Management of respiratory failure in immune checkpoint inhibitors-induced overlap syndrome: a case series and review of the literature.

BACKGROUND: Checkpoint inhibitor-induced overlap syndrome ([OS] myocarditis, and myositis with or without myasthenia gravis) is rare but life-threatening. CASES PRESENTATION: Here we present a case series of four cancer patients that developed OS. High troponinemia raised the concern for myocarditis in all the cases. However, the predominant clinical feature differed among the cases. Two patients showed marked myocarditis with a shorter hospital stay. The other two patients had a prolonged ICU stay due to severe neuromuscular involvement secondary to myositis and myasthenia gravis. Treatment was based on steroids, plasmapheresis, intravenous immunoglobulin, and immunosuppressive biological agents. CONCLUSION: The management of respiratory failure is challenging, particularly in those patients with predominant MG. Along with intensive clinical monitoring, bedside respiratory mechanics can guide the decision-making process of selecting a respiratory support method, the timing of elective intubation and extubation.

Transcatheter mitral valve repair in a liver transplant candidate.

Untreated severe mitral regurgitation (MR) is associated with poor outcomes due to the adverse consequences of long-standing volume overload on the left ventricle and left atrium, which leads to pulmonary hypertension and right-sided heart failure. Early intervention results in favorable long-term outcomes making appropriate timing of intervention very critical. We present a 53-year-old male with severe symptomatic MR and right sided-heart failure which progressed to cardiac cirrhosis necessitating enrollment to the liver transplant list. Transcatheter mitral valve repair (TMVR) using MitraClip implantation resulted in impressive clinical improvement and resolution of cirrhosis. Eventually, the patient was taken off the transplant list. Treatment of severe MR may lead to improvements in congestive hepatopathy.

Fractional Flow Reserve Cardio-Oncology Effects on Inpatient Mortality, Length of Stay, and Cost Based on Malignancy Type: Machine Learning Supported Nationally Representative Case-Control Study of 30 Million Hospitalizations.

Background and Objectives: There are no nationally representative studies of mortality and cost effectiveness for fractional flow reserve (FFR) guided percutaneous coronary interventions (PCI) in patients with cancer. Our study aims to show how this patient population may benefit from FFR-guided PCI. Materials and Methods: Propensity score matched analysis and backward propagation neural network machine learning supported multivariable regression was performed for inpatient mortality in this case-control study of the 2016 National Inpatient Sample (NIS). Regression results were adjusted for age, race, income, geographic region, metastases, mortality risk, and the likelihood of undergoing FFR versus non-FFR PCI. All analyses were adjusted for the complex survey design to produce nationally representative estimates. Results: Of the 30,195,722 hospitalized patients meeting criteria, 3.37% of the PCIs performed included FFR. In propensity score adjusted multivariable regression, FFR versus non-FFR PCI significantly reduced inpatient mortality (OR 0.47, 95%CI 0.35−0.63; p < 0.001) and length of stay (LOS) (in days; beta −0.23, 95%CI −0.37−−0.09; p = 0.001) while increasing cost (in USD; beta $5708.63, 95%CI, 3042.70−8374.57; p < 0.001), without significantly increasing complications overall. FFR versus non-FFR PCI did not specifically change cancer patients' inpatient mortality, LOS, or cost. However, FFR versus non-FFR PCI significantly increased inpatient mortality for Hodgkin's lymphoma (OR 52.48, 95%CI 7.16−384.53; p < 0.001) and rectal cancer (OR 24.38, 95%CI 2.24−265.73; p = 0.009). Conclusions: FFR-guided PCI may be safely utilized in patients with cancer as it does not significantly increase inpatient mortality, complications, and LOS. These findings support the need for an increased utilization of FFR-guided PCI and further studies to evaluate its long-term impact.

Reclassification of Treatment Strategy with Fractional Flow Reserve in Cancer Patients with Coronary Artery Disease.

