Durable Left Ventricular Assist Device Outflow Graft Obstructions: Clinical Characteristics and Outcomes.

PURPOSE: We report on the clinical course and management of patients supported with durable implantable LVADs who developed outflow graft obstructions at a large academic center. METHODS: We performed a retrospective review of patients receiving LVAD support from 2012 through 2020. Patients who developed an outflow graft obstruction diagnosed by computed tomography angiography (CTA) or angiogram were identified, and patient characteristics and outcomes were reported. RESULTS: Of the 324 patients supported by LVAD at our institution, 11 patients (3.4%) were diagnosed with outflow graft obstructions. The most common presentation was low flow alarms, which was present in 10/11 patients, and the remaining patient presented with lightheadedness. Patients had minimal LDH elevation with 8/11 presenting with less than 2-fold the upper limit of normal. Transthoracic echocardiograms were not diagnostic, but CTA enabled non-invasive diagnoses in 8/11 of the patients. Three patients with extrinsic compression of the outflow graft successfully underwent endovascular stent placement, and three patients with outflow cannula kinks received supportive care. Of the five patients diagnosed with intraluminal thromboses, one received a heart transplant, one underwent an outflow graft revision, and three received supportive care due to comorbidities. CONCLUSION: Outflow graft obstructions remain a rare, but serious complication. The true prevalence of this entity is likely underestimated due to the non-specific clinical presentation. CTA is a pivotal non-invasive diagnostic step. Patients with external compression were successfully treated with endovascular stenting.

Focused Cardiac Ultrasound Curriculum for Internal Medicine Residents.

Background: Focused cardiac ultrasound (FCU) is a safe and efficient diagnostic intervention for internal medicine physicians. FCU is a highly teachable skill, but is used in routine cardiac assessment in only 20% of surveyed training programs.We developed an FCU curriculum for internal medicine residents and an assessment tool to evaluate the impact of the curriculum on trainee knowledge and confidence. Methods: Internal medicine residents rotating through clinical cardiology services underwent 30 minutes of didactic and 60 minutes of hands-on teaching on acquisition and interpretation of FCU. A 20 item pre and post-curriculum online survey was administered (November 2018-December 2019) to assess confidence and knowledge in FCU. Results: 79 of 116 (68%) residents completed the pre-survey and 50 completed the post-survey, of whom 34 received the curriculum. The mean change in confidence score in those who received versus did not receive the curriculum was 0.99 versus 0.39 (p=0.046) on a 5-point Likert scale. Among 33 residents who had paired pre- and post-surveys the mean change in confidence score was 1.2 versus 0.85 (p<0.001) in those who received versus did not receive the curriculum. The mean increase in knowledge score was 13% versus 7% respectively (p<0.0001). Conclusions: We instituted a novel curriculum for internal medicine residents to gain experience in image acquisition and interpretation. Both confidence and knowledge in FCU improved following the curriculum, indicating that this is a highly teachable skill. Additional analysis of the of the FCU study images will be useful for informing future interventions.

Cardiovascular manifestations and treatment considerations in COVID-19.

Since its recognition in December 2019, covid-19 has rapidly spread globally causing a pandemic. Pre-existing comorbidities such as hypertension, diabetes, and cardiovascular disease are associated with a greater severity and higher fatality rate of covid-19. Furthermore, COVID-19 contributes to cardiovascular complications, including acute myocardial injury as a result of acute coronary syndrome, myocarditis, stress-cardiomyopathy, arrhythmias, cardiogenic shock, and cardiac arrest. The cardiovascular interactions of COVID-19 have similarities to that of severe acute respiratory syndrome, Middle East respiratory syndrome and influenza. Specific cardiovascular considerations are also necessary in supportive treatment with anticoagulation, the continued use of renin-angiotensin-aldosterone system inhibitors, arrhythmia monitoring, immunosuppression or modulation, and mechanical circulatory support.

Transcatheter aortic valve replacement thrombosis in patient supported with durable left ventricular assist device.

