Transcatheter edge-to-edge mitral valve repair for mitral regurgitation in patients with cardiogenic shock: A systematic review and meta-analysis.

BACKGROUND: There is currently little evidence for transcatheter edge-to-edge mitral valve repair (TEER) for mitral regurgitation (MR) in patients with cardiogenic shock (CS). Therefore, this study investigated the characteristics and outcomes of CS patients who underwent TEER for MR. METHODS: PubMed, EMBASE were searched in July 2023. Case series and observational studies reporting clinical characteristics and outcomes in CS patients with MR who underwent TEER were included. We performed a one-group meta-analysis using a random effects model. RESULTS: A total of 4060 patients from 7 case series and 5 observational studies were included. The mean age was 68.2 (95% confidence interval [CI]: 64.1-72.2) years, and 41.4% of patients (95% CI: 39.1%-43.7%) were female. Pre-TEER, severe MR was present in 85.3% (95% CI: 76.1%-91.3%) of patients. Mean left ventricular ejection fraction was 36.7% (95% CI: 29.2%-44.2%), and 54.6% (95% CI: 36.9%-71.2%) of patients received mechanical circulatory support. The severity of MR post-TEER was less than 2+ in 88% (95% CI: 87%-89%) of patients. In-hospital mortality was 11% (95% CI: 10%-13%), whereas 30-day and 1-year mortality rates were 15% (95% CI: 13%-16%), and 36% (95% CI: 21%-54%), respectively. CONCLUSIONS: This systematic review and meta-analysis assessed the clinical characteristics and outcomes of TEER in CS patients with MR. TEER for MR in patients with CS has been successful in reducing MR in most of the patients, but with a high mortality rate. Randomized controlled trials of TEER for MR and CS are needed.

Outcomes of transcatheter edge-to-edge repair for atrial functional mitral regurgitation: A meta-analysis of observational studies.

BACKGROUND: Transcatheter edge-to-edge repair (TEER) may have potential benefits in the treatment of atrial functional mitral regurgitation (AFMR), but robust evidence is currently lacking. We conducted a systematic review and meta-analysis to investigate the clinical outcomes of TEER for AFMR, including comparisons to ventricular functional MR (VFMR). METHODS: MEDLINE and EMBASE were searched through January 2023 to identify studies eligible for analysis. The primary outcome was postprocedural MR severity. Postprocedural New York Heart Association (NYHA) functional class classification and all-cause mortality were also evaluated. Outcomes were stratified into short term (postprocedure to 6 months) and long term (6 months to 2 years). RESULTS: A total of eight observational studies met the inclusion criteria, enrolling 539 AFMR and 3486 VFMR patients. Postprocedural MR grade ≤2 in the AFMR group was observed in 93.7% (454/491 patients; 95% confidence interval (CI), 91.1%-96.2%, I2 = 24.3%) and 97.1% (89/93 patients; 95% CI, 92.9%-100%, I2 = 26.4%) in short- and long-term follow-up, respectively. There was no difference in the rates of postprocedural MR grade ≤2 between AFMR and VFMR either in short-term (risk ratio [RR], 1.00 [95% CI, 0.95-1.06]; p = 0.90; I2 = 53%) or long-term follow-up (RR, 1.08 [95% CI, 0.89-1.32]; p = 0.44; I2 = 22%). Similarly, no difference was observed between AFMR and VFMR in the rates of postprocedural NYHA class ≤2 or all-cause mortality. CONCLUSION: TEER provides similar clinical outcomes for AFMR and VFMR. A high rate of MR grade ≤2 was observed in patients at both short- and long-term follow-ups. Further prospective studies with TEER versus medical therapy and/or rhythm control for AFMR are warranted.

P2Y12 Inhibitors for Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis.

