Sex-based differences in candidacy for transcatheter tricuspid valve intervention.

BACKGROUND: Women have a higher prevalence of tricuspid regurgitation (TR) and present at more advanced stages as compared with men. Given the high operative mortality associated with tricuspid valve (TV) surgery, transcatheter tricuspid valve interventions (TTVI) have emerged as a promising treatment option. We explored sex-based differences among patients with significant TR who would be expected to be eligible for TTVI. METHODS: Between March 2021-2022, 12,677 unique adult patients underwent a transthoracic echocardiogram at our tertiary care institution. Clinical and echocardiographic data were collected for patients with more than moderate TR. The 2021 European Society of Cardiology valve guidelines were used to retrospectively define sub-populations who would have been eligible for TTVI, TV surgery, or medical therapy. Patients were grouped by sex and compared using t-tests, Wilcoxon rank-sum, Pearson chi-square, and Cox regression for survival analysis. RESULTS: Of 569 patients, 52% (296/569) were female. Men had a higher prevalence of left ventricular dysfunction (p < 0.001), mitral regurgitation (p = 0.023), and signs of heart failure (New York Heart Association stage III (p = 0.031)). Women had more isolated TR (p = 0.020) and TR due to severe pulmonary hypertension (p < 0.001). Most patients (74.6% of women, 76.9% of men) were precluded from both transcatheter and surgical intervention due to advanced disease. 10.8% of women and 9.2% of men would have qualified for TTVI (p = 0.511). CONCLUSION: The majority of patients with significant TR presenting to a tertiary care center are not eligible for TTVI. Sex is not a predictor of eligibility for TTVI among patients with significant TR.

Three-dimensional cardiac print assisted percutaneous closure of left ventricular pseudoaneurysm in patient with Behçet's disease.

Spontaneous left ventricular pseudoaneurysms are very rare and can have catastrophic consequences if unrecognized. A case of combined spontaneous left ventricular aneurysm and pseudoaneurysm in Behcet's disease (BD) has been reported. The case emphasizes advanced techniques for percutaneous closure of the defects with the use of an ex-vivo three-dimensional cardiac printed model as a tool to facilitate the procedure.

Most hospitalized patients with significant tricuspid regurgitation have advanced disease preventing transcatheter tricuspid valve intervention.

BACKGROUND: More than moderate tricuspid regurgitation (TR) is associated with high mortality. Surgical tricuspid valve repair and replacements are rarely performed due to high operative mortality risk, mainly attributed to late presentation. Novel transcatheter tricuspid valve intervention (TTVI) devices are being developed as an alternative to surgery. The population of patients presenting to tertiary care centers who can benefit from TTVI has not been well defined. METHODS: We retrospectively analyzed 12,677 consecutive 2D echocardiograms completed at our tertiary care center between March 2021 and March 2022 and identified hospitalized patients with more than moderate TR. A total of 569 patients were included in this study. Clinical and echocardiographic data were collected by individual chart review. We used the European Society of Cardiology (ESC) guidelines on the management of valvular disease to retrospectively assign patients to medical, surgical, or transcatheter therapy. RESULTS: 458 patients (80.5 %) were assigned to medical therapy, 57 (10.0 %) were assigned to TTVI, and 54 (9.5 %) were assigned to tricuspid valve surgery. Of note, 75.7 % (431/569) of patients were precluded from any intervention due to advanced disease, and only 4.7 % (27/569) presented too early for intervention, being both asymptomatic and without RV dilatation. CONCLUSION: Only 10.0 % of patients presenting to a tertiary care center with significant TR would be candidates for TTVI when these technologies are approved in the United States. Earlier identification and treatment of TR could increase the number of patients who may benefit from interventions including TTVI.

Referral for Cardiac Amyloidosis in Patients Who Underwent Transcatheter Aortic Valve Replacement: Results of the Quality Outcome Project.

Background Transthyretin cardiac amyloidosis (ATTR) is an important comorbidity present in severe aortic stenosis (AS). The purpose of this study was to raise awareness of ATTR in patients who underwent transcatheter aortic valve replacement (TAVR) for severe AS among healthcare providers and patients. Methodology We reviewed 197 consecutive TAVR cases performed from 2019 to 2020. Adapting predefined high-risk features for ATTR based on prior literature, we contacted the patients to discuss our clinical suspicion of ATTR and offered a referral to a cardiac amyloid specialist. Results We identified 125 (69.4%) patients who had high-risk features of ATTR. Of the 105 patients contacted, 44 patients agreed to referral, 46 patients were not able to be contacted after several attempts, and 15 patients declined referral. Of the 44 patients who agreed to the referral, 20 patients completed the evaluation for cardiac amyloidosis, all of whom were negative for transthyretin and light-chain cardiac amyloidosis. Conclusions Our attempt to detect ATTR in prior TAVR patients was unsuccessful two to three years post-TAVR. We believe that early detection of cardiac amyloidosis close to the timing of TAVR is important and the most effective means.

