Atrial mitral regurgitation: Characteristics and outcomes of transcatheter mitral valve edge-to-edge repair.

BACKGROUND: Mitral transcatheter edge-to-edge repair (MTEER) is an established therapeutic approach for mitral regurgitation (MR). Functional mitral regurgitation originating from atrial myopathy (A-FMR) has been described. OBJECTIVES: We sought to assess the clinical, echocardiographic and hemodynamic considerations in A-FMR patients undergoing MTEER. METHODS: From 2014 to 2020, patients undergoing MTEER for degenerative MR (DMR), functional MR (FMR), and mixed MR were assessed. A-FMR was defined by the presence of MR > moderate in severity; left ventricular (LV) ejection fraction (LVEF) ≥ 50%; and severe left atrial (LA) enlargement in the absence of LV dysfunction, leaflet pathology, or LV tethering. The diagnosis of A-FMR (vs. ventricular-FMR [V-FMR]) was confirmed by three independent echocardiographers. Baseline characteristics, procedural outcomes as well as clinical and echocardiographic follow-up are reported. Device success was defined as final MR grade ≤ moderate; MR reduction ≥1 grade; and final transmitral gradient <5 mmHg. RESULTS: 306 patients underwent MTEER, including DMR (62%), FMR (19%), and mixed MR (19%). FMR cases included 37 (63.8%) V-FMR and 21 (36.2%) A-FMR. Tricuspid regurgitation (≥ moderate) was higher in A-FMR (80.1%) compared to V-FMR (54%) and DMR (42%). Device success did not significantly differ between A-FMR and V-FMR (57% vs. 73%, p = 0.34) or DMR (57% vs. 64%, p = 1.0). The A-FMR cohort was less likely to achieve ≥3 grades of MR reduction compared to V-FMR (19% vs. 54%, p = 0.01) and DMR (19% vs. 49.7%, p = 0.01). Patients with V-FMR and DMR demonstrated significant reductions in mean left atrial pressure (LAP) and peak LA V-wave, though A-FMR did not (LAP -0.24 ± 4.9, p = 0.83; peak V-wave -1.76 ± 9.1, p = 0.39). In follow-up, echocardiographic and clinical outcomes were similar. CONCLUSIONS: In patients undergoing MTEER, A-FMR represents one-third of FMR cases. A-FMR demonstrates similar procedural success but blunted acute hemodynamic responses compared with DMR and V-FMR following MTEER. Dedicated studies specifically considering A-FMR are needed to discern the optimal therapeutic approaches.

Hemodynamics rounds: Hemodynamics of mitral valve interventions.

Mitral valvulopathy presents as regurgitation, stenosis, or mixed disease and can occur in both native and prosthetic valves. Such disease develops in conjunction with pathophysiologic changes in the left atrium (LA) and drives changes in LA compliance, pressure, and thus clinical syndromes. With advances in the understanding and treatment of structural heart disease and in the setting of higher-risk patient populations, less-invasive transcatheter approaches have become increasingly commonplace in the treatment of mitral valve disease. Over time, transcatheter mitral valve interventions have evolved to include paravalvular leak closure, mitral valve repair, and mitral valve replacement. Parallel to this evolution, advances in invasive intracardiac pressure monitoring, particularly at the level of the LA, have also occurred. These advances emphasize the unique interplay between mitral valve disease and LA function; account for limitations of noninvasive assessment; and guide beneficial outcomes in each area of transcatheter mitral valve intervention. As a result, continuous transseptal LA pressure monitoring has developed into an indispensable instrument in successful percutaneous mitral valve intervention, complementing traditional noninvasive assessment.

Hemodynamic and clinical response to transseptal mitral valve-in-valve and valve-in-ring.

