The impact of moderate aortic stenosis in acute myocardial infarction: A multicenter retrospective study.

BACKGROUND: Aortic stenosis (AS) is associated with myocardial ischemia through different mechanisms and may impair coronary arterial flow. However, data on the impact of moderate AS in patients with acute myocardial infarction (MI) is limited. AIMS: This study aimed to investigate the impact of moderate AS in patients presenting with acute myocardial infarction (MI). METHODS: We conducted a retrospective analysis of all patients who presented with acute MI to all Mayo Clinic hospitals, using the Enterprise Mayo PCI Database from 2005 to 2016. Patients were stratified into two groups: moderate AS and mild/no AS. The primary outcome was all cause mortality. RESULTS: The moderate AS group included 183 (13.3%) patients, and the mild/no AS group included 1190 (86.7%) patients. During hospitalization, there was no difference between both groups in mortality. Patients with moderate AS had higher in-hospital congestive heart failure (CHF) (8.2% vs. 4.4%, p = 0.025) compared with mild/no AS patients. At 1-year follow-up, patients with moderate AS had higher mortality (23.9% vs. 8.1%, p < 0.001) and higher CHF hospitalization (8.3% vs. 3.7%, p = 0.028). In multivariate analysis, moderate AS was associated with higher mortality at 1-year (odds ratio 2.4, 95% confidence interval [1.4-4.1], p = 0.002). In subgroup analyses, moderate AS increased all-cause mortality in STEMI and NSTEMI patients. CONCLUSION: The presence of moderate AS in acute MI patients was associated with worse clinical outcomes during hospitalization and at 1-year follow-up. These unfavorable outcomes highlight the need for a close follow-up of these patients and for timely therapeutic strategies to best manage these coexisting conditions.

A randomized controlled trial of simulation training in teaching coronary angiographic views.

INTRODUCTION: Simulation technology has an established role in teaching technical skills to cardiology fellows, but its impact on teaching trainees to interpret coronary angiographic (CA) images has not been systematically studied. The aim of this randomized controlled study was to test whether structured simulation training, in addition to traditional methods would improve CA image interpretation skills in a heterogeneous group of medical trainees. METHODS: We prospectively randomized a convenience sample of 105 subjects comprising of medical students (N = 20), residents (N = 68) and fellows (N = 17) from the University of Arizona. Subjects were randomized in a stratified fashion into a simulation training group which received simulation training in addition to didactic teaching (n = 53) and a control training group which received didactic teaching alone (n = 52). The change in pre and post-test score (delta score) was analyzed by a two-way ANOVA for education status and training arm. RESULTS: Subjects improved in their post-test scores with a mean change of 4.6 ± 4.0 points. Subjects in the simulation training arm had a higher delta score compared to control (5.4 ± 4.2 versus 3.8 ± 3.7, p = 0.04), with greatest impact for residents (6.6 ± 4.0 versus 3.5 ± 3.4) with a p = 0.02 for interaction of training arm and education status. CONCLUSIONS: Simulation training complements traditional methods to improve CA interpretation skill, with greatest impact on residents. This highlights the importance of incorporating high-fidelity simulation training early in cardiovascular fellowship curricula.

Role of lipoprotein(a) concentrations in bioprosthetic aortic valve degeneration.

