Role of myocardial strain imaging in diagnosing inducible myocardial ischemia with treadmill contrast-enhanced stress echocardiography.

INTRODUCTION: The aim of this study is to analyze the diagnostic value of global longitudinal strain (GLS) in detecting inducible myocardial ischemia in patients with chest pain undergoing treadmill contrast-enhanced stress echocardiography (SE). METHODS: We retrospectively enrolled all patients who underwent invasive coronary angiography after treadmill contrast-enhanced SE. Rest and peak-stress myocardial GLS, segmental LS, and LS of 4-chamber (CH), 2-CH, and 3-CH views were reported. Luminal stenosis of more than 70% or fractional flow reserve (FFR) of < 0.8 was considered significant. RESULTS: In total 33 patients were included in the final analysis, among whom sixteen patients (48.4%) had significant coronary artery stenosis. Averaged GLS, 3-CH, and 4-CH LS were significantly lower in patients with critical coronary artery stenosis compared to those without significant stenosis (-17.1 ± 7.1 vs. -24.2 ± 7.2, p = 0.041), (-18.2 ± 8.9 vs. -24.6 ± 8.2, p = 0.045) and (-14.8 ± 6.2 vs. -22.8 ± 7.8, p = 0.009), respectively. Receiver operating characteristic (ROC) analysis of ischemic and non-ischemic segments demonstrated that a cut-off value of -20% of stress LS had 71% sensitivity and 60% specificity for ruling out inducible myocardial ischemia (Area under the curve was AUC = 0.72, P < 0.0001). CONCLUSION: Myocardial LS measured with treadmill contrast-enhanced stress echocardiography demonstrates potential value in identifying patients with inducible myocardial ischemia.

A novel approach to produce axial echocardiographic images by three-dimensional transesophageal echocardiography: A step-by-step guide.

Three-Dimensional (3-D) echocardiography is becoming increasingly used to diagnose and describe the spatial location of valvular pathologies and atrial septal defects during transesophageal echocardiography (TEE). The role of 3D-TEE is not well established in diagnosing other congenital heart diseases like partial anomalous pulmonary venous drainage (PAPVD) and coronary anomalous. We propose a step by step approach to producing computed tomography-simulated axial images from 3-D TEE to simplify TEE interpretation and diagnosis of cardiac abnormalities.

Radial versus femoral approach for saphenous vein grafts angiography and interventions.

BACKGROUND: Coronary angiography and intervention to saphenous venous grafts (SVGs) remain challenging. This study aimed to investigate the feasibility and safety of the radial approach compared to femoral access in a large cohort of patients undergoing SVG angiography and intervention. METHODS: Data from 1,481 patients from Canada, United States, and Spain who underwent procedures between 2010 and 2016 were collected. Patients must have undergone SVG coronary angiography and/or intervention. Demographics, procedural data, and in-hospital complications were recorded. RESULTS: Procedures were undertaken by either the radial (n = 863, 211 intervention) or femoral (n = 618, 260 intervention) approach. The mean number of SVGs per patient was similar between groups (radial 2.3 ± 0.7 vs femoral 2.6 ± 1.1, P = .61), but the radial group required a fewer number of catheters (2.6 ± 1.7 vs 4.1 ± 1.1, P < .001). Fluoroscopy time was comparable between groups, and there was a trend toward lower contrast volume in the radial group (P = .045). Overall, the total dose of heparin was significantly higher in the radial group (P < .001); however, radial patients experienced significantly less access-site bleeding complications (P < .001). Outpatients undergoing radial SVG interventions had a higher likelihood of a same-day discharge home (P < .001). CONCLUSIONS: Radial access for SVG angiography and intervention is safe and feasible, without increasing fluoroscopy time. In experienced centers, radial access was associated with fewer catheters used, lower contrast volume, and lower rate of vascular access-site bleeding complications. Moreover, outpatients undergoing SVG percutaneous coronary intervention though the radial approach had a higher likelihood of a same-day discharge home.

Diagnosis and follow-up of idiopathic dilatation of inferior vena cava.

