RÉSUMÉ
Tricuspid valve disease is an often underrecognized clinical problem that is associated with significant morbidity and mortality. Unfortunately, patients will often present late in their disease course with severe right-sided heart failure, pulmonary hypertension, and life-limiting symptoms that have few durable treatment options. Traditionally, the only treatment for tricuspid valve disease has been medical therapy or surgery; however, there have been increasing interest and success with the use of transcatheter tricuspid valve therapies over the past several years to treat patients with previously limited therapeutic options. The tricuspid valve is complex anatomically, lying adjacent to important anatomic structures such as the right coronary artery and the atrioventricular node, and is the passageway for permanent pacemaker leads into the right ventricle. In addition, the mechanism of tricuspid pathology varies widely between patients, which can be due to primary, secondary, or a combination of causes, meaning that it is not possible for 1 type of device to be suitable for treatment of all cases of tricuspid valve disease. To best visualize the pathology, several modalities of advanced cardiac imaging are often required, including transthoracic echocardiography, transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, to best visualize the pathology. This detailed imaging provides important information for choosing the ideal transcatheter treatment options for patients with tricuspid valve disease, taking into account the need for the lifetime management of the patient. This review highlights the important background, anatomic considerations, therapeutic options, and future directions with regard to treatment of tricuspid valve disease.
Sujet(s)
Association américaine du coeur , Valve atrioventriculaire droite , Humains , Valve atrioventriculaire droite/imagerie diagnostique , Valve atrioventriculaire droite/anatomopathologie , États-Unis , Valvulopathies/thérapie , Valvulopathies/imagerie diagnostique , Insuffisance tricuspide/imagerie diagnostique , Insuffisance tricuspide/thérapie , Implantation de valve prothétique cardiaqueRÉSUMÉ
BACKGROUND: Transcatheter tricuspid valve repair (TTVr) has significantly expanded treatment options for tricuspid regurgitation (TR). However, a sizeable proportion of patients are still declined for TTVr and little is known about their clinical characteristics and cardiac morphology. OBJECTIVES: This study sought to characterize patients who screen fail for TTVr with respect to their clinical characteristics and cardiac morphology. METHODS: A total of 547 patients were evaluated for TTVr between January 2016 to December 2021 from 3 centers in the United States and Germany. Clinical records and echocardiographic studies were used to assess medical history and right ventricular (RV) and tricuspid valve (TV) characteristics. RESULTS: Median age was 80 (IQR: 74-83) years and 60.0% were female. Over half (58.1%) were accepted for TTVr. Of those who were deemed unsuitable for TTVr (41.9%), the most common exclusion reasons were anatomical criteria (56.8%). In the regression analysis, RV and right atrial size, TV coaptation gap, and tethering area were identified as independent screen failure predictors. Other rejection reasons included clinical futility (17.9%), low symptom burden (12.7%), and technical limitations (12.7%). Most of the excluded patients (71.6%) were managed conservatively with medical therapy, while a small number either proceeded to TV surgery (22.3%) or subsequently became eligible for transcatheter tricuspid valve replacement in later available clinical trials in the United States (6.1%). CONCLUSIONS: The majority of TTVr screen failure patients are excluded due to TV, right atrial, and RV enlargement. However, a significant proportion is excluded due to clinical futility. These identifiable anatomical and clinical characteristics emphasize the importance of earlier referral and intervention of TR and the need for continued innovation of Transcatheter tricuspid valve interventions.
Sujet(s)
Auricule de l'atrium , Échocardiographie , Ventricules cardiaques , Insuffisance tricuspide , Valve atrioventriculaire droite , Humains , Mâle , Femelle , Sujet âgé de 80 ans ou plus , Sujet âgé , Insuffisance tricuspide/imagerie diagnostique , Insuffisance tricuspide/chirurgie , Valve atrioventriculaire droite/imagerie diagnostique , Valve atrioventriculaire droite/chirurgie , Auricule de l'atrium/imagerie diagnostique , États-Unis , Allemagne , Études rétrospectives , Tomodensitométrie , Résultat thérapeutique , Ventricules cardiaques/imagerie diagnostiqueSujet(s)
Sténose aortique , Implantation de valve prothétique cardiaque , Prothèse valvulaire cardiaque , Accident ischémique transitoire , Infarctus du myocarde , Remplacement valvulaire aortique par cathéter , Humains , Remplacement valvulaire aortique par cathéter/effets indésirables , Valve aortique/chirurgie , Sténose aortique/chirurgie , Résultat thérapeutique , Facteurs de risqueRÉSUMÉ
The treatment of left main (LM) coronary artery disease (CAD) requires complex decision-making. Recent clinical practice guidelines provide clinicians with guidance; however, decisions regarding treatment for individual patients can still be difficult. The American College of Cardiology's Cardiac Surgery Team and Interventional Council joined together to develop a practical approach to the treatment of LM CAD, taking into account randomized clinical trial, meta-analyses, and clinical practice guidelines. The various presentations of LM CAD based on anatomy and physiology are presented. Recognizing the complexity of LM CAD, which rarely presents isolated and is often in combination with multivessel disease, a treatment algorithm with medical therapy alone or in conjunction with percutaneous coronary intervention or coronary artery bypass grafting is proposed. A heart team approach is recommended that accounts for clinical, procedural, operator, and institutional factors, and features shared decision-making that meets the needs and preferences of each patient and their specific clinical situation.