Background and Objectives: Cancer and coronary artery disease (CAD) often coexist. Compared to quantitative coronary angiography (QCA), fractional flow reserve (FFR) has emerged as a more reliable method of identifying significant coronary stenoses. We aimed to assess the specific management, safety and outcomes of FFR-guided percutaneous coronary intervention (PCI) in cancer patients with stable CAD. Materials and Methods: FFR was used to assess cancer patients that underwent coronary angiography for stable CAD between September 2008 and May 2016, and were found to have ≥50% stenosis by QCA. Patients with lesions with an FFR > 0.75 received medical therapy alone, while those with FFR ≤ 0.75 were revascularized. Procedure-related complications, all-cause mortality, nonfatal myocardial infarction, or urgent revascularizations were analyzed. Results: Fifty-seven patients with stable CAD underwent FFR on 57 lesions. Out of 31 patients with ≥70% stenosis as measured by QCA, 14 (45.1%) had an FFR ≥ 0.75 and lesions were reclassified as moderate and did not receive PCI nor DAPT. Out of 26 patients with <70% stenosis as measured by QCA, 6 (23%) had an FFR < 0.75 and were reclassified as severe and were treated with PCI and associated DAPT. No periprocedural complications, urgent revascularization, acute coronary syndromes, or cardiovascular deaths were noted. There was a 22.8% mortality at 1 year, all cancer related. Patients who received a stent by FFR assessment showed a significant association with decreased risk of all-cause death (HR: 0.37, 95% CI 0.15−0.90, p = 0.03). Conclusions: Further studies are needed to define the optimal therapeutic approach for cancer patients with CAD. Using an FFR cut-off point of 0.75 to guide PCI translates into fewer interventions and can facilitate cancer care. There was an overall reduction in mortality in patients that received a stent, suggesting increased resilience to cancer therapy and progression.

Interventional Strategies in Cancer-induced Cardiovascular Disease.

PURPOSE OF REVIEW: To highlight the range of illnesses and procedures that the interventional onco-cardiologists face in their daily practice, along with the recent additions to anti-cancer therapies and their related cardiotoxicity. RECENT FINDINGS: Immune checkpoint inhibitors (ICI) are not devoid of cardiotoxicity as thought earlier and lead to an increased incidence of myocarditis. Transcatheter valve replacement has been shown to be a safer alternative to surgical replacement in cancer patients. Interventional onco-cardiology is a novel field that addresses cardiovascular diseases in the setting of cancer. Traditionally excluding cancer patients from clinical trials has led to a dearth of information needed to tackle cardiac conditions like Takotsubo cardiomyopathy, malignant pericardial effusions, and radiation-induced vascular diseases encountered either exclusively or predominantly in this high-risk population. This review discusses the various treatment options available in the interventional armamentarium with a particular focus on ICI-myocarditis and transcatheter aortic valve replacement in cancer patients.

Percutaneous coronary intervention and in-hospital outcomes in patients with leukemia: a nationwide analysis.

OBJECTIVES: To examine the association between current leukemia diagnosis and in-hospital clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) in the United States. BACKGROUND: Leukemia is the most common hematological malignancy and is associated with an increased risk of thrombotic and bleeding complications in patients undergoing PCI. There are limited data around clinical outcomes of leukemia patients undergoing PCI. METHODS: We used the National Inpatient Sample to investigate the outcomes of leukemia patients undergoing PCI between 2004 and 2014. Patients were then subdivided into diagnoses of acute myeloid leukemia (AML) or chronic myeloid leukemia and acute lymphoid leukemia or chronic lymphoid leukemia (CLL). Multiple logistic regressions were used to study the association of a leukemia diagnosis with in-hospital outcomes: mortality, bleeding, vascular and cardiac complications, and stroke. RESULTS: There were 6,561,445 records of patients who underwent PCI during the study time, of which 15,789 patients had a diagnosis of leukemia. The most common leukemia subtype was CLL accounting for 75% of the cohort (n = 10,800). After multivariable adjustment, a leukemia diagnosis was associated with significantly increased odds of in-hospital mortality (odds ratio [OR]: 1.41; 95% confidence interval [CI]: [1.11-1.79]) and bleeding (OR: 1.87; 95% CI: [1.56-2.09]), whereas patients with AML had a fivefold increase of in-hospital mortality (OR: 5.38; 95% CI: [2.94-9.76]). CONCLUSIONS: Patients with current diagnosis of leukemia are at increased risk of procedure-related complications following PCI. A multidisciplinary approach is needed among interventional cardiologists, oncologists, and hematologists to minimize procedural complications and improve outcomes in this high-risk cohort.

