Optimal antiplatelet and antithrombotic regimen post-transcatheter aortic valve replacement.

BACKGROUND: There are limited data regarding optimal antiplatelet/antithrombotic therapy following transcatheter aortic valve replacement (TAVR). METHODS: In this single-centre retrospective study including TAVR patients from 2012 to 2020, ischemic and bleeding outcomes were compared between antiplatelet (dual antiplatelet [DAPT] vs. single antiplatelet [SAPT]) and oral anticoagulation (OAC) groups using incidence rate, Kaplan-Meier and Cox proportional hazards analysis. RESULTS: Total 492 patients (mean age 79.7 ± 7.7 years, 53.7% males, 83.5% Caucasian) were included. There was higher incidence of 1-year death or ischemia with DAPT vs. SAPT (23.6 vs. 14.8 per 100 patient-years [PY], incidence rate ratio [IRR] 1.60, 95% confidence interval [CI] 0.97-2.68, p = .05), especially in those without coronary artery disease (23.9 vs. 10.7 per 100 PY, IRR 2.24, 95% CI 1.10-4.47, p = .017). There was significantly higher major bleeding in those on OAC vs. no OAC (15 vs. 8 per 100 PY, IRR 1.87, 95% CI 1.10-3.11, p = .016), especially late (>1-year) bleeding (10.2 vs. 3.6 per 100 PY, IRR 2.81, 95% CI 1.33-5.92, p = .004). In multivariate analysis, DAPT was an independent predictor of death or ischemia (adjusted hazard ratio [aHR] 1.41, 95% CI 1.01-1.96, p = .041). OAC was an independent predictor of major bleeding (aHR 2.32, 95% CI 1.31-4.13, p = .004). CONCLUSIONS: There is signal to harm with routine use of DAPT post-TAVR. There is higher incidence of late bleeding post-TAVR with OAC, suggesting potential role for alternate antithrombotic strategies.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Imaging Strategies for Evaluating Low-Flow, Low-Gradient Aortic Stenosis with Reduced and Preserved Left Ventricular Ejection Fraction.

PURPOSE OF REVIEW: Aortic stenosis (AS) is one of the most common valvular heart diseases, and aortic valve replacement (AVR) provides both symptomatic and survival benefit in symptomatic severe AS patients. The purpose of this review is to discuss low-flow low-gradient AS which is still a challenging diagnostic entity. RECENT FINDINGS: Thirty-forty percent of patients with AS have low flow which makes it difficult to differentiate truly severe AS that benefits from AVR compared to pseudo-severe AS which is currently managed conservatively. Patients with low-flow low-gradient AS (LF-LG AS) include those with reduced left ventricular systolic function (classical LF-LG AS) and those with preserved left ventricular systolic function (paradoxical LF-LG AS). Low-dose dobutamine stress echocardiography (DSE) helps to identify truly severe stenosis in patients with classical LF-LG AS. Aortic valve calcium scoring with multidetector computed tomography plays a major role in patients with paradoxical LF-LG AS and also among classical LF-LG AS patients who have reduced contractile reserve on DSE. This article will provide an overview of imaging strategies for evaluating LF-LG AS with reduced and preserved left ventricular ejection fraction.

Aortic Stenosis.

This issue provides a clinical overview of aortic stenosis, focusing on screening, diagnosis, treatment, and practice improvement. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of additional science writers and physician writers.

Introduction to aortic stenosis.

Aortic stenosis is perhaps the most common of all valvular heart diseases in the developed nations of the world. Once primarily caused by rheumatic fever, the most common pathogenesis today is an active inflammatory process with some features that are similar to atherosclerosis. Because of this shift, the age at onset of severe obstruction has changed from the sixth decade 50 years ago to the eighth decade in most individuals today. The onset of symptoms remains a key determinant of outcome, although the later age at onset may make it difficult to discern if aortic stenosis or other age-related comorbidities is the cause of the symptoms. Once symptoms of aortic stenosis develop, life expectancy is shortened to ≈3 years unless the mechanical obstruction to left ventricular outflow is relieved by aortic valve replacement. Traditionally performed during cardiac surgery, aortic valve replacement now may be performed safely and effectively using transcatheter techniques, potentially revolutionizing the approach to this potentially fatal disease.