BACKGROUND: For patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), prasugrel was recommended over ticagrelor in a recent randomized controlled trial, although more data are needed on the rationale. Here, the effects of P2Y12 inhibitors on ischemic and bleeding events in patients with NSTE-ACS were investigated. METHODS: Clinical trials that enrolled patients with NSTE-ACS were included, relevant data were extracted, and a network meta-analysis was performed. RESULTS: This study included 37,268 patients with NSTE-ACS from 11 studies. There was no significant difference between prasugrel and ticagrelor for any end point, although prasugrel had a higher likelihood of event reduction than ticagrelor for all end points except cardiovascular death. Compared with clopidogrel, prasugrel was associated with decreased risks of major adverse cardiovascular events (MACE) (hazard ratio [HR], 0.84; 95% CI, 0.71-0.99) and myocardial infarction (HR, 0.82; 95% CI, 0.68-0.99) but not an increased risk of major bleeding (HR, 1.30; 95% CI, 0.97-1.74). Similarly, compared with clopidogrel, ticagrelor was associated with a reduced risk of cardiovascular death (HR, 0.79; 95% CI, 0.66-0.94) and an increased risk of major bleeding (HR, 1.33; 95% CI, 1.00-1.77; P = .049). For the primary efficacy end point (MACE), prasugrel showed the highest likelihood of event reduction (P = .97) and was superior to ticagrelor (P = .29) and clopidogrel (P = .24). CONCLUSION: Prasugrel and ticagrelor had comparable risks for every end point, although prasugrel had the highest probability of being the best treatment for reducing the primary efficacy end point. This study highlights the need for further studies to investigate optimal P2Y12 inhibitor selection in patients with NSTE-ACS.

Vascular access for transcatheter aortic valve replacement: A network meta-analysis.

BACKGROUND: The choice of an alternative access for transcatheter aortic valve replacement (TAVR) remains controversial when transfemoral (TF) access is not feasible. METHODS: We conducted a network meta-analysis to compare the outcomes of TAVR via various peripheral vascular accesses. MEDLINE and EMBASE were searched through July 2022 to identify studies that investigated outcomes in patients who underwent TAVR via TF, trans-subclavian (Tsc), transcarotid (TC), or transcaval (Tcav) access. A network meta-analysis was conducted via random-effects model. Outcomes of interest were major or life-threatening bleeding, stroke, major vascular complication, and 30-day mortality. RESULTS: No randomized trial was identified. Our analysis included 33 observational studies that enrolled a total of 43,455 patients who underwent TAVR via TF (n = 36,202), Tsc (n = 3869), TC (n = 3066), or Tcav (n = 318) access. The risk of major or life-threatening bleeding was higher via Tsc compared with TF [odds ratio (OR); 95 % confidence interval (CI) =1.51 (1.03-2.23), p = 0.034]. The risk of stroke was higher via Tsc compared with TF and Tcav [OR (95 % CI) =2.00 (1.14-3.52), p = 0.018, OR (95 % CI) =2.43 (1.03-5.74), p = 0.044, respectively]. The risk of major vascular complications was lower via TC compared with Tsc, and Tcav and higher with Tcav compared with TF and Tsc. 30-day mortality was higher via Tsc compared with TF. Tsc was associated with higher risk of major or life-threatening bleeding compared with TF, and higher risk of stroke compared to TF and Tcav. Tcav had the highest risk of major vascular complications. CONCLUSION: In patients who underwent TF, Tsc, TC, or Tcav TAVR, Tsc had a higher rate of stroke compared to TF and Tcav, and major or life-threatening bleeding compared to TF. The rate of major vascular complications in Tcav was the highest among the four approaches.

Long-Term Surveillance of Coronary Artery Dissection in an Orthotopic Heart Transplant Recipient.

We describe a case of an orthotopic heart transplant recipient who presented with chest pain related to blunt chest trauma 3 weeks post-transplantation. Electrocardiogram showed anterior ST-segment elevation. Coronary angiography revealed a dissection of the mid-distal left anterior descending artery with preserved antegrade flow. Conservative management of the coronary artery dissection was pursued. While the patient had a favorable long-term clinical outcome, the coronary dissection persisted on 1- and 2-year follow-up coronary angiography.

Transcatheter interventions for valvular heart diseases in liver cirrhosis patients.

There is an increasing prevalence of patients who have both liver cirrhosis (LC) and severe valvular heart disease. This combination typically poses prohibitive risk for liver transplantation. LC related malnourishment, hypoalbuminemia and hyperdynamic circulation places patients with severe LC at higher rates for significant bleeding and/or thrombosis, as well as infectious and renal complications, after either surgical or transcatheter valvular interventions. Although there remains scarce comparative evidence, the preponderance of data suggest that percutaneous strategies are preferred over surgical ones. A multidisciplinary team is ideal for identifying those patients with LC who would benefit from transcatheter valvular heart interventions.

Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation and bioprosthetic valves: A meta-analysis.

BACKGROUND: The optimal anticoagulation strategy for patients with bioprosthetic valves and atrial fibrillation remains uncertain. We conducted a meta-analysis using updated evidence comparing direct anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with bioprosthetic valves and atrial fibrillation. METHODS: Medline and Embase were searched through March 2021 to identify randomized controlled trials (RCTs) and observational studies investigating the outcomes of DOAC therapy and VKA therapy in patients with bioprosthetic valves and atrial fibrillation. The outcomes of interest were all-cause death, major bleeding, and stroke or systemic embolism. RESULTS: Our analysis included 4 RCTs and 6 observational studies enrolling a total of 6405 patients with bioprosthetic valves and atrial fibrillation assigned to a DOAC group (n = 2142) or a VKA group (n = 4263). Pooled analysis demonstrated the similar rates of all-cause death (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.77-1.05; P = .18; I2 = 0%) in the DOAC and VKA groups. However, the rate of major bleeding was significantly lower in the DOAC group (HR, 0.66; 95% CI, 0.48-0.89; P = .006; I2 = 0%), whereas the rate of stroke or systemic embolism was similar in the 2 groups (HR, 0.72; 95% CI, 0.44-1.17; P = .18; I2 = 39%). CONCLUSIONS: DOAC might decrease the risk of major bleeding without increasing the risk of stroke or systemic embolism or all-cause death compared with VKA in patients with bioprosthetic valves and atrial fibrillation.

Spontaneous Coronary Artery Dissection (SCAD) Complicated With Post-Infarction Ventricular Septal Rupture and a Comparative Review on Mechanical Complications Related With SCAD.

Spontaneous coronary artery dissection (SCAD) is not uncommon but remains arguably an under-diagnosed etiology for acute coronary syndrome (ACS). It occurs predominantly in young-to-middle aged women who have no or few traditional atherosclerotic cardiovascular disease risk factors. Post-infarction mechanical complications are a dreaded outcome of ACS. However, very few case reports describe these mechanical complications related to SCAD. Unsuccessful revascularization is a particular concern for patients presenting with SCAD-induced ACS, which can increase the risk for certain mechanical complications. We present a case of a middle-aged woman who presented with anterior ST-segment elevation myocardial infarction and was found to have SCAD of left anterior descending coronary artery. Two attempts at revascularization were unsuccessful. Thereafter, her clinical course was complicated by the development of heart failure as a result of a reduced ejection fraction and a left ventricular pseudoaneurysm. Importantly she also suffered a ventricular septal rupture necessitating surgical intervention. Fortunately, our patient had a favorable longer-term outcome. Current literature, including five published case reports on SCAD complicated by mechanical complications are reviewed. Clinicians must remain aware of post-infarction mechanical complications in patients with high-risk and non-revascularized SCAD.

Selection of Vascular Closure Devices in Transcatheter Aortic Valve Replacement: Systematic Review and Network Meta-Analysis.

Various vascular closure devices (VCDs) are commonly used for percutaneous transcatheter aortic valve replacement (TAVR). However, superiority and safety profile among them remain unclear. We compared periprocedural complications among various VCDs in patients undergoing TAVR. PubMed and EMBASE were searched through January 2022 to identify clinical studies comparing any 2 VCDs of Prostar, Proglide and MANTA in patients who underwent TAVR. Studies using surgical cut-down or alternative access other than transfemoral approach were excluded. We analyzed the odds ratios (ORs) of vascular complications (VC), bleeding, acute kidney injury and all-cause mortality using a network meta-analysis. All outcomes were defined by Valve Academic Research Consortium 2 criteria. Two randomized controlled trials and 15 observational studies were identified, yielding a total of 11,344 patients including Prostar (n = 4499), Proglide (n = 5705), or MANTA group (n = 1140). The rates of major VC and life-threatening and major bleeding were significantly lower in Proglide compared to Prostar (OR [95 % CI] = 0.54 [0.32-0.89], 0.68 [0.52-0.90], and 0.49 [0.26-0.95], respectively). There was no significant difference in major VC and bleeding between Proglide and MANTA groups. Proglide was associated with a lower rate of acute kidney injury (0.56 [0.34-0.92]) and red blood cell transfusion (0.39 [0.16-0.98]) compared to Prostar. There was no significant difference in additional interventions and 30-day overall mortality among three groups. In this network meta-analysis of VCD in patients undergoing TAVR, MANTA and Proglide had comparable outcomes while Proglide appears superior to Prostar in terms of major VC and bleeding.

