Percutaneous versus surgical cut-down access in transfemoral transcatheter aortic valve replacement: A meta-analysis.

BACKGROUND: The transfemoral (TF) approach has become the preferred approach for transcatheter aortic valve replacement (TAVR) because of its low risk profile. However, the relative safety of the percutaneous approach (PC) compared to surgical cut-down (SC) remains unclear. Our aim was to compare the outcomes between PC versus SC access in patients undergoing TF-TAVR using a meta-analysis. METHODS: We conducted a systematic electronic database search for studies reporting major and minor vascular complications (VC), major and minor bleeding, and perioperative all-cause mortality, in PC versus SC TF-TAVR cases. Complications were reported based on the Valve Academic Research Consortium criteria. A random-effects model was used to calculate odds ratios and 95% confidence intervals. RESULTS: Eight observational cohort studies and one randomized control trial (2513 patients in PC and 1767 patients in SC) were included in the analysis. Major and minor VC, as well as bleeding complications, were comparable between the two approaches. The need for surgical intervention for VC was comparable between PC and SC. There was no difference in perioperative all-cause mortality. CONCLUSIONS: PC and SC have similar safety profiles and outcomes when used appropriately in selected patients.

Impact of transcatheter aortic valve implantation on left atrial appendage flow velocities.

PURPOSE: Left atrial appendage (LAA) flow velocity has not been extensively studied in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to assess the impact of TAVI on LAA flow velocity. METHODS: Medical records of consecutive TAVI recipients were reviewed retrospectively. Patients with persistent atrial fibrillation were excluded. LAA velocities were measured before and after TAVI by transesophageal echocardiography. RESULTS: Sixty-one patients were included. Mean LAA emptying (EV) and filling (FV) flow velocity before TAVI were 33 ± 16 cm/s and 31 ± 14 cm/s, respectively. They increased to 37 ± 20 (p = 0.0036) and 33 ± 13 cm/s (p = 0.047) after TAVI in the whole population sample, but not in patients with normal flow AS. In low-flow, low-gradient (LFLG) AS patients, EV and FV increased from 36 ± 22 to 47 ± 30 cm/s (p < 0.01), and from 29 ± 12 to 40 ± 15 cm/s (p < 0.01), respectively, after TAVI. There was no difference between normal flow and LFLG AS patients in the number of patients who achieved EV ≥ 40 cm/s post-TAVI (35% versus 47%, p = 0.54, respectively). CONCLUSIONS: LAA EV and FV were low prior to TAVI and increased significantly after TAVI only in patients with LFLG AS. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:375-382, 2016.

Iatrogenic Ventricular Septal Defect Following Transcatheter Aortic Valve Replacement: A Systematic Review.

BACKGROUND: Ventricular septal defects (VSD) are rarely reported as a complication following transcatheter aortic valve replacement (TAVR). We sought to characterise the patients, clinical management, and outcomes regarding this rare phenomenon. METHODS: Relevant articles were identified by a systematic search of MEDLINE and EMBASE databases from January, 2002 to September, 2015. RESULTS: A total of 18 case reports, including 20 patients, were identified. The median age was 83 years and six were male. Twelve were performed by trans-femoral approach. Pre-dilation was performed in 12 patients and post-dilation in four. Balloon expandable valves were used in the majority (85%) of cases. The clinical presentation varied from asymptomatic to progressive heart failure. The timing of the diagnosis also varied significantly from immediately post valve implantation to one year afterwards. There were two cases of Gerbode-type defect while the rest were inter-ventricular defects. The location was mostly membranous or perimembranous (79%) and adjacent to the valve landing zone. A total of seven interventions (one open surgery and six percutaneous closure) were performed. Four patients died during the same hospital admission. Sixteen survived past discharge (range 12 days to two years). CONCLUSIONS: Ventricular septal defects post-TAVR were seen more with balloon expandable valves and with pre-dilation or post-dilation. Percutaneous treatment of the VSD was preferred over open cardiac surgery given the high surgical risk in this patient population. Some, but not all, patients survived TAVR and VSD and had a good prognosis for both patient groups with or without VSD closure.

Meta-Analysis Comparing Patent Foramen Ovale Closure Versus Medical Therapy to Prevent Recurrent Cryptogenic Stroke.

