Simultaneous Transfemoral Mitral and Tricuspid Valve in Ring Implantation: First Case Report with Edwards Sapien 3 Valve.

Patients with advanced valvular disease may be at high or prohibitive risk for surgical management. We describe a patient with previous mitral and tricuspid valve repair and recurrent admissions for New York Heart Association Class IV heart failure symptoms due to severe mitral stenosis and severe tricuspid regurgitation. Due to her comorbidities and two previous sternotomies, the patient was at high risk for surgery. We performed a simultaneous transfemoral mitral and tricuspid valve-in-ring implantation. This is the first report of its kind using a Sapien 3 valve (Edwards Lifesciences).

Optimal positioning of self-expanding valves before deployment decreases paravalvular regurgitation following transcatheter aortic valve replacement.

OBJECTIVES: To evaluate the association between measurements performed during Medtronic CoreValve (MCV) deployment and paravalvular leak (PVL). BACKGROUND: The MCV can be recaptured and repositioned, allowing the TAVR operator to implant at a more favorable position. The association between angiographic measurements of MCV position while the valve is recapturable and PVL post deployment has not been investigated. METHODS: 493 patients undergoing TAVR with MCV (January 2011-July 2017) were included. PVL was defined as intraprocedural aortic regurgitation that was judged clinically to require balloon postdilation. Depth of the valve at the left coronary cusp (LCC) and noncoronary cusp (NCC) were measured when the valve was 80% deployed. An optimal cutoff value for the ratio LCC/NCC for PVL was identified in 40 patients. Using this cutoff value, the association between LCC/NCC and PVL was then validated in 453 patients. RESULTS: The median LCC/NCC was 1.51 (interquartile range 1.06-1.89).The optimal cutoff value for LCC/NCC was 1.48 (93% sensitivity, 77% specificity, AUC0.85). In the validation group 112 (24.7%) patients had PVL. For LCC/NCC ≥ 1.48, the incidence of PVL was lower compared to LCC/NCC < 1.48 (9.58% vs. 41.78%, P < 0.0001). LCC/NCC of 1.48 had a sensitivity of 79.5% and specificity of 63.6% for PVL (AUC0.72). In a multivariate model, LCC/NCC < 1.48 independently predicted PVL (OR = 6.67, 95% CI 3.96-11.23, P < 0.0001). CONCLUSION: Positioning the MCV such that the LCC/NCC is ≥1.48 may result in less PVL.

Postprandial Monocyte Activation in Individuals With Metabolic Syndrome.

CONTEXT: Postprandial hyperlipidemia has been suggested to contribute to atherogenesis by inducing proinflammatory changes in monocytes. Individuals with metabolic syndrome (MS), shown to have higher blood triglyceride concentration and delayed triglyceride clearance, may thus have increased risk for development of atherosclerosis. OBJECTIVE: Our objective was to examine fasting levels and effects of a high-fat meal on phenotypes of monocyte subsets in individuals with obesity and MS and in healthy controls. Design, Setting, Participants, Intervention: Individuals with obesity and MS and gender- and age-matched healthy controls were recruited. Blood was collected from participants after an overnight fast (baseline) and at 3 and 5 hours after ingestion of a high-fat meal. At each time point, monocyte phenotypes were examined by multiparameter flow cytometry. MAIN OUTCOME MEASURES: Baseline levels of activation markers and postprandial inflammatory response in each of the three monocyte subsets were measured. RESULTS: At baseline, individuals with obesity and MS had higher proportions of circulating lipid-laden foamy monocytes than controls, which were positively correlated with fasting triglyceride levels. Additionally, the MS group had increased counts of nonclassical monocytes, higher CD11c, CX3CR1, and human leukocyte antigen-DR levels on intermediate monocytes, and higher CCR5 and tumor necrosis factor-α levels on classical monocytes in the circulation. Postprandial triglyceride increases in both groups were paralleled by upregulation of lipid-laden foamy monocytes. MS, but not control, subjects had significant postprandial increases of CD11c and percentages of IL-1ß+ and tumor necrosis factor-α+ cells in nonclassical monocytes. CONCLUSIONS: Compared to controls, individuals with obesity and MS had increased fasting and postprandial monocyte lipid accumulation and activation.

Isolated perforation of left coronary cusp after blunt chest trauma.

Left coronary cusp perforation is an extremely rare consequence of blunt chest trauma. A 22-year-old male presented after a motor vehicle accident with dyspnea. Transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) showed moderate to severe aortic regurgitation with prolapsing right coronary cusp. In the operating room he was found to have a left coronary cusp tear near the annulus and an enlarged right cusp. The patient recovered well after successful aortic valve replacement with a mechanical valve. Traumatic aortic regurgitation with left cusp perforation is serious and surgical intervention may be lifesaving if performed timely.