Management strategies and clinical outcomes of acute myocardial infarction in leukaemia patients: Nationwide insights from United States hospitalisations.

BACKGROUND: Patients with leukaemia are at increased risk of cardiovascular events. There are limited outcomes data for patients with a history of leukaemia who present with an acute myocardial infarction (AMI). METHODS: We queried the Nationwide Inpatient Sample (2004-2014) for patients with a primary discharge diagnosis of AMI, and a concomitant diagnosis of leukaemia, and further stratified according to the subtype of leukaemia. Multivariable logistic regression was conducted to identify the association between leukaemia and major acute cardiovascular and cerebrovascular events (MACCE; composite of mortality, stroke and cardiac complications) and bleeding. RESULTS: Out of 6 750 878 AMI admissions, a total of 21 694 patients had a leukaemia diagnosis. The leukaemia group experienced higher rates of MACCE (11.8% vs 7.8%), mortality (10.3% vs 5.8%) and bleeding (5.6% vs 5.3%). Following adjustments, leukaemia was independently associated with increased odds of MACCE (OR 1.26 [1.20, 1.31]) and mortality (OR 1.43 [1.37, 1.50]) without an increased risk of bleeding (OR 0.86 [0.81, 0.92]). Acute myeloid leukaemia (AML) was associated with approximately threefold risk of MACCE (OR 2.81 [2.51, 3.13]) and a fourfold risk of mortality (OR 3.75 [3.34, 4.22]). Patients with leukaemia were less likely to undergo coronary angiography (CA) (48.5% vs 64.5%) and percutaneous coronary intervention (PCI) (28.2% vs 42.9%) compared with those without leukaemia. CONCLUSION: Patients with leukaemia, especially those with AML, are associated with poor clinical outcomes after AMI, and are less likely to receive CA and PCI compared with those without leukaemia. A multi-disciplinary approach between cardiologists and haematology oncologists may improve the outcomes of patients with leukaemia after AMI.

Percutaneous coronary intervention in cancer patients: a report of the prevalence and outcomes in the United States.

AIMS: This study aims to examine the temporal trends and outcomes in patients who undergo percutaneous coronary intervention (PCI) with a previous or current diagnosis of cancer, according to cancer type and the presence of metastases. METHODS AND RESULTS: Individuals undergoing PCI between 2004 and 2014 in the Nationwide Inpatient Sample were included in the study. Multivariable analyses were used to determine the association between cancer diagnosis and in-hospital mortality and complications. 6 571 034 PCI procedures were included and current and previous cancer rates were 1.8% and 5.8%, respectively. Both rates increased over time and the four most common cancers were prostate, breast, colon, and lung cancer. Patients with a current lung cancer had greater in-hospital mortality (odds ratio (OR) 2.81, 95% confidence interval (95% CI) 2.37-3.34) and any in-hospital complication (OR 1.21, 95% CI 1.10-1.36), while current colon cancer was associated with any complication (OR 2.17, 95% CI 1.90-2.48) and bleeding (OR 3.65, 95% CI 3.07-4.35) but not mortality (OR 1.39, 95% CI 0.99-1.95). A current diagnosis of breast was not significantly associated with either in-hospital mortality or any of the complications studied and prostate cancer was only associated with increased risk of bleeding (OR 1.41, 95% CI 1.20-1.65). A historical diagnosis of lung cancer was independently associated with an increased OR of in-hospital mortality (OR 1.65, 95% CI 1.32-2.05). CONCLUSIONS: Cancer among patients receiving PCI is common and the prognostic impact of cancer is specific both for the type of cancer, presence of metastases and whether the diagnosis is historical or current. Treatment of patients with a cancer diagnosis should be individualized and involve a close collaboration between cardiologists and oncologists.

