Trends in invasive treatment of patients hospitalized with aortic stenosis complicated by cardiogenic shock.

BACKGROUND: Before the development of transcatheter aortic valve replacement (TAVR), balloon aortic valvuloplasty (BAV) was the only potential nonsurgical intervention for patients with aortic stenosis complicated by cardiogenic shock. Emergent TAVR is now an option and has shown acceptable outcomes compared with elective TAVR. We explored how treatment patterns for aortic stenosis and cardiogenic shock among patients received invasive intervention have shifted since TAVR was introduced. METHODS: We used the Nationwide In patients Sample to identify nonelective hospitalizations for patient with aortic stenosis complicated by cardiogenic shock who received invasive treatment (TAVR, BAV, or surgical aortic valve replacement [SAVR]). We explored the proportion treated with each treatment modality over time, the patient characteristics and in-hospital mortality associated with each treatment, and used multivariable logistic regression to examine whether changes in in-hospital mortality over time differed by treatment. RESULTS: Between 2010 and 2019, we identified 9899 hospitalizations for decompensated aortic stenosis with cardiogenic shock during which patients received invasive treatment (TAVR 17.7%, BAV 20.2%, SAVR 62.1%). Use of both TAVR and BAV has increased over time compared with SAVR (TAVR 6.6% ≥ 33.8%, BAV 8.4% ≥ 23.2%, SAVR 91.6% ≥ 43.0%; p < 0.001 for trend). The overall in-hospital mortality rate was 21.0%, which decreased over time for all treatments (TAVR 20.0% ≥ 18.8%, BAV 66.0% ≥ 25.5%, SAVR 17.7% ≥ 11.8%; linear trend p < 0.001 for each), with lower mortality for TAVR versus BAV at all time points. Patients treated with TAVR (vs. BAV) were less likely to require mechanical ventilation (36.8% vs. 46.3%, p < 0.001) or mechanical circulatory support (22.5% vs. 29.9%, p < 0.001). In the multivariable analysis, the interaction between treatment and time was not significant (p = 0.245), indicating the reduction in in-hospital mortality over time did not differ among the treatments. CONCLUSIONS: Since the introduction of TAVR, there has been a shift toward increased use of nonsurgical invasive treatments (both BAV and TAVR) for aortic stenosis and cardiogenic shock. Although in-hospital mortality has declined, it remains high in all groups, but particularly among patients treated with BAV, where the severity of cardiogenic shock appears to be higher than in those treated with other modalities.

Bleeding, death, and costs of care during hospitalization for acute pulmonary embolism: Insights from the Saint Luke's Outcomes of Pulmonary Embolism (SLOPE) study.

Limited data exist that comprehensively describe the practical management, in-hospital outcomes, healthcare resource utilization, and rates of post-hospital readmission among patients with submassive and massive pulmonary embolism (PE). Consecutive discharges for acute PE were identified from a single health system over 3 years. Records were audited to confirm presence of acute PE, patient characteristics, disease severity, medical treatment, and PE-related invasive therapies. Rates of in-hospital major bleeding and death, hospital length of stay (LOS), direct costs, and hospital readmission are reported. From January 2016 to December 2018, 371 patients were hospitalized for acute massive or submassive PE. In-hospital major bleeding (12.1%) was common, despite low utilization of systemic thrombolysis (1.8%) or catheter-directed thrombolysis (3.0%). In-hospital death was 10-fold higher among massive PE compared to submassive PE (36.6% vs 3.3%, p < 0.001). Massive PE was more common during hospitalizations not primarily related to venous thromboembolism, including hospitalizations primarily for sepsis or infection (26.8% vs 8.2%, p = 0.001). Overall, the median LOS was 6.0 days (IQR, 3.0-11.0) and the median standardized direct cost of admissions was $10,032 (IQR, $4467-$20,330). Rates of all-cause readmission were relatively high throughout late follow-up but did not differ between PE subgroups. Despite low utilization of thrombolysis, in-hospital bleeding remains a common adverse event during hospitalizations for acute PE. Although massive PE is associated with high risk for in-hospital bleeding and death, those successfully discharged after a massive PE demonstrate similar rates of readmission compared to submassive PE into late follow-up.

