2020 Focused Update of the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation: A Report of the American College of Cardiology Solution Set Oversight Committee.

Mitral regurgitation (MR) is a complex valve lesion that can pose significant management challenges. This expert consensus decision pathway emphasizes that recognition of MR should prompt an assessment of its etiology, mechanism, and severity, as well as consideration of the indications for treatment. The document is a focused update of the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation, with some sections updated and others added in light of the publication of new trial data related to secondary MR, among other developments. A structured approach to evaluation based on clinical findings, accurate echocardiographic imaging, and, when necessary, adjunctive testing can help clarify decision making. Treatment goals include timely intervention by an experienced multidisciplinary heart team to prevent left ventricular dysfunction, heart failure, reduced quality of life, and premature death.

When to close iatrogenic atrial septal defect after percutaneous edge to edge repair of mitral valve regurgitation.

Transseptal puncture is increasingly utilized in electrophysiology and interventional cardiology. With a wide range of therapeutic indications, incidence of iatrogenic atrial septal defect (iASD) is likely to increase. However, the clinical and hemodynamic significance of iatrogenic atrial septal defect is not clear. We report a case of an 88year old woman with prior transcatheter aortic valve implantation and symptomatic severe degenerative mitral regurgitation. She developed persistent hypoxemia following MitraClip(®) procedure, requiring closure of iASD resulting in immediate recovery of hemodynamics. In here, we discuss the hemodynamic changes following percutaneous mitral valve repair and review the evidence supporting the closure of iatrogenic atrial septal defects.

Comparison of percutaneous device closure versus surgical closure of peri-membranous ventricular septal defects: A systematic review and meta-analysis.

BACKGROUND: While percutaneous device closure (PDC) is a first-line therapy for isolated muscular ventricular septal defects (mVSD), surgery is still the preferred approach for peri-membranous ventricular septal defects (pmVSD). OBJECTIVE: We sought to compare the outcomes of percutaneous versus open surgical closure of pmVSDs. METHODS: PubMed, Cochrane Library, and Web of Science databases were searched through October 15, 2014 for English language studies comparing outcomes of PDC with surgical closure of pmVSDs. Study quality, publication bias, and heterogeneity were assessed. A meta-analysis of selected studies was performed using a random effects model. Comparison was done for early (<1 month) safety and efficacy outcomes. RESULTS: Seven studies with a total of 3,134 patients (PDC = 1,312, surgery = 1,822) were identified. Patients in the PDC group were older than those treated surgically (mean age 12.2 vs. 5.5 years, respectively). In six out of seven studies, the mean VSD size was found to be comparable between the treatment arms (PDC 4.9 mm vs. surgery 6.0 mm). Males represented 52% of patients in either group. Follow-up ranged from 5 to 42 months. No significant differences were observed between PDC vs. surgery in terms of procedural success rate [relative risk (RR): 1.00, confidence interval (CI): 0.99-1.00; P = 0.67]. Combined safety end points for major complications (early death/reoperation/permanent pacemaker) were similar in both groups (RR: 0.55, CI: 0.23-1.35; P = 0.19) as were as other outcomes like post-procedure significant residual shunt (RR: 0.69, CI: 0.29-1.68; P = 0.41), significant valvular (aortic/tricuspid) regurgitation (RR: 0.70, CI: 0.26-1.86; P = 0.47), and advanced heart block (RR: 0.99, CI: 0.46-2.14; P = 0.98). The need for blood transfusion (RR: 0.02, CI: 0.00-0.05; P < 0.001) and duration of hospital stay [standard mean difference (SMD) -2.17 days, CI: -3.12 to -1.23; P < 0.001] were significantly reduced in the PDC group. CONCLUSION: Percutaneous closure of pmVSD when performed in a selected subgroup of patients is associated with similar procedural success rate without increased risk of significant valvular regurgitation or heart block when compared with surgical closure.

Left Atrial Volume and Post-Operative Atrial Fibrillation after Aortic Valve Replacement.

Post-operative atrial fibrillation (POAF) after valve surgery is associated with increased morbidity and mortality. Risk factors identified in the past to predict POAF are of moderate accuracy. We performed a retrospective analysis of 139 patients undergoing aortic valve replacement for aortic stenosis. Post-operative AF occurred in 44% of the patients. In multivariate analysis only left atrial volume (LAV) index was a predictor of POAF. A LAV index of >46 cc/m2 predicted POAF with a sensitivity and specificity of 92% and 77%. We propose that LAV index can be used preoperatively to identify patients at risk for POAF to target preventive interventions. Background: Post-operative atrial fibrillation (POAF) is common after valve surgery and is associated with increased morbidity and mortality. Many of the previously identified predictors of POAF are of moderate accuracy. Left atrial volume (LAV) index has been proposed in the past as a predictor of POAF in patients undergoing cardiac surgery. In patients with aortic stenosis (AS), increased LAV is a marker of severity of stenosis. Hypothesis: Left atrial volume index is a very good predictor of POAF in patients undergoing aortic valve replacement (AVR) for AS. Methods: We performed a retrospective analysis of 139 consecutive patients with no previous atrial fibrillation (AF) undergoing AVR for AS in our center. Results: Post-operative AF occurred in 44% of patients. Patients with POAF had a longer hospital stay compared to patients without (12 vs 8 days; p < 0.001). In univariate analysis, age (p = 0.046), aortic valve area (p = 0.005) and LAV index (p < 0.001) were significant predictors of POAF. In multivariate analysis only LAV index (R2= 0.58; p < 0.001) predicted POAF. A LAV index > 46ml/m2 predicted POAF with a sensitivity and specificity of 92% and 77% respectively. Moreover, there was a significant increase in the incidence of POAF with increasing quartiles of LAV index, supporting causality. Conclusion: Left atrial volume index is an excellent predictor of POAF in patients undergoing AVR for AS. It can be used for selecting patients who are at a high risk for developing POAF to target preventive interventions.