In the absence of cardiac pathology, the presence of a dilated inferior vena cava (IVC) is considered idiopathic. To date, this phenomenon has only been described in athletic individuals as an adaptation to chronically augmented venous return. This is the largest prospective cohort study, following ten individuals with idiopathic dilated IVC against an age-matched control group with annual echocardiograms and cardiac magnetic resonance (CMR) imaging for a median of 55 months. No significant difference was found between echocardiography and CMR measurements in IVC diameter assessment both at baseline and at follow-up. Over the study period, there was no significant progression of the IVC in diameter as measured either by echocardiography or CMR. None of the patients suffered any cardiovascular events, and there were no hospitalizations. Our findings indicate the benign nature of this condition and provide reassurance with regard to future clinical implications.

Left ventricular remodeling after mini-mitral repair-does the complexity of mitral disease matter?

OBJECTIVES: Degenerative mitral valve (MV) regurgitation (MR) is associated with left ventricular (LV) dilatation. Surgical treatment of MR has been shown to favorably affect LV remodeling. We prospectively compared the long-term echocardiographic outcomes of LV remodeling following mini-mitral repair for simple versus complex MV disease. METHODS: We prospectively followed up 203 consecutive patients who underwent mini-MV repair for severe degenerative MR over a 9-year period. Simple disease (n = 122 patients: posterior leaflet prolapse) was compared to complex disease (n = 81 patients: anterior, bilateral or commissural prolapse). Baseline demographics were similar between simple and complex groups (age: 63 ± 13 years vs 60 ± 15 years; p = .2; sex: 71% male vs 72% male, p = 1; preoperative MR grade ≥ 3+: 100%; n = 122; vs 100%; n = 81; p = 1), respectively. RESULTS: Preoperative left ventricular ejection fraction (LVEF) was significantly lower in the complex group as compared to the simple group (57.2% simple vs 56.0% complex; p = .04). Preoperative LV end-systolic diameter (LVESD: 35 mm simple vs 36 mm complex, p < .05) and LV end-diastolic diameter (LVEDD: 50 mm simple vs 51 mm complex; p < .05), as well as LV mass index (99.5 g/m2 vs 102.4 g/m2 ; p = .06) were larger in the complex group. Despite different baseline characteristics of LV function and geometry, both groups had similar remodeling of LV after MV repair. CONCLUSIONS: Patients with complex MV disease are referred late for surgical repair, causing LV function and dimensions to never fully recover. This suggests that earlier referral (before LV changes and potentially before symptoms) may be the preferred approach in those with complex disease.

Chronic atorvastatin and exercise can partially reverse established skeletal muscle microvasculopathy in metabolic syndrome.

It has long been known that chronic metabolic disease is associated with a parallel increase in the risk for developing peripheral vascular disease. Although more clinically relevant, our understanding about reversing established vasculopathy is limited compared with our understanding of the mechanisms and development of impaired vascular structure/function under these conditions. Using the 13-wk-old obese Zucker rat (OZR) model of metabolic syndrome, where microvascular dysfunction is sufficiently established to contribute to impaired skeletal muscle function, we imposed a 7-wk intervention of chronic atorvastatin treatment, chronic treadmill exercise, or both. By 20 wk of age, untreated OZRs manifested a diverse vasculopathy that was a central contributor to poor muscle performance, perfusion, and impaired O2 exchange. Atorvastatin or exercise, with the combination being most effective, improved skeletal muscle vascular metabolite profiles (i.e., nitric oxide, PGI2, and thromboxane A2 bioavailability), reactivity, and perfusion distribution at both individual bifurcations and within the entire microvascular network versus responses in untreated OZRs. However, improvements to microvascular structure (i.e., wall mechanics and microvascular density) were less robust. The combination of the above improvements to vascular function with interventions resulted in an improved muscle performance and O2 transport and exchange versus untreated OZRs, especially at moderate metabolic rates (3-Hz twitch contraction). These results suggest that specific interventions can improve specific indexes of function from established vasculopathy, but either this process was incomplete after 7-wk duration or measures of vascular structure are either resistant to reversal or require better-targeted interventions. NEW & NOTEWORTHY We used atorvastatin and/or chronic exercise to reverse established microvasculopathy in skeletal muscle of rats with metabolic syndrome. With established vasculopathy, atorvastatin and exercise had moderate abilities to reverse dysfunction, and the combined application of both was more effective at restoring function. However, increased vascular wall stiffness and reduced microvessel density were more resistant to reversal. Listen to this article's corresponding podcast at https://ajpheart.podbean.com/e/reversal-of-microvascular-dysfunction/ .

