Streptococcus alactolyticus Infective Endocarditis and Stroke in a Healthy Young Female.

Streptococcus bovis/Streptococcus equinus complex includes the subspecies Streptococcus alactolyticus. The prevalence of systemic infection in humans with S alactolyticus is scarce. We present a case of infective endocarditis complicated with hemorrhagic and ischemic stroke in a healthy 31-year-old woman.

Meta-analysis comparing valve-in-valve TAVR and redo-SAVR in patients with degenerated bioprosthetic aortic valve.

INTRODUCTION: The comparative efficacy and safety of valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) and redo-surgical AVR (redo-SAVR) in patients with degenerated bioprosthetic aortic valves remain unknown. METHOD: Digital databases were searched to identify relevant articles. Unadjusted odds ratios for dichotomous outcomes were calculated using a random effect model. A total of 11 studies comprising 8326 patients (ViV-TAVR = 4083 and redo-SAVR = 4243) were included. RESULTS: The mean age of patients undergoing ViV-TAVR was older, 76 years compared to 73 years for those undergoing SAVR. The baseline characteristics for patients in ViV-TAVR vs. redo-SAVR groups were comparable. At 30-days, the odds of all-cause mortality (OR 0.45, 95% CI 0.30-0.68, p = .0002), cardiovascular mortality (OR 0.44, 95% CI 0.26-0.73, p = .001) and major bleeding (OR 0.29, 95% CI 0.15-0.54, p = .0001) were significantly lower in patients undergoing ViV-TAVR compared to redo-SAVR. There were no significant differences in the odds of cerebrovascular accidents (OR 0.91, 95% CI 0.52-1.58, p = .74), myocardial infarction (OR 0.92, 95% CI 0.44-1.92, p = .83) and permanent pacemaker implantation (PPM) (OR 0.54, 95% CI 0.27-1.07, p = .08) between the two groups. During mid to long-term follow up (6-months to 5-years), there were no significant differences between ViV-TAVR and redo-SAVR for all-cause mortality, cardiovascular mortality and stroke. ViV-TAVR was, however, associated with higher risk of prosthesis-patient mismatch and greater transvalvular pressure gradient post-implantation. CONCLUSION: ViV-TAVR compared to redo-SAVR appears to be associated with significant improvement in short term mortality and major bleeding. For mid to long-term follow up, the outcomes were similar for both groups.

Volume-outcome relationships for transcatheter aortic valve replacement-risk-adjusted and volume stratified analysis of TAVR outcomes.

OBJECTIVES: This purpose of the study was to evaluate TAVR outcomes at low, intermediate and high volume institutions. BACKGROUND: For the care of complex patients, volume-outcome effect is well described. The initial US TAVR experience was limited to a few centers of excellence. The impact of institutional volume on outcomes after TAVR has not been systematically studied. METHODS: Within the Banner Health system, TAVR is performed at 3 institutions-a low volume, an intermediate volume and a high volume institution. 181 consecutive patients undergoing TAVR within these 3 institutions were the study cohort. To adjust for bias and confounders between the 3 groups, risk-adjusted multivariate logistic regression and propensity score analysis was performed. The primary endpoint was a composite of mortality, dialysis-dependent renal failure, cerebrovascular accident, need for new permanent pacemaker and readmission within 30days. RESULTS: The primary endpoint was reached in 38.8% of patients at the high volume institution and 76.2% of patients at the low volume institution (p<0.01). Having a TAVR procedure at a larger volume institution was an independent predictor of having improved outcomes (OR 0.33, 95% CI 0.16-0.68; p=0.003). These improved outcomes after the TAVR procedure noted at the large volume institution were seen in the most complex patients: age ≥80years, BMI >30, diabetes, hypertension, prior CAD, CKD and NYHA class III/IV heart failure. CONCLUSIONS: High-risk patients undergoing TAVR at a large volume institution have better 30-day outcomes compared to outcomes at intermediate and low volume centers.

Left atrial anatomy and patient-related factors associated with adverse outcomes with the watchman device-a real world experience.

