Long-term outcomes associated with the transaortic approach to transcatheter Aortic valve replacement.

OBJECTIVE: We investigated the long-term safety, efficacy and clinical outcomes associated with transaortic (TAO) transcatheter aortic valve replacement (TAVR) in the United States. BACKGROUND: We previously reported the technical feasibility and short-term safety of TAO TAVR. Compared to transapical (TAP) access, the TAO approach was associated with shorter median intensive care unit (ICU) length of stay (LOS) and more favorable technical learning curve. However, outcomes data beyond 30 days were lacking and the longer-term clinical consequences of this strategy were unknown. METHODS: Mortality outcomes at 1 year (and longer) of 44 consecutive patients who underwent TAO TAVR in our institution were compared with that of 76 consecutive patients who underwent TAP TAVR at our site. Risk-adjusted analysis was performed in propensity-matched patients (25 from each group) to account for baseline differences. RESULTS: TAO TAVR was associated with a trend towards lower all-cause mortality at 1 year compared to TAP TAVR (18% vs. 34%, P=0.09 in the overall sample; 12% vs. 40%, P=0.05 in the matched cohort). The higher probability of survival with TAO TAVR persisted after a median follow-up period of 23 months (hazard ratio [HR]=1.96, P=0.06 in the overall sample; HR=3.4, P=0.01 in the matched cohort). Cardiovascular mortality at 1 year was lower with TAO TAVR (2% vs. 22%, P=0.01 in the overall sample; 4% vs. 28%, P=0.05 in the matched cohort). ICU LOS (shorter in the TAO group) and implantation of second prosthetic valve (higher incidence in the TAP group) were independent predictors of long-term mortality. CONCLUSION: The outcomes associated with TAO TAVR compare favorably with TAP TAVR. Our results appear to corroborate the long-term safety and efficacy of the TAO approach in TAVR patients with inadequate iliofemoral access.

Effect of cardiovascular drugs on cardiovascular events in 1599 patients followed in an academic outpatient cardiology practice.

This study investigated the effects of medical therapy on incidences of myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABG) in an academic outpatient cardiology practice. Chart reviews were performed in 1599 treated patients (1138 men and 461 women), mean age 72 years. Medications investigated included the use of statins, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and aspirin. The mean follow-up was 63 months during 1977-2009. Of 1599 patients, MI occurred in 100 patients (6%), PCI occurred in 296 patients (19%), and CABG occurred in 235 patients (15%). Stepwise logistic regression analysis showed that significant independent risk factors for MI were statins [odds ratio = 0.07; 95% confidence interval (CI), 0.05-0.11, P < 0.001], beta blockers (odds ratio = 0.15, 95% CI, 0.10-0.23, P < 0.001), ACE inhibitors (odds ratio = 0.27, 95% CI, 0.16-0.45, P < 0.001), ARBs (odds ratio = 0.09, 95% CI, 0.04-0.20, P < 0.001), and aspirin (odds ratio = 0.18, 95% CI, 0.12-0.29, P < 0.001). Significant independent risk factors for PCI were statins (odds ratio = 0.15, 95% CI, 0.11-0.20, P < 0.001), beta blockers (odds ratio = 0.26, 95% CI, 0.20-0.35, P < 0.001), ACE inhibitors (odds ratio = 0.25, 95% CI, 0.18-0.34, P < 0.001), and ARBs (odds ratio = 0.18, 95% CI, 0.11-0.28, P < 0.001). Significant independent risk factors for CABG were statins (odds ratio = 0.16, 95% CI, 0.12-0.22, P < 0.001), beta blockers (odds ratio = 0.43, 95% CI, 0.32-0.58, P < 0.001), ACE inhibitors (odds ratio = 0.38, 95% CI, 0.27-0.53, P < 0.001), ARBs (odds ratio = 0.19, 95% CI, 0.11-0.31, P < 0.001), and aspirin (odds ratio = 0.45, 95% CI, 0.33-0.61, P < 0.001).

