Suicide left ventricle following protamine: A case report.

A patient with severe aortic stenosis and left ventricular hypertrophy underwent a transcatheter aortic valve replacement. The patient's blood pressure significantly dropped after protamine administration. A diagnosis of suicide left ventricle post-valve replacement was made. The diagnosis and management of the protamine reaction are detailed. This case highlights the need to slowly infuse protamine sulfate and monitor for adverse events.

Obesity and the paradox of mortality and heart failure hospitalization in heart failure with preserved ejection fraction.

BACKGROUND: Limited data exist on the association of obesity with both hospitalization and mortality in patients with heart failure with preserved ejection fraction (HFpEF), especially in the real-world ambulatory setting. We hypothesized that increasing body-mass index (BMI) in ambulatory heart failure with preserved ejection fraction would have a protective effect on these patients leading to decreased mortality and hospitalizations. METHODS: We studied the relationship between BMI and the time to all-cause mortality, time to heart failure (HF) hospitalization, and time to all-cause hospitalization over a 2-year follow-up in a national cohort of 2501 ambulatory HFpEF patients at 153 Veterans Affairs medical centers. RESULTS: Compared with normal BMI, overweight (HR 0.72; 95% CI 0.57-0.91), obesity class I (HR 0.59; 95% CI 0.45-0.77), obesity class II (HR 0.56; 95% CI 0.40-0.77), and obesity class III (HR 0.53; 95% CI 0.36-0.77) were associated with improved survival after adjustment for demographics and comorbidities. In contrast, the time to HF hospitalization showed an inverse relationship, with shorter time to HF hospitalization with increasing BMI compared with normal BMI; overweight (adjusted HR 1.30; 95% CI 0.88-1.90), obesity class I (HR 1.57; 95% CI 1.05-2.34), obesity class II (HR 1.79; 95% CI 1.15-2.78), and obesity class III (HR 1.96; 95% CI 1.23-3.12). However, time to first all-cause hospitalization was not significantly different by BMI groups. CONCLUSIONS: In a large, national ambulatory HFpEF cohort, despite the presence of the obesity paradox with respect to survival, increasing BMI was independently associated with an increased risk of HF hospitalization and similar risk of all-cause hospitalization. Future longer-term prospective trials evaluating the safety and efficacy of weight loss on morbidity and mortality, in patients with severe obesity and HFpEF are needed.

Acute Coronary Syndromes: Unstable Angina and Non-ST Elevation Myocardial Infarction.

Non-ST elevation acute coronary syndromes (NSTE-ACS) encompass the clinical entities of unstable angina and non-ST elevation myocardial infarction. Several advances have occurred over the past decade, including the emergence of new antiplatelet and antithrombotic therapies and novel treatment strategies, leading to marked improvements in mortality. However, there has also been an increased incidence in NSTE-ACS as a result of the use of high-sensitivity troponins and the increase in cardiovascular risk factors. This article provides a focused update on contemporary management strategies pertaining to antiplatelet, antithrombotic, and anti-ischemic therapies and to revascularization strategies in patients with ACS.

Association of body mass index and waist circumference with subclinical atherosclerosis in retired NFL players.

OBJECTIVES: It is unknown which measure of adiposity (body mass index [BMI] or waist circumference [WC]) is associated with subclinical atherosclerosis in retired National Football League (NFL) players and whether this relation is attenuated after adjusting for components of the metabolic syndrome (elevated triglycerides, fasting glucose, and low levels of high-density lipoprotein-cholesterol [HDL-C]) that frequently coexist with obesity. METHODS: Coronary artery calcium (CAC) was measured in 926 retired NFL players. BMI was calculated as weight (in kilograms)/height (in meters)(2) and WC was measured in inches. Logistic regression analyses adjusting for age, race, systolic blood pressure, high sensitivity C-reactive protein, triglycerides, HDL-C, and fasting blood glucose were performed to evaluate whether BMI or WC was independently associated with the presence of CAC (CAC score >0). RESULTS: The median age, BMI and WC were 54 years, 31 kg/m(2), and 40 inches, respectively. CAC was present in 61% (n = 562) of retired players. Adjusting for age, race, systolic blood pressure, high sensitivity C-reactive protein, triglycerides, HDL-C, and fasting blood glucose, each standard deviation increase in BMI (4.85 kg/m(2)) was significantly associated with CAC (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.03-1.50), but each standard deviation increase in WC (10.53 inches) was not significantly associated with CAC (OR 1.18, 95% CI 0.96-1.45). There was a significant association for the presence of CAC for highest versus lowest quartiles of both BMI (OR 1.93, 95% CI 1.13-3.28) and WC (OR 1.75, 95% CI 1.05-2.92), although the trend for the presence of CAC was significant only across increasing BMI quartiles, even in models that included WC. CONCLUSIONS: In retired NFL players both BMI and WC were associated with CAC. Higher BMI may be associated with an increasing trend for the presence of CAC independent of WC.