OBJECTIVE: This study sought to identify patient and left atrial morphology specific factors associated with early complications for left atrial appendage occlusion with the Watchman™ (Boston Scientific, Natick, MA) device. BACKGROUND: Oral anticoagulation (OAC) is recommended for patients with atrial fibrillation, however, long-term OAC compliance is poor. In randomized control trials, the Watchman™ device has demonstrated superiority over OAC with warfarin for all cause and cardiovascular mortality and hemorrhagic stroke. However, predictors of procedural complications have not yet been well established. METHODS: There were 137 patients included in this study from a total of 141 consecutive patients prospectively enrolled in the registry between 8/1/2015 and 08/31/2016. Unadjusted, multivariate cox proportional hazards model was used for analysis. Primary end-point was a composite major adverse cardiac and cerebrovascular event (MACCE) defined to include death, stroke, major and life threatening bleeding, major vascular complications, device embolization, need for cardiovascular surgery, need for cardiopulmonary resuscitation, and significant pericardial effusion. RESULTS: The primary endpoint was reached in 5.8% of patients. There were no device embolization and no strokes. Anterior chicken morphology (ACW) of the left atrial appendage (LAA) conferred a hazard ratio of 3.7 for MACCE and a body mass index >30 kg/m2 significantly lowered the likelihood of a MACCE. CONCLUSION: Certain LAA morphologies and patient characteristics increase the risk for a MACCE following left atrial appendage occlusion (LAAO) with the Watchman™ device. Anterior chicken wing morphology of the LAA and low BMI <30 kg/m2 were independent predictors of MACCE in the multivariate regression model.

"Putting it all together": Highlighting the global approach to chronic total occlusion revascularization.

Preprocedural planning and advanced imaging is vital to achieve a consistent and high level of success for complex coronary chronic total occlusion (CTO) revascularization. Various practice patterns exist around the world when performing coronary artery CTO revascularization. This case report highlights a fusion of global practices in CTO intervention and integration of advanced imaging to achieve successful revascularization.

Impact of institutional volume and experience with CT interpretation on sizing of transcatheter aortic valves: A multicenter retrospective study.

BACKGROUND: Computed tomography (CT) has become the standard imaging modality for pre-procedural aortic annular sizing prior to transcatheter aortic valve replacement (TAVR). We hypothesized that the accuracy of CT derived annular measurements would be greater at sites with higher TAVR procedural volume. METHODS: Within a large integrated health system, TAVR was performed at low (<40 cases), intermediate (40-75 cases), and high-volume sites (>75 cases). 181 patients underwent TAVR with a Sapien XT transcatheter heart valve (THV). Two blinded experienced readers independently remeasured the annulus on CT and compared their measurements to site reported measurements. Hypothetical THV sizes were chosen based on measurements from site CT reports and independent readers' measurements, and compared to the implanted THV size. RESULTS: Correlation between site reported measurements and independent readers measurements of mean annulus size varied between low-volume (r=0.31, p=0.18), intermediate-volume (r=0.34, p=0.01), and high-volume sites (r=0.96, p<0.01). On multivariate analysis, interpretation of ≥20 CT scans (OR 0.29; 95% CI 0.03-0.81; p 0.02) and high-volume site (OR 0.16; 95% CI 0.10-0.82; p 0.02) were associated with reduced mismatch between the site predicted THV size and independent readers predicted THV size. Mismatch between site predicted THV size and implanted THV size was associated with a worse 30-day composite of mortality, dialysis-dependent renal failure, cerebrovascular accident, new permanent pacemaker, and hospital readmission (55.3 vs. 38.7%; p=0.05). CONCLUSIONS: Accuracy of CT aortic annular sizing is improved with higher individual experience and site TAVR volume. These findings should be confirmed in larger, prospective studies.

Nickel elution properties of contemporary interatrial shunt closure devices.