Prosthetic Aortic Valve Obstruction With Pannus Formation, an Approach for Diagnosis and Management: A Case Report.

Mechanical valve obstructions are critical medical and surgical emergencies that require immediate attention when patients present with new complaints and exhibit signs such as the onset of murmurs or the disappearance of mechanical valve clicks. Obstructions can arise from various causes, including pannus formation, thrombus, vegetations, or subvalvular tissue growth. While pannus formations have been previously reported for the mitral valve, they are less commonly observed in the aortic valve, and several hypotheses have been proposed to understand pannus formation. Accurate diagnosis relies on imaging techniques such as echocardiography and fluoroscopy, and surgical intervention is considered the optimal treatment approach. Here, we present the case of a 69-year-old female who had previously undergone aortic valve replacement and subsequently developed progressive dyspnea, fatigue, and a new onset murmur. Imaging modalities revealed a closed leaflet and a high transvalvular gradient over the valve. The patient underwent a prosthetic redo valve replacement, and post-surgery, she was discharged home without complications.

Tracking outpatient continuity and chronic disease indicators-a novel use of the new innovations clinic module.

The Accreditation Council for Graduate Medical Education common program requirements for Practice-based Learning and Improvement in Internal Medicine specify that trainees must "systematically analyze [his/her] practice using quality improvement methods, and implement changes with the goal of practice improvement" and that the training program "must include use of performance data" in the assessment of the resident's practice. Before implementation of an electronic health record at our academic medical center, we found meeting these requirements to be challenging. This prompted us to set up the New Innovations (New Innovations, Inc, Uniontown, OH) Software Suite's Patient Continuity module to permit analysis and tracking of both quality of care indicators and patient continuity. By using the system, our residents were better able to monitor their patient panel sizes and composition and to correlate their practices with quality of care data. Residency programs, which currently utilize New Innovations software but lack an electronic health record, may find the continuity clinic module useful for engaging their house staff in structured practice improvement initiatives and in satisfying the Accreditation Council for Graduate Medical Education's common program requirements for practice-based learning.

Treatment of pulmonary hypertension.

Pulmonary arterial hypertension (PAH) is a chronic progressive disease of the pulmonary vasculature characterized by elevated pulmonary arterial pressure and secondary right ventricular failure. PAH is considered a life-threatening condition unless treated. This article provides a comprehensive review of controlled and uncontrolled trials to define the risk-benefit for different therapeutic options of this clinical disorder. Relevant published articles were identified through searches of the National Center for Biotechnology PubMed database. All therapeutic measures for PAH were discussed. Six drugs have been approved in the United States for the treatment of PAH. Extensive medical advancement has been achieved in treatment of PAH. However, none of the approved therapies have shown ability to cure the disease. New research should be performed to develop promising new therapies.

Hyperthyroidism.

Hyperthyroidism is a pathological syndrome in which tissue is exposed to excessive amounts of circulating thyroid hormone. The most common cause of this syndrome is Graves' disease, followed by toxic multinodular goitre, and solitary hyperfunctioning nodules. Autoimmune postpartum and subacute thyroiditis, tumors that secrete thyrotropin, and drug-induced thyroid dysfunction, are also important causes.

T cell lymphoma presenting as esophageal obstruction and bronchoesophageal fistula.