OBJECTIVES: Lipoprotein(a) (Lp(a)) is associated with an increased incidence of native aortic stenosis, which shares similar pathological mechanisms with bioprosthetic aortic valve (bAV) degeneration. However, evidence regarding the role of Lp(a) concentrations in bAV degeneration is lacking. This study aims to evaluate the association between Lp(a) concentrations and bAV degeneration. METHODS: In this retrospective multicentre study, patients who underwent a bAV replacement between 1 January 2010 and 31 December 2020 and had a Lp(a) measurement were included. Echocardiography follow-up was performed to determine the presence of bioprosthetic valve degeneration, which was defined as an increase >10 mm Hg in mean gradient from baseline with concomitant decrease in effective orifice area and Doppler Velocity Index, or new moderate/severe prosthetic regurgitation. Levels of Lp(a) were compared between patients with and without degeneration and Cox regression analysis was performed to investigate the association between Lp(a) levels and bioprosthetic valve degeneration. RESULTS: In total, 210 cases were included (mean age 74.1±9.4 years, 72.4% males). Median time between baseline and follow-up echocardiography was 4.4 (IQR 3.7) years. Bioprostheses degeneration was observed in 33 (15.7%) patients at follow-up. Median serum levels of Lp(a) were significantly higher in patients affected by degeneration versus non-affected cases: 50.0 (IQR 72.0) vs 15.6 (IQR 48.6) mg/dL, p=0.002. In the regression analysis, high Lp(a) levels (≥30 mg/dL) were associated with degeneration both in a univariable analysis (HR 3.6, 95% CI 1.7 to 7.6, p=0.001) and multivariable analysis adjusted by other risk factors for bioprostheses degeneration (HR 4.4, 95% CI 1.9 to 10.4, p=0.001). CONCLUSIONS: High serum Lp(a) is associated with bAV degeneration. Prospective studies are needed to confirm these findings and to investigate whether lowering Lp(a) levels could slow bioprostheses degradation.

Lipoprotein(a) and Long-term In-stent Restenosis after Percutaneous Coronary Intervention.

AIM: Lipoprotein(a) [Lp(a)] has demonstrated its association with atherosclerosis and myocardial infarction. However, its role in the development of in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) is not clearly established. The aim of this study is to investigate the association between Lp(a) and ISR. METHODS: A retrospective study of adult patients who underwent successful PCI between January 2006 and December 2017 at the three Mayo Clinic sites and had a preprocedural Lp(a) measurement was conducted. Patients were divided into two groups according to the serum Lp(a) concentration (high Lp(a) ≥50 mg/dl and low Lp(a) <50 mg/dl). Univariable and multivariable analyses were performed to compare risk of ISR between patients with high Lp(a) versus those with low Lp(a). RESULTS: A total of 1209 patients were included, with mean age 65.9 ±11.7 years and 71.8% were male. Median follow-up after baseline PCI was 8.8 (IQR 7.4) years. Restenosis was observed in 162 (13.4%) patients. Median serum levels of Lp(a) were significantly higher in patients affected by ISR versus non-affected cases: 27 (IQR 73.8) vs. 20 (IQR 57.5) mg/dL, p=0.008. The rate of ISR was significantly higher among patients with high Lp(a) versus patients with low Lp(a) values (17.0% vs 11.6%, p=0.010). High Lp(a) values were independently associated with ISR events (HR 1.67, 95%CI 1.18 to 2.37, p=0.004), and this association was more prominent after the first year following the PCI. CONCLUSION: Lipoprotein(a) is an independent predictor for long-term in-stent restenosis and should be considered in the evaluation of patients undergoing PCI.

The role of Lp(a) in the development of in-stent restenosis is not clearly established. In this study including 1209 patients who underwent successful percutaneous coronary intervention and had a preprocedural Lp(a) measurement between 2006 and 2017, the rates of restenosis were significantly higher among patients with high Lp(a) versus patients with low Lp(a) values and high Lp(a) concentrations were independently associated with restenosis events. Lp(a) should be considered as a risk factor for long term in-stent restenosis in the evaluation of patients undergoing percutaneous coronary intervention and assessed as a potential therapeutic target for reducing residual cardiovascular risk in this population.

Identifying the Causes of Unexplained Dyspnea at High Altitude Using Normobaric Hypoxia with Echocardiography.

