Outcomes of Transcatheter Aortic Valve Replacement in Patients With Bicuspid Aortic Valve Disease: A Report From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.

BACKGROUND: Patients with bicuspid aortic valve (AV) stenosis were excluded from the pivotal evaluations of transcatheter AV replacement (TAVR) devices. We sought to evaluate the outcomes of TAVR in patients with bicuspid AV stenosis in comparison with those with tricuspid AV stenosis. METHODS: We used data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry (November 2011 through November 2018) to determine device success, procedural outcomes, post-TAVR valve performance, and in-hospital clinical outcomes (mortality, stroke, and major bleeding) according to valve morphology (bicuspid versus tricuspid). Results were stratified by older and current (Sapien 3 and Evolut R) generation valve prostheses. Medicare administrative claims were used to evaluate mortality and stroke to 1 year among eligible individuals (≥65 years). RESULTS: After exclusions, there were 170 959 eligible procedures at 593 sites during the specified interval. Of these, 5412 TAVR procedures (3.2%) were performed in patients with bicuspid AV, including 3705 with current-generation devices. In comparison with patients with tricuspid valves, patients with bicuspid AV were younger and had a lower Society of Thoracic Surgeons Predicted Risk of Operative Mortality score. When current-generation devices were used to treat patients with bicuspid AV, device success increased (93.5 versus 96.3; P=0.001) and the incidence of 2+ aortic insufficiency declined (14.0% versus 2.7%; P<0.001) in comparison with older-generation devices. With current-generation devices, device success was slightly lower in the bicuspid (versus tricuspid) AV group (96.3% in bicuspid versus 97.4% in tricuspid, P=0.07), with a slightly higher incidence of residual moderate or severe aortic insufficiency among patients with bicuspid AV (2.7% versus 2.1%; P<0.001). A lower 1-year adjusted risk of mortality (hazard ratio, 0.88 [95% CI, 0.78-0.99]) was observed for patients with bicuspid AV versus patients with tricuspid AV in the Medicare-linked cohort, whereas no difference was observed in the 1-year adjusted risk of stroke (hazard ratio, 1.14 [95% CI, 0.94-1.39]). CONCLUSIONS: Using current-generation devices, procedural, postprocedural, and 1-year outcomes were comparable following TAVR for bicuspid AV versus tricuspid AV disease. With newer-generation devices, TAVR is a viable treatment option for patients with bicuspid AV disease.

Transcatheter aortic valve replacement for patients with severe bicuspid aortic stenosis.

BACKGROUND: Patients with bicuspid aortic valve stenosis (BAV) were excluded from all the trileaflet aortic valve stenosis (TAV) pivotal trials, and therefore, their outcomes are not clearly defined. The aim of the study was to evaluate the outcomes of transcatheter aortic valve replacement (TAVR) in patients with BAV and compared them with those of TAV. METHODS: We evaluated the outcomes following TAVR of patients with BAV at our institution between April 2011 and November 2016 and compared them with the outcomes of patients with TAV treated with TAVR. The χ2 and the Mann-Whitney U tests were used to compare the groups, and a Kaplan-Meier analysis was performed to estimate long-term survival. RESULTS: TAVR was performed in a total of 567 patients, from which 50 (8.8%) had BAV and 517 (91.2%) had TAV. Patients with BAV were younger and had higher prevalence of chronic obstructive pulmonary disease, lower prevalence of coronary artery disease, higher body mass index, and lower Society of Thoracic Surgeons score (STS PROM). Patients with BAV had a slightly higher mean aortic valve gradient postoperatively (median 12 mm Hg [10-15] vs 10 [7-13], P < .001), but paravalvular aortic regurgitation was not different between the groups (> mild 4.0% vs 3.5%, P = .541). Clinical outcomes were not different between the groups, including stroke (2.0% vs 1.5, P = .567) and the 30-day all-cause mortality (6.0% vs 1.5, P = .064). The 2-year survival (82.0% vs 83.4, P = .476) was similar between the groups. CONCLUSIONS: This initial experience suggests that TAVR can be safely performed in patients with BAV, achieving similar short-term procedural and clinical outcomes when compared with patients with TAV.

