Cardiology

Roberts, C. S., Y. M. Salam, A. J. Moore and W. C. Roberts (2019). “Pseudoaneurysm of the Ascending Aorta at the Cannulation Site Diagnosed More Than Four Decades After Repair of Ventricular Septal Defect.” Am J Cardiol 124(12): 1962-1965.

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Described herein is a 69-year-old woman who developed a large saccular aortic aneurysm at a previous cannulation site for repair of a ventricular septal defect at age 25 years. The aneurysm was resected and proved histologically to be a false one. The long interval between operations (44 years) exceeds those reported previously.

McMurray, J. J. V., A. M. Jackson, C. S. P. Lam, M. M. Redfield, I. S. Anand, J. Ge, M. P. Lefkowitz, A. P. Maggioni, F. Martinez, M. Packer, M. A. Pfeffer, B. Pieske, A. R. Rizkala, S. V. Sabarwal, A. M. Shah, S. J. Shah, V. C. Shi, D. J. van Veldhuisen, F. Zannad, M. R. Zile, M. Cikes, E. Goncalvesova, T. Katova, A. Kosztin, M. Lelonek, N. K. Sweitzer, O. Vardeny, B. Claggett, P. S. Jhund and S. D. Solomon (2019). “Effects of Sacubitril-Valsartan, versus Valsartan, in Women Compared to Men with Heart Failure and Preserved Ejection Fraction: Insights from PARAGON-HF.” Circulation Nov 17. [Epub ahead of print].

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Background: Unlike heart failure with reduced ejection fraction, there is no approved treatment for heart failure with preserved ejection fraction (HFpEF), the predominant phenotype in women. Therefore, there is a greater heart failure therapeutic deficit in women, compared with men. Methods: In a pre-specified subgroup analysis, we examined outcomes according to sex in the PARAGON-HF trial which compared sacubitril-valsartan and valsartan in patients with HFpEF. The primary outcome was a composite of first and recurrent hospitalizations for heart failure and death from cardiovascular causes. We also report secondary efficacy and safety outcomes. Results: Overall, 2479 women (51.7%) and 2317 men (48.3%) were randomized. Women were older, had more obesity, less coronary disease, and lower estimated glomerular filtration rate and NT-proBNP levels than men. For the primary outcome, the rate ratio for sacubitril-valsartan versus valsartan was 0.73 (95% CI 0.59-0.90) in women and 1.03 (0.84-1.25) in men; P interaction=0.017. The benefit from sacubitril-valsartan was due to reduction in heart failure hospitalization. The improvement in NYHA class and renal function with sacubitril-valsartan was similar in women and men, whereas the improvement in KCCQ-CSS was less in women than in men. The difference in adverse events, between sacubitril-valsartan and valsartan, was similar in women and men. Conclusions: As compared with valsartan, sacubitril-valsartan seemed to reduce the risk of heart failure hospitalization more in women than in men. While the possible sex-related modification of the effect of treatment has several potential explanations, the present study does not provide a definite mechanistic basis for this finding (Clinicaltrials.gov unique identifier: NCT01920711).

Lanfear, A. T., M. Hamandi, J. Fan, J. M. DiMaio and T. J. George (2019). “Trends in HeartMate 3: What we know so far.” J Card Surg Nov 6. [Epub ahead of print].

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BACKGROUND: The HeartMate 3 left ventricular assist device (LVAD) is a novel, intrapericardial, centrifugal-flow pump with a fully magnetically-levitated rotor designed to provide hemodynamic support in patients with end-stage heart failure. Unique aspects of this LVAD have allowed for improved hemocompatibility and the development of minimally-invasive implantation techniques. METHODS: The PubMed, EMBASE, and Google Scholar databases were searched for publications relating to the HeartMate 3 device, with a focus on hemocompatibility related outcomes, anticoagulation management, and surgical techniques. RESULTS: Nine articles analyzing hemocompatibility related outcomes from two clinical trials, two clinical studies, and one registry series were identified. CONCLUSION: HeartMate 3 has reduced the rate of disabling stroke and pump thrombosis. However, despite increased hemocompatibility due to specialized design features, the residual risk of both surgical, and gastrointestinal bleeding remains a major adverse outcome. Different anticoagulation management and surgical techniques have been evaluated to address the remaining complications.

