Sex differences in outcomes of transcatheter edge-to-edge repair with MitraClip: A meta-analysis.

BACKGROUND: Transcatheter edge-to-edge repair (TEER) with MitraClip improves outcomes among select patients with moderate-to-severe and severe mitral regurgitation; however, data regarding sex-specific differences in the outcomes among patients undergoing TEER are limited. METHODS: An electronic search of the PubMed, Embase, Central, and Web of Science databases for studies comparing sex differences in outcomes among patients undergoing TEER was performed. Summary estimates were primarily conducted using a random-effects model. RESULTS: Eleven studies with a total of 24,905 patients (45.6% women) were included. Women were older and had a lower prevalence of comorbidities, including diabetes, chronic kidney disease, and coronary artery disease. There was no difference in procedural success (odds ratio [OR]: 0.75, 95% confidence interval [CI]: 0.55-1.05) and short-term mortality (i.e., up to 30 days) between women and men (OR: 1.16, 95% CI: 0.97-1.39). Women had a higher incidence of periprocedural bleeding and stroke (OR: 1.34, 95% CI: 1.15-1.56) and (OR: 1.57, 95% CI: 1.10-2.25), respectively. At a median follow-up of 12 months, there was no difference in mortality (OR: 0.98, 95% CI: 0.89-1.09) and heart failure hospitalizations (OR: 1.07, 95% CI: 0.68-1.67). An analysis of adjusted long-term mortality showed a lower incidence of mortality among women (hazards ratio: 0.77, 95% CI: 0.67-0.88). CONCLUSIONS: Despite a lower prevalence of baseline comorbidities, women undergoing TEER with MitraClip had higher unadjusted rates of periprocedural stroke and bleeding as compared with men. There was no difference in unadjusted procedural success, short-term or long-term mortality. However, women had lower adjusted mortality on long-term follow-up. Future high-quality studies assessing sex differences in outcomes after TEER are needed to confirm these findings.

Patient-specific preprocedural planning for tricuspid valve repair and replacement procedures.

PURPOSE OF REVIEW: Despite the prevalence of tricuspid valve regurgitation disorders, isolated interventions on tricuspid valves were previously infrequent due to high mortality rates and lack of advanced clinical imaging technology. Due to advancements in cardiovascular imaging and interventional technologies tricuspid valve repairs and replacement interventions became increasingly more attainable. RECENT FINDINGS: Noninvasive clinical imaging of the tricuspid valve can be challenging, providing anincomplete assessment of unique tricuspid anatomy. 3D printing technology represents an additional tool for more comprehensive preprocedural planning of tricuspid interventions and observation of tricuspid valve geometry. Patient-specific 3D printed replicas of tricuspid valve apparatus are especially useful in highly complicated cases, where physiological tricuspid replicas allow benchtop observation of individual patient's anatomy, device implantation in physiological tricuspid valves and interactions of devices with native tricuspid tissue, frequently leading to optimization or change in operational strategy. SUMMARY: Comprehensive use of clinical imaging including echocardiography, computed tomography, and cardiac magnetic resonance along with 3D printed modeling is key to successful tricuspid repair and replacements. Patient-specific 3D printed models of tricuspid anatomy can facilitate preprocedural planning, educate patients and clinicians, and improve device design, leading to the overall improvement of patients' outcomes and care.

Mitral regurgitation: a contemporary review of percutaneous mitral valve repair and role of periprocedural imaging.

PURPOSE OF REVIEW: This article aims to review recent landmark clinical trials that have resulted in a paradigm shift in the management of patients with mitral regurgitation. This article additionally highlights the instrumental role that structural heart disease (SHD) imaging plays in evaluation of mitral regurgitation and determining candidacy for transcatheter mitral valve repair (TMVr), in addition to the procedural guidance and detection of complications. RECENT FINDINGS: Edge-to-edge TMVr with the MitraClip device (Abbott Vascular, Santa Clara, California) was initially studied and subsequently approved by the US Food and Drug Administration (FDA) for treatment of primary mitral regurgitation in 2013. After the publication of a landmark clinical trial in 2018, the indications have been expanded and FDA has subsequently, in 2019, approved TMVr for patients with functional mitral regurgitation. This has been paralleled by advances in cardiac imaging with more emphasis on the role of SHD imagers as a part of the heart team. SUMMARY: TMVr has revolutionized the management of mitral regurgitation and relies heavily on SHD imaging to ensure optimal outcomes.

