Outcomes of mitral TEER in non-responders to cardiac resynchronization therapy: A systematic review and meta-analysis.

BACKGROUND: Secondary mitral regurgitation (MR) worsens in 10-15 % of heart failure (HF) patients receiving cardiac resynchronization therapy (CRT). Transcatheter edge-to-edge repair (TEER) with Mitra-Clip (Abbot Vascular, Santa Clara, CA, USA) therapy is associated with improved survival and decreased rates of hospitalization for HF in selected patients with secondary MR. Data on TEER outcomes in CRT-non-responders are limited. The purpose of this meta-analysis was to evaluate outcomes of mitral TEER with Mitra-Clip in CRT-non-responders. METHODS: Cochrane, Scopus, MEDLINE, and EMBASE were searched for studies discussing outcomes of Mitra-Clip in CRT non-responders. Two reviewers were independently involved in screening studies and extracting relevant data. Individual study incidence rate estimates underwent logit transformation to calculate the weighted summary proportion under the random effect model. RESULTS: A total of eight reports met the inclusion criteria (439 patients). Mitra-Clip improved MR grade to ≤2+ in 83.8 % and 86.8 % of CRT non-responders at six months and one year, respectively. Symptomatic improvement (New York Heart Association class ≤II) was also found in 71 % and 78.1 % of CRT non-responders at six months and one year, respectively. The pooled overall incidence estimates of mortality at 30 days, 6 months, 1 year, and 2 years were 3.6 %, 9.2 %, 17.8 %, and 25.9 %, respectively. CONCLUSION: TEER with Mitra-Clip in patients with significant secondary MR who do not respond to CRT was associated with MR improvement, alleviation of symptoms, and mortality rates similar to those in the COAPT trial.

Challenges and outcomes of the double kissing crush stenting technique: Insights from the PROGRESS-BIFURCATION registry.

BACKGROUND: Although the double kissing (DK) crush stenting technique can provide excellent outcomes in percutaneous coronary intervention (PCI) of bifurcation lesions, it can be challenging to perform. METHODS: We examined the clinical and angiographic characteristics, challenges encountered, and procedural outcomes of bifurcation PCI with DK crush in Prospective Global Registry of Percutaneous Coronary Intervention in Bifurcation Lesions (PROGRESS-BIFURCATION, NCT05100992). RESULTS: DK crush was used in 48 of 435 bifurcation lesions (11%). Technical success was 100%, procedural success was 96%, and the incidence of in-hospital major adverse cardiovascular events was 4%. Challenges while performing DK crush were encountered in 26 lesions (54%): (1) difficulty in side branch (SB) first rewiring (38%) that was overcome with the use of a new guidewire (30%) or a microcatheter (15%); (2) inability to deliver balloon to an SB for the first kiss (54%) that was overcome with the use of a smaller balloon (86%), rewiring (29%), microcatheter (14%), and increased support 7%; (3) difficulty in SB second rewiring (19%) that was overcome with the use of a new guidewire (80%) and/or microcatheter (60%). DK crush was more often performed in left main and proximal left anterior descending artery lesions (70% vs. 50%, p = 0.014). DK crush cases required more contrast (198 ± 84 ml vs. 163 ± 70 ml, p = 0.003), fluoroscopy time (35 ± 20 min vs. 25 ± 21 min, p = 0.004), and lasted longer (137 ± 69 min vs. 99 ± 66 min, p = 0.001) compared with non-DK crush techniques. CONCLUSIONS: While challenges are common when performing DK crush bifurcation stenting, success rates are high and complication rates are low.

Update on chronic total occlusion percutaneous coronary intervention.

Chronic total occlusion (CTO) percutaneous coronary interventions (PCI) can be challenging to perform. The main indication for CTO PCI is to improve symptoms. Several contemporary studies have reported high CTO PCI success rates at experienced centers but success rates in all-comer registries remain low. Several scores can estimate the difficulty and the likelihood of success of CTO PCI. Dual arterial access and use of CTO crossing algorithms can improve the success and safety of CTO PCI. Intracoronary imaging can optimize stent expansion and minimize adverse cardiovascular events. While complications are more common in CTO PCI, careful planning and prompt diagnosis and treatment can prevent them or minimize their adverse consequences. In this article, we review contemporary data on the indications, safety and efficacy of CTO PCI.

Statins Disrupt Macrophage Rac1 Regulation Leading to Increased Atherosclerotic Plaque Calcification.

