Review of Prosthetic Paravalvular Leaks: Diagnosis and Management.

PURPOSE OF REVIEW: Paravalvular leak (PVL) is a relatively uncommon complication associated with prosthetic valve implantation. PVL can occasionally lead to serious adverse consequences such as congestive heart failure, infective endocarditis, and hemolytic anemia. Surgical re-operation carries a high mortality risk. RECENT FINDINGS: Transcatheter closure therapy provides a viable alternative for the treatment of this disorder with reasonable procedural and clinical success. The recent advent of hybrid imaging modalities has increased procedural success. This article summarizes the pathophysiology, clinical characteristics, and treatment modalities surroundings prosthetic paravalvular leak.

Percutaneous closure of post TAVR LV apical pseudoaneurysm.

Left ventricular (LV) apical pseudoaneurysm is a well known complication of myocardial infarction and open heart surgery procedures, and has more recently been described after transapical transcatheter aortic valve replacement (TAVR). Since the natural history includes a high incidence of cardiac rupture and mortality in the 30-45% range within the first year after diagnosis, surgical repair has been the main therapy. More recently, LV pseudoaneurysms have been closed using percutaneous methods. We describe a post-TAVR pseudoaneurysm for which closure was done via retrograde LV access using a vascular plug, and provide a review of recent literature on closure methods and outcomes. © 2015 Wiley Periodicals, Inc.

Low profile vascular plugs for paravalvular leaks after TAVR.

BACKGROUND: Paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) is associated with less good outcomes. The use of percutaneous plugs is among the strategies to treat PVL after TAVR. Plugs have been limited by the need to pass 4-6 F delivery sheaths between the TAVR stent frame and the native valve leaflets. METHODS: The study population consists of six patients who had at least moderate aortic insufficiency (AI), and also developed symptoms of heart failure after TAVR. We describe in detail the use of low profile vascular plugs that require crossing the leaks with only a 4 F diagnostic catheter. RESULTS: Low profile vascular plugs were successfully deployed in all six patients without significant complications. Fluoroscopy time ranged 16.7-69.4 min (44.8 ± 18.8 min). Contrast volume ranged 15-100 mL (45 ± 34 mL). One plug was used in five, and two adjacent plus in one case. AI severity was reduced from moderate or severe to mild or less in four patients, from severe to moderate in one, and in one, there was no change. Five of six patients were treated electively and were significantly improved in terms of both echocardiographic PVL and also symptoms. The one who did not have echocardiographic improvement did not improve clinically and expired one month later. CONCLUSIONS: PVL closure can be consistently accomplished after TAVR with low profile vascular plugs. Careful analysis of PVL location on echo before closure greatly facilitates finding the fluoroscopic location of the leak. Decreases in PVL severity are associated with significant clinical improvement.

4273π: bioinformatics education on low cost ARM hardware.

BACKGROUND: Teaching bioinformatics at universities is complicated by typical computer classroom settings. As well as running software locally and online, students should gain experience of systems administration. For a future career in biology or bioinformatics, the installation of software is a useful skill. We propose that this may be taught by running the course on GNU/Linux running on inexpensive Raspberry Pi computer hardware, for which students may be granted full administrator access. RESULTS: We release 4273π, an operating system image for Raspberry Pi based on Raspbian Linux. This includes minor customisations for classroom use and includes our Open Access bioinformatics course, 4273π Bioinformatics for Biologists. This is based on the final-year undergraduate module BL4273, run on Raspberry Pi computers at the University of St Andrews, Semester 1, academic year 2012-2013. CONCLUSIONS: 4273π is a means to teach bioinformatics, including systems administration tasks, to undergraduates at low cost.

Cardiac Structural Remodeling and Hemodynamic Patterns Following Transcatheter Aortic Valve Replacement.