OBJECTIVE: To understand the clinical and hemodynamic response of patients with stenotic versus regurgitant prosthetic mitral valve degeneration to transseptal transcatheter mitral valve-in-ring/-valve replacement (TMVR). BACKGROUND: Patients with prosthetic mitral valve repair/replacement failure frequently present high-risk surgical challenges. TMVR has been employed as an alternative to surgery. METHODS: Forty-four patients with stenotic/regurgitant degeneration of prior prosthetic mitral annuloplasty and replacement (38) underwent mitral TMVR. Clinical, echocardiographic, and invasive hemodynamic monitoring was conducted at baseline and follow-up. RESULTS: Relative to patients with regurgitant degeneration (28), patients with stenotic degeneration had baseline higher mitral valve gradients (12 ± 4 vs. 7 ± 3 mmHg, p < 0.01) and smaller areas (1.0 ± 0.4 vs. 1.5 ± 0.4 cm2 , p = 0.01). TMVR yielded significant reduction in left atrial v-wave pressures in stenotic and regurgitant cohorts (-7 ± 11, p = 0.03, and -11 ± 12 mmHg, p < 0.01, respectively) and significant, sustained symptomatic improvement. Intracardiac pressures overall, including left ventricular end diastolic pressures, remained elevated. CONCLUSION: Despite baseline differences in valvular disease, TMVR leads to significant hemodynamic and clinical improvement in both stenotic and regurgitant prosthetic mitral valve disease. In both cohorts, TMVR reduced intracardiac pressures to similar postprocedural levels, but pressures remained supranormal. This outcome suggests a multifactorial process defines the pathophysiology of patients undergoing TMVR, including contributions from prosthetic degeneration, changes in left atrial compliance, and diastolic dysfunction, and highlights the need to consider such factors in patient evaluation and treatment.

Effect of saline administration on left atrial pressure during transcatheter mitral valve repair.

OBJECTIVES: To measure the intraprocedural change in left atrial pressure (LAP) with saline administration during transcatheter mitral valve repair (TMVR). BACKGROUND: TMVR with MitraClip offers an alternative to surgery in select patients. During this procedure, large volumes of fluid are routinely administered with anesthesia and to facilitate transcatheter valve repair. LAP, a measure used to guide repair, may thereby change as a result of volume expansion, suggesting a need for continuous intracardiac pressure monitoring. METHODS: Consecutive patients with severe mitral regurgitation underwent TMVR with MitraClip and continuous LAP monitoring through a dedicated sampling catheter. Specific LAP values were acquired immediately after transseptal access; before first clip deployment; and after deployment of the last clip. RESULTS: 151 patients (age 80 ± 8 years, 64% male) underwent TMVR with MitraClip and continuous LAP monitoring. Mean LAP and v-wave pressure increased significantly from baseline to pre-MitraClip deployment (P < 0.0001) and decreased significantly from deployment to procedure end (P < 0.0001). Linear regression of v-wave pressure change (from procedure start to clip deployment) relative to volume administration yielded a significantly nonzero slope (0.28 mmHg/min, P < 0.0001, r = 0.30). CONCLUSION: Fluid administration during TMVR leads to time-dependent increases in LAP. Such intraprocedural change underscores the need for targeted, if not continuous, LAP measurement during TMVR to optimize MitraClip placement and mitral regurgitation reduction.

Acute invasive hemodynamic effects of percutaneous mitral paravalvular leak closure.