Transcatheter aortic-valve replacement with a self-expanding prosthesis.

BACKGROUND: We compared transcatheter aortic-valve replacement (TAVR), using a self-expanding transcatheter aortic-valve bioprosthesis, with surgical aortic-valve replacement in patients with severe aortic stenosis and an increased risk of death during surgery. METHODS: We recruited patients with severe aortic stenosis who were at increased surgical risk as determined by the heart team at each study center. Risk assessment included the Society of Thoracic Surgeons Predictor Risk of Mortality estimate and consideration of other key risk factors. Eligible patients were randomly assigned in a 1:1 ratio to TAVR with the self-expanding transcatheter valve (TAVR group) or to surgical aortic-valve replacement (surgical group). The primary end point was the rate of death from any cause at 1 year, evaluated with the use of both noninferiority and superiority testing. RESULTS: A total of 795 patients underwent randomization at 45 centers in the United States. In the as-treated analysis, the rate of death from any cause at 1 year was significantly lower in the TAVR group than in the surgical group (14.2% vs. 19.1%), with an absolute reduction in risk of 4.9 percentage points (upper boundary of the 95% confidence interval, -0.4; P<0.001 for noninferiority; P = 0.04 for superiority). The results were similar in the intention-to-treat analysis. In a hierarchical testing procedure, TAVR was noninferior with respect to echocardiographic indexes of valve stenosis, functional status, and quality of life. Exploratory analyses suggested a reduction in the rate of major adverse cardiovascular and cerebrovascular events and no increase in the risk of stroke. CONCLUSIONS: In patients with severe aortic stenosis who are at increased surgical risk, TAVR with a self-expanding transcatheter aortic-valve bioprosthesis was associated with a significantly higher rate of survival at 1 year than surgical aortic-valve replacement. (Funded by Medtronic; U.S. CoreValve High Risk Study ClinicalTrials.gov number, NCT01240902.).

Assessment of Paravalvular Leak After Transcatheter Aortic Valve Replacement: Transesophageal Echocardiography Compared With Transthoracic Echocardiography.

OBJECTIVES: Determine whether moderate or greater paravalvular leak (PVL) after transcatheter aortic valve replacement quantified using intraoperative transesophageal echocardiography (TEE) is associated with mortality and investigate the correlation between PVL grading using intraoperative TEE and postoperative transthoracic echocardiography (TTE). DESIGN: Retrospective, observational study. SETTING: Single academic institution. PARTICIPANTS: The study comprised adult patients undergoing elective transcatheter aortic valve replacement between April 2011 and February 2014. INTERVENTIONS: Patients were grouped by amount of PVL on intraoperative TEE into "significant" (moderate or greater) and "nonsignificant" (no, trivial, or mild) PVL groups. Demographics and patient characteristics were compared. Continuous variables were assessed with t-tests or Wilcoxon rank sum tests and categorical variables with the chi-square or Fisher exact test. A Cox proportional hazards model adjusted for EuroSCORE was used to test the independent association of PVL with late mortality, and covariate-adjusted survival curves were constructed. A Fleiss-Cohen-weighted kappa value was used to assess agreement between PVL grading using intraoperative TEE and postoperative TTE. MEASUREMENTS AND MAIN RESULTS: One hundred ninety-six patients were grouped into the "significant" (n = 22) or "nonsignificant" (n = 174) PVL group. Twenty patients (10%) died during the follow-up period. Significant PVL on either TTE (p = 0.62, hazard ratio 1.68, 95% confidence interval [CI] 0.22-12.85) or TEE (p = 0.49, hazard ratio 0.49; 95% CI 0.06-3.68) was not associated with a survival difference. Modest agreement was found between PVL on intraoperative TEE and postoperative TTE (kappa = 0.47, CI 0.37-0.57, p < 0.0001). CONCLUSIONS: Larger studies are needed to evaluate the association of PVL graded on intraoperative TEE with survival. There is modest agreement between the degree of PVL found on TEE and TTE.

Aortic valve surgery and survival in patients with moderate or severe aortic stenosis and left ventricular dysfunction.