New evidence suggests that closure of a patent foramen ovale (PFO) plus medical therapy (MT; antiplatelet or anticoagulation) is superior to MT alone to prevent recurrent cryptogenic stroke. We performed a meta-analysis of randomized controlled trials that compared PFO closure plus MT with MT alone in patients with cryptogenic stroke. The efficacy end points were recurrent stroke, transient ischemia attack, and death. The safety end points were major bleeding and newly detected atrial fibrillation. Trials were pooled using random effects and fixed effects models. A trial sequential analysis was performed to assess if the current evidence is sufficient. Risk ratios (RR) were calculated for pooled estimates of risk. Five randomized controlled trials (3,440 patients) were included. Mean follow-up was 4.1 years. PFO closure reduced the risk of recurrent stroke by 58% (RR 0.42, 95% CI 0.20 to 0.91, p = 0.03). The number needed to treat was 38. The cumulative Z-line crossed the trial sequential boundary, suggesting there is adequate evidence to conclude that PFO closure reduces the risk of recurrent stroke by 60%. PFO closure did not reduce the risk of transient ischemia attack (RR 0.78, 95% CI 0.53 to 1.15, p = 0.21), mortality (RR 0.74, 95% CI 0.35 to 1.60, p = 0.45), or major bleeding (RR 0.96, 95% CI 0.42 to 2.20, p = 0.93); it did increase the risk of atrial fibrillation (RR 4.69, 95% CI 2.17 to 10.12, p <0.0001).

Clinical End Points of Transcatheter Aortic Valve Implantation Compared With Surgical Aortic Valve Replacement in Patients <65 Years of Age (From the National Inpatient Sample Database).

It is unknown if transcatheter aortic valve implantation (TAVI) is a safe alternative to surgical aortic valve replacement (SAVR) in patients <65 years old. Data from the National Inpatient Sample database were utilized. Patients from 2011 to 2015, ages 18 to 64 years old (inclusive) who underwent TAVI and SAVR were included. Patients who underwent SAVR and who also received a concomitant nonaortic valve surgery were excluded. A propensity score analysis was used. A total of 18,970 (528 TAVI and 18,442 SAVR) patients were identified. Patients who underwent TAVI were older (57 ± 7 vs 54 ± 10 years old, p <0.001) with more frequent co-morbidities. Overall in-hospital mortality was similar between TAVI and SAVR (odds ratio [OR] = 0.52, p = 0.12). Postprocedure stroke (OR = 0.50, p = 0.24), acute kidney injury (OR = 0.98, p = 0.89), acute myocardial infarction (OR = 0.48, p = 0.08), and vascular complication requiring surgery (OR = 0.20, p = 0.11) were similar between patients who underwent TAVI and SAVR. Bleeding requiring transfusion (OR = 0.32, p <0.01) was less frequent in patients who underwent TAVI, but new pacemakers (OR = 1.7, p = 0.02) were more frequent in these patients. Patients who underwent TAVI had shorter hospital stays (7.9 vs 10.0 days, p <0.001) and were more likely to be discharged to home. Cost between TAVI and SAVR was similar ($49,014 vs $42,907, respectively, p = 0.82). In the <65 years old patient population, TAVI also conferred similar overall in-hospital mortality compared with patients who underwent SAVR. TAVI resulted in fewer major complications, shorter hospital stay, and more frequent discharge to home, but higher rates of pacemaker implantation compared with SAVR. Therefore, TAVI appears to be a safe alternative to SAVR in patients <65 years old.

Paradoxical low-flow aortic stenosis is defined by increased ventricular hydraulic load and reduced longitudinal strain.

