Cardiology

Curtain, J.P., Jackson, A., Shen, L., Jhund, P.S., Docherty, K.F., Petrie, M.C., Castagno, D., Desai, A.S., Rohde, L.E., Lefkowitz, M.P., Rouleau, J.L., Zile, M.R., Solomon, S.D., Swedberg, K., Packer, M. and McMurray, J.J.V. (2021). “Effect of sacubitril/valsartan on investigator-reported ventricular arrhythmias in PARADIGM-HF.” Eur J Heart Fail Dec 30. [Epub ahead of print].

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BACKGROUND: Sudden death is a leading cause of mortality in HFrEF. In PARADIGM-HF, sacubitril/valsartan reduced the incidence of sudden death. The purpose of this post hoc study was to analyze the effect of sacubitril/valsartan, compared to enalapril, on the incidence of ventricular arrhythmias. METHODS: Adverse event reports related to ventricular arrhythmias were examined in PARADIGM-HF. The effect of randomized treatment on two arrhythmia outcomes was analyzed: ventricular arrhythmias and the composite of a ventricular arrhythmia, ICD shock or resuscitated cardiac arrest. The risk of death related to a ventricular arrhythmia was examined in time-updated models. The interaction between heart failure aetiology, or baseline ICD/CRT-D use, and the effect of sacubitril/valsartan was analyzed. RESULTS: Of the 8399 participants, 333 (4.0%) reported a ventricular arrhythmia and 372 (4.4%) the composite arrhythmia outcome. Ventricular arrhythmias were associated with higher mortality. Compared with enalapril, sacubitril/valsartan reduced the risk of a ventricular arrhythmia [HR 0.76 (0.62-0.95); p = 0.015] and the composite arrhythmia outcome [HR 0.79 (0.65-0.97); p = 0.025]. The treatment effect was maintained after adjustment and accounting for the competing risk of death. Baseline ICD/CRT-D use did not modify effect of sacubitril/valsartan, but aetiology did: HR in patients with an ischaemic aetiology 0.93 (0.71-1.21) versus 0.53 (0.37-0.78) in those without an ischaemic aetiology (p for interaction = 0.020). CONCLUSIONS: Sacubitril/valsartan reduced the incidence of investigator-reported ventricular arrhythmias in patients with HFrEF. This effect may have been greater in patients with a non-ischaemic aetiology.

Chin, K., Ward, M.A., Meyer, D.M., Sanchez, C.E. and Leeds, S.G. (2022). “Laparoscopic repair of large diaphragmatic hernia after left ventricular assist device implantation followed by orthotopic heart transplantation.” Proc (Bayl Univ Med Cent) 35(1): 101-103.

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In patients with advanced heart failure and deteriorating clinical status, a left ventricular assist device (LVAD) can be used as a bridge to transplantation or as an alternative to transplantation. An uncommon complication of orthotopic heart transplant or LVADs is diaphragmatic hernia during implantation or explantation of the device. We describe a patient with a diaphragmatic hernia with incarcerated colon and small bowel treated previously with a HeartMate 3 LVAD and subsequent transplantation. This case highlights the need to consider the diagnosis of diaphragmatic hernia based on symptoms after HeartMate 3 implantation and/or subsequent transplantation, as well as the ability to manage these hernias with a minimally invasive laparoscopic approach to minimize postoperative morbidity and mortality.

Bissacco, D., Domanin, M., Weaver, F.A., Azizzadeh, A., Miller, C.C., Gable, D.R., Piffaretti, G., Lomazzi, C. and Trimarchi, S. (2021). “Differences in Mid-Term Outcomes Between Patients Undergoing Thoracic Endovascular Aortic Repair for Aneurysm or Acute Aortic Syndromes: Report From the Global Registry for Endovascular Aortic Treatment.” J Endovasc Ther Dec 15;15266028211064819. [Epub ahead of print]. 15266028211064819.

