Cardiology

Kirkpatrick, J. N., R. Grimm, A. M. Johri, B. J. Kimura, S. Kort, A. J. Labovitz, M. Lanspa, S. Phillip, S. Raza, K. Thorson and J. Turner (2020). “Recommendations for Echocardiography Laboratories Participating in Cardiac Point of Care Cardiac Ultrasound (POCUS) and Critical Care Echocardiography Training: Report from the American Society of Echocardiography.” J Am Soc Echocardiogr 33(4): 409-422.e404.

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Cardiac point of care ultrasound provides rapid bedside diagnosis of important cardiovascular pathology and is performed by a growing number of users in a variety of clinical settings. Echocardiographers and sonographers may be asked to play a role in training practitioners in cardiac ultrasound who come from disciplines outside of the cardiovascular field. These trainees’ backgrounds, needs, objectives, and available time can create challenges and opportunities for echocardiography laboratories. Furthermore, the presence of additional learners in the echocardiography laboratory will require additional resources. This document is the product of an American Society of Echocardiography writing group composed of representatives from cardiology, critical care medicine, emergency medicine, and cardiac anesthesiology and others, assembled to provide expert guidance. The following recommendations are intended as practical resource to assist echocardiography laboratories to train partners in the provision of high quality cardiac ultrasound: 1: Identify Trainee Needs; 2: Employ Educational Resources; 3: In General, Avoid Certifying Global Competency; 4: Count the Cost in Echocardiography Laboratory Resources; 5. Advocate for Resources to Meet Extra Needs.(Excerpt from text, p. 409; no abstract available.)

Guerrero, M., S. Vemulapalli, Q. Xiang, D. D. Wang, M. Eleid, A. K. Cabalka, G. Sandhu, M. Salinger, H. Russell, A. Greenbaum, S. Kodali, I. George, D. Dvir, B. Whisenant, M. J. Russo, A. Pershad, K. Fang, M. Coylewright, P. Shah, V. Babaliaros, J. M. Khan, C. Tommaso, J. Saucedo, S. Kar, R. Makkar, M. Mack, D. Holmes, M. Leon, V. Bapat, V. H. Thourani, C. Rihal, W. O’Neill and T. Feldman (2020). “Thirty-Day Outcomes of Transcatheter Mitral Valve Replacement for Degenerated Mitral Bioprostheses (Valve-in-Valve), Failed Surgical Rings (Valve-in-Ring), and Native Valve With Severe Mitral Annular Calcification (Valve-in-Mitral Annular Calcification) in the United States: Data From the Society of Thoracic Surgeons/American College of Cardiology/Transcatheter Valve Therapy Registry.” Circ Cardiovasc Interv 13(3): e008425.

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BACKGROUND: Transcatheter mitral valve replacement using aortic transcatheter heart valves has recently become an alternative for patients with degenerated mitral bioprostheses, failed surgical repairs with annuloplasty rings or severe mitral annular calcification who are poor surgical candidates. Outcomes of these procedures are collected in the Society of Thoracic Surgeons/American College of Cardiology/Transcatheter Valve Therapy Registry. A comprehensive analysis of mitral valve-in-valve (MViV), mitral valve-in-ring (MViR), and valve-in-mitral annular calcification (ViMAC) outcomes has not been performed. We sought to evaluate short-term outcomes of early experience with MViV, MViR, and ViMAC in the United States. METHODS: Retrospective analysis of data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. RESULTS: Nine hundred three high-risk patients (median Society of Thoracic Surgeons score 10%) underwent MViV (n=680), MViR (n=123), or ViMAC (n=100) between March 2013 and June 2017 at 172 hospitals. Median age was 75 years, 59.2% female. Technical and procedural success were higher in MViV. Left ventricular outflow tract obstruction occurred more frequently with ViMAC (ViMAC=10%, MViR=4.9%, MViV=0.7%; P<0.001). In-hospital mortality (MViV=6.3%, MViR=9%, ViMAC=18%; P=0.004) and 30-day mortality (MViV=8.1%, MViR=11.5%, ViMAC=21.8%; P=0.003) were higher in ViMAC. At 30-day follow-up, median mean mitral valve gradient was 7 mm Hg, most patients (96.7%) had mitral regurgitation grade

