Cardiology

Roberts, W. C. (2019). “Proceedings of the Editorial Board Meeting of The American Journal of Cardiology on March 17, 2019, in New Orleans, Louisiana.” Am J Cardiol 124(1): 164-165.

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The year 2018 was a good one for the AJC. The number of manuscripts submitted in 2018 increased 3.4% from the previous year (3,360 → 3,479), an average of 67 per week of which an average of 12 were accepted each week. The acceptance rate decreased from 19% in 2017 to 18% in 2018. The acceptance rate has continued to decrease during the present editorship even though the AJC publishes more manuscripts each year than any other cardiology journal in the world. A total of 573 articles were published in the AJC in 2018, a decrease from 700 published in 2017. This number excludes Readers’ Comments (Letters to the Editor). There is no limitation in the total number of tables and figures in articles published in the AJC, in contrast to the limitations (usually 8) of most cardiology journals. As a consequence, the AJC publishes more figures and tables than other major cardiovascular journals. The average length of the text of articles published in the AJC is almost certainly less than in other cardiology journals. The publisher of the AJC in 2018 provided a total of 3,891 editorial pages, of which 3735 (96%) were used for publishing articles and 42 for publishing Readers’ Comments. Total circulation of the AJC in 2018, according to the publisher, was just over 23,000. (Excerpt from text, p. 164-165; no abstract available.)

Packer, M. (2019). “Is Long-Standing Atrial Fibrillation a Biomarker of or Contributor to the Symptoms or Progression of Chronic Heart Failure?” Am J Med Jun 17. [Epub ahead of print].

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There is consensus that atrial fibrillation is a biomarker of the disease process in heart failure. Prolonged atrial distension due to chronic increases in left ventricular filling pressures contributes to the genesis of the arrhythmia. The disease process in the ventricles can also affect the atrial myocardium. Additionally, the atria are susceptible to fibrosis that results from the inflammation of epicardial adipose tissue that is seen in obesity or diabetes. The degree of atrial fibrosis is particularly marked in patients with persistent and long-standing atrial fibrillation. When the left atrium is severely fibrotic, restoration of sinus rhythm does not fully restore force transmission to the left ventricle. Patients with heart failure are at increased risk of stroke and systemic thromboembolism, whether in sinus rhythm or atrial fibrillation. The risk of stroke is higher in those with atrial fibrillation, perhaps because their atrial disease is more severe. Unless contraindicated, patients with atrial fibrillation should receive non–vitamin K-dependent oral anticoagulants, which have been shown to be noninferior or superior to warfarin in preventing stroke, but carry a lower risk of intracranial bleeding, particularly in patients with heart failure. However, even in sinus rhythm, the use of these drugs (e.g., rivaroxaban) in chronic heart failure appears to reduce the risk of stroke. Does atrial fibrillation itself contribute to the progression of heart failure? Atrial tachyarrhythmias can lead to cardiomyopathy, but if high ventricular rates can be minimized, irregularity of the ventricular response does not adversely affect cardiac performance. In patients whose rate is < 100 per minute, the outcomes of patients with atrial fibrillation are not influenced by the rapidity of the ventricular response. Additionally, although it is commonly believed that patients with heart failure with atrial fibrillation fare worse than those in sinus rhythm, this risk is confined to those with paroxysmal or recent-onset arrhythmias. Longstanding atrial fibrillation is not associated with an increased risk of death or hospitalization for heart failure, as compared with sinus rhythm. (Excerpt from article in press, unpaginated; no abstract available.)

Packer, M. (2019). “Effect of catheter ablation on pre-existing abnormalities of left atrial systolic, diastolic, and neurohormonal functions in patients with chronic heart failure and atrial fibrillation.” Eur Heart J 40(23): 1873-1879.

