Cardiology

Alam, A., Doshi, H., Patel, D.N., Patel, K., James, D. and Almendral, J. (2022). “Myocardial infarction and factor VIII elevation in a 36-year-old man.” Proc (Bayl Univ Med Cent) 35(1): 93-95.

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An association has been reported between factor VIII and arterial thrombosis such as ischemic stroke and myocardial infarction. We report a 36-year-old man who had a myocardial infarction despite lacking traditional cardiac risk factors. He developed end-stage heart failure and renal insufficiency necessitating a HeartMate II left ventricular assist device (LVAD). While on the transplant list, he experienced two episodes of LVAD thrombosis 6 months apart, prompting device exchange and escalation of anticoagulation therapy. He eventually underwent a successful heart-kidney transplant before suffering an extensive left lower extremity deep vein thrombosis 6 weeks later. A thrombophilia workup revealed elevated factor VIII activity of 319% (normal range, 50%-150%). He was placed on indefinite anticoagulation with apixaban with no further thrombotic episode in 18 months of follow-up to date.

Roberts, W.C. and Khan, O.S. (2021). “The Syndrome of Large Healed Single Discrete Myocardial Infarct with Severe Narrowing of Only One Major Epicardial Coronary Artery and Leading to Severe Chronic Heart Failure and Orthotopic Heart Transplantation.” Am J Cardiol 161: 1-11.

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Described herein are clinical and cardiac morphologic findings in 12 patients (age 43 to 70 years) (7 men) who underwent orthotopic heart transplantation (OHT) because of severe heart failure (HF) resulting from a single large discrete acute myocardial infarct that healed and was associated with severe narrowing of only one major epicardial coronary artery. Most myocardial infarcts are associated with severe narrowing of >1 major epicardial coronary artery and result in smaller myocardial infarcts. Another unusual feature was the total infarction of the ventricular septum in 3 of the 12 patients.

Sommer, R.J., Kim, J.H., Szerlip, M., Chandhok, S., Sugeng, L., Cain, C., Kaplan, A.V. and Gray, W.A. (2021). “Conformal Left Atrial Appendage Seal Device for Left Atrial Appendage Closure: First Clinical Use.” JACC Cardiovasc Interv 14(21): 2368-2374.

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OBJECTIVES: The authors report the first clinical experience with the Conformal Left Atrial Appendage Seal (CLAAS) device. BACKGROUND: The CLAAS device was designed to address the limitations of first-generation left atrial appendage closure (LAAC) devices by providing an implant that is minimally traumatic, can be deployed in a noncoaxial fashion, and does not require postprocedural oral anticoagulation. METHODS: Patients with atrial fibrillation at high stroke risk (CHA(2)DS(2)-VASc score ≥2) were recruited using standard selection criteria. The LAAC procedure was guided by transesophageal echocardiography with patients under general anesthesia. The CLAAS device is composed of a foam cup, with a Nitinol endoskeleton with an expanded polytetrafluoroethylene cover, delivered with a standard delivery system using a tether for full recapture. All patients received dual-antiplatelet therapy for 6 months, followed by aspirin alone. Transesophageal echocardiographic follow-up was scheduled for 45 days and 1 year. RESULTS: Twenty-two patients (63.7% with CHA(2)DS(2)-VASc scores ≥3, 76.2% with HAS-BLED scores ≥3) were enrolled. The device was successfully implanted in 18 patients and unsuccessfully in 4 patients. There were no serious procedural complications. On transesophageal echocardiography performed at 45 days, 1 significant leak (≥5 mm) was seen, which was due to a large posterior lobe not appreciated at the time of implantation, and 1 device-related thrombus was noted, which resolved on oral anticoagulation. There were no periprocedural strokes, major pericardial effusions, or systemic or device embolization. CONCLUSIONS: This first-in-human study demonstrates the clinical feasibility of the CLAAS device for LAAC.

Villablanca, P.A., Vemulapalli, S., Stebbins, A., Dai, D., So, C.Y., Eng, M.H., Wang, D.D., Frisoli, T.M., Lee, J.C., Kang, G., Szerlip, M., Ibrahim, H., Staniloae, C., Gaba, P., Lemor, A., Finn, M., Ramakrishna, H., Williams, M.R., Leon, M.B., O’Neill, W.W. and Shah, B. (2021). “Sex-Based Differences in Outcomes With Percutaneous Transcatheter Repair of Mitral Regurgitation With the MitraClip System: Transcatheter Valve Therapy Registry From 2011 to 2017.” Circ Cardiovasc Interv 14(11): e009374.

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BACKGROUND: Women have a higher rate of adverse events after mitral valve surgery. We sought to evaluate whether outcomes after transcatheter edge-to-edge repair intervention by sex have similar trends to mitral valve surgery. METHODS: The primary outcome was 1-year major adverse events defined as a composite of all-cause mortality, stroke, and any bleeding in the overall study cohort. Patients who underwent transcatheter edge-to-edge repair for mitral regurgitation with the MitraClip system in the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy registry were evaluated. Linked administrative claims from the Centers for Medicare and Medicaid Services were used to evaluate 1-year clinical outcomes. Associations between sex and outcomes were evaluated using a multivariable logistic regression model for in-hospital outcomes and Cox model for 1-year outcomes. RESULTS: From November 2013 to March 2017, 5295 patients, 47.6% (n=2523) of whom were female, underwent transcatheter edge-to-edge repair. Females were less likely to have >1 clip implanted (P<0.001) and had a lower adjusted odds ratio of device success (adjusted odds ratio, 0.78 [95% CI, 0.67-0.90]), driven by lower odds of residual mitral gradient <5 mm Hg (adjusted odds ratio, 0.54 [CI, 0.46-0.63]) when compared with males. At 1-year follow-up, the primary outcome did not differ by sex. Female sex was associated with lower adjusted 1-year risk of all-cause mortality (adjusted hazard ratio, 0.80 [CI, 0.68-0.94]), but the adjusted 1-year risk of stroke and any bleeding did not differ by sex. CONCLUSIONS: No difference in composite outcome of all-cause mortality, stroke, and any bleeding was observed between females and males. Adjusted 1-year all-cause mortality was lower in females compared with males.

Simonsen, K.A., Gunn, B.L., Malhotra, A., Beckles, D.L., Koerner, M.M., Tavilla, G. and Reddy, R.C. (2021). “Use of a novel bicarbonate-based Impella 5.5 purge solution in a coagulopathic patient.” J Card Surg 36(12): 4773-4775.

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The Impella 5.5 with Smart Assist (Abiomed) is a life-saving treatment option in acute heart failure which utilizes a continuous heparin purge solution to prevent thrombosis. In patients with contraindications to heparin, alternative anticoagulation strategies are required. We describe the stepwise management of anticoagulation in a coagulopathic patient with persistent cardiogenic shock following a coronary artery bypass procedure who underwent Impella 5.5 placement. A direct thrombin inhibitor-based purge solution was utilized while evaluating for heparin-induced thrombocytopenia. The use of a novel bicarbonate-based purge solution (BBPS) was successfully used due to severe coagulopathy. There were no episodes of pump thrombosis or episodes of severe bleeding on the BBPS and systemic effects of alkalosis and hypernatremia were minimal.