Cardiology

Grapsa, J., Blauth, C., Chandrashekhar, Y.S., Prendergast, B., Erb, B., Jr., Mack, M. and Fuster, V. (2021). “Staphylococcus Aureus Infective Endocarditis: JACC Patient Pathways.” J Am Coll Cardiol Nov 13;S0735-1097(21)07811-6. [Epub ahead of print].

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A 19-year-old female patient presented with Staphylococcus aureus infective endocarditis, with suspected subdural brain hemorrhage, disseminated intravascular coagulopathy, and septic renal as well as spleen infarcts. The patient had extensive vegetations on the mitral and tricuspid valves and underwent urgent mitral and tricuspid repair. This paper discusses the clinical case and current evidence regarding the management and treatment of Staphylococcus aureus endocarditis.

Gammie, J.S., Chu, M.W.A., Falk, V., Overbey, J.R., Moskowitz, A.J., Gillinov, M., Mack, M.J., Voisine, P., Krane, M., Yerokun, B., Bowdish, M.E., Conradi, L., Bolling, S.F., Miller, M.A., Taddei-Peters, W.C., Jeffries, N.O., Parides, M.K., Weisel, R., Jessup, M., Rose, E.A., Mullen, J.C., Raymond, S., Moquete, E.G., O’Sullivan, K., Marks, M.E., Iribarne, A., Beyersdorf, F., Borger, M.A., Geirsson, A., Bagiella, E., Hung, J., Gelijns, A.C., O’Gara, P.T. and Ailawadi, G. (2021). “Concomitant Tricuspid Repair in Patients with Degenerative Mitral Regurgitation.” N Engl J Med Nov 13. [Epub ahead of print].

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BACKGROUND: Tricuspid regurgitation is common in patients with severe degenerative mitral regurgitation. However, the evidence base is insufficient to inform a decision about whether to perform tricuspid-valve repair during mitral-valve surgery in patients who have moderate tricuspid regurgitation or less-than-moderate regurgitation with annular dilatation. METHODS: We randomly assigned 401 patients who were undergoing mitral-valve surgery for degenerative mitral regurgitation to receive a procedure with or without tricuspid annuloplasty (TA). The primary 2-year end point was a composite of reoperation for tricuspid regurgitation, progression of tricuspid regurgitation by two grades from baseline or the presence of severe tricuspid regurgitation, or death. RESULTS: Patients who underwent mitral-valve surgery plus TA had fewer primary-end-point events than those who underwent mitral-valve surgery alone (3.9% vs. 10.2%) (relative risk, 0.37; 95% confidence interval [CI], 0.16 to 0.86; P = 0.02). Two-year mortality was 3.2% in the surgery-plus-TA group and 4.5% in the surgery-alone group (relative risk, 0.69; 95% CI, 0.25 to 1.88). The 2-year prevalence of progression of tricuspid regurgitation was lower in the surgery-plus-TA group than in the surgery-alone group (0.6% vs. 6.1%; relative risk, 0.09; 95% CI, 0.01 to 0.69). The frequencies of major adverse cardiac and cerebrovascular events, functional status, and quality of life were similar in the two groups at 2 years, although the incidence of permanent pacemaker implantation was higher in the surgery-plus-TA group than in the surgery-alone group (14.1% vs. 2.5%; rate ratio, 5.75; 95% CI, 2.27 to 14.60). CONCLUSIONS: Among patients undergoing mitral-valve surgery, those who also received TA had a lower incidence of a primary-end-point event than those who underwent mitral-valve surgery alone at 2 years, a reduction that was driven by less frequent progression to severe tricuspid regurgitation. Tricuspid repair resulted in more frequent permanent pacemaker implantation. Whether reduced progression of tricuspid regurgitation results in long-term clinical benefit can be determined only with longer follow-up. (Funded by the National Heart, Lung, and Blood Institute and the German Center for Cardiovascular Research; ClinicalTrials.gov number, NCT02675244.).

Afzal, A., Alam, A., van Zyl, J.S., Zafar, H., Felius, J., Hall, S.A. and Carey, S.A. (2021). “Observed Elevated Donor-Derived Cell Free DNA in Orthotopic Heart Transplant Recipients Without Clinical Evidence of Rejection.” Clin Transplant Dec 4;e14549. [Epub ahead of print]. e14549.

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Donor-derived cell free DNA (dd-cfDNA) has rapidly become part of rejection surveillance following orthotopic heart transplantation. However, some patients show elevated dd-cfDNA without clinical evidence of rejection. With the aim to provide a clinical description of this subpopulation, we retrospectively analyzed 35 cardiac transplant recipients at our center who experienced elevated (≥0.20%) dd-cfDNA in the absence of clinical rejection, out of a total 106 recipients who had dd-cfDNA results available during the first year. The median time to first elevated dd-cfDNA level was 46 days, and the highest dd-cfDNA recorded within 1 year was 0.31% [inter-quartile range, 0.23 – 0.45]. Twenty-two (63%) patients experienced infections (cytomegalovirus (CMV) or other), and 16 (46%) presented with de novo donor-specific antibodies. Cluster analysis revealed 4 distinct groups characterized by (a) subclinical rejection with 50% CMV (n = 16), (b) non-CMV infections and the longest time to first elevated dd-cfDNA (187 days) (n = 8), (c) right ventricular dysfunction (n = 6), and (d) women who showed the youngest median age (45 years) and highest median dd-cfDNA (0.50%) (n = 5). Continued prospective analysis is needed to determine if these observations warrant changes in patient management to optimize the utilization of this vital non-invasive graft surveillance tool.

