Discriminative Ability of CHA2DS2-VASc and HAS-BLED Score in Whites and Nonwhites.

The CHA2DS2-VASc and HAS-BLED scoring systems are used in patients with atrial fibrillation (AF) to estimate risk of stroke and bleeding, respectively. Both were developed in minimally diverse European populations and these scores have not yet been extensively studied in US whites and nonwhites. In a retrospective cohort study, we included patients with AF who received inpatient or outpatient care in a large integrated academic health system from 2011 to 2017. Cox proportional hazards were used to analyze associations between stroke and CHA2DS2-VASc score in AF patients not prescribed anticoagulation and between incident bleeding and HAS-BLED score in anticoagulated patients. After exclusions for previous stroke, the cohort included 21,648 patients with a mean age of 66.8 ± 15.8. Anticoagulation was prescribed in 52% of whites and 46% of nonwhites (p < 0.001) with a CHA2DS2-VASc score of ≥2. Mean CHA2DS2-VASc scores were 2.4 ± 1.6 in whites and 2.2 ± 1.6 in nonwhites and mean HAS-BLED scores was 1.5 ± 1.1 in whites and 1.3 ± 1.0 in nonwhites. After adjusting for baseline differences, the discriminative ability of CHA2DS2-VASc and HAS-BLED was similar in whites and nonwhites (p = 0.52, 0.33, respectively). The discriminative ability of HAS-BLED was similar in patients on vitamin K antagonists and direct oral anticoagulants. In conclusion, oral anticoagulation was prescribed less frequently in nonwhites. However, the discriminative ability of CHA2DS2-VASc and HAS-BLED were similar in whites and nonwhites.

Novel shunt modification with an adjustable stent-embedded "fenestrated" septal occluder in a patient with pulmonary hypertension.

A 60-year-old woman with progressive dyspnea and cyanosis, O2-dependent pulmonary hypertension despite optimal medical therapy and remote atrial septostomy presented with worsening cyanosis and right-to-left shunting. The creation of a "fenestrated" ASD closure device with the insertion of a peripheral stent through an AMPLATZER™ ASD closure device was deployed to minimize right to left shunting and allow for enlargement of the shunt if needed. This case demonstrates the benefit of diminishing a right to left shunt with a self-fabricated fenestrated AMPLATZER device to improve symptoms in pulmonary hypertension patients with a pre-existing ASD.

Conduction recovery following pacemaker implantation after transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is increasingly used to treat severe aortic stenosis. A frequent complication of TAVR is high-grade or complete atrioventricular (AV) block requiring a permanent pacemaker (PPM). There are little data on the long-term dependency on pacing after TAVR. The objective of this study was to determine the proportion of patients receiving a PPM for high-grade or complete AV block after TAVR who remain dependent on the PPM in follow-up and to determine any risk factors for, particularly the effect of postballoon dilation (PBD) on, pacemaker dependency. METHODS: Of 594 consecutive patients without prior PPM undergoing TAVR (81.9% balloon-expandable, 18.1% self-expandable valve), 67 (13.1%) received a PPM after TAVR. PPM dependency was defined as AV block with a ventricular escape rate of ≤ 40 beats/min. Patient and procedural characteristics were examined according to PPM dependency status. RESULTS: Of the 67 patients who received a PPM within 10 days after TAVR, 27/67 (40.3%) were dependent at first follow-up and only 9/41 (21.9%) at 1 year. PPM dependency was more common after a self-expanding valve (76.9% vs 31.5%, P < 0.01), in those who underwent PBD (66.7% vs 24.4%, P < 0.01), and in patients in persistent complete AV block at PPM implantation (62.5% vs 7.4%, P < 0.01). CONCLUSIONS: Fewer than half of patients who receive a new PPM following TAVR are pacemaker dependent at early follow-up (< 30 days). The use of self-expanding valves and PBD are associated with a markedly increased risk of PPM dependency.

