Left atrial anatomy and patient-related factors associated with adverse outcomes with the watchman device-a real world experience.

OBJECTIVE: This study sought to identify patient and left atrial morphology specific factors associated with early complications for left atrial appendage occlusion with the Watchman™ (Boston Scientific, Natick, MA) device. BACKGROUND: Oral anticoagulation (OAC) is recommended for patients with atrial fibrillation, however, long-term OAC compliance is poor. In randomized control trials, the Watchman™ device has demonstrated superiority over OAC with warfarin for all cause and cardiovascular mortality and hemorrhagic stroke. However, predictors of procedural complications have not yet been well established. METHODS: There were 137 patients included in this study from a total of 141 consecutive patients prospectively enrolled in the registry between 8/1/2015 and 08/31/2016. Unadjusted, multivariate cox proportional hazards model was used for analysis. Primary end-point was a composite major adverse cardiac and cerebrovascular event (MACCE) defined to include death, stroke, major and life threatening bleeding, major vascular complications, device embolization, need for cardiovascular surgery, need for cardiopulmonary resuscitation, and significant pericardial effusion. RESULTS: The primary endpoint was reached in 5.8% of patients. There were no device embolization and no strokes. Anterior chicken morphology (ACW) of the left atrial appendage (LAA) conferred a hazard ratio of 3.7 for MACCE and a body mass index >30 kg/m2 significantly lowered the likelihood of a MACCE. CONCLUSION: Certain LAA morphologies and patient characteristics increase the risk for a MACCE following left atrial appendage occlusion (LAAO) with the Watchman™ device. Anterior chicken wing morphology of the LAA and low BMI <30 kg/m2 were independent predictors of MACCE in the multivariate regression model.

A retrospective analysis of Impella use in all-comers: 1-year outcomes.

BACKGROUND: There are non-randomized data about the benefits of Impella use in the setting of cardiogenic shock. However, limited data exist to help guide clinicians about whether in the context of the intervention the device should be implanted early or late; how long the device should stay in; and how the mode of explant should be. METHODS: This is a retrospective, single center registry over 5 years comparing in-hospital outcomes and 1-year mortality in all-comers who had the Impella device placed early versus those who had the device placed late as a bailout. The primary endpoint was a composite of in-hospital all-cause mortality, major vascular, bleeding complications, and stroke. A secondary endpoint was 1-year mortality. RESULTS: Of 262 total patients, 181 (69.1%) had early and 81 (30.9%) had late Impella placement. Patients in the early group had a lower combined MACCE (17.1% vs 59.3%, P < 0.001) and in-hospital mortality (8.8% vs 48.1%, P < 0.001) compared to the late group. Major vascular (3.3% vs 2.5%, P = 1.0), bleeding complications (5.0% vs 7.4%, P = 0.57), and stroke (3.3% vs 7.4%, P = 0.20) were not significant between groups. Early Impella placement had lower 6 month (17.7% vs 53.1%, P < 0.001) and 1-year mortality rates (21.5% vs 53.1%, P < 0.001) compared to those in the late group. CONCLUSION: For patients with need for an Impella device, regardless of the indication, early implantation is associated with better in-hospital and 1-year outcomes as compared to when the device is implanted late as a bailout.

The use of micropuncture technique for vascular or body cavity access.

More than 1 million cardiac catheterizations are performed every year in the United States, and incur substantial risk of access site bleeding. Furthermore, insertion of central venous catheters and performance of pericardio- or pleurocentesis are common practice, also with substantial risk of vascular or organ injury. One of the major risks for access site bleeding is multiple or posterior arterial puncture with a large needle. Using a very small needle to obtain initial access to vessels or organ cavities has the potential to reduce the risk of bleeding or organ injury. Multiple unsuccessful attempts to achieve vascular access are more forgiving, and accidental organ injury during pericardio- or pleurocentesis is less traumatic when using a small micropuncture needle. This article reviews the use of micropuncture technique for vascular or organ cavity access, a technique that has the potential to decrease vascular access site complications and organ injury.

Nanoliposomes protect against AL amyloid light chain protein-induced endothelial injury.