Severe Bicuspid Aortic Valve Disease in an Adult Cystic Fibrosis Patient.

Bicuspid aortic valve is the most common congenital heart disease. Bicuspid aortic valves are prone to accelerated degenerative changes and aortopathies. These changes often manifest in adulthood as severe aortic stenosis or mixed aortic valve disease. Cystic fibrosis patients are at high risk of adverse surgical outcomes. As survival in cystic fibrosis continues to increase, managing comorbidities including severe aortic stenosis requires consideration. The relatively non-invasive transcatheter aortic valve replacement has been posed as an intervention for high-risk patients with severe symptomatic aortic stenosis. However, traditional randomized trials have excluded patients with bicuspid aortic valves. Herein we present an extremely rare association of severe bicuspid aortic valve stenosis in an adult cystic fibrosis patient. Furthermore, we discuss the clinical course and a multi-disciplinary approach for the management of this rare scenario.

Characteristics, Process Metrics, and Outcomes Among Patients With ST-Elevation Myocardial Infarction in Rural vs Urban Areas in the US: A Report From the US National Cardiovascular Data Registry.

Importance: Patients with ST-segment elevation myocardial infarction (STEMI) living in rural settings often have worse clinical outcomes compared with their urban counterparts. Whether this discrepancy is due to clinical characteristics or delays in timely reperfusion with primary percutaneous coronary intervention (PPCI) or fibrinolysis is unclear. Objective: To assess process metrics and outcomes among patients with STEMI in rural and urban settings across the US. Design, Setting, and Participants: This cross-sectional multicenter study analyzed data for 70 424 adult patients with STEMI from the National Cardiovascular Data Registry Chest Pain-MI Registry in 686 participating US hospitals between January 1, 2019, and June 30, 2020. Patients without a valid zip code were excluded, and those transferred to a different hospital during the course of the study were excluded from outcome analysis. Main Outcomes and Measures: In-hospital mortality and time-to-reperfusion metrics. Results: This study included 70 424 patients with STEMI (median [IQR] age, 63 [54-73] years; 49 850 [70.8%] male and 20 574 [29.2%] female; patient self-reported race: 6753 [9.6%] Black, 60 114 [85.4%] White, and 2096 [3.0%] of another race [including American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander]; 5281 [7.5%] individuals of Hispanic or Latino ethnicity) in 686 hospitals (50 702 [72.0%] living in urban zip codes and 19 722 [28.0%] in rural zip codes). Patients from rural settings were less likely to undergo PPCI compared with patients from urban settings (14 443 [73.2%] vs 43 142 [85.1%], respectively; P < .001) and more often received fibrinolytics (2848 [19.7%] vs 937 [2.7%]; P < .001). Compared with patients from urban settings, those in rural settings undergoing PPCI had longer median (IQR) time from first medical contact to catheterization laboratory activation (30 [12-42] minutes vs 22 [15-59] minutes; P < .001) and longer median (IQR) time from first medical contact to device (99 minutes [75-131] vs 81 [66-103] minutes; P < .001), including those who arrived directly at PPCI centers (83 [66-107] minutes vs 78 [64-97] minutes; P < .001) and those who transferred to PPCI centers from another treatment center (125 [102-163] minutes vs 103 [85-135] minutes; P < .001). Among those who transferred in, median (IQR) door-in-door-out time was longer in patients from rural settings (63 [41-100] minutes vs 50 [35-80] minutes; P < .001). Out-of-hospital cardiac arrest was more common in patients from urban vs rural settings (3099 [6.1%] vs 958 [4.9%]; P < .001), and patients from urban settings were more likely to present with heart failure (4112 [8.1%] vs 1314 [6.7%]; P < .001). After multivariable adjustment, there was no significant difference in in-hospital mortality between rural and urban groups (adjusted odds ratio, 0.97; 95% CI, 0.89-1.06). Conclusions and Relevance: In this large cohort of patients with STEMI from US hospitals participating in the National Cardiovascular Data Registry Chest Pain-MI Registry, patients living in rural settings had longer times to reperfusion, were less likely to receive PPCI or meet guideline-recommended time to reperfusion, and more frequently received fibrinolytics than patients living in urban settings. However, there was no difference in adjusted in-hospital mortality between patients with STEMI from urban and rural settings.