Preoperative assessment of left ventricular diastolic function and right ventricular systolic function have independent and incremental prognostic value in prediction of early postoperative mortality in redo valve surgery.

OBJECTIVES: Redo valve surgery is associated with increased risk of mortality that may be underestimated by current risk scores. In this study, we hypothesized that additional echocardiographic assessment of left ventricular diastolic and right ventricular systolic function would have independent prognostic value in the prediction of early postoperative mortality in patients undergoing redo valve surgery. METHODS: We prospectively evaluated 145 patients who underwent redo mitral or aortic valve surgery at our center. All patients underwent comprehensive preoperative echocardiography. The primary outcome was all-cause mortality at 30 days. RESULTS: The 30-day mortality rate was 11.7%. Independent of EuroSCORE II both preoperative left ventricular diastolic dysfunction and right ventricular systolic dysfunction were a significant multivariable predictors of 30-day mortality (HR 5.47; 95% CI 1.12-26.74, P = 0.036 and HR 4.09; 95% CI 1.11-15.07, P = 0.035, respectively) in addition to EuroSCORE II. Diastolic dysfunction remained significant when added to other clinically significant variables. The assessment of both parameters increased the discriminatory power of EuroSCORE II for prediction of early mortality and the combination identified a group at very high risk of mortality. CONCLUSIONS: Comprehensive preoperative echocardiography including assessment of left ventricular diastolic and right ventricular systolic function has independent prognostic value over and above EuroSCORE II in the prediction of early postoperative mortality in patients undergoing redo valve surgery. The results of preoperative echocardiography should be taken into account during the selection and perioperative management of patients undergoing redo valvular surgery.

Very Late Patent Foramen Ovale Occluder Device Structural Dysfunction and Thrombosis.

Mechanical dysfunction of patent foramen ovale (PFO) closure device is extremely rare. We present a 58-year-old male patient who had multiple episodes of ischemic strokes 3 years after PFO closure, which was related to PFO device mechanical dysfunction and thrombosis. He was successfully treated with surgical intervention.

Diagnosis of double-chambered left ventricle using advanced cardiovascular imaging.

Double-chambered ventricle is a rare congenital cardiac abnormality, most commonly affecting the right ventricle. Here, we report a case of an incidental diagnosis of this condition affecting the left ventricle (LV), which is found much less frequently, and the use of contrast echocardiography in its evaluation. The addition of computed tomography (CT), highlighting the blood supply of both chambers by the left anterior descending (LAD) artery allowed us to confirm the diagnosis.

Diagnostic Accuracy of Transesophageal Echocardiographic Commissural-Biplane Approach in Identifying Mitral Valve Anatomy.

BACKGROUND: Transesophageal echocardiography (TEE) conventional multiplane approach (MPA) and the newly proposed commissural-biplane approach (CBA) are the recommended algorithms for identifying the affected mitral valve (MV) segments in the setting of mitral regurgitation. To date, there are no reports to address the diagnostic performance of CBA. In this study we aim to analyze the diagnostic accuracy of CBA and MPA in comparison with three-dimensional echocardiographic findings in patients with severe mitral regurgitation. METHODS: We prospectively enrolled 102 patients with severe mitral regurgitation. All patients underwent systematic TEE assessment of MV before surgical intervention to define the affected MV segments/scallops. The standard MPA includes 4-chamber, 2-chamber, long-axis, and commissural views; CBA was performed by obtaining the bicommissural view and simultaneous biplane imaging of the medial, middle, and lateral MV aspects. The findings of both TEE approaches were compared with three-dimensional TEE data to assess the diagnostic accuracy of MPA and CBA. RESULTS: The mean patient age was (65 ± 11) years, and 37 (36.3%) were female. We found that CBA had an overall diagnostic accuracy between 88% and 97% in identifying the abnormal MV scallops; in contrast, MPA accuracy ranged between 82% and 95%. The CBA and MPA were the least accurate in identifying the P3 scallop-88% and 82% respectively; however, both were the most accurate in assessing the A2 segment-95% and 97%, respectively. The sensitivity of identifying commissural abnormalities was 80% with CBA and 30% with MPA. Three-dimensional TEE was found to have a strong agreement with CBA (averaged kappa of 0.81, P < .0001) and a modest agreement with MPA (averaged kappa of 0.61, P < .0001) in identifying abnormal anterior or posterior segments. On the other hand, three-dimensional TEE had a weak agreement with CBA (kappa of 0.43, P < .0001) and no agreement with MPA (kappa of 0.14, P = .153) in the assessment of commissural involvements. CONCLUSION: The CBA is more accurate than the MPA in the assessment of MV commissural involvement. Given the accuracy differences of the 2 approaches for specific leaflet/scallops, a comprehensive evaluation using both approaches is recommended for all MV scallop assessments.

