Effect of ascending aorta replacement on the long-term outcomes of bicuspid aortic valve repair.

OBJECTIVE: The study objective was to determine the effect of sinutubular junction stabilization on long-term outcomes of bicuspid aortic valve repair. METHODS: From January 1998 to January 2020, 419 patients underwent bicuspid aortic valve repair with ascending aorta replacement and 421 without (bicuspid aortic valve repair alone). Propensity score matching (97 pairs) was used to compare outcomes. RESULTS: Before matching, prevalence of severe aortic regurgitation at 10 years was 5.4% after bicuspid aortic valve repair + ascending aorta replacement and 10% after bicuspid aortic valve repair alone; aortic valve gradient was 20 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 19 mm Hg after bicuspid aortic valve repair alone. Ten-year freedom from reoperation overall was 79% after bicuspid aortic valve repair + ascending aorta replacement and 75% after bicuspid aortic valve repair alone; freedom from late aortic regurgitation was 93% after bicuspid aortic valve repair + ascending aorta replacement and 92% after bicuspid aortic valve repair alone; and freedom from aortic stenosis was 87% after bicuspid aortic valve repair + ascending aorta replacement and 93% after bicuspid aortic valve repair alone. Ten-year survival was 95% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone. After matching, prevalence of severe aortic regurgitation at 10 years was 11% after bicuspid aortic valve repair + ascending aorta replacement and 9.1% after bicuspid aortic valve repair alone (P = .33); aortic valve gradient was 16 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 25 mm Hg after bicuspid aortic valve repair alone (P < .0001). Ten-year freedom from reoperation was 85% after bicuspid aortic valve repair + ascending aorta replacement and 72% after bicuspid aortic valve repair alone (P = .08) overall. Ten-year freedom from reoperation for late aortic regurgitation was 88% after bicuspid aortic valve repair + ascending aorta replacement and 86% after bicuspid aortic valve repair alone (P = .65). Freedom from aortic stenosis was 97% after bicuspid aortic valve repair + ascending aorta replacement and 91% after bicuspid aortic valve repair alone (P = .03). Ten-year survival was 96% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone (P = .16). CONCLUSIONS: Bicuspid aortic valve repair with or without ascending aorta replacement is associated with good short- and long-term outcomes. Bicuspid aortic valve repair + ascending aorta replacement has a minimal effect on long-term repair durability. Sinutubular junction stabilization should not be performed for the sole purpose of long-term repair durability.

N-3 polyunsaturated fatty acids for cardiovascular risk.

PURPOSE OF REVIEW: Use of omega-3 fatty acid (OM3FA) supplements to reduce risk of cardiovascular events has been investigated, largely without evidence of meaningful benefit, over the last 4 decades. RECENT FINDINGS: The first contemporary clinical trial to show benefit of OM3FA use was the REDUCE-IT trial (2018), showing a remarkable 25% relative risk reduction in the intervention group that received icosapent ethyl 4 g daily compared to a mineral oil placebo group. The STRENGTH trial (2020), which was similar in design to the REDUCE-IT trial but compared 4 g daily dose of combined OM3FA with a corn oil placebo, was terminated early due to futility. SUMMARY: This article provides a review of the data surrounding these trials and discusses the differing results of the two trials. There are key differences in the design of the two trials, the most notable is the use of mineral oil in the REDUCE-IT trial, which was potentially a nonneutral comparator. Additionally, both trials showed an increase in the incidence of atrial fibrillation. With the unclear benefit of OM3FA supplementation and possibility of harm, the current data suggest that the risk of routine use of OM3FA outweighs the possibility of reduction in risk of cardiovascular events.

Acute Limb Ischemia Secondary to Patent Foramen Ovale-Mediated Paradoxical Embolism: A Case Report and Systematic Review of the Literature.