Comparison of American and European Guidelines for the Management of Patients With Valvular Heart Disease.

This review compares the recommendations of the recent 2020 American College of Cardiology (ACC)/American Heart Association (AHA) and 2021 European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) guidelines on the management of patients with valvular heart disease (VHD). ACC/AHA and ESC/EACTS guidelines are both the updated versions of previous 2017 documents. Both guidelines fundamentally agree on the extended indications of percutaneous valve interventions, the optimal use of imaging modalities other than 2D echocardiography, the importance of a multidisciplinary Heart Team as well as active patient participation in clinical decision making, more widespread use of NOACs and earlier intervention with lower left ventricular dilatation thresholds to decrease long-term mortality. The differences between the guidelines are mainly related to the classification of the severity of valve pathologies and frequency of follow-up, level of recommendations of valve intervention indications in special patient groups such as frail patients and the left ventricular diameter and ejection fraction thresholds for intervention.

Correction: Referral for Cardiac Amyloidosis in Patients Who Underwent Transcatheter Aortic Valve Replacement: Results of the Quality Outcome Project.

[This corrects the article DOI: 10.7759/cureus.45024.].

2021. The year in review. Structural heart interventions.

Since the beginning of 2020, the corona virus (COVID-19) pandemic redefined in many ways the practice of cardiology, research and cardiology conferences. Virtual conferences replaced most major in-person venues. The number of "elective" structural heart interventions declined and clinical research endured major setbacks in regards to academic and industry-sponsored clinical trials. In this review, we attempt to provide a broad overview of the field for general and interventional cardiologists with a specific interest in structural heart interventions.

Management of Iatrogenic Atrial Septal Defects in the Era of Large-Bore Transcatheter Mitral Valve Therapies.

Several case reports described acute and subacute decompensations that were reversed after percutaneous interatrial septal defect (ASD) closure. At least 30% of patients post MitraClip will continue to have a persistent ASD at 1 year. Few retrospective studies described various echocardiographic associations with persistent ASD but there is no conclusive evidence that it is the cause of a poor outcome. Conclusion: At this time routine closure of ASD post MitraClip is not recommended unless there is hemodynamic decompensation that cannot be explained by other factors.

Implementation of 3D Printing in Medical Care for Preoperative Planning of Complex Ventricular Septal Defect.

Three-dimensional (3D) modeling and printing in medicine have emerged to encompass every aspect of medical applications. This ranges from education, illustration, and treatment, as well as patient care whether for purposes of diagnosis or treatment and surgical planning. In the past few decades, these novel tools have shown promising utility to help radiologists and the medical team to improve quality of patient care and outcomes via 3D printing application and utilization. This workflow will be illustrated through a ventricular septal defect (VSD) case at which 3D analysis was critical in the assessment and treatment planning of the patient's underlying medical condition.

Limitations of embolic protection in saphenous vein graft intervention: insights from 202 consecutive patients.

Between January 2003 and September 2006, a total of 2,541 patients had percutaneous coronary intervention (PCI). Of these, 202 (226 grafts) had at least one saphenous vein graft (SVG) intervention. Adjunctive distal embolic protection (DEP) devices were attempted in 123 SVGs (54.4%). The 30-day major adverse cardiac event (occurrence of death, myocardial infarction, or target vessel revascularization) rate in the overall group was 11.9%. The presence of angiographic thrombus independently predicted DEP use while the presence of in-stent restenosis predicted no DEP use. Although the presence of all angiographic technical feasibility criteria independently predicted DEP use, only 72 (32.4%) and 33 (14.6%) of the SVGs would have been eligible for the occlusive balloon- and filter-based distal embolic criteria, respectively. The most common technical reason for ineligibility was a graft size smaller than 3.0 mm, followed by the lack of a long enough landing zone. In a subset of 21 (9.3%) completely occluded lesions which would have excluded DEP use, angiographic success was 66.7%, and that was predicated on successful debulking with rheolytic thrombectomy in 13 (61.9%) with subsequent DEP in 5 (23.8%). In conclusion, not all grafts can be protected, and even in those that can, such protection may be incomplete. Newer embolic protection devices, such as the Proxis((R)), were recently introduced to expand the applicability to a wider population of vein grafts. However, further design improvements such as device miniaturizations applicable to sub-3.0-mm vessels and better particle removing/filtering mechanisms are needed in order to expand the use of embolic protection to reduce the persistently high complication rates associated with this difficult- to-treat subset of patients.

