Percutaneous mitral heart valve repair--MitraClip.

Mitral regurgitation (MR) is the most common cardiac valvular disease in the United States. Approximately 4 million people have severe MR and roughly 250,000 new diagnoses of MR are made each year. Mitral valve surgery is the only treatment that prevents progression of heart failure and provides sustained symptomatic relief. Mitral valve repair is preferred over replacement for the treatment of MR because of freedom from anticoagulation, reduced long-term morbidity, reduced perioperative mortality, improved survival, and better preservation of left ventricular function compared with valve replacement. A large proportion of patients in need of valve repair or replacement do not undergo such procedures because of a perceived unacceptable perioperative risk. Percutaneous catheter-based methods for valvular pathology that parallel surgical principles for valve repair have been developed over the last few years and have been proposed as an alternate measure in high-risk patients. The MitraClip (Abbott Labs) device is one such therapy and is the subject of this review.

Trends in incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction in the United States.

BACKGROUND: Limited information is available on the contemporary and potentially changing trends in the incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: We queried the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥ 40 years of age with STEMI and cardiogenic shock. Overall and age-, sex-, and race/ethnicity-specific trends in incidence of cardiogenic shock, early mechanical revascularization, and intra-aortic balloon pump use, and inhospital mortality were analyzed. From 2003 to 2010, among 1 990 486 patients aged ≥ 40 years with STEMI, 157 892 (7.9%) had cardiogenic shock. The overall incidence rate of cardiogenic shock in patients with STEMI increased from 6.5% in 2003 to 10.1% in 2010 (P(trend)<0.001). There was an increase in early mechanical revascularization (30.4% to 50.7%, P(trend)<0.001) and intra-aortic balloon pump use (44.8% to 53.7%, P(trend)<0.001) in these patients over the 8-year period. Inhospital mortality decreased significantly, from 44.6% to 33.8% (P(trend)<0.001; adjusted OR, 0.71; 95% CI, 0.68 to 0.75), whereas the average total hospital cost increased from $35 892 to $45 625 (P(trend)<0.001) during the study period. There was no change in the average length of stay (P(trend)=0.394). These temporal trends were similar in patients <75 and ≥ 75 years of age, men and women, and across each racial/ethnic group. CONCLUSIONS: The incidence of cardiogenic shock complicating STEMI has increased during the past 8 years together with increased use of early mechanical revascularization and intra-aortic balloon pumps. There has been a concomitant decrease in risk-adjusted inhospital mortality, but an increase in total hospital costs during this period.

ST-elevation myocardial infarction in the elderly--temporal trends in incidence, utilization of percutaneous coronary intervention and outcomes in the United States.

BACKGROUND: Elderly patients with ST-elevation myocardial infarction (STEMI) are often underrepresented in major percutaneous coronary intervention (PCI) trials. Use of PCI for STEMI, and associated outcomes in patients aged ≥65 years with STEMI needed further investigation. METHODS: We used the 2001-2010 United States Nationwide Inpatient Sample (NIS) database to examine the temporal trends in STEMI, use of PCI for STEMI, and outcomes among patients aged 65-79 and ≥80 years. RESULTS: During 2001-2010, of 4,017,367 patients aged ≥65 years with acute myocardial infarction (AMI), 1,434,579 (35.7%) had STEMI. Over this period, among patients aged 65-79 and ≥80 years, STEMI decreased by 16.4% and 19%, whereas the use of PCI for STEMI increased by 33.5% and 22%, respectively (Ptrend<0.001). There was a significant decrease in age-adjusted in-hospital mortality (per 1000) in patients aged ≥80 years (150 versus 116, Ptrend=0.02) but not in patients aged 65-79 years (63 versus 59, Ptrend=0.886). Stepwise logistic regression identified intra-aortic balloon pump use, acute renal failure, acute cerebrovascular disease, age ≥80 years, peripheral vascular disease, gastrointestinal bleeding, female gender, congestive heart failure, chronic lung disease, weekend admission and multivessel PCI as independent predictors of in-hospital mortality among all patients ≥65 years of age who underwent PCI for STEMI. CONCLUSIONS: In this large, multi-institutional cohort of elderly patients, a decreasing trend in STEMI, an increasing trend in PCI utilization for STEMI, and reduction in in-hospital mortality were observed from 2001 to 2010.

Second-hand tobacco smoke and cardiovascular disease risk: an epidemiological review.

In this review, we have sought to examine the epidemiological, basic science, and public health data regarding the association between second-hand smoke (SHS) exposure and the development of coronary heart disease (CHD). SHS increases the risk of CHD by 25-30% according to multiple cohort, case-control, and meta-analytical studies. Physiologic and basic science research suggest that the mechanisms by which SHS affects the cardiovascular system are multiple and include increased thrombogenesis and low-density lipoprotein oxidation, decreased exercise tolerance, dysfunctional flow-mediated vasodilatation, and activation of inflammatory pathways with concomitant oxidative damage and impaired vascular repair. As a result, chronic exposure promotes atherogenesis and the development of cardiovascular disease, increasing the risk of having an acute coronary syndrome (ACS). With the implementation of statewide and nationwide public smoke-free legislation across the United States and Europe, respectively, over the last 10-15 years, there has been a significant and reciprocal decline in the incidence of emergency admissions for ACS by an average 17% despite persistent attempts on the part of the tobacco industry to diminish the correlation between SHS exposure and CHD. These findings underscore the importance of the effects of smoking legislation on community health.

Mitral Stenosis, Sinus Venosus Atrial Septal Defect, and Partial Anomalous Pulmonary Venous Return: Diagnosis by Multiplane Transesophageal Echocardiography.

We describe a 42-year-old man with rheumatic mitral stenosis, sinus venosus atrial septal defect, and anomalous drainage of the right upper pulmonary vein to the superior vena cava. Transthoracic echocardiography (TTE) failed to identify the atrial septal defect and the partial anomalous pulmonary venous return. Transesophageal echocardiography (TEE), using a multiplane probe, was useful in delineating the abnormalities. To our knowledge, this is the first reported patient with rheumatic mitral stenosis and sinus venosus defect. (ECHOCARDIOGRAPHY, Volume 13, November 1996)