Comparison of Outcomes of Transcatheter Aortic Valve Implantation in Patients With Versus Without Mitral Annular Calcium.

There are limited data regarding the impact of mitral annular calcium (MAC) on the outcomes of patients who underwent transcatheter aortic valve implantation (TAVI). We performed a retrospective analysis of patients who underwent TAVI in 2018 and divided them into 2 groups based on the presence or absence of MAC, using a validated MAC computed tomography-based scoring system. Among 468 patients who underwent TAVI in 2018, 271 patients (58%) had MAC present compared with 197 patients (42%) without MAC. Compared with patients without MAC, patients in the MAC group were older (81 vs 79, p = 0.012), had a higher body mass index (29.30 vs 28.05, p = 0.031), lower left ventricular end-diastolic diameter (4.47 vs 4.80, p <0.001), higher mitral valve mean gradient (4.54 vs 3.01, p = 0.031), and a higher Society of Thoracic Surgeons risk score (5.69 vs 4.91, p = 0.127). There was no significant difference in the with versus without MAC groups in the all-cause mortality (at 1 year: 9% vs 6%, p = 0.8; at 2 years: 15% vs 13%, p = 0.47), incidence of myocardial infarction (1% vs 2%, p = 0.417), stroke (1% vs 3%, p = 0.4), and major adverse cardiac and cerebrovascular events (17% vs 19%, p = 0.53) at 1 year. Although the rate of new-onset left bundle branch block was higher in patients with MAC, there was no significant difference between the 2 groups in the rates of complete atrioventricular block (5% vs 3%, p = 0.483) or the need for pacemaker implantation (6% vs 3%, p = 0.168). The post-TAVI peak aortic valve gradient was comparable between the groups with and without MAC (22.52 vs 22.60, p = 0.931). In conclusion, TAVI is a safe alternative for patients with severe aortic stenosis and concomitant MAC, with comparable outcomes to patients without MAC.

Outcomes After Transfemoral Transcatheter Aortic Valve Implantation With a SAPIEN 3 Valve in Patients With Cirrhosis of the Liver (a Tertiary Care Center Experience).

Little is known about the utility of transcatheter aortic valve implantation (TAVI) in patients with cirrhosis of the liver, and their outcomes have not been studied extensively in literature. We performed a retrospective analysis of patients with severe symptomatic aortic stenosis (AS) who underwent transfemoral TAVI with a SAPIEN 3 valve at our institution between April 2015 and December 2018. We identified 32 consecutive patients with evidence of cirrhosis of the liver on imaging (including ultrasound and/or computed tomography) and patients with severe symptomatic AS who underwent transfemoral TAVI with a SAPIEN 3 valve. Among 1,028 patients, 32 had cirrhosis of the liver and 996 constituted the control group without cirrhosis. Mean age in the cirrhosis group was 74.5 years compared with 81.2 years in the control group. Baseline variables were comparable between the groups. Compared with the noncirrhotic group, patients with cirrhosis had a similar 1-year mortality (12% vs 12%, p = 1), a lower 30-day new pacemaker after TAVI rate (6% vs 9%, p = 0.85), a higher 30-day and 1-year readmission rate for heart failure (11% vs 1% and 12% vs 5%, p = 0.12, respectively), and a similar 1-year major adverse cardiac and cerebrovascular event rate (15% vs 14%, p = 0.98). In conclusion, patients with severe AS with concomitant liver cirrhosis who underwent TAVI demonstrated comparable outcomes to their noncirrhotic counterparts.

Outcomes of Transcatheter Aortic Valve Replacement in Mixed Aortic Valve Disease.

OBJECTIVES: The aim of this study was to compare outcomes after transcatheter aortic valve replacement (TAVR) in patients with pure aortic stenosis (AS) (i.e., no or trivial associated aortic regurgitation [AR]) with those in patients with AS and mild or more severe AR (i.e., mixed aortic valve disease [MAVD]). BACKGROUND: TAVR is indicated in treating patients with severe AS. Limited data exist regarding the outcomes of TAVR in patients with MAVD. METHODS: A total of 1,133 patients who underwent TAVR between January 2014 and December 2017 were included. The primary outcome was all-cause mortality. The comparison was adjusted to account for post-TAVR AR development in both groups. The secondary outcomes included composite endpoints of early safety and clinical efficacy as specified in the Valve Academic Research Consortium-2 criteria. Variables were compared using Mann-Whitney, chi-square, and Fisher exact tests, while Kaplan-Meier analyses were used to compare survival. RESULTS: A total of 688 patients (61%) had MAVD (median age 83 years , 43% women). Among these, 17% developed mild, 2% moderate, and <1% severe post-TAVR AR. Overall, patients with MAVD had better survival compared with patients with pure AS (p = 0.03). Among patients who developed post-TAVR AR, those in the MAVD group had better survival (p = 0.04). In contrast, in patients who did not develop post-TAVR AR, pre-TAVR AR did not improve survival (p = 0.11). CONCLUSIONS: Patients with MAVD who underwent TAVR had better survival compared with patients with pure AS. This is explained by the better survival of patients with MAVD who developed post-TAVR AR, likely due to left ventricular adaptation to AR.