Applications of Cardiac Computed Tomography in the Cardio-Oncology Population.

OPINION STATEMENT: The increased risk for cardiovascular events in aging cancer survivors and those undergoing certain chemotherapeutic treatments has raised concern for more rigorous screening and surveillance methods above that of the general population. At this time, there are limited guidelines for how to best manage this vulnerable cohort. Questions regarding timing of screening, choice of imaging modality and risk reduction strategies-especially in those patients with known atherosclerotic disease-remain to be elucidated. Over a decade of case series, retrospective studies and clinical trials have shed light on the evolving role of cardiac computed tomography (CT) in this population, of which there is a relative paucity of data regarding its potential utility in the specific cardio-oncology population. Focusing on ability of cardiac CT to evaluate multiple cardiac and vascular structures, provide diagnostic and prognostic information, as well as assist interventional and surgical colleagues in surgical/percutaneous valve replacement and revascularization strategies is the premise for this review.

Vascular Toxicities of Cancer Therapies: The Old and the New--An Evolving Avenue.

Since the late 1990s, there has been a steady decline in cancer-related mortality, in part related to the introduction of so-called targeted therapies. Intended to interfere with a specific molecular pathway, these therapies have, paradoxically, led to a number of effects off their intended cancer tissue or molecular targets. The latest examples are tyrosine kinase inhibitors targeting the Philadelphia Chromosome mutation product, which have been associated with progressive atherosclerosis and acute vascular events. In addition, agents designed to interfere with the vascular growth factor signaling pathway have vascular side effects ranging from hypertension to arterial events and cardiomyocyte toxicity. Interestingly, the risk of cardiotoxicity with drugs such as trastuzumab is predicted by preexisting cardiovascular risk factors and disease, posing the question of a vascular component to the pathophysiology. The effect on the coronary circulation has been the leading explanation for the cardiotoxicity of 5-fluorouracil and may be the underlying the mechanism of presentation of apical ballooning syndrome with various chemotherapeutic agents. Classical chemotherapeutic agents such as cisplatin, often used in combination with bleomycin and vinca alkaloids, can lead to vascular events including acute coronary thrombosis and may be associated with an increased long-term cardiovascular risk. This review is intended to provide an update on the evolving spectrum of vascular toxicities with cancer therapeutics, particularly as they pertain to clinical practice, and to the conceptualization of cardiovascular diseases, as well. Vascular toxicity with cancer therapy: the old and the new, an evolving avenue.

"Bringing on the light" in a complex clinical scenario: Optical coherence tomography-guided discontinuation of antiplatelet therapy in cancer patients with coronary artery disease (PROTECT-OCT registry).