Exposure to high altitude results in hypobaric hypoxia, leading to physiological changes in the cardiovascular system that may result in limiting symptoms, including dyspnea, fatigue, and exercise intolerance. However, it is still unclear why some patients are more susceptible to high-altitude symptoms than others. Hypoxic simulation testing (HST) simulates changes in physiology that occur at a specific altitude by asking the patients to breathe a mixture of gases with decreased oxygen content. This study aimed to determine whether the use of transthoracic echocardiography (TTE) during HST can detect the rise in right-sided pressures and the impact of hypoxia on right ventricle (RV) hemodynamics and right to left shunts, thus revealing the underlying causes of high-altitude signs and symptoms. A retrospective study was performed including consecutive patients with unexplained dyspnea at high altitude. HSTs were performed by administrating reduced FiO2 to simulate altitude levels specific to patients' history. Echocardiography images were obtained at baseline and during hypoxia. The study included 27 patients, with a mean age of 65 years, 14 patients (51.9%) were female. RV systolic pressure increased at peak hypoxia, while RV systolic function declined as shown by a significant decrease in the tricuspid annular plane systolic excursion (TAPSE), the maximum velocity achieved by the lateral tricuspid annulus during systole (S' wave), and the RV free wall longitudinal strain. Additionally, right-to-left shunt was present in 19 (70.4%) patients as identified by bubble contrast injections. Among these, the severity of the shunt increased at peak hypoxia in eight cases (42.1%), and the shunt was only evident during hypoxia in seven patients (36.8%). In conclusion, the use of TTE during HST provides valuable information by revealing the presence of symptomatic, sustained shunts and confirming the decline in RV hemodynamics, thus potentially explaining dyspnea at high altitude. Further studies are needed to establish the optimal clinical role of this physiologic method.

Impact of Social Vulnerability and Demographics on Ischemic Heart Disease Mortality in the United States.

Background: Cardiovascular disease is a leading cause of morbidity and mortality, largely dominated by ischemic heart diseases (IHDs). Social determinants of health, including geographic, psychosocial, and socioeconomic factors, influence the development of IHD. Objectives: This study aimed to evaluate yearly trends and disparities in IHD mortality and to assess the impact of social vulnerability. Methods: We performed cross-sectional analyses using United States county-level mortality data and social vulnerability index (SVI) obtained from the Centers for Disease Control and Prevention databases. Age-adjusted mortality rates (AAMRs) per 100,000 population were compared between aggregated U.S. county groups, stratified by demographic information and SVI quartiles. Log-linear regression models were used to identify mortality trends from 1999 to 2020, with inflection points determined through the Monte-Carlo permutation test. Results: We identified a total of 9,108,644 deaths related to IHD between 1999 and 2020. Overall AAMR decreased from 194.6 in 1999 to 91.8 in 2020. Males (AAMR: 161.51) and Black (AAMR: 141.49) populations exhibited higher AAMR compared to females (AAMR: 93.16) and White (AAMR: 123.34) populations, respectively. Disproportionate AAMRs were observed among nonmetropolitan (AAMR: 136.17) and Northeastern (AAMR: 132.96) regions. Counties with a higher SVI experienced a greater AAMR, with a cumulative excess of 20.91 deaths per 100,000 person-years associated with increased social vulnerability. Conclusions: Despite a decline in IHD mortality from 1999 to 2020, disparities persisted among racial, gender, and geographic subgroups. A higher SVI was linked to increased IHD mortality. Policy interventions should prioritize integrating the SVI into health care delivery systems to effectively address these disparities.

Meta-Analysis on Transcarotid Versus Transfemoral and Other Alternate Accesses for Transcatheter Aortic Valve Implantation.