CONTEXT: A newly-recognized pathogenic mechanism underlying light chain amyloidosis (AL) involves endothelial dysfunction and cell injury caused by misfolded light chain proteins (LC). Nanoliposomes (NL) are artificial phospholipid vesicles that could attach to misfolded proteins and reduce tissue injury. OBJECTIVE: To test whether co-treatment with NL reduces LC-induced endothelial dysfunction and cell death. METHODS: Abdominal subcutaneous adipose arterioles from 14 non-AL subjects were cannulated; dilator response to acetylcholine and papaverine were measured at baseline and following 1-hour exposure to LC (20 µg/mL, 2 purified from AL subjects' urine, 1 from human recombinant LC [AL-09]) ± NL (phosphatidylcholine/cholesterol/phosphatidic acid 70/25/5 molar ratio) or NL alone. Human aortic artery endothelial cells (HAEC) were exposed to Oregon Green-labeled LC ± NL for 24 hours and intracellular LC and apoptosis (Hoechst stain) were measured. Circular dichroism spectroscopy was performed on AL-09 LC ± NL to follow changes in secondary structure and protein thermal stability. RESULTS: LC caused impaired dilation to acetylcholine that was restored by NL (control - 94.0 ± 1.8%, LC - 65.0 ± 7.1%, LC + NL - 95.3 ± 1.8%, p ≤ 0.001 LC versus control or LC + NL). NL protection was inhibited by L-NG-nitroarginine methyl ester. NL increased the beta sheet structure of LC, reduced endothelial cell internalization of LC and protected against LC-induced endothelial cell death. CONCLUSIONS: LC induced human adipose arteriole endothelial dysfunction and endothelial cell death, which were reversed by co-treatment with NL. This protection may partly be due to enhancing LC protein structure and reducing LC internalization. Nanoliposomes represent a promising new class of agents to ameliorate tissue injury from protein misfolding diseases such as AL.

Chronic total occlusions: successful recanalization of very old lesions.

PURPOSE: The treatment of chronic total occlusion is thought to be the final frontier in treating coronary artery disease nonsurgically. In the past, an old occlusion was not likely to be treated successfully percutaneous. We have had success in revascularizing some very old 20 plus year old occlusions percutaneously. METHODS: Six patients were treated who had >20-year-old occlusions. Five patients were male; mean age of patients was 72.2 years (range 63-86). Mean age of the occlusion was 24.8 years. All patients had ischemia in the corresponding territory. Four of the patients had right coronary artery occlusions; one had a left circumflex occlusion and one had left anterior descending artery occlusion. RESULTS: Using a combination of radial and/or femoral approach, we successfully recanalized all of these old occlusions. No patients had major adverse cardiac events. Two patients developed restenosis at follow-up that was subsequently treated uneventfully. All the patients had a complete relief of angina. CONCLUSION: In a small single center experience, even very old occlusions >20-year old can be effectively treated with dedicated systems, excellent guiding catheter support and experienced physicians.

Diabetic cardiomyopathy.

Individuals with diabetes are at a significantly greater risk of developing cardioymyopathy and heart failure despite adjusting for concomitant risks such as coronary artery disease or hypertension. This has led to the increased recognition of a distinct disease process termed as "diabetic cardiomyopathy." In this article, we perform an extensive review of the pathogenesis and treatment of this disease. From a clinical perspective, physicians should be aware of this entity, and early screening should be considered because physical evidence of early diabetic cardiomyopathy could be difficult to detect. Early detection of the disease should prompt intensification of glycemic control, concomitant risk factors, use of pharmacologic agents such as ß-blockers and renin-angiotensin-aldosterone system antagosists. From a research perspective, more studies on myocardial tissue from diabetic patients are needed. Clinical trials to evaluate the development of diabetic cardiomyopathy and fibrosis in early stages of the disease, as well as clinical trials of pharmacologic intervention in patients specifically with diabetic cardiomyopathy, need to be conducted.

Operator Experience and Outcomes after Transcatheter Left Atrial Appendage Occlusion with the Watchman Device.

BACKGROUND: Transcatheter left atrial appendage occlusion (LAAO) has become a suitable alternative to anticoagulation in patients with atrial fibrillation (AF). However, volume-outcome relationships at the individual operator level have not been studied. METHODS: Study population included 425 consecutive patients with AF undergoing LAAO from August 2015 to November 2018 by seven operators at BUMC-Phoenix. Operator volume was divided in tertiles by those with <40 cases/year (2 operators), 41-80 cases/year (3 operators) and >80 cases/year (2 operators). Patient data including comorbidities, labs, medications, procedural characteristics and outcomes were collected. The primary composite outcome was major adverse cardiac events (MACE) including mortality, stroke, bleeding and vascular complications. RESULTS: Mean age was 75 ±â€¯8 years and 251 (59%) were males. Mean CHA2DS2-VASc score was 4.5 ±â€¯1.3 points and mean HASBLED score was 3.9 ±â€¯1.0 points. MACE outcome was similar in the three operator groups in both unadjusted (p = 0.83) and adjusted (OR = 0.59: 95% Confidence Interval [CI]: 0.15-2.29, p = 0.45) analysis. The occurrence MACE was also similar between Interventional Cardiologist (IC) and Electrophysiologist (EP) operators in an unadjusted (p = 0.24) and adjusted (OR = 0.60: 95% CI: 0.21-1.68, p = 0.33) analysis. The secondary outcome of technical success did not differ among the three tertiles (p = 0.37) and among IC & EP operators respectively (p = 0.24) as well. CONCLUSION: Operator experience does not affect MACE and technical success even after adjusting for comorbidities. These results suggest a lower learning curve for LAAO with high technical success achievable even by low volume operators.

