Impact of the COVID-19 Pandemic on Global TAVR Activity: The COVID-TAVI Study.

BACKGROUND: The COVID-19 pandemic adversely affected health care systems. Patients in need of transcatheter aortic valve replacement (TAVR) are especially susceptible to treatment delays. OBJECTIVES: This study sought to evaluate the impact of the COVID-19 pandemic on global TAVR activity. METHODS: This international registry reported monthly TAVR case volume in participating institutions prior to and during the COVID-19 pandemic (January 2018 to December 2021). Hospital-level information on public vs private, urban vs rural, and TAVR volume was collected, as was country-level information on socioeconomic status, COVID-19 incidence, and governmental public health responses. RESULTS: We included 130 centers from 61 countries, including 65,980 TAVR procedures. The first and second pandemic waves were associated with a significant reduction of 15% (P < 0.001) and 7% (P < 0.001) in monthly TAVR case volume, respectively, compared with the prepandemic period. The third pandemic wave was not associated with reduced TAVR activity. A greater reduction in TAVR activity was observed in Africa (-52%; P = 0.001), Central-South America (-33%; P < 0.001), and Asia (-29%; P < 0.001). Private hospitals (P = 0.005), urban areas (P = 0.011), low-volume centers (P = 0.002), countries with lower development (P < 0.001) and economic status (P < 0.001), higher COVID-19 incidence (P < 0.001), and more stringent public health restrictions (P < 0.001) experienced a greater reduction in TAVR activity. CONCLUSIONS: TAVR procedural volume declined substantially during the first and second waves of the COVID-19 pandemic, especially in Africa, Central-South America, and Asia. National socioeconomic status, COVID-19 incidence, and public health responses were associated with treatment delays. This information should inform public health policy in case of future global health crises.

Predictors of cardiac resynchronization therapy response: the pivotal role of electrocardiogram.

Heart failure affects millions of patients all over the world, and its treatment is a major clinical challenge. Cardiac dyssynchrony is common among patients with advanced heart failure. Resynchronization therapy is a major advancement in heart failure management, but unfortunately not all patients respond to this therapy. Hence, many diagnostic tests have been used to predict the response and prognosis after cardiac resynchronization therapy. In this paper we summarize the usefulness of different diagnostic modalities with special emphasis on the role of surface electrocardiogram as a major predictor of response to cardiac resynchronization therapy.

Left main approach for retrieval of retained guidewire fragment.

Entrapment and detachment of guidewire fractures during percutaneous coronary intervention (PCI) are very rare, but can lead to life-threatening complications such as embolization, thrombus formation, and perforation. Surgical extraction of the remnant fragments is recommended if the percutaneous retrieval is not possible. We present a case of remnant guidewire into the left anterior descending artery (LAD) and aorta that led to acute coronary thrombosis following primary angioplasty. Surgical retrieval was possible only through a left main (LM) approach.

Transcatheter Mitral Valve-in-Valve Implantation in Pediatric Patients.

BACKGROUND: Transcatheter implantation of the Edwards Sapien 3 valve (Edwards Lifesciences, Irvine CA) within the bioprosthetic mitral valve (MV) is an established method of treatment in adults. However, it has not been well studied in the pediatric age group. METHODS: Transcatheter mitral valve-in-valve implantation was attempted in 4 symptomatic pediatric patients with a dysfunctional MV bioprosthesis implanted at an earlier stage due to severe MV stenosis or regurgitation. We reviewed our experience with MV implantation in this cohort. RESULTS: The mean age and weight of the patients at the time of the procedure were 11.4 years (range: 10-14 years) and 36 kg (range: 31-44 kg), respectively. The transmitral mean gradient dropped from a mean of 19.75 mm Hg (range: 15-22 mm Hg) to a mean of 1 mm Hg (range: 0-3 mm Hg) after the procedure. The mean fluoroscopy time was 55.25 minutes (range: 40-72 minutes), and the mean hospital length of stay was 4 days (range: 3-7 days). The patients' functional class improved from New York Heart Association class IV to class I during the follow-up period. CONCLUSIONS: Transcatheter mitral valve-in-valve implantation can be performed safely for dysfunctional bioprosthetic MVs in the pediatric age group with favorable early and midterm outcomes. This procedure offers a viable alternative in patients who have high surgical risk or are deemed unfit for conventional surgery. However, we still recommend a long-term study of this approach in a large cohort, multicentre study.

