Association of ACEI/ARB and statin prescribing patterns with mortality after Transcatheter Aortic Valve Replacement (TAVR): Findings from real-world claims data.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has become the standard of care for most patients with severe aortic stenosis (AS), but the impact of medical therapy prescribing patterns on post-TAVR patients has not been thoroughly investigated. METHODS: We analyzed Optum claims data from 9,012 adults who received TAVR for AS (January 2014-December 2018). Pharmacy claims data were used to identify patients who filled ACEI/ARB and/or statin prescriptions during the study's 90-day landmark period post-TAVR. Kaplan-Meier and adjusted Cox Proportional Hazards models were used to evaluate the association of prescribing patterns with mortality during the 3-year follow-up period. Subgroup analyses were performed to examine the impact of 11 potential confounders on the observed associations. RESULTS: A significantly lower adjusted 3-year mortality was observed for patients with post-TAVR prescription for ACEI/ARBs (hazard ratio [HR] = 0.82, 95% confidence interval [CI] 0.74-0.91, P = .0003) and statins (HR = 0.85, 95% CI 0.77-0.94, P = .0018) compared to patients who did not fill prescriptions for these medications post-TAVR. Subgroup analyses revealed that the survival benefit associated with ACEI/ARB prescription was not affected by any of the potential confounding variables, except preoperative ACEI/ARB prescription was associated with significantly lower risk of mortality vs postoperative prescription only. No other subgroup variables had significant interactions associated with survival benefits, including preoperative use of statins. CONCLUSIONS: In this large-scale, real-world analysis of patients undergoing TAVR, the prescription of ACEI/ARB and statins was associated with a significantly lower risk of mortality at 3-years, especially in those where the medications were initiated preoperatively.

Pheochromocytoma manifesting as cortical blindness secondary to PRES with associated TMA: a case report and literature review.

BACKGROUND: Pheochromocytomas are neoplasms originating from neuroectodermal chromaffin cells leading to excess catecholamine production. They are notorious for causing a triad of headaches, palpitations, and sweats. Though the Menard triad is one to be vigilant of, symptomatic presentation can vary immensely, hence the tumor earning the label "the great masquerader." CASE PRESENTATION: We report a case of pheochromocytoma initially presenting with cortical blindness secondary to posterior reversible encephalopathy syndrome and thrombotic microangiopathy from malignant hypertension. Our patient was seen in our facility less than a week prior to this manifestation and discharged after an unremarkable coronary ischemia work-up. In the outpatient setting, she had been prescribed multiple anti-hypertensives with remarkably elevated blood pressure throughout her hospitalization history. CONCLUSION: Pheochromocytoma presenting with malignant hypertension and hypertensive encephalopathy should be expected if left untreated; nonetheless, the precipitation of cortical blindness is rare in the literature. This case contributes an additional vignette to the growing literature revolving adrenal tumors and their symptomatic presentation along with complex management. It also serves to promote increased diagnostic suspicion among clinicians upon evaluating patients with refractory hypertension.

Uninterrupted Continuation of VV-ECMO Without Anticoagulation for 44 Days in COVID-19 ARDS: A Precarious Quandary.

Venovenous extracorporeal membrane oxygenation (VV-ECMO) has become a mainstay treatment modality for a select patient population who do not respond to conventional medical therapy suffering from severe acute respiratory distress syndrome (ARDS) due to COVID-19. This therapy necessitates the utilization of anticoagulation, whether unfractionated heparin or bivalirudin, to prevent thrombotic complications. Scarce are reports of VV-ECMO implementation leading to acute hemorrhage mandating cessation of anticoagulation in a patient suffering from COVID-19 ARDS. Herein, the authors report a case of a successful outcome in a COVID-19 ARDS patient who suffered an acute hemorrhagic complication leading to pre-emptive termination of systemic anticoagulation. The authors believe this to be one of the first such cases in the literature.

Right Ventricular Failure Manifesting in Corona Virus Disease 2019 Acute Respiratory Distress Syndrome: A Call to Transition from Venovenous Extracorporeal Membranous Oxygenation to Right Ventricular Assist Device Extracorporeal Membranous Oxygenation.