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The critical role of the left atrium (LA) in cardiovascular homoeostasis is mediated by its reservoir, conduit, systolic, and neurohormonal functions. Atrial fibrillation is generally a reflection of underlying disease of the LA, especially in patients with heart failure. Disease-related LA remodelling leads to a decline in both atrial contractility and distensibility along with an impairment in the control of neurohormonal systems that regulate intravascular volume. Catheter ablation can lead to further injury to the atrial myocardium, as evidenced by post-procedural troponin release and tissue oedema. The cardiomyocyte loss leads to replacement fibrosis, which may affect up to 30-35% of the LA wall. These alterations further impair atrial force generation and neurohormonal functions; the additional loss of atrial distensibility can lead to a ‘stiff LA syndrome’, and the fibrotic response predisposes to recurrence of the atrial arrhythmia. Although it intends to restore LA systole, catheter ablation often decreases the chamber’s transport functions. This is particularly likely in patients with long-standing atrial fibrillation and pre-existing LA fibrosis, especially those with increased epicardial adipose tissue (e.g. patients with obesity, diabetes and/or heart failure with a preserved ejection fraction). Although the fibrotic LA in these individuals is an ideal substrate for the development of atrial fibrillation, it may be a suboptimal substrate for catheter ablation. Such patients are not likely to experience long-term restoration of sinus rhythm, and catheter ablation has the potential to worsen their haemodynamic and clinical status. Further studies in this vulnerable group of patients are needed.

Lim, D. S., S. Kar, K. Spargias, R. M. Kipperman, W. W. O’Neill, M. K. C. Ng, N. P. Fam, D. L. Walters, J. G. Webb, R. L. Smith, M. J. Rinaldi, A. Latib, G. N. Cohen, U. Schafer, L. Marcoff, P. Vandrangi, P. Verta and T. E. Feldman (2019). “Transcatheter Valve Repair for Patients With Mitral Regurgitation: 30-Day Results of the CLASP Study.” JACC Cardiovasc Interv Jun 19. [Epub ahead of print].

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OBJECTIVES: The authors report the procedural and 30-day results of the PASCAL Transcatheter Valve Repair System (Edwards Lifesciences, Irvine, California) in patients with mitral regurgitation (MR) enrolled in the multicenter, prospective, single-arm CLASP study. BACKGROUND: Severe MR may lead to symptoms, impaired quality of life, and reduced functional capacity when untreated. METHODS: Eligible patients had grade 3+ or 4+ MR despite optimal medical therapy and were deemed appropriate for the study by the local heart team. All outcomes were assessed through 30 days post-procedure. Major adverse events (MAEs) were adjudicated by an independent clinical events committee, and echocardiographic images were assessed by a core laboratory. The primary safety endpoint was the rate of MAEs at 30 days. RESULTS: Between June 2017 and September 2018, 62 patients with grade 3+ or 4+ MR were enrolled. The mean age was 76.5 years, and 51.6% of patients were in New York Heart Association functional class III or IV, with 56% functional, 36% degenerative, and 8% mixed MR etiology. At 30 days, the MAE rate was 6.5%, with an all-cause mortality rate of 1.6% and no occurrence of stroke; 98% had MR grade

Hamandi, M., R. L. Smith, W. H. Ryan, P. A. Grayburn, A. Vasudevan, T. J. George, J. M. DiMaio, K. A. Hutcheson, W. Brinkman, M. Szerlip, D. O. Moore and M. J. Mack (2019). “Outcomes of Isolated Tricuspid Valve Surgery Have Improved in the Modern Era.” Ann Thorac Surg 108(1): 11-15.

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BACKGROUND: Surgery for isolated tricuspid valve (TV) disease remains relatively infrequent because of significant patient comorbidities and poor surgical outcomes. This study reviewed the experience with isolated TV surgery in the current era to determine whether outcomes have improved. METHODS: From 2007 through 2017, 685 TV operations were performed in a single institution, of which 95 (13.9%) operations were isolated TV surgery. Patients were analyzed for disease origin, risk factors, operative mortality and morbidity, and long-term survival. RESULTS: A total of 95 patients underwent isolated TV surgery, an average of 9 patients per year increasing from an average of 5 per year to 15 per year during the study period. Surgery was reoperative in 41% (38 of 95) of patients, including 11.6% (11 of 95) with prior coronary artery bypass grafting and 29.4% (28 of 95) with prior valve surgery (9 TV, 11 mitral, 2 aortic, 5 mitral and aortic, and 1 mitral and TV). Repair was performed in 71.6% (68 of 95) of patients, and replacement was performed in 28.4% (27 of 95). Operative mortality was 3.2% (3 of 95), with no mortality in the most recent 73 patients over the last 6 years. Stroke occurred in 2.1% (2 of 95) of patients, acute kidney injury requiring dialysis in 5.3% (5 of 95), and the need for new permanent pacemaker in 16.8% (16 of 95). CONCLUSIONS: In the current era with careful patient selection and periprocedural management, isolated TV surgery can be performed with lower morbidity and mortality than has traditionally been reported with good long-term survival. These outcomes can also serve as a benchmark for catheter-based TV intervention outcomes.