Percutaneous coronary intervention for ventricular fibrillation in the setting of an anomalous right coronary artery.

We present a case of a quadriplegic male who developed ventricular fibrillation associated with an anomalous aortic origin of the right coronary artery. Successful revascularization was achieved with percutaneous coronary intervention. This case highlights the application of an unconventional approach to resolve ischemia in a patient with prohibitive surgical risk.

Precapillary Pulmonary Arterial Hypertension Despite Contrary Anchoring Bias.

We present the case of a patient with risk factors and a noninvasive evaluation that suggested postcapillary pulmonary hypertension, but in fact had invasive hemodynamics consistent with precapillary pulmonary hypertension. A thorough hemodynamic evaluation of pulmonary hypertension must be performed, as treatment is linked to the underlying physiology. (Level of Difficulty: Advanced.).

Sex Differences in Thoracic Aortic Disease and Dissection: JACC Review Topic of the Week.

Despite its higher prevalence among men, women with thoracic aortic aneurysm and dissection (TAAD) have lower rates of treatment and surgical intervention and often have worse outcomes. A growing number of women with TAAD also desire pregnancy, which can be associated with an increased risk of aortic complications. Understanding sex-specific differences in TAAD has the potential to improve care delivery, reduce disparities in treatment, and optimize outcomes for women with TAAD.

Cigarette Smoking and Competing Risks for Fatal and Nonfatal Cardiovascular Disease Subtypes Across the Life Course.

Background Cigarette smoking is significantly associated with premature death related and not related to cardiovascular disease (CVD). Whether risk associated with smoking is similar across CVD subtypes and how this translates into years of life lost is not known. Methods and Results We pooled and harmonized individual-level data from 9 population-based cohorts in the United States. All participants were free of clinical CVD at baseline with available data on current smoking status, covariates, and CVD outcomes. We examined the association between smoking status and total CVD and CVD subtypes, including fatal and nonfatal coronary heart disease, stroke, congestive heart failure, and other CVD deaths. We performed (1) modified Kaplan-Meier analysis to estimate long-term risks, (2) adjusted competing Cox models to estimate joint cumulative risks for CVD or noncardiovascular death, and (3) Irwin's restricted mean to estimate years lived free from and with CVD. Of 106 165 adults, 50.4% were women. Overall long-term risks for CVD events were 46.0% (95% CI, 44.7-47.3) and 34.7% (95% CI, 33.3-36.0) in middle-aged men and women, respectively. In middle-aged men who reported smoking compared with those who did not smoke, competing hazard ratios (HRs) were higher for the first presentation being a fatal CVD event (HR, 1.79 [95% CI, 1.68-1.92]), with a similar pattern among women (HR,1.82 [95% CI, 1.68-1.98]). Smoking was associated with earlier CVD onset by 5.1 and 3.8 years in men and women. Similar patterns were observed in younger and older adults. Conclusions Current smoking was associated with a fatal event as the first manifestation of clinical CVD.

Improving cardiology fellow education of right heart catheterization using a simulation based curriculum.

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.

Unique technical challenges in patients undergoing TAVR for failed aortic homografts.

OBJECTIVE: Surgical reoperation for aortic homograft structural valve degeneration (SVD) is a high-risk procedure. Transcatheter aortic valve replacement (TAVR) for homograft-SVD is an alternative to reoperation, but descriptions of implantation techniques are limited. This study compares outcome in patients undergoing into two groups by the type of previously implanted aortic valve prosthesis: TAVR for failed aortic homografts (TAVR-H) or for stented aortic bioprostheses (TAVR-BP). METHODS: From 2015 to 2017, TAVR was performed in 41 patients with SVD. Thirty-three patients in the TAVR-BP group (six for SVD of valved conduits), and eight patients in the TAVR-H group. The Valve Academic Research Consortium criteria were used for outcome reporting purposes. RESULTS: The patients with TAVR-BP had predominant prosthetic stenosis (94%, p = .002), whereas TAVR-H individuals presented mostly with regurgitation (88%, p = <.001). Patients with TAVR-H received: Sapien-3 (6), Sapien-XT (1), and CoreValve (1) devices. Low, 40% ventricular fixation in relation to homograft annulus was attempted to anchor the prosthesis on the homograft suture-line. One patient with TAVR-BP experienced intraoperative distal prosthesis migration and Type-B aortic dissection, and two patients in the TAVR-H group had late postoperative proximal device migration. In both groups, there was zero 30-day mortality, stroke, or pacemaker implantation. CONCLUSIONS: TAVR for failing aortic homografts may be a feasible and safe alternative to high-risk surgical reintervention. Precise, 40%-ventricular device positioning appears crucial for prevention of late paravalvular leak/late prosthesis migration and minimizing the risk of repeat surgical intervention.

