Transapical Mitral Valve-in-Valve Replacement in Patient With Previous Complex Sternal Reconstruction.

We present a complex case of a transapical redo mitral valve-in-valve replacement. Repeat mitral valve replacement was indicated for severe symptomatic bioprosthetic stenosis. In addition to the patient's numerous comorbidities that included diabetes, hepatic cirrhosis, ischemic cardiomyopathy, and atrial flutter, he had undergone a previous open mitral valve replacement that was complicated by sternal dehiscence requiring extensive chest wall reconstruction. Transapical approach was performed through left minithoracotomy incision with balloon-expandable valve. Transapical valve-in-valve replacement of a stenotic mitral bioprosthesis is a viable solution in a patient with previous complex chest wall reconstruction and multiple comorbidities.

Improvement in All-Cause Mortality With Blood Pressure Control in a Group of US Veterans With Drug-Resistant Hypertension.

The current definition of drug-resistant hypertension includes patients with uncontrolled (URH) (taking ≥3 antihypertensive medications) and controlled hypertension (CRH; blood pressure [BP] ≤140/90 mm Hg) (taking ≥4 medications). The authors hypothesized that all-cause mortality is reduced when URH is controlled. Qualified patients followed at the Washington DC VA Medical Center were included. BPs were averaged for each year of follow-up. In 2006, among 2906 patients who met the criteria for drug-resistant hypertension, 628 had URH. During follow-up, 234 patients were controlled (group 1) and 394 patients remained uncontrolled (group 2). The mortality rate among patients with URH was 28% (110 of 394) and among patients with CRH was 13% (30 of 234), a 54% reduction (P<.01). Multivariate analysis identified independent predictors of mortality as uncontrolled HTN (hazard ratio, 2.5; 95% confidence interval, 1.67-3.75; P<.01), age (hazard ratio, 1.03; 95% confidence interval, 1.01-1.04; P<.01), and diabetes (hazard ratio, 1.46; 95% confidence interval, 1.04-2.05; P<.027). The authors conclude that controlling drug-resistant hypertension markedly reduces all-cause mortality.

Comparison of Bleeding Outcomes After Percutaneous Coronary Intervention in Patients With Versus Without Aortic Stenosis.

Aortic stenosis (AS) is associated with an increased risk of bleeding, but little is known about the risk of bleeding during percutaneous coronary intervention (PCI) in patients with AS. In the era of transcutaneous aortic valve implantation, understanding the bleeding risks associated with AS is critical. This retrospective study included 7,926 patients who underwent PCI from 2004 to 2013. Patients were categorized according to the presence of significant AS: moderate or severe AS (n = 354) and mild or no AS (n = 7,572). The National Cardiovascular Data Registry (NCDR) definition of a bleeding event (transfusion, prolonged hospital stay, or decrease in hemoglobin >3.0 mg/dl) was used as the primary outcome, and the NCDR PCI Bleeding Risk Score was used to control for the underlying risk of bleeding because of baseline characteristics. Patients with AS had significantly higher NCDR PCI Bleeding Risk Scores and higher rates of bleeding events. Logistic regression showed that the NCDR PCI Bleeding Risk Score did predict bleeding outcomes. There was not, however, an independent association between AS and bleeding outcomes. The addition of AS to the risk score using net reclassification improvement did not enhance the model's ability to predict bleeding (p = 0.71). These data suggest that the NCDR PCI Bleeding Risk Score appropriately adjusts for bleeding risks in patients with AS. In conclusion, although patients with AS are more likely to have bleeding complications after PCI, the increased risk of bleeding is driven by the patients' baseline co-morbidities rather than their AS.

Safety and long-term outcomes after percutaneous coronary intervention in patients with human immunodeficiency virus.