Often labeled the forgotten ventricle, the right ventricle's (RV) importance has been magnified over the last 2 years as providers witnessed how severe acute respiratory syndrome coronavirus 2 infection has a predilection for exacerbating RV failure. Venovenous extracorporeal membranous oxygenation (VV-ECMO) has become a mainstay treatment modality for a select patient population suffering from severe COVID-19 acute respiratory distress syndrome. Concomitant early implementation of a right ventricular assist device with ECMO (RVAD-ECMO) may confer benefit in patient outcomes. The underlying mechanism of RV failure in COVID-19 has a multifactorial etiopathogenesis; nonetheless, clinical evaluation of a patient necessitating RV support remains unchanged. Herein, the authors report the case of a critically ill patient who was transitioned from a conventional VV-ECMO Medtronic Crescent cannula to RVAD-ECMO, with the insertion of the LivaNova ProtekDuo dual-lumen RVAD cannula.

Prosthetic valve leaflet perforation resulting in critical aortic insufficiency: A rare late complication after use of Cor-knot®.

The implementation of automatic fasteners such as the Cor-knot® device (LSI Solutions, Inc.) has revolutionized the field of minimally invasive valvular surgery. Nonetheless, paravalvular regurgitation, valvular embolization, and early leaflet perforation are all potential complications which may occur. Late manifestations of leaflet perforation (>5-year postimplantation) are rare. Herein, we discuss a patient who underwent remote Trifecta® (St. Jude, Inc.) surgical aortic valve replacement presenting with symptomatic critical aortic regurgitation secondary to leaflet perforation from automatically fastened metallic Cor-knot® sutures.

Long-Term Outcome of the First Completely Leadless Cardiac Resynchronization Therapy in the United States.

Completely leadless cardiac resynchronization therapy is feasible with the combination of Micra AV pacemaker (Medtronic Inc) and WiSE-CRT (EBR Inc) systems. Several reports have highlighted this combination in Europe. This case report presents a 1- year follow-up the first reported concomitant use of the leadless systems in the United States. (Level of Difficulty: Advanced.).

Structural Valve Deterioration in Transcatheter Aortic Bioprostheses: Diagnosis, Pathogenesis, and Treatment.

Transcatheter aortic valve replacement has emerged as the preferred treatment modality in most patients with severe aortic stenosis. With its global adoption and broader application in younger and healthier patients, the issue of transcatheter bioprosthetic valve degeneration and its impact on valve durability continues to earn clinical relevance. Differences in the pathophysiologic processes that separate native from transcatheter heart valve deterioration remain poorly understood. When compared to surgical aortic bioprostheses, the mechanisms of valve degeneration are similar in transcatheter heart valves, with meaningful differences most noticeably found between the individual constructs of their design. Recognizing the clinical and hemodynamic presentation of structural valve degeneration remains paramount. The recently revised consensus guidelines that incorporate the integration of advanced multimodality imaging with invasive hemodynamics represent a major step forward in our ability to accurately diagnose bioprosthetic valve degeneration, and to identify differences in durability patterns, and to establish treatment recommendations for the lifetime management of patients with aortic stenosis. Parallel efforts to unmask the biomolecular differences in atherosclerotic plaque burden, valve calcification, and thrombotic diathesis, including host immunocompetence, between the different available bioprostheses, will further advance the role of emerging valve tissue technologies to improve durability. As with surgical heart valves, the optimal treatment options for redo-transcatheter aortic valve replacement and surgical explant remain poorly understood. Ongoing translational research in bench testing coupled with prospectively designed core lab-adjudicated clinical trials are much needed. This report provides a contemporary overview of transcatheter structural valve degeneration, including evolving concepts in its pathogenesis, diagnosis, and treatment.

Synchronous Type 3 EVAR Endoleaks at Multiple Sites Following Transfemoral Transcatheter Aortic Valve Replacement.

We describe a complication following transfemoral transcatheter aortic valve replacement in a patient who underwent remote endovascular abdominal aortic aneurysm repair. This report highlights technical complications to be vigilant of when using intravascular catheterization in patients with previous aneurysm repair while also showcasing synchronous type 3 endoleaks at multiple sites. (Level of Difficulty: Advanced.).