INTRODUCTION: L'implantation de la prothèse valvulaire Edwards Sapien 3 (Edwards Lifesciences, Irvine, CA) par cathéter dans la bioprothèse valvulaire mitrale (VM) est une méthode de traitement établie chez les adultes. Toutefois, cette méthode n'a pas fait l'objet d'études approfondies auprès d'enfants. MÉTHODES: Une tentative d'implantation valvulaire mitrale de type valve-in-valve par cathéter a été réalisée chez quatre enfants symptomatiques qui avaient une bioprothèse VM dysfonctionnelle implantée antérieurement en raison d'une sténose VM ou d'une régurgitation grave. Nous avons passé en revue notre expérience d'implantation VM auprès de cette cohorte. RÉSULTATS: L'âge et le poids moyens des patients au moment de l'intervention étaient respectivement de 11,4 ans (étendue : 10-14 ans) et de 36 kg (étendue : 31-44 kg). La moyenne du gradient moyen transmitral a baissé. Elle est passée de 19,75 mmHg (étendue : 15-22 mmHg) à 1 mmHg (étendue : 0-3 mmHg) après l'intervention. La durée moyenne de la fluoroscopie était de 55,25 minutes (étendue : 40-72 minutes), et la durée moyenne du séjour à l'hôpital était de quatre jours (fourchette : 3-7 jours). La classification fonctionnelle des patients selon la New York Heart Association a montré une baisse. Les patients sont passés de la classe IV à la classe I durant la période de suivi. CONCLUSIONS: L'implantation valvulaire mitrale de type valve-in-valve par cathéter peut être pratiquée de façon sûre chez les enfants porteurs d'une bioprothèse VM dysfonctionnelle dont les issues à court ou à moyen terme sont favorables. Cette intervention est une alternative viable pour ces patients dont le risque lié à l'intervention chirurgicale est élevé ou considérés inaptes à subir une intervention chirurgicale traditionnelle. Toutefois, nous recommandons encore une étude à long terme sur cette approche, voire une vaste étude multicentrique de cohorte.

Monitoring metformin in cardiac patients exposed to contrast media using ultra-high-performance liquid chromatography tandem mass-spectrometry.

BACKGROUND: There is no evidence that the use of contrast media (CM) in diabetic patients with serum creatinine <130 µmole/L leads to metformin accumulation and subsequent lactic acidosis. Therefore, the objective of this investigation was to monitor cardiac patients for the effects of CM on their metformin plasma concentration and serum creatinine clearance (ClCr). METHODS: Metformin plasma concentrations were measured by a new, fully validated specific, precise, and accurate ultra-high-performance liquid chromatography tandem mass-spectrometric assay. The detection was performed using positive electrospray ionization in the multiple reaction monitoring mode. Fifty patients with serum creatinine levels <130 µmole/L were monitored for the effect of CM exposure on metformin concentration and ClCr. Pharmacokinetic parameters were calculated in 8 of these patients, and metformin accumulation was monitored in 10 patients before and after their exposure to CM. RESULTS: Linear response (r ≥ 0.998) was observed over the range of 5-2000 ng/mL of metformin, with the lower limit of quantification of 2.3 ng/mL. The intraday and interday precision (relative standard deviation) values were <13%, and the accuracy (relative error) was <-10% for metformin concentrations. The assay was sensitive to follow the pharmacokinetics of metformin in humans during a dosing interval after an oral dose at steady state. Metformin pharmacokinetic parameters were estimated in 8 patients exposed to CM. The mean C(max) of 1.9 ± 0.6 mg/L was attained at 4.1 ± 1.9 hours. There was no evidence of any drug accumulation or altered elimination due to the exposure to CM in the current population. ClCr showed no significant difference (P > 0.05) before (92.8 ± 11.3 mL/min) and after 48 hours (90.5 ± 10.5 mL/min) of exposure to CM. CONCLUSIONS: Our data suggest that the recommendation to withhold metformin in diabetic patients during CM exposure could be revised to withholding the drug only in patients with moderate to severe renal dysfunction.