OBJECTIVE: Calcification of atherosclerotic plaque is traditionally associated with increased cardiovascular event risk; however, recent studies have found increased calcium density to be associated with more stable disease. 3-hydroxy-3-methylglutaryl coenzymeA reductase inhibitors or statins reduce cardiovascular events. Invasive clinical studies have found that statins alter both the lipid and calcium composition of plaque but the molecular mechanisms of statin-mediated effects on plaque calcium composition remain unclear. We recently defined a macrophage Rac (Ras-related C3 botulinum toxin substrate)-IL-1ß (interleukin-1 beta) signaling axis to be a key mechanism in promoting atherosclerotic calcification and sought to define the impact of statin therapy on this pathway. Approach and Results: Here, we demonstrate that statin therapy is independently associated with elevated coronary calcification in a high-risk patient population and that statins disrupt the complex between Rac1 and its inhibitor RhoGDI (Rho GDP-dissociation inhibitor), leading to increased active (GTP bound) Rac1 in primary monocytes/macrophages. Rac1 activation is prevented by rescue with the isoprenyl precursor geranylgeranyl diphosphate. Statin-treated macrophages exhibit increased activation of NF-κB (nuclear factor kappa-light-chain-enhancer of activated B cells), increased IL-1ß mRNA, and increased Rac1-dependent IL-1ß protein secretion in response to inflammasome stimulation. Using an animal model of calcific atherosclerosis, inclusion of statin in the atherogenic diet led to a myeloid Rac1-dependent increase in atherosclerotic calcification, which was associated with increased serum IL-1ß expression, increased plaque Rac1 activation, and increased plaque expression of the osteogenic markers, alkaline phosphatase and RUNX2 (Runt-related transcription factor 2). CONCLUSIONS: Statins are capable of increasing atherosclerotic calcification through disinhibition of a macrophage Rac1-IL-1ß signaling axis.

Impact of Slice Thickness on the Predictive Value of Lung Cancer Screening Computed Tomography in the Evaluation of Coronary Artery Calcification.

Background Image reconstruction thickness may impact quantitative coronary artery calcium scoring (CACS) from lung cancer screening computed tomography (LCSCT), limiting its application in practice. Methods and Results We evaluated Agatston-based quantitative CACS from 1.25-mm LCSCT and cardiac computed tomography for agreement in 87 patients. We then evaluated Agatston-based quantitative CACS from 1.25-, 2.5-, and 5.0-mm slice thickness LCSCT for agreement in 258 patients. Secondary analysis included the impact of slice thickness on predictive value of 4-year outcomes. Median age of patients who underwent 1.25-mm LCSCT and cardiac computed tomography was 63 years (interquartile interval, 57, 68). CACS from 1.25-mm LCSCT and cardiac computed tomography demonstrated a strong Pearson correlation, R=0.9770 (0.965, 0.985), with good agreement. The receiver operating characteristic curve areas under the curve for cardiac computed tomography and LCSCT were comparable at 0.8364 (0.6628, 1.01) and 0.8208 (0.6431, 0.9985), respectively ( P=0.733). Median age of patients who underwent LCSCT with 3 slice thicknesses was 66 years (interquartile interval, 63, 73). Compared with CACS from 1.25-mm scans, CACS from 2.5- and 5.0-mm scans demonstrated strong Pearson correlations, R=0.9949 (0.9935, 0.996) and R=0.9478 (0.9338, 0.959), respectively, though bias was largely negative for 5.0-mm scans. Receiver operating characteristic curve areas under the curve for 1.25-, 2.5-, and 5.0-mm scans were comparable at 0.7040 (0.6307, 0.7772), 0.7063 (0.6327, 0.7799), and 0.7194 (0.6407, 0.7887), respectively ( P=0.6487). When using individualized high-risk thresholds derived from respective receiver operating characteristic curves, all slice thicknesses demonstrated similar prognostic value. Conclusions Slice thickness is an important consideration when interpreting Agatston CACS from LCSCTs. Despite the absence of ECG gating, it appears reasonable to report CACS from either 1.25- or 2.5-mm slice thickness LCSCT to help stratify cardiovascular risk. Conversely, 5.0-mm scans largely underidentify calcium, limiting practical use within the established CACS values used to categorize cardiovascular risk.

A Double Whammy: Lactobacillus acidophilus Bacteremia and Subsequent Lactobacillus rhamnosus Prosthetic Valve Infective Endocarditis in an Elderly Diabetic Patient.

The clinical significance of the relatively avirulent organ- ism, Lactobacillus, has been debated in the past. At times misdiagnosed as a contaminant, Lactobacillus has uncommonly been reported to cause intra-abdominal abscesses, peritonitis, meningitis, bacteremia, pneumonia and endocarditis, especially in the population of patients with underlying comorbid conditions including malignancy, diabetes, recent surgery or organ transplantation. We report a case of a 74-year-old male with Lactobacillus bacteremia leading to prosthetic valve infective endocarditis complicated by an aortic root abscess. He was managed with IV antibiotic therapy, ultimately penicillin G, and aortic valve replacement, and completely recovered after a period of rehabilitation. Several factors that predispose to Lactobacillus bacteremia were identified in our patient. This case further supports the proposition that Lactobacillus is not always a contaminant; when pathogenic, underlying disease conditions should be investigated.