BACKGROUND: The mediastinum is an uncommon location for presentation of peripheral T cell lymphoma. Esophageal involvement by non-Hodgkin's lymphoma is extremely unusual. Although staging can be performed with routine imaging studies, surgical intervention is often required to ensure accurate histologic diagnosis of these lymphomas. Peripheral T cell lymphomas not otherwise specified are among the most aggressive non-Hodgkin lymphomas with often a poor response to conventional chemotherapy. CASE REPORT: We report a case of a 63 year-old-man with an aggressive mediastinal T cell lymphoma presenting as esophageal obstruction and bronchoesophageal fistula. The patient was treated with a cyclophosphamide, vincristine, and prednisone (COP) regimen. Repeat computer tomography scan of the chest after chemotherapy noted a significant decrease in the cavitary lesion in the right paraesophageal region and right mediastinum. Bronchoscopy revealed a large opening in the posterior wall of the bronchus intermedius leading into the esophagus. A fistulogram was done which clearly demonstrated a fistulous tract between the lower esophagus and the right intermediate bronchus secondary to perforation from the lymphoma. The patient eventually underwent cervical esophagostomy and jejunostomy tube placement to correct the brochoesophageal fistula. CONCLUSIONS: The mediastinum is an uncommon location for presentation of peripheral T cell lymphomas, and surgical intervention is often required to ensure accurate histological diagnosis of these lymphomas. In our patient, aggressive mediastinal T cell lymphoma presented as esophageal obstruction and bronchoesophageal fistula.

The impact of statin therapy on long-term cardiovascular outcomes in an outpatient cardiology practice.

BACKGROUND: Statins reduce coronary events in patients with coronary artery disease. MATERIAL/METHODS: Chart reviews were performed in 305 patients (217 men and 88 women, mean age 74 years) not treated with statins during the first year of being seen in an outpatient cardiology practice but subsequently treated with statins. Based on the starting date of statins use, the long-term outcomes of myocardial infarction (MI), percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABGS) before and after statin use were compared. RESULTS: Mean follow-up was 65 months before statins use and 66 months after statins use. MI occurred in 31 of 305 patients (10%) before statins, and in 13 of 305 patients (4%) after statins (p < 0.01). PCI had been performed in 66 of 305 patients (22%) before statins and was performed in 41 of 305 patients (13%) after statins (p < 0.01). CABGS had been performed in 56 of 305 patients (18%) before statins and was performed in 20 of 305 patients (7%) after statins (p < 0.001). Stepwise logistic regression showed statins use was an independent risk factor for MI (odds ratio = 0.0207, 95% CI, 0.0082-0.0522, p < 0.0001), PCI (odds ratio = 0.0109, 95% CI, 0.0038-0.0315, p < 0.0001), and CABGS (odds ratio = 0.0177, 95% CI = 0.0072-0.0431, p<0.0001.) CONCLUSIONS: Statins use in an outpatient cardiology practice reduces the incidence of MI, PCI, and CABGS.

Thiazide-induced severe hypercalcemia: a case report and review of literature.

Most common causes of hypercalcemia are hyperparathyroidism, malignancy, vitamin D-mediated conditions such as sarcoidosis, and vitamin D toxicity. Less commonly, hypercalcemia can be caused by drugs such as thiazide diuretics and lithium. Mild hypercalcemia is usually asymptomatic but severe hypercalcemia is associated with nausea, vomiting, abdominal pain, excessive thirst, muscle weakness, lethargy, confusion, and fatigue. We are reporting a case of abdominal pain and altered mental status caused by thiazide-induced severe hypercalcemia of 19.8 mg/dL. This is the most severe case of thiazide-induced hypercalcemia that we have seen reported. Patients on thiazide diuretics should have their electrolytes frequently checked, especially patients on calcium supplements. Management usually includes hydration and discontinuation of drugs causing hypercalcemia.

Prevalence of complications during implantation and during 38-month follow-up of 1060 consecutive patients with implantable cardioverter-defibrillators.

During implantation and during 38-month follow-up of 1060 consecutive patients who had implantable cardioverter-defibrillators, complications occurred in 60 (5.7%) of 1060 patients. These complications consisted of fractured leads requiring lead revision in 36 (3.4%) patients, lead infection requiring antibiotics in 5 (0.5%) patients, device replacement because of malfunction in 5 (0.5%) patients, repositioning of leads in 3 (0.3%) patients, a hematoma at the time of implantation in 3 (0.3%) patients, pneumothorax at the time of implantation in 2 (0.2%) patients, repair of a defective generator in 1 (0.1%) patient, replacement of the device because of atrophy of the skin over the device in 1 (0.1%) patient, a transient ischemic attack because of atrial fibrillation developing during implantation in 1 (0.1%) patient, device replacement because of a recall from Guidant in 1 (0.1%) patient, pocket revision because of pain when lying on the side of the pacemaker in 1 (0.1%) patient, and pacemaker infection in 1 (0.1%) patient.