Background Transcatheter aortic valve replacement (TAVR) is increasingly utilized for most patients with symptomatic severe aortic stenosis. TAVR is linked to enhanced long-term cardiac hemodynamics, reversal of left ventricle (LV) hypertrophy, and improved aortic valve gradients. We present a retrospective observational study assessing cardiac remodeling and valvular flow patterns post-TAVR. Methods Retrospective echocardiographic data were collected, evaluating cardiac function and valvular flow patterns before and after TAVR at a single institution. Data was compiled and statistically analyzed using a paired t-test evaluating variations at approximately 30 days and one-year post-TAVR. Results On echocardiogram 30 days and one-year post-TAVR, there was a reduction in LV mass index from 132 g/m² to 110 g/m² (95%CI: 98-122; p=0.01) and 118 g/m² (95%CI: 102-133; p=0.03), and a reduction in relative wall thickness from 0.54 to 0.49 (95%CI: 0.46-0.52; p=0.05) and 0.44 (95%CI: 0.38-0.49; p=0.03), respectively. Doppler velocity indices (DVI) increased from 0.24 to 0.61 (95%CI: 0.49-0.73; p<0.001) and 0.57 (95%CI: 0.48-0.65; p<0.001). Expected improvement in aortic valve velocities and gradients were observed post-TAVR. Conclusions Following TAVR, LV remodeling can be observed as early as 30 days. This is demonstrated by a reduction in LV mass index and relative wall thickness in conjugation with an anticipated improvement in valvular flow patterns and flow across the aortic valve.

Randomized Comparison of Percutaneous Repair and Surgery for Mitral Regurgitation: 5-Year Results of EVEREST II.

BACKGROUND: In EVEREST II (Endovascular Valve Edge-to-Edge Repair Study), treatment of mitral regurgitation (MR) with a novel percutaneous device showed superior safety compared with surgery, but less effective reduction in MR at 1 year. OBJECTIVES: This study sought to evaluate the final 5-year clinical outcomes and durability of percutaneous mitral valve (MV) repair with the MitraClip device compared with conventional MV surgery. METHODS: Patients with grade 3+ or 4+ MR were randomly assigned to percutaneous repair with the device or conventional MV surgery in a 2:1 ratio (178:80). Patients prospectively consented to 5 years of follow-up. RESULTS: At 5 years, the rate of the composite endpoint of freedom from death, surgery, or 3+ or 4+ MR in the as-treated population was 44.2% versus 64.3% in the percutaneous repair and surgical groups, respectively (p = 0.01). The difference was driven by increased rates of 3+ to 4+ MR (12.3% vs. 1.8%; p = 0.02) and surgery (27.9% vs. 8.9%; p = 0.003) with percutaneous repair. After percutaneous repair, 78% of surgeries occurred within the first 6 months. Beyond 6 months, rates of surgery and moderate-to-severe MR were comparable between groups. Five-year mortality rates were 20.8% and 26.8% (p = 0.4) for percutaneous repair and surgery, respectively. In multivariable analysis, treatment strategy was not associated with survival. CONCLUSIONS: Patients treated with percutaneous repair more commonly required surgery for residual MR during the first year after treatment, but between 1- and 5-year follow-up, comparably low rates of surgery for MV dysfunction with either percutaneous or surgical therapy endorse the durability of MR reduction with both repair techniques. (EVEREST II Pivotal Study High Risk Registry; NCT00209274).

Age-related determinants of outcome after acute myocardial infarction: a dobutamine-atropine stress echocardiographic study.