Long-Term Major Adverse Cardiovascular Events in Patients "Appropriately" Tested for Troponin Assays in Emergency Department.

Cardiac biomarkers like troponin have become essential for detecting myocardial ischemia, a hallmark of the acute coronary syndrome (ACS), in the emergency department (ED). However, inappropriate and excessive biomarker testing can lead to false positive results, patient anxiety, and unnecessary treatment. Our study aimed to develop an appropriateness criterion for troponin testing and examine the long-term major adverse cardiac events (MACE) of patients tested with troponin in the ED. We retrospectively evaluated 407 patients who underwent troponin testing at a tertiary-care northeastern US hospital. The majority (n = 252, 62%) of troponin testing was appropriate, with the remainder deemed inappropriate. Baseline characteristics were equally distributed between the 2 groups. Of the appropriately ordered troponins, 34% were positive compared to 28% of the inappropriately ordered troponins (range 0.04-0.10 ng/mL). Patients were followed over 540 days. MACE occurred in 21% and 10% of patients in the appropriate and inappropriate groups, respectively. Unlike the inappropriate group (3.5%), 96% of the events in the appropriate group occurred within the first 200 days. Patients in the appropriate group were at an increased adjusted risk of MACE (HR 2.55, 95% CI (1.59-4.08), P < 0.001) on long-term follow-up. In addition, MACE was comparable between patients with positive and negative troponins in the inappropriate group (HR 1.46, 95% CI (0.28-7.71), P = 0.65). Our study supports judicious troponin testing and the need for robust appropriateness criteria for ordering troponin in the ED to avoid overdiagnosis and inappropriate testing.

Second-generation extracellular matrix patch for epicardial infarct repair.

Current myocardial infarction treatments focus on improving hemodynamics rather than addressing the problem of lost myocardium impairing left ventricular function. Epicardial infarct repair with a bioactive patch placed on the ischemic area is an emerging approach to promote endogenous myocardial repair. We report the use of a second-generation CorMatrix-extracellular matrix (ECM) patch as an adjunct to surgical revascularization in treating a young patient with diffuse, multivessel coronary artery disease unamenable to PCI and a large anterior myocardial infarction. The progressive myocardial scar shrinkage and increase in left ventricular ejection fraction from 10 to 51% are generally not observed with surgical revascularization therapy alone, suggesting this new patch has adjunctive potential to current revascularization therapy.

Volume overload.

Structural cardiac volume overload comprises a group of heterogeneous diseases, each creating a nearly unique set of loading conditions on the left ventricle and/or right ventricle. In turn, the heart responds to each with unique patterns of remodeling, leading to both adaptive and maladaptive consequences. An understanding of these different patterns of hypertrophy and/or remodeling should be useful in developing strategies for the timing and correction of cardiac volume overload.

Ischaemic mitral regurgitation: pathophysiology, outcomes and the conundrum of treatment.

Ischaemic mitral regurgitation is a frequent complication of left ventricular global or regional pathological remodelling due to chronic coronary artery disease. It is not a valve disease but represents the valvular consequences of increased tethering forces (papillary muscles displacement leading to a more apical position of the leaflets and their coaptation point) and reduced closing forces (reduced contractility, dyssynchrony of the papillary muscles, intra-left ventricular dyssynchrony). Although mitral regurgitation has an unloading effect and reduces impedance, the volume overload begets further left ventricular dilatation, increases ventricular wall stress leading to worsened performance. Ischaemic mitral regurgitation is characteristically dynamic: its severity may vary with haemodynamic conditions. Both the severity of ischaemic mitral regurgitation and its dynamic component worsen prognosis. There are numerous possible treatment modalities, but the management of the individual patient remains difficult. Medical therapy is mandatory; revascularization procedures are frequently not sufficient to reduce mitral regurgitation; the role of combined surgical therapy by mitral valve repair is not yet defined in the absence of large randomized trial. Some patients are good candidates for cardiac resynchronization therapy that may reduce the amount of regurgitation. New therapeutic targets are under investigation.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use. METHODS: A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. STRUCTURE: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Aortic stenosis.