Sujet(s)
Maladie des artères coronaires , Intervention coronarienne percutanée , Humains , Pontage aortocoronarien , Maladie des artères coronaires/diagnostic , Maladie des artères coronaires/chirurgie , Méta-analyse comme sujet , Essais contrôlés randomisés comme sujet , Guides de bonnes pratiques cliniques comme sujetRÉSUMÉ
Background: In-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI. Methods: Baseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient. Results: In-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 âyears, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P â< â.001), and the model demonstrated good discriminative power (c-statistic â= â0.81) and calibration (Hosmer-Lemeshow, P â= â.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high-risk score categories, respectively). Conclusions: The risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.
RÉSUMÉ
IMPORTANCE: More than 40 million people are living with either mitral or aortic valve disease worldwide, and more than 180â¯000 heart valve replacement surgeries are performed each year in the US. Transcatheter valve repair has emerged as an important therapeutic option for patients who are candidates for heart valve replacement. OBSERVATIONS: All transcatheter valve therapies involve a multidisciplinary team of interventional cardiologists, cardiothoracic surgeons, radiologists, echocardiographers, nurses, and social workers, termed the heart team, to determine the optimal approach for managing each patient. Transcatheter aortic valve implantation (TAVI) is an aortic valve replacement procedure that is performed percutaneously and is currently approved for patients with severe, symptomatic aortic stenosis in all surgical risk categories. The TAVI procedure can be performed using a balloon-expandable or self-expanding valve. In a low-risk cohort of patients (PARTNER [Placement of Aortic Transcatheter Valves] 3 trial), the rates of death from any cause, stroke, or rehospitalization were 8.5% for patients receiving TAVI and 15.1% for patients undergoing surgical aortic valve replacement. Decision-making regarding therapy choice should be based on individual anatomy (including the number of leaflets, annular size, and peripheral arterial anatomy), comorbidities (including concomitant coronary artery disease and aortopathies), and patient preference guide. A mitral transcatheter edge-to-edge repair device is approved by the US Food and Drug Administration for high-risk patients with degenerative and functional mitral regurgitation that has excellent safety and efficacy in these populations. In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial, the annualized rate of all hospitalizations for heart failure was 35.8% among patients who underwent transcatheter edge-to-edge repair and received medical therapy compared with 67.9% among patients in the medical therapy alone group. Transcatheter tricuspid valve repair and replacement trials are ongoing and show promise for the treatment of patients with tricuspid regurgitation, which previously had limited therapeutic options. Multimodality imaging, which includes transthoracic echocardiography, transesophageal echocardiography, computed tomography, and intracardiac echocardiography, is important for preprocedural planning, device selection, and optimal outcomes. CONCLUSIONS AND RELEVANCE: Approximately 78â¯000 TAVI procedures and 10â¯000 transcatheter mitral valve repairs take place yearly in the US to treat patients with severe, symptomatic aortic stenosis and mitral regurgitation, respectively. Transcatheter valve therapies have expanded therapeutic options for patients, including for those who previously had no viable surgical options.