Greason, K. L., E. H. Blackstone, J. Rajeswaran, A. M. Lowry, L. G. Svensson, J. G. Webb, E. M. Tuzcu, C. R. Smith, R. R. Makkar, M. J. Mack, V. H. Thourani, S. K. Kodali, M. B. Leon and D. C. Miller (2020). “Inter- and intrasite variability of mortality and stroke for sites performing both surgical and transcatheter aortic valve replacement for aortic valve stenosis in intermediate-risk patients.” J Thorac Cardiovasc Surg 159(4): 1233-1244.e1234.

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OBJECTIVES: Multisite procedure-based randomized trials may be confounded by performance variability and variability among sites. Therefore, we studied variability in mortality and stroke after patients were randomized to surgical (SAVR) or transcatheter aortic valve replacement (TAVR) in the Placement of Aortic Transcatheter Valves-2A (PARTNER-2A) randomized trial. METHODS: Patients at intermediate risk for SAVR were randomized to SAVR (n = 1017) or TAVR (n = 1011) with a SAPIEN XT device (Edwards Lifesciences, Irvine, Calif) at 54 sites. Patients were followed to 2 years. A mixed-effect model quantified variability at intersite and intrasite levels. RESULTS: There were 336 deaths (SAVR 170, TAVR 166) and 176 strokes (SAVR 85, TAVR 91). Intersite variability for mortality was similar across sites for SAVR (hazard ratios ranging from 0.52-1.93 among sites) and TAVR (hazard ratios ranging from 0.49-2.03), but intersite variability for stroke was greater for SAVR (hazard ratios ranging from 0.44-2.26) than for TAVR (no detectable variability). Case mix and lower site trial volume accounted for 37% of mortality intersite variability for SAVR and 73% for TAVR, but only 14% for stroke for SAVR. Intrasite mortality hazard ratios demonstrated all but 1 site’s 95% confidence interval overlapped 1.0, indicating generally similar SAVR and TAVR mortalities within sites. CONCLUSIONS: Intersite variability was similar for mortality in SAVR and TAVR, but variability for stroke was greater for SAVR than for TAVR. Intrasite events were similar for both SAVR and TAVR. These findings suggest that in performance-based trials, site variability and its sources should be taken into account in analyzing and interpreting trial results.

Filardo, G., G. Ailawadi, B. D. Pollock, B. da Graca, T. K. Phan, V. Thourani and R. J. Damiano, Jr. (2020). “Postoperative atrial fibrillation: Sex-specific characteristics and effect on survival.” J Thorac Cardiovasc Surg 159(4): 1419-1425.e1411.

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BACKGROUND: We sought to fill important gaps in the existing evidence regarding new-onset atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG) by comparing the incidence, characteristics, and effect on long-term survival between men and women. METHODS: Nine thousand two hundred three consecutive patients without preoperative AF underwent isolated CABG from 2002 to 2010 at 3 US academic medical centers and 1 high-volume specialty cardiac hospital. Detailed data on CABG AF events detected via continuous in-hospital electrocardiogram/telemetry monitoring were supplemented with Society of Thoracic Surgeons data, and survival data, censored at October 31, 2011, using a copy of the Social Security Death Master File archived before state-owned data were removed (November 1, 2011). RESULTS: Propensity-adjusted (Society of Thoracic Surgeons-recognized risk factors) incidence of post-CABG AF was 31.5% overall, 32.8% in men, and 27.4% in women. Over the 9-year study period, women had a significantly lower risk of post-CABG AF (absolute difference, -5.3% [95% confidence interval (CI), -10.5% to -0.6%]), and significantly shorter first (-2.9 hours; 95% CI, -5.8 to 0.0), and longest (-4.3 hours; 95% CI, -8.3 to -0.3) AF duration. Post-CABG AF was associated with significantly increased risk of long-term mortality (overall hazard ratio [HR], 1.56; 95% CI, 1.45-1.67; men HR, 1.57; 95% CI, 1.49-1.65; women HR, 1.54; 95% CI, 1.14-2.07). CONCLUSIONS: In our study, women had lower adjusted risk of post-CABG AF and experienced shorter episodes. The adjusted risk of long-term mortality was 56% greater among patients who developed post-CABG AF compared with those who did not. The effect of post-CABG AF on long-term survival did not differ between the sexes.