AIMS: Patients with paradoxical low-flow severe aortic stenosis (PLF-AS) reportedly have higher left ventricular hydraulic load and more systolic strain dysfunction than patients with normal-flow aortic stenosis. This study investigates the relationship of systolic loading and strain to PLF-AS to further define its pathophysiology. METHODS: One hundred and twenty patients (age 79 ±â€Š12 years, 37% men) with an indexed aortic valve area (AVAi) of 0.6 cm/m or less and an ejection fraction of 50% or higher were divided into two groups based on indexed stroke volume (SVi): PLF-AS, SVi ≤ 35 ml/m, N = 46; normal-flow aortic stenosis, SVi > 35 ml/m, N = 74). Valvular and arterial load were assessed using multiple measurements, and strain was assessed using speckle-tracking echocardiography. RESULTS: Patients with PLF-AS were found to have more valvular load (lower AVAi, P = 0.028; lower energy loss coefficient, P = 0.001), more arterial load [decreased arterial compliance and increased systemic vascular resistance (SVR), both P < 0.001] and more total hydraulic load [increased valvuloarterial impedance (Zva), P < 0.001]. Transvalvular gradients and arterial pressures were similar. Longitudinal strain was lower in PLF-AS (P < 0.001), but circumferential and rotation strains were similar. On adjusted regression, AVAi, SVR and longitudinal strain were associated with PLF-AS [odds ratio (OR) = 1.34, P = 0.043; OR = 1.31, P = 0.004; OR = 1.34, P = 0.011, respectively]. When SVR and AVAi were replaced with Zva, longitudinal strain and Zva (OR = 1.38, P = 0.015; OR = 1.33, P < 0.001 for both, respectively) were associated with PLF-AS. CONCLUSION: Increased hydraulic load, from more severe valvular stenosis and increased vascular resistance, and longitudinal strain impairment are associated with PLF-AS and their interplay is likely fundamental to its pathophysiology.

Circumferential strain acquired by CMR early after acute myocardial infarction adds incremental predictive value to late gadolinium enhancement imaging to predict late myocardial remodeling and subsequent risk of sudden cardiac death.

PURPOSE: Late adverse myocardial remodeling after acute myocardial infarction (AMI) is strongly associated with sudden cardiac death (SCD). Cardiac magnetic resonance (CMR) performed early after AMI can predict late remodeling and SCD risk with moderate accuracy. This study assessed the ability of CMR-measured circumferential strain (CS) to add incremental predictive information to late gadolinium enhancement (LGE). METHODS: Patients with an AMI and LVEF < 50% were screened for inclusion. A total of 27 patients, totaling 432 myocardial segments, prospectively underwent CMR 7 ± 5 days after percutaneous coronary intervention (PCI). LGE, microvascular obstruction (MVO), and myocardial CS were measured for each segment. The primary endpoint was late segmental adverse remodeling defined as segmental wall motion score (WMS) > 1 measured by echocardiography 3 months after PCI. RESULTS: A total of 141 segments experienced the primary endpoint at 3 months. The mean LGE volume was higher in these segments, but LGE was also present in many segments with normal WMS (40 ± 28 versus 20 ± 26%, p < 0.01). Segments that met the primary endpoint also showed greater impairment of CS. Segments with both LGE > 17% and impaired CS >- 7.2% on CMR were more likely to experience late adverse remodeling (73%) as compared to segments with neither (9%, p < 0.001) or one abnormal parameter (36%, p < 0.001). CS >- 7.2% also added incremental accuracy to LGE > 17% for predicting late adverse remodeling (AUC 0.81 from 0.70, p < 0.001). CONCLUSIONS: When performed early after AMI, LGE is a moderate predictor of late remodeling and CS is a powerful predictor of late myocardial remodeling. When combined, they can predict late remodeling, a surrogate of SCD, with high accuracy.

The Impact of Race on the Prognosis of Preclinical Diastolic Dysfunction: A Large Multiracial Urban Population Study.

