to the matched cohort.

Uncommon Anatomic Predisposition to Myocardial Infarction: A Case of Coronary Artery Ectasia.

Coronary artery ectasia (CAE) is a recognized cause of acute coronary syndrome (ACS), and can be associated with life-threatening complications, including thrombus formation with consequent distal coronary artery embolization. Several studies have demonstrated a higher incidence of cardiovascular adverse events and cardiac death in patients with CAE or coronary artery aneurysms compared to those without such abnormalities. Management of symptomatic CAE is similar to coronary artery disease (CAD), where guideline-directed medical therapy is indicated due to coexistence of CAD with acquired CAE. Percutaneous coronary intervention can be attempted; however, it is challenging, as it is associated with lower procedural success, higher rates of stent thrombosis, and repeat revascularization.

Spectrum of Cardiac Involvement in COVID-19.

Cardiac involvement in coronavirus disease 2019 (COVID-19) commonly accompanies multi-organ system failure with acute respiratory syndrome; however, infrequently myocarditis and pericardial effusions may be isolated, yet fulminant. In this report, we highlight significant variations in cardiac involvement and presentation among patients with COVID-19. This article reports two cases of fulminant myocarditis in COVID-19 positive patients who presented to our facility with contrasting symptoms, laboratory and imaging findings. A 65-year-old patient A had a more typical presentation including respiratory distress, chest pain, ST-segment elevations on electrocardiogram (EKG), lymphopenia, elevated levels of inflammatory markers and cardiac troponin I. A 34-year-old patient B presented with shortness of breath and chest pain similar to patient A; however, she had isolated cardiac involvement with systolic dysfunction and an acute pericardial effusion causing tamponade physiology. Inflammatory marker and cardiac troponin I levels for patient B were within normal range. Patient A had a rapid progression of multi-organ system failure leading to her death within 24 hours from presentation on maximal inopressor support. Patient B, however, is one of few reported cases of cardiac tamponade and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use in COVID-19 who underwent pericardiocentesis and was additionally managed with colchicine and steroids, leading to complete recovery in systolic function within three weeks from initial presentation. Isolated myocardial dysfunction and pericardial effusions in COVID-19 may have catastrophic sequalae even in the absence of elevated biomarkers described in literature. Therefore, early detection and management of cardiac involvement is warranted. Additionally, the role of mechanical circulatory support devices and VA-ECMO in COVID-19 needs further investigation.

Optimizing Computed Tomography for Detection of Pulmonary Thromboembolism in Patients With Fontan Circulation.

Congenital heart disease (CHD) patients who have undergone the Fontan procedure or one of its variants usually have altered vascular anatomy. Consequently, this poses a challenge when diagnosing pulmonary thromboembolism (PTE) with computed tomography (CT). Detailed review of the type of surgery performed and the person's individual anatomy beforehand can help in choosing the appropriate diagnostic CT modality and technique. It would also help reduce false-positive and false-negative test results that would otherwise result in unnecessary anticoagulation, as well as avoid needless radiation exposure and additional cost, respectively.

Embolic ST-elevation Myocardial Infarction from Candida Endocarditis.

Infective endocarditis in intravenous drug users is uncommon in left-sided native valves. Adding to the rarity, in this case, is endocarditis from Candida species complicated by ST-elevation myocardial infarction. Embolic myocardial infarction has worse outcomes as compared to other etiologies, and the management of septic embolic myocardial infarction is rather challenging. The management of embolic myocardial infarction from Candida endocarditis vegetation includes antifungal therapy. The use of anti-thrombotic therapy and anticoagulation carries a significant risk of fatal neurologic complications and has been controversial, with limited observational data available. Among percutaneous coronary interventions, balloon angioplasty and stenting have been associated with multiple complications while aspiration embolectomy appears to be a safer option. Surgical management is considered if medical and interventional therapies fail or if there is an indication for valve replacement.

Digoxin Initiation and Outcomes in Patients with Heart Failure with Preserved Ejection Fraction.

BACKGROUND: Digoxin reduces the risk of heart failure hospitalization in patients with heart failure with reduced ejection fraction. Less is known about this association in patients with heart failure with preserved ejection fraction (HFpEF), the examination of which was the objective of the current study. METHODS: In the Medicare-linked OPTIMIZE-HF registry, 7374 patients hospitalized for HF had ejection fraction ≥50% and were not receiving digoxin prior to admission. Of these, 5675 had a heart rate ≥50 beats per minute, an estimated glomerular filtration rate ≥30 mL/min/1.73 m2 or did not receive inpatient dialysis, and digoxin was initiated in 524 of these patients. Using propensity scores for digoxin initiation, calculated for each of the 5675 patients, we assembled a matched cohort of 513 pairs of patients initiated and not initiated on digoxin, balanced on 58 baseline characteristics (mean age, 80 years; 66% women; 8% African American). Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with digoxin initiation were estimated in the matched cohort. RESULTS: Among the 1026 matched patients with HFpEF, 30-day heart failure readmission occurred in 6% and 9% of patients initiated and not initiated on digoxin, respectively (HR 0.70; 95% CI, 0.45-1.10; P = .124). HRs (95% CIs) for 30-day all-cause readmission and all-cause mortality associated with digoxin initiation were 0.95 (0.73-1.23; P = .689) and 0.93 (0.55-1.56; P = .773), respectively. Digoxin initiation had no association with 6-year outcomes. CONCLUSION: Digoxin initiation prior to hospital discharge was not associated with 30-day or 6-year outcomes in older hospitalized patients with HFpEF.