AIMS: We aimed to determine the frequency of aortic valve surgery (AVR) with or without coronary artery bypass grafting (CABG), among patients with moderate/severe aortic stenosis (AS) and left ventricular systolic dysfunction (LVSD), and its relationship with survival. METHODS AND RESULTS: The Duke Echocardiographic Database (N = 132 804) was queried for patients with mean gradient ≥25 mmHg and/or peak velocity ≥3 m/s and LVSD (left ventricular ejection fraction ≤50%) from 1 January 1995-28 February 2014. For analyses purposes, AS was defined both by mean gradient and calculated aortic valve area (AVA) criteria. Time-dependent indicators of AVR in multivariable Cox models were used to assess the relationship of AVR and all-cause mortality. A total of 1634 patients had moderate (N = 1090, 67%) or severe (N = 544, 33%) AS by mean gradient criteria. Overall, 287 (26%) patients with moderate AS and 263 (48%) patients with severe AS underwent AVR within 5 years of the qualifying echo. There were 863 (53%) deaths observed up to 5 years following index echo. After multivariable adjustment in an inverse probability weighted regression model, AVR was associated with higher 5-year survival amongst patients with moderate AS and severe AS whether classified by AVA or mean gradient criteria. Over all, AVR ± CABG compared with medical therapy was associated with significantly lower mortality [hazard ratio, HR = 0.49 (0.38, 0.62), P < 0.0001]. Compared with CABG alone, CABG + AVR was associated with better survival [HR = 0.18 (0.12, 0.27), P < 0.0001]. CONCLUSIONS: In patients with moderate/severe AS and LVSD, mortality is substantial and amongst those selected for surgery, AVR with or without CABG is associated with higher survival. Research is required to understand factors contributing to current practice patterns and the possible utility of transcatheter approaches in this high-risk cohort.

Assessment of single-bolus contrast administration technique using hybrid dual-source ECG-gated thoracic and dual-source non-ECG-gated high-pitch abdominopelvic CT acquisitions for procedural planning before transcatheter aortic valve replacement.

PURPOSE: This study aimed to assess vascular contrast opacification and homogeneity using single-bolus contrast administration with hybrid thoracic and abdominopelvic computed tomographic angiography in patients with severe aortic valve stenosis. MATERIALS AND METHODS: Combination electrocardiogram-gated thoracic and dual-source, high-pitch abdominopelvic computed tomographic angiography examinations of 50 patients with severe aortic stenosis between December 2013 and March 2014 were reviewed. Contrast administration was individualized to patient-specific physiology. Image analysis of vascular opacification was obtained and interdependencies of vascular contrast and homogeneity of contrast distribution were assessed. RESULTS: The mean volume of contrast administered was 106 ± 11.7 mL. Mean attenuation was 371 ± 90.7 Hounsfield units (HU) in the thoracic aorta and 388 ± 95.9 HU in the abdominal aorta. Homogeneous opacification was obtained throughout with coefficient of variation of 11%. CONCLUSIONS: Procedural planning for transcatheter aortic valve replacement can be achieved using a single-injection bolus contrast protocol in combination with a 2-part multidetector computed tomographic image acquisition technique with optimal opacification of major arterial structures.

Immediate mechanical effects of acute left bundle branch block by speckle tracked strain.

