Arrhythmias During Pregnancy: Ventricular Tachycardia in the Setting of Maternal Beta Thalassemia Minor.

Non-sustained ventricular tachycardia (NSVT) poses significant risks during pregnancy, particularly in patients with underlying conditions such as ß-thalassemia. We present a case of a 29-year-old pregnant woman with a history of ß-thalassemia minor who experienced NSVT at 27 weeks gestation. Despite initial concerns for structural heart disease, the workup was unrevealing. Challenges in medication selection and risk assessment were addressed in the context of maternal and fetal well-being. This case underscores the importance of a multidisciplinary approach involving cardiology, obstetrics, and hematology in managing NSVT during pregnancy, emphasizing risk stratification, collaborative decision-making, and long-term follow-up to ensure optimal outcomes for both mother and fetus.

Catheter ablation as first-line treatment for ventricular tachycardia in patients with structural heart disease and preserved left ventricular ejection fraction: a systematic review and meta-analysis.

In this systematic review and meta-analysis, we aim to evaluate the efficacy and safety of catheter ablation as the first-line treatment of ventricular tachycardia (VT) in patients with structural heart disease (SHD) and preserved left ventricular ejection fraction (LVEF). Patients with SHD are particularly susceptible to VT, a condition that increases the risk of sudden cardiac death (SCD). Implantable cardioverter-defibrillators (ICDs) can terminate VT and prevent SCD but do not prevent VT recurrence. The efficacy and safety of CA as a first-line treatment in SHD patients with preserved LVEF remain unclear. We searched PubMed/Medline, EMBASE, Web of Science, and Cochrane CENTRAL for studies reporting the outcomes of CA therapy in patients with VT and preserved LVEF, published up to January 19, 2023. The primary outcome was the incidence of SCD following catheter ablation as the first-line treatment of VT in patients with SHD and preserved LVEF. Secondary outcomes included all-cause mortality, VT recurrence, procedural complications, CA success rate, and ICD implantation after catheter ablation. We included seven studies in the meta-analysis, encompassing a total of 920 patients. The pooled success rate of catheter ablation was 84.6% (95% CI 67.2-93.6). Complications occurred in 6.4% (95% CI 4.0-9.9) of patients, and 13.9% (95% CI 10.1-18.8) required ICD implantation after ablation. VT recurrence was observed in 23.2% (95% CI 14.8-34.6) of patients, while the rate of sudden cardiac death (SCD) was 3.1% (95% CI 1.7-5.6). The overall prevalence of all-cause mortality in this population was 5% (95% CI 1.8-13). CA appears promising as a first-line VT treatment in patients with SHD and preserved LVEF, especially for monomorphic hemodynamically tolerated VT. However, due to the lack of direct comparisons with ICDs and anti-arrhythmic drugs, further research is needed to confirm these findings.

Predictors of permanent pacemaker implantation for transcatheter self-expandable aortic valve implant in the cusp overlap era.

BACKGROUND: Predictors of permanent pacemaker implantation (PPMI) after self-expanding transcatheter aortic valve implant (TAVI) were described. Is unknown if PPMI predictors remain in the era of high implants using the cusp overlap (COP). METHODS: Single-center, prospective, consecutive case series of patients undergoing self-expanding TAVI with the COP approach. The status of PPMI and other clinical events were ascertained at 30 days. RESULTS: A total of 261 patients were included (84% with Evolut, n = 219). Implant depth >4 mm was infrequent (13.8%). TAVI depth (OR 1.259; p = 0.005), first or second-degree auriculo-ventricular block (OR 3.406; p = 0.033), right-bundle (OR 15.477; p < 0.0001), and incomplete left-bundle branch block (OR 7.964; p = 0.036) were found to be independent predictors of PPMI. The risk of PPMI with deep implant and no electrical disturbances was 3%, and 0% with high implant and no prior electrical disturbances. Those who received PPMI had no statistically significant increased risk of death, myocardial infarction, stroke, bleeding events, or vascular complications at 30 days, but longer hospital stay (mean difference 1.43 days more, p = 0.003). CONCLUSIONS: Implant depth and prior conduction abnormalities remain the main predictors of PPMI using self-expanding TAVI in the COP era. Patients with high implants and no prior conduction abnormalities may be candidates for early discharge after uneventful self-expanding TAVI, while the rest may need inpatient monitoring regardless of achieving a high implant. The need for PPMI was associated with longer hospital stays.