Lipid lowering with PCSK9 inhibitors.

Statins are the most-effective therapy currently available for lowering the LDL-cholesterol (LDL-C) level and preventing cardiovascular events. Additional therapies are necessary for patients who cannot reach the target LDL-C level when taking the maximum-tolerated dose of a statin. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is an enzyme with an important role in lipoprotein metabolism. Rare gain-of-function mutations in PCSK9 lead to a high LDL-C level and premature coronary heart disease, whereas loss-of-function variants lead to a low LDL-C level and a reduced incidence of coronary heart disease. Furthermore, the PCSK9 level is increased with statin therapy through negative feedback, which promotes LDL-receptor degradation and decreases the efficacy of LDL-C lowering with statins. PCSK9 inhibition is, therefore, a rational therapeutic target, and several approaches are being pursued. In phase I, II, and III trials, inhibition of PCSK9 with monoclonal antibodies has produced an additional 50-60% decrease in the LDL-C level when used in combination with statin therapy, compared with statin monotherapy. In short-term trials, PCSK9 inhibitors were well tolerated and had a low incidence of adverse effects. Ongoing phase III trials will provide information about the long-term safety of these drugs, and their efficacy in preventing cardiovascular events.

Ceruloplasmin and heart failure in the Atherosclerosis Risk in Communities study.

BACKGROUND: Ceruloplasmin (Cp) decreases nitric oxide bioavailability in blood and has been associated with cardiovascular disease (CVD) in clinical studies. We assessed the associations between Cp and incident heart failure (HF), death, and CVD in the Atherosclerosis Risk in Communities (ARIC) study. METHODS AND RESULTS: Cp was measured at ARIC visit 4 (1996-1998). We studied 9240 individuals without HF or CVD at ARIC visit 4 and followed them for a mean of 10.5 years. Genome-wide association study was performed to identify genetic determinants of Cp levels and evaluate their association with incident HF in ARIC participants. Cp levels (mean±SD) were higher in women versus men (335±79 versus 258±44 mg/L; P<0.0001), women on versus not on hormone-replacement therapy (398±89 versus 291±60 mg/L; P<0.0001), and African Americans versus whites (299±63 versus 293±74 mg/L; P=0.0005). After adjusting for traditional risk factors, high-sensitivity C-reactive protein, N-terminal pro-B-type natriuretic peptide, and high-sensitivity cardiac troponin T, higher levels of Cp were associated with HF (hazard ratio, 1.44; 95% confidence interval, 1.13-1.83) and mortality (hazard ratio, 1.38; 95% confidence interval, 1.11-1.63). A locus on the ceruloplasmin gene on chromosome 3 was significantly associated with Cp levels (normal 295.56±77.60 mg/L; heterozygote 316.72±88.02 mg/L; homozygote 331.04±85.40 mg/L; P=8.3×10(-13)) but not with incident HF. After adjustment for traditional risk factors, Cp levels were also weekly associated with CVD. CONCLUSIONS: Cp was associated with incident HF, mortality, and CVD in the ARIC population. A single locus on chromosome 3 was associated with Cp levels but not with HF.

The ventriculophasic response: relationship to sinus arrhythmia and the duration of interposed QRS complexes.

BACKGROUND: The ventriculophasic response (VR) refers to shortening of sinus cycle length during heart block when a QRS complex is interposed between 2 P waves. Our purpose was to analyze its relationship to respiratory sinus arrhythmia (SA) and to compare VR in relation to paced versus intrinsic QRS complexes. METHODS: Patients with advanced heart block had their pacer devices temporarily programmed to ventricular inhibited mode at 30 ppm. In 35 subjects, we analyzed VR and SA before, during and after 3 cycles of deep breathing. In 16 other patients we compared VR in the presence of paced versus narrower intrinsic QRS complexes. RESULTS: The magnitude of P-P interval shortening surrounding QRS complexes during inspiration correlated with SA (r = 0.36, P = 0.03). The prevalence of VR increased from 37% at baseline to 77% of subjects during deep breathing (P = 0.02). The mean P-P interval shortening was greater surrounding intrinsic QRS complexes than paced QRS complexes (3.6 ± 3.6% vs. 1.4 ± 1.1%, P = 0.02). The prevalence of VR increased from 25% during paced rhythm to 56% when intrinsic complexes were present. CONCLUSION: VR, like SA, increases with deep breathing and likely reflects intact parasympathetic nervous system function. Its increase in the presence of narrower beats suggests it may reflect ventricular synchrony.

Cardiovascular biomarkers and subclinical brain disease in the atherosclerosis risk in communities study.