Role of 3-dimensional transesophageal echocardiography in guiding transcatheter mitral valve replacement.

BACKGROUND: Transcatheter mitral valve replacement technologies have been developed to treat a wide range of mitral valve pathologies including primary and secondary mitral regurgitation, mitral stenosis, in addition to degenerative bioprosthetic valves and failed annuloplasty rings. OBJECTIVE: Transesophageal echocardiography, particularly with use of 3-dimensional imaging is key in successfully guiding these interventions. In this review, we highlight the key role of 3D transesophageal echocardiography in guiding TMVR, including valve-in-native valve, valve-in-prosthetic valve, valve-in-prosthetic ring, and valve-in-mitral annular calcification interventions.

Effectiveness of NPs and PAs in managing diabetes and cardiovascular disease.

BACKGROUND: The effectiveness of cardiovascular disease (CVD) and diabetes care delivered by NPs and physician assistants (PAs), and resource use by these providers has not been studied. METHODS: We performed regression analyses of patients with diabetes or CVD with a primary care visit in 130 Veterans Affairs (VA) facilities to assess the association between provider type and effectiveness or resource use. RESULTS: The diabetes cohort consisted of 156,034 patients assigned to NPs and 54,590 assigned to PAs. Glycemic and BP control, statin use, number of primary or specialty care visits, lipid panels, and A1C results were comparable between groups. The CVD cohort consisted of 185,694 patients assigned to NPs and 66,217 assigned to PAs. BP control; use of beta-blockers, statins, or antiplatelets; primary or specialty care visits; lipid panels; and number of stress tests ordered were comparable between groups. CONCLUSION: Effectiveness of care and resource use among patients in both groups were comparable.

Bleeding complications of triple antithrombotic therapy after percutaneous coronary interventions.

BACKGROUND: 5% of patients undergoing coronary stenting have an indication for anticoagulation. The aim of our study was to determine the bleeding rates and complications in patients on triple oral antithrombotic therapy (TOAT) after coronary stenting. METHODS: We studied patients who underwent coronary stenting in our institution between 2003-2013 and were started on TOAT. Bleeding was the primary outcome. RESULTS: Totally, 999 patients were treated with TOAT with a median follow up of 127 days. All patients were treated with warfarin as an anticoagulant. 267 patients (26.7%) developed a total of 331 bleeding events. 100 patients had bleeding during the first 30 days of therapy. Major bleeding, minor bleeding, bleeding requiring medical attention, and minimal bleeding developed in 2.9%, 3.3%, 17.2%, and 3.3% of the patients respectively as their most significant bleeding event. Patients with anticoagulation initiated at time of stenting had a significantly higher bleeding rate compared to those already on chronic anticoagulation [adjusted HR (95% CI): 1.37 (1.03-1.79), P = 0.03]. The bleeding likelihood was significantly higher for patients with drug-eluted stents (DES) compared to bare-metal stents (BMS) [adjusted OR (95% CI): 1.52 (1.14 - 2.04), P < 0.05]. Patients with atrial fibrillation had an increased rate of bleeding after 6 month of initiation of TOAT with significantly worse outcomes. CONCLUSIONS: TOAT after coronary stenting is associated with high bleeding rates. Patients with AF had worse outcomes. Patients with newly initiated anticoagulation at time of stenting bleed significantly more than people already on chronic anticoagulation prior to stenting. © 2016 Wiley Periodicals, Inc.

Understanding Treatment Preferences for Patients with Tricuspid Regurgitation.