BACKGROUND: Cancer patients with recently placed drug-eluting stents (DESs) often require premature dual antiplatelet therapy (DAPT) discontinuation for cancer-related procedures. Optical coherence tomography (OCT) can identify risk factors for stent thrombosis such as stent malapposition, incomplete strut coverage and in-stent restenosis and may help guide discontinuation of DAPT. METHODS: We conducted a single-center prospective study in cancer patients with recently placed (1-12 months) DES who required premature DAPT discontinuation. Patients were evaluated with diagnostic coronary angiogram and OCT. Individuals with appropriate stent strut coverage, expansion, apposition, and absence of in-stent restenosis or intraluminal masses were considered low risk and transiently discontinued DAPT to allow optimal cancer therapy. Patients who did not meet all these criteria were considered high risk and underwent further endovascular treatment when appropriate and bridging with low-molecular weight heparin. The incidence of adverse cardiovascular events was assessed after the procedure and at 12 months. RESULTS: A total of 40 patients were included. Twenty-seven patients (68%) were considered low risk by OCT criteria and DAPT was transiently discontinued. Thirteen patients (32%) were considered high risk with one or more OCT findings: uncovered stent struts (4 patients, 10%); stent underexpansion (3 patients, 8%); malapposition (8 patients, 20%); in-stent restenosis (2 patients, 5%). The high-risk patients with uncovered stent struts and malapposition underwent additional stent dilatation. There were no cardiovascular events in the low-risk group. One myocardial infarction occurred in the high-risk group. Fourteen non-cardiac deaths were registered before 12 months due to cancer progression or cancer therapy. CONCLUSION: OCT imaging allows identification of low-risk cancer patients with DES placed who may safely discontinue DAPT and proceed with cancer-related surgery or procedures.

SCAI Expert consensus statement: Evaluation, management, and special considerations of cardio-oncology patients in the cardiac catheterization laboratory (endorsed by the cardiological society of india, and sociedad Latino Americana de Cardiologia intervencionista).

In the United States alone, there are currently approximately 14.5 million cancer survivors, and this number is expected to increase to 20 million by 2020. Cancer therapies can cause significant injury to the vasculature, resulting in angina, acute coronary syndromes (ACS), stroke, critical limb ischemia, arrhythmias, and heart failure, independently from the direct myocardial or pericardial damage from the malignancy itself. Consequently, the need for invasive evaluation and management in the cardiac catheterization laboratory (CCL) for such patients has been increasing. In recognition of the need for a document on special considerations for cancer patients in the CCL, the Society for Cardiovascular Angiography and Interventions (SCAI) commissioned a consensus group to provide recommendations based on the published medical literature and on the expertise of operators with accumulated experience in the cardiac catheterization of cancer patients.

Radiation-related heart and vascular disease.

Improvement in cancer therapy has led to increasing number of cancer survivors, some of whom have previously been treated with mediastinal radiation. Cardiac complication may manifest years after completion of radiation therapy. Hence long-term follow-up is essential in these patients. In this paper, we have discussed the short- and long-term cardiovascular side effects of radiation therapy.

Prevalence, mortality, cost, and disparities in transcatheter mitral valve repair and replacement in cancer patients: Artificial intelligence and propensity score national 5-year analysis of 7495 procedures.

INTRODUCTION: We conducted the first comprehensive evaluation of the therapeutic value and safety profile of transcatheter mitral edge-to-edge repair (TEER) and transcatheter mitral valve replacement (TMVR) in individuals concurrently afflicted with cancer. METHODS: Utilizing the National Inpatient Sample (NIS) dataset, we analyzed all adult hospitalizations between 2016 and 2020 (n = 148,755,036). The inclusion criteria for this retrospectively analyzed prospective cohort study were all adult hospitalizations (age 18 years and older). Regression and machine learning analyses in addition to model optimization were conducted using ML-PSr (Machine Learning-augmented Propensity Score adjusted multivariable regression) and BAyesian Machine learning-augmented Propensity Score (BAM-PS) multivariable regression. RESULTS: Of all adult hospitalizations, there were 5790 (0.004%) TMVRs and 1705 (0.001%) TEERs. Of the total TMVRs, 160 (2.76%) were done in active cancer. Of the total TEERs, 30 (1.76%) were done in active cancer. After the comparable rates of TEER/TMVR in active cancer in 2016, the prevalence of TEER/TMVR was significantly less in active cancer from 2017 to 2020 (2.61% versus 7.28% p < 0.001). From 2017 to 2020, active cancer significantly decreased the odds of receiving TEER or TMVR (OR 0.28, 95%CI 0.13-0.68, p = 0.008). In patients with active cancer who underwent TMVR/TEER, there were no significant differences in socio-economic disparities, mortality or total hospitalization costs. CONCLUSION: The presence of malignancy does not contribute to increased mortality, length of stay or procedural costs in TMVR or TEER. Whereas the prevalence of TMVR has increased in patients with active cancer, the utilization of TEER in the context of active cancer is declining despite a growing patient population.