Global longitudinal strain from resting echocardiogram is associated with long-term adverse cardiac outcomes in patients with suspected coronary artery disease.

PURPOSE: Measuring myocardial strain using two-dimensional speckle tracking echocardiography has emerged as a new tool to identify subclinical ventricular dysfunction. Abnormal strain has been shown to have superior sensitivity compared with dobutamine stress echocardiography for viability assessment; however, there is a paucity of data regarding the prediction of long-term major adverse cardiac events. We compared the prognostic ability of both global longitudinal strain (GLS) from resting echocardiograms to regional wall motion score index (WMSI) from stress echocardiograms in their ability to predict long-term major adverse cardiac events. METHODS: Patients referred for stress echocardiography, who also underwent coronary angiography within 3 months of stress echo (n=122), were enrolled. Patients with reduced ejection fractions (<40%) were excluded. Patients were followed for a median of 3.4 years for major adverse cardiac events, readmissions and repeat cardiac testing. RESULTS: Patients with abnormal GLS (GLS <16.8%) from the resting echocardiogram obtained as part of the exercise echocardiogram experienced a significantly shorter time to major adverse cardiac events (p=0.026), first cardiovascular hospitalization and repeat cardiac testing (p=0.0011) compared to those with normal GLS. Abnormal GLS appears to be a better predictor than abnormal WMSI in predicting major adverse cardiac events (p=0.174) and time to first cardiovascular hospitalization or repeat cardiac testing (p=0.0093). CONCLUSION: GLS may be a better predictor of long-term major adverse cardiac events, readmissions and repeat cardiac testing than WMSI in patients undergoing stress echocardiography.

Contemporary management of ST-segment elevation myocardial infarction.

ST-elevation myocardial infarction (STEMI), which constitutes nearly 25-40 % of current acute myocardial infarction (AMI) cases, is a medical emergency that requires prompt recognition and treatment. Since the 2013 STEMI practice guidelines, a wealth of additional data that may further advance optimal STEMI practices has emerged. These data highlight the importance of improving patient treatment and transport algorithms for STEMI from non-primary percutaneous coronary intervention (PCI) centers. In addition, a focus on the reduction of total pain-to-balloon (P2B) times rather than simply door-to-balloon (D2B) times may further improve outcomes after primary PCI for STEMI. The early administration of newer oral P2Y12 inhibitors, including crushed forms of these agents for faster absorption, represents another treatment advancement. Recent data also suggest avoiding concurrent morphine use due to interactions with P2Y12 inhibitors. Furthermore, new technological advancements and investigational therapies, including Bioresorbable Vascular Scaffolds and the use of pre-intervention intravenous microbubbles with transthoracic ultrasound, hold promise to play a useful role in future STEMI care. Despite these advancements, the prompt recognition of STEMI, at both the patient and health care system level, remains the cornerstone of optimal treatment.

Ultrasound-Accelerated Thrombolysis in Patients With Intracardiac Thrombi: A Case Series.

We describe a case series of 3 patients presenting with intracardiac thrombi treated with standard anticoagulation therapy and intervention with ultrasound-accelerated thrombolysis therapy. Right-sided intracardiac thrombi portend significant mortality due to their susceptibility for embolization and pulmonary embolus despite the continuation of current standard of therapy of parenteral anticoagulation and surgical embolectomy if warranted. We demonstrate the safety and clinical efficacy of ultrasound-accelerated thrombolysis therapy with the EkoSonic Endovascular System infusion catheter system (EKOS Corporation) and highlight its use in resolving intracardiac thrombi and impeding the propagation of pulmonary emboli.

Efficacy and safety of novel oral anticoagulants in patients with bioprosthetic valves.