Muller, D.W.M., Sorajja, P., Duncan, A., Bethea, B., Dahle, G., Grayburn, P., Babaliaros, V., Guerrero, M., Thourani, V.H., Bedogni, F., Denti, P., Dumonteil, N., Modine, T., Jansz, P., Chuang, M.L., Blanke, P., Leipsic, J. and Badhwar, V. (2021). “2-Year Outcomes of Transcatheter Mitral Valve Replacement in Patients With Severe Symptomatic Mitral Regurgitation.” J Am Coll Cardiol 78(19): 1847-1859.

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BACKGROUND: Transcatheter mitral valve replacement (TMVR) is feasible for selected patients with severe mitral regurgitation (MR) who are poor candidates for valve surgery. Intermediate-term to long-term TMVR outcomes have not been reported. OBJECTIVES: This study sought to evaluate the safety and effectiveness through 2-year follow-up of TMVR in high-surgical-risk patients with severe MR. METHODS: The first 100 patients enrolled in the Expanded Clinical Study of the Tendyne Mitral Valve System, an open-label, nonrandomized, prospective study of transapical TMVR, were followed for 2 years. RESULTS: The patients (aged 74.7 ± 8.0 years, 69.0% male) had symptomatic (66.0% New York Heart Association [NYHA] functional class III or IV) grade 3+ or 4+ MR that was secondary or mixed in 89 (89.0%). Prostheses were successfully implanted in 97 (97.0%) patients. At 2 years, all-cause mortality was 39.0%; 17 (43.6%) of 39 deaths occurred during the first 90 days. Heart failure hospitalization (HFH) fell from 1.30 events per year preprocedure to 0.51 per year in the 2 years post-TMVR (P < 0.0001). At 2 years, 93.2% of surviving patients had no MR. No patient had >1+ MR. The improvement in symptoms at 1 year (88.5% NYHA functional class I or II) was sustained to 2 years (81.6% NYHA functional class I or II). Among survivors, the left ventricular ejection fraction was 45.6 ± 9.4% at baseline and 39.8 ± 9.5% at 2 years (P = 0.0012). Estimated right ventricular systolic pressure decreased from 47.6 ± 8.6 mm Hg to 32.5 ± 10.4 mm Hg (P < 0.005). CONCLUSIONS: In this study, the impact of TMVR on severity of MR, reduction in HFH rate, and improvement in symptoms was sustained through 2 years. All-cause mortality and the need for HFH was highest in the first 3 months postprocedure. (Expanded Clinical Study of the Tendyne Mitral Valve System; NCT02321514).

Shih, E., DiMaio, J.M., Squiers, J.J., Krueger, A.R., Schwartz, G.S., Herd, J. and Bleich, A.T. (2021). “Treatment of acute respiratory distress syndrome from COVID-19 with extracorporeal membrane oxygenation in obstetrical patients.” Am J Obstet Gynecol MFM 4(2): 100537.

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BACKGROUND: Extracorporeal membrane oxygenation therapy has been used as a rescue therapy for patients with severe acute respiratory distress syndrome from COVID-19 who have failed conventional ventilatory strategies. Little is known about the outcome of pregnant and postpartum patients on extracorporeal membrane oxygenation therapy. OBJECTIVE: To describe the medical and surgical outcomes of pregnant and postpartum patients who were placed on extracorporeal membrane oxygenation therapy for severe acute respiratory distress syndrome from COVID-19. STUDY DESIGN: A case series reviewing pregnant or postpartum patients with laboratory-confirmed COVID-19 who were placed on extracorporeal membrane oxygenation therapy was conducted within the Baylor Scott & White Healthcare system. The demographics and the medical and surgical outcomes were collected and reviewed. RESULTS: Between March 2020 and October 2021, 5 pregnant and 5 postpartum women were supported with venovenous extracorporeal membrane oxygenation therapy. The median age was 30 years (interquartile range, 26-33.5) and the median body mass index was 36.6 kg/m(2) (interquartile range, 29.5-42.0). There was a median of 4.5 days (interquartile range, 1.5-6.8) from admission to any hospital to intubation and 9 days (interquartile range, 7-13) to extracorporeal membrane oxygenation therapy cannulation. One patient had an ischemic stroke, 1 patient had a presumed hemorrhagic stroke, and 9 patients developed bleeding while on extracorporeal membrane oxygenation therapy. Of the 5 pregnant women, 2 patients had intrauterine fetal demise and 3 underwent delivery for maternal hemodynamic instability. The 5 postpartum women were initiated on extracorporeal membrane oxygenation therapy a median of 10 days (interquartile range, 3-11) after delivery. The median length of time on extracorporeal membrane oxygenation therapy was 22 days (interquartile range, 11-31). At the time of the study, there were 2 inpatient mortalities, 6 patients survived to discharge from the extracorporeal membrane oxygenation therapy hospital, and 2 patients were still admitted. CONCLUSION: There is limited information regarding the use of extracorporeal membrane oxygenation therapy for COVID-19 acute respiratory distress syndrome in obstetrical patients. This case series describes the use of extracorporeal membrane oxygenation therapy and survival in pregnant and postpartum patients with COVID-19.