The change in mitral regurgitation severity after trans-catheter aortic valve implantation.

BACKGROUND: Mitral regurgitation (MR) is a frequent finding in patients with aortic stenosis (AS). The objective of this study is to assess the change in MR severity following transcatheter aortic valve implantation (TAVI). METHODS: MR changes were assessed by comparing transthoracic echocardiography before and after the procedure. RESULTS: The prosthetic aortic valve was successfully implanted in 65 patients. The number of patients with pre-procedure MR was reduced from 58 (85.3%) to 43 (63.2%) (p < 0.001). Vena contracta width was decreased from 0.47 ± 0.28 to 0.25 ± 0.21, (p = 0.043). About 59.4% (19/32) of those who had moderate to severe MR and 85.7% (12/14) of those with severe MR experienced a significant improvement in MR after the procedure (p < 0.001). Improvement in MR was independent of prosthetic valve type with 54.2% in CoreValve and 43.9% in Edwards SAPIEN, p = 0.424; valve sizes were 25.8 ± 1.9 in those who improved vs. 25.0 ± 1.9 mm in those who did not improve, p = 0.105; femoral approach was 51.2% and apical approach was 41.7%, p = 0.457; MR etiology was 48.1% in organic and 48.6% in functional, p = 0.968; and operative risk was 50.0% in EuroScore >20 and 48.6% in EuroScore <20, p = 0.356. CONCLUSIONS: TAVI is associated with a significant improvement in MR, especially in severe types. The lack of influence of MR improvement by the etiology of MR, the type of valve implanted, and the operative risk need to be confirmed in a larger multi-center study.

Management of retained intervention guide-wire: a literature review.

Percutaneous coronary angioplasty is increasingly employed in the treatment of patients with complex coronary artery disease. Different steerable guide wires used to open occluded vessel and facilitate balloon and stent deployment. However, the guide-wire itself is not without hazard: it may perforate or dissect the vessel, but fracture or entrapment is uncommon. Its management depends on the clinical situation of the patient, as well as the position and length of the remnant. In this review we discuss the angioplasty guide-wire fracture and entrapment risk factors, potential risks and management.

Significant increases in monocyte counts and serum creatine kinase in acute myocardial infarction versus general infections.

BACKGROUND: Biomarkers specificity is an important factor for their reliable utilization. Known markers for acute myocardial infarction (AMI), including creatine kinase (CK), C-reactive protein (CRP), and blood cell counts are thought to be altered in other pathologic conditions, such as infections. AIM: To compare the level of these biomarkers in AMI patients and infected controls with respect to normal subjects. MATERIALS AND METHODS: We recruited 15 AMI patients, 15 patients with bacterial infections (infected control group) and 35 normal subjects. Peripheral blood samples were obtained for blood cell counts and biochemical analyses. RESULTS: Only monocytes were significantly increased in AMI patients (0.793×10(9)/L) than normal controls (0.497×10(9)/L). Infected controls showed a significant increase in total white blood cell (11.50×10(9)/L versus 6.149×10(9)/L) and neutrophil (9.360 versus 3.223×10(9)/L) counts and a significant decrease in red blood cell (3.750 versus 5.105×10(12)/L) counts as compared with normal controls. Serum CK was significantly increased in AMI patients (313.20±94.84 U/L) and decreased in infected controls (48.40±10.35 U/L) as compared with normal controls (100.82±8.86 U/L). The levels of CRP were significantly higher in infected controls (136.93±34.83 mg/L) and nonsignificantly higher in AMI patients (38.53±12.76 mg/L) than normal controls (3.48±0.59 mg/L). Monocytes were significantly correlated with both CK and CRP; however, there was no correlation between CK and CRP. CONCLUSION: Differential trends of monocytes and CK in AMI and infective controls point toward their possible application in prognosis of AMI patients.