Clinical Advances in Cardiovascular Computed Tomography: From Present Applications to Promising Developments.

PURPOSE OF THE REVIEW: This review aims to provide a profound overview on most recent studies on the clinical significance of Cardiovascular Computed Tomography (CCT) in diagnostic and therapeutic pathways. Herby, this review helps to pave the way for a more extended but yet purposefully use in modern day cardiovascular medicine. RECENT FINDINGS: In recent years, new clinical applications of CCT have emerged. Major applications include the assessment of coronary artery disease and structural heart disease, with corresponding recommendations by major guidelines of international societies. While CCT already allows for a rapid and non-invasive diagnosis, technical improvements enable further in-depth assessments using novel imaging parameters with high temporal and spatial resolution. Those developments facilitate diagnostic and therapeutic decision-making as well as improved prognostication. This review determined that recent advancements in both hardware and software components of CCT allow for highly advanced examinations with little radiation exposure. This particularly strengthens its role in preventive care and coronary artery disease. The addition of functional analyses within and beyond coronary artery disease offers solutions in wide-ranging patient populations. Many techniques still require improvement and validation, however, CCT possesses potential to become a "one-stop-shop" examination.

Mitral Valve Edge-to-Edge Repair Through an Atrial Septal Shunt Device.

Atrial shunt devices are being implanted with increasing frequency, and there are potential concerns for subsequent procedures using transseptal access. A 79-year-old woman presented with progressive dyspnea of multifactorial etiology with already implanted atrial shunt device. Due to comorbidities, successful mitral-valve edge-to-edge repair was performed transseptally through the shunt device.

Economic Disparities in Utilization and Outcomes of Structural Heart Disease Interventions in the United States.

Background: Disparities in access to care cause negative health consequences for underserved populations. Economic disparities in structural heart disease (SHD) interventions are not well characterized. Objectives: The objective of this study was to evaluate economic disparities in the utilization and outcomes of SHD interventions in the United States. Methods: We queried the National Inpatient Sample (2016-2020) to examine economic disparities in the utilization, in-hospital outcomes, length of stay, and cost of SHD interventions among patients ≥65 years of age. Outcomes were determined using logistic regression models. Results: A total of 401,005 weighted hospitalizations for transcatheter aortic valve replacement, left atrial appendage occlusion, transcatheter mitral valve repair, and transcatheter mitral valve replacement were included. Utilization rates (number of procedures performed per 100,000 hospitalizations) were higher in patients with high income compared with medium and low income for transcatheter aortic valve replacement (559 vs 456 vs 338), left atrial appendage occlusion (148 vs 136 vs 99), transcatheter mitral valve repair (65 vs 54 vs 41), and transcatheter mitral valve replacement (7.7 vs 6.7 vs 1.2) (all P < 0.01). Low- and medium-income patients had distinctive demographic and clinical risk profiles compared with high-income patients. There were no significant differences in the adjusted in-hospital mortality, key complications, or length of stay between high-, medium-, and low-income patients following any of the 4 SHD interventions. High-income patients incurred a modestly higher cost with any of the 4 SHD interventions compared with medium- and low-income patients. Conclusions: Economic disparities exist in the utilization of SHD interventions in the United States. Nonetheless, adjusted in-hospital outcomes were comparable among high-, medium-, and low-income patients. Multifaceted implementation strategies are needed to attenuate these utilization disparities.

Left Ventricular Outflow Tract and Transcatheter Mitral Valve Replacement Obstruction and TMVR: Predictors, Evaluation, and Solutions.

In this issue of Structural Heart, high-impact presentations from Transcatheter Valve Therapies 2023 are reviewed. Dr Jaffar Khan provided updates on the current understanding of left ventricular outflow tract obstruction in the field of transcatheter mitral valve replacement, highlighting known predictors of obstruction, a generally agreed-upon strategy for preprocedure assessment, and a host of management strategies in various stages of development and study.

A Comprehensive Evaluation of the NAVITOR Transcatheter Aortic Valve Replacement System.