Use of Subclavian Extracorporeal Carbon Dioxide Removal for COVID-19 Acute Respiratory Distress Syndrome as a Bridge to Lung Transplantation.

Severe acute hypercapnia is independently associated with increased adverse effects and intensive care unit mortality in mechanically ventilated patients. During the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic, some patients were placed on extracorporeal carbon dioxide removal support when extracorporeal membrane oxygenation (ECMO) support was at capacity or not offered. We present a patient with severe acute respiratory distress syndrome caused by COVID-19 pneumonia, who was supported with Hemolung Respiratory Assist System (ALung Technologies, Inc., LivaNova, Pittsburgh, PA) via the right subclavian vein as a bridge to lung transplantation after venovenous ECMO support. The patient survived and was discharged home.

Current status of percutaneous ventricular assist devices for cardiogenic shock.

PURPOSE OF REVIEW: Percutaneous ventricular assist devices (pVADs) are being increasingly used in patients with cardiogenic shock. They offer a means of instituting rapid and adequate cardiac support in patients with cardiogenic shock unresponsive to inotropes/vasopressors and intraaortic balloon pumps (IABPs). However, there is considerable debate on the appropriate use of these devices given the difficulty of conducting randomized trials in patients with cardiogenic shock, lack of clear guidelines on indications, device selection, and cost-effective care of patients implanted with these devices. RECENT FINDINGS: Several centers have recently reported data on the use of these devices for cardiogenic shock in a variety of different settings, including myocardial ischemia and its complications, high-risk percutaneous coronary intervention, myocarditis, and refractory arrhythmias. Recent randomized trials have compared the use of IABP with different pVADs evaluating hemodynamic outcomes as well as short-term mortality. SUMMARY: We review the current evidence on the use of pVADs (Tandemheart pVAD, Impella, percutaneous extracorporeal membrane oxygenation), their indications, relative merits, and adverse effects, and discuss the current approach to the appropriate use of pVADs in patients with cardiogenic shock. We also propose an algorithm for device selection tailored to each patient's needs based on severity of cardiogenic shock, amount of support needed, and the overall clinical scenario.

Percutaneous Thrombus Removal in COVID-19-Infected Patient with Pulmonary Embolism.

We present a case describing the use of the AngioVac system (AngioDynamics, Inc.) and SENTINEL™ cerebral protection system (SCPS; Boston Scientific) in a patient with COVID-19 who initially presented with a large deep-vein thrombosis of the left lower extremity, complicated by a pulmonary embolism. Although he initially improved with systemic alteplase, he later developed a second large clot diagnosed in transit in the right atrium. Within 12 hours from initial thrombolysis, this large clot wedged across an incidental patent foramen ovale (PFO), the atrial septum, and the cavotricuspid annulus. We emergently performed a percutaneous clot extraction with preemptive placement of the SCPS in anticipation of cardioembolic phenomenon. A large (> 10 cm) clot was extracted without complication, and the patient was discharged home. The combined use of SCPS and AngioVac in this case suggests a potential role for percutaneous treatment of severe and consequential thromboembolic disease, especially in patients with a PFO, and may be considered as an alternative and less-invasive option in patients with COVID-19. While cerebral embolic protection devices are approved for and widely used in transcatheter aortic valve replacement procedures, there is a theoretical benefit for use in percutaneous thrombolectomies as well.