Aortic insufficiency (AI) is a frequent problem after continuous-flow left ventricular assist device (LVAD) implantation and results in increased morbidity and mortality. Advances in transcatheter aortic valve replacement (TAVR) technology have resulted in this being discussed as a potential option for LVAD patients with AI. While small case series have been published, we report the first case of TAVR thrombosis in an LVAD patient. This case highlights a major diagnostic and management dilemma that should become more present if this strategy becomes more widespread.

Impact of Aortic Root Anatomy and Geometry on Paravalvular Leak in Transcatheter Aortic Valve Replacement With Extremely Large Annuli Using the Edwards SAPIEN 3 Valve.

OBJECTIVES: The aim of this study was to determine factors affecting paravalvular leak (PVL) in transcatheter aortic valve replacement (TAVR) with the Edwards SAPIEN 3 (S3) valve in extremely large annuli. BACKGROUND: The largest recommended annular area for the 29-mm S3 is 683 mm2. However, experience with S3 TAVR in annuli >683 mm2 has not been widely reported. METHODS: From December 2013 to July 2017, 74 patients across 16 centers with mean area 721 ± 38 mm2 (range: 684 to 852 mm2) underwent S3 TAVR. The transfemoral approach was used in 95%, and 39% were under conscious sedation. Patient, anatomic, and procedural characteristics were retrospectively analyzed. Valve Academic Research Consortium-2 outcomes were reported. RESULTS: Procedural success was 100%, with 2 deaths, 1 stroke, and 2 major vascular complications at 30 days. Post-dilatation occurred in 32%, with final balloon overfilling (1 to 5 ml extra) in 70% of patients. Implantation depth averaged 22.3 ± 12.4% at the noncoronary cusp and 20.7 ± 9.9% at the left coronary cusp. New left bundle branch block occurred in 17%, and 6.3% required new permanent pacemakers. Thirty-day echocardiography showed mild PVL in 22.3%, 6.9% moderate, and none severe. There was no annular rupture or coronary obstruction. Mild or greater PVL was associated with larger maximum annular and left ventricular outflow tract (LVOT) diameters, larger LVOT area and perimeter, LVOT area greater than annular area, and higher annular eccentricity. CONCLUSIONS: TAVR with the 29-mm S3 valve beyond the recommended range by overexpansion is safe, with acceptable PVL and pacemaker rates. Larger LVOTs and more eccentric annuli were associated with more PVL. Longer term follow-up will be needed to determine durability of S3 TAVR in this population.

Contrast-Enhanced Echocardiography Has the Greatest Impact in Patients with Reduced Ejection Fractions.

BACKGROUND: Contrast-enhanced echocardiography (CE) helps to improve image quality in patients with suboptimal acoustic windows. Despite current recommendations, contrast use remains low. The aim of this study was to identify populations that would benefit more from contrast use. METHODS: A total of 176 subjects (137 men; mean age, 60.8 ± 13.7 years) with technically difficult transthoracic echocardiographic studies who received clinically indicated intravenous contrast were prospectively studied. The impact on clinical decision making (including alterations in medical therapy, referral, imaging, or clinical procedures) was evaluated. RESULTS: The use of CE enabled biplane left ventricular (LV) ejection fraction measurement in 97.2% of studies and the interpretation of regional wall motion in 95% of studies. CE allowed definitive assessment of the presence or absence of LV thrombus in 99% of the cases. In the 174 patients whose ordering physicians could be reached at the time of image interpretation, changes in management occurred in 51% of subjects. There was no difference in the proportion of management changes between inpatients and outpatients (60.0% vs 48.1%, P = .225). Subjects with heart failure, cardiomyopathy, and arrhythmia had a higher proportion of changes (61.4% vs 44.2% [P = .031], 62.5% vs 45.0% [P = .028], and 72.0% vs 47.7% [P = .030], respectively). The proportion of management change after CE increased as pre-CE estimated ejection fraction decreased. Logistic regression showed that pre-CE estimated LV ejection fraction < 50% was the only significant predictor of change of management after contrast (P = .004). CONCLUSIONS: The use of CE has a significant impact on clinical decision making in patients with suboptimal acoustic windows, especially in those with depressed pre-CE LV ejection fractions.