OBJECTIVES: We sought to compare nickel elution properties of contemporary interatrial shunt closure devices in vitro. INTRODUCTION: There are two United States Food and Drug Administration (FDA)-approved devices for percutaneous closure of secundum atrial septal defect: the Amplatzer septal occluder (ASO; St Jude Medical Corporation) and Gore Helex septal occluder (HSO; W.L. Gore & Associates). The new Gore septal occluder (GSO) device is in clinical trials. These are also used off-label for patent foramen ovale closure in highly selected patients. These devices have high nickel content. Nickel allergy is the most common reason for surgical device explantation. Nickel elution properties of contemporary devices remain unknown. METHODS: We compared nickel elution properties of 4 devices - ASO, GSO, HSO, and sternal wire (SW) - while Dulbecco's phosphate-buffered saline (DPBS) served as control. Three samples of each device were submerged in DPBS. Nickel content was measured at 14 intervals over 90 days. RESULTS: Nickel elution at 24 hours, compared to control (0.005 ± 0.0 mg/L), was significantly higher for ASO (2.98 ± 1.65 mg/L; P=.04) and SW (0.03 ± 0.014 mg/L; P=.03). Nickel levels at 90 days, compared to control (0.005 ± 0.0 mg/L) and adjusting for multiple comparisons, were significantly higher for ASO (19.80 ± 2.30 mg/L; P=.01) and similar for HSO (P=.34), GSO (P=.34), and SW (P=.34). ASO had significantly higher nickel elution compared to HSO, GSO, and SW (P=.01). CONCLUSION: There is substantial variability in nickel elution; devices with less exposed nickel (HSO and GSO) have minimal elution. The safety of low nickel elution devices in patients with nickel allergy needs to be evaluated in prospective trials.

Characterization of diffuse fibrosis in the failing human heart via diffusion tensor imaging and quantitative histological validation.

Non-invasive imaging techniques are highly desirable as an alternative to conventional biopsy for the characterization of the remodeling of tissues associated with disease progression, including end-stage heart failure. Cardiac diffusion tensor imaging (DTI) has become an established method for the characterization of myocardial microstructure. However, the relationships between diffuse myocardial fibrosis, which is a key biomarker for staging and treatment planning of the failing heart, and measured DTI parameters have yet to be investigated systematically. In this study, DTI was performed on left ventricular specimens collected from patients with chronic end-stage heart failure as a result of idiopathic dilated cardiomyopathy (n = 14) and from normal donors (n = 5). Scalar DTI parameters, including fractional anisotropy (FA) and mean (MD), primary (D1 ), secondary (D2 ) and tertiary (D3 ) diffusivities, were correlated with collagen content measured by digital microscopy. Compared with hearts from normal subjects, the FA in failing hearts decreased by 22%, whereas the MD, D2 and D3 increased by 12%, 14% and 24%, respectively (P < 0.01). No significant change was detected for D1 between the two groups. Furthermore, significant correlation was observed between the DTI scalar indices and quantitative histological measurements of collagen (i.e. fibrosis). Pearson's correlation coefficients (r) between collagen content and FA, MD, D2 and D3 were -0.51, 0.59, 0.56 and 0.62 (P < 0.05), respectively. The correlation between D1 and collagen content was not significant (r = 0.46, P = 0.05). Computational modeling analysis indicated that the behaviors of the DTI parameters as a function of the degree of fibrosis were well explained by compartmental exchange between myocardial and collagenous tissues. Combined, these findings suggest that scalar DTI parameters can be used as metrics for the non-invasive assessment of diffuse fibrosis in failing hearts.

Management of hypercholesterolemia for prevention of atherosclerotic cardiovascular disease: focus on the potential role of recombinant anti-PCSK9 monoclonal antibodies.