Background. Tricuspid regurgitation (TR) is a high-prevalence disease associated with poor quality of life and mortality. This quantitative patient preference study aims to identify TR patients' perspectives on risk-benefit tradeoffs. Methods. A discrete-choice experiment was developed to explore TR treatment risk-benefit tradeoffs. Attributes (levels) tested were treatment (procedure, medical management), reintervention risk (0%, 1%, 5%, 10%), medications over 2 y (none, reduce, same, increase), shortness of breath (none/mild, moderate, severe), and swelling (never, 3× per week, daily). A mixed logit regression model estimated preferences and calculated predicted probabilities. Relative attribute importance was calculated. Subgroup analyses were performed. Results. An online survey was completed by 150 TR patients. Shortness of breath was the most important attribute and accounted for 65.8% of treatment decision making. The average patients' predicted probability of preferring a "procedure-like" profile over a "medical management-like" profile was 99.7%. This decreased to 78.9% for a level change from severe to moderate in shortness of breath in the "medical management-like" profile. Subgroup analysis confirmed that patients older than 64 y had a stronger preference to avoid severe shortness of breath compared with younger patients (P < 0.02), as did severe or worse TR patients relative to moderate. New York Heart Association class I/II patients more strongly preferred to avoid procedural reintervention risk relative to class III/IV patients (P < 0.03). Conclusion. TR patients are willing to accept higher procedural reintervention risk if shortness of breath is alleviated. This risk tolerance is higher for older and more symptomatic patients. These results emphasize the appropriateness of developing TR therapies and the importance of addressing symptom burden. Highlights: This study provides quantitative patient preference data from clinically confirmed tricuspid regurgitation (TR) patients to understand their treatment preferences.Using a targeted literature search and patient, physician, and Food and Drug Administration feedback, a cross-sectional survey with a discrete-choice experiment that focused on 5 of the most important attributes to TR patients was developed and administered online.TR patients are willing to accept higher procedural reintervention risk if shortness of breath is alleviated, and this risk tolerance is higher for older and more symptomatic patients.

Physical and Computational Modeling for Transcatheter Structural Heart Interventions.

Structural heart disease interventions rely heavily on preprocedural planning and simulation to improve procedural outcomes and predict and prevent potential procedural complications. Modeling technologies, namely 3-dimensional (3D) printing and computational modeling, are nowadays increasingly used to predict the interaction between cardiac anatomy and implantable devices. Such models play a role in patient education, operator training, procedural simulation, and appropriate device selection. However, current modeling is often limited by the replication of a single static configuration within a dynamic cardiac cycle. Recognizing that health systems may face technical and economic limitations to the creation of "in-house" 3D-printed models, structural heart teams are pivoting to the use of computational software for modeling purposes.

Myocardial Blood Flow Reserve, Microvascular Coronary Health, and Myocardial Remodeling in Patients With Aortic Stenosis.

BACKGROUND: Coronary microvascular function and hemodynamics may play a role in coronary circulation and myocardial remodeling in patients with aortic stenosis (AS). We aimed to evaluate the relationship between myocardial blood flow and myocardial function in patients with AS, no AS, and aortic valve sclerosis. METHODS AND RESULTS: We included consecutive patients who had resting transthoracic echocardiography and clinically indicated positron emission tomography myocardial perfusion imaging to capture their left ventricular ejection fraction, global longitudinal strain (GLS), and myocardial flow reserve (MFR). The primary outcome was major adverse cardiovascular event (all-cause mortality, myocardial infarction, or late revascularization). There were 2778 patients (208 with aortic sclerosis, 39 with prosthetic aortic valve, 2406 with no AS, and 54, 49, and 22 with mild, moderate, and severe AS, respectively). Increasing AS severity was associated with impaired MFR (P<0.001) and GLS (P<0.001), even when perfusion was normal. Statistically significant associations were noted between MFR and GLS, MFR and left ventricular ejection fraction, and MFR and left ventricular ejection fraction reserve. After a median follow-up of 349 (interquartile range, 116-662) days, 4 (7.4%), 5 (10.2%), and 6 (27.3%) patients experienced a major adverse cardiovascular event in the mild, moderate, and severe AS groups, respectively. In a matched-control analysis, patients with mild-to-moderate AS had higher rates of impaired MFR (52.9% versus 39.9%; P=0.048) and major adverse cardiovascular event (11.8% versus 3.0%; P=0.002). CONCLUSIONS: Despite lack of ischemia, as severity of AS increased, MFR decreased and GLS worsened, reflecting worse coronary microvascular health and myocardial remodeling. Positron emission tomography-derived MFR showed a significant independent correlation with left ventricular ejection fraction and GLS. Patients with prosthetic aortic valve showed a high prevalence of impaired MFR.