Comparison of Non-Contrast Cardiovascular Magnetic Resonance Imaging to Computed Tomography Angiography for Aortic Annular Sizing Before Transcatheter Aortic Valve Replacement.

BACKGROUND: Accurate measurement of aortic annulus is crucial before transcatheter aortic valve replacement (TAVR). Computed tomography (CT) angiography is the most commonly utilized method, but requires contrast administration. Cardiovascular magnetic resonance (CMR) imaging is a promising alternative modality to provide aortic annulus measurements. Few studies have compared the clinical feasibility and accuracy of non-contrast CMR to contrast-enhanced computed tomography (CT) angiography in order to provide a non-contrast alternative to CT annular sizing. METHODS: Twenty-one consecutive patients (mean age, 85.7 ± 5.2 years) with severe aortic stenosis (mean aortic valve area, 0.6 ± 0.1 cm²) underwent pre-TAVR CT angiography and a non-contrast CMR at 1.5 T. CT measurements were performed during systole as the clinical non-invasive standard. CMR measurements were performed during systole and diastole and included three-dimensional (3D) and two-dimensional (2D) methods. Interobserver differences were assessed using intraclass correlation. We recorded scan time in each patient. RESULTS: The mean systolic annular area was not significantly different between CT and 3D-CMR (480.0 ± 77.9 mm² vs 479.4 ± 66.2 mm²; P=.98) in systole. There was no clinically relevant systematic difference between area measurements [mean difference, 0.6 mm²; limits of agreement -38.2 mm²; 39.3 mm²] using Bland-Altman analyses. Interobserver correlation was excellent. The diagnostic systolic 3D-CMR annular sizing scan was achieved in 4.4 ± 2.7 min. CONCLUSION: Non-contrast CMR protocol for the measurement of aortic annulus area is feasible and accurate. 3D-CMR could provide an alternative for annular sizing pre-TAVR assessment in patients who cannot undergo contrast-enhanced CT studies.

New Ventricular Septal Defects Following Balloon-Expandable Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement (TAVR) has been commercially approved in the United States for the treatment of high-risk and inoperable patients with severe symptomatic aortic stenosis. While TAVR has proven benefits with regard to survival and quality of life in studied populations, the procedure is also associated with several well-described complications including stroke, vascular injury, and paravalvular regurgitation. More infrequent complications are less well described. Here, we report the development of new ventricular septal defects after TAVR in 4 patients with left ventricular outflow tract calcification. We discuss imaging and post-TAVR management of these patients.

Echocardiographic determinants of LV functional improvement after transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an established therapy in high-risk patients with severe aortic stenosis. Among patients with reduced left ventricular ejection fraction (LVEF), it is unclear which patients will derive maximal benefit from TAVR. METHODS: Clinical and echocardiographic data of patients with severe aortic stenosis and low LVEF (≤50%) who underwent TAVR at a single institution during 2009-2013 were retrospectively analyzed. Patients were divided into 2 groups post-TAVR based on improved LV function (Group A = ΔLVEF ≥ 10%) versus persistent LV dysfunction (Group B = ΔLVEF<10%). Echocardiographic parameters were assessed for their association with LVEF change post-TAVR. Kaplan-Meier analysis was performed to generate survival estimates. RESULTS: Of 382 patients who underwent TAVR, 60 patients had low LVEF, LV function failed to improve ≥10% in 50% of patients following the procedure (Group B). At baseline echocardiograms, Group B had higher LVEF, stroke volume (SV), SV index; and lower E, E/E', and estimated pulmonary arterial systolic pressure (PASP) compared to Group A. Higher mortality was found in Group B compared to the Group A (p = 0.003) with a significantly shorter survival (Group A = 3.3 ± 0.1 years vs Group B = 2.7 ± 0.2 years, p = 0.003). One-year event free survival was 53.3% in Group B compared to 93.3% in Group A, with a stable trend over ensuing years (5-year survival; 53.3% versus 90.0%, p = 0.003). CONCLUSIONS: In patients undergoing TAVR with depressed LV function, those who failed to improve were more likely to have relatively higher LVEF, SV, and SVI; and lower E, E/E', and PASP at baseline. Mortality rates were found to be higher in persistent LV dysfunction group. © 2015 Wiley Periodicals, Inc.