Transcarotid access has emerged as the preferred access site for transcatheter aortic valve implantation (TAVI) in patients with prohibitive iliofemoral anatomy. This study aimed to compare outcomes with transcarotid with those of other accesses in patients who underwent TAVI. Cochrane, EMBASE, and MEDLINE databases were searched for all published studies that compared outcomes with transcarotid with those of other accesses (transfemoral, transaxillary/subclavian, transaortic, and transapical) in patients who underwent TAVI. The primary outcome was all-cause mortality. Secondary outcomes included major bleeding, major vascular complications, stroke, myocardial infarction, permanent pacemaker implantation, and peri-aortic valve insufficiency. We included 22 observational studies with a total of 11,896 patients. Outcomes were reported during hospitalization and at 1-month follow-up. The transcarotid approach had higher mortality at 1 month (3.7% vs 2.6%, p = 0.02) but lower major vascular complications during hospitalization (1.5% vs 3.4%, p = 0.04) than did transfemoral access. The transcarotid approach had lower major vascular complications (2% vs 2.3%, p = 0.04) than did the transaxillary/subclavian but higher major bleeding (5.3% vs 2.6%, p = 0.03). The transaortic approach was associated with higher in-hospital (11.7% vs 1.9%, p = 0.02) and 1-month mortality (14.4% vs 3.9%, p = 0.007) rates than was transcarotid access. The transcarotid approach numerically reduced mortality and the risk of major vascular complications and major bleeding compared with the transapical approach; however, this did not reach statistical significance. The transcarotid approach did not increase the risk of stroke compared with transfemoral or the other alternative accesses. In conclusion, the transcarotid or transaxillary/subclavian approach had associated comparable outcomes that were better than those of the transapical and transaortic approaches. There was no difference in stroke risk between transcarotid access and other accesses.

Transcatheter Aortic Valve Replacement Prognostication with Augmented Mean Arterial Pressure.

BACKGROUND: Post-transcatheter aortic valve replacement (TAVR) patient outcome is an important research topic. To accurately assess post-TAVR mortality, we examined a family of new echo parameters (augmented systolic blood pressure (AugSBP) and arterial mean pressure (AugMAP)) derived from blood pressure and aortic valve gradients. METHODS: Patients in the Mayo Clinic National Cardiovascular Diseases Registry-TAVR database who underwent TAVR between 1 January 2012 and 30 June 2017 were identified to retrieve baseline clinical, echocardiographic and mortality data. AugSBP, AugMAP and valvulo-arterial impedance (Zva) (Zva) were evaluated using Cox regression. Receiver operating characteristic curve analysis and the c-index were used to assess the model performance against the Society of Thoracic Surgeons (STS) risk score. RESULTS: The final cohort contained 974 patients with a mean age of 81.4 ± 8.3 years old, and 56.6% were male. The mean STS risk score was 8.2 ± 5.2. The median follow-up duration was 354 days, and the one-year all-cause mortality rate was 14.2%. Both univariate and multivariate Cox regression showed that AugSBP and AugMAP parameters were independent predictors for intermediate-term post-TAVR mortality (all p < 0.0001). AugMAP1 < 102.5 mmHg was associated with a 3-fold-increased risk of all-cause mortality 1-year post-TAVR (hazard ratio 3.0, 95%confidence interval 2.0-4.5, p < 0.0001). A univariate model of AugMAP1 surpassed the STS score model in predicting intermediate-term post-TAVR mortality (area under the curve: 0.700 vs. 0.587, p = 0.005; c-index: 0.681 vs. 0.585, p = 0.001). CONCLUSIONS: Augmented mean arterial pressure provides clinicians with a simple but effective approach to quickly identify patients at risk and potentially improve post-TAVR prognosis.

Prediction of permanent pacemaker implantation after transcatheter aortic valve replacement: The role of machine learning.

BACKGROUND: Atrioventricular block requiring permanent pacemaker (PPM) implantation is an important complication of transcatheter aortic valve replacement (TAVR). Application of machine learning could potentially be used to predict pre-procedural risk for PPM. AIM: To apply machine learning to be used to predict pre-procedural risk for PPM. METHODS: A retrospective study of 1200 patients who underwent TAVR (January 2014-December 2017) was performed. 964 patients without prior PPM were included for a 30-d analysis and 657 patients without PPM requirement through 30 d were included for a 1-year analysis. After the exclusion of variables with near-zero variance or ≥ 50% missing data, 167 variables were included in the random forest gradient boosting algorithm (GBM) optimized using 5-fold cross-validations repeated 10 times. The receiver operator curve (ROC) for the GBM model and PPM risk score models were calculated to predict the risk of PPM at 30 d and 1 year. RESULTS: Of 964 patients included in the 30-d analysis without prior PPM, 19.6% required PPM post-TAVR. The mean age of patients was 80.9 ± 8.7 years. 42.1 % were female. Of 657 patients included in the 1-year analysis, the mean age of the patients was 80.7 ± 8.2. Of those, 42.6% of patients were female and 26.7% required PPM at 1-year post-TAVR. The area under ROC to predict 30-d and 1-year risk of PPM for the GBM model (0.66 and 0.72) was superior to that of the PPM risk score (0.55 and 0.54) with a P value < 0.001. CONCLUSION: The GBM model has good discrimination and calibration in identifying patients at high risk of PPM post-TAVR.