BACKGROUND: This study was performed to assess the impact of race on the incidence of heart failure and survival in patients with preclinical diastolic dysfunction. METHODS: All adults during a 5-year period with grade 1 diastolic dysfunction on echocardiogram, left ventricular ejection fraction ≥ 50%, and no diagnosis of heart failure were included in this study. Clinical endpoints were new diagnosis of heart failure (International Classification of Diseases-Ninth Revision code 428.0) and all-cause mortality. A total of 7878 patients: 20.8% non-Hispanic White, 35.8% non-Hispanic Black, and 31.0% Hispanic individuals (mean age was 68 ± 12 years, 37% men) were included in the study. Non-Hispanic Whites were older, more frequently male, and had a higher mean socioeconomic status and more antecedent myocardial infarction. RESULTS: Non-Hispanic Blacks and Hispanics had more hypertension, diabetes, renal disease, and cerebrovascular disease. After a median follow-up time of 6 years, 1356 patients developed heart failure and 2078 patients died. The 10-year cumulative probabilities of heart failure and all-cause mortality were 23.9% and 32.6%, respectively. Time to incident heart failure was similar among the 3 racial groups. However, non-Hispanic Blacks (hazard ratio 0.80, P = .002) and Hispanics (hazard ratio 0.67, P < .001) experienced lower mortality compared with non-Hispanic Whites, which was confirmed on a propensity-scored sensitivity analysis. CONCLUSIONS: Time to heart failure was similar among the 3 racial groups, however, non-Hispanic Whites experienced worse survival compared with non-Hispanic Blacks and Hispanics, despite their higher burden of risk factors. The reasons for worse survival in the non-Hispanic white population need to be further explored.

Spontaneous Echocardiographic Contrast in the Left Atrium During Transcatheter Aortic Valve Replacement is Associated With Worse Outcomes.

OBJECTIVES: Patients undergoing transcatheter aortic valve replacement (TAVR) often have spontaneous echocardiographic contrast (SEC) observed in the left atrium (LA). Mid-term prognosis of patients with SEC following TAVR is not well studied. We assessed the impact of SEC on outcomes after TAVR. METHODS: Medical records of 93 consecutive patients who underwent TAVR at a single center were reviewed retrospectively. The primary endpoint was defined as the composite of a cardioembolic event, death from any cause, and admission for decompensated heart failure within 3 months of TAVR. RESULTS: After excluding 3 patients who had procedural complications, 90 patients were included in the study. The mean age was 81 ± 8 years old and 50% were male. There were 12 patients with SEC in the LA (group 1) and 78 patients without SEC in the LA (group 2) during the TAVR procedure. Atrial fibrillation was more common in group 1 (50% vs 13%, respectively; P=.01) and diabetes was more common in group 2 (17% vs 53%, respectively; P=.03). The primary endpoint occurred in 22 patients (24%) and occurred more in group 1 (58% vs 19%, respectively; P<.01). On regression analysis, after adjusting for sex and STS score, SEC had a hazard ratio (HR) of 5.02 (95% confidence interval [CI], 1.96-12.9; P<.001) and STS ≥15 had an HR of 6.37 (95% CI, 2.02-20.1; P=.01). On survival analysis, group 1 had lower event-free survival compared with group 2 (log-rank P=.01). CONCLUSION: SEC during TAVR procedure is a negative prognostic marker for death, cardioembolic events, or admission for decompensated heart failure in the first 3 months post procedure.

Transcatheter aortic valve replacement versus surgical aortic valve replacement in patients with previous coronary artery bypass surgery: A systematic review and meta-analysis.

BACKGROUND: Patients with severe aortic stenosis (AS) and previous coronary artery bypass graft (CABG) surgery have increased risk for aortic valve replacement. Whether surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) offers better outcomes in this population is unclear. We aimed to assess outcomes of TAVR and SAVR in patients with previous CABG. METHODS: A systematic literature search of Medline, EMBASE and Cochrane library was conducted. Studies that reported clinical outcomes (perioperative or mid-term all-cause-mortality, cardiovascular mortality, pacemaker implantation, hospital duration and stroke) were included. Random-effect modeling was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Five cohort studies including a total of 872 patients (423 in TAVR, 449 in SAVR) were analyzed. STS scores were comparable between the two groups. No difference in all-cause-mortality, cardiovascular mortality and stroke at 30days, 1year and total follow-up period was seen between the two groups. TAVR patients had higher pacemaker implantation rates (OR 3.41, 95% CI 1.66-6.38, p<0.001, I(2)=21%) and shorter hospital stay (-2.63days, 95% CI -5.20 to -0.04, p=0.05, I(2)=43%). CONCLUSIONS: Patients with previous CABG who underwent TAVR had similar perioperative and long-term survival while experiencing more pacemaker implantations and shorter hospital stay compared to those who had SAVR making TAVR a safe and efficacious alternative to SAVR.