Assessment of right ventricular function following left ventricular assist device (LVAD) implantation-The role of speckle-tracking echocardiography: A meta-analysis.

BACKGROUND: Right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation is associated with worse outcomes. Prediction of RVF is difficult with routine transthoracic echocardiography (TTE), while speckle-tracking echocardiography (STE) showed promising results. We performed systematic review and meta-analysis of published literature. METHODS: We queried multiple databases to compile articles reporting preoperative or intraoperative right ventricle global longitudinal strain (RVGLS) or right ventricle free wall strain (RVFWS) in LVAD recipients. The standard mean difference (SMD) in RVGLS and RVFWS in patients with and without RVF postoperatively was pooled using random-effects model. RESULTS: Seventeen studies were included. Patients with RVF had significantly lower RVGLS and RVFWS as compared to non-RVF patients; SMD: 2.79 (95% CI: -4.07 to -1.50; P: <.001) and -3.05 (95% CI: -4.11 to -1.99; P: <.001), respectively. The pooled odds ratio (OR) for RVF per percentage increase of RVGLS and RVFWS were 1.10 (95 CI: 0.98-1.25) and 1.63 (95% CI 1.07-2.47), respectively. In a subgroup analysis, TTE-derived GLS and FWS were significantly lower in RVF patients as compared to non-RVF patients; SMD of -3.97 (95% CI: -5.40 to -2.54; P: <.001) and -3.05 (95% CI: -4.11 to -1.99; P: <.001), respectively. There was no significant difference between RVF and non-RVF groups in TEE-derived RVGLS and RVFWS. CONCLUSION: RVGLS and RVFWS were lower in patients who developed RVF as compared to non-RVF patients. In a subgroup analysis, TTE-derived RVGLS and RVFWS were reduced in RVF patients as compared to non-RVF patients. This difference was not reported with TEE.

Global longitudinal strain assessment of the left ventricle by speckle tracking echocardiography detects acute cellular rejection in orthotopic heart transplant recipients: A systematic review and meta-analysis.

BACKGROUND: In orthotopic heart transplant recipients, surveillance with endomyocardial biopsy is crucial to detect acute cellular rejection (ACR) early. ACR is a common and serious complication of transplantation with substantial morbidity and mortality. Speckle tracking echocardiography with global longitudinal strain (GLS) assessment of the left ventricle has emerged as a possible noninvasive screening modality. We have conducted a systematic literature review and meta-analysis to evaluate the role of GLS in diagnosing ACR. METHODS: The following databases were queried: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Embase. We compiled all articles evaluating changes in GLS in comparison to endomyocardial biopsy in ACR dated prior to September 2019. Weighted mean differences (WMD) and 95% confidence intervals (CIs) were pooled by using a random effects model. In order to determine the risk of bias, we used the revised version of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. RESULTS: Twelve studies met inclusion criteria of which ten were chosen. These studies encompassed 511 patients and 1267 endomyocardial biopsies. There was a significant difference in GLS between patients who did and did not have ACR proven by biopsy (WMD = 2.18; 95% CI: 1.57-2.78, P = <.001; I2  = 76%). The overall sensitivity for GLS in detecting ACR was 78% (CI: 63%-90%, P = .123; I2  = 52.2%) while the overall specificity was 68% (CI: 50%-83%, P = <.001; I2  = 88.3%). CONCLUSION: Global longitudinal strain assessment of the left ventricle by speckle tracking echocardiography is useful in detecting ACR and could potentially reduce the burden of frequent endomyocardial biopsies in heart transplant recipients.

Implantable cardioverter-defibrillators and survival in advanced heart failure patients with continuous-flow left ventricular assist devices: a systematic review and meta-analysis.