Patients with ischemic stroke have a higher prevalence of a planar QRS-T angle >90° than patients with transient ischemic attack.

BACKGROUND: The aim of the study was to investigate the prevalence of a planar QRS-T angle >90° in patients with ischemic stroke versus transient ischemic attack (TIA). MATERIAL/METHODS: In a prospective study of 279 consecutive patients who had ischemic stroke (197 patients) or TIA (82 patients), the planar QRS-T angle was measured from a 12-lead electrocardiogram taken at the time of the stroke or TIA. All QRS-T angle measurements were made by 3 authors who agreed on the measurements and who were blinded to the clinical findings. A QRS-T angle >90° was considered abnormal. RESULTS: The mean age was 66±6 years in patients with ischemic stroke versus 62±6 years in patients with TIA (p=0.04). The mean body mass index and the prevalence of gender, smoking, hypertension, diabetes mellitus, dyslipidemia, and coronary artery disease were not significantly different between patients with ischemic stroke versus TIA. A QRS-T angle >90° was present in 55 of 197 patients (28%) with ischemic stroke and in 10 of 82 patients (12%) with TIA (p=0.004). CONCLUSIONS: The prevalence of a planar QRS-T angle >90° was higher in patients with ischemic stroke than in patients with TIA (p=0.004).

Prevalence of appropriate cardioverter-defibrillator shocks in 1038 consecutive patients with implantable cardioverter-defibrillators.

During a 33-month follow-up of 1038 consecutive patients who had implantable cardioverter-defibrillators, appropriate shocks occurred in 329 of 1038 patients (32%). Appropriate shocks occurred in 101 of 380 patients (27%) treated with beta-adrenergic blockers alone; in 31 of 95 patients (33%) treated with amiodarone alone; in 39 of 149 patients (26%) treated with beta-blockers plus amiodarone; in 11 of 28 patients (39%) treated with sotalol alone; and in 147 of 386 patients (38%) treated with no beta-blockers, amiodarone, or sotalol (P < 0.001 comparing patients treated with beta-adrenergic blockers alone with patients treated with no beta-blockers, amiodarone, or sotalol; and P < 0.01 comparing patients treated with beta-blockers plus amiodarone with patients treated with no beta-blockers, amiodarone, or sotalol). In conclusion, patients having implantable cardioverter-defibrillators should also be treated with beta-adrenergic blockers to reduce the frequency of appropriate shocks.

Statins reduce appropriate cardioverter-defibrillator shocks and mortality in patients with heart failure and combined cardiac resynchronization and implantable cardioverter-defibrillator therapy.

Of 209 patients with heart failure treated with combined cardiac resynchronization therapy and implantable cardioverter-defibrillator therapy, appropriate cardioverter-defibrillator shocks occurred at 34-month follow-up in 22 of 121 patients (18%) on statins and in 30 of 88 patients (34%) not on statins (P = .009). Deaths occurred in 3 of 121 patients (2%) on statins and in 9 of 88 patients (10%) not on statins (P = .017). Stepwise Cox regression analysis showed that significant independent prognostic factors for appropriate shocks were use of statins (risk ratio = 0.46), smoking (risk ratio = 3.5), and diabetes (risk ratio = 0.34). Significant independent prognostic factors for the time to mortality were use of statins (risk ratio = 0.05), use of digoxin (risk ratio = 4.2), systemic hypertension (risk ratio = 14.2), diabetes (risk ratio = 4.3), and left ventricular ejection fraction (risk ratio = 1.1).

Effect of beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins on mortality in patients with implantable cardioverter-defibrillators.