In developed countries, aortic stenosis is the most prevalent of all valvular heart diseases. A manifestation of ageing, the disorder is becoming more frequent as the average age of the population increases. Symptomatic severe disease is universally fatal if left untreated yet is consistent with a typical lifespan when mechanical relief of the stenosis is provided in a timely fashion. Management of mild disease, severe asymptomatic disease, and far advanced disease, and the effect of new percutaneous treatments, provide both controversy and exciting promise to care of patients with aortic stenosis. We discuss these issues in this Review.

The SEAS Trial.

The pathobiology of aortic stenosis (AS) now is recognized to have many similiarities to that of atherosclerosis, a disease in which lipid lowering therapy with statin drugs has been successful. Accordingly statins have been used to attempt to retard the progression of AS with variable success. The SEAS trial compared the effects of the combination of simvastatin and ezetimibe to placebo in retarding the progression of aortic stenosis (AS) and was the largest randomized trial of such therapies. One thousand eight hundred seventy three patients with moderate AS were included. The group receiving the drugs had a large reduction in LDL cholesterol and a reduction in coronary events. However drug therapy had no effect on the progression of AS. Conclusion. While AS has many similarities to atherosclerosis, lipid lowering therapy does not affect progression of moderate to severe AS.

Left Ventricular Contractility and Wall Stress in Patients With Aortic Stenosis With Preserved or Reduced Ejection Fraction.

OBJECTIVES: This study sought to determine the prevalence of reduced contractility and uncompensated wall stress in patients with aortic stenosis (AS) with preserved or reduced left ventricular ejection fraction (LVEF) and their impact on survival. BACKGROUND: LVEF in AS is determined not only by contractility but also by loading conditions. METHODS: Patients with first diagnosis (time 0) of severe AS (aortic valve area [AVA]≤1 cm2) with prior echo study (-3±1 years) were identified. Contractility was evaluated by plotting midwall fractional shortening (mFS) against circumferential end-systolic wall stress (cESS), stratified by LVEF of 60% at time 0. The temporal changes (from -3 years to time 0) and prognostic value of LVEF, contractility, and wall stress were assessed. RESULTS: Of 445 patients, 290 (65%) had LVEF ≥60% (median: 66% [interquartile range {IQR}: 63% to 69%]) and 155 patients (35%) had LVEF <60% (median: 47% [IQR: 34% to 55%]). Median AVA was 1.27 cm2 (IQR: 1.13 to 1.43 cm2) at -3 years and 0.90 cm2 (IQR: 0.83 to 0.96 cm2) at time 0. Decreased contractility was already present at -3 years (49 [17%] vs. 59 [38%]; LVEF ≥60% vs. <60%; p < 0.001) and became more prevalent at time 0 (69 [24%] vs. 106 [68%]; p < 0.001). Overall, wall stress was well controlled in both groups at -3 years (1 [0%] vs. 12 [8%]; p < 0.001) but deteriorated over time in patients with LVEF <60% (time 0: 0 [0%] vs. 26 [17%]; p < 0.001). During a median follow-up of 3.4 years, LVEF <60%, decreased contractility and high wall stress were associated with worse survival (p < 0.01 for all). Decreased contractility remained incremental to LVEF in patients with LVEF ≥60% (p < 0.01), but less so when LVEF was <60% (p = 0.11). CONCLUSIONS: In patients with severe AS, LVEF <60% is associated with a poor prognosis, being linked with decreased contractility and/or high wall stress. Decreased contractility is also present in a subset of patients with LVEF ≥60% and provides incremental prognostic value. These abnormalities already exist before AVA reaches 1.0 cm2.