PURPOSE: Prosthetic valve replacement is performed in several hundred thousand patients worldwide annually, and many of these patients have or will ultimately develop atrial fibrillation or flutter (AF). Novel oral anticoagulants (NOACs) are not recommended in patients with AF and mechanical valves but have not been evaluated in patients with bioprosthetic valves. This study sought to evaluate the efficacy and safety of NOACs in patients with AF and bioprosthetic valves. METHODS: A retrospective single-center cohort study was performed on all patients with bioprosthetic valve implantation, for whom a NOAC was prescribed for the indication of AF. Patients were evaluated for thromboembolic events including imaging confirmed ischemic stroke, clinically suspected transient ischemic attack, and major bleeding events (according to International Society on Thrombosis and Hemostasis definition). RESULTS: In total, 73 patients (26 female, 35.6 %) were identified. NOAC therapy began, on average, 990.0 ± 1029.1 days after bioprosthetic valve implantation for an average duration of 511.8 ± 400.8 days. Aspirin was used concomitantly in a majority of patients (72.6 %). There were no ischemic strokes identified (0.0 %) and one possible TIA (1.4 %). There were 6 (8.2 %) minor and 5 (6.9 %) major bleeding events. CONCLUSION: The use of NOAC therapy for AF in patients with bioprosthetic valves appears safe and effective in the occurrence of thromboembolic events, however, at the expense of increased bleeding. Larger studies are necessary to confirm these findings.

Statin Use and Aneurysm Risk in Patients With Bicuspid Aortic Valve Disease.

BACKGROUND: No medical therapy has been proven to prevent the progression of aortic dilatation in bicuspid aortic valve (BAV) disease, and prophylactic aortic surgery remains the mainstay of treatment. HYPOTHESIS: Among patients with BAV disease who are referred for surgery, preoperative statin use is associated with decreased odds of ascending aortic dilatation. METHODS: We reviewed all BAV patients who underwent aortic valve and/or aortic surgery at our center between April 2004 and December 2013. Aortic diameter (AD), defined as the maximum ascending aortic dimension, was determined by magnetic resonance imaging, computed tomography, or echocardiography. Patients were divided into 2 groups: maximal AD <4.5 cm or ≥4.5 cm. The association between preoperative statin use and aortic dilatation was assessed using multivariable logistic regression modeling. RESULTS: Of 680 consecutive patients, 405 (60%) had AD <4.5 cm (mean age, 60 ± 14 years; 45% on statins), whereas 275 (40%) had AD ≥4.5 cm (mean age, 54 ± 13 years; 35% on statins) at the time of surgery. After adjusting for age, body surface area, sex, hypertension, aortic stenosis, severity of aortic regurgitation, and use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and ß-blockers, patients with AD ≥4.5 cm had 0.66× lower odds (95% confidence interval: 0.45-0.96) of being on preoperative statins compared with those with AD <4.5 cm (P = 0.029). CONCLUSIONS: In a retrospective study of BAV patients referred for surgery, preoperative statin use was associated with lower odds of clinically significant ascending aortic dilatation.

Comparison of outcomes and presentation in men-versus-women with bicuspid aortic valves undergoing aortic valve replacement.

Gender disparities in short- and long-term outcomes have been documented in cardiac and valvular heart surgery. However, there is a paucity of data regarding these differences in the bicuspid aortic valve (BAV) population. The aim of this study was to examine gender-specific differences in short- and long-term outcomes after surgical aortic valve (AV) replacement in patients with BAV. A retrospective analysis was performed in 628 consecutive patients with BAV who underwent AV surgery from April 2004 to December 2013. To reduce bias when comparing outcomes by gender, propensity score matching obtained on the basis of potential confounders was used. Women with BAV who underwent AV surgery presented with more advanced age (mean 60.7 ± 13.8 vs 56.3 ± 13.6 years, p <0.001) and less aortic regurgitation (29% vs 44%, p <0.001) and had a higher risk for in-hospital mortality (mean Ambler score 3.4 ± 4.4 vs 2.5 ± 4.0, p = 0.015). After propensity score matching, women received more blood products postoperatively (48% vs 34%, p = 0.028) and had more prolonged postoperative lengths of stay (median 5 days [interquartile range 5 to 7] vs 5 days [interquartile range 4 to 6], p = 0.027). Operative, discharge, and 30-day mortality and overall survival were not significantly different. In conclusion, women with BAV who underwent AV surgery were older, presented with less aortic regurgitation, and had increased co-morbidities, lending higher operative risk. Although women received more blood products and had significantly longer lengths of stay, short- and long-term outcomes were similar.

