Cardiology

Iribarne, A., S. Pan, J. N. McCullough, J. P. Mathew, J. Hung, X. Zeng, P. Voisine, P. T. O’Gara, N. M. Sledz, A. C. Gelijns, W. C. Taddei-Peters, S. R. Messe, A. J. Moskowitz, V. H. Thourani, M. Argenziano, M. A. Groh, G. Giustino, J. R. Overbey, J. M. DiMaio and P. K. Smith (2019). “Impact of Aortic Atherosclerosis Burden on Outcomes of Surgical Aortic Valve Replacement.” Ann Thorac Surg Aug 7. [Epub ahead of print].

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BACKGROUND: Epiaortic ultrasound detects and localizes ascending aortic atherosclerosis. In this analysis we investigated the association between epiaortic ultrasound-based atheroma grade during surgical aortic valve replacement (SAVR) and perioperative adverse outcomes. METHODS: SAVR patients in a randomized trial of two embolic protection devices underwent a protocol-defined 5-view epiaortic ultrasound read at a core-laboratory. Aortic atherosclerosis was quantified with Katz atheroma grade and patients were categorized into mild (grade I-II) versus moderate/severe (grade III-V). Multivariable logistic regression was used to estimate associations between atheroma grade and adverse outcomes including death, clinically apparent stroke, cerebral infarction on diffusion-weighted magnetic resonance imaging (DW-MRI), delirium, and acute kidney injury (AKI) by 7 and 30 days. RESULTS: Of the 383 randomized patients, 326 (85.1%) had pre-cannulation epiaortic ultrasound data available. Of these, 106 (32.5%) had moderate/severe Katz atheroma grade at any segment of the ascending aorta. While there were no significant differences in the composite of death, stroke or cerebral infarction on DW-MRI by 7 days, moderate/severe atheroma grade was associated with a greater risk of AKI by 7 days (adjusted odds ratio [OR]: 2.63; 95% confidence interval [CI]: 1.24-5.58; p=0.01). At 30 days, patients with moderate/severe atheroma grade had a greater risk of death, stroke or AKI (adjusted OR: 1.97; 95%CI: 1.04-3.71; p=0.04). CONCLUSIONS: Moderate/severe aortic atherosclerosis was associated with an increased risk of adverse events following SAVR. Epiaortic ultrasound may serve as a useful adjunct for identifying patients who may benefit from strategies to reduce atheroembolic complications during SAVR.

Goldsweig, A. M., H. J. Tak, L. W. Chen, H. D. Aronow, B. Shah, D. S. Kolte, P. Velagapudi, N. Desai, M. Szerlip and J. D. Abbott (2019). “The Evolving Management of Aortic Valve Disease: 5-Year Trends in SAVR, TAVR, and Medical Therapy.” Am J Cardiol 124(5): 763-771

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Aortic stenosis (AS) and regurgitation (AR) may be treated with surgical aortic valve replacement (SAVR), transcatheter AVR (TAVR), or medical therapy (MT). Data are lacking regarding the usage of SAVR, TAVR, and MT for patients hospitalized with aortic valve disease and the characteristics of the patients and hospitals associated with each therapy. From the Nationwide Readmissions Database, we determined utilization trends for SAVR, TAVR, and MT in patients with aortic valve disease admitted from 2012 to 2016 for valve replacement, heart failure, unstable angina, non-ST-elevation myocardial infarction, or syncope. We also performed multinomial logistic regressions to investigate associations between patient and hospital characteristics and treatment. Among 366,909 patients hospitalized for aortic valve disease, there was a 48.1% annual increase from 2012 through 2016. Overall, 19.9%, 6.7%, and 73.4% of patients received SAVR, TAVR, and MT, respectively. SAVR decreased from 21.9% in 2012 to 18.5% in 2016, whereas TAVR increased from 2.6% to 12.5%, and MT decreased from 75.5% to 69.0%. Older age, female sex, greater severity of illness, more admission diagnoses, not-for-profit hospitals, large hospitals, and urban teaching hospitals were associated with greater use of TAVR. In multivariable analysis, likelihood of TAVR relative to SAVR increased 4.57-fold (95% confidence interval 4.21 to 4.97). TAVR has increased at the expense of both SAVR and MT, a novel finding. However, this increase in TAVR was distributed inequitably, with certain patients more likely to receive TAVR certain hospitals more likely to provide TAVR. With the expected expansion of indications, inequitable access to TAVR must be addressed.