Ratio of Mixed Venous Oxygen Saturation-to-Pulmonary Capillary Wedge Pressure: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.

BACKGROUND: Hemodynamic values from right heart catheterization aid diagnosis and clinical decision-making but may not predict outcomes. Mixed venous oxygen saturation percentage and pulmonary capillary wedge pressure relate to cardiac output and congestion, respectively. We theorized that a novel, simple ratio of these measurements could estimate cardiovascular prognosis. METHODS: We queried Veterans Affairs' databases for clinical, hemodynamic, and outcome data. Using the index right heart catheterization between 2010 and 2016, we calculated the ratio of mixed venous oxygen saturation-to-pulmonary capillary wedge pressure, termed ratio of saturation-to-wedge (RSW). The primary outcome was time to all-cause mortality; secondary outcome was 1-year urgent heart failure presentation. Patients were stratified into quartiles of RSW, Fick cardiac index (CI), thermodilution CI, and pulmonary capillary wedge pressure alone. Kaplan-Meier curves and Cox proportional hazards models related comparators with outcomes. RESULTS: Of 12 019 patients meeting inclusion criteria, 9826 had values to calculate RSW (median 4.00, interquartile range, 2.67-6.05). Kaplan-Meier curves showed early, sustained separation by RSW strata. Cox modeling estimated that increasing RSW by 50% decreases mortality hazard by 19% (estimated hazard ratio, 0.81 [95% CI, 0.79-0.83], P<0.001) and secondary outcome hazard by 28% (hazard ratio, 0.72 [95% CI, 0.70-0.74], P<0.001). Among the 3793 patients with data for all comparators, Cox models showed RSW best associated with outcomes (by both C statistics and Bayes factors). Furthermore, pulmonary capillary wedge pressure was superior to thermodilution CI and Fick CI. Multivariable adjustment attenuated without eliminating the association of RSW with outcomes. CONCLUSIONS: In a large national database, RSW was superior to conventional right heart catheterization indices at assessing risk of mortality and urgent heart failure presentation. This simple calculation with routine data may contribute to clinical decision-making in this population.

Meta-Analysis Comparing Valve Durability Among Different Transcatheter and Surgical Aortic Valve Bioprosthesis.

Durability of transcatheter heart valve (THV) is critical as the indication of transcatheter aortic valve implantation (TAVI) expands to patients with longer life-expectancy. We aimed to compare the durability of different THV systems (balloon-expandable [BE] and self-expandable [SE]) and surgical aortic valve replacement (SAVR) prosthesis. PUBMED and EMBASE were searched through February 2021 for randomized trials investigating parameters of valve durability after TAVI and/or SAVR in severe aortic stenosis. A network meta-analysis using random-effect model was performed. Synthesis was performed with 5-year follow-up data for echocardiographic outcomes and the longest available follow-up data for clinical outcomes. Ten trials with a total of 9,388 patients (BE-THV: 2,562; SE-THV: 2,863; SAVR: 3,963) were included. Follow-up ranged from 1 to 6 years. SE-THV demonstrated significantly larger effective orifice area, lower mean aortic valve gradient (AVG), and less increase in mean AVG at 5-year compared with BE-THV and SAVR. Structural valve deterioration (SVD) was less frequent in SE-THV compared with BE-THV and SAVR (HR 0.14, 95% CI 0.07 to 0.27; HR 0.34, 95% CI 0.24 to 0.47, respectively). Total moderate-severe aortic regurgitation and reintervention was more frequent in BE-THV (HR 4.21, 95% CI 2.40 to 7.39; HR 2.22, 95% CI 1.16 to 4.26, respectively), and SE-THV (HR 7.51, 95% CI 3.89 to 14.5; HR 2.86, 95% CI 1.59 to 5.13, respectively) compared with SAVR. In conclusion, TAVI with SE-THV demonstrated favorable forward-flow hemodynamics and lowest risk of SVD compared with BE-THV and SAVR at mid-term. However, both THV systems suffer an increased risk of AR and re-intervention, and long-term data from newer generation valves is warranted.