Comparison of Frequency of Vascular Complications With Ultrasound-Guided Versus Fluroscopic Roadmap-Guided Femoral Arterial Access in Patients Who Underwent Transcatheter Aortic Valve Implantation.

To compare outcomes of ultrasound guidance (USG) versus fluoroscopy roadmap guidance (FG) angiography for femoral artery access in patients who underwent transfemoral (TF) transcatheter aortic valve implantation (TAVI) to determine whether routine USG use was associated with fewer vascular complications. Vascular complications are the most frequent procedural adverse events associated with TAVI. USG may provide a decreased rate of access site complications during vascular access compared with FG. Patients who underwent TF TAVI between July 2012 and July 2017 were reviewed and outcomes were compared. Vascular complications were categorized by Valve Academic Research Consortium-2 criteria and analyzed by a multivariable logistic regression adjusting for potential confounding risk factors including age, gender, body mass index, peripheral vascular disease, Society of Thoracic Surgeons score and sheath to femoral artery ratio. Of the 612 TAVI patients treated, 380 (63.1%) were performed using USG for access. Routine use of USG began in March 2015 and increased over time. Vascular complications occurred in 63 (10.3%) patients and decreased from 20% to 3.9% during the study period. There were fewer vascular complications with USG versus FG (7.9% vs 14.2%, p = 0.014). After adjusting for potential confounding risk factors that included newer valve systems, smaller sheath sizes and lower risk patients, there was still a 49% reduction in vascular complications with USG (odds ratio 0.51, 95% confidence interval 0.29 to 0.88, p = 0.02). In conclusion, USG for TF TAVI was associated with reduced vascular access site complications compared with FG access even after accounting for potential confounding risk factors and should be considered for routine use for TF TAVI.

Axillary Access TAVR: Entrapment of a Transcatheter Aortic Valve in the Innominate Artery With Aortic Dissection.

Non-femoral transcatheter aortic valve replacement (TAVR) is indicated when peripheral vascular disease is diagnosed. We describe the "double-stick" technique via the axillary artery. During the procedure, the pigtail coiled around the TAVR system. While retracting the TAVR sheath, the seam along system split dislodging the valve from the balloon. The valve was entrapped in the innominate artery, and an aortic dissection required surgery. With the double-stick technique, friction and resistance between the pigtail and delivery system must be avoided. Pre-procedural planning and early identification is paramount. Smaller and more seamless delivery systems may reduce risk for dissection and entrapment.

Description of a Method to Obtain Complete One-Year Follow-Up in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.

The Centers for Medicare and Medicaid Services National Coverage Determination requires centers performing transcatheter aortic valve implantation (TAVI) to report clinical outcomes up to 1 year. Many sites encounter challenges in obtaining complete 1-year follow-up. We report our process to address this challenge. A multidisciplinary process involving clinical personnel, data and quality managers, and research coordinators was initiated to collect TAVI data at baseline, 30 days, and 1 year. This process included (1) planned clinical follow-up of all patients at 30 days and 1 year; (2) query of health-care system-wide integrated data warehouse (IDW) to ascertain last date of clinical contact within the system for all patients; (3) online obituary search, cross-referencing for unique patient identifiers to determine if mortality occurred in remaining unknown patients; and (4) phone calls to remaining unknown patients or patients' families. Between January 2012 and December 2016, 744 patients underwent TAVI. All 744 patients were eligible for 30-day follow-up and 546 were eligible for 1-year follow-up. At routine clinical follow-up of 22 of 744 (3%) patients at 30 days and 180 of 546 (33%) patients at 1 year had unknown survival status. The integrated data warehouse query confirmed status-alive for an additional 1 of 22 patients at 30 days (55%) and 91 of 180 patients at 1 year (51%). Obituaries were identified for 23 of 180 additional patients at 1 year (13%). Phone contact identified the remaining unknown patients at 30 days and 1 year, resulting in 100% known survival status for patients at 30 days (744 of 744) and at 1 year (546 of 546). In conclusion, using a comprehensive approach, we were able to determine survival status in 100% of patients who underwent TAVI.

