Molly Szerlip M.D.

Sannino, A., S. Potluri, B. Pollock, G. Filardo, A. Gopal, R. C. Stoler, M. Szerlip, A. Chowdhury, M. J. Mack and P. A. Grayburn (2019). “Impact of Mitral Stenosis on Survival in Patients Undergoing Isolated Transcatheter Aortic Valve Implantation.” Am J Cardiol 123(8): 1314-1320.

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This study was performed to investigate the prevalence and impact on survival of baseline mitral stenosis (MS) in patients who underwent transcatheter aortic valve implantation (TAVI) due to the presence of severe symptomatic aortic stenosis. This retrospective study included 928 consecutive patients with severe, symptomatic aortic stenosis who underwent TAVI in 2 institutions, from January 2012 to August 2016. Mean follow-up was 40.8 +/- 13.9 months. Based on the mean mitral gradient (MMG) at baseline, 3 groups were identified: MMG <5 mm Hg (n=737, 81.7%); MMG >/=5 and <10 mm Hg (n=147, 16.3%); MMG >/=10 mm Hg (n=17, 1.9%). These latter were more frequently women, with a smaller body surface area, a higher prevalence of atrial fibrillation, chronic obstructive pulmonary disease, and previous history of coronary-artery bypass graft/percutaneous coronary intervention. At baseline, patients with MMG >/=10 mm Hg compared with >/=5 and <10 mm Hg and <5 mm Hg patients had a lower mitral valve area (2.4 +/- 0.94 vs 2.1 +/- 0.86 vs 1.5 +/- 0.44 cm(2)), a lower prevalence of MR >/=2+ (5.9% vs 28.6% and 15.6%, p <0.0001), a higher prevalence of severe mitral annular calcium (70.6% vs 45.6% and 13.0%, p <0.0001) and a higher systolic pulmonary arterial pressure (50.6 +/- 12.1 vs 47.2 +/- 14.5 and 41.6 +/- 14.4, p <0.0001). Despite the low prevalence of MMG >/=10 mm Hg, these patients had higher 5-year mortality compared with the other groups (adjusted hazard ratio 2.91, 95% confidence interval 1.17 to 7.20, p=0.02). In conclusion, severe calcific MS is uncommon in patients who underwent TAVI. Its presence is associated with higher long-term mortality whereas moderate MS is not.

Hamandi, M., R. L. Smith, W. H. Ryan, P. A. Grayburn, A. Vasudevan, T. J. George, J. M. DiMaio, K. A. Hutcheson, W. Brinkman, M. Szerlip, D. O. Moore and M. J. Mack (2019). “Outcomes of Isolated Tricuspid Valve Surgery Have Improved in the Modern Era.” Ann Thorac Surg Apr 2. [Epub ahead of print].

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BACKGROUND: Surgery for isolated tricuspid valve (TV) disease remains relatively infrequent due to significant patient comorbidities and poor surgical outcomes. We reviewed our experience with isolated TV surgery in the current era to determine if outcomes have improved. METHODS: From 2007 through 2017, 685 TV operations were performed in a single institution of which 95 (13.9%) were isolated TV surgery. Patients were analyzed for disease etiology, risk factors, operative mortality and morbidity and long term survival. RESULTS: 95 patients underwent isolated TV surgery, an average of 9 patients/year increasing from an average of 5/year to 15/year during the study period. Surgery was reoperative in 41% (38/95), including 11.6% (11/95) with prior CABG and 29.4% (28/95) with prior valve surgery (9 tricuspid, 11 mitral, 2 aortic, 5 mitral/aortic and 1 mitral/tricuspid).Repair was performed in 71.6% (68/95) and replacement in 28.4% (27/95). Operative mortality was 3.2% (3/95) with no mortality in the most recent 73 patients over the last 6 years. Stroke occurred in 2.1% (2/95), acute kidney injury requiring dialysis in 5.3% (5/95) and need for new permanent pacemaker in 16.8% (16/95). CONCLUSIONS: In the current era with careful patient selection and periprocedural management, isolated TV surgery can be performed with lower morbidity and mortality than has traditionally been reported with good long term survival. These outcomes can also serve as a benchmark for catheter-based tricuspid valve intervention outcomes.

Sannino, A., S. Potluri, B. Pollock, G. Filardo, A. Gopal, R. C. Stoler, M. Szerlip, A. Chowdhury, M. J. Mack and P. A. Grayburn (2019). “Impact of Mitral Stenosis on Survival in Patients Undergoing Isolated Transcatheter Aortic Valve Implantation.” Am J Cardiol Jan 25. [Epub ahead of print].

