Characteristics and outcomes of patients with normal left atrial pressure undergoing transcatheter mitral valve repair.

OBJECTIVE: A subset of patients at the time of transcatheter mitral valve repair (TMVR) will have normal left atrial pressure (LAP) (<13 mm Hg) despite having severe mitral regurgitation (MR). The goal of this study was to determine clinical characteristics and outcomes in patients with normal LAP undergoing TMVR. METHODS: A single-centre retrospective cohort of consecutive patients who underwent transcatheter edge-to-edge mitral valve clip and continuous LAP monitoring between 5/1/2014 and 5/1/2018 was analysed. One-year mortality was compared by Kaplan-Meier survival curves. Multivariable analysis was performed to identify predictors of normal LAP and 1 year mortality. RESULTS: Of the 204 patients undergoing TMVR, 65% were men and the mean age was 81. Of these patients, 31 (15%) had normal LAP (mean LAP 10.5 mm Hg, mean V wave 16.5 mm Hg) and 173 had elevated LAP (mean LAP 19 mm Hg, mean V wave 32.5 mm Hg). The prevalence of severe MR was not different between groups, although the normal LAP group had significantly lower effective regurgitant orifice area and regurgitant volume. Other notable baseline characteristics including prior cardiac surgery, atrial fibrillation, hypertension, diabetes, congestive heart failure, body mass index, mechanism of MR and ejection fraction were similar between groups. However, there was an increased prevalence of chronic lung disease (CLD) (45.2% vs 17.3%, p<0.001) in the normal LAP group. On multivariate analysis, the only significant predictor of normal LAP was the presence of CLD (OR 4.79 (1.83-12.36), p=0.001) and 1-year mortality was significantly higher in the normal LAP group (32.3% vs 12.7%, p=0.006). After adjustment for comorbidities, normal LAP was no longer a predictor of 1-year mortality (RR 1.62 (0.64-4.06), p=0.32); however, CLD (RR 3.44 (1.37-8.67), p=0.01) remained a statistically significant predictor. CONCLUSION: Normal LAP at the time of TMVR is associated with a higher incidence of CLD which independently predicts increased 1-year mortality. In patients with CLD and apparently severe MR, measurement of LAP may help identify those with lower likelihood of benefit from TMVR.

Utility of cardiac computed tomography scanning in the diagnosis and pre-operative evaluation of patients with infective endocarditis.

Transesophageal echocardiography (TEE) is the gold standard imaging study used in the diagnosis of infective endocarditis (IE). Computed tomography angiography (CTA) has undergone rapid advancement as a cardiac imaging technique and has previously shown promise in small non-randomized studies for evaluation of IE. We hypothesized that cardiac CTA would perform similarly to TEE in the detection of endocarditic lesions and that there would be no difference in clinical outcomes whether the coronary arteries were evaluated by CTA or invasive coronary angiography (ICA). 255 adults who underwent surgery for IE at the Mayo Clinic Rochester between January 1, 2006 and June 1, 2014 were identified retrospectively. 251 patients underwent TEE and 34 patients underwent cardiac CTA. TEE had statistically higher detection of vegetations (95.6 vs. 70.0%, p < 0.0001) and leaflet perforations (81.3 vs. 42.9%, p = 0.02) as compared to cardiac CTA. For detection of abscess/pseudoaneurysm TEE had a similar sensitivity to cardiac CTA (90.5 vs. 78.4%, p = 0.21). There was no significant difference in peri-operative outcomes whether coronary arteries were evaluated by CTA or ICA. The greatest advantage of cardiac CT in the setting of IE is its ability to couple the detection of complex cardiac anatomic abnormalities with coronary artery delineation, serving two important components of the diagnostic evaluation, particularly among patients who will require surgical intervention due to IE complications. Cardiac CTA may be considered as an alternate coronary artery imaging modality in IE patients with low to intermediate risk of disease but meet guideline recommendations for coronary artery imaging.

Clinical, Radiographic, and Microbiologic Features of Infective Endocarditis in Patients With Hypertrophic Cardiomyopathy.

Infective endocarditis (IE) is an infection of the inner lining of the heart with high morbidity and mortality despite medical and surgical advancements in recent decades. Hypertrophic cardiomyopathy (HC) is one of several medical conditions that have been linked to an increased risk of IE, but there is a paucity of data on this association. We therefore sought to define the clinical phenotype of IE in patients with HC at a single tertiary care center. A retrospective cohort of 30 adult patients with HC diagnosed with IE between January 1, 2006 and December 31, 2016 at Mayo Clinic Rochester were identified. Similar rates of aortic (n = 14) and mitral (n = 16) valve involvement by IE were noted (47% vs 53%). This finding persisted even in patients with left-ventricular outflow tract obstruction and systolic anterior motion of the mitral valve. Symptomatic embolic complications occurred in 10 cases (33%). Surgical intervention was performed in 11 cases (37%). One-year mortality was remarkably low at 7%. In conclusion, in the largest single-center cohort of IE complicating HC, there were similar rates of both mitral and aortic valve involvement regardless of the presence of left ventricular outflow tract obstruction, which is contrary to a long-standing tenet regarding the association of HC and IE. Moreover, no "high risk" IE subset was identified based on HC-related parameters.

Postoperative dyspnoea.

CLINICAL INTRODUCTION: A man in his 50s presented with abscessed aortic valve methicillin-sensitive Staphylococcus aureus endocarditis, received intravenous antibiotics and underwent bioprosthetic aortic valve replacement with removal of all infected tissues. He returned 18 days later with severe dyspnoea, subjective fever and bilateral lower extremity oedema. Physical examination revealed tachypnoea and tachycardia without fever, prominent neck CV waves visible at 90°, left parasternal heave, 3/6 holosystolic murmur across the precordium, lung rales and severe peripheral oedema. C reactive protein was 211 mg/L (normal <8 mg/L). Blood cultures were obtained. ECG showed sinus tachycardia and right axis deviation. Transthoracic echocardiogram (TTE) parasternal zoomed short-axis systolic frame (figure 1A, B), apical four-chamber systolic frame (figure 1C) and subcostal continuous wave (CW) Doppler (figure 1D), are shown. QUESTION: Given the clinical presentation and TTE findings, what is the diagnosis?Severe tricuspid regurgitation due to extension of endocarditisAortic valve obstruction resulting in severe pulmonary hypertensionAcquired Gerbode defectAortic valve dehiscence with severe paraprosthetic regurgitation.