Clinical Leaflet Thrombosis in Transcatheter and Surgical Bioprosthetic Aortic Valves by Four-Dimensional Computed Tomography.

BACKGROUND: The incidence of leaflet thrombosis after transcatheter aortic valve replacement (TAVR) with active surveillance by four-dimensional computed tomography (4DCT) ranges from 7% to 14%. The incidence of leaflet thrombosis when 4DCT is performed for clinical and echocardiographic indications is unknown. METHODS: All patients with prior TAVR or surgical aortic valve replacement (SAVR) who underwent evaluation between October 2015 and January 2017 at our institution and had clinical or echocardiographic indications of leaflet thrombosis were evaluated by 4DCT. Indications for 4DCT by echocardiography included (1) interval increase in mean gradient of 10 mm Hg or more, (2) interval decrease in ejection fraction of 10% or more, (3) thrombus seen on transthoracic echocardiography, (4) persistent or increasing paravalvular leak, or (5) valve dehiscence or thickened leaflets seen on transthoracic echocardiography. Clinical indicators were (1) stroke, (2) transient ischemic attack, or (3) new or worsening heart failure. RESULTS: During the study period, 612 patients underwent TAVR, and 101 patients (55 TAVR; 46 SAVR) met the criteria for 4DCT imaging. Leaflet thrombosis was seen in 17 of 55 TAVR patients (30.9%) and 15 of 46 SAVR patients (32.6%). Follow-up imaging with 4DCT after treatment with anticoagulation showed improvement or resolution in thrombus burden and leaflet excursion in all TAVR patients and in two-thirds of SAVR patients. CONCLUSIONS: One-third of patients with clinical or echocardiographic indications suggestive of leaflet thrombosis were found to have evidence of leaflet thrombosis using 4DCT. This allowed tailored anticoagulation therapy with resolution of the thrombus in most patients and avoiding unnecessary anticoagulation in the remaining two-thirds of patients.

Ticagrelor Use in Acute Myocardial Infarction: Insights From the National Cardiovascular Data Registry.

BACKGROUND: Ticagrelor is a P2Y12 receptor inhibitor with superior clinical efficacy compared with clopidogrel. However, it is associated with reduced efficacy when combined with a high-dose aspirin. METHODS AND RESULTS: Patients in the acute coronary treatment and intervention outcomes network (ACTION) Registry-Get With The Guidelines (GWTG) with acute myocardial infarction from October 2013 through December 2014 were included in the study (167 455 patients; 622 sites). We evaluated temporal trends in the prescription of P2Y12 inhibitors, and identified factors associated with ticagrelor use at discharge. Among patients discharged on ticagrelor and aspirin (21 262 patients), we evaluated the temporal trends and independent factors associated with high-dose aspirin prescription at discharge. Ticagrelor prescription at discharge increased significantly from 12% to 16.7% (P<0.0001). Decreases in prasugrel and clopidogrel use at discharge (15.7%-13.9% and 54.2%-51.1%, respectively, P<0.0001) were also observed. Independent factors associated with preferential ticagrelor prescription at discharge over clopidogrel included younger age, white race, home ticagrelor use, invasive management, and in-hospital re-infarction and stroke (P<0.0001 for all), whereas older age, female sex, prior stroke, home ticagrelor use, and in-hospital stroke (P<0.0001 for all) were associated with preferential ticagrelor prescription at discharge over prasugrel. High-dose aspirin was used in 3.1% of patients discharged on ticagrelor. Independent factors associated with high-dose aspirin prescription at discharge included home aspirin use, diabetes mellitus, previous myocardial infarction, previous coronary artery bypass graft, ST-segment-elevation myocardial infarction, cardiogenic shock, and geographic region (P=0.01). CONCLUSIONS: Our contemporary analysis shows a modest but significant increase in the use of ticagrelor and a high rate of adherence to the use of low-dose aspirin at discharge.

Impact of Aortic Root Anatomy and Geometry on Paravalvular Leak in Transcatheter Aortic Valve Replacement With Extremely Large Annuli Using the Edwards SAPIEN 3 Valve.

