Cardiology

Zoghbi, W. A., D. Adams, R. O. Bonow, M. Enriquez-Sarano, E. Foster, P. A. Grayburn, R. T. Hahn, Y. Han, J. Hung, R. M. Lang, S. H. Little, D. J. Shah, S. Shernan, P. Thavendiranathan, J. D. Thomas and N. J. Weissman (2017). “Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance.” J Am Soc Echocardiogr: 2017 Mar [Epub ahead of print].

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This update on the evaluation of valvular regurgitation is a comprehensive review of the noninvasive assessment of valvular regurgitation with echocardiography and CMR in the adult. It provides recommendations for the assessment of the etiology and severity of valvular regurgitation based on the literature and a consensus of a panel of experts. This guideline is accompanied by a number of tutorials and illustrative case studies on evaluation of valvular regurgitation, posted on the following website (www. asecho.org/vrcases), which will build gradually over time. Issues regarding medical management and timing of surgical interventions are beyond the scope of this document and have been recently updated.

VanderPluym, C. J., A. Cedars, P. Eghtesady, B. G. Maxwell, J. M. Gelow, L. J. Burchill, S. Maltais, D. A. Koehl, R. S. Cantor and E. D. Blume (2017). “Outcomes following implantation of mechanical circulatory support in adults with congenital heart disease: An analysis of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS).” J Heart Lung Transplant: 2017 Mar [Epub ahead of print].

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BACKGROUND: Adults with congenital heart disease represent an expanding and unique population of patients with heart failure (HF) in whom the use of mechanical circulatory support (MCS) has not been characterized. We sought to describe overall use, patient characteristics, and outcomes of MCS in adult congenital heart disease (ACHD). METHODS: All patients entered into the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) between June 23, 2006, and December 31, 2015, were included. Patients with ACHD were identified using pre-operative data and stratified by ventricular morphology. Mortality was compared between ACHD and non-ACHD patients, and multivariate analysis was performed to identify predictors of death after device implantation. RESULTS: Of 16,182 patients, 126 with ACHD stratified as follows: systemic morphologic left ventricle (n = 63), systemic morphologic right ventricle (n = 45), and single ventricle (n = 17). ACHD patients were younger (42 years +/- 14 vs 56 years +/- 13; p < 0.0001) and were more likely to undergo device implantation as bridge to transplant (45% vs 29%; p < 0.0001). A higher proportion of ACHD patients had biventricular assist device (BiVAD)/total artificial heart (TAH) support compared with non-ACHD patients (21% vs 7%; p < 0.0001). More ACHD patients on BiVAD/TAH support were INTERMACS profile 1 compared with patients on systemic left ventricular assist device (LVAD) support (35% vs 15%; p = 0.002). ACHD and non-ACHD patients with LVADs had similar survival; survival was worse for patients on BIVAD/TAH support. BiVAD/TAH support was the only variable independently associated with mortality (early phase hazard ratio 4.4; 95% confidence interval, 1.8-11.1; p = 0.001). For ACHD patients receiving MCS, ventricular morphology was not associated with mortality. CONCLUSIONS: ACHD patients with LVADs have survival similar to non-ACHD patients. Mortality is higher for patients requiring BiVAD/TAH support, potentially owing to higher INTERMACS profile. These outcomes suggest a promising role for LVAD support in ACHD patients as part of the armamentarium of therapies for advanced HF.

Mumtaz, M., H. Gada, M. J. Mack and M. J. Reardon (2017). “Who’s afraid of the big bad wolf?” J Thorac Cardiovasc Surg: 2017 Mar [Epub ahead of print].

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Cardiac surgeons traditionally have been leaders in the development of innovative therapy for the treatment of cardiovascular diseases. We hold deep convictions and strong opinions on discovering and delivering the best treatment for our patients. We have led the way in all of medicine in data collection and rigorous outcomes analysis to improve the care of our patients. Our passion for rigorous self-examination is unparalleled. Simply put, we are staunch patient advocates who do not run from the challenges of finding and delivering the best care to our patients. Surgical aortic valve replacement (SAVR) for the treatment of symptomatic severe aortic stenosis is arguably one of the most successful cardiac procedures ever developed. Since the introduction of SAVR in 1960, millions of lives have been saved and improved. Although never tested against the previous standard of care, medical therapy, we as surgeons knew it was the right choice because without SAVR these patients were resigned to heart failure and death. We did track our outcomes both individually and nationally by the creation of the Society of Thoracic Surgery Adult Cardiac Surgery database, which now encompasses more than 6.1 million patients contributed by more than 95% of cardiac surgeons in the United States.

Joseph, S. M. and M. W. Rich (2017). “Targeting Frailty in Heart Failure.” Curr Treat Options Cardiovasc Med 19(4): 31.

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OPINION STATEMENT: Frailty is a systemic syndrome characterized by impaired physiologic reserve, slowness, weakness, and wasting. It is associated with, but distinct from, aging, disability, and multimorbidity. Frailty is extremely common in patients with heart failure and portends a worse prognosis. The two syndromes worsen one another via complex molecular and cellular mechanisms which are not fully understood but include increased levels of stress hormones and cytokines. In this article, we discuss the mechanisms of frailty and review common frailty metrics. We review and summarize the literature on the impact of frailty in heart failure and discuss treatment and management options.

Grover, F. L., S. Vemulapalli, J. D. Carroll, F. H. Edwards, M. J. Mack, V. H. Thourani, R. G. Brindis, D. M. Shahian, C. E. Ruiz, J. P. Jacobs, G. Hanzel, J. E. Bavaria, E. M. Tuzcu, E. D. Peterson, S. Fitzgerald, M. Kourtis, J. Michaels, B. Christensen, W. F. Seward, K. Hewitt and D. R. Holmes, Jr. (2017). “2016 annual report of the society of thoracic surgeons/american college of cardiology transcatheter valve therapy registry.” J Am Coll Cardiol 69(10): 1215-1230.

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BACKGROUND: The Society of Thoracic Surgeons (STS)/American College of Cardiology Transcatheter Valve Therapy (TVT) Registry captures all procedures with Food and Drug Administration-approved transcatheter valve devices performed in the United States, and is mandated as a condition of reimbursement by the Centers for Medicaid & Medicare Services. OBJECTIVES: This annual report focuses on patient characteristics, trends, and outcomes of transcatheter aortic and mitral valve catheter-based valve procedures in the United States. METHODS: We reviewed data for all patients receiving commercially approved devices from 2012 through December 31, 2015, that are entered in the TVT Registry. RESULTS: The 54,782 patients with transcatheter aortic valve replacement demonstrated decreases in expected risk of 30-day operative mortality (STS Predicted Risk of Mortality [PROM]) of 7% to 6% and transcatheter aortic valve replacement PROM (TVT PROM) of 4% to 3% (both p < 0.0001) from 2012 to 2015. Observed in-hospital mortality decreased from 5.7% to 2.9%, and 1-year mortality decreased from 25.8% to 21.6%. However, 30-day post-procedure pacemaker insertion increased from 8.8% in 2013 to 12.0% in 2015. The 2,556 patients who underwent transcatheter mitral leaflet clip in 2015 were similar to patients from 2013 to 2014, with hospital mortality of 2% and with mitral regurgitation reduced to grade