Cardiology

Habib, P. J. and S. M. Joseph (2017). “Why all the pushback against counterpulsation?” Cardiology 138(1): 66-68.

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Intra-aortic balloon counterpulsation (IABP) has been a mainstay of mechanical circulatory support (MCS) for over 50 years. There are many intuitive reasons for this: the expansive familiarity with the technology, the ease of insertion, the low risk profile, and the relatively low costs. Despite this, following the IABP-SHOCK II trial, there has been a substantial decline in the use of IABP in cardiogenic shock (CS), and its value as a viable option has been heatedly debated. Indeed, the European Society of Cardiology even gave the IABP a class III recommendation and stated that routine use cannot be recommended [1].

Basra, S. and M. Szerlip (2017). “Transcatheter aortic valve replacement and mitraclip to reverse heart failure.” Interv Cardiol Clin 6(3): 373-386.

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Valvular heart diseases such as aortic stenosis and mitral regurgitation are often associated with heart failure, which in turn increases patients’ Surgical Thoracic Society (STS) score. A high STS score means the patient is high risk for surgical aortic valve replacement and mitral valve repair/replacement. Transcatheter aortic valve replacement and percutaneous mitral valve repair offer a minimally invasive alternative for the treatment of valvular heart disease in patients with severe heart failure. We aim to review the current evidence on the safety, efficacy, and outcomes of these devices in patients with severe heart failure.

Carroll, J. D., S. Vemulapalli, D. Dai, R. Matsouaka, E. Blackstone, F. Edwards, F. A. Masoudi, M. Mack, E. D. Peterson, D. Holmes, J. S. Rumsfeld, E. M. Tuzcu and F. Grover (2017). “Procedural experience for transcatheter aortic valve replacement and relation to outcomes: The sts/acc tvt registry.” J Am Coll Cardiol 70(1): 29-41.

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BACKGROUND: Transcatheter aortic valve replacement (TAVR) has been introduced into U.S. clinical practice with efforts to optimize outcomes and minimize the learning curve. OBJECTIVES: The goal of this study was to assess the degree to which increasing experience during the introduction of this procedure, separated from other outcome determinants including patient and procedural characteristics, is associated with outcomes. METHODS: The authors evaluated the association of hospital TAVR volume and patient outcomes for TAVR by using data from 42,988 commercial procedures conducted at 395 hospitals submitting to the Transcatheter Valve Therapy Registry from 2011 through 2015. Outcomes assessed included adjusted and unadjusted in-hospital major adverse events. RESULTS: Increasing site volume was associated with lower in-hospital risk-adjusted outcomes, including mortality (p < 0.02), vascular complications (p < 0.003), and bleeding (p < 0.001) but was not associated with stroke (p = 0.14). From the first case to the 400th case in the volume-outcome model, risk-adjusted adverse outcomes declined, including mortality (3.57% to 2.15%), bleeding (9.56% to 5.08%), vascular complications (6.11% to 4.20%), and stroke (2.03% to 1.66%). Vascular and bleeding volume-outcome associations were nonlinear with a higher risk of adverse outcomes in the first 100 cases. An association of procedure volume with risk-adjusted outcomes was also seen in the subgroup having transfemoral access. CONCLUSIONS: The initial adoption of TAVR into practice in the United States showed that increasing experience was associated with better outcomes. This association, whether deemed a prolonged learning curve or a manifestation of a volume-outcome relationship, suggested that concentrating experience in higher volume heart valve centers might be a means of improving outcomes.

Becker, T. M., P. A. Grayburn and W. C. Roberts (2017). “Mitral valve repair for pure mitral regurgitation followed years later by mitral valve replacement for mitral stenosis.” Am J Cardiol 120(1): 160-166.

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We describe herein 2 patients who developed severe mitral stenosis (MS) approximately two decades after a mitral valve repair operation for pure mitral regurgitation (MR) secondary to mitral valve prolapse. This report’s purpose is to point out that use of a circumferential mitral annular ring during the repair has the potential to produce a transmitral pressure gradient just like that occurring after mitral valve replacement utilizing a mechanical prosthesis or a bioprosthesis in the mitral position.

Blanke, P., J. K. Park, P. Grayburn, C. Naoum, K. Ong, K. Kohli, B. L. Norgaard, J. G. Webb, J. Popma, D. Boshell, P. Sorajja, D. Muller and J. Leipsic (2017). “Left ventricular access point determination for a coaxial approach to the mitral annular landing zone in transcatheter mitral valve replacement.” J Cardiovasc Comput Tomogr 11(4): 281-287.

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INTRODUCTION: To facilitate coaxial device deployment in transcatheter mitral valve replacement (TMVR), a coaxial approach to the mitral annular plane is needed. We sought to establish a method to determine an ‘orthogonal’ left ventricular (LV) access point for transapical TMVR and to quantitatively characterize its location in patients with severe mitral regurgitation using cardiac computed tomography. METHODS: Cardiac CT data sets of 54 patients with moderate-severe mitral regurgitation evaluated for potential TMVR were analyzed. The D-shaped mitral annular contour was segmented and a 2-dimensional annular plane was derived, allowing for subsequent definition of the perpendicularly oriented mitral annular trajectory. The ‘orthogonal’ LV access point was defined as the transection point of mitral trajectory with the LV epicardial surface. The location of the access point was quantified by its epicardial distance from the true apex and by the rotational offset from a 3-chamber view. RESULTS: LV access points orthogonal to the mitral annular plane were most frequently located in the anterolateral (n = 22, 40.7%) and anterior (n = 16, 29.6%), less frequently anteroseptal (n = 6, 11.1%) and inferolateral (n = 5, 9.3%) ventricular segment; none inferior or inferoseptal. The mean distance to the LV apex was 17.6 +/- 7.7 mm. The mean forward rotational offset from the 3-chamber view was 96.4 +/- 43.4 degrees , relating to a mean forward rotational offset of 6.4 +/- 43.4 degrees in regard to a hypothetical, secondary 90 degrees x-plane view. No significant difference between patients with degenerative mitral valve disease or functional mitral regurgitation was observed. CONCLUSION: The location of the LV access point that provides an orthogonal trajectory to the mitral annular plane exhibits relevant inter-individual variability. It is commonly not identical with the true apex, and frequently localized in the anterolateral or anterior ventricular segments.