Allergic reaction to abciximab with atypical manifestations.

Abciximab (ReoPro, Eli Lilly and Company, Indianapolis, Indiana) is an intravenous agent that had been approved for treatment of acute coronary syndrome undergoing coronary interventions. It is a chimeric monoclonal antibody fragment that binds to the glycoprotein IIb/IIIa receptor with a potential for the development of an immune response to variable portions within the antigen binding site following its administration. We describe a 58-year-old man who developed sudden headache, short of breath, choking and restlessness after receiving Abciximab for coronary intervention. Discontinuation of abciximab and administration of intravenous fluids, steroid and antihistamines led to improvement of his symptoms gradually.

The clinical significance of cardiac troponins in medical practice.

Troponins are regulatory proteins that form the cornerstone of muscle contraction. The amino acid sequences of cardiac troponins differentiate them from that of skeletal muscles, allowing for the development of monoclonal antibody-based assay of troponin I (TnI) and troponin T (TnT). Along with the patient history, physical examination and electrocardiography, the measurement of highly sensitive and specific cardiac troponin has supplanted the former gold standard biomarker (creatine kinase-MB) to detect myocardial damage and estimate the prognosis of patients with ischemic heart disease. The current guidelines for the diagnosis of non-ST segment elevation myocardial infarction are largely based on an elevated troponin level. The implementation of these new guidelines in clinical practice has led to a substantial increase in the frequency of myocardial infarction diagnosis. Automated assays using cardiac-specific monoclonal antibodies to cardiac TnI and TnT are commercially available. They play a major role in the evaluation of myocardial injury and prediction of cardiovascular outcome in cardiac and non-cardiac causes. In this review we discuss the clinical applications of cardiac troponins and the interpretation of elevated levels in the context of various clinical settings.

Surgical treatment of functional mitral regurgitation in dilated cardiomyopathy.

Functional mitral regurgitation is a significant complication of end-stage cardiomyopathy. Dysfunction of one or more components of the mitral valve apparatus occurs in 39-74% and affects almost all heart failure patients. Survival is decreased in subjects with more than mild mitral regurgitation irrespective of the aetiology of heart failure. The goal of treating functional mitral regurgitation is to slow or reverse ventricular remodelling, improve symptoms and functional class, decrease the frequency of hospitalization for congestive heart failure, slow progression to advanced heart failure (time to transplant) and improve survival. This article reviews the role of mitral valve surgery in patients with heart failure and dilated cardiomyopathy.

Libman-Sacks endocarditis with an unusual presentation.

Systemic lupus erythematosus is relatively common medical disorder with female predominance. This disorder can affect any organ system. Cardiac involvement is variable which can include pericardium, myocardium and endocardium. The endocardial involvement commonly affects mitral and aortic valves. This report discusses lupus endocarditis in young man with atypical presentation.

Stress-induced cardiomyopathy (Tako-Tsubo) in a premenopausal woman: A case report from Saudi Arabia.

Tako-Tsubo cardiomyopathy (TTC) is a nonischemic cardiomyopathy characterized by reversible left ventricular dysfunction that is seen predominantly in postmenopausal women (>80%). The syndrome has symptoms that are similar to acute myocardial infarction, such as electrocardiogram changes (ST-segment elevation and subsequent giant T wave inversion) and abnormal cardiac enzymes. The clinical prognosis is usually benign. This article reports the first case of a TTC in a premenopausal Saudi woman. Early diagnosis of TTC excludes the use of stents, thrombolytics, and long-term coronary heart disease medications.