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PURPOSE: To analyze differences in baseline characteristics, overall mortality, device-related mortality, and re-intervention rates in patients who underwent thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (DTAA) with atherosclerotic/degenerative cause or acute aortic syndrome (AAS), using the Global Registry For Endovascular Aortic Treatment (GREAT). MATERIALS AND METHODS: Patients submitted to TEVAR for AAS or DTAA, included in GREAT, were eligible for this analysis. Primary outcome was 30-day all-cause mortality rate. Secondary outcomes were 30-day aorta-related mortality and re-intervention rate, 1-year and 3-year all-cause mortality, aorta-related mortality and re-intervention rate. RESULTS: Five-hundred and seventy-five patients were analyzed (305 DTAA and 270 AAS). Thirty-day mortality rate was 1.3% and 1.8% for DTAA and AAS, respectively (p=0.741). One-year and 3-year mortality rates were 6.2% versus 9.3 and 17.3% versus 15.9% for DTAA and AAS, respectively (p=0.209 and p=0.655, respectively). Aorta-related mortality rates at 30 days, 1 year and 3 years were 1.3%, 1.3%, and 2.6% for DTAA, 1.8%, 4.2%, and 4.2% for AAS (p=ns). Re-intervention rates at 30 days, 1 year, and 3 years were 1.3%, 4.3%, and 7.5% for DTAA, 3.3%, 8.1%, and 10.7% for AAS (p=ns). Furthermore, a specific analysis with similar outcomes was performed dividing follow-up in 3 periods (1-30 days, 31-365 days, 366-1096 days) and describing mutual differences between 2 groups and temporal trends in each group. CONCLUSION: Patients who underwent TEVAR for DTAA or AAS experienced different mortality and re-intervention rates among years during mid-term follow-up. Although all-cause related deaths within 30 days were TEVAR-related, aorta-related deaths were more common for AAS patients within 1 year. A greater re-intervention rate was described for AAS patients, although only 1 year after TEVAR.

Bagiella, E., Puskas, J.D., Moskowitz, A.J., Gelijns, A.C., Alexander, J.H., Narula, J., Smith, P.K., Hutcheson, K., Chang, H.L., Gammie, J.S., Iribarne, A., Marks, M.E., Vengrenyuk, Y., Yasumura, K., Raymond, S., Taylor, B.S., Yarden, O., Orion, E., Dagenais, F., Ailawadi, G., Chu, M.W.A., Gupta, L., Levitan, R.G., Williams, J.B., Jr., Crestanello, J.A., Jessup, M., Rose, E.A., Scavo, V., Acker, M.A., Gillinov, M., O’Gara, P.T., Voisine, P., Mack, M.J. and Goldstein, D.J. (2021). “Rationale and Design of a Randomized Trial Evaluating an External Support Device for Saphenous Vein Coronary Grafts.” Am Heart J Dec 19;S0002-8703(21)00482-8. [Epub ahead of print].

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BACKGROUND: Coronary artery bypass grafting (CABG) is the most common revascularization approach for the treatment of multi-vessel coronary artery disease. While the internal mammary artery is nearly universally used to bypass the left anterior descending coronary artery, autologous saphenous vein grafts (SVGs) are still the most frequently used conduits to grafts the remaining coronary artery targets Long-term failure of these grafts, however, continues to limit the benefits of surgery. DESIGN: The Cardiothoracic Surgical Trials Network trial of the safety and effectiveness of a Venous External Support (VEST) device is a randomized, multicenter, within-patient trial comparing VEST-supported versus unsupported saphenous vein grafts in patients undergoing CABG. Key inclusion criteria are the need for CABG with a planned internal mammary artery to the left anterior descending and two or more saphenous vein grafts to other coronary arteries. The primary efficacy endpoint of the trial is SVG intimal hyperplasia (plaque + media) area assessed by intravascular ultrasound at 12 months post randomization. Occluded grafts are accounted for in the analysis of the primary endpoint. Secondary confirmatory endpoints are lumen diameter uniformity and graft failure (>50% stenosis) assessed by coronary angiography at 12 months. The safety endpoints are the occurrence of major adverse cardiac and cerebrovascular events and hospitalization within 5 years from randomization. CONCLUSIONS: The results of the VEST trial will determine whether the VEST device can safely limit SVG intimal hyperplasia in patients undergoing CABG as treatment for coronary atherosclerotic disease.

Arunthamakun, J., Vallabhan, R., Ayad, R. and Roberts, C.C. (2022). “Shotgun recoil causing severe acute aortic regurgitation years after replacement of the aortic valve and ascending aorta.” Proc (Bayl Univ Med Cent) 35(1): 96-97.

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Blunt chest trauma can lead to severe, life-threatening injury to chest organs, including the aorta, heart, lungs, and major airways. We describe a 64-year-old man who had undergone replacement of his aortic valve and ascending aorta 14 years earlier (at age 50) and suddenly developed severe aortic regurgitation after firing his shotgun while hunting. Such an event has not been reported previously.