Cardiology

Abramowitz, Y., Y. Kazuno, T. Chakravarty, H. Kawamori, Y. Maeno, D. Anderson, Z. Allison, G. Mangat, W. Cheng, A. Gopal, H. Jilaihawi, M. J. Mack and R. R. Makkar (2016). “Concomitant mitral annular calcification and severe aortic stenosis: Prevalence, characteristics and outcome following transcatheter aortic valve replacement.” Eur Heart J: 2016 Dec [Epub ahead of print].

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AIMS: Calcified aortic stenosis (AS) and mitral annular calcification (MAC) have certain similar etiology and pathophysiological mechanisms. MAC is frequently encountered in pre-procedural computed tomography (CT) imaging of patients that undergo transcatheter aortic valve replacement (TAVR), but its prognostic implications for these patients have not been thoroughly investigated. This study sought to evaluate the prevalence of MAC among patients with severe AS and to assess the clinical implications of MAC on these patients during and following TAVR. METHODS AND RESULTS: Consecutive patients that underwent TAVR were compared according to the existence of MAC and its severity in pre-TAVR CT scans. From the entire cohort of 761 patients, 49.3% had MAC, and 50.7% did not have MAC. Mild MAC was present in 231 patients (30.4%), moderate MAC in 72 patients (9.5%), and severe MAC in 72 patients (9.5%). Thirty-day mortality and major complications were similar between patients with and without MAC. In a multivariable survival analysis, severe MAC was found to be an independent strong predictor of overall mortality following TAVR (all-cause mortality: hazards ratio [HR] 1.95, 95% confidence interval [CI] 1.24-3.07, P = 0.004; cardiovascular mortality: HR 2.35, 95% CI 1.19-4.66; P = 0.01). Severe MAC was also found to be an independent strong predictor of new permanent pacemaker implantation (PPI) after TAVR (OR 2.83, 95% CI 1.08-7.47; P = 0.03). CONCLUSION: Half of the patients with severe AS evaluated for TAVR were found to have MAC. Severe MAC is associated with increased all-cause and cardiovascular mortality and with conduction abnormalities following TAVR and should be included in future risk stratification models for TAVR.

Badhwar, V., J. S. Rankin, R. J. Damiano, Jr., A. M. Gillinov, F. G. Bakaeen, J. R. Edgerton, J. M. Philpott, P. M. McCarthy, S. F. Bolling, H. G. Roberts, V. H. Thourani, R. M. Suri, R. J. Shemin, S. Firestone and N. Ad (2017). “The society of thoracic surgeons 2017 clinical practice guidelines for the surgical treatment of atrial fibrillation.” Ann Thorac Surg 103(1): 329-341.

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EXECUTIVE SUMMARY: Surgical ablation for atrial fibrillation (AF) can be performed without additional risk of operative mortality or major morbidity, and is recommended at the time of concomitant mitral operations to restore sinus rhythm. (Class I, Level A) Surgical ablation for AF can be performed without additional operative risk of mortality or major morbidity, and is recommended at the time of concomitant isolated aortic valve replacement, isolated coronary artery bypass graft surgery, and aortic valve replacement plus coronary artery bypass graft operations to restore sinus rhythm. (Class I, Level B nonrandomized) Surgical ablation for symptomatic AF in the absence of structural heart disease that is refractory to class I/III antiarrhythmic drugs or catheter-based therapy or both is reasonable as a primary stand-alone procedure, to restore sinus rhythm. (Class IIA, Level B randomized) Surgical ablation for symptomatic persistent or longstanding persistent AF in the absence of structural heart disease is reasonable, as a stand-alone procedure using the Cox-Maze III/IV lesion set compared with pulmonary vein isolation alone. (Class IIA, Level B nonrandomized) Surgical ablation for symptomatic AF in the setting of left atrial enlargement (>/=4.5 cm) or more than moderate mitral regurgitation by pulmonary vein isolation alone is not recommended. (Class III no benefit, Level C expert opinion) It is reasonable to perform left atrial appendage excision or exclusion in conjunction with surgical ablation for AF for longitudinal thromboembolic morbidity prevention. (Class IIA, Level C limited data) At the time of concomitant cardiac operations in patients with AF, it is reasonable to surgically manage the left atrial appendage for longitudinal thromboembolic morbidity prevention. (Class IIA, Level C expert opinion) In the treatment of AF, multidisciplinary heart team assessment, treatment planning, and long-term follow-up can be useful and beneficial to optimize patient outcomes.