AIMS: Implantable cardioverter-defibrillators (ICDs) implantation in heart failure (HF) patients with reduced ejection fraction improves survival by reducing mortality secondary to arrhythmic events. Whether advanced HF patients treated with continuous-flow left ventricular assist devices (CF-LVADs) derive similar benefit is controversial. METHODS AND RESULTS: We searched PubMed, Cochrane Central Register of Controlled Trials, Embase, and Scopus from inception through November 2018 for studies examining the association between ICD implantation and all-cause mortality in patients with advanced HF and CF-LVADs. Analyses were performed using a random-effects model. Hazard ratios (HRs) were calculated with 95% confidence intervals (CIs). Heterogeneity and publication bias were formally assessed, using I2 and funnel plots, respectively. Eight observational studies with a total of 6416 patients (ICD group = 3450, no ICD group = 2966) met inclusion criteria. The majority of patients (84.6%) came from the two largest observational studies. There was no difference in mortality in the ICD and no ICD groups (HR 0.96, 95% CI 0.73-1.27, P = 0.79, I2 = 42%), and ICD implantation post-CF-LVAD was not associated with an improvement in mortality (HR 0.87, 95% CI 0.48-1.57, P = 0.64, I2 = 0%). Additionally, there was no significant difference in the likelihood of transplantation (HR 1.10, 95% CI 0.93-1.30, P = 0.28, I2 = 26%) or non-mortality adverse events between the two groups. CONCLUSION: Implantable cardioverter-defibrillator use was not associated with improved survival in advanced HF patients with CF-LVADs. These findings underscore the need to formally study the efficacy of ICDs in this population in a dedicated randomized controlled study.

Diagnostic accuracy of dobutamine stress echocardiography in the detection of cardiac allograft vasculopathy in heart transplant recipients: A systematic review and meta-analysis study.

BACKGROUND: Dobutamine stress echocardiography (DSE) is a well-established imaging modality used to screen patients with mild-to-moderate risk for coronary artery disease. In heart transplantation recipients, cardiac allograft vasculopathy (CAV) is a common and lethal complication. The use of DSE to detect CAV showed promising results initially, but later studies showed limitation in its use to detect CAV. It is unclear if this cohort of patients derives benefit from DSE. METHODS: We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Scopus from inception through March 2018 for studies examining the accuracy of DSE in correlation to coronary angiography (CA) or intravascular ultrasound (IVUS) to detect CAV. Original studies comparing the ability of DSE to detect CAV in comparison with CA or IVUS were included. Relevant data were extracted and hierarchical summary receiver operating characteristic analysis was conducted to test the overall diagnostic accuracy of DSE for patients with CAV. RESULTS: Eleven studies (749 participants) met the inclusion criteria. The sensitivity of DSE varied from 1.7% to 93.8%, and specificity, from 54.8% to 98.8%. Pooled sensitivity was 60.2% (95% confidence interval (CI), 33.0%-82.3%) and specificity 85.7% (95% CI, 73.8%-92.7%). DSE had an overall diagnostic odds ratio (OR) of 9.1 (95% CI, 4.6-17.8), positive likelihood ratio (LR+) of 4.1 (95% CI, 2.8-6.1), negative likelihood ratio (LR-) of 0.47 (95% CI: 0.23-0.73), and area under curve (AUC) of 0.73 (95% CI, 0.72-0.75). Heterogeneity among studies was not statistically significant (τ2  = 0.32, Cochran's Q = 9.5, P = 0.483). CONCLUSION: Dobutamine stress echocardiography has a limited sensitivity to detect early CAV but its specificity is much higher. There remains a need for an alternative noninvasive modality which will have both high sensitivity and high specificity for detecting CAV.

Three-dimensional transesophageal echocardiography is an attractive alternative to cardiac multi-detector computed tomography for aortic annular sizing: Systematic review and meta-analysis.

BACKGROUND: Cardiac imaging is the cornerstone of the pretranscatheter aortic valve replacement (TAVR) assessment. Multi-detector computed tomography (MDCT) is considered the conventional imaging modality. However, there is still no definitive gold standard. Targeted cohort of inoperable high-risk patients with underlying comorbidities, particularly renal impairment, makes apparent the need for MDCT alternative. We aimed to demonstrate the correlation extent between MDCT and three-dimensional transesophageal echocardiography (3DTEE) aortic annular area measures and to answer the question: Is 3DTEE a good alternative to MDCT? METHODS: A systematic literature search and meta-analysis were conducted to evaluate the degree of correlation and agreement between 3DTEE and MDCT aortic annular sizing. A thorough assessment of EMBASE, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed. All studies comparing 3DTEE and MDCT in relation to aortic annular sizing were included. RESULTS: Thirteen studies were included (N = 1228 patients). A strong linear correlation was found between 3DTEE and MDCT measurements of aortic annulus area (r = 0.84, P < 0.001), mean perimeter (r = 0. 0.85, P < 0.001), and mean diameter (r = 0.80, P < 0.001). Bland-Altman plots revealed smaller mean 3DTEE values in comparison to MDCT for aortic annular area, the mean difference being -2.22 mm2 with 95% limits of agreement -12.79 to 8.36. CONCLUSION: Aortic annulus measurements obtained by 3DTEE demonstrated a high level of correlation with those evaluated by MDCT. This makes 3DTEE a feasible choice for aortic annulus assessment, with advantage of real time assessment, lack of contrast, and no radiation exposure.