Outcomes of patients with severe tricuspid regurgitation and congestive heart failure.

OBJECTIVES: A substantial number of patients with severe tricuspid regurgitation (TR) and congestive heart failure (CHF) are medically managed without undergoing corrective surgery. We sought to assess the characteristics and outcomes of CHF patients who underwent tricuspid valve surgery (TVS), compared with those who did not. METHODS: Retrospective observational study involving 2556 consecutive patients with severe TR from the Cleveland Clinic Echocardiographic Database. Cardiac transplant patients or those without CHF were excluded. Survival difference between patients who were medically managed versus those who underwent TVS was compared using Kaplan-Meier survival curves. Multivariate analysis was performed to identify variables associated with poor outcomes. RESULTS: Among a total of 534 patients with severe TR and CHF, only 55 (10.3%) patients underwent TVS. Among the non-surgical patients (n=479), 30% (n=143) had an identifiable indication for TVS. At 38 months, patients who underwent TVS had better survival than those who were medically managed (62% vs 35%; p<0.001). On multivariate analysis, advancing age (HR: 1.23; 95% CI 1.12 to 1.35 per 10-year increase in age), moderate (HR: 1.39; 95% CI 1.01 to 1.90) and severe (HR: 2; 95% CI 1.40 to 2.80) right ventricular dysfunction were associated with higher mortality. TVS was associated with lower mortality (HR: 0.44; 95% CI 0.27 to 0.71). CONCLUSION: Although corrective TVS is associated with better outcomes in patients with severe TR and CHF, a substantial number of them continue to be medically managed. However, since the reasons for patients not being referred to surgery could not be ascertained, further randomised studies are needed to validate our findings before clinicians can consider surgical referral for these patients.

Impact of Tricuspid Regurgitation in Patients With Heart Failure and Mitral Valve Disease from a Nationwide Cohort Study.

Concomitant heart failure (HF) and mitral valve disease (MVD) portend significant morbidity and mortality. Although associated Tricuspid regurgitation (TR) is a common occurrence in this scenario, it is not well known whether there are additional prognostic implications. We sought to assess whether coexistent TR is associated with higher readmission rates or increased mortality in patients with HF and MVD. We identified 1,520,871 encounters with a primary diagnosis of HF in the 2013 to 2014 Nationwide Readmission Database. We excluded patients without MVD, patients <18 years old, those with rheumatic heart disease and infective endocarditis. We also excluded patients who were discharged in December, hospital transfers, and cases where follow-up or outcomes were missing. Logistic regression was used to evaluate the association between baseline characteristics (including the presence of tricuspid valve disease), mortality as well as 30-day readmission rates. A total of 221,127 admissions with HF and MVD were identified. Median age was 79 years (IQR, 67 to 87), 55% were female, 2.7% died during hospitalization, and the 30-day readmission rate was 20.3%. Nearly 1/3 had concomitant TR (n = 78,356, 35%). The presence of TR was neither associated with elevated risk of mortality (hazard ratio 0.98, 95% confidence interval 0.93 to 1.04) nor 30-day readmission rate (odds ratio 1.01, 95% confidence interval 0.98 to 1.03). HF accounted for 33% of 30-day readmissions, while combined cardiac causes accounted for 54%. In conclusion concomitant TR in patients with HF and MVD was not associated with worse short-term outcomes in terms of inpatient hospital mortality and 30-day readmission rates.

An Interesting Case of Atherosclerotic Occlusion of the First Septal Perforator in a Physically Young and Fit Individual Causing Complete Heart Block.

Complete heart block (CHB) is an unfortunate complication of an anterior and inferior myocardial infarction (MI). We present a case of an atherosclerotic occlusion of the first septal perforator leading to CHB requiring permanent pacemaker placement in a young patient. A 33-year-old healthy white male presented to the emergency department with an episode of syncope. His vitals were stable, and his physical exam was unremarkable. His electrocardiogram (EKG) showed CHB and ST elevations in V1, V2, and V3 suggestive of septal MI. He underwent emergent left heart catheterization which revealed significant stenosis of the proximal left anterior descending (LAD) artery, proximal diagonal artery, and the first septal perforator. An intervention was done with stent placement in the LAD and insertion of a temporary pacemaker. After removal of the temporary pacemaker two days later, the patient developed asystole with alternating bundle branch block which prompted immediate reinsertion of the temporary pacemaker which was replaced later with a permanent pacemaker. The patient was stable afterward and discharged. The persistent atherosclerotic occlusion of the first septal perforator prevented adequate perfusion of the conduction system, even after revascularization of the proximal LAD. In conclusion, it is essential to acknowledge that difficulty to revascularize an occluded septal perforator raises the need for a permanent pacemaker to prevent a CHB.

Acute Aortic Dissection Presenting with a Headache: An Easily Missed Life-threatening Emergency.