OBJECTIVES: To investigate the cause of worse survival in older patients after myocardial infarction (MI). DESIGN: Prospective 18-month and longer follow-up study of a cohort of 167 patients (mean age +/- standard deviation 58 +/- 12, including 71 aged >or=65) with acute MI for cardiac events, defined as cardiac death, recurrent MI, or resuscitated ventricular tachycardia or fibrillation (VT/VF). SETTING: Milwaukee County Medical Complex and the Zablocki Veterans Affairs Medical Center, Milwaukee, WI. PARTICIPANTS: One hundred sixty-seven patients who underwent dobutamine-atropine stress echocardiography (DASE) in the first week (2-7 days) after acute MI and were medically managed. MEASUREMENTS: Comparison of event rates in older (>or=65 years) and younger (<65 years) patients and of clinical, resting echocardiographic, DASE, and angiographic findings in patients with and without events. Coronary angiography was performed in 141. RESULTS: Older and younger patients tolerated DASE well. During follow-up, there were 29 cardiac events (cardiac death in 17, nonfatal MI in 10, and VT/VF in 2). Events were more common in older patients (26% vs 12%, P <.05), especially death (19% vs 5%, P <.05). Scar size in the infarct zone by DASE was larger (4.0 +/- 2.8 vs 3.0 +/- 2.7 segments, P <.05) and remote wall motion abnormalities more common (47 vs 29%, P <.05) in older patients. Univariate determinants of outcome (P <.05) in older patients were diabetes mellitus; remote wall motion abnormalities; angiographic multivessel disease; scar size; ejection fraction; and resting, low-, and peak-dose wall motion score. Univariate determinants in younger patients were similar, but diabetes mellitus was not. Multivariate analysis revealed that remote wall motion abnormalities and scar size by DASE were independently predictive of outcome in older and younger patients and diabetes mellitus only in older patients. Low- and peak-dose DASE data enhanced (P <.01) the prediction of outcome in all patients with acute MI relative to clinical data and resting echocardiography. CONCLUSION: DASE was more predictive of outcome than clinical data and resting echocardiography in both age groups. Scar size and remote wall motion abnormalities were the primary determinants of outcome irrespective of age. The worse prognosis of older patients correlated with diabetes mellitus, greater scar size, and higher incidence of remote inducible ischemia.

Diagnostic and Prognostic Use of Stress Echocardiography and Radionuclide Scintigraphy.

Stress echocardiography and radionuclide scintigraphy are effective diagnostic and prognostic techniques in patients with known or suspected coronary artery disease (CAD), myocardial infarction (MI), chronic left ventricular dysfunction (LVD), and those undergoing noncardiac surgery. Both are sensitive and specific for the detection and extent of CAD. Negative tests confer a high negative predictive value for cardiac events irrespective of clinical risk. Positive studies confer a high positive predictive value for ischemic events in patients with intermediate to high clinical risk. Both provide incremental diagnostic and prognostic information relative to clinical, resting echocardiographic, and angiographic data. Meta-analysis studies have shown that the diagnostic and prognostic information provided by stress echocardiography is comparable with radionuclide scintigraphic stress tests. Stress echocardiography may be more specific for the detection and extent of CAD, whereas radionuclide scintigraphy may be more sensitive for single-vessel disease. Sensitivities are similar for the detection and extent of disease in patients with multivessel CAD.

How should I treat a challenging case of MitraClip implantation?

BACKGROUND: A 71-year-old woman affected by idiopathic dilated cardiomyopathy with normal coronary arteries and permanent atrial fibrillation was found to have severe mitral regurgitation at transthoracic echocardiography (TTE), due to annular dilatation and restricted motion of the posterior leaflet. Because of poor quality of life, high functional class (NYHA Class III) and the high risk of surgery, the patient agreed to undergo the implantation of a MitraClip device. During the procedure, the transoesophageal echocardiographic (TEE) images were of a poor quality since the view of the mitral valve in the mid-oesophageal and transgastric projections did not accurately show the valve leaflets and the convergence area of the regurgitation at colour Doppler, which is indispensable for the correct positioning of the clip. INVESTIGATION: Physical examination, transthoracic echocardiography, transoesophageal echocardiography. DIAGNOSIS: Severe mitral regurgitation suitable for MitraClip implantation. MANAGEMENT: Transthoracic, and not transoesophageal, echocardiography approach during MitraClip procedure.