Sujet(s)
Valve aortique/chirurgie , Procédures de chirurgie cardiaque/méthodes , Insuffisance mitrale/chirurgie , Valve atrioventriculaire gauche/chirurgie , Remplacement valvulaire aortique par cathéter , Humains , Facteurs de risque , Remplacement valvulaire aortique par cathéter/méthodes , Valve atrioventriculaire droite/chirurgie , Insuffisance tricuspide/chirurgieRÉSUMÉ
BACKGROUND: Medical procedures are traditionally taught informally at patients' bedside through observation and practice using the adage "see one, do one, teach one." This lack of formalized training can cause trainees to be unprepared to perform procedures independently. Simulation based education (SBE) increases competence, reduces complications, and decreases costs. We developed, implemented, and evaluated the efficacy of a right heart catheterization (RHC) SBE curriculum. METHODS: The RHC curriculum consisted of a pretest, video didactics, deliberate practice, and a posttest. Pre-and posttest skills examinations consisted of a dichotomous 43-item checklist on RHC skills and a 14-item hemodynamic waveform quiz. We enrolled two groups of fellows: 6 first-year, novice cardiology fellows at Northwestern University in their first month of training, and 11 second- and third-year fellows who had completed traditional required, level I training in RHC. We trained the first-year fellows at the beginning of the 2018-2019 year using the SBE curriculum and compared them to the traditionally-trained cardiology fellows who did not complete SBE. RESULTS: The SBE-trained fellows significantly improved RHC skills, hemodynamic knowledge, and confidence from pre- to posttesting. SBE-trained fellows performed similarly to traditionally-trained fellows on simulated RHC skills checklists (88.4% correct vs. 89.2%, p = .84), hemodynamic quizzes (94.0% correct vs. 86.4%, p = .12), and confidence (79.4 vs. 85.9 out of 100, p = .15) despite less clinical experience. CONCLUSIONS: A SBE curriculum for RHC allowed novice cardiology fellows to achieve level I skills and knowledge at the beginning of fellowship and can train cardiology fellows before patient contact.
Sujet(s)
Cardiologie , Compétence clinique , Cathétérisme cardiaque , Cardiologie/enseignement et éducation , Programme d'études , Enseignement spécialisé en médecine , Bourses d'études et bourses universitaires , Humains , Résultat thérapeutiqueRÉSUMÉ
Severe acute isolated right ventricular failure has limited dedicated percutaneous temporary mechanical circulatory support options, especially after orthotopic heart transplantation. The advent of the Impella RP device provides a newer option, though an absolute contraindication to device placement is thrombus within the right heart. We present a novel case where catheter-based embolectomy was used to evacuate right heart thrombus before Impella RP placement in a patient with severe acute right ventricular failure due to primary graft dysfunction after orthotopic heart transplantation.
Sujet(s)
Défaillance cardiaque , Transplantation cardiaque , Dispositifs d'assistance circulatoire , Cathéters , Embolectomie , Défaillance cardiaque/chirurgie , HumainsRÉSUMÉ
The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), that causes coronavirus disease 2019 (COVID-19), has resulted in a global pandemic. Patients with cardiovascular risk factors or established cardiovascular disease are more likely to experience severe or critical COVID-19 illness and myocardial injury is a key extra-pulmonary manifestation. These patients frequently present with ST-elevation on an electrocardiogram (ECG) due to multiple etiologies including obstructive, non-obstructive, and/or angiographically normal coronary arteries. The incidence of ST-elevation myocardial infarction (STEMI) mimics in COVID-19-positive hospitalized patients, and the association with morbidity and mortality is unknown. Understanding the natural history and appropriate management of COVID-19 patients presenting with ST elevation is essential to inform patient management decisions and protect healthcare workers. Methods: The Society for Cardiovascular Angiography and Interventions (SCAI) and The Canadian Association of Interventional Cardiology (CAIC) in conjunction with the American College of Cardiology Interventional Council have collaborated to create a multi-center observational registry, NACMI. This registry will enroll confirmed COVID-19 patients and persons under investigation (PUI) with new ST-segment elevation or new onset left bundle branch block (LBBB) on the ECG with clinical suspicion of myocardial ischemia. We will compare demographics, clinical findings, outcomes and management of these patients with a historical control group of over 15,000 consecutive STEMI activation patients from the Midwest STEMI Consortium using propensity matching. The primary clinical outcome will be in- hospital major adverse cardiovascular events (MACE) defined as composite of all-cause mortality, stroke, recurrent MI, and repeat unplanned revascularization in COVID-19 confirmed or PUI. Secondary outcomes will include the following: reporting of etiologies of ST Elevation; cardiovascular mortality due to myocardial infarction, cardiac arrest and /or shock; individual components of the primary outcome; composite primary outcome at 1 year; as well as ECG and angiographic characteristics. Conclusion: The multicenter NACMI registry will collect data regarding ST elevation on ECG in COVID-19 patients to determine the etiology and associated clinical outcomes. The collaboration and speed with which this registry has been created, refined, and promoted serves as a template for future research endeavors.