Incremental benefit of three-dimensional transesophageal echocardiography in the assessment of left main coronary artery stent protrusion.

Ostial lesions represent a challenging clinical scenario and percutaneous intervention (PCI) of left main coronary artery ostial lesions has been associated with postintervention complications, including protrusion of deployed stents into a sinus of Valsalva or aortic root. We report a case of stent protrusion into the aortic root following aorto-ostial left main coronary artery PCI, in which three-dimensional transesophageal echocardiography (3DTEE) provided incremental benefit over standard two-dimensional images. Specifically, 3DTEE confirmed the presence of stent protrusion by allowing clear visualization of the stent scaffold, in addition to characterizing the relationship between the stent and surrounding structures.

Incremental benefit of three-dimensional transesophageal echocardiography in the assessment of a primary pericardial hemangioma.

Hemangiomas are rarely found in the heart and pericardial involvement is even more rare. We report a case of primary pericardial hemangioma, in which three-dimensional transesophageal echocardiography (3DTEE) provided incremental benefit over standard two-dimensional images. Our case also highlights the importance of systematic cropping of the 3D datasets in making a diagnosis of pericardial hemangioma with a greater degree of certainty. In addition, we also provide a literature review of the features of cardiac/pericardial hemangiomas in a tabular form.

Usefulness of two- and three-dimensional transesophageal echocardiography in the assessment of proximal left coronary system compression by a paraprosthetic aortic valve abscess.

Paraprosthetic aortic valve abscess represents a rare, but lethal complication of infective endocarditis. We report a case of proximal left coronary system compression by a paraprosthetic aortic valve abscess whose detection was augmented using live/real time three-dimensional transesophageal echocardiography. Our case illustrates the usefulness of combined two- and three-dimensional transesophageal echocardiography in detecting this finding.

Incremental value of live/real time three-dimensional transesophageal echocardiography in the assessment of ventricular septal rupture following acute myocardial infarction.

Ventricular septal rupture is a serious complication following acute myocardial infarctions and is associated with a significant mortality rate. Classically, two-dimensional transthoracic echocardiography has been used to diagnose this complication and visualize its location. Two-dimensional transesophageal echocardiography has supplemented the transthoracic approach by providing more accurate assessment of the defect size and in guiding closure both percutaneously and intraoperatively. This modality, however, is limited to two-dimensional views only, and a greater breadth of information is instead available through the use of three-dimensional transesophageal echocardiography. We present a series of 11 patients in which live/real time three-dimensional transesophageal echocardiography offered incremental benefits over two-dimensional imaging alone.

Two- and three-dimensional transthoracic echocardiographic assessment of superior vena cava, crista terminalis, and right atrial appendage using the right parasternal approach.

BACKGROUND: The noninvasive assessment of superior vena cava (SVC), crista terminalis (CT), and the right atrial appendage (RAA) has clinical implications in determining the right atrium (RA) pressure in adult patients in whom the inferior vena cava cannot be imaged, in planning electrophysiological procedures and for evaluation of thrombi in RA/RAA. It is difficult to image these structures using standard two-dimensional transthoracic echocardiography (2DTTE), but the right parasternal approach has shown promise in the very few studies published so far. AIM: The aim of this study was to show the feasibility of this approach and its usefulness in qualitative and quantitative assessments of these structures by both 2D and three (3D) TTE in patients with and without known cardiac pathologies. MATERIAL AND METHODS: The study consisted of 38 adult patients, 17 of whom had cardiac pathologies (Group 1) while the remainder (Group 2) had no evidence of heart disease clinically or by echocardiography. RESULTS AND CONCLUSION: Both SVC and RAA could be imaged by 2DTTE and 3DTTE in 53% of 40 patients (two separate groups of 20 consecutive patients) studied demonstrating the technical feasibility of this approach. SVC size and collapsibility, CT and RAA size, and RAA fractional shortening were evaluated in both groups by both 2D and 3DTTE. 3DTTE provided incremental value over 2DTTE by its ability to view en face the SVC in short axis and the base of RAA and RAA volumes resulting in more comprehensive assessment of their size and function.