Primary Endovascular Treatment of Late-Onset Type 3 Endovascular Aortic Repair Rupture Using The Endurant II Stent Graft and Rapid Response Protocol.

The objective of this article is to describe a patient with hemorrhagic shock due to type 3 postendovascular aortic repair rupture successfully treated with the endurant II stent graft via a primary endovascular approach with a rapid response protocol. A 65-year-old male patient who underwent endovascular aortic repair 3 years ago was admitted to the emergency department with severe abdominal pain and hemorrhagic shock. The patient was rapidly taken to the angiography laboratory, and aortography demonstrated distal aortic graft rupture and extravasation of contrast media. The repair was performed successfully with 3 stent-grafts by paying attention to rupture localization and renal artery ostia. The hemodynamics of the patient improved very quickly, and the patient was discharged after 5 days. Emergency primary stent grafting using a rapid response protocol could be a crucial alternative to open surgery for late endoleaks, which are complicated with hemorrhagic shock.

2021. The year in review. Structural heart interventions.

Since the beginning of 2020, the corona virus (COVID-19) pandemic redefined in many ways the practice of cardiology, research and cardiology conferences. Virtual conferences replaced most major in-person venues. The number of "elective" structural heart interventions declined and clinical research endured major setbacks in regards to academic and industry-sponsored clinical trials. In this review, we attempt to provide a broad overview of the field for general and interventional cardiologists with a specific interest in structural heart interventions.

Percutaneous coronary intervention in patients with cancer using bare metal stents compared to drug-eluting stents.

Background: Management of coronary artery disease (CAD) is unique and challenging in cancer patients. However, little is known about the outcomes of using BMS or DES in these patients. This study aimed to compare the outcomes of percutaneous coronary intervention (PCI) in cancer patients who were treated with bare metal stents (BMS) vs. drug-eluting stents (DES). Methods: We identified cancer patients who underwent PCI using BMS or DES between 2013 and 2020. Outcomes of interest were overall survival (OS) and the number of revascularizations. The Kaplan-Meier method was used to estimate the survival probability. Multivariate Cox regression models were utilized to compare OS between BMS and DES. Results: We included 346 cancer patients who underwent PCI with a median follow-up of 34.1 months (95% CI, 28.4-38.7). Among these, 42 patients were treated with BMS (12.1%) and 304 with DES (87.9%). Age and gender were similar between the BMS and DES groups (p = 0.09 and 0.93, respectively). DES use was more frequent in the white race, while black patients had more BMS (p = 0.03). The use of DES was more common in patients with NSTEMI (p = 0.03). The median survival was 46 months (95% CI, 34-66). There was no significant difference in the number of revascularizations between the BMS and DES groups (p = 0.43). There was no significant difference in OS between the BMS and DES groups in multivariate analysis (p = 0.26). In addition, independent predictors for worse survival included age > 65 years, BMI ≤ 25 g/m2, hemoglobin level ≤ 12 g/dL, and initial presentation with NSTEMI. Conclusions: In our study, several revascularizations and survival were similar between cancer patients with CAD treated with BMS and DES. This finding suggests that DES use is not associated with an increased risk for stent thrombosis, and as cancer survival improves, there may be a more significant role for DES.

Trigger related outcomes of takotsubo syndrome in a cancer population.

