Renal Outcomes Following Transcatheter Mitral Valve Repair - Analysis of COAPT Trial Data.

The prevalence of valvular heart disease in the United States has been estimated at 4.2-to-5.6 million, with mitral regurgitation (MR) being the most common lesion. Significant MR is associated with heart failure (HF) and death if left untreated. When HF is present, renal dysfunction (RD) is common and is associated with worse outcomes (ie, it is a marker of HF disease progression). Additionally, a complex interplay exists in patients with HF who also have MR, as this combination further impairs renal function, and the presence of RD further worsens prognosis and often limits guideline-directed management and therapy (GDMT). This has important implications in secondary MR because GDMT is the standard of care. However, with the development of minimally invasive transcatheter mitral valve repair, mitral transcatheter edge-to-edge repair (TEER) has become a new treatment option for secondary MR that is now incorporated into current guidelines published in 2020 that listed mitral TEER as a class 2a recommendation (moderate recommendation with benefit >> risk) as an addition to GDMT in a subset of patients with left ventricular ejection fraction <50%. The Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) trial, which demonstrated favorable outcomes in secondary MR by adding mitral TEER to GDMT versus GDMT alone, was the evidence base for these guidelines. Considering these guidelines and the understanding that concomitant RD often limits GDMT in secondary MR, there is emerging research studying the renal outcomes from the COAPT trial. This review analyzes this evidence, which could further influence current decision-making and future guidelines.

Robotic Cardiac Surgery Part II: Anesthetic Considerations for Robotic Coronary Artery Bypass Grafting.

Coronary artery bypass grafting represents one of the most commonly performed cardiac surgeries worldwide. Recently, interest has increased in providing patients with a less invasive approach to cardiac surgery, such as thoracotomy and endoscopic techniques using robotic technology as an alternative to traditional sternotomy. As the population gets older, the need for additional methods to provide care for sick patients will continue to expand. These advancements will further allow physicians to provide cardiac surgical procedures with less pain and faster recovery for patients.

Atypical Presentation of Acute Mitral Regurgitation Secondary to Papillary Muscle Rupture.

Acute mitral regurgitation (MR) is a life-threatening condition presenting with severe decompensated heart failure due to sudden retrograde blood flow into the left atrium. The causes are broadly classified into ischemic and non-ischemic. Rapid and accurate diagnosis of acute MR and its potential causes is essential. This case uniquely highlights an atypical presentation of severe MR secondary to papillary muscle rupture without a known, identifiable cause. Therefore, suspicion of acute MR should be high if clinical symptoms are present, even without known risk factors, due to the high morbidity and mortality associated with delayed management.

Success Begins With Failure: An Alternative Approach in Transfemoral Transcatheter Aortic Valve Replacement Using an Antegrade Wire Crossing Technique.

Transcatheter aortic valve replacement has transitioned from an experimental procedure to an important alternative therapy for patients with symptomatic aortic stenosis and high surgical risk. We present a case outlining an approach to deal with the issue of "failure to cross" the aortic valve in transcatheter aortic valve replacement from the transfemoral retrograde approach.

Le remplacement valvulaire aortique par cathéter est passé d'une intervention expérimentale à un traitement alternatif important pour les patients atteints d'une sténose aortique symptomatique et exposés à un risque opératoire élevé. Nous présentons un cas qui décrit une approche pour remédier au problème d'« échec à traverser ¼ la valvule aortique lors du remplacement valvulaire aortique par cathéter selon une approche par voie rétrograde fémorale.

Lex parsimoniae.

We present a noteworthy case of dual pathology in a 62-year-old female with recurrent chest pains and extensive cardiac risk factors. From computed tomography coronary angiography, a left anterior descending artery lesion was identified and successfully revascularized with a drug-eluting stent. Due to persistent chest pain, further investigation revealed a descending aortic dissection, which was conservatively managed. This case highlights the potential challenges of diagnosis in dual pathologies and emphasizes initiating appropriate investigations. .

Usefulness of the ankle-brachial index to predict high coronary SYNTAX scores, myocardium at risk, and incomplete coronary revascularization.

Peripheral artery disease (PAD) is strongly associated with coronary artery disease and poor outcomes after coronary revascularization. The aim of this study was to test the hypothesis that patients with PAD diagnosed by a low ankle-brachial index (ABI; ≤0.90) have more complex coronary artery disease and more myocardium at risk than patients with normal ABIs (1.00 to 1.40) and that subsequent coronary revascularization is less complete. Adults referred for coronary angiography underwent ABI measurement using a standard Doppler ultrasound technique. Blinded reviewers calculated SYNTAX scores and Duke jeopardy scores at baseline and 3 months after angiography. Of 814 patients, 8% had PAD (ABI ≤0.90), 9% had borderline PAD (ABI 0.91 to 0.99), 77% were normal (ABI 1.00 to 1.40), and 7% had vascular calcification artifact (ABI >1.40). Patients with PAD were more likely to have high SYNTAX scores (≥33), with an odds ratio of 4.3 (95% confidence interval 1.2 to 14.9), compared with those with normal ABIs after adjustment for traditional cardiovascular risk factors. Similarly, there was a positive association between baseline high Duke jeopardy score (≥8) and PAD (adjusted odds ratio 3.5, 95% confidence interval 1.7 to 7.1). Postrevascularization high Duke jeopardy scores (≥5) were also positively associated with PAD (adjusted odds ratio 3.0, 95% confidence interval 1.1 to 8.8). In conclusion, PAD is associated with higher SYNTAX scores, more myocardium at risk, and less complete coronary revascularization than in patients with normal ABIs. More complex coronary artery disease and incomplete revascularization may contribute to worse cardiovascular outcomes in patients with PAD.