INTRODUCTION: Left bundle branch block (LBBB) is a known complication of transcatheter aortic valve replacement (TAVR) and has been shown to predict worsened outcomes in TAVR patients. A regional longitudinal strain pattern, termed the "classic" pattern of left ventricular (LV) dyssynchrony, which is thought to be due to LBBB, is highly predictive of response to cardiac resynchronization therapy. Whether LBBB causes this "classic" pattern is not known. METHODS: We retrospectively studied patients undergoing TAVR who also underwent pre- and post-TAVR strain analysis to determine if the "classic" pattern arose in those who developed TAVR-induced true LBBB. After removing patients with baseline conduction abnormalities or insufficient studies 9 patients had sufficient data for analysis. Six patients developed LBBB after TAVR and 3 patients did not develop LBBB after TAVR. ECGs were analyzed for the new onset of LBBB after TAVR. Global longitudinal strain (GLS) and regional longitudinal strain patterns were analyzed for changes between pre- and immediately post-TAVR examinations. RESULTS: Patients who did not develop LBBB showed no significant changes in their regional longitudinal strain pattern. Those patients who did develop LBBB showed significant increase in their difference of time-to-onset of contraction between the septal and lateral walls post-TAVR (22 ± 14 ms vs 111 ± 49 ms; p=0.003) and in their difference of time-to-peak contraction between the septal and lateral walls post-TAVR (63 ± 56 ms vs 133 ± 46 ms; p=0.002). Early lateral wall pre-stretch and delayed lateral wall peak contraction emerged in all patients with LBBB but early septal peak contraction meeting the established criteria was present in only one patient. DISCUSSION: The onset of LBBB led to acute, measurable changes in the regional longitudinal strain pattern consisting of early lateral wall pre-stretch and delayed lateral wall peak contraction. These represent 2 of the 3 findings in the "classic" pattern of LV dyssynchrony. Early termination of septal wall contraction meeting established criteria was not routinely found. Time and/or other factors may be required to develop the full "classic" pattern.

Role of cardiac evaluation before thoracic endovascular aortic repair.

BACKGROUND: Patients with thoracic aortic disease undergoing thoracic endovascular aortic repair (TEVAR) often have concomitant coronary artery disease and are at risk for perioperative adverse cardiac events. Despite this risk, the need for and extent of preoperative cardiac workup before TEVAR remain undefined. This study seeks to assess the adequacy of a limited cardiac evaluation before TEVAR, including assessment of cardiac symptoms, resting electrocardiography (ECG), and transthoracic echocardiography (TTE), as well as to estimate the incidence of perioperative cardiac events in patients undergoing TEVAR. METHODS: Retrospective analysis of a prospectively maintained Institutional Review Board-approved database was performed for all patients undergoing TEVAR at a single referral institution between May 2002 and June 2013. The analysis identified 463 TEVAR procedures. All procedures involving median sternotomy were excluded, and 380 procedures (343 patients) were included in the final analysis. Degree of cardiac workup was classified on the basis of the highest level of preoperative testing: no workup, resting ECG only, resting TTE, exercise/pharmacologic stress testing, or coronary angiography. Standard workup consisted of cardiac symptom assessment along with resting ECG or TTE, with further workup indicated for unstable symptoms, significantly abnormal findings on ECG or TTE, or multiple cardiac risk factors. Categorical and continuous variables were compared by Fisher's exact test and analysis of variance, respectively. RESULTS: No preoperative cardiac workup was performed for 28 patients (7.4%); 127 patients (33.4%) had resting ECG only, 208 patients (54.7%) had resting echocardiography, 12 patients (3.2%) underwent stress testing, and five patients (1.3%) had coronary angiography. Patients undergoing stress testing or coronary angiography were older and had a higher incidence of known coronary artery disease (P < .01) and prior myocardial infarction (P = .01). Complex hybrid aortic repairs and TEVAR for aneurysmal disease were more likely to have an extensive workup, whereas nonelective procedures more commonly had no workup. A total of nine patients (2.4%) experienced a perioperative cardiac event (myocardial infarction or cardiac arrest), with no significant difference noted among all groups (P = .45), suggesting that the extent of cardiac workup was appropriate. The incidence of 30-day/in-hospital mortality (5.5%) and cardiac-specific mortality (0.8%) was similar among all groups. CONCLUSIONS: The risk of a postoperative cardiac event after TEVAR is low (2.4%), and initial screening with either resting TTE or ECG, in addition to assessment of cardiac symptom status, appears adequate for most TEVAR patients. As such, we recommend resting TTE or ECG as the initial cardiovascular screening mechanism in patients undergoing TEVAR, with subsequent more invasive studies if initial screening reveals cardiovascular abnormalities.

Impact of ostium secundum atrial septal defect closure on the resolution of falsely positive electrocardiographic criteria for myocardial scarring.

