Severe mitral stenosis masquerading as cardiogenic shock successfully managed with extracorporeal membrane oxygenation and percutaneous mitral commissurotomy: a case report.

Background: Rheumatic fever is still a major cause of mitral valve (MV) stenosis in the developing world. Few patients with critical rheumatic MV stenosis can present with acute cardiogenic shock (CS) that requires urgent treatment with circulatory support and definitive valvular repair or replacement. Case summary: A 37-year-old gentleman was admitted with heart failure, CS Society for Cardiovascular Angiography and Interventions D, and atrial fibrillation with a rapid ventricular response. He had no prior medical history. He had multiple organ failures and required intubation, two DC shocks of 200 joules without haemodynamic improvement, continuous renal replacement therapy, and medical and mechanical circulatory support using extracorporeal membrane oxygenation (ECMO). His echocardiography showed severe rheumatic mitral stenosis (mitral valve area 2D of 0.7 cm2, mean diastolic gradient of 17 mmHg, Wilkins score 7). His Society of Thoracic Surgery score and EuroScore were 50.1% and 12.1%, respectively. Thus, a percutaneous transcatheter mitral commissurotomy (PTMC) was decided as the definitive treatment in a multidisciplinary team meeting. Following the procedure, the patient's circulatory support was gradually weaned off, and he was successfully extubated with a marked improvement in his renal functions. The patient achieved a complete recovery without any long-term sequelae. Discussion: Cardiogenic shock related to severe rheumatic MV stenosis requires multidisciplinary team management with prompt diagnosis, initiation of the most appropriate mechanical support device (e.g. ECMO or tandem heart), and relief of the MV obstruction. Percutaneous transcatheter mitral commissurotomy can be the preferred option in this setting if the valve is pliable.

Percutaneous Mitral Valve Repair for Secondary Mitral Regurgitation: A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to investigate whether percutaneous mitral valve repair (PMVr) using MitraClip was more effective than surgery or medical therapy for long-term morbidity and mortality. We searched MEDLINE, EMBASE, and CENTRAL (Cochrane Library) databases to identify relevant studies that recruited adult patients with functional or secondary mitral valve regurgitation who underwent PMVr with MitraClip implantation using appropriate search terms and Boolean operators. The odds ratios (ORs) were pooled using the random-effects model. A total of 14 studies recruiting 2,593 patients were included. Within 12 months of follow-up, patients who underwent PMVr did not maintain mitral valve regurgitation grade 2+ (OR 0.22, 95% confidence interval [CI] 0.12 to 0.41, p <0.0001, I2 = 0.0%, p = 0.52) or symptom-free heart failure (OR 0.47, 95% CI 0.29 to 0.77, p = 0.0028, I2 = 0.0%, p = 0.66) compared with their surgical counterparts. Patients were more likely to be rehospitalized for heart failure (OR 2.79, 95% CI 1.54 to 5.05, p = 0.0007, I2 = 0.0%, p = 0.51). However, there was no difference between the groups in terms of all-cause or cardiovascular mortality. Whereas, in comparison with medical therapy, PMVr significantly reduced all-cause mortality at 12 and ≥24 months of follow-up (OR 0.41, 95% CI 0.24, 0.69, p = 0.0009, I2 = 32%, p = 0.23 and OR 0.55, 95% CI 0.40, 0.75, p = 0.0002, I2 = 0.0%, p = 0.45, respectively). In conclusion, there was no difference in all-cause death at 12 or 24 months of follow-up between PMVr and the surgical approach, but the durability of valvular repair was inferior with PMVr. In comparison with medical therapy, there was a significant reduction in mortality with PMVr.

Transcatheter Mitral Valve Repair in Acute and Critical Cardiac Conditions.

Acute mitral valve regurgitation (MR) is an emergency condition that requires an early diagnosis of the etiology and rapid management. Surgical intervention is the first-line treatment for acute severe MR. However, many patients are denied surgical intervention due to the acute risk of surgery. Transcatheter mitral valve repair (TMVr) is a less invasive technique and becoming a potential alternative to surgery in inoperable patients but is underrepresented in the literature. This review aims to discuss the published data on the use of TMVr in unstable MR patients presenting with acute or critical cardiac conditions.

Risks of Right Heart Catheterization and Right Ventricular Biopsy: A 12-year, Single-Center Experience.