OBJECTIVES: The aim of this study was to demonstrate the physiologic effects of percutaneous mitral paravalvular leak (PVL) closure through pre- and post-closure left and right heart catheterization. BACKGROUND: Mitral PVL represents a significant source of morbidity and mortality following mitral valve repair and replacement. Although percutaneous PVL closure is an effective treatment with improvements in symptoms and mortality, data regarding the acute hemodynamic effects of such closure are lacking. METHODS: Consecutive patients with clinically significant heart failure and/or hemolysis attributed to mitral PVL underwent percutaneous mitral PVL closure with pre- and post-procedural right and left heart catheterization. Hemodynamic measurements of cardiovascular function obtained in this manner were compared and stratified according to pre- and post-procedural echocardiographic severity of PVL. RESULTS: Twenty-four patients (age 68 ± 9.4 years, 75% male) underwent percutaneous mitral PVL closure. Significant improvements were found in left atrial pressure (LAP) (mean LAP lowered from 21 ± 4 to 19 ± 3 mm Hg, P = 0.005), pulmonary artery pressure (PAP) (mean PAP lowered from 36 ± 11 to 33 ± 9, P = 0.04), and cardiac index (increased from 2.8 ± 0.8 to 3.0 ± 0.7 L/min/m2 , P = 0.01). Left atrial v-wave reduction of 20% was associated with ≤ mild residual PVL by transesophageal echocardiography (P = 0.09). CONCLUSIONS: Percutaneous mitral PVL closure is associated with significant reductions in LAP and PAP and an increase in cardiac index. These hemodynamic effects underlie the clinical benefits of PVL closure and may be a useful tool for intraprocedural guidance. © 2017 Wiley Periodicals, Inc.

The Changing Fiscal Environment for Academic Veterinary Medicine.

The fiscal environment for academic veterinary medicine has changed substantially over the past 50 years. Understanding the flux of state and federal government support and the implications for student debt, academic programs, and scholarly work is critical for planning for the future. The recent precipitous decline in public funding highlights the urgent need to develop and maintain an economically sustainable model that can adapt to the changing landscape and serve societal needs.

Monitoring the Veterinary Medical Student Experience: An Institutional Pilot Study.

Veterinary medical school challenges students academically and personally, and some students report depression and anxiety at rates higher than the general population and other medical students. This study describes changes in veterinary medical student self-esteem (SE) over four years of professional education, attending to differences between high and low SE students and the characteristics specific to low SE veterinary medical students. The study population was students enrolled at the Michigan State University College of Veterinary Medicine from 2006 to 2012. We used data from the annual anonymous survey administered college-wide that is used to monitor the curriculum and learning environment. The survey asked respondents to rate their knowledge and skill development, learning environment, perceptions of stress, skill development, and SE. Participants also provided information on their academic performance and demographics. A contrasting groups design was used: high and low SE students were compared using logistic regression to identify factors associated with low SE. A total of 1,653 respondents met inclusion criteria: 789 low SE and 864 high SE students. The proportion of high and low SE students varied over time, with the greatest proportion of low SE students during the second-year of the program. Perceived stress was associated with low SE, whereas perceived supportive learning environment and skill development were associated with high SE. These data have provided impetus for curricular and learning environment changes to enhance student support. They also provide guidance for additional research to better understand various student academic trajectories and their implications for success.

New directions for veterinary technology.

Veterinary technology has generally established itself well in companion-animal and mixed-animal veterinary medical practice, but the career's growth trajectory is uncertain. Michigan State University (MSU) convened a national conference, "Creating the Future of Veterinary Technology-A National Dialogue," in November 2011 to explore ways to elevate the veterinary technician/technologist's role in the veterinary medical profession and to identify new directions in which the career could expand. Veterinary technicians/technologists might advance their place in private practice by not only improving their clinical skills, but by also focusing on areas such as practice management, leadership training, business training, conflict resolution, information technology, and marketing/communications. Some new employment settings for veterinary technicians/technologists include more participation within laboratory animal medicine and research, the rural farm industry, regulatory medicine, and shelter medicine. Achieving these ends would call for new training options beyond the current 2-year and 4-year degree programs. Participants suggested specialty training programs, hybrid programs of various types, online programs, veterinary technician residency programs of 12-18 months, and more integration of veterinary technician/technology students and veterinary medicine students at colleges of veterinary medicine.

Acute and Complicated Inflammatory Pericarditis: A Guide to Contemporary Practice.