Sapien 3 versus Sapien XT prosthetic valves in transcatheter aortic valve implantation: A meta-analysis.

OBJECTIVES: The S3 prosthetic valve was introduced to overcome several issues with its predecessor, the SXT, in transcatheter aortic valve implantation (TAVI), however, the clinical outcomes of this new model are not clearly defined. We performed a meta-analysis to compare the outcomes in Sapien 3 (S3) and Sapien XT (SXT) recipients. METHODS: A literature search through PUBMED and EMBASE was conducted. Articles that included at least one of the clinical outcomes of interest were included in the meta-analysis: moderate to severe paravalvular regurgitation (PVR), permanent pacemaker implantation (PPI), major vascular complications (MVC), cerebrovascular events (stroke and transient ischemic attack) (CVE), failure rate of device implantation, life-threatening, disabling or major bleeding, need for post-dilation and early all-cause-mortality. RESULTS: A total of 9 observational cohort studies were included. S3 was implanted in 945 and SXT in 1553 patients. S3 was associated with a lower incidence of moderate to severe PVR (1.6% vs 6.9%, p<0.0001), lower MVC (5.1% vs 8.9%, p=0.01) and less serious bleeding (8.1% vs 15.2%, p=0.003) compared to the SXT. Device deployment failure rate was lower in the S3 (1.2% vs 5.9%, p=0.004) and the S3 required less post-dilation (16.9% vs 26.9%, p=0.05). Rates of CVE, perioperative mortality and PPI were similar between the two valves. CONCLUSIONS: Implantation of the S3 prosthetic valve results in lower rates of moderate to severe PVR, MVC, post-dilation and serious bleeding however it does not improve on the SXT in terms of CVE, PPI and early mortality.

Increased apical rotation in severe aortic stenosis is associated with reduced survival: a speckle-tracking study.

BACKGROUND: Patients with severe aortic stenosis (AS) are known to have increased left ventricular apical rotation (ApRot) during systole, but its clinical relevance is unknown. The aim of this study was to assess the association of ApRot with patient symptoms and total mortality. METHODS: A retrospective analysis was performed on 82 patients (mean age, 77 ± 14 years; 40% men) with newly diagnosed severe AS with indexed aortic valve areas ≤ 0.6 cm(2)/m(2) and left ventricular ejection fractions ≥ 50%. Sixty-three percent of patients were symptomatic. ApRot was calculated using speckle-tracking echocardiography. Patients were divided into two groups on the basis of ApRot: high ApRot (>4.0°, n = 41) and low ApRot (≤4.0°, n = 41). RESULTS: There were 33 deaths and 30 aortic valve replacement procedures after 33 ± 17 months of follow-up. Patients in the high-ApRot group had smaller indexed aortic valve areas (P = .021) and increased valvuloarterial impedance (P = .014). There was no difference in overall symptoms, but the low-ApRot group experienced more syncope (P = .020). Patients in the high-ApRot group had reduced survival with medical therapy (log-rank P = .018) after aortic valve replacement (log-rank P = .039) and overall (log-rank P = .009). Asymptomatic patients with low ApRot had the best survival, while asymptomatic patients with high ApRot had similar survival to that of symptomatic patients (log-rank P = .008). On adjusted Cox regression, ApRot ≥ 6.0° was independently associated with death (hazard ratio, 3.06; P = .003). On receiver operating characteristic curve analysis, ApRot added incremental prognostic value to indexed aortic valve area, symptom status, and aortic valve replacement status. CONCLUSION: Increased ApRot is independently associated with poor survival and may represent a compensatory mechanism to preserve cardiac output against severe obstruction to flow and high systolic load.

Does the transapical approach impair early recovery of systolic strain following transcatheter aortic valve replacement?