Initial Findings From the North American COVID-19 Myocardial Infarction Registry.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has impacted many aspects of ST-segment elevation myocardial infarction (STEMI) care, including timely access to primary percutaneous coronary intervention (PPCI). OBJECTIVES: The goal of the NACMI (North American COVID-19 and STEMI) registry is to describe demographic characteristics, management strategies, and outcomes of COVID-19 patients with STEMI. METHODS: A prospective, ongoing observational registry was created under the guidance of 3 cardiology societies. STEMI patients with confirmed COVID+ (group 1) or suspected (person under investigation [PUI]) (group 2) COVID-19 infection were included. A group of age- and sex-matched STEMI patients (matched to COVID+ patients in a 2:1 ratio) treated in the pre-COVID era (2015 to 2019) serves as the control group for comparison of treatment strategies and outcomes (group 3). The primary outcome was a composite of in-hospital death, stroke, recurrent myocardial infarction, or repeat unplanned revascularization. RESULTS: As of December 6, 2020, 1,185 patients were included in the NACMI registry (230 COVID+ patients, 495 PUIs, and 460 control patients). COVID+ patients were more likely to have minority ethnicity (Hispanic 23%, Black 24%) and had a higher prevalence of diabetes mellitus (46%) (all p < 0.001 relative to PUIs). COVID+ patients were more likely to present with cardiogenic shock (18%) but were less likely to receive invasive angiography (78%) (all p < 0.001 relative to control patients). Among COVID+ patients who received angiography, 71% received PPCI and 20% received medical therapy (both p < 0.001 relative to control patients). The primary outcome occurred in 36% of COVID+ patients, 13% of PUIs, and 5% of control patients (p < 0.001 relative to control patients). CONCLUSIONS: COVID+ patients with STEMI represent a high-risk group of patients with unique demographic and clinical characteristics. PPCI is feasible and remains the predominant reperfusion strategy, supporting current recommendations.

Rapid Development of Methicillin-Resistant Staphylococcus aureus (MRSA) Purulent Pericarditis in the Setting of Endocarditis.

Methicillin-resistant Staphylococcus aureus (MRSA) purulent pericarditis is a rare but potentially fatal complication of MRSA bacteremia. We describe a case of a 27-year-old patient with active intravenous drug use, who presented with fever, chills, and dyspnea and was found to have tricuspid valve endocarditis. Echocardiogram on admission showed no pericardial effusion. The patient became hypotensive, with worsening dyspnea, in the following 3 days. A computed tomography scan of the chest was repeated and showed a large pericardial effusion. The patient underwent pericardiocentesis and pericardial drain placement. Antibiotics were continued, with resolution of effusion. Early pericardiocentesis of a large purulent pericardial effusion may prevent catastrophic outcomes.

La péricardite purulente à Staphylococcus aureus résistant à la méthicilline (SARM) est une complication rare, mais potentiellement mortelle de la bactériémie à SARM. Nous décrivons le cas d'une patiente de 27 ans, consommatrice active de drogues par voie intraveineuse, qui présentait de la fièvre, des frissons et une dyspnée, et chez qui on a découvert une endocardite de la valve tricuspide. L'échocardiogramme à l'admission n'a montré aucun épanchement péricardique. La patiente est devenue hypotendue, et la dyspnée s'est aggravée, dans les trois jours suivants. Un tomodensitogramme de la poitrine a été répété, montrant un important épanchement péricardique. La patiente a subi une ponction péricardique et la pose d'un drain péricardique. Les antibiotiques ont été poursuivis, avec résolution de l'épanchement. La ponction péricardique précoce d'un important épanchement péricardique purulent peut prévenir des résultats catastrophiques.

Effect of Sex Difference on Discordance Between Instantaneous Wave-Free Ratio and Fractional Flow Reserve.