Inflammatory disease of the pericardium represents a relatively common presentation, especially among the young. For the most part, inflammatory pericardial disease can be expeditiously and effectively managed without significant sequelae. However, some individuals present with severe and recurrent illness, representing significant therapeutic challenges. During the past decade, there have been great strides made in developing an evidence-based approach to management of inflammatory pericardial disease, the result of which has been the development of (1) a systematic, protocoled approach to initial care; (2) targeted therapeutics; and (3) specialized, collaborative, and integrated care pathways. Herein we present a review of the current state of the art as it pertains to the diagnostic evaluation and therapeutic considerations in inflammatory pericardial disease with a focus on acute and complicated pericarditis.

Financial dimensions of veterinary medical education: an economist's perspective.

Much discussion has transpired in recent years related to the rising cost of veterinary medical education and the increasing debt loads of graduating veterinarians. Underlying these trends are fundamental changes in the funding structure of higher education in general and of academic veterinary medicine specifically. As a result of the ongoing disinvestment by state governments in higher education, both tuition rates and academic programs have experienced a substantial impact across US colleges and schools of veterinary medicine. Programmatically, the effects have spanned the entire range of teaching, research, and service activities. For graduates, both across higher education and in veterinary medicine specifically, the impact has been steadily increasing levels of student debt. Although the situation is clearly worrisome, viable repayment options exist for these escalating debt loads. In combination with recent income and employment trends for veterinarians, these options provide a basis for cautious optimism for the future.

Multimodality Imaging in Differentiating Constrictive Pericarditis From Restrictive Cardiomyopathy: A Comprehensive Overview for Clinicians and Imagers.

In the evaluation of heart failure, 2 differential diagnostic considerations include constrictive pericarditis and restrictive cardiomyopathy. The often outwardly similar clinical presentation of these 2 pathologic entities routinely renders their clinical distinction difficult. Consequently, initial assessment requires a keen understanding of their separate pathophysiology, epidemiology, and hemodynamic effects. Following a detailed clinical evaluation, further assessment initially rests on comprehensive echocardiographic investigation, including detailed Doppler evaluation. With the combination of mitral inflow characterization, tissue Doppler assessment, and hepatic vein interrogation, initial differentiation of constrictive pericarditis and restrictive cardiomyopathy is often possible with high sensitivity and specificity. In conjunction with a compatible clinical presentation, successful differentiation enables both an accurate diagnosis and subsequent targeted management. In certain cases, however, the diagnosis remains unclear despite echocardiographic assessment, and additional evaluation is required. With advances in noninvasive tools, such evaluation can often continue in a stepwise, algorithmic fashion noninvasively, including both cross-sectional and nuclear imaging. Should this additional evaluation itself prove insufficient, invasive assessment with appropriate expertise may ultimately be necessary.

Teaching of professional skills in US colleges and schools of veterinary medicine in 2019 and comparisons with 1999 and 2009.

OBJECTIVE: To quantify the extent that professional skills topics were presented to veterinary students at US colleges and schools of veterinary medicine (ie, veterinary schools) in 2019 and compare findings with similar data collected in 1999 and 2009. SAMPLE: All 30 US veterinary schools in 2019. PROCEDURES: An electronic questionnaire was sent to the associate deans for academic affairs of all 30 veterinary schools in the United States during fall of 2019. Results were compared with published results of a similar survey performed in 1999 and 2009. RESULTS: A 100% (30/30) response rate was achieved for 2019. A total of 173 courses on professional skills topics were reported, of which 115 (66%) were required. The most common topic was communication (79/136 [58%] courses). Overall, courses were most frequently delivered in the first 3 years of the curriculum (129/158 [82%]), with required courses most common in years 1 and 2 (79/112 [71%]). Most courses (116/150 [77%]) were assigned 1 or 2 credit hours. These results represented continuation of a substantial increase in the teaching of professional skills, compared with findings for 1999 and 2009. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested a growing commitment to the teaching of professional skills on the part of US veterinary schools and the willingness to change on the basis of the current perceived needs of their graduates. The observed increases align nicely with the emerging framework for competency-based veterinary education and its substantial focus on assessing competency in professional skills as an important outcome of veterinary medical education.