Association of Secondary Mitral Regurgitation and Right Ventricular Dysfunction among Patients with Non-Ischemic Cardiomyopathy.

AIMS: The association between secondary mitral regurgitation (MR) and right ventricular (RV) dysfunction in heart failure patients with non-ischemic cardiomyopathy (NICM) is unclear. Hence, our objective was to study the association between secondary MR and the occurrence of RV dysfunction among patients with NICM using cardiac magnetic resonance (CMR). METHODS AND RESULTS: Patients with NICM were enrolled in a prospective observational registry between 2008-2019. CMR was used to quantify MR severity along with RV function. RV dysfunction was defined as RV ejection fraction <45%. The outcome of the study was a composite event of all-cause death, heart transplantation, or left ventricular assist device implantation at follow-up. In the study cohort of 241 patients, RV dysfunction (RVEF < 45%) was present in 148 (61%). In comparison to patients without RV dysfunction, those with RV dysfunction had higher median MR volume (23 ml [IQR 16-31ml] vs 18 ml [IQR 12-25 ml], P=0.002) and MR fraction (33% [IQR 25-43%] vs 22% [IQR 15-29%], P<0.001). Furthermore, secondary MR was independently associated with RV dysfunction: MR volume ≥ 24ml (OR 3.21, 95% CI 1.26-8.15, P= 0.01) and MR fraction≥ 30% (OR 5.46, 95% 2.23-13.35, P=0.002). Increasing RVEF (every 1% increase) was independently associated with lower risk of adverse events (HR 0.98, 95% 0.95, 1.00, P=0.047). CONCLUSIONS: In patients with NICM, the severity of secondary MR is associated with an increased prevalence of RV dysfunction. RV dysfunction is not only associated with the severity of LV dysfunction, but also with the severity of secondary MR.

Diagnostic Value of Aortic Valve Calcification Levels in the Assessment of Low-Gradient Aortic Stenosis.

BACKGROUND: In patients with low-gradient aortic stenosis (AS) and low transvalvular flow, dobutamine stress echocardiography (DSE) is recommended to determine AS severity, whereas the degree of aortic valve calcification (AVC) supposedly correlates with AS severity according to current European and American guidelines. OBJECTIVES: The purpose of this study was to assess the relationship between AVC and AS severity as determined using echocardiography and DSE in patients with aortic valve area <1 cm2 and peak aortic valve velocity <4.0 m/s. METHODS: All patients underwent DSE to determine AS severity and multislice computed tomography to quantify AVC. Receiver-operating characteristics curve analysis was used to assess the diagnostic value of AVC for AS severity grading as determined using echocardiography and DSE in men and women. RESULTS: A total of 214 patients were included. Median age was 78 years (25th-75th percentile: 71-84 years) and 25% were women. Left ventricular ejection fraction was reduced (<50%) in 197 (92.1%) patients. Severe AS was diagnosed in 106 patients (49.5%). Moderate AS was diagnosed in 108 patients (50.5%; in 77 based on resting transthoracic echocardiography, in 31 confirmed using DSE). AVC score was high (≥2,000 for men or ≥1,200 for women) in 47 (44.3%) patients with severe AS and in 47 (43.5%) patients with moderate AS. AVC sensitivity was 44.3%, specificity was 56.5%, and positive and negative predictive values for severe AS were 50.0% and 50.8%, respectively. Area under the receiver-operating characteristics curve was 0.508 for men and 0.524 for women. CONCLUSIONS: Multi-slice computed tomography-derived AVC scores showed poor discrimination between grades of AS severity using DSE and cannot replace DSE in the diagnostic work-up of low-gradient severe AS.

Tricuspid Regurgitation Related Mortality in United States, 1999-2019.

Tricuspid regurgitation (TR) is being increasingly recognized in patient population. We aimed to investigate the long-term mortality due to TR in the United States (US) and demographic disparities in TR-related mortality using "Multiple Cause of Death data" via the Centers for Disease Control and Prevention Wide-Ranging On-line Data for Epidemiologic Research datasets, 1999 to 2019. The results from present analysis suggest that TR related deaths in the US may have increased over the last 20 years. This trend may justify greater focus on timely diagnosis and management of TR.