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This study was performed to investigate the prevalence and impact on survival of baseline mitral stenosis (MS) in patients who underwent transcatheter aortic valve implantation (TAVI) due to the presence of severe symptomatic aortic stenosis. This retrospective study included 928 consecutive patients with severe, symptomatic aortic stenosis who underwent TAVI in 2 institutions, from January 2012 to August 2016. Mean follow-up was 40.8 +/- 13.9 months. Based on the mean mitral gradient (MMG) at baseline, 3 groups were identified: MMG <5 mm Hg (n=737, 81.7%); MMG >/=5 and <10 mm Hg (n=147, 16.3%); MMG >/=10 mm Hg (n=17, 1.9%). These latter were more frequently women, with a smaller body surface area, a higher prevalence of atrial fibrillation, chronic obstructive pulmonary disease, and previous history of coronary-artery bypass graft/percutaneous coronary intervention. At baseline, patients with MMG >/=10 mm Hg compared with >/=5 and <10 mm Hg and <5 mm Hg patients had a lower mitral valve area (2.4 +/- 0.94 vs 2.1 +/- 0.86 vs 1.5 +/- 0.44 cm(2)), a lower prevalence of MR >/=2+ (5.9% vs 28.6% and 15.6%, p <0.0001), a higher prevalence of severe mitral annular calcium (70.6% vs 45.6% and 13.0%, p <0.0001) and a higher systolic pulmonary arterial pressure (50.6 +/- 12.1 vs 47.2 +/- 14.5 and 41.6 +/- 14.4, p <0.0001). Despite the low prevalence of MMG >/=10 mm Hg, these patients had higher 5-year mortality compared with the other groups (adjusted hazard ratio 2.91, 95% confidence interval 1.17 to 7.20, p=0.02). In conclusion, severe calcific MS is uncommon in patients who underwent TAVI. Its presence is associated with higher long-term mortality whereas moderate MS is not.

Giri, J. S., M. Szerlip, C. Devireddy, D. A. Cox, C. Kavinsky, P. Genereux, S. S. Naidu, C. Bruner, J. Struck, J. Kurz and J. Dunham (2019). “SCAI 2018 Think Tank Proceedings: “What should the role of the surgeon be in TAVR, both as a co-operator and in-patient evaluation for TAVR?” Catheter Cardiovasc Interv 93(1): 178-179.

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The Society for Cardiovascular Angiography and Interventions (SCAI) Think Tank is held annually bringing together expert opinion from interventional cardiologists, administrative partners, and select members of the cardiovascular industry community in a collaborative venue. During the SCAI 2018 Scientific Session, topics in interventional cardiology felt to be relevant to the contemporary practice of the field were identified with the goals of defining the state of the field, current challenges, and future directions. . . Consensus emerged around several points relevant to the specific questions outlined above: 1. Preoperative evaluation by the heart team should remain intact. However, the group felt that the appropriate preprocedure evaluation should consist of a cardiac surgeon and a cardiologist who are both experienced in evaluating patients for TAVR. There was consensus that the current mandate of “TAVR clearance” based on the judgment of two cardiac surgeons is redundant and outdated. Given the equipoise between traditional surgical AVR and TAVR in a growing proportion of cases that is likely to include even low‐risk cases in the near future, it was felt that patients needed to participate in a shared decision‐making model involving a balanced discussion of risk and benefit involving both specialties rather than a perspective from only two cardiac surgeons, who may or may not be familiar with the pros and cons of TAVR. 2. The specialty of a TAVR operator is less important than his/her ability to both evaluate the potential TAVR patient and technically perform the case in a competent fashion. Rather than emphasizing which specialty should be present in the operating room or procedure suite, the group felt that the most important issue was assuring that any operators nominally performing the procedure have both the requisite training and experience to meaningfully contribute to the planned procedure. 3. Given continual advances in the procedure mentioned above, the concept of TAVR continuing to be a mandated two‐operator procedure appears to be a case of “swimming against the tide.” Thus, consensus was reached to recommend against a mandatory 62‐modifier code for TAVR going forward. Rather, an optional 62‐modifier could be used when physicians from two different specialties participated in the procedure or an 82‐modifier when physicians from the same specialty work together. This would allow for either a single operator or two operators from the same or different specialties to perform the TAVR procedure, with potential cost savings in the former scenario. 4. Instead, an optional 62‐modifier code could be used similar to what is done in other procedures in which “co‐surgeons” are deemed necessary to complete a complex procedure. The optional 62‐modifier could be used when physicians from two different specialties participated in the procedure or an 82‐modifier when physicians from the same specialty work together. This would allow for either a single operator or two operators from the same or different specialties to perform the TAVR procedure. Additionally, the heart team evaluation could determine which specific TAVR procedures may benefit from “co‐operators” and which would have good results with a single operator. Importantly, in cases where two operators are deemed advantageous, the heart team would choose the most appropriate two operators to successfully perform the case, regardless of specialty. (Excerpts from text, p. 178-179; no abstract available.)

Kapadia, S. R., C. P. Huded, S. K. Kodali, L. G. Svensson, E. M. Tuzcu, S. J. Baron, D. J. Cohen, D. C. Miller, V. H. Thourani, H. C. Herrmann, M. J. Mack, M. Szerlip, R. R. Makkar, J. G. Webb, C. R. Smith, J. Rajeswaran, E. H. Blackstone and M. B. Leon (2018). “Stroke After Surgical Versus Transfemoral Transcatheter Aortic Valve Replacement in the PARTNER Trial.” J Am Coll Cardiol 72(20): 2415-2426.

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BACKGROUND: Transfemoral-transcatheter aortic valve replacement (TF-TAVR) is increasingly used to treat aortic stenosis, but risk of post-procedure stroke is uncertain. OBJECTIVES: The purpose of this study was to assess stroke risk and its association with quality of life after surgical aortic valve replacement (SAVR) versus TF-TAVR. METHODS: The authors performed a propensity-matched study of 1,204 pairs of patients with severe aortic stenosis treated with SAVR versus TF-TAVR in the PARTNER (Placement of AoRTic TraNscathetER Valves) trials from April 2007 to October 2014. Outcomes were: 1) 30-day neurological events; 2) time-varying risk of neurological events early (