Cardiology

Tavilla, G., Malhotra, A., Gunn, B., Beckles, D. L. and Reddy, R. C. (2022). “Redo surgical aortic valve replacement for prosthetic valve valve-in-valve dysfunction.” J Card Surg.

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Transcatheter aortic valve replacement (TAVR) has become the preferred intervention for patients with severe aortic stenosis and significant comorbidities. This technique can also be used for failed bioprosthetic valves and is known as the valve-in-valve (ViV) procedure. Placing TAVR in a small bioprosthesis (<23 mm) can lead to delayed dysfunction of the prosthetic valve. We present a case of a late explanted ViV 8 years post-initial aortic valve replacement and coronary artery bypass grafting, and 3 years post-ViV procedure in a 76-year-old female. A video of the surgical procedure is provided.

Roberts, W. C. and Roberts, C. S. (2022). “Combined Cardiovascular Syphilis and Type A Acute Aortic Dissection.” Am J Cardiol.

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The occurrence of acute aortic dissection with the initiating tear in the ascending aorta superimposed on cardiovascular syphilis is an exceedingly rare occurrence. Such was the case, however, in a recently seen patient who presented with typical features of acute dissection (type A). Operative repair yielded the entire ascending aorta to examine both grossly and histologically and classic features of both conditions were observed.

Peikert, A., Vaduganathan, M., Mc Causland, F., Claggett, B. L., Chatur, S., Packer, M., Pfeffer, M. A., Zannad, F., Lefkowitz, M. P., Pieske, B., Düngen, H. D., McMurray, J. J. V. and Solomon, S. D. (2022). “Effects of sacubitril/valsartan versus valsartan on renal function in patients with and without diabetes and heart failure with preserved ejection fraction: insights from PARAGON-HF.” Eur J Heart Fail.

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AIMS: Diabetes is associated with a faster rate of renal function decline in patients with heart failure (HF). Sacubitril/valsartan attenuates the deterioration of renal function to a greater extent in patients with diabetes and HF with reduced ejection fraction compared with renin-angiotensin system inhibitors alone. We assessed whether the same may be true in HF with preserved ejection fraction (HFpEF). METHODS AND RESULTS: In the PARAGON-HF trial in patients with HF and left ventricular ejection fraction of ≥45% (n = 4796), we characterized the effects of sacubitril/valsartan on changes in estimated glomerular filtration rate (eGFR) over a period of 192 weeks, and on the pre-specified renal composite outcome (eGFR reduction of ≥50%, end-stage renal disease, or death attributable to renal causes) in patients with (n = 2388) and without diabetes (n = 2408). The decline in eGFR was greater in patients with diabetes than in those without (-2.6 vs. -1.7 ml/min/1.73 m(2) per year, p < 0.001), regardless of treatment assignment. Sacubitril/valsartan attenuated decline in eGFR similarly in patients with (-2.2 vs. -2.9 ml/min/1.73 m(2) per year, p = 0.001) and without diabetes (-1.5 vs. -2.0 ml/min/1.73 m(2) per year, p = 0.006) (p(interaction) for difference in eGFR slopes = 0.40). Compared with valsartan, sacubitril/valsartan reduced the renal composite outcome similarly in patients without diabetes (hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.19-0.91) and those with diabetes (HR 0.54, 95% CI 0.33-0.89; p(interaction) = 0.59), as well as across a range of baseline glycated haemoglobin (p(interaction) = 0.71). CONCLUSION: Sacubitril/valsartan, compared with valsartan, attenuates the decline of eGFR and reduces clinically relevant kidney events similarly among patients with HFpEF with and without diabetes.

Pabón, M. A., Cunningham, J. W., Claggett, B. L., Packer, M., Zile, M., Pfeffer, M. A., Lefkowitz, M., Shi, V., Rizkala, A., McMurray, J. J. V., Solomon, S. D. and Vaduganathan, M. (2022). “Natriuretic peptide-based inclusion criteria in heart failure with preserved ejection fraction clinical trials: insights from PARAGON-HF.” Eur J Heart Fail.

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AIM: Natriuretic peptides (NPs) are now routinely incorporated as key inclusion criteria in clinical trials of heart failure with preserved ejection fraction (HFpEF) as objective measures of risk. An early amendment in PARAGON-HF required all participants to have elevated NP concentrations, but some were enrolled pre-amendment, providing a unique opportunity to understand the influence of enrolment pathway in HFpEF clinical trials. METHODS AND RESULTS: Among 4796 participants in PARAGON-HF, 193 (4.0%) did not meet the final NP-based enrolment criteria (N-terminal pro-B-type natriuretic peptide >300 pg/ml for patients in sinus rhythm or >900 pg/ml for patients in atrial fibrillation/flutter). These patients had lower rates of the primary endpoint of total heart failure hospitalizations and cardiovascular death as compared with patients meeting final enrolment criteria (8.6 [6.7-11.2] events per 100 patient-years vs. 14.0 [13.4-14.7] events per 100 patient-years; p = 0.01). The rate ratio for the treatment effect comparing sacubitril/valsartan with valsartan was 0.85 (95% confidence interval 0.74-0.99; p = 0.04) in those who met final criteria. CONCLUSIONS: Natriuretic peptides are an important tool in HFpEF clinical trials to objectively affirm diagnoses and enrich clinical event rates.

Cochran, J. M., Alam, A. and Guerrero-Miranda, C. Y. (2022). “Importance of right heart catheterization in advanced heart failure management.” Rev Cardiovasc Med 23(1): 12.

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Patients with chronic congestive heart failure belong to a population with reduced quality of life, poor functional class, and increased risk of mortality and morbidity. In these patients, assessment of invasive hemodynamics both serves therapeutic purposes and is useful for stratification roles. The right heart catheterization has become a cornerstone diagnostic tool for patients in refractory heart failure or cardiogenic shock, as well as for the assessment of candidacy for heart replacement therapies, and the management of patients following mechanical circulatory assist device implantation and heart transplantation.