OBJECTIVES: The aim of this study was to determine factors affecting paravalvular leak (PVL) in transcatheter aortic valve replacement (TAVR) with the Edwards SAPIEN 3 (S3) valve in extremely large annuli. BACKGROUND: The largest recommended annular area for the 29-mm S3 is 683 mm2. However, experience with S3 TAVR in annuli >683 mm2 has not been widely reported. METHODS: From December 2013 to July 2017, 74 patients across 16 centers with mean area 721 ± 38 mm2 (range: 684 to 852 mm2) underwent S3 TAVR. The transfemoral approach was used in 95%, and 39% were under conscious sedation. Patient, anatomic, and procedural characteristics were retrospectively analyzed. Valve Academic Research Consortium-2 outcomes were reported. RESULTS: Procedural success was 100%, with 2 deaths, 1 stroke, and 2 major vascular complications at 30 days. Post-dilatation occurred in 32%, with final balloon overfilling (1 to 5 ml extra) in 70% of patients. Implantation depth averaged 22.3 ± 12.4% at the noncoronary cusp and 20.7 ± 9.9% at the left coronary cusp. New left bundle branch block occurred in 17%, and 6.3% required new permanent pacemakers. Thirty-day echocardiography showed mild PVL in 22.3%, 6.9% moderate, and none severe. There was no annular rupture or coronary obstruction. Mild or greater PVL was associated with larger maximum annular and left ventricular outflow tract (LVOT) diameters, larger LVOT area and perimeter, LVOT area greater than annular area, and higher annular eccentricity. CONCLUSIONS: TAVR with the 29-mm S3 valve beyond the recommended range by overexpansion is safe, with acceptable PVL and pacemaker rates. Larger LVOTs and more eccentric annuli were associated with more PVL. Longer term follow-up will be needed to determine durability of S3 TAVR in this population.

Transcatheter Aortic Valve Replacement and MitraClip to Reverse Heart Failure.

Valvular heart diseases such as aortic stenosis and mitral regurgitation are often associated with heart failure, which in turn increases patients' Surgical Thoracic Society (STS) score. A high STS score means the patient is high risk for surgical aortic valve replacement and mitral valve repair/replacement. Transcatheter aortic valve replacement and percutaneous mitral valve repair offer a minimally invasive alternative for the treatment of valvular heart disease in patients with severe heart failure. We aim to review the current evidence on the safety, efficacy, and outcomes of these devices in patients with severe heart failure.

BNP and obesity in acute decompensated heart failure with preserved vs. reduced ejection fraction: The Atherosclerosis Risk in Communities Surveillance Study.

BACKGROUND: Levels of B-type natriuretic peptide (BNP), a prognostic marker in patients with heart failure (HF), are lower among HF patients with obesity or preserved Left Ventricular Ejection Fraction (LVEF). We examined the distribution and prognostic value of BNP across BMI categories in acute decompensated heart failure (ADHF) patients with preserved vs. reduced LVEF. METHODS: We analyzed data from the Atherosclerosis Risk in Communities (ARIC) HF surveillance study which sampled and adjudicated ADHF hospitalizations in patients aged ≥55years from 4 US communities (2005-2009). We examined 5 BMI categories: underweight (<18.5kg/m2), normal weight (18.5-<25), overweight (25-<30), obese (30-<40) and morbidly obese (≥40) in HF with preserved LVEF (HFpEF) and reduced LVEF (HFrEF). The outcome was 1-year mortality from admission. We used ANCOVA to model log BNP and logistic regression for 1-year mortality, both adjusted for demographics and clinical characteristics. RESULTS: The cohort included 9820 weighted ADHF hospitalizations (58% HFrEF; 42% HFpEF). BNP levels were lower in HFpEF compared to HFrEF (p<0.001) and decreased as BMI increased within the LVEF groups (p<0.001). After adjustment for covariates, log10 BNP independently predicted 1-year mortality (adjusted OR 1.62 (95% CI 1.17-2.24)) with no significant interaction by BMI or LVEF groups. CONCLUSIONS: BNP levels correlated inversely with BMI, and were higher in HFrEF compared to HFpEF. Obese patients with HFpEF and ADHF had a significant proportion with BNP levels below clinically accepted thresholds. Nevertheless, BNP was a predictor of mortality in ADHF across groups of BMI in HFpEF and HFrEF.

