Elevated Lipoprotein A Levels and Development of Moderate or Severe Cardiac Allograft Vasculopathy in Patients with Heart Transplants.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is a high-incident complication of heart transplant (HT) and is the leading cause of death beyond the first post-HT year. Traditional risk factors have been related to CAV development. Elevated lipoprotein (a) (Lp[a]) is an independent, genetic, and causal risk factor for cardiovascular disease; nonetheless, its association with the development or worsening of CAV in HT has not been firmly established. METHODS: An observational nested case-control study including HT recipients under follow-up in a tertiary center. Lipoprotein (a) levels were determined at the time of inclusion. We considered elevated Lp(a) ≥30 mg/dL. We evaluated the association between Lp(a) levels and the presence and severity of CAV (The International Society For Heart And Lung Transplantation [ISHLT] Cardiac Allograft Vasculopathy Grading Scheme), dividing the sample between No or Mild CAV (0-1) and Moderate-Severe CAV (2-3). Routine coronary angiographies were performed the first year after the transplant and were subsequently symptom-driven. RESULTS: One hundred fifty patients with HTs were included, with a mean follow-up of 110 ± 77 months. Patients with CAV 2 to 3 presented higher median Lp(a) levels (17 vs 86 mg/dL, P = 0.001). Elevated Lp(a) level was an independent risk factor for developing CAV 2 to 3 (odds ratio 8.57 [95% CI 2.82-26.04]; P < .001). Patients with Lp(a) ≥30 mg also showed an earlier onset compared with those with Lp(a) <30 mg/dL. CONCLUSIONS: Our study suggests that Lp(a) may play a role in the development of CAV. Lipoprotein (a) ≥30 mg/dL defines a subgroup of high-risk patients with HTs as portends to earlier onset and more severe CAV. Lipoprotein (a) determination should be a standard-of-care test in patients with HTs.

Heart Transplantation and Thromboembolic Risk In Patients With Percutaneous Aortic Valve Prosthesis and Left Ventricular Assist Device: A Case Report.

Transcatheter aortic valve replacements have become a good option for patients with aortic valve disease and high surgical risk. Thromboembolism is reported as a relatively common complication of Transcatheter aortic valve replacement. This risk may be increased in patients who have left ventricular assist devices, as valve motion is drastically reduced. We present the case of a 65-year-old man with a history of alcoholism and valvular cardiomyopathy (severe chronic aortic insufficiency) with severe left ventricular dysfunction. Improvement in ventricular function followed the cessation of alcohol consumption, but still in poor clinical condition. Due to his high surgical risk, it was decided to implant a percutaneous aortic valve to treat the valve deficiency. Two months later, he suffered from a first episode of embolic stroke, which he successfully recovered. Despite the treatment, his clinical status did not improve (INTERMACS 3-4), and he was referred for heart transplantation. A left ventricular assist device was implanted as a bridge to the transplant. While on the waiting list, he suffered from other 3 episodes of stroke, 2 of them requiring mechanical thrombectomy. Finally, his transplant was performed with a favorable postoperative clinical course. Heart transplantation may be feasible in patients with multiple intracardiac devices in left chambers, although we must be aware of the increased thromboembolic risk, especially when used in combination.

Transthyretin amyloidosis with cardiomyopathy after domino liver transplantation: Results of a cross-sectional study.

Domino liver transplantation (DLT) has been used widely in patients with hereditary amyloid transthyretin (ATTR) amyloidosis. New-onset polyneuropathy in recipients of DLT has been reported, but there are few cases of cardiac involvement reported. We aimed to perform a cross-sectional study for ATTR amyloidosis with cardiomyopathy (ATTR-CM) in DLT recipients. We evaluated 23 living DLT recipients a median of 9 years since DLT at 2 referral centers with a systematic cardiac evaluation, including bone scintigraphy. Median age was 72 years, 91% had hypertension, 35% had diabetes mellitus, 67% had chronic renal failure, and 8 patients (35%) developed new-onset polyneuropathy. Only 13% had a normal electrocardiogram and a normal echocardiography, and most of them showed some conduction disturbance or increase in left ventricular wall thickness, but only 1 patient with a Glu89Lys mutation developed ATTR-CM diagnosed by bone scintigraphy and endomyocardial biopsy. None of the recipients of a DLT with Val30Met mutation showed cardiac involvement by bone scintigraphy. In conclusion, DLT from Val30Met donors seems to be safe regarding the development of ATTR-CM. Evaluation of cardiomyopathy in DLT recipients is challenging due to concomitant comorbidities and in this context, bone scintigraphy can be helpful to evaluate ATTR-CM.

Impact of Preoperative Pulmonary Hypertension on Survival in Patients Undergoing Elective Heart Transplant.