Background: Takotsubo syndrome (TTS) occurs more frequently in cancer patients than in the general population, but the effect of specific TTS triggers on outcomes in cancer patients is not well studied. Objectives: The study sought to determine whether triggering event (chemotherapy, immune-modulators vs. procedural or emotional stress) modifies outcomes in a cancer patient population with TTS. Methods: All cancer patients presenting with acute coronary syndrome (ACS) between December 2008 and December 2020 at our institution were enrolled in the catheterization laboratory registry. Demographic and clinical data of the identified patients with TTS were retrospective collected and further classified according to the TTS trigger. The groups were compared with regards to major adverse cardiac events, overall survival and recovery of left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) after TTS presentation. Results: Eighty one of the 373 cancer patients who presented with ACS met the Mayo criteria for TTS. The triggering event was determined to be "cancer specific triggers" (use of chemotherapy in 23, immunomodulators use in 7, and radiation in 4), and "traditional triggers" (medical triggers 22, and procedural 18 and emotional stress in 7). Of the 81 patients, 47 died, all from cancer-related causes (no cardiovascular mortality). Median survival was 11.9 months. Immunomodulator (IM) related TTS and radiation related TTS were associated with higher mortality during the follow-up. Patients with medical triggers showed the least recovery in LVEF and GLS while patients with emotional and chemotherapy triggers, showed the most improvement in LVEF and GLS, respectively. Conclusion: Cancer patients presenting with ACS picture have a high prevalence of TTS due to presence of traditional and cancer specific triggers. Survival and improvement in left ventricular systolic function seem to be related to the initial trigger for TTS.

Bioprosthetic valve monitoring in patients with carcinoid heart disease.

Background: Carcinoid heart disease (CnHD) is a frequent cause of morbidity and mortality in patients with neuroendocrine tumors and carcinoid syndrome. Although valve replacement surgery appears to decrease all-cause mortality in patients with advanced CnHD, few studies have investigated the outcomes of patients after valve replacement. Methods: We conducted a multi-institution retrospective registry of patients who received both tricuspid and pulmonic bioprosthetic valve (TV/PV) replacements for advanced CnHD from November 2005 to March 2021. Patients were followed post-operatively with echocardiographic studies every 3 months. Carcinoid valvular heart disease scores were used to monitor valve degeneration. Neuroendocrine tumor treatment, their administration times, and associations with echocardiographic findings were recorded. Results: Of 87 patients with CnHD, 22 patients underwent simultaneous surgical TV and PV replacement. In 6 patients (27.3%), increased PV Vmax was the first echocardiographic manifestation of valve degeneration in the setting of occult neurohormonal release. Post-operative telotristat ethyl and peptide receptor radionuclide therapy appeared to stabilize PV Vmax. The PV Vmax showed consistent elevation in the entire patient population when compared to baseline, while bioprosthetic TV echocardiographic parameters were relatively unchanged throughout. Post-operative warfarin therapy did not affect the rate of PV degeneration, and no major bleeding was recorded during or after post-operative anticoagulation therapy. Conclusion: Bioprosthetic valve degeneration is common in CnHD. Monitoring with echocardiographic studies every 3 months, focusing on PV velocities, could identify patients with occult disease that very likely promotes valve degeneration. Novel neuroendocrine tumor therapies may have a beneficial impact on valve degeneration.

Percutaneous Muscular Ventricular Septal Defect Closure with 2D Transthoracic Echocardiography: Can We Sufficiently Visualize It?

Ventricular septal defect (VSD) is one of the most common congenital heart diseases worldwide today. Although the majority close spontaneously, transcatheter VSD closure is a common option for symptomatic patients with suitable anatomy in adult age. Although transesophageal echocardiography (TEE) and intracardiac echocardiography are the most common imaging modalities for the procedure, in patients with poor TEE images, Transthoracic echocardiography (TTE) can be used as a reliable alternative. Here we present an adult patient with pulmonary hypertension associated with a muscular VSD which was closed percutaneously using 2-dimensional TTE because of poor TEE images.