Advanced heart failure therapies in the Eastern Mediterranean Region: current status, challenges, and future directions.

While there has been a global decrease in rates of heart failure (HF) prevalence between 1990 and 2019, the Eastern Mediterranean region (EMR) is experiencing an increase. In 2019, approximately 1,229,766 individuals lived with moderate to severe HF in the EMR. Despite the growth in the utilization of advanced heart failure (AHF) therapies in the EMR in the past two decades, current volumes are yet to meet the growing AHF burden in the region. Heart transplantation (HT) volumes in EMR have grown from 9 in the year 2000 to 179 HTs in 2019. However, only a few centers provide the full spectrum of AHF therapies, including durable mechanical circulatory support (MCS) and HT. Published data on the utilization of left ventricular assist devices (LVAD) in the EMR are scarce. Notably, patients undergoing LVAD implantation in the EMR are on average, 13 year younger, and more likely to present with critical cardiogenic shock, as compared to their counterparts in the Western world. Furthermore, AHF care in the region is hampered by the paucity of multidisciplinary HF programs, inherent costs of AHF therapies, limited access to short and long-term MCS, organ shortage, and lack of public awareness and acceptance of AHF therapeutics. All stakeholders in the EMR should work together to strategize tackling the challenging AHF burden in the region.

Original Article--Mid-term Clinical and Hemodynamic Outcomes in Middle Age Patients Post Trifecta™ (Abbott) Aortic Valve Replacement: A Single-center Study.

Background: Trifecta™ is an externally wrapped bovine pericardial aortic valve with a favorable hemodynamic performance and acceptable rate of freedom from structural valve degeneration. However, recent reports of early Trifecta valve failure question its durability. Rheumatic valve disease in young population is predominant, there is no data on the Trifecta performance, durability or safety available worldwide over the middle age population, as well as there are no previous similar reports from Middle East region. We report on mid-term clinical and hemodynamic performance of Trifecta valve in middle age population with small aortic annuls, a single center report. Methods: A retrospective study of all patients who underwent Trifecta™ SAVR between June 2014 and December 2019 at a cardiac center in Riyadh, Saudi Arabia. Hemodynamic performance was analyzed by longitudinal Doppler echocardiography. Results: During a 5.5-year period, a total of 24 patients underwent SAVR with Trifecta™ valves at our heart center. Patients had a median age of 47.1 years (IQR = 37) and male:female ratio of 1:1. Patients had a median EuroScoreII of 2 (IQR = 1). The 19 mm valve was the most frequently used (29.2%) followed by the 21 mm and 23 mm (both 25.0%). Concomitant procedure was (54.2%). All patients survived their operations and most (87.0%) had their symptoms relieved. A 30-day mortality rate of 4.2%. Patients were followed up for a median of 58.5 months (IQR = 38), during which 8.3% required re interventions, giving an overall freedom from re-intervention of 91.7%. The re-intervention after valve implantation was recorded in two (8.3%). These re-interventions were performed 3 years post initial surgery and were due to structural valve deterioration (SVD). The mean gradient reduced significantly from 43.6 ± 23.9 mmHg (median = 41, IQR = 21) at baseline to 13.0 ± 7.4 mmHg (median = 11, IQR = 5) one-week post intervention (p < 0.001). The average mean gradients were stable from post-operation to follow-up (13.0 ± 7.4 vs 14.1 ± 6.4 mmHg). Conclusion: Our study confirms excellent mid-term durability, clinical and hemodynamic performance of the Trifecta™ valve in middle age population, despite the fact of non-statically significant trend-up of transvalvular gradient over the follow up period. Further long-term studies with larger sample-size are warranted to confirm these results.

Role of three-dimensional transesophageal echocardiography in cardiac myxomas: an imaging challenge.