BACKGROUND: Pulmonary arterial hypertension (PAH) represents a marker of bad prognosis in left heart disease. Nonetheless, the effect on survival after heart transplant remains controversial. The objective was to study the impact of preoperative PAH on survival in patients undergoing elective heart transplant. METHODS: A retrospective study of 173 transplant recipients was conducted at a single hospital from January 2009 to December 2018. Congenital etiology and emergent heart transplant were exclusion criteria as well as those patients without enough data in the hemodynamic study. Two groups were considered: A (without PAH) and B (with HTP). PAH was classified as mild (mean pulmonary arterial pressure [mPAP] 25-34 mm Hg, pulmonary vascular resistance [PVR] 2.5-3.4 Wood units and/or transpulmonary gradient [TPG] 13-16 mm Hg), moderate (mPAP 35-44 mm Hg, PVR 3.5-4.9 Wood units and/or TPG 17-19 mm Hg), and severe (mPAP > 44 mm Hg, PVR > 4.9 Wood units and/or TPG > 19 mm Hg). RESULTS: A total of 102 patients were enrolled; 71.6% were male and average age was 52.3 (SD, 10.02) years. The main etiology was ischemic cardiomyopathy; 13.7% underwent previous heart operations. A total of 61 patients (59.8%) had PAH prior to heart transplant: 25 mild, 34 moderate, and 2 severe. Mean overall survival after transplant was 79.9 (SD, 5.68) months, without differences between the 2 groups (P = .82). One-month survival was 89% (the main cause of mortality was primary graft dysfunction), and 1-year survival was 78%. Four patients required mechanical circulatory support during early post-transplant period. CONCLUSIONS: Preoperative PAH does not have a significant impact on survival in elective heart transplant.

Overview of mitral regurgitation in Europe: results from the European Registry of mitral regurgitation (EuMiClip).

Aims: To determine the prevalence of mitral regurgitation (MR) in a large cohort of consecutive patients undergoing clinically indicated echocardiography and to examine the distribution of primary and secondary MR. Methods and results: All patients undergoing an echocardiographic study in 19 European centres within a 3-month period were prospectively included. MR assessment was performed as recommended by the European Association of Cardiovascular Imaging (EACVI). MR was classified according to mechanism as primary or secondary and aetiologies were reported. A total of 63 463 consecutive echocardiographic studies were reviewed. Any degree of MR was described in 15 501 patients. Concomitant valve disease of at least moderate grade was present in 28.5% of patients, being tricuspid regurgitation the most prevalent. In the subgroup of moderate and severe MR (n = 3309), 55% of patients had primary MR and 30% secondary MR. Both mechanisms were described in 14% of the studies. According to Carpentier's classification, 26.7% of MR were classified as I, 19.9% of MR as II, 22.4% of MR as IIIa, and 31.1% of MR as IIIb. Conclusion: To date, this is the largest echocardiography-based study to analyse the prevalence and aetiology distribution of MR in Europe. The burden of secondary MR was higher than previously described, representing 30% of patients with significant MR. In our environment, degenerative disease is the most common aetiology of primary MR (60%), whereas ischaemic is the most common aetiology of secondary MR (51%). Up to 70% of patients with severe primary MR may have a Class I indication for surgery. However, the optimal therapeutic approach for secondary MR remains uncertain.

Prevalence of optimal valve morphology for MitraClip in patients with mitral regurgitation.

AIMS: To evaluate how often patients with moderate-to-severe or severe mitral regurgitation (MR) meet the anatomical criteria for MitraClip implant and to examine the role of transthoracic echocardiography (TTE) for this task. METHODS AND RESULTS: From February to June 2015, all patients undergoing a TTE in nine Spanish hospitals were prospectively included. Patients with moderate-to-severe and severe mitral regurgitation were selected for analysis. Anatomical eligibility criteria for MitraClip were defined according to the EVEREST trial. A total of 39 855 consecutive TTE were reviewed, and 1403 patients with moderate-to-severe and severe MR were finally included. Primary MR was found in 779 patients (56%). Only in 74 patients (16%), all anatomical criteria for MitraClip could be assessed by TTE. Of these, 56% of patients had optimal valve morphology. Secondary MR was described in 361 patients (26%), and at least 249 of these (69%) had a high surgical risk. All five criteria for MitraClip were adequately assessed by TTE in 299 patients (83%). Of them, 118 patients (39%) had optimal valve morphology. CONCLUSIONS: A considerable proportion of patients have optimal mitral valve morphology for MitraClip. Moreover, TTE was particularly useful in determining whether or not the anatomical criteria for MitraClip implant were met in the majority of patients with secondary MR but in only a minority of those with primary MR.

Frequency, Mechanism and Severity of Mitral Regurgitation: Are There any Differences Between Primary and Secondary Mitral Regurgitation?

BACKGROUND AND AIM OF THE STUDY: Although mitral regurgitation (MR) is a well-recognized prognosis factor, its true prevalence is probably underestimated and its etiology and mechanisms have not been sufficiently explored. The study aim was to evaluate the burden of MR, focusing attention on its frequency, severity, etiology, mechanism, and other associated conditions. METHODS: Between February and June 2015, a total of 39,855 consecutive echocardiographic studies was performed at nine tertiary hospitals, and were prospectively included in the study. MR severity was graded into four groups, ranging from none or trace to severe MR, in accordance with the recommendations of the European Association of Cardiovascular Imaging. Patients with moderate to severe MR were selected for the analysis. RESULTS: MR was detected in 22.6% of cases. MR severity was mild in 82.5% of patients (n = 7,376), moderate in 11.7% (n = 1,048), and severe in 5.8% (n = 521). Concomitant valvular heart disease was present in 3,544 patients (39.7%), with tricuspid regurgitation the most frequently encountered (21.6%). Among moderate and severe MR, primary MR was more frequent than secondary MR (58.8% versus 23.5%), with degenerative valve disease being the most common cause of primary MR (49.2%). A third group composed of mixed forms of MR was described in 17.8% of cases. CONCLUSIONS: MR is a common finding on echocardiography, and is frequently associated with other valvular heart disease. Most MRs are of degenerative origin. The primary and secondary forms of MR differ significantly in their clinical presentation with regard to gender, age, and ventricular function. There appears to be a gap for a 'mixed' group, though further studies are needed to confirm this suggestion.