Transcatheter aortic valve replacement (TAVR) has undergone significant advancements in the last two decades, expanding its indications and refining transcatheter heart valve (THV) and delivery system designs to improve procedural success and patient outcomes. This review focuses on the Navitor™ valve, a third-generation intra-annular Portico™ valve (Abbott Structural Heart, St Paul, MN, USA) designed to address TAVR complications, particularly paravalvular leak (PVL). We present an overview of the Navitor™ system, comparing it to the first-generation Portico™ THV in terms of THV design, key iterations and clinical outcomes. The Navitor™ THV introduces two key refinements-a protective outer sealing skirt and a more flexible delivery system. These enhancements have led to a significant reduction in 30 day PVL rates, from 6.3% with the first-generation Portico™ to 0% with the Navitor™ system. Additionally, the Navitor™ system exhibited lower rates of severe bleeding (27.3% versus 13.1%) and major vascular complications (5.8% versus 0.7%) compared with the first-generation Portico™. The Navitor™ valve represents a promising advancement in TAVR technology, with notable reductions in complications such as PVL, severe bleeding, and major vascular issues, compared with its predecessor. While further research is needed to assess long-term durability, these results underscore its potential benefits in enhancing patient outcomes and reducing complications. This review provides insights into the evolving landscape of TAVR technology and its quantifiable impact on patient care.

Understanding the role of the left atrial appendage on the flow in the atrium.

BACKGROUND: The exclusion/occlusion of the left atrial appendage (LAA) is a treatment option for atrial fibrillation (AF) patients who are at high risk of stroke and high risk of bleeding. As the role of the LAA is not well understood or explored, this study aims to assess its role on flow dynamics in the left atrium. METHODS: Computational fluid dynamics (CFD) simulations were carried out for nine AF patients before and after LAA exclusion. The flow parameters investigated included the LA velocities, Time Averaged Wall Shear Stress (TAWSS), Oscillatory Shear Index (OSI), Relative Residence Time (RRT), and Pressure in the LA. RESULTS: This study shows that, on average, a decrease in TAWSS (1.82 ± 1.85 Pa to 1.27 ± 0.96 Pa, p < 0.05) and a slight increase in OSI (0.16 ± 0.10 to 0.17 ± 0.10, p < 0.05), RRT (1.87 ± 1.84 Pa-1 to 2.11 ± 1.78 Pa-1, p < 0.05), and pressure (-19.2 ± 6.8 mmHg to -15.3 ± 8.3 mmHg, p < 0.05) were observed in the LA after the exclusion of the LAA, with a decrease in low-magnitude velocities. CONCLUSION: The exclusion of the LAA seems to be associated with changes in LA flow dynamics. Further studies are needed to elucidate the clinical implications of these changes.

Cardiac magnetic resonance reveals concealed structural heart disease in patients with frequent premature ventricular contractions and normal echocardiography: A systematic review.

Premature ventricular contractions (PVCs) are a common form of arrhythmic events, often representing an idiopathic and benign condition without further therapeutic interventions. However, in certain circumstances PVCs may represent the epiphenomenon of a concealed structural heart disease (SHD). Surface 12­leads EKG and 24-h dynamic EKG are necessary to assess their main characteristics such as site of origin, frequency and complexity. Echocardiography represents the first-line imaging tool recommended to evaluate cardiac structures and function. Cardiac Magnetic Resonance (CMR) is recognized as a superior modality for detecting structural cardiac alterations, that might evade detection by conventional echocardiography. Moreover, in specific populations such as athletes, CMR may have a crucial role to exclude a concealed SHD and the risk of serious arrhythmic events during sport activity. Some clinical characteristics such as male sex, older age or family history of sudden cardiac death (SCD) or cardiomyopathy, and some electrocardiographic features of PVCs, in particular a right branch bundle block (RBBB) with superior/intermediate axis morphology, the reproducibility of VAs during exercise test (ET) or the evidence of complex ventricular arrhythmias, may warrant a CMR evaluation, due to the high probability of SHD. In this systematic review our objective was to provide an exhaustive overview on the role of CMR in detecting a concealed SHD in patients with high daily burden of PVCs and a normal echocardiographic evaluation, paving the way for a more extensive utilization of CMR in presence of certain high-risk clinical and/or EKG features identified during the diagnostic workup.

Clinical impact of novel CMR technology on patients with congenital heart disease. A scientific statement of the Association for European Pediatric and Congenital Cardiology (AEPC) and the European Association of Cardiovascular Imaging (EACVI) of the ESC.