OBJECTIVE: To study the incidence of complications when undergoing right heart catheterization (RHC) and right ventricular biopsy (RVB). METHODS: Complications following RHC and RVB are not well reported. We studied the incidence of death, myocardial infarction, stroke, unplanned bypass, pneumothorax, hemorrhage, hemoptysis, heart valve repair/replacement, pulmonary artery perforation, ventricular arrhythmias, pericardiocentesis, complete heart block, and deep vein thrombosis (primary endpoint) following these procedures. We also adjudicated the severity of tricuspid regurgitation and causes of in-hospital death following RHC. Diagnostic RHC procedures, RVB, multiple right heart procedures alone or combined with left heart catheterization, and complications from January 1, 2002, through December 31, 2013, were identified using the clinical scheduling system and electronic records at Mayo Clinic, Rochester, Minnesota. International Classification of Diseases, Ninth Revision billing codes were used. Registration was queried to identify all-cause mortality. All clinical events and echocardiograms for worsening tricuspid regurgitation were reviewed and adjudicated. RESULTS: A total of 17,696 procedures were identified. Procedures were categorized into those undergoing RHC (n=5556), RVB (n=3846), multiple right heart catheterization (n=776), and combined right and left heart catheterization procedures (n=7518). Primary endpoint was seen in 21.6 and 20.8 of 10,000 procedures for RHC and RVB, respectively. There were 190 (1.1%) deaths during hospital admission and none was related to the procedure. CONCLUSION: Complications following diagnostic RHC and RVB are seen in 21.6 and 20.8 procedures, respectively, of 10,000 procedures and all deaths were secondary to acute illness.

Percutaneous Transvenous Balloon Mitral Commissurotomy: A Single-Center Experience.

Background: Rheumatic heart disease and its impact on cardiac health is still a concern in developing countries. Percutaneous trans-mitral commissurotomy (PTMC) is the standard of care in managing severe rheumatic mitral stenosis (MS). This article reports a single-center, 10-year real-world experience in Qatar. Methods: In this retrospective study, we reviewed all the patients who underwent PTMC in Qatar between January 1, 2012, and January 1, 2022. Periprocedural data were collected at baseline, postprocedural, 1 year, and during the last follow-up. The primary outcome was procedural success (improvement in valve area by 50%, final valve area >1.5 cm2, and freedom from > moderate mitral regurgitation, stroke, or pericardial effusion). Safety endpoints were freedom from death, periprocedural cardiogenic shock and cardiac arrest, stroke urgent mitral valve replacement (MVR), or pericardiocentesis. Long-term outcomes included the requirement of redo PTMC or MVR, in addition to rehospitalization due to arrhythmias, heart failure, or stroke. Results: Sixty-five patients were included in the review (age 42 ± 10, female 38 [58.5%]). Sixty-two patients (95.4%) had a successful procedure. One patient developed a hemorrhagic pericardial tamponade and cardiogenic shock, for which he underwent pericardiocentesis and emergency aortic root repair. One patient developed acute stroke 8 h after the procedure, and one patient had tamponade resolved with emergency pericardiocentesis. Two patients required MVR after 1 and 4 years, respectively. Conclusion: PTMC is the mainstay of rheumatic MS management in patients with suitable anatomy as most patients have excellent outcomes with long-term freedom from surgery, which has been the case in our single-center experience.

Outcomes of Radial Versus Femoral Access in Patients With Severe Aortic Stenosis Undergoing Percutaneous Coronary Intervention Prior to Transcatheter Aortic Valve Replacement.