Nowadays, the diagnosis of cardiac myxomas (CM), particularly the histological types, remains a challenge. Two-dimensional (2D) transthoracic (TT) and transesophageal (TEE)  echocardiography (ECHO) represent the first steps in the imaging pathway. 3D ECHO,  implemented in imaging practice, appears to be an emerging diagnostic technique that overcomes some of the limitations of 2D ECHO while integrating the information provided by magnetic resonance (MRI). However, its role in the imaging arena is still debatable. Analyzing 17 myxomas in 13 patients, the study uncovers a diverse anatomical spectrum. Classical CM morphology is a minority, with most myxomas being sessile and originating from unexpected locations (right ventricular outflow tract and left atrial appendage). Texture and size variations are also noted. Comparing imaging, 2D TEE outperforms 2D TT in visualizing anatomical features, especially attachment types. 3D TEE confirms 2D TT findings and offers more detailed assessments, identifying peduncles missed in four cases by 2D TEE. Two small recurrent myxomas were exclusively detected by 3D TEE, not by 2D TEE or MRI. Two patients have papillary myxomas, one has an embolism. Another patient with a solid myxoma also suffers an embolism, with a clot found at the apex during surgery. Our study showed that CM has a wide anatomical spectrum beyond the typical features, making the diagnosis challenging. Therefore, a multimodality imaging approach is essential for distinguishing CM from other cardiac masses and differentiating myxoma histological types. These findings stress the importance of incorporating 3D ECHO alongside other imaging techniques for a comprehensive evaluation.

A multicenter evaluation of external outflow graft obstruction with a fully magnetically levitated left ventricular assist device.

BACKGROUND: The HeartMate 3 (HM 3; Abbott) left ventricular assist device (LVAD) has improved hemocompatibility-related adverse outcomes. In sporadic cases, external compression of the outflow graft causing obstruction (eOGO) can result from substance accumulation between the outflow graft and its bend relief. We sought to evaluate the prevalence, course, and clinical implications of eOGO in an international study. METHODS: A multicenter retrospective analysis of HM 3 LVADs implanted between November 2014 and April 2021 (n = 2108) was conducted across 17 cardiac centers in 8 countries. We defined eOGO as obstruction >25% in the cross-sectional area in imaging (percutaneous angiography, computed tomography, or intravascular ultrasound). The prevalence and annual incidence were calculated. Serious adverse events and outcomes (death, transplantation, or device exchange) were analyzed for eOGO cases. RESULTS: Of 2108 patients, 62 were diagnosed with eOGO at a median LVAD support duration of 953 (interquartile range, 600-1267) days. The prevalence of eOGO was 3.0% and the incidence at 1, 2, 3, 4, and 5 years of support was 0.6%, 2.8%, 4.0%, 5.2%, and 9.1%, respectively. Of 62 patients, 9 were observed, 27 underwent surgical revision, 15 underwent percutaneous stent implantation, 8 received a heart transplant, and 2 died before intervention. One patient underwent surgical revision and later stent implantation. The mortality with therapeutic intervention was 9/53 (17.0%). CONCLUSIONS: Although uncommon, HM 3 LVAD-supported patients might develop eOGO with an increasing incidence after 1 year of support. Although engineering efforts to reduce this complication are under way, clinicians must maintain a focus on early detection and remain vigilant.

Right-sided infective endocarditis and pulmonary embolism: a multicenter study.

The incidence of right-sided infective endocarditis (RSIE) is steadily increasing and it has been reported to be associated with high risk of embolic events (EE). Aim of our study was to identify the clinical characteristics of patients with RSIE complicated by PE. Indeed, the identification of patients at high risk of significant PE who will benefit from a more aggressive therapeutic strategy may improve the prognosis. From January 2015 to September 2020, 176 patients (Pts) in 6 centers were found to have definite RSIE complicated by PE. Advanced imaging for PE including computed tomography pulmonary angiography (CTPA) was performed in 28 pts (16%) who represent our study group (24 male, mean age 50.6 ±18.29 years). They all underwent transesophageal echocardiography (TEE), in 12 cases (43%) also three-dimensional (3D) TEE, and 27 patients (99%) had both TEE and transthoracic echocardiography (TTE). A total of 53 vegetations (V) were detected. In 18 pts (64%) two or more vegetations were found. Native tricuspid valve was the most frequently involved valve (38 V, 71.7%), followed by catheter (5 V, 9.4%), tricuspid valve prosthesis (4 V, 7.5%), chordae and papillary muscle (2 V, 3.8%) and one vegetation (9%) in each of the following: pulmonic valve, inferior vena cava, eustachian valve, and right atrium. The most common location for vegetations was the anterior leaflet of the tricuspid valve (19 V, 35.8 %) followed by the posterior leaflet (11 V, 20.8%). The most common vegetations morphology was raceme-like shaped (35.8%). Staphylococcus aureus (S. aureus) was the most common causative pathogen (14 pts, 50%). The incidence of PE was very high in patients with vegetation length above 1.5 cm (median 17.6±6.5 mm by TEE). Our results suggest that a routine CTPA should be advised in the presence of vegetations larger than 1.5 cm and with S. aureus infection. This behavior would identify patients at high risk of PE who will benefit from a more aggressive therapeutic strategy, leading to an improvement in the prognosis. Further prospective studies are required to better confirm our hypothesis.