Nine hundred sixty-five patients (mean age 70 years) with implantable cardioverter-defibrillator were followed for 32 +/- 33 months for all-cause mortality. Death occurred in 73 of 515 patients (13%) treated with beta blockers (group 1), in 84 of 494 patients (17%) treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (group 2), in 56 of 402 patients (14%) treated with statins (group 3), in 40 of 227 patients (18%) treated with amiodarone (group 4), in 5 of 26 patients (19%) treated with sotalol (group 5), and in 64 of 265 patients (24%) treated with no beta blocker, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, statin, amiodarone, or sotalol (group 6) (p <0.001 for group 1 vs group 6 and group 3 vs group 6, p <0.02 for group 2 vs group 6). In conclusion, patients with implantable cardioverter-defibrillators should be treated with beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins to reduce mortality.

A unique complication of the GuideZilla guide extension support catheter and the risk of stent stripping in interventional & endovascular interventions.

Supporting catheters in percutaneous stenting of anatomically difficult coronary lesions are utilized by interventional cardiologists. The GuideZilla guide extension catheter is designed for deep seating in coronary arteries to provide extra guidance support for equipment delivery during difficult coronary interventions or for coaxial alignment in tortuous vessels. There are limited GuideZilla-related complications reported in the literature. We present a challenging case of a left main and left anterior descending artery dissection, complicated with stent stripping off the delivery balloon by the GuideZilla support catheter.

Percutaneous aortic balloon valvotomy in the United States: a 13-year perspective.

BACKGROUND: We determined the contemporary trends of percutaneous aortic balloon valvotomy and its outcomes using the nation's largest hospitalization database. There has been a resurgence in the use of percutaneous aortic balloon valvotomy in patients at high surgical risk because of the development of less-invasive endovascular therapies. METHODS: This is a cross-sectional study with time trends using the Nationwide Inpatient Sample database between the years 1998 and 2010. We identified patients using the International Classification of Diseases, 9th Revision, Clinical Modification procedure code for valvotomy. Only patients aged more than 60 years with aortic stenosis were included. Primary outcome included in-hospital mortality, and secondary outcomes included procedural complications and length of hospital stay. RESULTS: A total of 2127 percutaneous aortic balloon valvotomies (weighted n = 10,640) were analyzed. The use rate of percutaneous aortic balloon valvotomy increased by 158% from 12 percutaneous aortic balloon valvotomies per million elderly patients in 1998-1999 to 31 percutaneous aortic balloon valvotomies per million elderly patients in 2009-2010 in the United States (P < .001). The hospital mortality decreased by 23% from 11.5% in 1998-1999 to 8.8% in 2009-2010 (P < .001). Significant predictors of in-hospital mortality were the presence of increasing comorbidities (P = .03), unstable patient (P < .001), any complication (P < .001), and weekend admission (P = .008), whereas increasing operator volume was associated with significantly reduced mortality (P = .03). Patients who were admitted to hospitals with the highest procedure volume and the highest volume operators had a 51% reduced likelihood (P = .05) of in-hospital mortality when compared with those in hospitals with the lowest procedure volume and lowest volume operators. CONCLUSION: This study comprehensively evaluates trends for percutaneous aortic balloon valvotomy in the United States and demonstrates the significance of operator and hospital volume on outcomes.

Balloon mitral valvuloplasty in the United States: a 13-year perspective.