Coronary arteriovenous fistula secondary to percutaneous coronary intervention of chronic total occlusion.

This is a case report of a 61-year-old female presenting with ongoing chest pain in the setting of an NSTEMI with lateral ST-T changes. On attempting to open the left circumflex (LCX), it resulted in a proximal LCX dissection. The patient remained stable with no further chest pain. She was treated with IV Eptifibatide for 48 hours and restudied in 72 hours. Repeat coronary angiography showed a marginally improved proximal dissection plane with a coronary AV fistula. She was managed conservatively and discharged with a non-invasive assessment in 8 weeks. The patient had a negative stress echocardiogram and was managed with maximal medical therapy.

Coronary artery disease in South Asians.

It is well established that South Asians living in the western world have a higher burden of cardiovascular disease than other ethnicities. Additionally, South Asians develop cardiovascular disease at a younger age, have a more aggressive form of coronary artery disease, and a higher overall mortality. This predilection seems to be multifactorial and includes a combination of traditional and emerging risk factors with an absence of ethnic-specific prevention and control measures. Future direction points toward ongoing research with the aim of discovering technology for earlier detection. Additionally, coronary artery disease in South Asians could be addressed by increasing awareness, modifying health beliefs through health-promotion strategies, and instituting ethnic-specific control measures including appropriate and early pharmacological intervention.

Simultaneous very late stent thrombosis in multiple coronary arteries.

We report 2 noteworthy cases of very late stent thrombosis presenting as ST-segment-elevation myocardial infarction, with vastly different manifestations. Both patients were women who had histories of multivessel percutaneous coronary intervention with first-generation sirolimus-eluting stents, in 2005 and 2006. On the more recent occasions reported here, one underwent successful multivessel primary percutaneous coronary intervention, while the other underwent successful multivessel "plain old balloon angioplasty." Both were discharged from the hospital with advice to stop smoking and to follow a lifelong regimen of aspirin and clopidogrel.On the basis of these two cases and our review of the current literature, we ask whether it is now prudent to recommend lifelong dual antiplatelet therapy after drug-eluting stent deployment. Moreover, in order to account for cases of stent thrombosis that occur ≥ 5 years after drug-eluting stent implantation, should we perhaps suggest the addition of "extremely late stent thrombosis" to the existing Academic Research Consortium classification?

A rare case of isolated congenital right ventricular inflow obstruction due to the presence of an intraventricular muscular shelf.

A 56-year-old man presented with anasarca and a 40-lb weight gain that had occurred over the course of 3 to 4 weeks. He had a history of permanent atrial fibrillation and a congenital anomaly of the right ventricular inflow tract. This defect consisted of a muscular shelf in the right ventricular inflow tract, which encased the tricuspid subvalvular apparatus in such a manner that it created tricuspid stenosis. The clinical consequences of this anatomic and hemodynamic situation were a massively dilated right atrium, permanent atrial fibrillation, and clinical evidence of right-sided heart failure, including fluid retention and ascites. The patient underwent surgical resection of the muscular shelf, which was followed by progressive resolution of the ascites and fluid retention.

Hybrid coronary revascularization: a review.

The long-term benefits of a left internal mammary artery bypass graft compared to the left anterior descending artery have been well described. The use of drug-eluting stents has minimized the morbidity of revascularization. Hybrid coronary revascularization is the planned use of minimally invasive surgical techniques for left internal mammary artery-left anterior descending artery grafting and the use of percutaneous coronary intervention for nonleft anterior descending coronary artery target revascularization. The optimal timing and order of revascularization in hybrid coronary revascularization remains unclear.

Influence of age on long-term outcome after emergent percutaneous coronary intervention for ST-elevation myocardial infarction.

BACKGROUND: Percutaneous coronary intervention (PCI) provides advantages compared to thrombolytic therapy in the treatment of ST-elevation myocardial infarction (STEMI). Elderly patients have increased in-hospital mortality; the predictors of adverse outcomes are not well established, with limited data available regarding late follow up of these patients. We evaluated early and late outcomes of patients undergoing emergent PCI for STEMI to identify the predictors of subsequent late adverse events and, in particular, determine if age alone was a predictor of an adverse outcome. MATERIALS AND METHODS: A retrospective review of all patients referred for emergent PCI for STEMI to a single tertiary referral center was performed. All patients undergoing primary PCI for STEMI or rescue PCI for failed thrombolysis between December 2003 and December 2007 were included for assessment. RESULTS: During the study period, 269 patients underwent primary or rescue PCI for STEMI. Patients > or = 70 years of age were more likely to have established cardiovascular risk factors and documented coronary artery disease. Thrombolysis in myocardial infarction (TIMI) 3 flow predicted a good outcome, whereas recurrent ischemia in hospital, prior aspirin therapy and discharge creatinine predicted a poor outcome; age alone was not an adverse prognostic factor. CONCLUSIONS: The increased mortality in elderly patients undergoing PCI for STEMI reflects comorbidity and suboptimal procedural outcomes rather than any age effect per se. Future approaches to optimize the management of STEMI in the elderly should include identification of those patients most likely to benefit from an invasive approach.