Prognostic value of coronary computed tomography angiography compared to radionuclide myocardial perfusion imaging in patients With coronary stents.

Objectives: The aim of this study is to compare the prognostic value of coronary computed tomography angiography (CCTA) with single-photon emission computed tomography (SPECT) in predicting cardiovascular events in patients with stents. Design: Retrospective analysis. Setting: University Hospital, London, Ontario Canada. Participants: Between January 2007 and December 2018, 119 patients post-percutaneous coronary intervention (PCI) who were referred for hybrid imaging with CTA and 2-day rest/stress SPECT were enrolled. Primary and secondary outcome measures: Patients were followed for any major adverse cardiovascular event (MACE) including: All-cause mortality, Non-fatal myocardial infarction (MI), Unplanned revascularization, Cerebrovascular accident and hospitalization for arrhythmia or heart failure. We define hard cardiac events (HCE) as: cardiac death, non-fatal MI or unplanned revascularization. We used two cut-off values to define obstructive lesions with CCTA ≥50% and ≥70% in any coronary segment. SPECT scan defined as abnormal in the presence of >5% reversible myocardial perfusion defect. Results: During the follow-up period of 7.2 ± 3.4 years. 45/119 (37.8%) patients experienced 57 MACE: Ten deaths (2 cardiac deaths and 8 of non-cardiac deaths), 29 acute coronary syndrome including non-fatal MI (25 required revascularization), 7 hospitalizations for heart failure, 6 cerebrovascular accidents and 5 new atrial fibrillation. 31 HCEs were reported. Cox regression analysis showed that obstructive coronary stenosis (≥50% and ≥70%) and abnormal SPECT were associated of MACE (p = 0.037, 0.018 and 0.026), respectively. In contrast, HCEs were significantly associated with obstructive coronary stenosis of ≥50% and ≥70% with p = 0.004 and p = 0.007, respectively. In contrast, abnormal SPECT was a nonsignificant predictor of HCEs (p = 0.062). Conclusion: Obstructive coronary artery stenosis on CCTA can predict MACE and HCE. However, abnormal SPECT can only predict MACE but not HCE in patients post-PCI with a follow-up period of approximately 7 years.

Readmissions After Left Atrial Appendage Closure in Patients With Previous Ischemic Stroke or Transient Ischemic Attack.

Background: We examined the frequency and risk factors associated with readmission after left atrial appendage closure (LAAC) in patients with and without previous ischemic stroke and/or transient ischemic attack (TIA). Methods: Hospitalizations for LAAC were identified from the US National Readmission Database, 2016-2018. The primary outcome was the first unplanned readmission after LAAC, with readmission times stratified into those occurring within 0 to 30 days vs within 31 to 180 days. Patients were stratified based on the history of previous stroke and/or TIA. Results: Of 12,901 discharges after LAAC, 28% had previous stroke and/or TIA, and 8.2% had a readmission within 30 days while 18% had a readmission within 31 to 180 days. The rates of in-hospital complications and readmissions at both periods were not significantly different between individuals with vs without previous stroke and/or TIA. Cardiac causes accounted for 28% of readmissions within 30 days and 32% of those within 31 to 180 days, and congestive failure, bleeding, and infections were the most common readmission diagnoses. New stroke and/or TIA accounted for 4% and 6% of the total noncardiac readmissions within 30 days and 31 to 180 days, respectively, and the incidence was higher among those with previous stroke and/or TIA. Female sex and index hospitalization length of stay (LOS) > 1 day were factors independently associated with readmission within 30 days, whereas LOS, diabetes, renal disease, chronic obstructive pulmonary disease, and anemia were among the factors associated with readmissions within 31 to 180 days. Conclusions: Unplanned rehospitalizations were common after LAAC and had similar frequency for patients with vs without previous ischemic stroke and/or TIA. Female sex and index hospitalization LOS > 1 day were among the strongest factors that were independently associated with readmission within 30 days.