The impact of gender on cardiovascular system calcification in very elderly patients with severe aortic stenosis.

There is an established sex difference in cardiovascular disease among pre-menopausal women and age-matched men, with men having greater susceptibility to cardiovascular and coronary artery disease. Cardiovascular calcification may be linked to the atherosclerotic process and resulting disease, but the sex difference regarding coronary artery disease susceptibility and calcification is incompletely understood. We thought to measure calcium volume in different chest vascular beds in very elderly men and women with severe aortic stenosis (AS). Computed tomography scans of 94 patients with severe AS were calcium volume scored on Aquarius iNtuition Terarecon (Terarecon Inc., CA, USA) work stations. Coronary beds, aortic valve, mitral valve apparatus, and the thoracic aorta were examined. A significant sex difference in the mean total calcium volume of the coronary arteries was found in elderly (p = 0.001), with men having greater levels of calcification. There is also a significant sex difference in the amount of aortic valve calcium (p = 0.003). Furthermore, aortic and coronary calcification was independently correlated with sex. This study demonstrates a significant sex impact on calcification in the coronary beds and aortic valve in elderly patients with severe AS.

Outcomes of transcatheter aortic valve replacement in patients with chronic liver disease.

OBJECTIVE: Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to high-risk surgery in patients with comorbid conditions. The role of TAVR in patients with liver disease has not been examined. METHODS: We examined the procedural and intermediate to long-term follow-up outcomes of patients with severe symptomatic aortic valve stenosis and chronic liver disease, identified by liver biopsy or from a combination of clinical findings. All patients were treated with balloon-expandable transfemoral (TF) or transapical (TA) TAVR between November 2007 and February 2014. RESULTS: A total of 17 of 706 (2.41%) patients treated at our institution with TF [n=14] or TA [n=3] TAVR had chronic liver disease (mean age 77.65±9.06 years, 7 women, mean STS score 8.37, mean Charlson score 5.00, mean MELD score 11.35, Child-Turcotte-Pugh (CTP) Class A [n=11], B [n=6], C [n=0], biopsy proven liver disease [n=5]). Median follow-up was 466 days (range=12-1,403 days). The mean post-procedure length of hospital stay was 5.88±3.08 days. Procedural success was achieved in all cases. In-hospital mortality was 5.88% and 90-day mortality was 17.65%. Safety and efficacy endpoints as defined by the valve academic research consortium (VARC) were significant for one perioperative death from a proximate cardiac cause (post-operative day 14), one death after hospital discharge of unknown cause (post-operative day 12), two late deaths from non-cardiac causes (post-operative days 50 and 487, respectively), and one late death of unknown cause (post-operative day 1,005). There were no life-threatening or major bleeding complications. One patient had an MI, one had a transient ischemic attack, four had transient, Stage I, acute kidney injury and one had transient, Stage II, acute kidney injury. CONCLUSION: TF and TA TAVR are feasible methods for treating aortic stenosis in patients with chronic liver disease. In patients with mild to moderate chronic liver disease there are acceptable rates of early and late complications, however, outcomes in patients with advanced liver disease (MELD>20 or CTP class C) warrant further study.

The functional aortic annulus in the 3D era: focus on transcatheter aortic valve replacement for the perioperative echocardiographer.

The functional aortic annulus represents a sound clinical framework for understanding the components of the aortic root complex. Recent three-dimensional imaging analysis has demonstrated that the aortic annulus frequently is elliptical rather than circular. Comprehensive three-dimensional quantification of this aortic annular geometry by transesophageal echocardiography and/or multidetector computed tomography is essential to guide precise prosthesis sizing in transcatheter aortic valve replacement to minimize paravalvular leak for optimal clinical outcome. Furthermore, three-dimensional transesophageal echocardiography accurately can quantify additional parameters of the functional aortic annulus such as coronary height for complete sizing profiles for all valve types in transcatheter aortic valve replacement. Although it is maturing rapidly as a clinical imaging modality, its role in transcatheter aortic valve replacement is seen best as complementary to multidetector computed tomography in a multidisciplinary heart team model.