Does three-dimensional transesophageal echocardiography provide incremental value in percutaneous closure of ascending aortic pseudoaneurysm?

Ascending aortic pseudoaneurysms (AO PSAs), if left untreated, are complicated by a high rate of rupture resulting in significant morbidity and mortality. New transcatheter modalities have emerged as acceptable surgical alternatives for their management. We present a case of an ascending aortic PSA in which intraoperative two- and three-dimensional transesophageal echocardiography (2DTEE and 3DTEE) provided a comprehensive assessment of the PSA in pre- and postclosure settings.

Incremental value of live/real time three-dimensional transthoracic echocardiography over the two-dimensional technique in assessing carcinoid heart disease involving the aortic valve.

We present a case of an adult with metastatic carcinoid heart disease, in whom live/real time three-dimensional transthoracic echocardiography provided incremental value over two-dimensional transthoracic echocardiography in assessing involvement of the aortic valve.

Normal-Flow Low-Gradient Aortic Stenosis: Comparing the U.S. and European Guidelines.

Patients with normal-flow low-gradient (NFLG) severe aortic stenosis present both diagnostic and management challenges, with debate about the whether this represents true severe stenosis and the need for valve replacement. Studies exploring the natural history without intervention have shown similar outcomes of patients with NFLG severe aortic stenosis to those with moderate aortic stenosis and better outcomes after valve replacement than those with low-flow low-gradient severe aortic stenosis. Most studies (all observational) have shown that aortic valve replacement was associated with a survival benefit vs surveillance. Based on available data, the European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines and European Association of Cardiovascular Imaging/American Society of Echocardiography suggest that these patients are more likely to have moderate aortic stenosis. This clinical entity is not mentioned in the American Heart Association/American College of Cardiology guidelines. Here we review the definition of NFLG severe aortic stenosis, potential diagnostic algorithms and points of error, the data supporting different management strategies, and the differing guidelines and outline the unanswered questions in the diagnosis and management of these challenging patients.

Association between cancer, CHA2DS2VASc risk, and in-hospital ischaemic stroke in patients hospitalized for atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is commonly encountered in cancer patients. We investigated the CHA2DS2VASc score, and its association with in-hospital ischaemic stroke in patients with cancer who were hospitalized for AF. METHODS AND RESULTS: Using the United States National Inpatient Sample, all hospitalizations with principal diagnosis of AF between October 2015 and December 2018 were stratified by cancer diagnosis, type, and CHA2DS2VASc risk categories (low risk, low-moderate risk, moderate-high risk). In-hospital ischaemic stroke and its association with the CHA2DS2VASc risk score was assessed across the groups using hierarchical multivariable logistic regression with adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). Discrimination of CHA2DS2VASc score for in-hospital ischaemic stroke was evaluated with Receiver Operating Characteristic and Area Under the Curve (AUC). Among 1 341 870 included hospitalizations, 71 965 (5.4%) had comorbid cancer. Cancer patients had a higher proportion of moderate-high CHA2DS2VASc risk compared with their non-cancer counterparts (86.5% vs. 82.3%, P < 0.001). Compared with their low CHA2DS2VASc risk counterparts, cancer patients in low-moderate and moderate-high risk scores had similar odds of developing stroke (aOR 1.28 95% CI 0.22-7.63 and aOR 1.78 95% CI 0.41-7.66, respectively). The CHA2DS2VASc risk score had poor discrimination for ischaemic stroke in the cancer group (AUC 0.538 95% CI 0.477-0.598). CONCLUSION: Cancer patients with AF have high CHA2DS2VASc risk. Discrimination of CHA2DS2VASc for ischaemic stroke is lower in cancer than non-cancer patients, and CHA2DS2VASc may not be adequate in determining ischaemic risk in cancer population.