Percutaneous Coronary Intervention Vs Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Disease: G-LM Registry.

Coronary artery bypass surgery (CABG) has been the standard of care for revascularization for patients with obstructive unprotected left main coronary disease (ULMCA). There have been multiple randomized and registry data demonstrating the technical and clinical efficacy of PCI in certain patients with ULMCA. The purpose of this study is to evaluate clinical outcomes of ULMCA PCI as compared to CABG in patients requiring revascularization in three Gulf countries. All ULMCA cases treated by PCI with DES versus CABG were retrospectively identified from 14 centers in 3 Arab Gulf countries (KSA, UAE, and Bahrain) from January 2015 to December 2019. In total, 2138 patients were included: 1222 were treated with PCI versus 916 with CABG. Patients undergoing PCI were older, and had higher comorbidities and mean European System for Cardiac Operative Risk Evaluation (EuroSCORE). Aborted cardiac arrest and cardiogenic shock were reported more in the PCI group at hospital presentation. In addition, lower ejection fractions were reported in the PCI group. In hospital mortality and major adverse cardiovascular and cerebrovascular events (MACCE) occurred more in patients undergoing CABG than PCI. At median follow-up of 15 months (interquartile range, 30), no difference was observed in freedom from revascularization, MACCE, or total mortality between those treated with PCI and CABG. While findings are similar to Western data registries, continued follow-up will be needed to ascertain whether this pattern continues into latter years.

Pericardial Patch Exclusion Technique for Left Atrial Appendage Closure.

We describe a technique of left atrial appendage occlusion that consists of autologous pericardial patch closure of the left atrial appendage orifice from within the left atrium. This pericardial patch exclusion technique has little added risk of bleeding, can be performed through sternotomy or right minithoracotomy, and can be used in re-operative situations.

Hybrid Coronary Revascularization Versus On-Pump Coronary Artery Bypass Grafting.

BACKGROUND: Hybrid coronary revascularization (HCR) is an evolving coronary revascularization strategy for the treatment of multivessel coronary artery disease. We provide a comparative analysis to conventional on-pump coronary artery bypass graft surgery (CABG) with long-term follow-up. METHODS: We included all double on-pump CABG (n = 682) and HCR (147 robotic-assisted minimally invasive bypass grafts of the left internal thoracic artery to the left anterior descending coronary artery and percutaneous coronary intervention to one of the non-left anterior descending coronary artery vessels) performed in our institution between March 2004 and November 2015. We performed an adjusted analysis using inverse-probability weighting based on the propensity score of receiving either on-pump CABG or HCR. RESULTS: In the adjusted analysis, there was no statistically significant difference in the incidence of reexploration for bleeding, perioperative myocardial infarction, stroke, need for hemodialysis, blood transfusion rate, prolonged mechanical ventilation, and intensive care unit length of stay. Hybrid coronary revascularization was associated with lower inhospital mortality (CABG 1.3%, HCR 0%, p = 0.008), and shorter mean (± SD) hospital length of stay (CABG 6.7 ± 4.7 days, HCR 4.5 ± 2.1 days, p < 0.001). After a median follow-up period of 70 months (range, 37 to 106) for the CABG group and 96 months (range, 53 to 114) for the HCR group, there was no significant difference in survival (CABG 92%, HCR 97%, p = 0.13) or freedom from any form of revascularization (CABG 93%, HCR 91%, p = 0.27). Hybrid coronary revascularization was superior in freedom from angina (CABG 70%, HCR 91%, p < 0.001). CONCLUSIONS: For selected patients, HCR is associated with a faster postoperative recovery as well as similar short-term and long-term outcomes when compared with standard on-pump CABG.