BACKGROUND: Paradoxical embolism is the translocation of a thrombus originating in the systemic venous circulation into the arterial circulation through a cardiac defect, most commonly a patent foramen ovale (PFO). PFO exists in 15-35% of the adult population. The most common manifestation is cerebrovascular accident; acute limb ischemia is much rarer. METHODS: A 67-year-old woman with multiple confounding risk factors for hypercoagulability presented with grade IIb left lower limb ischemia secondary to thromboembolism through a previously silent PFO. Management included urgent embolectomy, prophylactic fasciotomy, postoperative anticoagulation, and PFO closure. A systematic literature review of PFO-mediated acute limb ischemia was performed to identify the patient populations most commonly affected, the anatomic distribution of emboli, and patient management. RESULTS: Forty-three reports including 51 patients with first-time PFO-mediated paradoxical embolism were identified. Fifty-one percent were men, and the average age at presentation was 54 years. Multiple limbs were affected in 14 patients (27.5%), and a propensity for the lower limbs (72%) and left-sided circulation (82%) was noted. Deep venous thromboembolism was identified in 36 patients (71%). Immediate anticoagulation was instituted in 31 patients. Embolectomy and/or fibrinolysis were performed in 45 patients (88%). CONCLUSIONS: Acute limb ischemia is a rare manifestation of PFO-mediated paradoxical embolism that requires a high index of suspicion for diagnosis. Middle-aged individuals appear to be more commonly affected, and acute limb ischemia most often occurs in the lower limbs and left-sided circulation, with the potential to affect multiple extremities simultaneously. Prompt identification and surgical embolectomy with prophylactic fasciotomy can facilitate successful outcomes. Perioperative management should include anticoagulation and may include workup with echocardiography, duplex ultrasound, and hypercoagulability testing.

Heart rate increase after pulmonary vein isolation predicts freedom from atrial fibrillation at 1 year.

INTRODUCTION: Ablation of atrial vagal ganglia has been associated with improved pulmonary vein isolation (PVI) outcomes. Disruption of vagal reflexes results in heart rate (HR) increase. We investigated the association between HR change after PVI and freedom from atrial fibrillation (AF) at 1 year. METHODS AND RESULTS: Patients who underwent PVI for paroxysmal AF were identified from the Johns Hopkins Hospital AF registry. Electrocardiograms taken pre-PVI and post-PVI were used to determine the change in HR. Patients followed-up at 3, 6, and 12 months. Of 257 patients (66% male, age 59+/-11 years), 134 (52%) remained free from AF at 1 year. The average HR increased from 60.6 ± 11.3 beats per minute (bpm) pre-PVI to 70.7 ± 12.0 bpm post-PVI. Patients with recurrence of AF had lower post-PVI HR than those who remained free from AF (67.8 ± 0.2 vs 73.3 ± 13.0 bpm; P <.001). The probability of AF recurrence at 1-year decreased as the change in HR increased (estimated odds ratio [OR], 0.83; 95% confidence interval [CI, 0.74-0.93]; P = .002). HR increase more than 15 bpm was associated with the lowest odds of AF recurrence (estimated OR, 0.39; 95% [0.17-0.85]; P = .018) compared to HR decrease. CONCLUSIONS: Resting HR was found to increase after PVI. Increase in HR more than 15 bpm has a positive association with remaining free from atrial fibrillation at 1 year.

Drug discount cards in an era of higher prescription drug prices: A retrospective population-based study.

OBJECTIVES: Drug discount programs have emerged as a potential option for patients seeking greater accessibility and affordability. However, there is limited knowledge regarding program utilization and cost savings. The objective of this study was to evaluate medication prescriptions with drug discount card usage and estimate cost savings. DESIGN: Retrospective study. SETTING AND PARTICIPANTS: Using population-based prescription data, the study included patients who filled prescriptions from January 2009 to December 2016 nationwide using NeedyMeds.org drug discount cards. OUTCOME MEASURES: We determined the frequency of drug discount card prescriptions (across pharmacy types, pharmacy location, and prescriber specialty), estimated cost savings using the drug discount card (average per drug discount card and total program dollars saved) and evaluated the top prescription drugs by frequency. RESULTS: A total of 4,638,581 prescriptions with discount cards were identified (79.8% at national, 6.3% at regional, and 12.9% at local pharmacies). Most were filled at urban locations (urban clusters, 88.6%; urbanized areas, 8.4%) and in ZIP codes with lower median household incomes (62.7%). Overall, 3.62 million prescriptions (78.0% of the total) were associated with discounts, resulting in a total savings of $199,183,112 (median cost savings, $17.80 [47.8%] per prescription). Opiates were the most common class of drugs for which discount cards were used. CONCLUSION: The use of a drug discount program over 8 years resulted in total savings of nearly $200 million (approximately $18 per prescription) compared with the original cost. However, although patients might accrue financial benefit, there is still a lack of price transparency. Additional research is needed to better understand the impact of these programs and to evaluate ways to improve medication access at a reasonable cost to patients.