Collagen mechanics: a rationale for radiofrequency energy to treat mitral regurgitaton.

Despite a variety of pharmacological interventions to limit the regurgitant fraction, mitral regurgitation requires surgical intervention for definitive treatment. New nonsurgical techniques are being applied to treat mitral regurgitation. The mitral and tricuspid annuli are areas of dense collagen. Application of heat, in the form of radiofrequency energy, can be used to shrink mitral valve annuli and offers a promising approach to the treatment of mitral regurgitation.

Vitamins for Cardiovascular Diseases: Is the Expense Justified?

Despite the knowledge that a well-balanced diet provides most of the nutritional requirements, the use of supplemental vitamins is widespread among adults in the United States. Evidence from large randomized controlled trials over the last 2 decades does not support vitamin supplementation for the reduction of cardiovascular risk factors or clinical outcomes. Many of the vitamins used in common practice likely are safe when consumed in small doses, but long-term consumption of megadoses is not only expensive but has the potential to cause adverse effects. Therefore, a need exists to revisit this issue, reminding the public and healthcare providers about the data supporting the use of vitamins for cardiovascular disease, and the potential for harm and the expense associated with their unnecessary use. In this review, we highlight the scientific evidence from randomized controlled studies regarding the efficacy and safety of vitamin supplementation for primary and secondary prevention of cardiovascular diseases and outcomes. We also draw attention to issues related to widespread and indiscriminate use of vitamin supplements and the need to educate the public to curtail unnecessary consumption and expense by limiting their use based on strong scientific evidence.

Chelation therapy in cardiovascular disease: an update.

INTRODUCTION: The off-label use of chelation therapy (disodium edetate or EDTA) for prevention of cardiovascular disease (CVD) is widespread, despite the lack of convincing evidence for efficacy or approval from the Food and Drug Administration. After the publication of results from the National Institute of Health-sponsored Trial to Assess Chelation Therapy (TACT), a randomized controlled trial (RCT) in patients after myocardial infarction (MI), there is a renewed interest in clarifying the role of this treatment modality for patients with coronary artery disease. Areas covered: This narrative review highlights the evidence from observational studies and RCT in assessing the effect of chelation therapy on cardiovascular outcomes and potential for adverse effects or harm. Expert commentary: Although encouraging results were reported in TACT, the evidence is insufficient to recommend the routine use of chelation therapy even in the post-MI diabetic subgroup, which appeared to benefit. The ongoing TACT2 trial may clarify its use in post-MI diabetic patients. Unsubstantiated claims of chelation therapy as an effective treatment of atherosclerosis should be avoided and patients made aware of the inadequate evidence for efficacy and potential adverse effects, especially the harm that can occur if used as a substitute for proven therapies.

Challenges in coronary CTO intervention after TAVR: a case report and discussion.

Progression of coronary arteries after transcatheter aortic valve replacement is an important issue. Coronary revascularization in these patients can be challenging because of potential hindrance posed by the artificial valve structure in getting access to the coronary ostium. This gets even more difficult in chronic total occlusions (CTOs) that represent the most complex subset of coronary lesions. We report the first case of coronary CTO revascularization in a patient who underwent TAVR a few months prior and discuss the complexities involved in intervening such lesions.

Comparison of 30-Day Outcomes of Transfemoral Versus Transapical Approach for Transcatheter Aortic Valve Replacement: A Single-Center US Experience.

BACKGROUND: The optimal access route for transcatheter aortic valve replacement (TAVR) remains debatable. We compared early safety outcomes at 30 days between the transfemoral (TF) and transapical (TA) approaches in a single, high-volume center in the United States. METHODS: Data were collected retrospectively on consecutive patients who underwent TAVR by the TF or TA approach. The primary endpoints included the following: all-cause mortality; stroke; major and life threatening bleeding; renal failure; valve-related dysfunction requiring an intervention; and moderate to severe paravalvular leak and major vascular complications at 30 days. The secondary endpoints included need for a pacemaker and hospital length of stay. RESULTS: A total of 123 well-matched patients underwent TAVR (TF 66 [54%] and TA 57 [46%]). All-cause mortality at 30 days was identical in both groups (TF 4.5% vs TA 5.3%, p = 0.999). The rates of myocardial infarction (TF 1.6% vs TA 1.5%, p = 0.999) and stroke (TF 3.0% vs TA 5.3%, p = 0.662) were similar. Major bleeding, acute renal failure, valve-related dysfunction, paravalvular leak, and mean hospital length of stay were also similar in both groups. Unplanned vascular complications, fluoroscopy time, and contrast utilization were significantly lower in the TA group. CONCLUSIONS: The TA approach has similar early safety outcomes when compared with the TF approach. The TA approach is more procedurally efficient when compared with the TF approach.