OBJECTIVE: This study aims to report the long-term outcomes after percutaneous coronary intervention (PCI) in human immunodeficiency virus (HIV+) patients. BACKGROUND: Sparse data exists regarding the risk of patients with HIV who undergo PCI. METHODS: Using a case-control design, we compared baseline characteristics, procedure-related outcomes, in-hospital, and 2-year clinical outcomes of 112 consecutive HIV+ patients versus 112 HIV- controls matched for age, gender, and diabetes mellitus who underwent PCI from April 2003 to September 2011. RESULTS: Baseline characteristics were generally comparable, save for more African Americans and history of chronic renal insufficiency in the HIV+ vs. HIV- group (62.5% vs. 21.4%, P < 0.001) and (27.7% vs. 9.9%, P < 0.001). There was no correlation between CD4 nadir count and extent and diffuseness of coronary artery disease. The occurrence of major adverse cardiac events at 2 years was similar in both groups. Multivariable analysis for independent correlates of major adverse cardiac events at 2 years detected patients with a history of chronic renal insufficiency (OR: 2.44, 95% confidence interval: 1.02-5.83; P = 0.04) and acute myocardial infarction (OR: 2.92, 95% confidence interval: 1.39-6.15; P = 0.005) as correlates for outcome. Post-hoc analysis showed that drug-eluting stent (DES) use in the HIV+ group was beneficial. CONCLUSION: PCI in HIV+ patients is safe, with high procedural success rates, and produces similar outcomes to those seen in HIV- patients at 2 years. HIV+ patients should be treated with DES if possible.

Impact of intensive glycemic control on the incidence of atrial fibrillation and associated cardiovascular outcomes in patients with type 2 diabetes mellitus (from the Action to Control Cardiovascular Risk in Diabetes Study).

Atrial fibrillation (AF) is prevalent in patients with type 2 diabetes mellitus (DM) and is associated with markers of poor glycemic control; however, the impact of glycemic control on incident AF and outcomes is unknown. The aims of this study were to prospectively evaluate if intensive glycemic control in patients with DM affects incident AF and to evaluate morbidity and mortality in patients with DM and incident AF. A total of 10,082 patients with DM from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) cohort were studied in a randomized, double-blind fashion. Participants were randomized to an intensive therapeutic strategy targeting a glycated hemoglobin level of <6.0% or a standard strategy targeting a glycated hemoglobin level of 7.0% to 7.9%. Incident AF occurred in 159 patients (1.58%) over the follow-up period, at a rate of 5.9 per 1,000 patient-years in the intensive-therapy group and a rate of 6.37 per 1,000 patient-years in the standard-therapy group (p = 0.52). In a multivariate model, predictors of incident AF were age, weight, diastolic blood pressure, heart rate, and heart failure history. Patients with DM and new-onset AF had a hazard ratio of 2.65 for all-cause mortality (95% confidence interval 1.8 to 3.86, p <0.0001), a hazard ratio of 2.1 for myocardial infarction (95% confidence interval 1.33 to 3.31, p = 0.0015), and a hazard ratio of 3.80 for the development of heart failure (95% confidence interval 2.48 to 5.84, p <0.0001). In conclusion, intensive glycemic control did not affect the rate of new-onset AF. Patients with DM and incident AF had an increased risk for morbidity and mortality compared with those without AF.

Overview of the 2012 Food and Drug Administration circulatory system devices panel meeting on the reclassification of external counterpulsation, intra-aortic balloon pump, and non-roller-type cardiopulmonary bypass blood pump devices.

The Food and Drug Administration held a Circulatory System Devices Advisory Panel meeting, December 5 and 6, 2012, to review the classification or potential reclassification of the following device types: external counterpulsation, intra-aortic balloon pump (IABP), and non-roller-type cardiopulmonary bypass blood pumps. These 3 devices are preamendment (Medical Device Amendments of 1976) class III devices. The advisory panel discussed the data and provided recommendations for reclassification of these devices. The panel recommended reclassification of ECP to class II for stable angina pectoris and to retain a class III for all other indications. For IABP, the recommendation was to reclassify IABP to class II for several indications (acute coronary syndrome, cardiac and noncardiac surgery, and heart failure complications) and remain class III for all other indications. As for non-roller type, the panel recommended that for cardiopulmonary bypass and temporary circulatory bypass, these devices should be reclassified to class II while retaining a class III device status for all other indications, including ventricular support both for hemodynamically unstable patients and for prophylactic support in high-risk percutaneous interventions.

Red cell distribution width as a bleeding predictor after percutaneous coronary intervention.

