Impact of Pressure Recovery Adjustment on Aortic Valve Area Classification of Disease Severity in Transcatheter Aortic Valve Replacement Patients.

OBJECTIVES: To determine the impact of pressure recovery (PR) adjustment on disease severity grading in patients with severe aortic stenosis. The authors hypothesized that accounting for PR would result in echocardiographic reclassification of aortic stenosis severity in a significant number of patients. DESIGN: A retrospective observational study between October 2013 and February 2021. SETTING: A single-center, quaternary-care academic center. PARTICIPANTS: Adults (≥18 years old) who underwent transcatheter aortic valve implantation (TAVI). INTERVENTIONS: TAVI. MEASUREMENTS AND MAIN RESULTS: A total of 342 patients were evaluated in this study. Left ventricle mass index was significantly greater in patients who continued to be severe after PR (100.47 ± 28.77 v 90.15 ± 24.03, p = < 0.000001). Using PR-adjusted aortic valve area (AVA) resulted in the reclassification of 81 patients (24%) from severe to moderate aortic stenosis (AVA >1.0 cm2). Of the 81 patients who were reclassified, 23 patients (28%) had sinotubular junction (STJ) diameters >3.0 cm. CONCLUSION: Adjusting calculated AVA for PR resulted in a reclassification of a significant number of adult patients from severe to moderate aortic stenosis. PR was significantly larger in patients who reclassified from severe to moderate aortic stenosis after adjusting for PR. PR appeared to remain relevant in patients with STJ ≥3.0 cm. Clinicians need to be aware of PR and how to account for its effect when measuring pressure gradients with Doppler.

Preoperative Pulmonary Artery-to-Aorta Diameter Ratio as a Predictor of Postoperative Severe Right Ventricular Failure and 1-Year Mortality After Left Ventricular Assist Device Implantation.

OBJECTIVES: To evaluate the association of pulmonary artery diameter and pulmonary artery- to-aorta diameter ratio (PA/Ao) with right ventricular failure and mortality within 1 year after left ventricular assist device implantation. DESIGN: This was a retrospective observational study between March 2013 and July 2019. SETTING: The study was conducted at a single, quaternary-care academic center. PARTICIPANTS: Adults (≥18 years old) receiving a durable left ventricular assist device (LVAD). Inclusion if (1) a chest computed tomography scan was performed within 30 days before the LVAD and (2) a right and left heart catheterization was completed within 30 days before the LVAD. INTERVENTIONS: A left ventricular assist device was used for intervention. MEASUREMENTS AND MAIN RESULTS: A total of 176 patients were included in this study. Median PA diameter and PA/Ao ratio were significantly greater in the severe right ventricular failure (RVF) group (p = 0.001, p < 0.001, respectively). Receiver operating characteristic analysis revealed PA/Ao and RVF as predictors for mortality (area under the curve = 0.725 and 0.933, respectively). Logistic regression analysis-predicted probability gave a PA/Ao ratio cutoff point of 1.04 (p < 0.001). Survival probability was significantly worse in patients with a PA/Ao ratio ≥1.04 (p = 0.005). CONCLUSIONS: The PA/Ao ratio is an easily measurable noninvasive indicator that can predict RVF and 1-year mortality after LVAD implantation.

The association of sex with pain scores and perioperative opioid administration following laparoscopic sleeve gastrectomy.

Aim: We investigated whether sex is associated with pain scores and opioid administration after laparoscopic sleeve gastrectomy. Materials & methods: We performed a single-center, retrospective analysis of laparoscopic sleeve gastrectomy patients from December 2016-July 2018. Multivariable linear regressions were performed to investigate the association of sex with pain scores and opioid administration. Results: Baseline pain scores were similar between women and men (n = 266; 78% women). Men reported lower pain scores in all phases of care and received more opioids during their hospitalization (ß = 25.48; 95% CI: 5.77-45.20; p = 0.01), compared with women. Conclusion: Our data suggest that women self-report greater postoperative pain scores, while men received more opioids during their hospitalization. Further studies are needed to understand the reasons for such differences in postoperative pain management.

Men are at higher risk for long-term opioid use compared with women, but it remains unclear whether perioperative management is a sentinel event for such outcomes. Since patients who receive higher amounts of postoperative opioids are more likely to remain on long term narcotics, we investigated whether sex is associated with pain scores and opioid administration after bariatric surgery. We demonstrate that men self-report lower pain scores in the postanesthesia care unit, surgical floor and at discharge, compared with women. We also show that while men and women received comparable doses of opioids in the operating room and postanesthesia care unit, men received more opioids on the surgical floor. Our findings suggest that strategies to reduce opioid administration after bariatric surgery should largely focus on care after the immediate postoperative period.

Tissue Doppler Imaging (E/e') and Pulmonary Capillary Wedge Pressure in Patients With Severe Aortic Stenosis.

OBJECTIVE: Although American and European consensus statements advocate using the ratio of the transmitral E velocity and tissue Doppler early diastolic mitral annular velocity (E/e') in the assessment of left-sided heart filling pressures, recent reports have questioned the reliability of this ratio to predict left atrial pressures in a variety of disease states. The authors hypothesized that there is a clinically significant correlation between E/e' and pulmonary capillary wedge pressure (PCWP) in patients with severe aortic stenosis. DESIGN: Retrospective cohort study. PARTICIPANTS: The study comprised 733 consecutive patients with severe aortic stenosis who underwent transcatheter aortic valve replacement for severe aortic stenosis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: PCWP and E/e'ave (average of the lateral and medial annulus tissue Doppler velocities) were measured with a pulmonary artery catheter and transthoracic echocardiography during preprocedural evaluation. Patients were grouped by left ventricular ejection fraction (LVEF) ≥50% and LVEF <50%. Spearman rank correlation, analysis of variance, and t and chi-square tests were used to analyze the data. Seventy-nine patients met the inclusion criteria. There was no significant correlation between E/e'ave and PCWP (n = 79, Spearman r = 0.096; p = 0.3994). This correlation did not improve when ventricular function was considered (LVEF <50%: n = 11, Spearman r = -0.097; p = 0.776 and LVEF ≥50%: n = 68, Spearman r = 0.116; p = 0.345). There was no statistically significant difference in mean PCWP between each range of E/e'ave. CONCLUSION: A clinically relevant relationship between E/e' and PCWP was not observed in patients with severe aortic stenosis.

A Tale of Two Valves: Bioprosthetic Aortic Valve Obstruction in Systemic Lupus Erythematosus and Antiphospholipid Antibody Syndrome.

Patients with systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APLAS) are at risk for cardiac manifestations, specifically valvular heart disease requiring valve replacement. Bioprosthetic valve endocarditis is an important cause of valve failure, and it is important to keep a wide differential, especially in patients with preexisting SLE and APLAS. In this E-challenge, 2 cases of bioprosthetic aortic valve endocarditis are presented; 1 case describes infective bacterial endocarditis on an aortic prosthesis and the second describes a patient with SLE and APLAS who developed bioprosthetic valve obstruction secondary to vegetations, consistent with nonbacterial endocarditis and thrombus. Etiologies for bioprosthetic valve obstruction and evaluation by echocardiography are explored. The comparison between these 2 cases specifically highlights the importance of keeping a wide differential in endocarditis, prosthetic valve vegetations, and bioprosthetic valve obstruction.