BACKGROUND: Electrocardiographic (ECG) Selvester QRS score criteria with false indication of anteroseptal scarring consistent with myocardial infarction have been found in patients with ostium secundum atrial septal defect (OS-ASD). The objective of this study was to evaluate ECGs pre and post percutaneous transcatheter OS-ASD closure to test the hypothesis that the falsely positive criteria for anteroseptal scar decline 1 day post procedure. METHODS: Patients (n = 34, mean age 48 ± 17 years, 79% female) that underwent OS-ASD closure and had undergone pre procedure cardiac magnetic resonance imaging showing no left ventricular (LV) scarring were included in this study. ECGs pre and 1 day post procedure were assessed according to the QRS Selvester scoring system and compared. RESULTS: Mean Selvester score in anteroseptal regions pre procedure was 6.6 (0.0-6.8) % LV scar and decreased to 4.3 (0.0-6.0) % LV scar one day after the procedure (p = 0.01). Mean Selvester score in lateral regions pre procedure was 3.7 (0.0-3.0) %LV scar and decreased to 2.8 (0.0-0.0) % LV scar one day post procedure (p = 0.25). DISCUSSION: OS-ASD patients with falsely positive anteroseptal scar criteria by the Selvester QRS score pre procedure have a significant decrease in anteroseptal Selvester score 1 day post procedure. The falsely positive anteroseptal scar criteria did not completely resolve 1 day post procedure. Further studies are needed to investigate the relationship between ECG criteria for anteroseptal scar and right ventricular volume overload in late follow up.

Invasive hemodynamic evaluation in patients with mechanical aortic valves.

Invasive hemodynamic evaluation in the patient with a mechanical aortic valve has in the past required transseptal or apical left ventricular puncture in order to obtain left ventricular pressure measurements. Over the last few years, several case reports have described the feasibility of using a coronary pressure-sensing guidewire to cross mechanical prosthetic aortic valves. In the current manuscript, we report four cases in which the use of a pressure-sensing guidewire was utilized for invasive hemodynamic diagnostic evaluation in patients with mechanical aortic valves. Furthermore, we present a detailed description of the technical approach to this technique and the limitations of this approach.

Radiation-associated valvular heart disease.

Therapeutic ionizing radiation, such as that used in the treatment of Hodgkin's lymphoma, can cause cardiac valvular damage that may take several years to manifest as radiation-associated valvular heart disease. Treatment can be complicated by comorbid radiation injury to other cardiac and mediastinal structures that lead to traditional surgical valve replacement or repair becoming high-risk. A representative case is presented that demonstrates the complexity of radiation-associated valvular heart disease and its successful treatment with percutaneous transcatheter valve replacement. The prevalence and pathophysiologic mechanism of radiation-associated valvular injury are reviewed. Anthracycline adjuvant therapy appears to increase the risk of valvular fibrosis. Left-sided heart valves are more commonly affected than right-sided heart valves. A particular pattern of calcification has been noted in some patients, and experimental data suggest that radiation induction of an osteogenic phenotype may be responsible. A renewed appreciation of the cardiac valvular effects of therapeutic ionizing radiation for mediastinal malignancies is important, and the treatment of such patients may be assisted by the development of novel, less-invasive approaches.

Transcatheter aortic valve replacement: an update.

Aortic stenosis affects many people worldwide with a significant impact on morbidity and mortality with uncorrected, symptomatic aortic valve stenosis carrying mortality of 50% at one year. Degenerative calcific pathology, the most common cause of aortic stenosis, increases in prevalence with age; estimated prevalence of 5% in individuals over 75 years of age. Despite the malignant prognosis without valve replacement, many patients are not offered surgery due to advanced age and co-existing medical conditions; reported to be a third of symptomatic patients. In the last several years, transcatheter aortic valve replacement has emerged as an alternative treatment in patients with high or prohibitive open surgical risk. The PARTNER cohort B data, employing the Sapien valve, demonstrated a 20% absolute mortality benefit at one year compared with medical therapy. In this review, we provide an update of this technology and discuss patient selection, procedural planning, complications, and look toward the future of transcatheter heart valves in the treatment of aortic stenosis.

Relationships between cardiac magnetic resonance imaging abnormalities in the inter-ventricular septum and Selvester QRS scoring criteria for anterior-septal myocardial infarction in patients with right ventricular volume overload.