Tough Crossing: A Challenging Case of Valve-in-Valve Transcatheter Tricuspid Valve Replacement.

Transcatheter tricuspid valve replacement is a feasible treatment alternative in high-risk patients with degenerated tricuspid prosthesis. Either transjugular or transfemoral approaches are feasible, with the latter being used more commonly. We describe a challenging case of valve-in-valve transcatheter tricuspid valve replacement where we used a long sheath positioned in the right ventricular outflow tract to deliver the transcatheter heart valve.

Cor Triatriatum Dexter: An Innocent Bystander.

Cor triatriatum dexter is a rare congenital heart defect with a varied clinical presentation ranging from asymptomatic to right heart failure. Accurate diagnosis is imperative as it may affect clinical decision making. We present a multimodality imaging assessment of cor triatriatum dexter in a 70-year-old woman with severe tricuspid regurgitation.

An Atrial Septal Ridge Diagnosed by Transesophageal Echocardiography.

A left atrial ridge is an anomaly of irregular fusion between the septum primum and septum secundum.1 Aberrant fusion of the septa results in thickened and fibrotic tissue along the region of the fossa ovalis that will occasionally protrude into the left atrium.2 The presence of a left atrial ridge has multiple clinical implications due to its close proximity to the fossa ovalis. The location of this uncommon incongruence may make transseptal catheter-based approaches more challenging, underscoring the importance of imaging guidance to determine the ideal transseptal puncture site. Figure 1 shows cardiac images of a 64-year-old female with a history of severe mitral regurgitation, atrial fibrillation, sick sinus syndrome status post pacemaker implantation, pulmonary hypertension, systemic lupus erythematosus, and chronic kidney disease. She was seen by the valve team and underwent a transesophageal echocardiogram (TEE) to determine candidacy for transcatheter edge-to-edge repair of the mitral valve. Two-dimensional biplane imaging of the interatrial septum (IAS) shows a linear structure on the left atrial side of the fossa ovalis. Three-dimensional imaging of the IAS revealed that the structure was consistent with an atrial septal ridge.

The Pandemic and Beyond: Innovation in Cardiovascular Training to Improve Quality of Education and Trainees' Well-being.

During the first 2 years of the coronavirus-19 pandemic, many changes and innovations occurred to overcome the challenges associated with the pandemic and improve cardiovascular training. This review highlights the literature on the pandemic response regarding cardiovascular fellowship education and identifies areas of need to ensure future opportunities for fellows to achieve competency and career advancement. Specifically, we describe the recent changes to the four cornerstones of cardiovascular training: core content education, procedural training, career development, and the well-being of trainees.

An Integrative, Multiparametric Approach to Mitral Regurgitation Evaluation: A Case-Based Illustration.

Echocardiography is the first-line modality for assessing mitral regurgitation (MR). In addition to evaluation of the MR jet characteristics, echocardiography can provide quantitative parameters of MR severity. This case series illustrates the importance of integrating multiple parameters in the evaluation of MR and the role of multimodality imaging. (Level of Difficulty: Advanced.).

Association of Twitter Metrics and Cardiology and Heart Surgery National Hospital Rankings.

Since 1990, the U.S. News and World Report (USNWR) has been publishing rankings of US adult and children's hospitals. The aim of this study was to analyze the association between hospital Twitter metrics and the 2020 USNWR hospital cardiology and heart surgery ranking. We collected data on the cardiology and heart surgery overall ranking score and expert opinion. Twitter metrics were obtained on October 20, 2020, and included time on Twitter, number of followers, accounts being followed, total tweets, reach score (difference between followers and followed), and annual tweet rate (total tweets divided by time on Twitter). The final cohort consisted of 463 hospitals (48 of which were top-ranking hospitals). A significant positive relation was observed with Twitter metrics and hospital ranking. On multivariable regression after adjusting for time on Twitter, the overall score was independently associated with annual tweet rate and reach score (ß=12.45% and ß=0.34% for each 1,000 tweets per year and 10,000 reach score accounts; P<.001). Similarly, expert opinion was independently associated with annual tweet rate and reach score (ß=0.025% and ß=0.002% for each 1000 tweets per year and 10,000 reach score accounts; P<.001). Our results emphasize how hospital leaders may leverage social media platforms as an important medium to disseminate accomplishments and increase their visibility and reputation, potentially translating to higher USNWR ranking.