Cardiovascular magnetic resonance (CMR) imaging is recommended in patients with congenital heart disease (CHD) in clinical practice guidelines as the imaging standard for a large variety of diseases. As CMR is evolving, novel techniques are becoming available. Some of them are already used clinically, whereas others still need further evaluation. In this statement the authors give an overview of relevant new CMR techniques for the assessment of CHD. Studies with reference values for these new techniques are listed in the supplement.

Whispers of the Cath lab: "Cases we would rather forget".

In the dynamic field of interventional cardiology, significant strides have been made in reducing periprocedural complications. Echocardiography, particularly transesophageal echocardiography, plays a key role in ensuring the safety and success of structural heart interventions. Its real-time imaging capabilities allow for precise monitoring of device positioning, deployment, and procedural outcomes. By adhering to established imaging protocols and acquiring standard imaging planes, periprocedural echocardiography has become an essential tool for the successful performance of many structural heart interventions. In this manuscript, we present a series of unusual yet significant complications that we encountered during structural interventional procedures in our catheter laboratory. These complications, detected through echocardiography, underscore the critical role of imaging guidance in recognizing, and addressing unforeseen challenges, such as device malposition, thrombus formation in cardiac chambers during structural heart interventions, and cardiac tamponade during transcatheter mitral valve procedures. Through these cases, we highlight the effectiveness of transesophageal echocardiography in promptly identifying complications, allowing for timely intervention and resolution.

Indications and outcomes of the MitraClip G4 device with controlled gripper actuation system.

The MitraClip G4 device has controlled gripper actuation (CGA) system, which allows the anterior and posterior grippers operate separately in transcatheter edge-to-edge repair (TEER). We investigated the indications and outcomes of the use of CGA system during TEER for significant mitral regurgitation (MR). We reviewed 158 patients undergoing TEER with MitraClip G4 from September 2020 to July 2023. The CGA indications were: (1) for grasping and (2) for leaflet insertion confirmation. Leaflet grasping was completed with CGA in 18 patients (11 and 7 patients for grasping and leaflet insertion confirmation, respectively). Patients with flail leaflets or coaptation gap more frequently required CGA, indicating more complex mitral valve anatomy. The procedural success and adverse event rates (death, leaflet tear and single leaflet device attachment) were not different between the CGA and non-CGA groups. In patients requiring CGA, single leaflet device attachment was observed in 1 patient and leaflet tear in 1 patient during follow-up. In these two cases, CGA was required for grasping, and the clip was moved over a large distance (6.5 and 12.4 mm, respectively). In patients who had undergone CGA for confirmation, no device-related adverse event or MR recurrence was noted. In patients with complex mitral valve anatomy, CGA may be a safe and effective method for confirming leaflet insertion. It should be noted that when using CGA for leaflet grasping, especially when the clip is moved significantly, attention should be paid to leaflet adverse events.

Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers After Transcatheter Aortic Valve Replacement: A Meta-Analysis.

Background: Persistent left ventricular hypertrophy after transcatheter aortic valve replacement (TAVR) has been associated with poor outcomes. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), due to their favorable effects on ventricular remodeling, have been hypothesized to improve outcomes post-TAVR, yet there are no recommendations regarding their use. Objectives: This study aimed to compare the outcomes of patients receiving ACEIs/ARBs with those not receiving ACEIs/ARBs after TAVR. Methods: We performed a literature search on PubMed and Cochrane Library until June 14, 2023, and included all studies comparing clinical outcomes between patients given ACEIs/ARBs and those not given ACEIs/ARBs after TAVR. All-cause mortality was the primary outcome. We used a random effects model with appropriate corrections to calculate relative risk (RR) and CIs, with all analyses carried out using R v4.0.3. Results: We included ten studies on the use of ACEIs/ARBs post-TAVR. Patients on ACEIs/ARBs had lower risk of all-cause mortality (RR: 0.74, 95% CI: 0.65-0.86, I2 = 62%, chi-square P < 0.01), cardiovascular mortality (RR: 0.70, 95% CI: 0.56-0.88, I2 = 0%, chi-square P = 0.54), and new-onset atrial fibrillation (RR: 0.71, 95% CI: 0.52-0.96, I2 = 0%, chi-square P = 0.59). Patients on ACEIs/ARBs had a similar risk of myocardial infarction, heart failure, stroke, new permanent pacemaker implantation, acute kidney injury, major bleeding, vascular complications, aortic regurgitation, and mitral regurgitation. Conclusions: We found that patients receiving ACEIs/ARBs had a lower risk of all-cause mortality, cardiovascular mortality, and new-onset atrial fibrillation. Risk of other outcomes was similar to patients not receiving ACEIs/ARBs. Randomized clinical trials are needed to explore the benefits of ACEIs/ARBs post-TAVR, so that definitive guidelines can be developed.