BACKGROUND: Patients with ostium secundum atrial septal defects (ASDs) were studied to determine the prevalence of Selvester anteroseptal myocardial infarction QRS points, and to test the hypothesis that there is a relationship between these criteria and thinning and/or scarring of the inter-ventricular septum (IVS). METHODS: Demographic, electrocardiographic (ECG), and cardiac magnetic resonance imaging (CMR) data were acquired on 46 patients with a secundum ASD closed percutaneously. Selvester QRS scoring on patient ECGs was performed for areas representing the anteroseptal region of the left ventricle (LV). The IVS to LV free wall thickness ratio was used to assess thinning of the IVS while late gadolinium enhancement (LGE) of the IVS was used for scarring; both using CMR. RESULTS: Twenty-four (52%) patients scored Selvester QRS points in the anteroseptal region with a mean score of 2.6±1.8. The mean IVS/LV free wall thickness ratio at the basal level and mid-ventricular level was 1.1±0.3 and 1.3±0.3, respectively. There was no association of Selvester QRS points with IVS/LV free wall ratio at the basal (p=0.59) or mid-ventricular (p=0.13) levels. The one patient with LGE in the IVS had 4 Selvester anteroseptal QRS points. CONCLUSION: The results of our study demonstrate that in our patient population there is a 52% prevalence of Selvester anteroseptal QRS points which are due to thinning and/or scarring of the IVS in only one patient.

Improving patient outcomes with a mobile digital health platform for patients undergoing transcatheter aortic valve replacement.

PURPOSE: ManageMySurgery (MMS) is a digital health application (app) for patients undergoing surgery, including Transcatheter Aortic Valve Replacement (TAVR). Patients using MMS review procedure-specific education, view FAQs, and report patient-reported outcomes. This study assessed the impact of app use on postoperative outcomes. METHODS: Patients who underwent TAVR and invited to use MMS between March 2019 and November 2021 were identified. Patients received standard perioperative care and were defined as App users if they signed into the app at least once and engaged with at least one task or FAQ. Demographics and postoperative outcomes were collected via medical record review. Multivariable logistic regression models were used to determine odds of 90-day readmission, Emergency Room (ER) visits, and complications. RESULTS: 388 patients met inclusion criteria, of which 238 used the app. The average age at surgery was 76.4±7.7 years for users and 78.1±7.6 for non-users. 63.0% of users and 59.3% of non-users were male. App users had significantly lower 90-day readmission rates, (8.8% vs 16.0%, OR=0.51, p=0.0373), ER visit rates (12.6% vs 27.3%, OR=0.36, p=0.0003), and complication rates (Minor: 12.2% vs 20.7%, OR=0.48, P=0.0126; Major: 8.8% vs. 16%, OR=0.47, P=0.0235). CONCLUSIONS: In this non-randomized, retrospective study, we found significant decreases in 90-day readmissions, ER visits, and complications in TAVR patients using an app compared to traditional care. By engaging patients throughout their interventional journey with structured education and tasks, mobile health platforms may mitigate unnecessary use of emergency and inpatient care, thereby improving patient well-being and lowering the burden on healthcare resources.

Infarct exclusion repair of postmyocardial infarction ventricular septal rupture with a hybrid patch and septal occluder device compared with patch only.