Cunningham, J. W., M. Vaduganathan, B. L. Claggett, M. R. Zile, I. S. Anand, M. Packer, F. Zannad, C. S. P. Lam, S. Janssens, P. S. Jhund, L. Kober, J. Rouleau, S. J. Shah, V. K. Chopra, V. C. Shi, M. P. Lefkowitz, M. F. Prescott, M. A. Pfeffer, J. J. V. McMurray and S. D. Solomon (2020). “Effects of Sacubitril/Valsartan on N-Terminal Pro-B-Type Natriuretic Peptide in Heart Failure With Preserved Ejection Fraction.” JACC Heart Fail Mar 26. pii: S2213-1779(20)30146-3. [Epub ahead of print].

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OBJECTIVES: The authors sought to evaluate the prognostic significance of baseline N-terminal pro-B-type natriuretic peptide (NT-proBNP), whether NT-proBNP modified the treatment response to sacubitril/valsartan, and the treatment effect of sacubitril/valsartan on NT-proBNP overall and in key subgroups. BACKGROUND: Sacubitril/valsartan reduces NT-proBNP in heart failure (HF) with both reduced and preserved ejection fraction (EF), but did not significantly reduce total HF hospitalizations and cardiovascular death compared with valsartan in patients with HF with preserved EF (HFpEF). METHODS: In the PARAGON-HF (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction) trial, 4,796 patients with HFpEF and elevated NT-proBNP were randomized to sacubitril/valsartan or valsartan. NT-proBNP was measured at screening in all patients and at 5 subsequent times in >2,700 patients: before, between, and after sequential valsartan and sacubitril/valsartan run-in periods, and 16 and 48 weeks post-randomization. RESULTS: Median NT-proBNP was 911 pg/ml (interquartile range: 464 to 1,613 pg/ml) at screening. Screening NT-proBNP was strongly associated with the primary endpoint, total HF hospitalizations and cardiovascular death (rate ratio [RR]: 1.68 per log increase in NT-proBNP, 95% confidence interval [CI]: 1.53 to 1.85; p < 0.001). This relationship was stronger in patients with atrial fibrillation (adjusted RR: 2.33 [95% CI: 1.89 to 2.87] vs. 1.58 [95% CI: 1.42 to 1.75] in patients without atrial fibrillation; p interaction <0.001) and weaker in obese patients (adjusted RR: 1.50 [95% CI: 1.31 to 1.71] vs. 1.92 [95% CI: 1.70 to 2.17] in nonobese patients; p interaction <0.001). Screening NT-proBNP did not modify the treatment effect of sacubitril/valsartan compared with valsartan (p interaction = 0.96). Sacubitril/valsartan reduced NT-proBNP by 19% (95% CI: 14% to 23%; p < 0.001) compared with valsartan 16 weeks post-randomization, with similar reductions in men (20%) and women (18%), and in patients with left ventricular EF 57% (18%). Decreases in NT-proBNP predicted lower subsequent risk of the primary endpoint. CONCLUSIONS: Baseline NT-proBNP predicted HF events but did not modify the sacubitril/valsartan treatment effect in patients with HFpEF. Sacubitril/valsartan reduced NT-proBNP consistently in men and women, and in patients with lower or higher EF. (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).