Cedars, A. M. (2016). “In heart failure, where you have been may be more important than where you are: A role for patient-reported outcomes.” Am J Cardiol 26(1): 116-124.

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Current advanced care for patients with heart failure requires unique resources available only at a few large institutions. As a result, end-stage heart failure patients are often referred for care by teams who lack the insight of their regular primary cardiologist into their unique disease trajectory. This situation may result in clinical missteps. By tapping into a patient’s familiarity with their own trajectory through the use of patient-reported outcome metrics however, it is possible that this problem may be easily addressed.

Chen, S. and P. A. Grayburn (2017). “Ultrasound-targeted microbubble destruction for cardiac gene delivery.” Methods Mol Biol 1521: 205-218.

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Ultrasound targeted microbubble destruction (UTMD) is a novel technique that is used to deliver a gene or other bioactive substance to organs of living animals in a noninvasive manner. Plasmid DNA binding with cationic liposome into nanoparticles are assembled into the shell of microbubbles, which are circulated by intravenous injection. Intermittent bursts of ultrasound with low frequency and high mechanical index destroys the microbubbles and releases the nanoparticles into targeted organ to transfect local organ cells. Cell-specific promoters can be used to further enhance cell specificity. Here we describe UTMD applied to cardiac gene delivery.

Daubert, M. A., N. J. Weissman, R. T. Hahn, P. Pibarot, R. Parvataneni, M. J. Mack, L. G. Svensson, D. Gopal, S. Kapadia, R. J. Siegel, S. K. Kodali, W. Y. Szeto, R. Makkar, M. B. Leon and P. S. Douglas (2016). “Long-term valve performance of tavr and savr: A report from the partner i trial.” JACC Cardiovasc Imaging: 2016 Dec [Epub ahead of print].

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OBJECTIVES: The aim of this study was to evaluate the long-term performance of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) through longitudinal echocardiographic analysis. BACKGROUND: The long-term performance of the SAPIEN TAVR is not well-described. Therefore, we examined the hemodynamic and valvular profile of the SAPIEN TAVR over 5 years. METHODS: All patients receiving TAVR or SAVR with first post-implant (FPI) and 5-year echoes were analyzed for aortic valve (AV) peak velocity, AV mean gradient, AV area, peak left ventricular (LV) outflow tract and in-stent velocities, Doppler velocity index, aortic regurgitation (AR), LV mass index, stroke volume index, and cardiac index. The FPI and 5-year data were compared using a paired t test or McNemar’s analyses. RESULTS: There were 86 TAVR and 48 SAVR patients with paired FPI and 5-year echocardiograms. Baseline characteristics were similar between groups. The AV area did not change significantly 5 years after TAVR (p = 0.35). The AV mean gradient also remained stable: 11.5 +/- 5.4 mm Hg at FPI to 11.0 +/- 6.3 mm Hg at 5 years (p = 0.41). In contrast, the peak AV and LV outflow tract velocities decreased (p = 0.03 and p = 0.008, respectively), as did in-stent velocity (p = 0.015). Correspondingly, the TAVR Doppler velocity index was unchanged (p = 0.07). Among TAVR patients, there was no change in total AR (p = 0.40), transvalvular AR (p = 0.37), or paravalvular AR (p = 0.26). Stroke volume index and cardiac index remained stable (p = 0.16 and p = 0.25, respectively). However, there was a significant regression of LV mass index (p < 0.0001). The longitudinal evaluation among SAVR patients revealed similar trends. There was a low rate of adverse events among TAVR and SAVR patients alive at 5 years. CONCLUSIONS: Longitudinal assessment of the PARTNER I trial (THE PARTNER TRIAL: Placement of AoRTic TraNscathetER Valve Trial) demonstrates that valve performance and cardiac hemodynamics are stable after implantation in both SAPIEN TAVR and SAVR in patients alive at 5 years.