Peripartum cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is a rare, idiopathic, life-threatening disease of late pregnancy and early puerperium, occurring in patients with previously healthy hearts. Risk factors include multiparity, age>30 years, African American race, multiple pregnancies, obesity, hypertension, and toxemia. Signs and symptoms of PPCM resemble systolic heart failure, and it is diagnosed by exclusion. An echocardiogram typically reveals an ejection fraction of <45% and/or fractional shortening of <30%, along with a left ventricular end-diastolic dimension>2.7 cm/m2 of body surface area. Early diagnosis and treatment are important for a successful outcome. Management is similar to other forms of systolic heart failure. Patients with PPCM are at high risk of thromboembolism, and therefore anticoagulation therapy should be considered. The prognosis is variable, ranging from complete recovery, to worsening heart failure requiring cardiac transplantation, or death. Future pregnancies are often discouraged because of the high mortality rate and risk of recurrence.

Ventricular metastasis without atrial or caval involvement: a rare presentation.

Right ventricular metastases from renal cell carcinoma without inferior vena cava (IVC) or right atrium involvement are rare. We discuss a 44-year-old male who presented with a left thigh mass, which was resected and the pathology revealed an epithelial sarcoma or a possible metastasis from another organ. His preradiotherapy cardiac evaluation showed mass in the right and left ventricles, which was confirmed by transesophagial echocardiogram. Computed tomography revealed a right renal mass in addition to the ventricular masses without any involvement of IVC or the atria. The patient underwent right radical nephrectomy without complications and systemic chemotherapy with interleukin-1 for metastatic renal cell carcinoma. He is doing well and follow-up echocardiogram showed significant reduction in the size of the cardiac metastases, even without surgical resection of these tumors. Thus, our article presents this unique case of asymptomatic ventricular metastases of renal cell carcinoma without any atrial or caval involvement and provides a new insight into the management of this syndrome.

Delayed defibrillator lead perforation: an increasing phenomenon.

Delayed intracardiac lead perforation has been defined as migration and perforation after one month of implantation. It is a rare complication; pathophysiology and optimal management are currently unclear. Recognition of these cases becomes important with increasing use of these devices. We describe such a case of delayed lead perforation.

Fibrosing mediastinitis presenting as pulmonary stenosis: stenting works.

A rare case of fibrosing mediastinitis from histoplasmosis with extrinsic compression of the right pulmonary artery is reported. A 41-year-old patient presented with worsening symptoms of cough, fever, migratory arthralgia, chest pain, and progressive dyspnea. The pulmonary artery involvement was suspected by transthoracic echo and was confirmed by transesophageal echo, CT scan of chest, and right heart catheterization. Diagnosis of histoplasmosis was confirmed by biopsy and serological tests. Patient has been free from symptoms of pulmonary stenosis for 4 years after successful pulmonary artery stenting.

Diagnosis and management of diastolic dysfunction and heart failure.

Diastolic heart failure occurs when signs and symptoms of heart failure are present but left ventricular systolic function is preserved (i.e., ejection fraction greater than 45 percent). The incidence of diastolic heart failure increases with age; therefore, 50 percent of older patients with heart failure may have isolated diastolic dysfunction. With early diagnosis and proper management the prognosis of diastolic dysfunction is more favorable than that of systolic dysfunction. Distinguishing diastolic from systolic heart failure is essential because the optimal therapy for one may aggravate the other. Although diastolic heart failure is clinically and radiographically indistinguishable from systolic heart failure, normal ejection fraction and abnormal diastolic function in the presence of symptoms and signs of heart failure confirm diastolic heart failure. The pharmacologic therapies of choice for diastolic heart failure are angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics, and beta blockers.

The effect of soy protein isolate on bone metabolism.

OBJECTIVE: This double-blind, 15-month pilot study was designed to investigate the effect of soy protein isolate with varying concentrations of isoflavones on early postmenopausal bone loss and lipids. DESIGN: A total of 65 women, with a mean age of 55 years and 7.5 years since menopause, were randomized to one of three groups; soy protein with 96 mg isoflavones/day, soy with 52 mg isoflavones/day, or soy without isoflavones (< 4 mg isoflavones/day). Soy was given for 9 months and then discontinued; participants were followed for an additional 6 months. Bone mineral density (BMD) and blood lipids were measured during this time. RESULTS: Measurement of serum isoflavones at 3 months showed dose-related increases in the three groups. There was no significant effect of the soy supplements on BMD of the spine or femoral neck in any of the three groups. BMD increased significantly in the trochanter at 9 months (P = 0.0219) and at 15 months (P < 0.05) in the group given isoflavone-free soy compared with the other two groups. There was no significant effect of soy on lipid metabolism at the end of the intervention. CONCLUSION: The present study did not find a significant positive effect of soy protein isolate supplemented with isoflavones on BMD and the serum lipid profile in early postmenopausal women.