Impact of Loop Diuretic Use on Outcomes Following Transcatheter Aortic Valve Implantation.

The use of LDT may signify significant hemodynamic changes and left ventricular remodeling in severe aortic stenosis (AS). Therefore, we sought to determine whether loop diuretic therapy (LDT) is associated with adverse outcomes following transcatheter aortic valve implantation (TAVI) in patients with severe symptomatic AS. Subjects undergoing TAVI at a single institution from June 2008 to December 2017 were analyzed. LDT doses were normalized to oral furosemide daily equivalents. All outcomes were adjudicated using VARC2 criteria. Descriptive statistics, multivariate logistic regression, and propensity score matching were used. Of the 804 subjects studied, 48.3% were on pre-TAVI LDT with a mean dose of 51.1 mg furosemide dose-equivalents. Subjects on LDT were higher risk, frail patients with more co-morbidities including chronic kidney disease, coronary artery disease requiring prior bypass grafting, peripheral arterial disease, atrial fibrillation or flutter, and diabetes with more severe heart failure symptoms. Those on LDT also had worse left ventricular systolic function, lower transvalvular gradients, and markers of adverse left ventricular remodeling, including increased left ventricular mass index and higher rates of concentric and eccentric hypertrophy. On propensity-score matching, death within one year post-TAVI was borderline significantly higher in the pre-LDT as compared with no-LDT group (16.9% vs 10.4 %, p = 0.068). In conclusion, use of pre-TAVI LDT for severe symptomatic AS is associated with a trend towards worse 1-year mortality and is a marker of high-risk, frail individuals with advanced left ventricular remodeling.

Transcatheter Aortic Valve Replacement Outcomes Based on the Presence of Chronic Total Occlusion.

AIMS: Chronic total occlusion (CTO) has been linked to worse survival. While controversial and limited to observational data, successful CTO percutaneous coronary intervention (PCI) has been associated with improved left ventricular (LV) function and mortality. However, the role of CTO PCI prior to transcatheter aortic valve replacement (TAVR) is not clear. We sought to explore the prognostic impact of a pre-TAVR CTO on post-TAVR outcomes. METHODS AND RESULTS: We retrospectively reviewed 783 consecutive TAVR cases performed at a single tertiary care medical center. Pre-TAVR angiograms were analyzed for the presence of a CTO. At the time of TAVR, 12.6% (n = 99) patients had a CTO. At one-year post-TAVR, there was no significant association between the presence of a CTO and death (14.2% vs 13.1%, p = 0.75), functional status, quality of life, or adverse events. There was also no difference in long-term survival (4.1 years vs 4.1 years, p = 0.55). LV ejection fraction was lower in the CTO group at baseline and one year (p < 0.01). CONCLUSIONS: The presence of a CTO did not have any prognostic impact on mortality, change in LV function, or improvement in functional status and angina scores following TAVR in our cohort of elderly, high-risk patients. CTO before TAVR was associated with decreased ejection fraction at baseline and at one year.

Comparison of Monitored Anesthesia Care and General Anesthesia for Transcatheter Aortic Valve Replacement.

OBJECTIVE: Transcatheter aortic valve replacement is a safe, minimally invasive treatment for severe aortic stenosis in patients with moderate-to-high surgical risk. Monitored anesthesia is administered by an anesthesiologist. This study compares transcatheter aortic valve outcomes under monitored anesthesia vs general anesthesia. METHODS: Data were prospectively collected for 286 patients undergoing transcatheter aortic valve replacement at a single academic hospital from March 2012 to August 2016. The patients were grouped by type of anesthesia: monitored vs general. A propensity score match was performed to compare intraoperative and post-operative outcomes between groups. RESULTS: General anesthesia was used in 102 patients and moderate sedation in 184. Propensity score matching produced 80 pairs. Compared to procedures under general anesthesia, patients receiving monitored anesthesia had shorter procedure (1.6 [1.4, 2.0] vs 2.0 [1.6, 2.5] hours;P < 0.001) and fluoroscopy times (17 [14.5, 22.5] vs 25 [17.9, 30.3] minutes;P < 0.001) and shorter hospital length-of-stay (3 [2.0, 4.0] vs 5 [3.0, 7.0] days;P < 0.001) but no difference in intensive care unit length-of-stay. Blood transfusion was more common in patients undergoing general anesthesia, but there was no difference in stroke, renal failure, postoperative atrial fibrillation, or need for permanent pacemaker. More patients were discharged to home after monitored anesthesia (90% vs 64%;P < 0.001). There was no difference in 30-day mortality (0% vs 3%;P = 0.15). CONCLUSIONS: Transcatheter aortic valve replacement under monitored anesthesia provides the safety of anesthesia-led sedation without intubation and general anesthetic. We found no compromise in patient safety or clinical outcomes.