BACKGROUND: The safety and feasibility of radial access in patients undergoing percutaneous coronary intervention (PCI) prior to transcatheter aortic valve replacement (TAVR) has not been studied. METHODS: This study included consecutive patients who underwent PCI within 30 days before TAVR at Mayo Clinic. Vascular access was left to the discretion of the operator. Baseline demographics, procedural data, PCI outcomes, and subsequent transfemoral TAVR outcomes were extracted from patient charts. RESULTS: A total of 331 patients were included in this study, with 107 patients undergoing PCI via radial access (rPCI), and 224 via femoral access (fPCI). Mean age was 80.6 years and 35.6% were females (35.5% rPCI vs 35.3% fPCI). More patients in the fPCI group had previous coronary artery bypass graft surgery (13.1% rPCI vs 34.4% fPCI; P<.001). Fluoroscopy time (13.36 minutes vs 18.86 minutes; P<.001) and contrast use (115 mL vs 140 mL; P<.01) were lower in the rPCI group than in the fPCI group. Crossover rate from radial to femoral was 6.5%. There were more access-site hematomas in the fPCI group (2.8% rPCI vs 14.3% fPCI; P<.001), with no statistically significant rate of other access-related complications. There was no difference in stroke, myocardial infarction, cardiac arrest, or unplanned surgery. There was no difference in bleeding or stroke between both groups during subsequent transfemoral TAVR. CONCLUSION: Radial access for pre-TAVR PCI is feasible and safe and is associated with a lower rate of access-site hematoma. This study supports the increased use of transradial access for pre-TAVR PCI.

The impact of pulmonary hypertension on outcomes of transcatheter mitral valve replacement in mitral annular calcification.

OBJECTIVES: To assess the impact of pulmonary hypertension (PH) on outcomes of patients with severe mitral annular calcification (MAC) undergoing transcatheter mitral valve replacement (TMVR). BACKGROUND: PH is associated with poor outcomes after mitral valve surgery. Whether the presence of PH in patients with MAC undergoing (TMVR) is associated with poor outcomes, is unknown. METHODS: Retrospective evaluation of 116 patients from 51 centers in 11 countries who underwent TMVR with valve in mitral annular calcification (ViMAC) using balloon-expandable aortic transcatheter valves (THVs) from September 2012 to March 2017. Pulmonary artery systolic blood pressure (PASP) by echocardiogram was available in 90 patients. The subjects were stratified based on PASP: No PH = PASP ≤35 mmHg (n = 11); mild to moderate PH = PASP 36-49 mmHg (n = 21) and severe PH = PASP ≥50 mmHg (n = 58). Clinical, procedural, and echocardiographic outcomes were assessed. RESULTS: Mean age was 72.7 (±12.8) years, 59 (65.6%) were female, Society of Thoracic Surgeons score was 15.8 + 11.8% and 90.0% where in New York Heart Association (NYHA) class III-IV. There was no significant difference in all-cause mortality at 30 days (no PH = 27.3%, mild-moderate PH = 19.0%, severe PH = 31.6%; p = 0.55) or at 1 year (no PH = 54.5%, mild-moderate PH = 38.1%, severe PH = 56.1%; p = 0.36). No difference in adverse events, NYHA class or amount of residual mitral regurgitation at 1 year were observed between the groups. CONCLUSION: This study suggests that the presence of PH in patients with predominantly mitral stenosis with MAC undergoing TMVR does not impact mortality or adverse events. Further studies are needed to fully understand the effect of PH in this group of patients.

Novel Antegrade Approach to Transcatheter Aortic Valve Paravalvular Leak Closure.

Aortic paravalvular leak (PVL) is a known complication of TAVR. PVL closure using vascular occluder devices can be used, particularly in cases with annular calcification preventing adequate seal; however, delivery of equipment can be challenging in TAVR patients due to interaction with the valve stent. We describe a novel antegrade closure approach to treat transcatheter aortic PVL.

Safety and Risk of Major Complications With Diagnostic Cardiac Catheterization.

BACKGROUND: We aim to study the incidence of major complications related to procedure defined as in-hospital death, myocardial infarction, stroke, pericardial effusion or tamponade, percutaneous coronary intervention due to iatrogenic coronary dissection, or unplanned bypass surgery within 72 hours after diagnostic left heart catheterization (LHC; primary end point). Furthermore, all causes of in-hospital death after LHC were adjudicated and reported (secondary end point). METHODS AND RESULTS: Diagnostic LHC procedures (aortic angiography; coronary, including graft, angiography; and left ventricular angiography) from January 1, 2002, through December 31, 2013, were identified using the clinical scheduling system at Mayo Clinic, Rochester, and complications were identified through electronic records. International Classification of Diseases, Ninth Revision billing codes were used. Registration was queried to identify all-cause mortality. All events were reviewed and adjudicated. There were 43 786 diagnostic LHC procedures; 97.3% were coronary angiograms. The mean age of patients was 64.5 years (13.6), and the majority were male (61.5%). Primary end point was seen in 36 (0.082%) procedures or 8.2 of 10 000 LHCs. Combined right sided procedures with LHC did not increase the risk of major complications. Cardiogenic and septic shock, cardiac arrhythmia, and postsurgical complication were the most common causes of in-hospital death after LHC. CONCLUSIONS: The overall rates of major complications related to diagnostic cardiac catheterization procedures are extremely rare. The majority of the deaths occurring post-diagnostic LHC procedures were secondary to acute illness rather than directly related to diagnostic procedure.

