Research Spotlight

Sengupta, A., S. Zaid, N. Kamioka, J. Terre, M. Miyasaka, S. A. Hirji, M. Hensey, N. Geloo, G. Petrossian, N. Robinson, E. Sarin, L. Ryan, S. H. Yoon, C. W. Tan, O. K. Khalique, S. K. Kodali, T. Kaneko, P. B. Shah, S. C. Wong, A. Salemi, K. Sharma, J. A. Kozina, M. A. Szerlip, C. W. Don, S. Gafoor, M. Zhang, Z. Newhart, S. R. Kapadia, S. L. Mick, A. Krishnaswamy, A. Kini, H. Ahmad, S. L. Lansman, M. J. Mack, J. G. Webb, V. Babaliaros, V. H. Thourani, R. R. Makkar, M. B. Leon, I. George and G. H. L. Tang (2020). “Mid-Term Outcomes of Transcatheter Aortic Valve Replacement in Extremely Large Annuli With Edwards SAPIEN 3 Valve.” JACC Cardiovasc Interv 13(2): 210-216.

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OBJECTIVES: The aim of this study was to report the 1-year results of transcatheter aortic valve replacement (TAVR) with the Edwards SAPIEN 3 (S3) valve in extremely large annuli. BACKGROUND: Favorable 30-day outcomes of S3 TAVR in annuli >683 mm(2) have previously been reported. Pacemaker implantation rates were acceptable, and a larger left ventricular outflow tract and more eccentric annular anatomy were associated with increasing paravalvular leak. METHODS: From December 2013 to December 2018, 105 patients across 15 centers with mean area 721.3 +/- 36.1 mm(2) (range 683.5 to 852.0 mm(2)) underwent TAVR using an S3 device. Clinical, anatomic, and procedural characteristics were analyzed. One-year survival and echocardiographic follow-up were reached in 94.3% and 82.1% of patients, respectively. Valve Academic Research Consortium-2 30-day and 1-year outcomes were reported. RESULTS: The mean age was 76.9 +/- 10.4 years, and Society of Thoracic Surgeons predicted risk score averaged 5.2 +/- 3.4%. One-year overall mortality and stroke rates were 18.2% and 2.4%, respectively. Quality-of-life index improved from baseline to 30 days and at 1 year (p < 0.001 for both). Mild paravalvular aortic regurgitation occurred in 21.7% of patients, while moderate or greater paravalvular aortic regurgitation occurred in 4.3%. Mild and moderate or severe transvalvular aortic regurgitation occurred in 11.6% and 0%, respectively. Valve gradients remained stable at 1 year. CONCLUSIONS: S3 TAVR in annular areas >683 mm(2) is feasible, with favorable mid-term outcomes.

Schinstock, C. A., R. B. Mannon, K. Budde, A. S. Chong, M. Haas, S. Knechtle, C. Lefaucheur, R. A. Montgomery, P. Nickerson, S. G. Tullius, C. Ahn, M. Askar, M. Crespo, S. J. Chadban, S. Feng, S. C. Jordan, K. Man, M. Mengel, R. E. Morris, I. O’Doherty, B. H. Ozdemir, D. Seron, A. R. Tambur, K. Tanabe, J. L. Taupin and P. J. O’Connell (2020). “Recommended Treatment for Antibody-mediated Rejection After Kidney Transplantation: the 2019 Expert Consensus From the Transplantion Society Working Group.” Transplantation Jan 8. [Epub ahead of print].

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With the development of modern solid-phase assays to detect anti-HLA antibodies and a more precise histological classification, the diagnosis of antibody-mediated rejection (AMR) has become more common and is a major cause of kidney graft loss. Currently, there are no approved therapies and treatment guidelines are based on low level evidence. The number of prospective randomized trials for the treatment of AMR is small and the lack of an accepted common standard for care has been an impediment to the development of new therapies. To help alleviate this, The Transplantation Society convened a meeting of international experts to develop a consensus as to what is appropriate treatment for active and chronic active AMR. The aim was to reach a consensus for standard of care treatment against which new therapies could be evaluated.At the meeting, the underlying biology of AMR, the criteria for diagnosis, the clinical phenotypes and outcomes were discussed. The evidence for different treatments was reviewed and a consensus for what is acceptable standard of care for the treatment of active and chronic active AMR was presented.Whilst it was agreed that the aims of treatment are to preserve renal function, reduce histological injury and reduce the titer of donor specific antibody (DSA), there was no conclusive evidence to support any specific therapy. As a result, the treatment recommendations are largely based on expert opinion. It is acknowledged that properly conducted and powered clinical trials of biologically plausible agents are urgently needed to improve patient outcomes.

Roberts, W. C. and A. T. Kietzman (2020). “Severe Eosinophilic Myocarditis in the Portion of Left Ventricular Wall Excised to Insert a Left Ventricular Assist Device for Severe Heart Failure.” Am J Cardiol 125(2): 264-269.

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Described herein are 3 adults in whom histologic study of the left ventricular myocardium excised (“LV core”) to insert a left ventricular assist device (LVAD) disclosed severe acute myocarditis and the inflammatory cells included numerous eosinophils (eosinophilic myocarditis). Examination of the clinical records disclosed elevated absolute eosinophil counts at the time of insertion of the LVAD and the counts rapidly (<30 days) returned to normal after the operation. Because of the numerous medications that each patient was taking at the time of LVAD insertion, identification of a specific initiating medication as its cause was not possible. Of the 3 patients, 2 had idiopathic-dilated cardiomyopathy and 1 had ischemic cardiomyopathy and each had had heart failure for years. The eosinophilic myocarditis in these 3 patients appears to have been transient and superimposed on the earlier cardiomyopathy.

Roberts, W. C. and O. S. Khan (2020). “Massive Cardiomegaly (>1000 g Heart) and Obesity.” Am J Cardiol 125(2): 277-281.

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Described herein are certain clinical and morphologic findings in 9 patients who at necropsy had hearts weighing >1000 g, a weight approximately 3 times normal. With the exception of 2 patients with hypertrophic cardiomyopathy, the common finding in the remaining 7 patients was obesity. None had valvular heart disease, the previously described major cause of massive cardiomegaly. Thus, obesity needs to be added to the causes of massive cardiomegaly, a cause not previously recognized. Electrocardiograms in 4 patients disclosed high total 12-lead QRS voltage on the electrocardiogram in only one despite the massive cardiomegaly.

Roberts, W. C., I. Kale and C. S. Roberts (2020). “Perforation of a Stenotic Congenitally Bicuspid Aortic Valve Cusp by Heavy Calcium in the Other Cusp.” Am J Cardiol 125(2): 299-301.

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On occasion in patients with stenotic congenitally bicuspid aortic valves (BAVs), the quantity of calcium in one of the cusps is considerably greater than in the other cusp. We examined operatively excised stenotic congenitally BAVs in 630 patients having isolated aortic valve replacement (No other cardiac valve was replaced, and none had had infective endocarditis.) Of the 630 valves, 3 contained a perforation in the mildly calcified cusp due to a large calcific “spur” extending across the orifice from a heavily calcified cusp. In conclusion, heavy calcific deposits in 1 of 2 BAVs may extend across the orifice causing a perforation in the noncalcified portion of the opposing cusp.