The State of the Absorb Bioresorbable Scaffold: Consensus From an Expert Panel.

Significant progress has been made in the percutaneous coronary intervention technique from the days of balloon angioplasty to modern-day metallic drug-eluting stents (DES). Although metallic stents solve a temporary problem of acute recoil following balloon angioplasty, they leave behind a permanent problem implicated in very late events (in addition to neoatherosclerosis). BRS were developed as a potential solution to this permanent problem, but the promise of these devices has been tempered by clinical trials showing increased risk of safety outcomes, both early and late. This is not too dissimilar to the challenges seen with first-generation DES in which refinement of deployment technique, prolongation of dual antiplatelet therapy, and technical iteration mitigated excess risk of very late stent thrombosis, making DES the treatment of choice for coronary artery disease. This white paper discusses the factors potentially implicated in the excess risks, including the scaffold consideration and deployment technique, and outlines patient and lesion selection, implantation technique, and dual antiplatelet therapy considerations to potentially mitigate this excess risk with the first-generation thick strut Absorb scaffold (Abbott Vascular, Abbott Park, Illinois). It remains to be seen whether these considerations together with technical iterations will ultimately close the gap between scaffolds and metal stents for short-term events while at the same time preserving options for future revascularization once the scaffold bioresorbs.

Angiographic and clinical outcomes of bivalirudin versus heparin in patients with acute coronary syndrome undergoing percutaneous coronary intervention.

BACKGROUND: Heparin with adjunctive glycoprotein IIb/IIIa platelet receptor (GP IIb/IIIa) inhibitors has demonstrated its effectiveness in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Bivalirudin, a direct thrombin inhibitor, has recently been shown to be an effective alternative for patients undergoing elective PCI. OBJECTIVES: To assess the angiographic and clinical outcomes of adjunctive pharmacological strategies in a high-risk population presenting with ACS. METHODS: Of 891 consecutive PCI patients with ACS, 304 received bivalirudin (60.5% male, 68+/-11 years) and were compared with 283 who received heparin (58.7% male, 66+/-12 years). A 30-day major adverse cardiac event was defined as the occurrence of cardiac death, nonfatal myocardial infarction, urgent revascularization or major hemorrhage. RESULTS: Adjunctive GP IIb/IIIa inhibitors were used in 14.1% of the bivalirudin group and in 72.4% of the heparin group (P<0.010). The occurrence of Thrombolysis In Myocardial Infarction (TIMI) flow less than grade 3 was lower and the achievement of angiographic success was higher in the bivalirudin group than in the heparin group (5.2% versus 8.2%, 94.7% versus 89.7%, P=0.039 and P<0.010, respectively). There was no difference between groups in the incidence of bleeding events (bivalirudin 2.0% versus heparin 3.5%, P not significant) and in 30-day major adverse cardiac events (bivalirudin 8.3% versus heparin 5.7%, P=0.223). CONCLUSIONS: In the high-risk cohort undergoing PCI, bivalirudin with provisional GP IIb/IIIa inhibitors achieved better angiographic results. Although not powered to show a difference, and while acknowledging that a selection bias could have affected the data, the present study showed that bivalirudin may be as clinically effective and safe as heparin with adjunctive GP IIb/IIIa inhibitors.

When should fractional flow reserve be performed to assess the significance of borderline coronary artery lesions: Derivation of a simplified scoring system.

OBJECTIVES: To derive a simplified scoring system (SSS) that can assist in selecting patients who would benefit from the application of fractional flow reserve (FFR). BACKGROUND: Angiographers base decisions to perform FFR on their interpretation of % diameter stenosis (DS), which is subject to variability. Recent studies have shown that the amount of myocardium at jeopardy is an important factor in determining the degree of hemodynamic compromise. METHODS: We conducted a retrospective multivariable analysis to identify independent predictors of hemodynamic compromise in 289 patients with 317 coronary vessels undergoing FFR. A SSS was derived using the odds ratios as a weighted factor. The receiver operator characteristics curve was used to identify the optimal cutoff (≥3) to discern a functionally significant lesion (FFR≤0.8). RESULTS: Male gender, left anterior descending artery apical wrap, disease proximal to lesion, minimal lumen diameter and % DS predicted abnormal FFR (≤0.8) and lesion location in the left circumflex predicted a normal FFR. Using a cutoff score of ≥3 on the SSS, a specificity of 90.4% (95% CI: 83.0-95.3) and a sensitivity of 38.0% (95% CI: 31.5-44.9) was generated with a positive predictive value of 89.0% (95% CI: 80.7%-94.6%) and negative predictive value of 41.6% (95% CI: 35.1%-48.3%). CONCLUSIONS: The decision to use FFR should be based not only on the % DS but also the size of the myocardial mass jeopardized. A score of ≥3 on the SSS should prompt further investigation with a pressure wire.