Frequency and practice-level variation in inappropriate aspirin use for the primary prevention of cardiovascular disease: insights from the National Cardiovascular Disease Registry's Practice Innovation and Clinical Excellence registry.

BACKGROUND: Among patients without cardiovascular disease (CVD) and low 10-year CVD risk, the risks of gastrointestinal bleeding and hemorrhagic strokes associated with aspirin use outweigh any potential atheroprotective benefit. According to the guidelines on primary prevention of CVD, aspirin use is considered appropriate only in patients with 10-year CVD risk ≥6% and inappropriate in patients with 10-year CVD risk <6%. OBJECTIVES: The goal of this study was to examine the frequency and practice-level variation in inappropriate aspirin use for primary prevention in a large U.S. nationwide registry. METHODS: Within the National Cardiovascular Disease Registry's Practice Innovation and Clinical Excellence registry, we assessed 68,808 unique patients receiving aspirin for primary prevention from 119 U.S. practices. The frequency of inappropriate aspirin use was determined for primary prevention (aspirin use in those with 10-year CVD risk <6%). Using hierarchical regression models, the extent of practice-level variation using the median rate ratio (MRR) was assessed. RESULTS: Inappropriate aspirin use frequency was 11.6% (7,972 of 68,808) in the overall cohort. There was significant practice-level variation in inappropriate use (range 0% to 71.8%; median 10.1%; interquartile range 6.4%) for practices; adjusted MRR was 1.63 (95% confidence interval [CI]: 1.47 to 1.77). Results remained consistent after excluding 21,052 women age ≥65 years (inappropriate aspirin use 15.2%; median practice-level inappropriate aspirin use 13.8%; interquartile range 8.2%; adjusted MRR 1.61 [95% CI: 1.46 to 1.75]) and after excluding patients with diabetes (inappropriate aspirin use 13.9%; median practice-level inappropriate aspirin use 12.4%; interquartile range 7.6%; adjusted MRR 1.55 [95% CI: 1.41 to 1.67]). CONCLUSIONS: More than 1 in 10 patients in this national registry were receiving inappropriate aspirin therapy for primary prevention, with significant practice-level variations. Our findings suggest that there are important opportunities to improve evidence-based aspirin use for the primary prevention of CVD.

Are there any new pharmacologic therapies on the horizon to better treat hypertension? A state-of-the-art paper.

Hypertension is the most important cardiovascular risk factor. We have witnessed a significant improvement in hypertension treatment and control and an impressive growth in the pharmacologic options available to clinicians and hypertension specialists. With up to a third of patients with hypertension not at the recommended goal blood pressures, it is critically important to develop novel therapeutic approaches to better treat hypertension. This review will explore the ever-expanding horizon of antihypertensive treatment and will focus on 2 major areas of drug development. First, we will review novel targets for pharmacologic treatment and novel molecules and classes of drugs in various phases of development and recognize the limitations we face in their transition from research and development to clinical practice. Then, we will discuss an expanding array of combination strategies to better treat hypertension with the goal of minimizing the burden of cardiovascular and renal complications of hypertension.

Acute coronary syndromes: unstable angina and non-ST elevation myocardial infarction.

Non-ST elevation acute coronary syndromes (NSTE-ACS) encompass the clinical entities of unstable angina and non-ST elevation myocardial infarction. Several advances have occurred over the past decade, including the emergence of new antiplatelet and antithrombotic therapies and novel treatment strategies, leading to marked improvements in mortality. However, there has also been an increased incidence in NSTE-ACS as a result of the use of high-sensitivity troponins and the increase in cardiovascular risk factors. This article provides a focused update on contemporary management strategies pertaining to antiplatelet, antithrombotic, and anti-ischemic therapies and to revascularization strategies in patients with ACS.