Sudden death related cardiomyopathies - Arrhythmogenic right ventricular cardiomyopathy, arrhythmogenic cardiomyopathy, and exercise-induced cardiomyopathy.

Sudden cardiac death (SCD) is a devastating possible outcome of all cardiomyopathies. The risk of SCD is increased in patients with structural heart disease and continues to increase as ventricular dysfunction worsens. There is, however, a subset of cardiomyopathy, so-called "arrhythmogenic cardiomyopathy" (ACM), that carries an inherent propensity for arrhythmia in all stages of the disease, even preceding ventricular dysfunction. The aim of this review is to identify cardiomyopathies, other than ischemic and dilated cardiomyopathies, that are associated with ventricular arrhythmias (VAs) and SCD. We discuss prevalence, diagnosis, natural history and management of arrhythmogenic right ventricular dysplasia/cardiomyopathy, ACM, and exercise-induced cardiomyopathy, with emphasis on the morbidity and mortality of VAs associated with these cardiomyopathies and how they can be mitigated through lifestyle modification, medical management, and implantation of cardioverter defibrillators.

Sudden death related cardiomyopathies - Hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a form of inherited cardiomyopathy. Most individuals with HCM experience minimal symptoms throughout their lifetime. However, those with HCM are at risk of ventricular arrhythmias and sudden cardiac death (SCD), the most feared complication of HCM. Implantable cardioverter defibrillator (ICD) implantation has played a large role in transforming this disease from one with an ominous prognosis to one with mortality rates that are on par with the general public. Since the early 2000s, balance between SCD prevention and unnecessary ICD placement has been sought, this is reflected in the evolution of SCD risk stratification models for patients with HCM. This review discusses key concepts pertaining to HCM, with emphasis on prevention of SCD, and summarizes and compares the recommendations for ICD implantation in current guidelines.

Vasopressin antagonism for decompensated right-sided heart failure.

BACKGROUND: Targeted treatment for decompensated right heart failure (RHF) with or without left heart failure is lacking. Vasopressin antagonists (vaptans) may offer an option by increasing urine output and fluid mobilization when used in acute decompensated RHF without impacting blood pressure or renal function, both common complications of loop diuretics. METHODS AND RESULTS: We searched electronic medical records from 2 institutions over 4 years for patients with RHF treated with vaptans. Urine output, creatinine, BUN and sodium, 1 day pre- versus 1 day post-vaptan initiation were compared. Baseline (admission) pre-vaptan values for patients with RHF who met inclusion criteria (n = 112) were RAP, median (interquartile range) = 19 (13-24) mmHg; cardiac index, mean ±â€¯standard deviation = 1.8 ±â€¯0.4 L/min/m2; BNP, 1078 (523-1690) pg/ml; creatinine clearance of 51 (39-69) ml/min, BUN, 37 (26-54) mg/dl, and serum [Na+] 132 (126-135) mEq/L. Most patients (n = 103/112) received intravenous inotrope (prior to vaptan, n = 91). Overall length of stay was 27 (16-43) days. Vaptan treatment (90% tolvaptan, 10% conivaptan) was associated with increased 24 h urine output, 1517 (906-2394) vs 2337 (1425-3744) mL, p = 0.005, and [Na+], 127 (124-130) vs 130 (126-135) mEq/L, p = 0.001, without significant change in Cr or BUN. Furosemide IV dose equivalent decreased or remained unchanged in 75% of patients at 24 h and 64% at 72 h compared to the 24 h prior to vaptan use. CONCLUSION: Vaptans were associated with a significant increase in urine output and serum sodium with an apparent reduction or stabilization of furosemide equivalent dosing in the early treatment period in patients with decompensated RHF. Vaptans may offer a management option for patients failing conventional diuretic-based treatment.