Prediction of the Individual Aortic Stenosis Progression Rate and its Association With Clinical Outcomes.

Background: The progression rate of aortic stenosis differs between patients, complicating clinical follow-up and management. Objectives: This study aimed to identify predictors associated with the progression rate of aortic stenosis. Methods: In this retrospective longitudinal single-center cohort study, all patients with moderate aortic stenosis who presented between December 2011 and December 2022 and had echocardiograms available were included. The individual aortic stenosis progression rate was calculated based on aortic valve area (AVA) from at least 2 echocardiograms performed at least 6 months apart. Baseline factors associated with the progression rate of AVA were determined using linear mixed-effects models, and the association of progression rate with clinical outcomes was evaluated using Cox regression. Results: The study included 540 patients (median age 69 years and 38% female) with 2,937 echocardiograms (median 5 per patient). Patients had a linear progression with a median AVA decrease of 0.09 cm2/y and a median peak jet velocity increase of 0.17 m/s/y. Rapid progression was independently associated with all-cause mortality (HR: 1.77, 95% CI: 1.26-2.48) and aortic valve replacement (HR: 3.44, 95% CI: 2.55-4.64). Older age, greater left ventricular mass index, atrial fibrillation, and chronic kidney disease were associated with a faster decline of AVA. Conclusions: AVA decreases linearly in individual patients, and faster progression is independently associated with higher mortality. Routine clinical and echocardiographic variables accurately predict the individual progression rate and may aid clinicians in determining the optimal follow-up interval for patients with aortic stenosis.

Transcatheter Structural Heart Interventions in the Acute Setting: An Emerging Indication.

Structural heart disease is increasingly prevalent in the general population, especially in patients of increased age. Recent advances in transcatheter structural heart interventions have gained a significant following and are now considered a mainstay option for managing stable valvular disease. However, the concept of transcatheter interventions has also been tested in acute settings by several investigators, especially in cases where valvular disease comes as a result of acute ischemia or in the context of acute decompensated heart failure. Tested interventions include both the mitral and aortic valve, mostly evaluating mitral transcatheter edge-to-edge repair and transcatheter aortic valve implantation, respectively. This review is going to focus on the use of acute structural heart interventions in the emergent setting, and it will delineate the available data and provide a meaningful discussion on the optimal patient phenotype and future directions of the field.

Postextrasystolic repolarization changes of ventricular premature beats correlate with structural heart disease and suggest prognostic implications.

Ventricular premature beats (VPBs) can potentially lead to life-threatening arrhythmias, especially in patients with structural heart disease (SHD). However, identifying dangerous VPBs has always been a topic and challenge in clinical research. This study aimed to evaluate the relationship of postextrasystolic repolarization changes of VPBs with SHD and its possible additional prognostic value. 125 cases of frequent VPBs with SHD and 156 cases without SHD were included. VPBs were stratified selected from 24 h Holter recording according to the scale of heart rate. Average QTDV (difference value of QT interval between the first beat follow VPB with beats preceding VPB) and max QTDV were significantly longer in SHD group than that in the non-SHD group. For identifying patients with SHD, the best cutoff value were 19 ms for average QTDV (AUC = 0.931) and 29 ms for max QTDV (AUC = 0.910) respectively. For Tu morphology analysis, PT2 (postextrasystolic T wave amplitude change ≥2 mV), reversed T wave, and Pu (postextrasystolic u wave) change were all highly specific, but low sensitive as identification of SHD. Compared with average QTDV < 19 ms patients, average QTDV ≥ 19 ms patients had significantly larger left heart size and wores left cardiac function. The presence of non-persistent ventricular tachycardia runs was higher in average QTDV ≥ 19 ms group and positive Pu change group than that in control groups. The findings indicated that postextrasystolic repolarization changes of VPBs correlated with SHD and suggested potential value in prognosis asssessment.