Is the Future of Coronary Arterial Revascularization a Hybrid Approach?: The Canadian Experience Across Three Centers.

OBJECTIVE: Hybrid coronary revascularization offers and combines the advantages of both surgical and percutaneous revascularization and eliminates at the same time the disadvantages of both procedures. The objective of this study was to assess graft and stent patency at 6 months, rate of bleeding, intensive care unit and hospital stay, rate of reintervention, and long-term clinical follow-up. METHODS: From March 2004 to November 2015, a total of 203 patients underwent robotic-assisted minimally invasive direct coronary artery bypass graft of the left internal thoracic artery to the left anterior descending artery and PCI of a non-left anterior descending vessel in a single or two stage, at three different centers. Patients underwent 6-month angiographic follow-up. The mean ± SD clinical follow-up was 77.82 ± 41.4 months. RESULTS: Successful hybrid coronary revascularization occurred in 196 of the 203 patients. One hundred forty-six patients underwent simultaneous surgical and percutaneous intervention. Nineteen patients underwent PCI before surgery, and 38 patient underwent PCI after surgery. No in-hospital mortality occurred. The mean ± SD ICU stay was 1 ± 1 days and the mean ± SD hospital stay was 5 ± 2 days. Only 13.3% of the patients required a blood transfusion. Six-month angiographic follow-up has been performed in the 95 patients, and it demonstrated a left internal thoracic artery anastomotic patency of 97.9% and stent patency of 92.6%. A total of 77.8 ± 41.4-month clinical follow-up demonstrated 95.1% survival, 92.6% freedom from angina, and 90.7% freedom from any form of coronary revascularization. CONCLUSIONS: Hybrid coronary revascularization seems to be a promising and safe revascularization strategy. It provides selected patients with an alternative, functionally complete revascularization with minimal surgical trauma and good long-term clinical outcomes.

Consequences of Hybrid Procedure Addition to Robotic-Assisted Direct Coronary Artery Bypass.

OBJECTIVE: Patients postcoronary artery revascularization surgery often receives blood product transfusion, which could delay their intensive care unit and hospital discharge. We investigated our robotic-assisted direct coronary artery bypass (RADCAB) transfusion rate to determine whether performing the minimal invasive coronary surgery with percutaneous coronary intervention in one stage would increase the incidence of blood transfusion, morbidity, and length of stay. METHODS: Between November 2003 and November 2015, 483 consecutive patients underwent RADCAB surgery. They were divided into two groups. Group 1 (147 patients; mean ± SD age, 61.2 ± 11 years; 23% females) underwent robotic-assisted hybrid coronary artery revascularization with left internal thoracic artery to the left anterior descending coronary artery with percutaneous coronary intervention to a nonleft anterior descending coronary artery vessel in the same stage. Group 2 (336 patients; mean ± SD age, 61.2 ± 10.5 years; 25% females) underwent nonhybrid RADCAB. Early and late postoperative follow-up at mean ± SD of 83.6 ± 11.1 months was obtained. RESULTS: Blood transfusion rate in group 1 was statistically different, as illustrated in Table 2. Based on the intraoperative cardiac catheterization, the incidence of graft revision was higher in the nonhybrid group. There was no difference between the two groups in terms of renal failure, neurological complication, prolonged mechanical ventilation, and gastrointestinal bleed. CONCLUSIONS: Despite similar preoperative demographics in the two groups, we have observed a significant difference in the blood transfusion rate in group 1. However, this did not lead into a statistically significant re-exploration rate for bleeding. Hence, we assume that dual antiplatelet therapy usage in the hybrid group might be the cause of the increase in blood transfusion rate. Nevertheless, it did not affect postoperative morbidity and length of hospital stay. A randomized multicenter clinical trial is needed.