Safety of short-term use of dabigatran or rivaroxaban for direct-current cardioversion in patients with atrial fibrillation and atrial flutter.

Direct-current cardioversion (DCCV) for persistent atrial fibrillation or atrial flutter (AF) carries a risk of thromboembolic events (TEs). Therapeutic anticoagulation with warfarin is recommended for 3 to 4 weeks before and 4 weeks after DCCV to reduce TE; however, the safety of short-term anticoagulation with the novel oral anticoagulants (dabigatran and rivaroxaban) before DCCV has not been assessed. A retrospective cohort study was performed on all patients undergoing elective DCCV for AF at Northwestern Memorial Hospital from June 1, 2012 to September 30, 2013. Inclusion criteria included patients taking any of the novel oral anticoagulants for 21 to 60 days before DCCV and successful DCCV to sinus rhythm. Patients were monitored for a minimum of 60 days after DCCV to evaluate for TEs including stroke, transient ischemic attack, systemic emboli, and death. In total, 53 patients (47 men, 89%; age 65±10 years, median 66) were evaluated. Agents used were dabigatran (30 patients, 57%) and rivaroxaban (23 patients, 43%) for an average of 38±9 days. The mean CHADS2 score was 1.2±1.1 (score=0, 26%; 1, 43%; 2, 17%; and >3, 13%). Eleven patients (21%) underwent a transesophageal echocardiography before their DCCV; all showed no thrombus. No patients were found to have episodes of TE within 60 days of DCCV. No patients were found to have major bleeding events. In conclusion, the use of short-term dabigatran or rivaroxaban therapy for DCCV of AF appears safe.

Comprehensive hemodynamic comparison and frequency of patient-prosthesis mismatch between the St. Jude Medical Trifecta and Epic Bioprosthetic aortic valves.

BACKGROUND: Patient-prosthesis mismatch (PPM) has been reported with a wide range of bioprosthetic valves after aortic valve replacement (AVR) and has been associated with multiple adverse outcomes. The aim of this study was to test the hypothesis that a novel low-profile stented pericardial tissue bioprosthesis for AVR, the Trifecta aortic valve, would have superior hemodynamics, a lower incidence of PPM, and an improvement in clinical outcomes. Its hemodynamic performance was evaluated, and a comparison was performed with a traditional stented pericardial bioprosthesis (Epic) with respect to hemodynamics, PPM, and clinical events. METHODS: One hundred twenty-four patients (mean age, 73.6 ± 11.0 years) underwent AVR. Prosthetic valve types used were Trifecta (n = 75 [60.5%]) and Epic (n = 49 [39.5%]). Intraoperative transesophageal echocardiography was used to evaluate hemodynamic variables before and after AVR. RESULTS: Postoperative comparison of the Epic valve and the Trifecta valve revealed a lower mean pressure gradient (16.5 ± 6.7 vs 8.8 ± 3.4 mm Hg, P < .001), a lower peak gradient (33.3 ± 11.8 vs 19.4 ± 8.6 mm Hg, P < .001), and higher indexed effective orifice area (0.8 ± 0.2 vs 1.1 ± 0.4 cm(2)/m(2), P < .001), favoring the Trifecta valve across several valve sizes. Severe PPM (6% vs 27%, P < .001) and valvular-related complications at follow-up (14.3% vs 36.7%, P = .005) were less frequent in the Trifecta group. CONCLUSIONS: The hemodynamic performance of the Trifecta valve is superior to that of the Epic valve across many conventional prosthesis sizes, and its implantation resulted in lower rates of severe PPM. These improvements were associated with lower valvular-related adverse events.