"Snake" shaped vegetation in right coronary artery.

Infective endocarditis is a rare cause of coronary embolism. This can result in myocardial infarction. Prompt identification is necessary as management is different from a regular myocardial infarction. Unlike in regular myocardial infarction, use of thrombolytics in this scenario could result in life-threatening complications and hence not indicated. In a patient who appears to be septic, embolic myocardial infarction should always be in the working differential diagnosis. An early transesophageal echocardiogram and cardiac catheterization could assist in diagnosis and management. We present an interesting case of a 45-year-old man who was admitted with vision loss, fevers and was found to have a non-ST segment elevation myocardial infarction. He had persistent bacteremia and developed systemic emboli. Investigation revealed mitral valve vegetation and a cardiac catheterization showed an interesting "snake"-shaped embolic vegetation in right coronary artery. He was treated with surgery to the mitral valve and antibiotics. In a septic patient with myocardial infarction, possibility of coronary embolism from vegetation should be kept in mind.

Pyogenic liver abscess secondary to disseminated streptococcus anginosus from sigmoid diverticulitis.

Pyogenic liver abscess secondary to dissemination from Sigmoid Diverticulitis is rare. Streptococcus Anginosus has been linked to abscesses but has been rarely reported from a Sigmoid Diverticulitis source. We report a case of liver abscess in which the source was confounding but eventually was traced to Sigmoid Diverticulitis on laparotomy.

Epstein Barr Virus-positive large T-cell lymphoma presenting as acute appendicitis 17 years after cadaveric renal transplant: a case report.

INTRODUCTION: The majority of post-transplant lymphoproliferative disorders in renal transplant patients are of the B-cell phenotype, while the T-cell phenotype is rare. We report a case of Epstein Barr Virus-positive, T-cell lymphoma in a renal transplant patient, presenting unusually as acute appendicitis. CASE PRESENTATION: A 45-year-old Hispanic male renal transplant patient presented with right-side abdominal pain 17 years after transplant. The laboratory studies were unremarkable. Laparoscopic exploration showed an inflamed appendix so a laparoscopic appendectomy was performed. Pathology of the appendix showed large cells positive for CD3, CD56 and Epstein Barr Virus-encoded RNA staining, and negative for CD20 and CD30. The tissue tested positive for T-cell receptor gene rearrangement by polymerase chain reaction analysis. Treatment management involved reduction of immunosuppression and initiation of chemotherapy with cisplatin, etoposide, gemcitabine, and solumedrol followed by cyclophosphamide, hydroxydaunorubicin, vincristine and prednisone). He recovered and the allo-grafted kidney is fully functional. CONCLUSION: We report a rare case of post-renal transplant large T-cell lymphoma, with an unusual presentation of acute appendicitis and Epstein Barr Virus-positivity, which responded well to chemotherapy.

A novel method of ventricular closure following transapical access.

AIM: left ventricular direct access and sheath placement through a minithoracotomy has been utilized to allow minimally invasive valvular surgery. One potential problem encountered is the closure of the ventricular puncture incision in a beating heart. Our aim was to develop a sutureless closure technique that does not leave behind a foreign body exposed on the endocardial surface. MATERIALS & METHODS: we sought to evaluate this concept in vivo in the porcine model. Thoracotomy was performed with exposure of the beating heart. A total of six Fr sheaths were placed in the transapical territory in the left and right ventricle with fluoroscopy confirming sheath placement. The incisions were then closed using three types of commercially available femoral vascular closure systems (AngioLink, StarClose and Mynx). RESULTS: one animal had one device placed in the left and right ventricle and closure was then immediately observed intraoperatively (AngioLink). Another animal had five devices (StarClose) placed in the left ventricle and one in the right ventricle, with closure observed within 1 min of application. A third animal had the sheath removed and spontaneous closure then observed at two sites. These two sites continued to bleed for 2-3 min. The same animal had an application of six Mynx devices at sheath sites using an extravascular bio-inert sealant. One site failed and the five others were immediately successful. Histopathology evaluation confirmed no evidence of device exposure on the endovascular surface in the first two animals. The Mynx device sealant was present on the endocardial surface at closure sites postmortem. CONCLUSION: we have introduced a new concept of using vascular closure systems for closing ventricular wall stab incisions after transapical surgery. We intend to expand the scale of animal studies and evaluate the device for any modifications in the mechanism or technique for ultimate use in human subjects.