Objective: We developed a hybrid technique for repairing post-myocardial infarction (MI) ventricular septal defect (VSD) that combines infarct exclusion with patch and a nitinol-mesh septal occluder device (SOD) to provide a scaffold to support the damaged septal wall. Here, we compare outcomes of patients with post-MI VSD repaired using patch only or hybrid patch/SOD. Methods: Patients undergoing post-MI VSD repair at our institution from 2013 to 2022 who received patch alone or patch/SOD repair were analyzed. Primary outcome was survival to hospital discharge. Clinical outcomes and echocardiograms were also analyzed. Results: Over a 9-year period, 24 patients had post-MI VSD repair at our institution with either hybrid patch/SOD (n = 10) or patch only repair (n = 14). VSD size was 18 ± 5.8 mm for patch/SOD and 17 ± 4.6 mm for patch only. In the patch/SOD repair cohort, average size of SOD implant was 23.6 ± 5.6 mm. Mild left ventricular dysfunction was present prerepair and was unchanged postrepair in both groups; however, moderate-to-severe right ventricular (RV) dysfunction was common in both groups before repair. RV function worsened or persisted as severe in 10% of hybrid versus 54% of patch-only patients postrepair. Tricuspid annular systolic excursion and RV:left ventricle diameter ratio, quantitative metrics of RV function, improved after patch/SOD repair. No intraoperative mortality occurred in either group. Postoperative renal, hepatic, and respiratory failure requiring tracheostomy was common in both groups. Survival to hospital discharge in both cohorts was 70%. Conclusions: Post-MI VSD repair with patch/SOD has comparable short-term outcomes with patch alone. Addition of a SOD to patch repair provides a scaffold that may enhance the repair of post-MI VSD with patch exclusion.

Cardiac conduction system disease after transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) is a rapidly-evolving technology for patients with severe, calcific aortic stenosis. Although these procedures lessen many of the risks and complications of open surgical aortic valve replacement, there remain challenges with TAVR including electrophysiologic complications. Among TAVR prostheses, rates of conduction abnormalities (CAs) vary from less than 10% to more than 50%, with up to one-third of patients requiring placement of a permanent pacemaker following TAVR. Several predictors of CAs have been identified related to device selection, baseline conduction defects, and anatomical considerations. Current data support the hypothesis that CAs result primarily from mechanical compression of the specialized conduction system by the device, although other factors may be involved. Such abnormalities can arise immediately during the procedure or as late as several days after implantation, and can be transient or permanent. Currently, there are no clinical tools to identify patients at highest risk for CAs post-TAVR, or to predict the course of CAs in patients who experience them. Early data suggest outcomes may be worse in high-risk patients, and further studies are needed to identify these patients so as to minimize electrophysiologic complications and determine appropriate monitoring in this expanding population.

Echocardiography for the detection of cardiac sources of embolism in patients with stroke or transient ischemic attack.

BACKGROUND: Transthoracic echocardiography (TTE) is commonly obtained during the evaluation of patients with ischemic stroke or transient ischemic attack (TIA) to detect potential sources of cardiogenic embolism. Specific indications for the tests remain uncertain. METHODS: TTE and transesophageal echocardiography (TEE) use in routine clinical practice were assessed retrospectively in a consecutive series of patients with acute ischemic stroke to determine whether clinical features were useful in identifying those in whom echocardiography led to a change in patient evaluation or treatment. RESULTS: TTE identified a potential source of cardiogenic embolism in 35 of 186 (18.8%) patients, and led to a change in management in 10.8%, including anticoagulation or surgery in 5.4%. Of the 186 patients, 30 (16%) also had a TEE that identified a potential source of cardiogenic embolism in 18 (60.0%), with 33.3% subsequently having a change in evaluation or treatment. Changes in management based on TEE findings occurred in 44.4% of those with an abnormal TTE and 28.6% of those with a normal TTE. There was no association between patients' age, history of coronary heart disease, carotid stenosis, or stroke topology and the frequency of management-changing echocardiographic findings. CONCLUSIONS: TTE and TEE are useful for identifying management-changing potential sources of cardiogenic embolism in patients with acute ischemic stroke. Specific clinical factors increasing the yield of these tests as used in routine clinical practice, including stroke topology, could not be identified.

Surgical Sutureless and Sutured Aortic Valve Replacement in Low-risk Patients.