Clinical features and prognosis of surgically proven constrictive pericarditis after orthotopic heart transplantation.

Constrictive pericarditis (CP) results in pericardial non-compliance and diastolic dysfunction. Definitive treatment is pericardiectomy, but data on CP after orthotopic heart transplantation (OHT) are limited. Accordingly, a retrospective review of 8 cases of surgically proven CP after OHT undergoing pericardiectomy was conducted. In this series, all patients were male. The median time to symptomatic CP after OHT was 1.7 years (range: 0.8-18.1 years). The echocardiographic assessment was diagnostic for CP in 3 cases (38%). Cross-sectional imaging was performed in 6 cases, revealing ≥ mild pericardial thickening in all. A total of 6 patients (75%) underwent cardiac catheterization, which revealed CP in 5 (83%). Post-pericardiectomy 30-day mortality was 13% (1 patient). The median survival after pericardiectomy was 2.3 years (range: 18 days-14.6 years) and 5-year survival was 29%. Overall, CP after OHT represents a subset of patients with CP with high morbidity and mortality, and multimodality assessment is essential for its diagnosis. Despite a relatively low surgical mortality, long-term survival is poor.

Comparison of long-term financial implications for five veterinary career tracks.

OBJECTIVE: To compare present values of expected income streams for 5 distinct veterinary medical career tracks. DESIGN: Present value model. SAMPLE POPULATION: AVMA survey data. PROCEDURES: Present values of expected income streams (net of debt repayment) were created and ranked. Sensitivity to each independent variable was assessed. RESULTS: Career present value at 34 years after graduation (CPV(34)) was highest for board-certified specialist (SP; $2,272,877), followed by practice owner (PO; $2,119,596), practice owner buying into practice after 10 years (PO-10; $1,736,333), SP working three-fourths time (SP3/4; $1,702,744), and general practitioner (GP; $1,221,131). Compared with CPV(34) for SP, other career tracks yielded values of 93.3% (PO), 76.4% (PO-10), 74.9% (SP3/4), and 53.7% (GP). The model was robust to debt, interest rate, loan term, and discount rate but was sensitive to mean starting incomes and mean incomes. CONCLUSIONS AND CLINICAL RELEVANCE: Greatest return on time and money invested by a veterinary student is through practicing full-time as an SP or through being a PO. Being an SP or SP3/4 was substantially more lucrative than being a GP and was comparable to being a PO. Practice ownership and working as an SP3/4 may be options for balancing financial gain with free time. Specialty training and practice ownership may be career tracks with the best potential repayment options for veterinarians with a large educational debt. Regardless of the amount of debt, the type of practice, mean incomes in a particular field, personal lifestyle, and professional interests are important factors when deciding among career tracks.

Preparing faculty for the future: AAVMC members' perceptions of professional development needs.

Our purpose in this study was to determine professional development needs of faculty in the Association of American Veterinary Medical Colleges' (AAVMC's) member institutions, including those needs associated with current and emerging issues and leadership development. The survey asked respondents to report their level of job satisfaction and their perceptions of professional development as they related to support and resources, teaching, research, career planning, and administration. Five hundred and sixty-five individuals from 49 member institutions responded to an online professional development needs survey. We found that job satisfaction was associated with a variety of workplace variables correlated with academic rank, with those of higher academic rank expressing greater levels of satisfaction. Respondents with tenure also expressed generally higher levels of satisfaction. Most of the respondents expressed interest in learning more about topics related to teaching (e.g., effective questioning, giving feedback, principles of learning and motivation), research (e.g., research design, writing grants), career planning (e.g., mentoring, time management), and administration (e.g., fostering innovation, enhancing productivity, improving the work environment). Just more than half of the respondents indicated moderate to high interest in an AAVMC multi-phase leadership training program. The study suggests topics for which AAVMC should provide professional development opportunities either at existing meetings or through new programming. The study also suggests directions for individual institutions as they seek to implement professional development activities at the local level.