Sujet(s)
Betacoronavirus , Bloc de branche/épidémiologie , Infections à coronavirus/épidémiologie , Bases de données factuelles , Pneumopathie virale/épidémiologie , Enregistrements , Infarctus du myocarde avec sus-décalage du segment ST/épidémiologie , Bloc de branche/étiologie , COVID-19 , Cause de décès , Infections à coronavirus/complications , Collecte de données/méthodes , Électrocardiographie , Humains , Ischémie myocardique/épidémiologie , Pandémies , Pneumopathie virale/complications , SARS-CoV-2 , Infarctus du myocarde avec sus-décalage du segment ST/étiologieSujet(s)
Cathétérisme cardiaque/normes , Infections à coronavirus/prévention et contrôle , Transmission de maladie infectieuse/prévention et contrôle , Prévention des infections/normes , Infarctus du myocarde/thérapie , Pandémies/prévention et contrôle , Pneumopathie virale/prévention et contrôle , Aérosols/effets indésirables , COVID-19 , Réanimation cardiopulmonaire/effets indésirables , Réanimation cardiopulmonaire/normes , Infections à coronavirus/étiologie , Infections à coronavirus/transmission , Unités hospitalières/normes , Humains , Transmission de maladie infectieuse du patient au professionnel de santé/prévention et contrôle , Intubation trachéale/effets indésirables , Intubation trachéale/normes , Sélection de patients , Intervention coronarienne percutanée/effets indésirables , Intervention coronarienne percutanée/normes , Équipement de protection individuelle/normes , Pneumopathie virale/étiologie , Pneumopathie virale/transmission , Guides de bonnes pratiques cliniques comme sujet/normes , Allocation des ressources/normes , Aspiration (technique)/effets indésirables , Aspiration (technique)/normesRÉSUMÉ
The optimal revascularization strategy for CAD in the TAVR population is not well-defined and decisions about which patients require PCI have been largely operator dependent or based on SYNTAX score. In a TAVR population, complete revascularization does not improve short or long term mortality, but is associated with decreased acute myocardial infarction and revascularization, when compared with incomplete revascularization. Future prospective studies should evaluate revascularization strategies in TAVR patients, including considering functional lesion assessment with fractional flow reserve, especially as TAVR indications are likely to soon expand to a younger and healthier cohort.
Sujet(s)
Maladie des artères coronaires/chirurgie , Intervention coronarienne percutanée , Remplacement valvulaire aortique par cathéter , Humains , Études prospectives , Résultat thérapeutiqueRÉSUMÉ
BACKGROUND: Rehospitalization for heart failure (HF) is common, and subclinical congestion may be present at discharge. Larger inferior vena cava (IVC) size and lower collapsibility at discharge assessed via bedside ultrasound are predictive of rehospitalization; however, the utility of IVC assessment with the use of pocket-carried ultrasound (PCUS) during the transition from discharge to the posthospitalization follow-up visit (FU) has not been investigated. METHODS AND RESULTS: IVCmax and IVCmin were measured with the use of PCUS, and the collapsibility index (IVCCIâ¯=â¯[IVCmaxâ¯-â¯IVCmin]/IVCmax) was determined. The primary outcome was 90-day rehospitalization or death. We prospectively enrolled 49 adults (71 ± 13 years of age, 51% male, 47% black, 43% preserved ejection fraction) hospitalized for HF. Nineteen patients (39%) experienced the outcome. Within the rehospitalized group, discharge and FU mean IVCmax were both >2.1 cm (2.2 ± 0.5 and 2.2 ± 0.7) and IVCCIs <50% (44 ± 20% and 45 ± 24%). Within those not rehospitalized, FU IVCmax was ≤2.1 cm (2.1 ± 0.6 and 1.9 ± 0.6; Pâ¯=â¯.038) and IVCCI >50% at both time points (55 ± 25% and 62 ± 19%; Pâ¯=â¯NS). FU IVCCI below an optimal cutoff of 42% had modest discrimination alone (c-statisticâ¯=â¯0.73). FU IVCCI <42% was associated with a greater hazard of the outcome independent of admission log B-type natriuretic peptide (adjusted hazard ratioâ¯=â¯6.8; 95% confidence interval 2.4-19.0; P < .001). CONCLUSIONS: Posthospitalization IVCCI assessment with PCUS predicts HF rehospitalization and may identify patients in need of intervention.