Outcomes of Patients With Severe Symptomatic Aortic Valve Stenosis After Chest Radiation: Transcatheter Versus Surgical Aortic Valve Replacement.

Background Patients with symptomatic severe aortic stenosis and a history of chest radiation therapy represent a complex and challenging cohort. It is unknown how transcatheter aortic valve replacement ( TAVR ) compares with surgical aortic valve replacement in this group of patients, which was the objective of this study. Methods and Results We retrospectively reviewed all patients with severe aortic stenosis who underwent either TAVR or surgical aortic valve replacement at our institution with a history of mediastinal radiation (n=55 per group). End points were echocardiographic and clinical outcomes in-hospital, at 30 days, and at 1 year. Inverse propensity weighting analysis was used to account for intergroup baseline differences. TAVR patients had a higher STS score than surgical aortic valve replacement patients (5.1% [3.2, 7.7] versus 1.6% [0.8, 2.6], P<0.001) and more often ( P<0.01 for all) a history of atrial fibrillation (45.5% versus 12.7%), chronic lung disease (47.3% versus 7.3%), peripheral arterial disease (38.2% versus 7.3%), heart failure (58.2% versus 18.2%), and pacemaker therapy (23.6% versus 1.8%). Postoperative atrial fibrillation was less frequent (1.8% versus 27.3%; P<0.001) and hospital stay was shorter in TAVR patients (4.0 [2.0, 5.0] versus 6.0 [5.0, 8.0] days; P<0.001). The ratio of observed-to-expected 30-day mortality was lower after TAVR as was 30-day mortality in inverse propensity weighting-adjusted Kaplan-Meier analyses. Conclusions In patients with severe aortic stenosis and a history of chest radiation therapy, TAVR performs better than predicted along with less adjusted 30-day all-cause mortality, postoperative atrial fibrillation, and shorter hospitalization compared with surgical aortic valve replacement. These data support further studies on the preferred role of TAVR in this unique patient population.

Circulating Osteogenic Progenitor Cells in Mild, Moderate, and Severe Aortic Valve Stenosis.

The aim of this study was to characterize endothelial progenitor cells with osteoblastic phenotype (EPC-OCNs) and their role in individuals with varying degrees of aortic stenosis (AS). Peripheral blood mononuclear cells retrieved from blood samples of individuals with mild (n=40), moderate (n=35), or severe (n=103) AS from September 16, 2008, through March 30, 2015, were analyzed by flow cytometry for the EPC surface markers CD34, CD133, and kinase insert domain receptor (KDR) and the osteoblastic cell surface marker OCN. Levels of EPC-OCNs were correlated with AS severity and calcifications. Patients with severe AS had significantly elevated numbers of total circulating EPC-OCNs, including the EPC-OCN subtypes CD133+/OCN+, CD34+/CD133+/OCN+, and CD133+/KDR+/OCN+, compared with those with mild AS. Individuals with moderate AS also had significantly increased numbers of the circulating progenitor cell CD133+/OCN+ compared with patients with mild AS. There was a significant association between total circulating EPC-OCN levels and aortic valve (AV) calcification, AV mean gradient, and AV area measured by echocardiography. In summary, this study found the presence of circulating EPC-OCNs in patients with progressive AV stenosis. These findings might support the potential role for EPC-OCNs in the progression of AV stenosis and calcification.

Paravalvular leak repair after balloon-expandable transcatheter mitral valve implantation in mitral annular calcification: Early experience and lessons learned.