Knowledge, skills, and attitudes of veterinary college deans: AAVMC survey of deans in 2010.

The purposes of this Association of American Veterinary Medical Colleges (AAVMC) study was to develop a profile of deans to understand the knowledge, skills, and attitudes that current deans of schools and colleges of veterinary medicine consider important to job success and to inform the association's leadership development initiatives. Forty-two deans responded to an online leadership program needs survey, which found that knowledge, skills, and abilities related to communication, finance and budget management, negotiation, conflict management, public relations, and fundraising were recommended as the most important areas for fulfilling a deanship. Most respondents speculated that the greatest challenges for their institutions will be in the areas of faculty recruitment and retention and financing veterinary education. Reflecting on their experiences, respondents offered an abundance of advice to future deans, often citing the importance of preparation, communication, and leadership qualities as necessary for a successful and satisfying deanship. More than three-quarters of the respondents indicated moderate to high interest in an AAVMC multi-phase leadership training program to develop administrative leaders. A nearly equal number also indicated support for formal leadership training for current veterinary medical college and school deans. The study suggests leadership development topics that AAVMC could provide at existing meetings or through new programming. The study also suggests directions for individual institutions as they seek to implement leadership development activities at the local level.

Innovations in food-supply veterinary medicine: the michigan state university college of veterinary medicine summer food systems fellowship program.

The purpose of this article is to outline a new educational model at Michigan State University's College of Veterinary Medicine. The Summer Food Systems Fellowship Program provides opportunities for food industry-oriented students to experience summer employment with agriculture industry partners, and gives the industry partners exposure to the veterinary profession.

An examination of US consumer pet-related and veterinary service expenditures, 1980--2005.

OBJECTIVE: To evaluate US consumer expenditures for veterinary services, pets-pet supplies, and pet-related services. DESIGN: Retrospective economic analysis. SAMPLE POPULATION: US consumers from 1980 through 2005. PROCEDURES: Descriptive statistics and probit regressions were calculated. RESULTS: From 1980 to 2005, total inflation-adjusted expenditures on pet-related and veterinary services increased, as did the percentage of households with a pet-related expenditure. The percentage of households with veterinary service expenditures was fairly constant. Among households with a pet-related expenditure, the percentage purchasing veterinary services decreased. The probability for pet-related and veterinary service expenditures increased with income, education, and family size and was higher for household heads who were white, were married, owned their residence, and lived in a rural area. CONCLUSIONS AND CLINICAL RELEVANCE: Overall spending on veterinary services increased substantially, providing no indication that successful practices should change strategy. Households that spent money on veterinary services increased their spending sufficiently to exceed the loss of income for veterinarians associated with the increasing proportion of pet-owning households that did not spend anything on veterinary services. Because the probability of veterinary service expenditures was strongly related to household income, caution is suggested in planning provision of veterinary services when incomes are constrained. Among households with pet-related expenditures, the decreasing percentage of households with veterinary service expenditures suggests a growing proportion of pet owners who are not having their veterinary service needs met. Because non-white households were less likely to purchase veterinary services, the veterinary profession cannot afford to delay efforts to enhance diversity and cultural competence.

Developing veterinary colleges and leaders: a whole-system approach.

The current environment in higher education calls for increasingly progressive leadership and management. This report describes the efforts of the College of Veterinary Medicine (CVM) at Michigan State University (MSU) to strengthen its leadership using a whole-system approach. Developing a leadership culture is the responsibility of leaders, and the pursuit of such a culture requires considerable and justifiable investment of time, energy, and resources. The volatile and changing environment in which colleges of veterinary medicine exist makes creating such a culture imperative if society's needs are to be successfully met. Noteworthy cultural change has occurred within the MSU CVM because of the efforts described here.