Using Augmented Mean Arterial Pressure to Identify High Mortality Risk Patients With Moderate Aortic Stenosis.

OBJECTIVE: To study the usefulness of a novel echocardiographic marker, augmented mean arterial pressure (AugMAP = [(mean aortic valve gradient + systolic blood pressure) + (2 × diastolic blood pressure)] / 3), in identifying high-risk patients with moderate aortic stenosis (AS). PATIENTS AND METHODS: Adults with moderate AS (aortic valve area, 1.0-1.5 cm2) at Mayo Clinic sites from January 1, 2010, through December 31, 2020, were identified. Baseline demographic, echocardiographic, and all-cause mortality data were retrieved. Patients were grouped into higher and lower AugMAP groups using a cutoff value of 80 mm Hg for analysis. Kaplan-Meier and Cox regression models were used to assess the performance of AugMAP. RESULTS: A total of 4563 patients with moderate AS were included (mean ± SD age, 73.7±12.5 years; 60.5% men). Median follow-up was 2.5 years; 36.0% of patients died. The mean ± SD left ventricular ejection fraction (LVEF) was 60.1%±11.4%, and the mean ± SD AugMAP was 99.1±13.1 mm Hg. Patients in the lower AugMAP group, with either preserved or reduced LVEF, had significantly worse survival performance (all P<.001). Multivariate Cox regression showed that AugMAP (hazard ratio, 0.962; 95% CI, 0.942 to 0.981 per 5-mm Hg increase; P<.001) and AugMAP less than 80 mm Hg (hazard ratio, 1.477; 95% CI, 1.241 to 1.756; P<.001) were independently associated with all-cause mortality. CONCLUSION: AugMAP is a simple and effective echocardiographic marker to identify high-risk patients with moderate AS independent of LVEF. It can potentially be used in the candidate selection process if moderate AS becomes indicated for aortic valve intervention in the future.

Embolic Stroke in Setting of Iliac Vein Stenosis in an Avid Cyclist.

External iliac vein stenosis related to cycling has rarely been reported as a cause of deep vein thrombosis. Ischemic stroke occurring in this condition due to paradoxical embolism across a preexisting patent foramen ovale (PFO) has yet to be reported. Here we report a case of embolic ischemic strokes in a young, avid cyclist with no prior known vascular risk factors. A thorough cerebrovascular workup revealed a right-to-left shunt on transesophageal echocardiogram that prompted venous thrombosis evaluation. Pelvic MR venogram demonstrated a 3.5 cm high-grade stenosis of the right external iliac vein, concerning for possible prior thrombotic disease. His strokes were deemed most likely a result of paradoxical emboli originating in the pelvis at the site of right external iliac vein stenosis. The patient ultimately opted for PFO closure for secondary stroke prevention, as he wished to continue daily cycling. This case highlights the importance of neurohospitalists considering iliac vein stenosis as a potential cause of embolic stroke of undetermined source, especially in young patients who are avid cyclists, as part of a thorough vascular workup.

Impact of Persistent Iatrogenic Atrial Septal Defect following MitraClip.