Obesity Paradox in Off-Pump Coronary Artery Bypass Surgery: Does It Benefit the Elderly?

BACKGROUND: The obesity paradox is a well-known phenomenon in cardiovascular disease; how it interferes with coronary artery revascularization remains controversial. The purpose of this study was to investigate the impact of obesity body mass index (BMI > 30; in kg/m2) on short- and long-term survival and major adverse cardiovascular event (MACE)-free survival in obese patients after off-pump coronary artery bypass operation. METHODS: We retrospectively reviewed our prospective cohort of 1,400 consecutive and systematic patients who underwent off-pump coronary artery bypass operation between September 1996 and November 2007 and identified 448 (32%) with preoperative BMI greater than 30. RESULTS: Patients with BMI greater than 30 patients were younger and had a higher prevalence of diabetes, dyslipidemia, hypertension, and percutaneous coronary interventions than patients with BMI less than 30. Thirty-day mortality and perioperative myocardial infarction were similar in both groups. No significant difference was observed for wound infections, sternal dehiscence, and reoperation for bleeding. Overall, long-term survival was comparable in the two groups, although obese patients older than 65 years had a better survival than the nonobese patients even after correction for risk factors (p = 0.04). MACE-free survival at 10 years was 65.3% ± 5.7% in obese and 76.3% ± 2.3% in nonobese patients (p = 0.007). Statistical significance was maintained (p = 0.008) after correction for risk factors. Among MACE, only new episodes of congestive heart failure were more prevalent in obese patients (p = 0.002). CONCLUSIONS: In our series of off-pump coronary artery bypass operation, obesity was not an independent cause of short- and long-term mortality and was shown beneficial for older patients. However, obese patients had a lower MACE-free survival because of an increased incidence of rehospitalization for congestive heart failure.

Thrombolytic Therapy as the Management of Mitral Transcatheter Valve-in-Valve Implantation Early Thrombosis.

A 70-year-old male underwent mitral transcatheter valve-in-valve implantation for a failed bioprosthesis implanted 11 years earlier. In the first days following the procedure, he developed thrombosis of the new bioprosthesis with restricted cusp motion. The transmitral mean gradient increased significantly despite effective anticoagulation therapy using unfractionated heparin infusion. Low dose and slow infusion of alteplase resulted in resolution of the thrombus and normalisation of cusp motion. Thereafter long-term anticoagulation using a vitamin K antagonist was instituted and the patient remained asymptomatic.

A bailout approach: Transaxillary Impella implantation in toxic cardiomyopathy.

The femoral artery has been the traditional approach for implantation of the Impella left ventricular assist device. We describe the case of a young man with toxic (cocaine-related) cardiomyopathy, severe left ventricular dysfunction, and moderate mitral insufficiency who received a transfemoral Impella left ventricular assist device that was relocated to the right axillary artery due to uncontrolled femoral access bleeding. The patient immediately stabilized post-implantation and was successfully bridged to a full recovery 6 days later.

Use of Rotaflow pump for left ventricular assist device bridging for 15 weeks.

Mechanical circulatory support systems have been described for short- and long-term left ventricular assistance. We report the use of a Rotaflow centrifugal pump in a 55-year-old man with ischemic cardiomyopathy and severe left ventricular dysfunction. He was successfully bridged to transplantation with 15 weeks of Rotaflow support, with no major adverse events.

Delayed migration of Sapien valve following a transcatheter mitral valve-in-valve implantation.

We report two cases of delayed migration of the Sapien XT device after a successful mitral valve-in-valve (VIV) implantation. The procedure was performed through a transapical approach. Echocardiography was used to choose the size of the Sapien XT device. Although the immediate results were satisfactory both the cases presented with severe regurgitation (1 week and 3 months). Investigations revealed atrial migration of the Sapien device in both the cases, which was confirmed at the time of reoperation. We discuss possible mechanisms, which could have resulted in the delayed migration and highlight the difference between VIV procedures in mitral position versus other positions.