Contexte: Nous avons examiné la fréquence et les facteurs de risque des réadmissions consécutives à une fermeture de l'appendice auriculaire gauche (FAOG) chez les patients ayant ou non subi un accident vasculaire cérébral (AVC) ischémique et/ou un accident ischémique transitoire (AIT). Méthodologie: Les hospitalisations pour une FAOG ont été recensées au moyen de la US National Readmission Database (base de données nationale des réadmissions aux États-Unis) pour la période 2016-2018. Le critère d'évaluation principal était la première réadmission non prévue après une FAOG, avec stratification du moment de la réadmission selon que celle-ci était survenue de 0 à 30 jours ou de 31 à 180 jours après l'intervention. Les patients ont été stratifiés en fonction des antécédents d'AVC et/ou d'AIT. Résultats: Parmi les 12 901 patients ayant reçu leur congé de l'hôpital après une FAOG, 28 % avaient des antécédents d'AVC et/ou d'AIT; 8,2 % des patients admissibles ont été réadmis dans les 30 jours et 18 %, entre le 31e et le 180e jour suivant l'intervention. Aucune différence significative n'a été observée entre les patients ayant subi un AVC et/ou un AIT et les patients qui n'en avaient pas subi en ce qui concerne les taux de complications hospitalières et de réadmission durant ces deux périodes. Les causes cardiaques représentaient 28 % des réadmissions dans les 30 jours et 32 % des réadmissions entre le 31e et le 180e jour. L'insuffisance cardiaque congestive, les hémorragies et les infections ont été les causes les plus fréquentes de réadmission. Les nouveaux cas d'AVC et/ou d'AIT ont respectivement été à l'origine de 4 % et de 6 % de l'ensemble des réadmissions de cause non cardiaque dans les 30 jours, et entre le 31e et le 180e jour, et leur fréquence a été plus élevée chez les patients ayant des antécédents d'AVC et/ou d'AIT. Le sexe féminin et une durée d'hospitalisation initiale > 1 jour ont été des facteurs indépendants associés aux réadmissions dans les 30 jours, tandis que la durée de l'hospitalisation, un diabète, une néphropathie, une maladie pulmonaire obstructive chronique et une anémie faisaient partie des facteurs associés aux réadmissions entre le 31e et le 180e jour. Conclusions: Les réhospitalisations non prévues ont été courantes après une FAOG, et leur fréquence a été similaire en présence ou en l'absence d'antécédents d'AVC ischémique et/ou d'AIT. Le sexe féminin et une durée d'hospitalisation initiale > 1 jour ont été les facteurs les plus importants associés aux réadmissions dans les 30 jours.

Coaptation length predicts early- and intermediate-term durability following degenerative mitral repair.

OBJECTIVES: The impact of coaptation length on recurrent mitral regurgitation following degenerative mitral repair is not fully understood. METHODS: Between May 2008 and February 2021, 386 consecutive patients underwent mitral repair for degenerative mitral regurgitation at a single centre. We compared patients with a post-repair coaptation length >11 mm (long-coaptation group, n = 230) and ≤11 mm (short-coaptation group, n = 156). The coaptation length cutoff was selected based on published postoperative transesophageal echocardiographic measurement of mitral repair patients and healthy controls. Propensity score with inverse probability of treatment weighting (IPTW) analyses were performed. The median duration of clinical follow-up was 41 months and follow-up was complete in the entire cohort. RESULTS: The long-coaptation patients underwent more neochord implantation (89% vs 65%, P < 0.001) and less leaflet resection (11% vs 29%, P < 0.001). Overall in-hospital/30-day mortality and mitral reintervention occurred in 3 (1%) and 4 (1%) patients, respectively, and freedom from recurrent mitral regurgitation was 98% at 1 year and 94% at 5 years. Freedom from recurrent mitral regurgitation moderate or greater was significantly higher in the long-coaptation patients (IPTW-adjusted difference in average time to recurrent mitral regurgitation: 31 months, 95% confidence interval 9-53, P = 0.006). However, there was no difference in intermediate-term survival between both groups (IPTW-adjusted difference in average time to death: 9.5 months, 95% confidence interval -27 to 46, P = 0.61). Stratified analysis and pairwise comparison of different coaptation intervals also appeared to support the protective effect of longer coaptation on repair durability. CONCLUSIONS: Longer coaptation length appears to be associated with improved intermediate-term durability after mitral repair.