Conduction recovery following pacemaker implantation after transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is increasingly used to treat severe aortic stenosis. A frequent complication of TAVR is high-grade or complete atrioventricular (AV) block requiring a permanent pacemaker (PPM). There are little data on the long-term dependency on pacing after TAVR. The objective of this study was to determine the proportion of patients receiving a PPM for high-grade or complete AV block after TAVR who remain dependent on the PPM in follow-up and to determine any risk factors for, particularly the effect of postballoon dilation (PBD) on, pacemaker dependency. METHODS: Of 594 consecutive patients without prior PPM undergoing TAVR (81.9% balloon-expandable, 18.1% self-expandable valve), 67 (13.1%) received a PPM after TAVR. PPM dependency was defined as AV block with a ventricular escape rate of ≤ 40 beats/min. Patient and procedural characteristics were examined according to PPM dependency status. RESULTS: Of the 67 patients who received a PPM within 10 days after TAVR, 27/67 (40.3%) were dependent at first follow-up and only 9/41 (21.9%) at 1 year. PPM dependency was more common after a self-expanding valve (76.9% vs 31.5%, P < 0.01), in those who underwent PBD (66.7% vs 24.4%, P < 0.01), and in patients in persistent complete AV block at PPM implantation (62.5% vs 7.4%, P < 0.01). CONCLUSIONS: Fewer than half of patients who receive a new PPM following TAVR are pacemaker dependent at early follow-up (< 30 days). The use of self-expanding valves and PBD are associated with a markedly increased risk of PPM dependency.

Association of Body Mass Index With Lifetime Risk of Cardiovascular Disease and Compression of Morbidity.

Importance: Prior studies have demonstrated lower all-cause mortality in individuals who are overweight compared with those with normal body mass index (BMI), but whether this may come at the cost of greater burden of cardiovascular disease (CVD) is unknown. Objective: To calculate lifetime risk estimates of incident CVD and subtypes of CVD and to estimate years lived with and without CVD by weight status. Design, Setting, and Participants: In this population-based study, we used pooled individual-level data from adults (baseline age, 20-39, 40-59, and 60-79 years) across 10 large US prospective cohorts, with 3.2 million person-years of follow-up from 1964 to 2015. All participants were free of clinical CVD at baseline with available BMI index and CVD outcomes data. Data were analyzed from October 2016 to July 2017. Exposures: World Health Organization-standardized BMI categories. Main Outcomes and Measures: Total CVD and CVD subtype, including fatal and nonfatal coronary heart disease, stroke, congestive heart failure, and other CVD deaths. Heights and weights were measured directly by investigators in each study, and BMI was calculated as weight in kilograms divided by height in meters squared. We performed (1) modified Kaplan-Meier analysis to estimate lifetime risks, (2) adjusted competing Cox models to estimate joint cumulative risks for CVD or noncardiovascular death, and (3) the Irwin restricted mean to estimate years lived free of and with CVD. Results: Of the 190 672 in-person examinations included in this study, the mean (SD) age was 46.0 (15.0) years for men and 58.7 (12.9) years for women, and 140 835 patients (73.9%) were female. Compared with individuals with a normal BMI (defined as a BMI of 18.5 to 24.9), lifetime risks for incident CVD were higher in middle-aged adults in the overweight and obese groups. Compared with normal weight, among middle-aged men and women, competing hazard ratios for incident CVD were 1.21 (95% CI, 1.14-1.28) and 1.32 (95% CI, 1.24-1.40), respectively, for overweight (BMI, 25.0-29.9), 1.67 (95% CI, 1.55-1.79) and 1.85 (95% CI, 1.72-1.99) for obesity (BMI, 30.0-39.9), and 3.14 (95% CI, 2.48-3.97) and 2.53 (95% CI, 2.20-2.91) for morbid obesity (BMI, ≥40.0). Higher BMI had the strongest association with incident heart failure among CVD subtypes. Average years lived with CVD were longer for middle-aged adults in the overweight and obese groups compared with adults in the normal BMI group. Similar patterns were observed in younger and older adults. Conclusions and Relevance: In this study, obesity was associated with shorter longevity and significantly increased risk of cardiovascular morbidity and mortality compared with normal BMI. Despite similar longevity compared with normal BMI, overweight was associated with significantly increased risk of developing CVD at an earlier age, resulting in a greater proportion of life lived with CVD morbidity.