Acute aortic dissection is a deadly disease that should be recognized promptly. We report an exceptional case of a 44-year-old African American female who presented with a rapidly progressing severe frontal headache. Initial computed tomography of the brain was negative. The following day, she developed uncontrolled hypertension and worsening headache. Magnetic resonance imaging of the brain was therefore done and showed evidence of acute/subacute ischemic infarcts. The patient was managed as having an ischemic stroke. For that reason, an echocardiogram was done the next day that showed a dilated aortic root and moderate-to-severe aortic regurgitation. This was followed by a computed tomography angiography which showed ascending aortic dissection involving bilateral common carotid arteries. After an urgent surgical intervention, the patient recovered without any sequelae. Patients with an acute dissection can present with atypical clinical features, such as an isolated rapidly progressive headache, which might delay the diagnosis and jeopardize their lives. Hence, high-risk patients with rapidly progressive unexplained severe headaches should be considered for imaging of the aorta.

Risk of coronary artery disease in celiac disease population.

BACKGROUND/AIMS: Celiac disease (CD), a chronic autoimmune condition, is associated with systemic inflammation capable of causing extra intestinal manifestations. Chronic inflammatory process has been implicated in the pathogenesis of accelerated atherosclerosis. Studies examining the burden of coronary artery disease (CAD) in patients with CD are lacking. We evaluated the prevalence of CAD in patients with CD. PATIENTS AND METHODS: Electronic health records from different health care systems were obtained utilizing a Health Insurance Portability and Accountability Act-compliant, patient de-identified web application. Among the 48,642,290 patients, 59,010 were diagnosed with CD. The remaining 48,583,280 patients without CD served as comparison controls. RESULTS: The prevalence of CAD was significantly higher in patients with CD than in the controls [5140 (8.7%) vs. 2119060 (4.4%), P < 0.001], with the odds ratio (OR) being 2.09 (95% confidence interval [CI]: 2.03-2.15, P < 0.0001). There was a similarly higher prevalence among younger patients (age, <65 years) with CD compared with those without CD (3.72% vs 1.98% [OR: 1.85, 95% CI: 1.7488-1.9417, P < 0.0001). CONCLUSIONS: The prevalence of CAD increased nearly two-fold in patients with CD.

A systematic review on the safety of second-generation transcatheter aortic valves.

AIMS: To review the outcomes of studies and the safety of newer transcatheter aortic valves (THV). METHODS AND RESULTS: All studies reporting on second-generation THV were identified and pooled using the systematic review guidelines. Twenty-four reports on 1,708 patients and eight THV were included in the analysis. The pooled 30-day event rate for mortality after transcatheter aortic valve implantation (TAVI) was 5.7% (95% CI: 4.0-7.8), myocardial infarction (MI) was 1.7% (95% CI: 1.1-2.6), stage 3 acute kidney injury (AKI) was 3.4% (95% CI: 2.0-5.6), life-threatening bleeding was 5.1% (95% CI: 3.3-7.8), major vascular complications was 4.9% (95% CI: 3.5-6.6%), major bleeding was 10.5% (95% CI: 5.1-20.4), major stroke was 2.4% (95% CI: 1.7-3.4), permanent pacemaker utilisation was 13.5% (95% CI: 10.8-16.9), and coronary obstruction was 1.2% (95% CI: 0.6%-2.4%). Moderate or severe aortic insufficiency (AI) after TAVI was 4.2% (95% CI: 2.0-8.5). The pooled 30-day mean gradient and effective orifice area (EOA) were 11.63 mmHg (95% CI: 10.19-13.07) and 1.60 cm2 (95% CI: 1.5-1.7), respectively. All estimates compare favourably to events reported for first-generation valves. CONCLUSIONS: Our findings suggest that the new THV have a low risk of TAVI-related short-term complications.

Inflammatory bowel "Cardiac" disease: Point prevalence of atrial fibrillation in inflammatory bowel disease population.

BACKGROUND/AIM: Proinflammatory markers such as interleukin (IL)-6 have been closely associated with atrial fibrillation (AF). These markers are characteristically elevated in chronic inflammatory bowel disease (IBD) and positively correlate with disease activity. Although IBD and AF have similar pathogenesis, there have been very limited studies looking at their association. The aim of this study is to determine the prevalence of AF in patients with IBD. PATIENTS AND METHODS: Medical records of patients with biopsy proven IBD (n = 203, both in and outpatient) were retrospectively reviewed. One hundred and forty-one IBD patients with documentary evidence of electrocardiograms (ECG's) were included. The "Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA)" study, a large cross-sectional study (n = 1.89 million) done to evaluate the prevalence of AF among the US population, was our control population. All ECGs available till December 2010 for each IBD patient were reviewed carefully for evidence of AF. We studied the prevalence of AF among IBD population and compared it to that of control (ATRIA) population. RESULTS: The prevalence of AF was significantly higher among IBD patients compared with the ATRIA study patients (11.3% vs 0.9%, P < 0.0001). Additionally, the IBD patient population were much younger compared with the controls (64.4 ± 10.7 vs 71.2 ± 12.2, P = 0.02). CONCLUSION: AF has an overall higher prevalence across all age groups in IBD compared with the subjects of ATRIA study, which could be due to the chronic inflammatory state of IBD. Further studies are needed to study the association in detail.