Fathima, S. and W. C. Roberts (2019). “Comparison of Clinical and Morphologic Findings in Patients With Cardiac Sarcoidosis Severe Enough to Warrant Heart Transplantation in Those With -vs- Those Without Non-Caseating Granulomas in the Explanted Heart (Burnt-Out Sarcoid).” Am J Cardiol 124(4): 599-603.

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Can cardiac sarcoidosis with heart failure severe enough to warrant orthotopic heart transplantation (OHT) be present without non-caseating granulomas in the explanted heart? The objective is to compare clinical and morphological features in patients with cardiac sarcoidosis severe enough to warrant OHT with -vs-without non-caseating granulomas in the explanted heart. The study was conducted at Baylor University Medical Center in Dallas, Texas. From a total of 671 explanted hearts examined from 1993 to 2018, twenty-five (4%) had gross morphologic features characteristic of cardiac sarcoidosis. At the time of OHT, the patients ranged in age from 50 to 69 years [mean 57]. Cardiac sarcoidosis was diagnosed before OHT in 3 (12%) patients, by percutaneous biopsy of the heart in 2 patients and by histologic examination of the “left ventricular core” in 1 patient who had a left ventricular assist device inserted, and, by examination of the native heart after OHT in the remaining 22 (88%) patients. Of the 25 patients, 16 (64%) had typical sarcoid non-caseating granulomas in the explanted heart, and 9 (36%) had no granulomas in the explanted heart. Comparison of certain clinical and morphologic features in the group with -vs- the group without cardiac granulomas showed no significant differences. In conclusion, of patients with cardiac sarcoidosis severe enough to warrant OHT, some have typical non-caseating granulomas in the explanted heart and some do not. The clinical and gross morphologic features of those with and those without cardiac granulomas are similar.

Rodes-Cabau, J., K. A. Ellenbogen, A. D. Krahn, A. Latib, M. Mack, S. Mittal, G. Muntane-Carol, T. M. Nazif, L. Sondergaard, M. Urena, S. Windecker and F. Philippon (2019). “Management of Conduction Disturbances Associated With Transcatheter Aortic Valve Replacement: JACC Scientific Expert Panel.” J Am Coll Cardiol 74(8): 1086-1106.

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Despite major improvements in transcatheter aortic valve replacement (TAVR) periprocedural complications in recent years, the occurrence of conduction disturbances has not decreased over time and remains the most frequent complication of the procedure. Additionally, there has been an important lack of consensus on the management of these complications, which has indeed translated into a high degree of uncertainty regarding the most appropriate treatment of a large proportion of such patients along with major differences between centers and studies in pacemaker rates post-TAVR. There is therefore an urgent need for a uniform strategy regarding the management of conduction disturbances after TAVR. The present expert consensus scientific panel document has been formulated by a multidisciplinary group of interventional cardiologists, electrophysiologists, and cardiac surgeons as an initial attempt to provide a guide for the management of conduction disturbances after TAVR based on the best available data and group expertise.

Elkayam, U., A. Schafer, A. Chieffo, A. Lansky, S. Hall, Z. Arany and C. Grines (2019). “Use of Impella heart pump for management of women with peripartum cardiogenic shock.” Clin Cardiol Aug 22. [Epub ahead of print].

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BACKGROUND: Percutaneous mechanical circulatory support (MCS), such as the Impella heart pump is a valuable option for cardiogenic shock (CS), although the use of Impella in CS due to peripartum cardiomyopathy (PPCM) is limited. OBJECTIVE: To assess outcomes in women with PPCM supported with an Impella device from the global catheter-based ventricular assist device (cVAD) Registry. METHODS AND RESULTS: A total of 15 women with PPCM supported with Impella devices between November 2008 and October 2015 were included. Of the 15 women, five were treated at Hannover medical school and have been reported previously, the rest were managed at various US hospitals. The mean age was 30.0 +/- 7.34 years, eight women were Caucasian, and seven were African-American. The occurrence of PPCM was post-delivery in eight (53.3%), at delivery in one (6.7%), and during gestation in four women (26.7%). At admission, all women had severe heart failure with a mean ejection fraction of 14.7 +/- 6% and 13 women (86.7%) presented with CS. Prior to Impella, 100% were mechanically ventilated, 79% received inotropes/vasopressors, 20% supported with IABP, and 27% received veno-arterial extracorporeal membrane oxygenation (VA ECMO) during Impella support. Two women (13.3%) died, and 13 (87.7%) survived to discharge. Eight women (53.3%) had a recovery of native heart function and six (40%) were bridged to durable left ventricular assist device (LVAD). CONCLUSION: MCS with Impella devices can be successfully used as a bridge to early improvement, heart recovery, or successful implantation of durable LVAD in women with PPCM complicated by severe LV dysfunction.