Percutaneous coronary intervention for myocardial infarction during pregnancy: a new trend?

Recent studies report that American women are increasingly delaying their first births. While the proportion of births in older women has been increasing, there is also increased prevalence of cardiovascular risk factors and complications of pregnancy with increasing maternal age. We present 2 cases of acute myocardial infarction occurring during pregnancy. The mothers were both over 35 years old, and had significant risk factors for coronary disease. Both were found to have atherosclerotic coronary lesions, and were managed with coronary intervention with successful reperfusion. One woman successfully delivered a healthy infant at term. The other had a spontaneous abortion shortly after discharge from the hospital. Given current demographic trends, it is likely that such cases will be more commonly seen.

The management of thrombotic lesions in the cardiac catheterization laboratory.

Plaque rupture with superimposed thrombosis is the major mechanism of acute coronary syndromes. Although angiography underestimates the presence of thrombi, their detection is a poor prognostic indicator which is proportional to their size. Although emergent percutaneous coronary intervention (PCI) in the setting of ST elevation myocardial infarction (STEMI) and early PCI in the setting of unstable angina and non-STEMI were shown to be preferred strategies, the presence of angiographic thrombosis by virtue of causing micro and macro embolization can reduce the benefit of the intervention. Antiplatelet therapy especially using glycoprotein IIb/IIIa inhibitors reduces thrombus size, and improves myocardial perfusion and ventricular function. Routine manual aspiration prior to PCI in STEMI also improves myocardial flow and reduces distal embolization and improves survival. Distal embolic protection devices and mechanical thrombectomy do not have the same clinical benefits however, rheolytic thrombectomy may have a role in large vessels with a large thrombi.

Renal dysfunction in heart failure is due to congestion but not low output.

BACKGROUND: Renal dysfunction in heart failure is thought to be due to poor perfusion of the kidney. HYPOTHESIS: We tested the hypothesis that passive congestion is more important than poor perfusion. METHODS: We retrospectively studied the data on 178 patients who underwent right heart catheterization for evaluation of heart failure and had serum creatinine (Cr) measured on the same day. RESULTS: Serum Cr and glomerular filtration rate (GFR) correlated with central venous pressure (r = 0.22, P = 0.001 and r = -0.55, P < 0.0001, respectively) and renal perfusion pressure (r = 0.21, P = 0.001 and r = 0.27, P = 0.015, respectively). Neither correlated with cardiac index or left ventricular ejection fraction. Serum Cr was significantly higher and GFR was significantly lower in the upper tertile of central venous pressure, pulmonary capillary wedge pressure as well as in the lower tertile of renal perfusion pressure. CONCLUSIONS: Renal dysfunction in heart failure is determined more by passive congestion than by low perfusion.

Synergism of rheolytic thrombectomy and embolic distal protection using the percusurge guard wire for fresh thrombus removal: an in vitro study.

OBJECTIVES: To test the effectiveness of Rheolytic Thrombectomy (RT) and distal protection balloon wires when used synergistically in an in vitro model. BACKGROUND: Although effective, currently available technologies may not be individually ideal for fresh clots removal. METHODS: Fourteen, fresh blood samples were placed in 14 plastic tubes and left to clot for 6 h. A Percusurge Guardwire balloon was inflated distal to the clot and aspiration was performed using RT in seven tubes and manual aspiration (MA) with the Export catheter in seven tubes. The residual clot in each tube was dried and weighed. Both aspiration systems were advanced over the Guardwire. RESULTS: During RT, none of the protection balloons ruptured and no retrograde clot embolization were observed. MA was most effective when the Export catheter tip was not in direct contact with the clot. The residual clot mass post RT was significantly less than post MA (9.7+/-2.2 versus 59.2+/-45.9, P = 0.01). CONCLUSION: RT is compatible with Distal Protection Balloon Wires and results in more complete clot removal than manual aspiration with the export catheter. Although manual aspiration results in a large variation in extraction efficacy, it is most effective when direct catheter-clot contact is kept to a minimum.