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death and disability in the United States and other developed nations, and is rising rapidly in the rest of the world. Low-density lipoprotein (LDL) is the major atherogenic particle in most patients at high risk for ASCVD events, and statin-based LDL-lowering treatment is the major focus of treatment for prevention of ASCVD. Despite this, an estimated 57 million US adults (25%) still have moderately elevated levels of LDL-cholesterol (LDL-C) > 160 mg/dL, and many others have an LDL-C above the level considered appropriate for their high-risk status. Although statins are very effective for lowering LDL-C, and other classes of LDL-lowering medications are available, many patients still cannot achieve adequate LDL-lowering with maximal tolerated doses of US Food and Drug Administration-approved treatments. Thus, there is an unmet medical need for statin adjuncts in these patients, as well as for statin alternatives in statin-intolerant patients. A recently discovered human protein, proprotein convertase subtilisin/kexin type 9 (PCSK9), plays an important role in LDL metabolism by promoting degradation of the LDL receptor, and thus reducing clearance of LDL and increasing LDL-C levels. Accordingly, inhibition of PCSK9 activity has become an attractive target for drug development for lowering LDL-C, and human monoclonal antibodies against PCSK9, are now in late-stage clinical development. These antibodies are at least as effective as statins for LDL-C lowering (or more so), and their effects are additive to those of statins. To date, they have been well tolerated and apparently safe in clinical trials. Long-term randomized, controlled trials of their safety, tolerability, and ability to reduce ASCVD are now underway.

Clinical and hemodynamic effects of renin-angiotensin system blockade in cardiac transplant recipients.

Chronic kidney disease continues to be a major limiting factor for long-term survival of heart transplant recipients. Little is known about the early use of renin-angiotensin system (RAS) blocking agents and their impact on renal function and hemodynamics in heart transplant recipients. In this cohort study all eligible recipients of orthotopic heart transplants at the UTAH cardiac transplantation program from 2001 through 2007 were divided into 2 groups-patients who were started on angiotensin-converting enzyme inhibitors or angiotensin receptor blockers within the first 4 weeks of transplantation and continued on these for ≥4 weeks during the first 3 months (RAS blockade group, n = 75) and those who were not (non-RAS blockade group, n = 52). All patients were followed for 1 year after transplantation. There were no significant differences at baseline between the 2 groups. Estimated glomerular filtration rate at 12 months was significantly higher in the RAS blockade group compared to the non-RAS blockade group (mean ± SD, 56.3 ± 22.4 vs 47.3 ± 18.1 ml/min/1.73 m(2), p = 0.036). At 12 months pulmonary artery systolic pressure was significantly lower in the RAS blockade group compared to the non-RAS blockade group (30.2 ± 7.4 vs 32.9 ± 9.3 mm Hg, p = 0.023). Left ventricular ejection fraction and pulmonary capillary wedge pressure were similar between the 2 groups. In conclusion, early RAS blockade after heart transplantation is safe, well tolerated, and associated with better renal function and hemodynamic profile at 1 year after transplantation.

Left ventricular assist device unloading effects on myocardial structure and function: current status of the field and call for action.

PURPOSE OF REVIEW: Myocardial remodeling driven by excess pressure and volume load is believed to be responsible for the vicious cycle of progressive myocardial dysfunction in chronic heart failure. Left ventricular assist devices (LVADs), by providing significant volume and pressure unloading, allow a reversal of stress-related compensatory responses of the overloaded myocardium. Herein, we summarize and integrate insights from studies which investigated how LVAD unloading influences the structure and function of the failing human heart. RECENT FINDINGS: Recent investigations have described the impact of LVAD unloading on key structural features of cardiac remodeling - cardiomyocyte hypertrophy, fibrosis, microvasculature changes, adrenergic pathways and sympathetic innervation. The effects of LVAD unloading on myocardial function, electrophysiologic properties and arrhythmias have also been generating significant interest. We also review information describing the extent and sustainability of the LVAD-induced myocardial recovery, the important advances in understanding of the pathophysiology of heart failure derived from such studies, and the implications of these findings for the development of new therapeutic strategies. Special emphasis is given to the great variety of fundamental questions at the basic, translational and clinical levels that remain unanswered and to specific investigational strategies aimed at advancing the field. SUMMARY: Structural and functional reverse remodeling associated with LVADs continues to inspire innovative research. The ultimate goal of these investigations is to achieve sustained recovery of the failing human heart.