BACKGROUND: Red cell distribution width (RDW), a measure of variability in the size of circulating erythrocytes, is an independent predictor of mortality in cardiovascular disease and in patients undergoing percutaneous coronary intervention (PCI). We set out to determine if RDW is a prognostic marker of major bleeding post-PCI. METHODS: The study population included 6,689 patients who were subjected to PCI. The RDW was derived from a complete blood count drawn before PCI. Major inhospital bleeding was defined as a hematocrit decrease ≥12%, hemoglobin drop of ≥4, transfusion of ≥2 units of packed red blood cells, retroperitoneal, or gastrointestinal or intracranial bleeding. Multivariable logistic analysis of major inhospital bleeding was performed using a logistic regression model that comprised the National Cardiovascular Data Registry (NCDR) risk score model as a single variable. RESULTS: Major bleeding (P < .001), vascular complications (P = .005), and transfusions (P < .001) were significantly higher in patients with higher baseline RDW values. After adjustment for known bleeding correlates, RDW was a significant predictor for major bleeding (odds ratio 1.12, 95% CI 1.06-1.19, P < .001). Although the c statistic of the NCDR risk prediction model changed from 0.730 to 0.737 (P = .032), the net reclassification improvement increased significantly after the addition of RDW as a continuous variable (17.3% CI 6.7%-28%, P = .002). CONCLUSIONS: Red cell distribution width, an easily obtainable marker, has an independent, linear relationship with major bleeding post-PCI and incrementally improves the well-validated NCDR risk prediction model. These data suggest that further investigation is necessary to determine the relationship of RDW and post-PCI bleeding.

Components of the complete blood count as risk predictors for coronary heart disease: in-depth review and update.

Atherosclerosis is an inflammatory disease, and several inflammatory biomarkers, such as C-reactive protein, have been used to predict the risk of coronary heart disease. High white blood cell count is a strong and independent predictor of coronary risk in patients of both sexes, with and without coronary heart disease. A high number of white blood cells and their subtypes (for example, neutrophils, monocytes, lymphocytes, and eosinophils) are associated with the presence of coronary heart disease, peripheral arterial disease, and stroke. The coronary heart disease risk ratios associated with a high white blood cell count are comparable to those of other inflammatory markers, including C-reactive protein. In addition, other components of the complete blood count, such as hematocrit and the erythrocyte sedimentation rate, also are associated with coronary heart disease, and the combination of the complete blood count with the white blood cell count can improve our ability to predict coronary heart disease risk. These tests are inexpensive, widely available, and easy to order and interpret. They merit further research.

Red cell distribution width is a predictor of mortality in patients undergoing percutaneous coronary intervention.

Red cell distribution width (RDW), a measure of the variability in size of circulating erythrocytes, is an independent predictor of mortality in patients with cardiovascular disease. We hypothesized that RDW is a prognostic marker of death, myocardial infarction and unplanned revascularization in a broad population undergoing percutaneous coronary intervention (PCI). We investigated the prognostic value of RDW derived from a complete blood count drawn ≤24 h of PCI in 1,689 patients at four centers who underwent PCI between 2004 and 2007 in the evaluation of drug eluting stents and ischemic events registry. Patients who underwent blood transfusions were excluded. Multivariable analyses of death, MI, unplanned revascularization, and the combined occurrence of these events at 1 year were performed using methods from survival analysis. The analysis was adjusted for creatinine ≥1.5 mg/dL, hemoglobin, congestive heart failure, coronary artery bypass grafting history, male sex, BMI, atherosclerosis of ≥2 coronary vessels, and hypertension. In univariate analysis of RDW stratified by quartiles, membership in the highest quartile was a predictor of mortality as compared to the lowest quartile (HR 5.07, CI 2.07-12.40, p < 0.001). In multivariate analysis, RDW was not an independent predictor of unplanned revascularization after PCI; however, RDW remained an independent correlate of 1 year mortality (HR 1.65, CI 1.22-2.23, p = 0.001); with a continuous net reclassification improvement of 46.5% (95% CI 15.1-76.4%) and a relative integrated discrimination improvement of 57.8% (95% CI 22.1-94.9%) after PCI. RDW is a widely available independent correlate of 1-year mortality after PCI that increases the discriminative value of risk prediction in these patients.