Trends, Predictors, and Outcomes of Cardiovascular Complications Associated With Polycystic Ovary Syndrome During Delivery Hospitalizations: A National Inpatient Sample Analysis (2002-2019).

Background Women with polycystic ovary syndrome (PCOS) have an increased risk of pregnancy-associated complications. However, data on peripartum cardiovascular complications remain limited. Hence, we investigated trends, outcomes, and predictors of cardiovascular complications associated with PCOS diagnosis during delivery hospitalizations in the United States. Methods and Results We used data from the National Inpatient Sample (2002-2019). International Classification of Diseases, Ninth Revision (ICD-9), or International Classification of Diseases, Tenth Revision (ICD-10), codes were used to identify delivery hospitalizations and PCOS diagnosis. A total of 71 436 308 weighted hospitalizations for deliveries were identified, of which 0.3% were among women with PCOS (n=195 675). The prevalence of PCOS, and obesity among those with PCOS, increased during the study period. Women with PCOS were older (median, 31 versus 28 years; P<0.01) and had a higher prevalence of diabetes, obesity, and dyslipidemia. After adjustment for age, race and ethnicity, comorbidities, insurance, and income, PCOS remained an independent predictor of cardiovascular complications, including preeclampsia (adjusted odds ratio [OR], 1.56 [95% CI, 1.54-1.59]; P<0.01), eclampsia (adjusted OR, 1.58 [95% CI, 1.54-1.59]; P<0.01), peripartum cardiomyopathy (adjusted OR, 1.79 [95% CI, 1.49-2.13]; P<0.01), and heart failure (adjusted OR, 1.76 [95% CI, 1.27-2.45]; P<0.01), compared with no PCOS. Moreover, delivery hospitalizations among women with PCOS were associated with increased length (3 versus 2 days; P<0.01) and cost of hospitalization ($4901 versus $3616; P<0.01). Conclusions Women with PCOS had a higher risk of preeclampsia/eclampsia, peripartum cardiomyopathy, and heart failure during delivery hospitalizations. Moreover, delivery hospitalizations among women with PCOS diagnosis were associated with increased length and cost of hospitalization. This signifies the importance of prepregnancy consultation and optimization for cardiometabolic health to improve maternal and neonatal outcomes.

Clinical Impact of Tricuspid Regurgitation on Transcatheter Edge-to-Edge Mitral Valve Repair for Mitral Regurgitation.

OBJECTIVES: This study aimed to evaluate whether baseline tricuspid regurgitation (TR) impacted clinical outcomes after mitral valve transcatheter edge-to-edge repair (M-TEER) for severe secondary mitral regurgitation (MR). BACKGROUND: Baseline TR is common among patients undergoing M-TEER for secondary MR, although its impact on clinical outcomes is unclear. METHODS: The Cochrane Library, PubMed/MEDLINE, and Google Scholar were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines from January 1, 2011 through January 31, 2021. Randomized controlled trials and nonrandomized prospective studies that evaluated baseline TR by echocardiography before M-TEER for MR were included. The primary outcome was a composite of mortality and heart failure hospitalization (HFH) at 1-year. RESULTS: A total of 5 studies (n = 1395 patients) were included in the primary analysis. Concurrent moderate/severe TR was associated with a worse 1 year composite of all-cause mortality and HFH (OR: 2.13; 95% CI: 1.12-4.05; p = 0.02) after M-TEER for severe MR. In studies that reported TR grade pre- and post-M-TEER for severe MR, 32% of patients with moderate-to-severe baseline TR had a reduction in TR severity after the intervention. CONCLUSIONS: Baseline moderate-to-severe TR was associated with increased 1-year mortality and heart failure hospitalizations among patients undergoing M-TEER. Further randomized studies are needed to assess the interaction of TR among patients undergoing M-TEER.