Sujet(s)
Défaillance cardiaque/thérapie , Réadmission du patient/statistiques et données numériques , Systèmes automatisés lit malade , Échographie/instrumentation , Veine cave inférieure/imagerie diagnostique , Maladie aigüe , Sujet âgé , Conception d'appareillage , Femelle , Études de suivi , Défaillance cardiaque/diagnostic , Défaillance cardiaque/physiopathologie , Humains , Mâle , Projets pilotes , Valeur prédictive des tests , Études prospectives , Facteurs tempsSujet(s)
Abcès/microbiologie , Vaisseaux coronaires/microbiologie , Lésions traumatiques du coeur/étiologie , Intervention coronarienne percutanée/effets indésirables , Infections dues aux prothèses/microbiologie , Infections à staphylocoques/microbiologie , Endoprothèses/effets indésirables , Lésions du système vasculaire/étiologie , Abcès/diagnostic , Abcès/thérapie , Sujet âgé , Coronarographie , Vaisseaux coronaires/imagerie diagnostique , Vaisseaux coronaires/traumatismes , Vaisseaux coronaires/chirurgie , Échocardiographie , Issue fatale , Lésions traumatiques du coeur/imagerie diagnostique , Humains , Mâle , Intervention coronarienne percutanée/instrumentation , Péricarde , Infections dues aux prothèses/diagnostic , Infections dues aux prothèses/thérapie , Choc septique/microbiologie , Infections à staphylocoques/diagnostic , Infections à staphylocoques/thérapie , Tomodensitométrie , Résultat thérapeutique , Lésions du système vasculaire/imagerie diagnostique , Lésions du système vasculaire/thérapieRÉSUMÉ
Stroke leads to significant morbidity, disability, and mortality after TAVR. CKD and prior stroke are risk factors for stroke. Stratification of stroke risk would improve outcomes associated with TAVR. Ongoing prospective randomized trials on embolic protection and post implant anticoagulation are promising strategies to reduce stroke risk and new brain MRI lesions.
Sujet(s)
Sténose aortique , Valve aortique/chirurgie , Humains , Études prospectives , Accident vasculaire cérébral , Facteurs temps , Remplacement valvulaire aortique par cathéter , Résultat thérapeutiqueRÉSUMÉ
OBJECTIVES: This study was designed to evaluate the efficacy and safety of the CardioDex arterial closure device, which is a novel femoral artery closure device used following percutaneous cardiac catheterization. BACKGROUND: Current devices utilized to achieve hemostasis of the femoral artery following percutaneous cardiac catheterization include collagen plug and suture mediated devices, but are associated with significant vascular complications. The CardioDex closure device utilizes thermal energy to cause collagen shrinking and swelling and thereby, achieve hemostasis. METHODS: The device was evaluated in a prospective nonrandomized single-center trial with patients undergoing 6F invasive cardiac procedures. Femoral artery puncture closure was performed immediately at completion of the procedure, followed by 3-4 minutes of manual compression. Time to hemostasis (TTH), time to ambulation (TTA), and short-term clinical follow-up data were collected. RESULTS: A total of 34 patients including 21 diagnostic and 13 interventional cases were evaluated. The median TTH was 3 min in diagnostic and 4 min in interventional cases. TTH was independent of activated clotting time (ACT). The median TTA was 2.75 hr and 3.37 hr in diagnostic and interventional groups, respectively. There were no major adverse events identified at 1 week and 30 day follow up. CONCLUSIONS: This first in human clinical experience with the CardioDex closure device demonstrates that in the small cohort studied, it is safe and effective in diagnostic cardiac catheterization and also in interventional cases on mild anticoagulation (mean ACT = 188 sec). It has the advantage of leaving no foreign material in the body following use.
Sujet(s)
Cathétérisme cardiaque/méthodes , Artère fémorale/chirurgie , Hémostase chirurgicale/instrumentation , Hémorragie postopératoire/chirurgie , Ponctions/méthodes , Adolescent , Adulte , Sujet âgé , Sujet âgé de 80 ans ou plus , Conception d'appareillage , Femelle , Études de suivi , Humains , Mâle , Adulte d'âge moyen , Études prospectives , Jeune adulteRÉSUMÉ
As programs to prepare advanced practice nurses for primary care have flourished during the past decade, faculty aspire to teach a health assessment course that is more than a review of undergraduate work. Therefore, course faculty constructed a list of advanced assessment competencies. The purpose of this descriptive study was to validate the competencies clinical preceptors' rated as important via a mailed survey. Overall, the competencies received high mean ratings. The item receiving the highest mean score was "detects and interprets abnormalities in rate and rhythm" from the heart body system. Items within the gynecological and breast systems received the highest ratings. This study suggests a need to help advanced practice nursing students master all advanced assessment competencies on the survey.