BACKGROUND: Treatment of hemodynamically significant mitral annular calcification (MAC) using transcatheter approaches is in the early learning phase. The occurrence of paravalvular leak (PVL) following transcatheter mitral valve in MAC is common. AIMS: To report the initial experience and techniques of percutaneous PVL closure after transcatheter valve in MAC. METHODS: This series includes five consecutive patients who underwent percutaneous PVL closure following transcatheter balloon expandable SAPIEN S3 valve in MAC. RESULTS: Mean patient age was 73.6 ± 5.4 years (4 [80%] female), with average Society of Thoracic Surgeons score of 8.1 ± 2.8%. Three patients had a single PVL defect while two patients had two defects; all were located at the commissural sites. Closure was performed primarily for heart failure in four patients and hemolytic anemia in one patient. Transfemoral transseptal antegrade approach and Amplatz Vascular Plug (AVP)-II occluders were utilized in all patients. Procedure success was achieved in three patients. One patient developed significant occluder related leaflet impingement and subsequent severe prosthetic mitral regurgitation requiring a second transcatheter mitral valve in valve implantation. The procedure was aborted in one patient due to difficulty crossing PVL defect after balloon post-dilatation of SAPIEN prosthesis with 10 mL of additional volume. There was no in hospital or 30 day mortality or the need for emergent surgery. CONCLUSION: Early experience with percutaneous PVL closure of SAPIEN valve in MAC demonstrated feasibility of this approach. Careful procedure planning and monitoring for SAPIEN prosthesis leaflet impingement and frame instability is of utmost importance to increase the chances of procedural success.

Transapical percutaneous closure of rapidly expanding post-surgical left ventricular outflow tract pseudoaneurysm.

Left ventricular pseudoaneurysm is an infrequent but potentially fatal complication following cardiac surgery, with spontaneous rupture being the most feared result. Moreover, surgical repair is associated with significant morbidity and mortality. We present a successful transapical percutaneous closure of a post-surgical rapidly expanding left ventricular outflow tract (LVOT) pseudoaneurysm utilizing Amplatz Vascular Plug-II (AVP-II) (St. Jude Medical, St. Paul, MN) with the aid of 3D prototyping for pre-procedural planning.

Acute coronary syndromes in patients with active hematologic malignancies - Incidence, management, and outcomes.

BACKGROUND: Cancer and cardiovascular diseases are the two leading causes of death in industrialized countries. Optimal management of life-threatening presentations of both of their diseases can pose significant challenges. The current study aimed to address the incidence, management, and outcome of acute coronary syndromes (ACS) in patients with active hematological malignancies. METHODS: This retrospective registry-based cohort study included adults with active leukemia or lymphoma who were hospitalized at Mayo Clinic Rochester from 01/01/2004 to 12/31/2014. The diagnosis of ST-segment elevation MI (STEMI) or non-ST-segment elevation MI (NSTEMI) was made based on the 3rd Universal Definition for MI, or of unstable angina (UA) in the absence of cardiac troponin elevation. Main outcome measures included all-cause, cardiac, and non-cardiac death in-hospital and at one year. RESULTS: Of 5300 adult patients with active hematological malignancies, 73 (1.4%) were diagnosed with an ACS (78.1% NSTEMI and 13.7% STEMI). 17.5% and 40% of NSTEMI and STEMI patients underwent coronary angiography, with percutaneous coronary intervention in 5.3% and 30%, respectively. While >80% of patients received ß-blocker therapy, only half of all and <50% of patients managed "medically" received antiplatelet, anticoagulant, and/or statin therapy. The in-hospital and 1-year mortality was 21.9% and 58.9%, respectively, of which 25% and 15% were cardiac in etiology. Aspirin, beta-blocker, statins, and angiotensin-converting enzyme inhibitor/angiotensin-II receptor blocker were associated with better mortality outcomes. CONCLUSIONS: In a large, contemporary study of adults with active hematologic malignancies, ACS was uncommon, but commonly managed not in keeping with societal guideline recommendations.

Revascularization for Left Main and Multivessel Coronary Artery Disease: Current Status and Future Prospects after the EXCEL and NOBLE Trials.