BACKGROUND: Incidence and prevalence of mitral stenosis is declining in the US. We performed this study to determine recent trends in utilization, complications, mortality, length of stay, and cost associated with balloon mitral valvuloplasty. METHODS: Utilizing the nationwide inpatient sample database from 1998 to 2010, we identified patients using the International Classification of Diseases, 9th Revision, Clinical Modification procedure code for "percutaneous valvuloplasty." Patients ≥18 years of age with mitral stenosis were included. Patients with concomitant aortic, tricuspid, or pulmonic stenosis were excluded. Primary outcome included death and procedural complications. RESULTS: A total of 1308 balloon mitral valvuloplasties (weighted n = 6540) were analyzed. There was a 7.5% decrease in utilization of the procedure from 24.6 procedures/10 million population in 1998-2001 to 22.7 procedures/10 million population in 2008-2010 (P for trend = .098). We observed a 15.9% overall procedural complication rate and 1.7% mortality rate. The procedural complication rates have increased in recent years (P = .001), corresponding to increasing age and burden of comorbidities in patients. The mean cost per admission for balloon mitral valvuloplasty has gone up significantly over the 10 years, from $11,668 ± 1046 in 2001 to $23,651 ± 301 in 2010 (P <.001). CONCLUSIONS: In a large cross-sectional study of balloon mitral valvuloplasty in the US, we have reported trends of decreasing overall utilization and increasing procedural complication rates and cost over a period of 13 years.

The transaortic approach for transcatheter aortic valve replacement: initial clinical experience in the United States.

OBJECTIVES: This study sought to investigate the technical feasibility and safety of the transaortic (TAO) transcatheter aortic valve replacement (TAVR) approach in patients not eligible for transfemoral (TF) access by using a device commercially available in the United States. BACKGROUND: A large proportion of candidates for TAVR have inadequate iliofemoral vessels for TF access. The transapical route (TAP) is the current alternative but is associated with less favorable outcomes. Other access options need to be explored. METHODS: Forty-four consecutive patients with inoperable, severe aortic stenosis underwent TAO TAVR in our institution. Procedural and 30-day clinical outcomes data were compared with data from 76 consecutive patients who underwent TAP TAVR at our site. Technical learning curves were assessed by comparing outcomes of the first 20 cases with the subsequent patients who underwent each procedure. RESULTS: The TAO and TAP TAVR groups were similar in terms of device success according to Valve Academic Research Consortium criteria (89% vs. 84%; p = 0.59) and rates of the 30-day combined safety endpoint of all-cause mortality, myocardial infarction, major stroke, disabling bleeding, severe acute kidney injury, and valve reintervention (20% vs. 33%; p = 0.21). The TAO approach, compared with TAP TAVR, was associated with lower combined bleeding and vascular event rate (27% vs. 46%; p = 0.05), shorter median intensive care unit length of stay (3 vs. 6 days; p = 0.01), and a favorable learning curve. CONCLUSIONS: TAVR via the TAO approach is technically feasible, seems to be associated with favorable outcomes, and expands the current alternative options for access sites in patients with inoperable aortic stenosis who are ineligible for TF TAVR.

Risk factor reduction in progression of angiographic coronary artery disease.

INTRODUCTION: To investigate differences between outpatients with progressive and nonprogressive coronary artery disease (CAD) measured by coronary angiography. MATERIAL AND METHODS: Chart reviews were performed in patients in an outpatient cardiology practice having ≥ 2 coronary angiographies ≥ 1 year apart. Progressive CAD was defined as 1) new non-obstructive or obstructive CAD in a previously disease-free vessel; or 2) new obstruction in a previously non-obstructive vessel. Coronary risk factors, comorbidities, cardiovascular events, medication use, serum low-density lipoprotein cholesterol (LDL-C), and blood pressure were used for analysis. RESULTS: The study included 183 patients, mean age 71 years. Mean follow-up duration was 11 years. Mean follow-up between coronary angiographies was 58 months. Of 183 patients, 108 (59%) had progressive CAD, and 75 (41%) had nonprogressive CAD. The use of statins, ß-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and aspirin was not significantly different in patient with progressive CAD or nonprogressive CAD Mean arterial pressure was higher in patients with progressive CAD than in patients with nonprogressive CAD (97±13 mm Hg vs. 92±12 mm Hg) (p<0.05). Serum LDL-C was insignificantly higher in patients with progressive CAD (94±40 mg/dl) than in patients with nonprogressive CAD (81±34 mg/dl) (p=0.09). CONCLUSIONS: Our data suggest that in addition to using appropriate medical therapy, control of blood pressure and serum LDL-C level may reduce progression of CAD.