BACKGROUND: Randomized clinical trials have shown that transcatheter aortic valve replacement is noninferior to surgery in low surgical risk patients. We compared outcomes in patients treated with a sutured (stented or stentless) or sutureless surgical valve from the Evolut Low Risk Trial. METHODS: The Evolut Low Risk Trial enrolled patients with severe aortic stenosis and low surgical risk. Patients were randomized to self-expanding transcatheter aortic valve replacement or surgery. Use of sutureless or sutured valves was at the surgeons' discretion. RESULTS: Six hundred eighty patients underwent surgical aortic valve implantation (205 sutureless, 475 sutured). The Valve Academic Research Consortium-2 30-day safety composite endpoint was similar in the sutureless and sutured group (10.8% vs 11.0%, P = .93). All-cause mortality between groups was similar at 30 days (0.5% vs 1.5%, P = .28) and 1 year (3.3% vs 2.6%, P = .74). Disabling stroke was also similar at 30 days (2.0% vs 1.5%, P = .65) and 1 year (2.6% vs 2.2%, P = .76). Permanent pacemaker implantation at 30 days was significantly higher in the sutureless compared with the sutured group (14.4% vs 2.9%, P < .001). Aortic valve-related hospitalizations occurred more often at 1 year with sutureless valves (9.1% vs 5.1%, P = .04). Mean gradients 1 year after sutureless and sutured aortic valve replacement were 9.9 ± 4.2 versus 11.7 ± 4.7 mm Hg (P < .001). CONCLUSIONS: Among low-risk patients, sutureless versus sutured valve use did not demonstrate a benefit in terms of 30-day complications and produced marginally better hemodynamics but with an increased rate of pacemaker implantation and valve-related hospitalizations.

Trends in the use of diagnostic coronary angiography, percutaneous coronary intervention, and coronary artery bypass graft surgery across North Carolina.

BACKGROUND: Although variation in use of invasive coronary procedures has been shown, the relationship between invasive diagnostic cardiac catheterization (Cath) and subsequent revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) is not known. We evaluated the temporal trends and variation in invasive Cath, PCI, and CABG across hospital systems in North Carolina. METHODS: All Cath, PCI, and CABG procedures performed in North Carolina from 2003 to 2009 were identified using data reported in the annual North Carolina State Medical Facilities Plan. Rates and variation in procedure use, relative rates of PCI to Cath, CABG to Cath, and CABG to PCI were compared over the study period between hospitals that performed at least 25 Cath, 25 PCI, and 25 CABG procedures. RESULTS: The rates of all invasive procedures per 100,000 population declined: 24% for Cath, 16% for PCI, and 35% for CABG. However, the relative rate of PCI to Cath over the study period increased by 11%, whereas the relative rate of CABG to Cath decreased by 13%. Hospital level analysis showed significant variation in the relative rate of both PCI to Cath (10%-90%, P < .05) and CABG to Cath (5%-35%, P < .05). CONCLUSIONS: Although the use of all invasive cardiac procedures declined, the relative rate of PCI to Cath increased over the study period. There was also significant variation in the mode of revascularization (CABG and PCI) across hospital systems in North Carolina. Further research is needed to understand drivers of coronary revascularization.

Response to inhaled nitric oxide predicts survival in patients with pulmonary hypertension.

OBJECTIVE: To examine the ability of vasodilator response to predict survival in a diverse cohort of patients with pulmonary hypertension (PH). PATIENTS & METHODS: A total of 214 consecutive treatment-naive patients referred for invasive PH evaluation were enrolled between November 1998 and December 2008. Vasoreactivity was assessed during inhalation of 40 parts per million nitric oxide (iNO) and vasodilator responders were defined as those participants who achieved a mean pulmonary artery pressure (PAP) of ≤ 40 mm Hg and a drop in mean PAP ≥ the median for the cohort (13%). Kaplan-Meier analysis and Cox proportional hazards modeling were used to identify predictors of survival. RESULTS: There were 51 deaths (25.9%) over a mean follow-up period of 2.3 years. Kaplan-Meier analysis demonstrated that vasodilator responders had significantly improved survival (P < .01). Vasodilator responders had improved survival regardless of whether or not they had idiopathic or nonidiopathic PH (P = .02, P < .01) or whether or not they had Dana Point class 1 or non-Dana Point class 1 PH (P < .01, P = .01). In multivariate modeling, advanced age, elevated right atrial pressure, elevated serum creatinine, and worsened functional class significantly predicted shorter survival (P = .01, P = .01, P = .01, P < .01), whereas vasodilator response predicted improved survival (P = .01). CONCLUSIONS: Vasodilator responsiveness to iNO is an important method of risk stratifying PH patients, with results that apply regardless of clinical etiology.