BACKGROUND AND PURPOSE: Cerebrovascular and cardiovascular disease share common risk factors. Our goal was to determine whether levels of N-terminal brain natriuretic peptide (NT-proBNP) and cardiac troponin T measured with a highly sensitive assay (hs-cTnT) are associated with silent brain infarcts (BIs) and white matter lesions (WMLs) on MRI in the Atherosclerosis Risk in Communities (ARIC) study. METHODS: At ARIC visit 3 (1993-1995), 1920 participants had brain MRI. NT-proBNP and hs-cTnT were measured in all individuals at ARIC visit 4 (1996-1998). Of 1920 individuals, 1112 had a follow-up MRI [2004-2006]). We analyzed the association of NT-proBNP and hs-cTnT with MRI-defined BI and WML on the initial MRI and incident BI and WML progression on the follow-up MRI in participants without heart failure, coronary heart disease, or stroke. RESULTS: In the adjusted model, individuals in the highest NT-proBNP quartile had significantly more BI (odds ratio, 3.50; 95% confidence interval, 2.03-6.20), and WML (ß-coefficient, 0.09; SE, 0.03) on the baseline MRI and more incident BI (odds ratio, 2.18; 95% confidence interval, 1.38-3.47) and WML progression (ß-coefficient, 0.22; SE, 0.10) on the follow-up MRI. Individuals in the highest hs-cTnT category had more BI (odds ratio, 3.03; 95% confidence interval, 1.57-5.82) and WML (ß-coefficient, 0.11; SE, 0.04) on the initial MRI and more WML progression (ß-coefficient, 0.43; SE, 0.17) on the follow-up MRI. CONCLUSIONS: NT-proBNP and hs-cTnT are independently associated with silent MRI-defined BI and WML, suggesting that cardiovascular biomarkers may be useful to identify individuals with subclinical cerebral injury.

Unusual presentation of endocarditis with nutritional variant Streptococci.

Patients presenting with endocarditis often will give clues to the diagnosis within the history and the physical exam. A history of valvular heart disease and obvious signs of bacteriemia are classical stigmata of infective endocarditis. However, we should keep in mind that endocarditis can present with unusual signs and symptoms that can mislead to the wrong diagnosis and if unrecognized it can lead to severe complications.

Developing and assessing cardiovascular biomarkers.

Atherosclerosis is a slow process that over time can lead to fatal events. Early identification and prediction of future risk can allow for preventive strategies to be instituted. There is an increasing interest in utilizing novel biomarkers in cardiovascular disease screening and management. These novel biomarkers may help in cardiovascular disease risk assessment and treatment monitoring, and some may be treatment targets. To be useful for risk prediction, novel biomarkers need to show a significant association with cardiovascular disease events and bring additional value in risk stratification when added to known risk prediction models. Biomarkers used for treatment monitoring need to show that they can serve as good surrogates of cardiovascular disease status. In this article, we present 3 biomarkers that are currently approved by the U.S. Food and Drug Administration for use in cardiovascular disease management and risk assessment: C-reactive protein, lipoprotein-associated phospholipase A2, and myeloperoxidase. Other new biomarkers have also been shown recently to help in cardiovascular disease risk prediction and management. In this article, we will review 2 of these new biomarkers: cardiac troponin T measured by a highly sensitive assay and brain natriuretic peptide.

The ventriculophasic response revisited: analysis of clinical correlations using a new proposed definition derived in pacemaker patients.

BACKGROUND: The ventriculophasic response (VR) refers to shortening of atrial cycle length during heart block when a QRS complex is interposed between P waves. No formal quantitative definition has heretofore been proposed, nor have its potential clinical correlations been studied. HYPOTHESIS: We hypothesized that VR is present in selected patients who are distinguished by clinical features from those who lack VR. METHODS: Pacing devices were temporarily programmed to VVI mode at 30 ppm as electrocardiogram and intracardiac electrograms were recorded at 50 mm/sec paper speed. We measured the percentage decrease in a P-P interval (A-A interval on the atrial electrogram) containing a QRS, compared to the preceding P-P interval. Left ventricular ejection fraction (LVEF) was measured by echocardiogram. RESULTS: Shortening of P-P interval was observed chiefly when the interposed QRS occurred early in the anticipated P-P interval (as judged by the preceding P-P interval). P-P shortening of 0% to 3% occurred randomly. Defining VR as being a >3% P-P interval shortening when an interposed QRS occurred in the first 60% of the anticipated P-P interval, we found that VR was present in 28 (55%) of our patients. It was quite reproducible, was more common in women (81% vs 37% of men; P = 0.004), and positively correlated with LVEF (r = 0.41, P = 0.004). It did not correlate with age, diabetes, or ß-blocker use. CONCLUSIONS: Using our newly derived definition of VR, we found the phenomenon was present in 55% of our patients. It was reproducible and more commonly seen in women and patients with LVEF ≥40%.