Comparing risk-prediction methods using administrative or clinical data in assessing excess in-hospital mortality in patients with acute myocardial infarction.

OBJECTIVES: To compare results of statistical process-control analyses of in-hospital deaths of patients with acute myocardial infarction by using either administrative or clinical data sources and prediction models, and to assess variation in results according to selected patient characteristics. DESIGN: Retrospective, cross-sectional study comparing variable life-adjusted display (VLAD) curves derived by using administrative or clinical prediction models applied to a single patient sample. PARTICIPANTS AND SETTING: Data from 467 consecutive patients admitted to a tertiary hospital in Queensland, between 1 July 2003 and 31 March 2006, with a coded discharge diagnosis of acute myocardial infarction. MAIN OUTCOME MEASURE: Statistical estimates of cumulative lives gained or lost in excess of those predicted at the end of the study period. RESULTS: The two prediction models, when applied to all patients, generated almost identical VLAD curves, showing a steadily increasing excess mortality over the study period, culminating in an estimated 11 excess deaths. Risk estimates for individual patients from each model were significantly correlated (r = 0.46, P < 0.001). After exclusion of misclassified cases, out-of-hospital cardiac arrests and deaths within 30 minutes of presentation, replotting the curves reversed the mortality trend and yielded, depending on the model, a net gain of three or seven lives. After further exclusion of transfers in from other hospitals and patients whose care had a palliative or conservative intent, the net gain increased to seven or 10 lives. CONCLUSION: Appropriate patient selection is more important than choice of dataset or risk-prediction model when statistical process-control methods are used to flag unfavourable mortality trends suggestive of suboptimal hospital care.

Hemochromatosis gene mutations, liver function tests and iron status in alcohol-dependent patients admitted for detoxification.

BACKGROUND: Screening of target populations for hemochromatosis (HFE) gene allele status has been recommended. Alcoholic liver disease may be associated with iron overload and there is evidence of excessive alcohol consumption among patients with hereditary hemochromatosis. This study determined the HFE gene allele status in alcohol-dependent patients and explored the associations between iron status, liver enzymes, and HFE status. METHODS: A total of 151 consecutive patients admitted for alcohol detoxification were tested for HFE mutations, iron status, and liver function tests. The prevalence data were compared with those from a New Zealand population. manova was used to compare liver function tests and iron status for subjects with different HFE mutations. RESULTS: Three compound heterozygotes, one homozygote for C282Y, and one homozygote for H63D were found among the 151 patients. For the remaining 146 patients, there was no difference in the distribution of heterozygote status by allele, compared to the general New Zealand population. No HFE mutation: general population 64.4%, alcohol-dependent patients 64.4%; H63D: general population 23.6%, alcohol-dependent patients 28.1%; C282Y: general population 11.9%, alcohol-dependent patients 7.5% (P = 0.20). There was no relationship between liver function tests or iron status and HFE mutation status among the study group. CONCLUSIONS: No evidence has been found in the present that HFE allele status prevalence is different from the general population or associated with different liver function or iron status among alcohol-dependent patients. The cause of altered iron status among alcohol-dependent patients does not appear to be related to HFE status.

International medical graduates' training needs: perceptions of New Zealand hospital staff.

OBJECTIVE: To determine the opinion of New Zealand doctors and nurses on the possible training needs of international medical graduates (IMGS) in New Zealand hospitals. DESIGN: A postal questionnaire sent to hospital doctors and nurses. METHODS: All doctors working at Wellington, Kenepuru, and Hutt Hospitals in the greater Wellington region, and nurses working in acute medical wards at the same hospitals, were asked to complete a questionnaire based on the Northern Clinical Training Network and Capital Coast District Health Board resident medical officer assessment forms regarding an overseas-trained doctor they had worked with in the last year. RESULTS: The response rate for the doctor's questionnaires was 68/174 (39.1%), with 51 of these from New Zealand doctors rating an international medical graduate. The response rate for the nurses was 58/60 (96.7%). Areas where the median score of the questionnaire was unsatisfactory (less than three out of five on an ordinal scale rating performance) were clinical documentation; communication with patients, families, and other health professionals; knowledge of hospital policies and procedures, and medicolegal matters; and some aspects of patient management. There was no difference in median ratings between doctors and nurses. CONCLUSIONS: More specific training may improve the performance of overseas-trained doctors in the New Zealand health system. A further study of the perceived needs of the overseas-trained doctors themselves may be useful.