Complementary role of computed tomography angiography with fixed perfusion defects on SPECT myocardial perfusion imaging.

PURPOSE: We present this case series exploring the complementary role of coronary computed tomography angiography (CCTA) to SPECT myocardial perfusion imaging (MPI) in the detection of myocardial necrosis. METHODS: A cardiac hybrid imaging database search identified 144 patients with a previous history of ST-segment elevation myocardial infarction treated with coronary revascularization. CCTA and MPI scans were evaluated to determine whether CCTA had an added value to MPI in detecting myocardial necrosis. RESULTS: Five patients with patent stents and/or bypass grafts and both fixed perfusion defects on MPI and sub-endocardial hypo-perfusion on CCTA were identified. The extent and location of the perfusion defects were closely correlated between the CCTA and SPECT MPI images. CONCLUSION: In this series, CCTA and SPECT MPI were found to play a complementary role in the assessment of fixed perfusion defect, with CCTA adding specificity to the diagnosis of myocardial necrosis.

Aggressive Cholesterol Pericarditis With Minimal Effusion Masquerading as Treatment-Refractory Autoimmune Disease.

A middle-aged woman with rheumatoid arthritis presented with treatment-refractory pericarditis. Symptoms persisted despite escalation of immunosuppression, and she had recurrent admissions for heart failure. Imaging revealed minimal pericardial effusion and a thickened pericardium. Invasive hemodynamics confirmed constrictive physiology, and a pericardiectomy was required. Pathology testing confirmed cholesterol pericarditis, a rare condition of inflammatory cholesterol deposits within the pericardium. Previous reports describe moderate-to-large volumes of gold-coloured pericardial fluid. This case illustrates that cholesterol pericarditis can present with minimal pericardial effusion and rapidly progress to pericardial constriction.

Une femme d'âge moyen atteinte d'arthrite rhumatoïde a présenté une péricardite réfractaire. Les symptômes ont persisté en dépit de l'escalade de l'immunodépression. Elle a été admise de façon répétitive en raison d'insuffisance cardiaque. L'imagerie a révélé un épanchement péricardique minimal et un péricarde épaissi. L'exploration hémodynamique invasive a permis de confirmer la physiologie constrictive. Une péricardectomie a été nécessaire. L'examen pathologique a permis de confirmer la péricardite cholestérolique, une affection inflammatoire rare due aux dépôts de cholestérol dans le péricarde. Les observations précédentes décrivent des volumes modérés à élevés de liquide péricardique doré. Ce cas illustre que la péricardite cholestérolique peut se traduire par un épanchement péricardique minimal et progresser rapidement vers la péricardite constrictive.

Multimodality Imaging in Transcatheter Mitral Interventions.

Multimodality imaging is of imperative value for the planning and guidance of transcatheter mitral valve interventions. This review employs the value of different imaging modalities and future implications for clinical practice.

Comorbidity burden in patients undergoing left atrial appendage closure.