BACKGROUND: In transcatheter aortic valve replacement (TAVR) the trans-apical approach (TA) is associated with apical myocardial injury but it is unknown if this injury impacts myocardial function. This study was performed to assess the impact of TA on apical longitudinal strain (ALS) and global longitudinal strain (GLS) after TAVR. METHODS: 44 consecutive patients (age 81 ± 7 years, 48% male) underwent TAVR via trans-femoral (TF) (n=27) or TA (n=17) approach. Speckle-tracking analysis of left ventricular longitudinal strain was performed on images from peri-procedure transesophageal echocardiograms immediately before and after valve implantation. The primary endpoint was a GLS improvement of at least 25% post-TAVR. RESULTS: GLS improved significantly above baseline after valve implantation in both TF (p<0.001) and TA (p=0.027) groups. The absolute magnitudes of ALS and GLS improvement were similar between TF and TA patients (ALS: p=0.282; GLS: p=0.248). Peak ALS and GLS achieved post-TAVR were similar between TF and TA patients (ALS: p=0.933; GLS: p=0.365). 47% of patients achieved a GLS improvement of >25%; 16 of which improved their GLS to <-15%. The severity of pre-TAVR GLS impairment was a strong independent predictor of GLS improvement (OR=1.61, p=0.003). A pre-TAVR GLS ≥-13.7% was 82% sensitive and 82% specific for TAVR to confer a GLS improvement >25%. CONCLUSION: Equal improvement in myocardial strain was observed in the TF and TA patients. Pre-TAVR GLS impairment was an independent predictor of post-TAVR GLS recovery, highlighting how it is the patient's baseline GLS dysfunction, not the method of approach, that dictates post-TAVR functional recovery.

Physiological adaptation of the left ventricle during the second and third trimesters of a healthy pregnancy: a speckle tracking echocardiography study.

BACKGROUND: During a healthy pregnancy women experience cardiovascular and hemodynamic changes and normal ranges of left ventricular (LV) function on two-dimensional speckle tracking echocardiography (STE) are not well defined. The aim of this study was to describe the cardiovascular changes that occur during the second and third trimesters of a healthy pregnancy using STE. METHODS: Pregnant subjects were enrolled retrospectively if they underwent a transthoracic echocardiography (TTE) between 2011-2014. Subjects with abnormal TTE findings, hypertension, diabetes, preeclampsia, prior cardiac surgery, poor imaging quality or in the 1st trimester were excluded. A total of 74 pregnant subjects were categorized into the 2nd or 3rd trimesters. Twenty-one healthy age-matched females were selected as a control group. RESULTS: The heart undergoes extensive remodeling during pregnancy with increased LV septal thickness, posterior wall thickness, cavity size and mass (p=0.045, p=0.002, p<0.001, p=0.018, respectively). However, myocardial mechanical function measured by: global longitudinal strain, radial strain, circumferential strain, systolic and diastolic global longitudinal strain rate (GLSR), global radial strain rate (GRSR) and global circumferential strain rate, remains preserved. Only time to peak strain rate corrected for heart rate for diastolic GRSR and diastolic GLSR were significantly increased in the third trimester (p=0.016 for both). CONCLUSION: Despite extensive heart remodeling, many STE derived parameters of LV function in healthy pregnant women remain unchanged and valid for women in the 2nd and 3rd trimester. Future studies investigating early detection of pregnancy related heart disease can refer to these parameters as reference ranges.

Non-invasive assessment of low risk acute chest pain in the emergency department: A comparative meta-analysis of prospective studies.

BACKGROUND: The aim of this meta-analysis was to compare the diagnostic accuracy of cardiac computed tomographic angiography (CCTA), stress echocardiography (SE) and radionuclide single photon emission computed tomography (SPECT) for the assessment of chest pain in emergency department (ED) setting. METHODS: A systematic review of Medline, Cochrane and Embase was undertaken for prospective clinical studies assessing the diagnostic efficacy of CCTA, SE or SPECT, as compared to intracoronary angiography (ICA) or the later presence of major adverse clinical outcomes (MACE), in patients presenting to the ED with chest pain. Standard approach and bivariate analysis were performed. RESULTS: Thirty-seven studies (15 CCTA, 9 SE, 13 SPECT) comprising a total of 7800 patients fulfilled inclusion criteria. The respective weighted mean sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and total diagnostic accuracy for CCTA were: 95%, 99%, 84%, 100% and 99%, for SE were: 84%, 94%, 73%, 96% and 96%, and for SPECT were: 85%, 86%, 57%, 95% and 88%. There was no significant difference between modalities in terms of NPV. Bivariate analysis revealed that CCTA had statistically greater sensitivity, specificity, PPV and overall diagnostic accuracy when compared to SE and SPECT. CONCLUSIONS: All three modalities, when employed by an experienced clinician, are highly accurate. Each has its own strengths and limitations making each well suited for different patient groups. CCTA has higher accuracy than SE and SPECT, but it has many drawbacks, most importantly its lack of physiologic data.