BACKGROUND: Prior studies have reported conflicting results of persistent iatrogenic atrial septal defect (iASD) and its impact following a transcatheter edge-to-edge repair (TEER) procedure. This study aims to evaluate the incidence of iASD and its clinical and hemodynamic impact after a TEER. METHODS: Consecutive patients who underwent a TEER procedure from June 2014 to September 2020 at the Mayo Clinic were identified. The presence of iASD was retrospectively identified on post-procedure transthoracic echocardiography (TTE) to group patients into an iASD+ group and an iASD- group for comparison of prognosis and cardiac function. RESULTS: A total of 316 patients were included; the mean age was 79.1 ± 9.1 years, and 67.7% were male. Persistent iASD was diagnosed in 108 (34.2%) patients. There was no difference concerning all-cause mortality, heart failure hospitalization, and stroke/TIA between groups at follow-up (median follow-up of 9 months). Post-procedure TTE demonstrated no differences regarding right ventricle (RV) and left ventricle (LV) dimensions and function, including TAPSE (15.2 ± 4.6 vs. 15.4 ± 5.5 mm, p = 0.875), and LV ejection fraction (51.1 ± 14.0% vs. 51.3 ± 13.9%, p = 0.933). However, patients with iASD had higher RV systolic pressure (48.7 ± 14.4 vs. 45.5 ± 14.5 mmHg, p = 0.042) compared with patients without iASD. CONCLUSION: Notwithstanding higher RV pressures, patients with persistent iASD had no hemodynamic compromise and an equal prognosis compared with those without a residual atrial defect after a TEER procedure. These findings support the mid-term safety of procedures in which an interatrial defect needs to be created and would argue against the need for interventional closure.

Meta-Analysis of Studies Comparing Dual- Versus Mono-Antiplatelet Therapy Following Transcatheter Aortic Valve Implantation.

Current guidelines recommend dual-antiplatelet therapy (DAPT) after transcatheter aortic valve implantation (TAVI), although some studies suggest mono-antiplatelet therapy is equally efficacious with an improved safety profile. We performed a meta-analysis of studies comparing DAPT with mono-antiplatelet therapy after TAVI. Study quality and heterogeneity were assessed using Jadad score, Newcastle-Ottawa Scale, and Cochran's Q statistics. Mantel-Haenszel odds ratios (ORs) were calculated using fixed effect models as the primary analysis. Eight studies including 2,439 patients met the inclusion criteria. At 30 days, DAPT was associated with an increased risk of all-cause mortality (OR 2.06, 95% confidence interval [CI] 1.34 to 3.18, p = 0.001), major or life-threatening bleeding (OR 2.04, 95% CI 1.60 to 2.59, p <0.001), and major vascular complications (OR 2.15, 95% CI 1.51 to 3.06, p <0.001). There was no difference in the rate of the combined end point of stroke or transient ischemic attack, or myocardial infarction. Outcome data up to 6 months were available in 5 studies; all-cause mortality and stroke were similar between groups, although major or life-threatening bleeding was more frequent with DAPT. In conclusion, in patients undergoing TAVI, DAPT is associated with increased risk at 30 days of all-cause mortality, major or life-threatening bleeding, and major vascular complications without a decrease in ischemic complications; at 6 months, the excess bleeding risk persisted. These data suggest a safety concern with DAPT and justify further investigation of the optimal antiplatelet therapy regimen after TAVI.

Anomalous coronary artery in a transplanted heart: a rare incidental diagnosis.

Coronary artery anomaly is a rare postoperative coronary angiographic finding in heart transplant recipients. We report a case of anomalous origin of the right coronary artery in an asymptomatic 70-year-old heart transplant patient. Most coronary artery anomalies are benign, but surgical treatment may be necessary in major coronary artery anomalies that are known to have adverse outcomes.

Noninvasive assessment of right atrial pressure using Doppler tissue imaging.

Right atrial pressure (RAP) reflects volume and pressure hemodynamics of right cardiac chambers. Previous attempts for noninvasive assessment of RAP include 2-dimensional and Doppler correlates of RAP, which require the presence of optimal subcostal views that may not be always feasible. In this study we utilized Doppler tissue imaging of the tricuspid annulus in the apical 4-chamber view, for noninvasive assessment of RAP. An inverse relationship was demonstrated between mean RAP and the interval between the end of the systolic annular motion to the onset of the early diastolic filling wave (right ventricular regional isovolumic relaxation time).