BACKGROUND: Physiology-guided percutaneous coronary intervention (PCI) has demonstrated to improve clinical outcomes. Previous trials showed the agreement between iFR and FFR is approximately 80%, however the details of discordance pattern remain to be elucidated. METHODS: We retrospectively reviewed 1024 consecutive intermediate stenotic lesions for which functional evaluation using both iFR and FFR were performed between January 2015 and June 2016. The lesions were classified into 4 groups according to iFR and FFR concordance [(iFR+/FFR+) and (iFR-/FFR-)] or discordance [(iFR+/FFR-) and (iFR-/FFR+)]. RESULTS: Our study evaluated 451 lesions, 264 lesions (58.5%) from men and 187 lesions (41.5%) from women. iFR was similar between women and men, however FFR was significantly higher in women than men. The rate of discordance between iFR and FFR was 21.3% (iFR+/FFR- 12.4% and iFR-/FFR+ 8.9%) in overall cohort. The prevalence of overall concordance and discordance were similar between men and women, however iFR+/FFR- discordance was significantly higher in women (17.1% vs. 9.1%) whereas iFR-/FFR+ discordance was significantly higher in men (11.3% vs. 4.8%). In multivariable analysis, female sex and older age were significantly associated with iFR+/FFR- discordance (odds ratio 1.88 and 1.48, respectively). Conversely, younger age, higher stenosis, and concomitant chronic total occlusion were independent predictors for iFR-/FFR+ discordance (odds ratio 0.67, 1.82, and 4.32, respectively). CONCLUSIONS: Despite similar prevalence of overall concordance and discordance between men and women, iFR+/FFR- discordance was higher in women and iFR-/FFR+ discordance was higher in men. Multivariable analysis showed female sex to be independent predictor of iFR+/FFR- discordance.

Hemodynamic response to transseptal transcatheter mitral valve replacement in patients with severe mitral stenosis due to severe mitral annular calcification.

OBJECTIVES: We aimed to investigate the invasive hemodynamic changes with transcatheter mitral valve replacement (TMVR) in patients with severe mitral stenosis due to severe mitral annular calcification. BACKGROUND: The hemodynamic response to TMVR in patients with mitral stenosis related to degenerative mitral annular calcification has not been fully elucidated. METHODS: We conducted retrospective review of patients who underwent successful transseptal TMVR with balloon-expandable valves for symptomatic severe mitral stenosis due to mitral annular calcification at our institution between January 2014 and February 2020. Invasive hemodynamic measurements were obtained both before valve implantation (predeployment) and after (postdeployment). RESULTS: Eighteen patients (age 72 ± 10 years, 44% female) were included for the analysis. There was a significant reduction in mean left atrial pressure (23.7 ± 5.6 mmHg versus 20.6 ± 4.8 mmHg; p = .01), left atrial v-wave (mean 39.3 ± 10.2 mmHg versus 32.9 ± 9.9 mmHg; p = .01), and an increase in systemic mean blood pressure (72.6 mmHg ±11.2 versus 79.5 ± 9.9 mmHg; p = .02) postdeployment compared to predeployment. Patients who had symptom improvement at 30-day follow-up tended to have greater reduction in mean left atrial pressure (4.4 ± 4.4 mmHg versus 0.5 ± 5.2 mmHg; p = .16) and v-wave (8.6 ± 9.0 mmHg versus 0.7 ± 8.4 mmHg; p = .10) compared to those who did not experience improvement of symptoms. CONCLUSIONS: Transseptal TMVR for severe mitral stenosis due to mitral annular calcification is associated with reductions in mean left atrial pressure and left atrial v-wave, and an increase in systemic arterial pressure.

Edge-to-edge tricuspid valve repair for severe tricuspid regurgitation 20 years after cardiac transplantation.

Tricuspid valve regurgitation in orthotopic heart transplant recipients is common. Surgical corrections have been the mainstay of the treatment for diuretic-refractory heart failure due to severe tricuspid regurgitation. However, post-transplant patients inherently carry higher surgical risk owing to previous sternotomy and immunocompromised state. We report a case of successful percutaneous edge-to-edge tricuspid valve repair for severe tricuspid regurgitation after cardiac transplantation. A 27-year-old man with a history of idiopathic restrictive cardiomyopathy status after orthotopic heart transplant presented with severe right-sided heart failure symptoms. A transthoracic echocardiogram showed bi-atrial enlargement and moderate-to-severe tricuspid regurgitation, and an increase to the severe range with exercise. Percutaneous edge-to-edge tricuspid valve repair was performed. The patient's symptoms improved, and follow-up echocardiogram showed mild tricuspid regurgitation. Percutaneous tricuspid valve repair can be considered as an alternative option to conventional surgery for symptomatic severe tricuspid regurgitation in orthotopic heart transplant recipients with suitable anatomy.