Hebeler, K. R., G. Filardo and J. M. DiMaio (2019). “Serum albumin and 1-year mortality in patients with transcatheter aortic valve replacement therapy (Reply).” Ann Thorac Surg Nov 28. [Epub ahead of print].

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We thank Dr. Kawada for the comments related to our study. The aim of our study was to assess the predictive ability of combining widely used frailty markers and sarcopenia measurements with the STS-PROM for 1-year mortality after TAVR and not to make inference on the magnitude of single point estimates. We agree that the relatively small number of events would have limited this latter analysis but this was beyond the purpose of our study. Nonetheless, the very large p-values estimated for all frailty markers (with the exception of albumin) [gait speed (Model 3: 0.54, Model 4: 0.59), grip strength (Model 3: 0.24, Model 4: 0.13), Katz ADL (Model 3: 0.43, Model 4: 0.43), and psoas muscle area (Model 4: 0.53)] suggest that a higher number of events would have not affected our results and conclusions regarding the poor prediction of these markers for 1-year mortality after TAVR. Likewise, we agree that the area under the curve of model 4 is not very high but again, the goal of the study was to present the predictive ability of combining widely used frailty markers and sarcopenia measurements with the STS-PROM for 1-year mortality. In fact, we stated in the conclusion of our manuscript that “…commonly used pre-TAVR risk assessments are poorly predictive of 1-year mortality.” In summary, we are confident that albumin was the only frailty marker that was associated with higher mortality. Future studies should investigate whether optimization of nutritional status can improve outcomes after TAVR. (Text of authors’ response to comments on their article, Hebeler KR, Baumgarten H, Squiers JJ, et al. “Albumin is predictive of 1-year mortality after transcatheter aortic valve replacement.” Ann Thorac Surg 2018;106:1302-7.)

Hamandi, M., A. T. Lanfear, J. Fan, M. L. Bolin, J. M. DiMaio, R. L. Smith and C. Dib (2019). “Incidental finding of giant coronary artery aneurysm.” J Card Surg Nov 25. [Epub ahead of print].

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A 58‐year‐old asymptomatic man presented to our institution after a routine cardiac computed tomography (CT) for calcium scoring. He did not have any history of connective tissue disorders or Kawasaki disease. CT angiogram confirmed the presence of a coronary artery aneurysm (CAA) measuring 10.3 × 6.8 cm arising from the right coronary artery (RCA) with true lumen enhancement. The rest of the aneurysm was thrombosed, and distal calcification of the RCA was also noted. Management for patients with CAA is not standardized, as CAAs appear in only 0.3% to 5.3% of patients undergoing coronary angiographies, while “giant” CAAs (>5 cm) appear in less than 0.02%. Surgical or percutaneous intervention and antiplatelet/anticoagulation therapy are commonly reported. Due to the rarity of giant coronary aneurysms, there is no standardized management strategy supported by controlled trials. Data assessing the risk of mortality associated with these management options is sparse. The patient was referred for aneurysm ligation with distal bypass grafting due to the size and potential high risk of rupture and the risk of distal embolization which can result in myocardial ischemia or infarction. His perioperative risk of mortality and morbidity was deemed to be extremely low. Following the median sternotomy, the aneurysm was opened and the large orifice of the main right coronary artery was noted. The right coronary ostium was ligated and the old mural thrombus within the aneurysm was removed. The patient underwent coronary artery bypass grafting. The clinical course was uneventful and he was discharged on postoperative day 4. In conclusion, the management of a giant coronary artery aneurysm should be guided by the patient’s clinical presentation and perioperative risk, the size of the aneurysm, and the final decision should be made by an experienced Heart Team approach. (Full text of this image study.)