Research Spotlight

Grayburn, P. A. (2016). “Sex differences in mitral regurgitation before and after mitral valve surgery.” Jacc-Cardiovascular Imaging 9(4): 397-399.

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In this issue of iJACC, Mantovani et al. (3) provide evidence that there are important differences between men and women referred for surgery for primary MR in an experienced mitral valve center of excellence. The authors report a retrospective analysis of 217 women and 447 men who underwent surgery at Mayo Clinic between 1990 and 2000 with comprehensive echocardiographic imaging, including MR quantitation performed pre-operatively (27 ± 35 days) and post-operatively (6 ± 10 months). Age and other demographic characteristics were very similar between the sexes, but women had smaller body surface area (BSA) and were more likely to have heart failure (HF) symptoms (41% vs. 19%, respectively; p < 0.0001) and be prescribed HF therapy. LV diastolic and systolic diameters, left atrial (LA) diameter, LV mass, regurgitant volume (RVol), and effective regurgitant orifice area (EROA) were all significantly smaller in women, and fewer women were classified with severe MR, presumably due to lower RVol and EROA. After they were indexed for BSA, women had slightly higher LV and LA diameters than men, with no differences in RVol, suggesting that the LV volume overload was similar between men and women when BSA was taken into account. This hypothesis is further supported by strikingly similar reductions in men and women in LV and LA diameters post-operatively. Reduction in PA systolic pressure post-operatively was slightly greater in women, despite starting with higher PA pressures.

Hamm, C. W., M. Arsalan and M. J. Mack (2016). “The future of transcatheter aortic valve implantation.” European Heart Journal 37(10): 803-U876.

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Since the introduction of transcatheter aortic valve implantation (TAVI) into clinical practice, the treatment of aortic stenosis has changed dramatically. In the past, medical therapy with or without balloon aortic valvuloplasty was the only option for inoperable patients. More recently, TAVI has become the treatment of choice for these patients and the preferred alternative for high-risk operable patients. Surgical aortic valve replacement (SAVR) currently remains the gold standard for patients at low or intermediate operative risk. As randomized trials have demonstrated comparable results between TAVI and SAVR in the high-risk population, there is now a clear trend towards performing TAVI even in intermediate-risk patients while awaiting the results of randomized trials in that population. Nevertheless, there are still questions regarding TAVI involving paravalvular leak (PVL), stroke, pacemaker requirements, and durability that remain to be more definitively answered before TAVI can routinely be performed in a broader, lower risk population. Improvements in patient selection, imaging, and second and third generation devices have decreased the incidence of PVLs and vascular complications that followed the earliest TAVI procedures, but the rates of perioperative stroke and permanent pacemaker implantation must still be addressed. Furthermore, the long-term durability of TAVI devices and a role for post-procedure antithrombotic management remain unanswered. Until these questions are more clearly answered, it is the Heart Team’s task to determine the optimal treatment for each patient based on risk scores, frailty metrics, comorbidities, patient preference, and potential for improvement in quality of life.

Kim, P. T. and G. Testa (2016). “Living donor liver transplantation in the USA.” Hepatobiliary Surg Nutr 5(2): 133-140.

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Living donor liver transplant (LDLT) accounts for a small volume of the transplants in the USA. Due to the current liver allocation system based on the model for end-stage liver disease (MELD), LDLT has a unique role in providing life-saving transplantation for patients with low MELD scores and significant complications from portal hypertension, as well as select patients with hepatocellular carcinoma (HCC). Donor safety is paramount and has been a topic of much discussion in the transplant community as well as the general media. The donor risk appears to be low overall, with a favorable long-term quality of life. The latest trend has been a gradual shift from right-lobe grafts to left-lobe grafts to reduce donor risk, provided that the left lobe can provide adequate liver volume for the recipient.

Cedars, A. M., A. S. Schmidt, C. Broberg, A. Zaidi, A. Opotowsky, J. Grewal, J. Kay, A. B. Bhatt, E. Novak and J. Spertus (2016). “Adult congenital heart disease patients experience similar symptoms of disease activity.” Circulation-Cardiovascular Quality and Outcomes 9(2): 161-170.

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Background There is a lack of objective data on the symptoms characterizing disease activity among adults with congenital heart disease (ACHD). The purpose of this study was to elicit the most important symptoms from patients across the spectrum of ACHD and to examine whether reported symptoms were similar across the spectrum of ACHD as a foundation for creating a patient-reported outcome measure(s). Methods and Results We constructed a 39-item survey using input from physicians specializing in ACHD to assess the symptoms patients associate with disease activity. Patients (n=124) prospectively completed this survey, and the results were analyzed based on underlying anatomy and disease complexity. A confirmatory cohort of patients (n=40) was then recruited prospectively to confirm the validity of the initial data. When grouped based on underlying anatomy, significant differences in disease-related symptom rankings were found for only 6 of 39 symptoms. Six symptoms were identified which were of particular significance to patients, regardless of underlying anatomy. Patients with anatomy of great complexity experienced greater overall symptom severity than those with anatomy of low or moderate complexity, attributable exclusively to higher ranking of 5 symptoms. The second patient cohort had symptom experiences similar to those of the initial cohort, differing in only 5 of 39 symptoms. Conclusions This study identified 6 symptoms relevant to patients across the spectrum of ACHD and remarkable homogeneity of patient experience, suggesting that a single disease-specific patient-reported outcome can be created for quality and outcome assessments.

Fallahzadeh, M. K. and N. Singh (2016). “Reply to Hamidian Jahromi and Bastani: Acute early transplant renal artery thrombosis; a complex etiologic diagnosis.” Journal of Nephropathology 5(1): 60-61.

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This article discusses renal artery thrombosis as a complication of distal renal artery stenosis in a kidney transplant recipient. This important complication should be considered in the differential diagnosis of acute kidney injury occurring immediately post-kidney transplantation.