Outcomes in patients with various forms of aortic stenosis including those with low-flow low-gradient normal and low ejection fraction.

Low-flow low-gradient aortic stenosis with normal ejection fraction (LFLGNEF AS) is a newly characterized poorly understood entity within the AS spectrum. Whether LFLGNEF AS has a worse prognosis than typical AS remains controversial. We retrospectively identified 4,546 individual patients with any type of AS on echocardiogram from 2003 through 2013 and categorized them into 5 cohorts: (1) mild AS, (2) moderate AS, (3) severe AS, (4) LFLGNEF AS (ejection fraction≥55%), and (5) low-flow low-gradient low ejection fraction AS (LFLGLEF AS; ejection fraction<55%). Survival analysis was used to compare outcomes of LFLGNEF AS with those of the other cohorts. AS was classified as mild in 591 patients, moderate in 2,358, severe in 500, LFLGNEF in 776, and LFLGLEF in 318. The study group had a mean age of 80.5 years, 61% were women, and the patients were followed for 2.26±1.16 years. Among subjects managed without valve replacement, total mortality for the LFLGNEF AS group was lower compared with that in both the severe AS and the LFLGLEF AS groups (p=0.007 and p<0.001, respectively). The prognosis for LFLGNEF AS was worse, however, compared with those with mild and moderate AS (p<0.001, both). In conclusion, no survival differences were found among AS types among those who received valve replacement. The survival rate in LFLGNEF is better than that in severe AS or LFLGLEF but is worse than that in mild or moderate AS. Valve replacement seems reasonable to pursue in select patients.

The Contegra conduit: Late outcomes in right ventricular outflow tract reconstruction.

OBJECTIVES: To report the clinical outcomes (early death, late death, and rate of reintervention) and performance of the Contegra conduit as a right ventricle outflow tract implant and to determine the risk factors for early reintervention. METHODS: Forty-nine Contegra conduits were implanted between January 2002 and June 2009. Data collection was retrospective. The mean age and follow-up duration of Contegra recipients was 3.5 ± 4.6 years and 4.2 ± 2.0 years, respectively. RESULTS: There were three deaths (two early, one late), giving a survival rate of 93.9%. The rate of conduit-related reintervention was 19.6% and was most often due to distal conduit stenosis. Age at implantation of <3 months, receipt of a conduit of 12-16 mm diameter, and a diagnosis of truncus arteriosus were each significant contributors to the rate of reintervention. CONCLUSION: The Contegra is a cost-effective and readily available solution. However, there is a limited range of larger calibers, which means that the homograft conduit (>22 mm) remains the first choice of implant in older children. The rates of reintervention are significantly higher with a diagnosis of truncus arteriosus, age at implantation of <3 months, and implantation of conduits sized 12-16 mm.

Kingella kingae endocarditis: A rare case of mitral valve perforation.

Kingella kingae, a HACEK (Haemophilus parainfluenzae, Aggregatibacter actinomycetemcomitans, Aggregatibacter aphrophilus, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae) organism, is a common resident of the upper airway in children; it has been associated with endocarditis in children with pre-existing heart conditions. This case report describes K. kingae endocarditis leading to valvular damage in a previously healthy 18-month-old child. Our patient developed a K. kingae bacteremia that was later complicated by meningitis, septic embolic stroke, and endocarditis of the mitral valve, leading to perforation of the posterolateral leaflet. The patient was initially treated conservatively with cefotaxime but, subsequently, required a mitral valve repair with a pericardial patch and annuloplasty. This report draws attention to the need for clinicians to be aware of the potentially serious complications of K. kingae infection in young children. If K. kingae infection is suspected then therapy should be initiated promptly with a ß-lactam, followed by early echocardiographic assessment. This case also highlights the lack of specific guidelines available for K. kingae endocarditis.