Revascularization of severe left main and multivessel coronary artery disease has been shown to improve survival in both stable ischemic heart disease and acute coronary syndrome. While revascularization with coronary artery bypass surgery for these disease entities carries class I recommendation in most current guidelines, recent trials has shown potential comparable survival and cardiovascular outcomes between percutaneous and surgical interventions in patients with less complex coronary anatomy. Despite the conflicting results observed in the most recent left main revascularization trials, Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease (EXCEL) and Nordic-Baltic-British left main revascularization (NOBLE), both treatment strategies remain important for the management of left main disease (LMD) and multivessel disease (MVD) reflecting on the importance of heart team discussion. This review is focused on revascularization of LMD and MVD in patients who are not presenting with ST-segment elevation myocardial infarction, encompassing the evidence from historic and contemporary trials which shaped up current practices. This review discusses the heart team approach to guide decision making, including special populations that are not represented in clinical trials.

The Various Applications of 3D Printing in Cardiovascular Diseases.

PURPOSE OF REVIEW: To highlight the various applications of 3D printing in cardiovascular disease and discuss its limitations and future direction. RECENT FINDINGS: Use of handheld 3D printed models of cardiovascular structures has emerged as a facile modality in procedural and surgical planning as well as education and communication. Three-dimensional (3D) printing is a novel imaging modality which involves creating patient-specific models of cardiovascular structures. As percutaneous and surgical therapies evolve, spatial recognition of complex cardiovascular anatomic relationships by cardiologists and cardiovascular surgeons is imperative. Handheld 3D printed models of cardiovascular structures provide a facile and intuitive road map for procedural and surgical planning, complementing conventional imaging modalities. Moreover, 3D printed models are efficacious educational and communication tools. This review highlights the various applications of 3D printing in cardiovascular diseases and discusses its limitations and future directions.

Three-dimensional prototyping for procedural simulation of transcatheter mitral valve replacement in patients with mitral annular calcification.

INTRODUCTION: Three-dimensional (3D) prototyping is a novel technology which can be used to plan and guide complex procedures such as transcatheter mitral valve replacement (TMVR). METHODS: Eight patients with severe mitral annular calcification (MAC) underwent TMVR. 3D digital models with digital balloon expandable valves were created from pre-procedure CT scans using dedicated software. Five models were printed. These models were used to assess prosthesis sizing, anchoring, expansion, paravalvular gaps, left ventricular outflow tract (LVOT) obstruction, and other potential procedure pitfalls. Results of 3D prototyping were then compared to post procedural imaging to determine how closely the achieved procedural result mirrored the 3D modeled result. RESULTS: 3D prototyping simulated LVOT obstruction in one patient who developed it and in another patient who underwent alcohol septal ablation prior to TMVR. Valve sizing correlated with actual placed valve size in six out of the eight patients and more than mild paravalvular leak (PVL) was simulated in two of the three patients who had it. Patients who had mismatch between their modeled valve size and post-procedural imaging were the ones that had anterior leaflet resection which could have altered valve sizing and PVL simulation. 3D printed model of one of the latter patients allowed modification of anterior leaflet to simulate surgical resection and was able to estimate the size and location of the PVL after inserting a valve stent into the physical model. CONCLUSION: 3D prototyping in TMVR for severe MAC is feasible for simulating valve sizing, apposition, expansion, PVL, and LVOT obstruction.

Sex-stratified analysis of national trends and outcomes in isolated tricuspid valve surgery.

Objective: Female sex is a known risk factor for cardiac surgery, and tricuspid valve (TV) disease is more common in women. There are few data on sex-stratified surgical outcomes for isolated TV surgery. An administrative database was used to compare acute in-hospital outcomes between men and women undergoing isolated TV surgery. Methods: Patients aged >18 who underwent TV repair or replacement from 2004 to 2013 were identified using the National Inpatient Sample. Patients were excluded if they had congenital heart disease, endocarditis, or were undergoing concomitant cardiac surgeries except coronary bypass. Results were weighted to represent national averages. Sex-stratified analysis was performed using propensity score matching to compare in-hospital mortality, postoperative complications and hospital costs. Results: Over 10 years, women represented 58% of the 5005 TV surgeries performed. With propensity matching, hospital mortality (7.9% vs 7.7%; P=0.99) and median length of stay (11 vs 11 days; P=0.99) were similar between men and women. However, median hospital charges were higher for men ($166 000 vs $155 000; P=0.04). Conclusion: Isolated TV surgery is rare, but women more commonly undergo the procedure. In-hospital mortality was similar between men and women after propensity matching, but remains markedly high for both men and women in comparison to that reported for left-sided isolated valve surgery.