Review of Movahed's sign (D shaped left ventricle seen on gated SPECT) suggestive of right ventricular overload.

Recently, D shaped ventricle seen on gated SPECT imaging (Movahed's sign) has shown to correlate with right ventricular overload similar to the D shape ventricle seen on echocardiography. Right ventricle (RV) imaging during gated SPECT studies is challenging because of the low tracer uptake due to relatively smaller right ventricular myocardial mass and lower coronary flow to the RV. Increased mass or workload causes higher tracer uptake in the RV wall secondary to increase in RV wall thickness and higher coronary flow. Furthermore, increased RV volume or pressure load can cause displacement of the septum towards the left ventricle causing septal flattening and a D shaped configuration of the left ventricular septum. This is an important finding that should be a part of nuclear gated SPECT interpretation.

Correlation between estimated ejection fraction measured by echocardiography with ejection fraction estimated by cardiac catheterization in patients awaiting cardiac transplantation.

BACKGROUND: Ejection fraction measurement is an integral part of pre-heart transplant evaluation. In the clinical arena, the correlation and agreement between ejection fraction (EF) measured by echocardiography versus catheterization in pre-heart transplant patients has not been studied. METHODS: Data on all patients evaluated for heart transplantation at our program between 2003 and 2005 (n = 64) were retrospectively reviewed. Patients with both transthoracic echocardiography (with interpretable images) and left heart catheterization with ventriculography were included (n=63, mean time difference 2.2 days, median 2 days). We correlated reported echocardiographically estimated EF with that estimated EF by left heart catheterization. RESULTS: Mean estimated EF by ventriculography was 21.2 ± 10.0 in comparison to 22.8 ± 10.5 by echocardiography. The correlation between echocardiographic and measured EF was poor in the total population (r² = 0.36, p < 0.001) and in patients with non-ischemic cardiomyopathy (r² = 0.23). However, limiting this statistic to patients with ischemic cardiomyopathy only, we found strong correlation between these two methods (r² = 0.75, p < 0.001). CONCLUSIONS: Among patients referred for heart transplant evaluation, there is a poor agreement and correlation between echocardiographically estimated EF and estimated EF by ventriculography. However, this correlation is strong in patients with ischemic cardiomyopathy. The cause of this discrepancy is not known and warrants further investigation.

Remodeling of the mitral valve using radiofrequency energy: review of a new treatment modality for mitral regurgitation.

Mitral regurgitation (MR) is a common valvular pathology with significant morbidity and mortality implications. Mechanical treatment of this condition is more effective than medical treatment and surgical correction has traditionally been the mechanical method of choice. Following major advances and wide acceptance of percutaneous interventions for coronary artery diseases, the field of valvular heart disease became an attractive target for transcatheter treatment modalities. Significant steps have been achieved in the field of percutaneous treatment of mitral stenosis as well as aortic stenosis, and lately, mitral regurgitation has been the focus of interest for many investigators looking for transcatheter solutions. Percutaneous edge-to-edge techniques and annuloplasty are innovative but have many disadvantages including the inability to reintervene and leaving a foreign body behind, respectively. Since the mitral and tricuspid annuli have dense collagen, a treatment modality targeting that collagen is logical. Observing the thermal effect on collagen, which causes conformational changes and shrinkage, radiofrequency energy was tested to evaluate its effect on the collagen-rich structure that is the mitral valve annulus. The potential of shrinking the mitral annulus by applying direct thermal source could be a promising modality for the treatment of mitral regurgitation with potential open and percutaneous applications. This paper presents an overview of the recent advances in transcatheter treatment of mitral regurgitation focusing on a new treatment modality that aims at reducing the mitral valve annulus diameter through the direct application of thermal energy using a radiofrequency energy probe.

Polytetrafluoroethylene-covered stents: 15 years of hope, success and failure.

Even after almost 15 years, polytetrafluoroethylene-covered stents are an important part of the armory of cardiac catheterization laboratory. They are invaluable in the emergent management of coronary perforations and are also used in the treatment of coronary aneurysms and fistulae. However, they are no longer routinely used in the treatment of saphenous venous graft disease. Future research may be aimed at premedicating them to effectively treat saphenous venous graft lesions.