OBJECTIVE: To estimate the risk of in-hospital complications after left atrial appendage closure (LAAC) in relationship with comorbidity burden. METHODS: Cohort-based observational study using the US National Inpatient Sample database, 1 October 2015 to 31 December 2017. The main outcome of interest was the occurrence of in-hospital major adverse events (MAE) defined as the composite of bleeding complications, acute kidney injury, vascular complications, cardiac complications and postprocedural stroke. Comorbidity burden and thromboembolic risk were assessed by the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Score (ECS) and CHA2DS2-VASc score. MAE were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. The associations of comorbidity with in-hospital MAE were evaluated using logistic regression models. RESULTS: A total of 3294 hospitalisations were identified, among these, the mean age was 75.7±8.2 years, 60% were male and 86% whites. The mean CHA2DS2-VASc score was 4.3±1.5 and 29.5% of the patients had previous stroke or transient ischaemic attack. The mean CCI and ECS were 2.2±1.9 and 9.7±5.8, respectively. The overall composite rate of in-hospital MAE after LAAC was 4.6%. Females and non-whites had about 1.5 higher odds of in-hospital AEs as well participants with higher CCI (adjusted OR (aOR): 1.19, 95% CI: 1.13 to 1.24, p<0.001), ECS (aOR: 1.06, 95% CI: 1.05 to 1.08, p<0.001) and CHA2DS2-VASc score (aOR: 1.08, 95% CI: 1.02 to 1.15, p=0.01) were significantly associated with in-hospital MAE. CONCLUSION: In this large cohort of LAAC patients, the majority of them had significant comorbidity burden. In-hospital MAE occurred in 4.6% and female patients, non-whites and those with higher burden of comorbidities were at higher risk of in-hospital MAE after LAAC.

Sex Differences in Outcomes Following Left Atrial Appendage Closure.

OBJECTIVE: To evaluate the effects of female sex on in-hospital outcomes and to provide estimates for sex-specific prediction models of adverse outcomes following left atrial appendage closure (LAAC). PATIENTS AND METHODS: Cohort-based observational study querying the National Inpatient Sample database between October 1, 2015, and December 31, 2017. Demographics, baseline characteristics, and comorbidities were assessed with the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index score (ECS), and CHA2DS2-VASc score. The primary outcome was in-hospital major adverse events (MAEs) defined as the composite of bleeding, vascular, cardiac complications, post-procedural stroke, and acute kidney injury. The associations of the CCI, ECS, and CHA2DS2-VASc score with in-hospital MAE were examined using logistic regression models for women and men, respectively. RESULTS: A total of 3294 hospitalizations were identified, of which 1313 (40%) involved women and 1981 (60%) involved men. Women were older (76.3±7.7 vs 75.2±8.4 years, P<.001), had a higher CHA2DS2-VASc score (4.9±1.4 vs 3.9±1.4, P<.001) but showed lower CCI and ECS compared with men (2.1±1.9 vs 2.3±1.9, P=.01; and 9.3±5.9 vs 9.9±5.7, P=.002, respectively). The primary composite outcome occurred in 4.6% of patients and was higher in women compared with men (women 5.6% vs men 4.0%, P=.04), and this was mainly driven by the occurrence of cardiac complications (2.4% vs 1.2%, P=.01). In women, older age, higher median income, and higher CCI (adjusted odds ratio [aOR], 1.32; 95% confidence interval [CI], 1.21 to 1.44; P<.001), ECS (aOR, 1.04; 95% CI, 1.02 to 1.07; P=.002), and CHA2DS2-VASc score (aOR, 1.24; 95% CI, 1.10 to 1.39; P<.001) were associated with increased risk of in-hospital MAE. In men, non-White race/ethnicity, lower median income, and higher ECS (aOR, 1.06; 95% CI, 1.04 to 1.09; P<.001) were associated with increased risk of in-hospital MAE. CONCLUSION: Women had higher rates of in-hospital adverse events following LAAC than men did. Women with older age and higher median income, CCI, ECS, and CHA2DS2-VASc scores were associated with in-hospital adverse events, whereas men with non-White race/ethnicity, lower median income, and higher ECS were more likely to experience adverse events. Further research is warranted to identify sex-specific, racial/ethnic, and socioeconomic pathways during the patient selection process to minimize complications in patients undergoing LAAC.

Endoscopic Mitral Repair for Degenerative Mitral Regurgitation: Effect of Disease Complexity on Short- and Mid-term Outcomes.