Recurrent low-level troponin I elevation is a worse prognostic indicator than occasional injury pattern in patients hospitalized with heart failure.

BACKGROUND: Elevated troponin at baseline is associated with higher mortality in heart failure (HF) patients, but the prognostic role of recurrently elevated troponin is not well described. METHODS AND RESULTS: We performed chart reviews of 196 HF patients without acute coronary syndrome, with at least three Troponin I (TnI) measurements on different admissions. For the analyses, three sets of TnI values closest to baseline, one year and two years were selected for each patient. Based on the three sets of TnI, the lowest value of TnI (minimum), the highest value of TnI (maximum), median value of TnI and delta TnI (3rd TnI-baseline TnI) were derived for each patient. The study population of 196 patients had 632 person-year follow-up, consisted predominantly of elderly (68 ± 10 years) male patients (99%) with mean ejection fraction of 26 ± 13%. Using multivariate Cox proportional hazards model only minimum TnI, but not the maximum, median or delta of TnI values, was significantly associated with mortality (HR: 13.7, 95% CI: 3.7 to 50.8, p<0.001). As a categorical variable, minimum TnI value of >0.04ng/ml was also independently associated with mortality (p=0.01, HR=1.6, 95% CI: 1.1 to 2.3). CONCLUSIONS: In HF patients without acute coronary syndrome, the persistence of TnI elevation, even at low levels, is associated with a worse survival than sporadic TnI elevations of higher magnitude or any single elevation in TnI; and a recurrent elevation of TnI >0.04ng/ml portends a poor prognosis.

The association between Staphylococcus aureus bacteremia and acute myocardial infarction.

We evaluated a possible association between S. aureus bacteremia (SAB) and the occurrence of myocardial infarction (MI) in 588 patients using the self-controlled case series method. SAB increased the risk for MI 35-fold in the 2 d after recognition of this infection (IRR = 35.3; CI 16.7-74.7).

Cardiac cycle-dependent left atrial dynamics: implications for catheter ablation of atrial fibrillation.

BACKGROUND: Left atrial (LA) volume determines prognosis and response to therapy for atrial fibrillation. Integration of electroanatomic maps with three-dimensional images rendered from computed tomography and magnetic resonance imaging (MRI) is used to facilitate atrial fibrillation ablation. OBJECTIVE: The purpose of this study was to measure LA volume changes and regional motion during the cardiac cycle that might affect the accuracy of image integration and to determine their relationship to standard LA volume measurements. METHODS: MRI was performed in 30 patients with paroxysmal atrial fibrillation. LA time-volume curves were generated and used to divide LA ejection fraction into pumping ejection fraction and conduit ejection fraction and to determine maximum LA volume (LA(max)) and preatrial contraction volume. LA volume was measured using an MRI angiogram and traditional geometric models from echocardiography (area-length model and ellipsoid model). In-plane displacement of the pulmonary veins, anterior left atrium, mitral annulus, and LA appendage was measured. RESULTS: LA(max) was 107 +/- 36 mL and occurred at 42% +/- 5% of the R-R interval. Preatrial contraction volume was 86 +/- 34 mL and occurred at 81% +/- 4% of the R-R interval. LA ejection fraction was 45% +/- 10%, and pumping ejection fraction was 31% +/- 10%. LA volume measurements made from MRI angiogram, area-length model, and ellipsoid model underestimated LA(max) by 21 +/- 25 mL, 16 +/- 26 mL, and 35 +/- 22 mL, respectively. Anterior LA, mitral annulus, and LA appendage were significantly displaced during the cardiac cycle (8.8 +/- 2.0 mm, 13.2 +/- 3.8 mm, and 10.2 +/- 3.4 mm, respectively); the pulmonary veins were not displaced. CONCLUSION: LA volume changes significantly during the cardiac cycle, and substantial regional variation in LA motion exists. Standard measurements of LA volume significantly underestimate LA(max) compared to the gold standard measure of three-dimensional volumetrics.