Aortic and mitral valve replacement versus transcatheter aortic valve replacement in propensity-matched patients.

BACKGROUND: Recent studies have suggested that transcatheter aortic valve replacement (TAVR) may have superior outcomes compared with aortic valve replacement (AVR) for high-risk patients with significant mitral regurgitation (MR). Considering significant MR is frequently addressed with a mitral valve repair or replacement (MVR) at the time of open aortic valve replacement, this study compares TAVR and AVR/MVR in propensity-matched pairs of patients with significant MR. METHODS: We evaluated all patients presenting with moderate or greater MR undergoing either TAVR or AVR/MVR at a single institution from 2002 to 2012. Patients who underwent other cardiac operations or had preoperative endocarditis were excluded. Of 306 patients in the AVR/MVR group and 147 patients in the TAVR group, propensity analysis matched 40 pairs of patients. Standard univariate, logistic regression, and propensity matching techniques were used. RESULTS: There was no significant difference between TAVR patients and AVR/MVR patients, respectively, in preoperative average age (76 ± 7.4 versus 78 ± 6.9 years, p = 0.68), ejection fraction (53 ± 15 versus 51 ± 17, p = 0.68), The Society of Thoracic Surgeons score (9.9 ± 3.1 versus 9.3 ± 3.4, p = 0.61), or 30-day mortality (7.5% versus 2.5%, p = 0.6). Postoperative MR was significantly improved for both TAVR and AVR/MVR, but AVR/MVR showed significantly greater improvement (-2.33 ± 1.23 versus -0.88 ± 0.79, p < 0.001). Among 30-day survivors, midterm survival was significantly better in the AVR/MVR group compared with the TAVR group (log rank p = 0.04). CONCLUSIONS: In a propensity-matched analysis of patients with significant MR, AVR/MVR and TAVR had equivalent perioperative outcomes, but AVR/MVR had more reduction in MR and may have superior midterm survival when compared with TAVR among 30-day survivors.

Factors associated with vascular complications in patients undergoing balloon-expandable transfemoral transcatheter aortic valve replacement via open versus percutaneous approaches.

BACKGROUND: Vascular complications after transfemoral transcatheter aortic valve replacement are common and associated with significant morbidity and mortality. Little is known about the effect of access approach on vascular complications. METHODS AND RESULTS: Between 2007 and 2013, 331 patients underwent transfemoral transcatheter aortic valve replacement via open surgical (OS) or fully percutaneous (PC) approaches. Patient data and clinical outcomes were collected. Valve Academic Research Consortium-defined vascular complications were noted. Multivariable analysis with propensity matching was performed, and vascular complications, mortality, and length of stay were assessed. One hundred twenty patients were treated with the OS approach and 211 patients via the PC approach. There were fewer major vascular complications (11% versus 20%; P=0.03) and shorter length of stay (7.5 versus 9.9 days; P=0.003) in the PC group when compared with those in the OS group. In multivariable analysis, vascular complications were more likely in women (odds ratio, 2.2; P=0.02) and with increasing differences between sheath outer diameter and minimal artery diameter (overall vascular complications: odds ratio, 1.4; P=0.02 and major vascular complications: odds ratio, 2.0; P<0.001). Propensity-matched analysis demonstrated no difference in vascular complications between the OS and the PC groups (22% versus 19%; P=0.73) but significantly reduced length of stay in the PC group (7.9 versus 10.0 days; P=0.04). CONCLUSIONS: Transfemoral transcatheter aortic valve replacement performed via the PC route is associated with similar risk of vascular complications and significantly lower postprocedural length of stay than the OS route. The degree of sheath oversizing with respect to iliofemoral minimal artery diameter and female sex are associated with vascular complications regardless of access approach.