BACKGROUND: We set out to compare in a prospective cohort study the mid-term clinical and echocardiographic outcomes of mini-mitral repair for simple (posterior prolapse) vs complex regurgitation (anterior/bileaflet prolapse). METHODS: A total of 245 consecutive patients underwent mini-mitral repair for severe degenerative mitral regurgitation through a right, endoscopic approach (n = 145 simple, n = 100 complex). The most common repair technique was annuloplasty + artificial chordae (84%, n = 121 for simple vs 88%, n = 88 for complex, P = 0.3). Patients were prospectively followed for a maximal duration of 9 years. Patients' characteristics were well balanced between groups. RESULTS: The 30-day/in-hospital mortality was similar (0%, n = 0 simple vs 1%, n = 1 complex, P = 0.2). Both groups had similar rates of early postoperative complications: myocardial infarction (1.4%, n = 2 vs 0%, n = 0, P = 0.2), neurologic complications (1.4%, n = 2 vs 0%, n = 0, P = 0.2), reoperation for bleeding (0.7%, n = 1 vs 3%, n = 3, P = 0.2), intensive care unit length of stay (1 interquartile range, 1-1 days vs 1 interquartile range, 1-1 days, P = 0.7). Late survival (88% for simple vs 92% for complex, P = 0.4) was similar between groups. Cumulative incidence of late reoperation at 6 years is 0% for both groups (subdistribution hazard ratio = 1, P = 1). There was no difference in recurrent mitral regurgitation greater than 2+ at each year after surgery up to 6 years postoperatively. CONCLUSION: Mitral repair using an endoscopic, minimally invasive approach yields excellent mid-term outcomes regardless of disease complexity.

CONTEXTE: Dans le cadre d'une étude de cohorte prospective, on a comparé les résultats cliniques et échocardiographiques que la réparation mitrale mini-invasive procurait à moyen terme selon que cette dernière était pratiquée dans un contexte de régurgitation simple (prolapsus postérieur) ou de régurgitation complexe (prolapsus antérieur/bivalvulaire). MÉTHODOLOGIE: Au total, 245 patients consécutifs qui présentaient une régurgitation mitrale dégénérative sévère ont subi une réparation mitrale mini-invasive par abord endoscopique droit (n = 145 cas de régurgitation simple et n = 100 cas de régurgitation complexe). La technique de réparation la plus courante était l'annuloplastie avec implantation de cordages artificiels (84 %, n = 121 cas de régurgitation simple vs 88 %, n = 88 cas de régurgitation complexe, p = 0,3). Les patients ont été l'objet d'un suivi prospectif d'une durée maximale de 9 ans. Il y avait une répartition équilibrée des caractéristiques des patients entre les groupes. RÉSULTATS: Les taux de mortalité à 30 jours et de mortalité hospitalière se sont avérés semblables (0 %, n = 0 cas chez les patients qui présentaient une régurgitation simple vs 1 %, n = 1 cas chez les patients qui présentaient une régurgitation complexe, p = 0,2). Les taux de complications postopératoires précoces se sont également révélés semblables chez les patients des deux groupes, notamment en ce qui concerne l'infarctus du myocarde (1,4 %, n = 2 vs 0 %, n = 0, p = 0,2), les complications neurologiques (1,4 %, n = 2 vs 0 %, n = 0, p = 0,2), les nouvelles interventions chirurgicales en raison d'une hémorragie (0,7 %, n = 1 vs 3 %, n = 3, p = 0,2) et la durée de l'hospitalisation à l'unité de soins intensifs (1 intervalle interquartile, 1-1 jour vs 1 intervalle interquartile, 1-1 jour, p = 0,7). De même, des taux de survie tardive similaires ont été notés chez les patients des deux groupes (88 % chez les patients qui présentaient une régurgitation simple vs 92 % chez les patients qui présentaient une régurgitation complexe, p = 0,4). L'incidence cumulative de nouvelles interventions chirurgicales tardives à 6 ans s'est établie à 0 % dans les deux groupes (rapport des risques instantanés de sous-distribution = 1, p = 1). Aucune différence quant à la récidive de régurgitation mitrale de grade supérieur à 2 n'a été relevée au cours de chacune des 6 années suivant l'intervention chirurgicale. CONCLUSIONS: La réparation mitrale minimalement invasive par abord endoscopique permet d'obtenir d'excellents résultats à moyen terme, indépendamment de la complexité de la maladie.