Comprehensive hemodynamic performance and frequency of patient-prosthesis mismatch of the St. Jude Medical Trifecta bioprosthetic aortic valve.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the performance of a new stented pericardial bioprosthesis, the Trifecta (St. Jude Medical, St. Paul, MN, USA), for aortic valve replacement (AVR) with respect to valvular hemodynamics and frequency of patient-prosthesis mismatch (PPM). PPM has been reported in a wide range of bioprosthetic valves following AVR, and has been associated with multiple adverse outcomes. It was hypothesized that the Trifecta aortic valve would have superior hemodynamics and an acceptable incidence of PPM following AVR. METHODS: A prospective cohort study was performed between January 2010 and May 2012, following 75 patients (mean age 71.9 _ 11.1 years) who had undergone AVR with a Trifecta valve for aortic stenosis (88%) or regurgitation (12%) at the authors' institutions. Intraoperative three-dimensional and Doppler transesophageal echocardiography were used to evaluate hemodynamic variables before and after AVR, as well as pre-discharge. RESULTS: Echocardiographic evaluation showed a preoperative average mean gradient (MG) of 40.6 ± 21.6 mmHg, an average peak gradient (PG) of 72.1 ± 19.4 mmHg, and an average effective orifice area index (EOAI) of 0.39 ± 0.20 cm2/m2. Postoperative mean pressure gradient measurements showed a postoperative average MG of 8.76 ± 3.75 mmHg (p < 0.001), an average PG of 19.4 ± 8.6 mmHg (p < 0.001), and EOAI of 1.09 ± 0.36 cm2/m2 (p < 0.001), which demonstrated a significantly improved hemodynamic performance across all valve sizes. Postoperative MG versus measured EOAI demonstrated a fairly linear relationship (R2 = 0.0703), rather than a rapid increase in MG with EOAI < 0.85 and < 0.65, as was seen with previous valve designs. Severe PPM (defined as EOAI ≤ 0.65 cm2/m2) was found in four patients (6%), while moderate PPM (EOAI > 0.65 and < 0.85 cm2/m2) was seen in 11 patients (16%). CONCLUSION: The Trifecta pericardial valve demonstrated excellent hemodynamic performance at all valve sizes, and resulted in very low postoperative transvalvular pressure gradients and PPM, without the need for aortic root enlargement.

Preoperative cardiac variables of diastolic dysfunction and clinical outcomes in lung transplant recipients.

Background. Orthotopic lung transplantation is now widely performed in patients with advanced lung disease. Patients with moderate or severe ventricular systolic dysfunction are typically excluded from lung transplantation; however, there is a paucity of data regarding the prognostic significance of abnormal left ventricular diastolic function and elevated pretransplant pulmonary pressures. Methods. We reviewed the characteristics of 111 patients who underwent bilateral and unilateral lung transplants from 200 to 2009 in order to evaluate the prognostic significance of preoperative markers of diastolic function, including invasively measured pulmonary capillary wedge pressure (PCWP) and echocardiographic variables of diastolic dysfunction including mitral A > E and A' > E'. Results. Out of 111 patients, 62 were male (56%) and average age was 54.0 ± 10.5 years. Traditional echocardiographic Doppler variables of abnormal diastolic function, including A' > E' and A > E, did not predict adverse events (P = 0.49). Mildly elevated pretransplant PCWP (16-20 mmHg) and moderately/severely elevated PCWP (>20 mmHg) were not associated with adverse clinical events after transplant (P = 0.30). Additionally, all clinical endpoints did not show any statistical significance between the two groups. Conclusions. Pre-lung transplant invasive and echocardiographic findings of elevated pulmonary pressures and abnormal left ventricular diastolic function are not predictive of adverse posttransplant clinical events.