Fortuin, David

AbstractBackgroundAortic stenosis (AS) is associated with myocardial ischemia through different mechanisms and may impair coronary arterial flow. However, data on the impact of moderate AS in patients with acute myocardial infarction (MI) is limited.AimsThis study aimed to investigate the impact of moderate AS in patients presenting with acute myocardial infarction (MI).MethodsWe conducted a retrospective analysis of all patients who presented with acute MI to all Mayo Clinic hospitals, using the Enterprise Mayo PCI Database from 2005 to 2016. Patients were stratified into two groups: moderate AS and mild/no AS. The primary outcome was all cause mortality.ResultsThe moderate AS group included 183 (13.3%) patients, and the mild/no AS group included 1190 (86.7%) patients. During hospitalization, there was no difference between both groups in mortality. Patients with moderate AS had higher in‐hospital congestive heart failure (CHF) (8.2% vs. 4.4%, p = 0.025) compared with mild/no AS patients. At 1‐year follow‐up, patients with moderate AS had higher mortality (23.9% vs. 8.1%, p < 0.001) and higher CHF hospitalization (8.3% vs. 3.7%, p = 0.028). In multivariate analysis, moderate AS was associated with higher mortality at 1‐year (odds ratio 2.4, 95% confidence interval [1.4–4.1], p = 0.002). In subgroup analyses, moderate AS increased all‐cause mortality in STEMI and NSTEMI patients.ConclusionThe presence of moderate AS in acute MI patients was associated with worse clinical outcomes during hospitalization and at 1‐year follow‐up. These unfavorable outcomes highlight the need for a close follow‐up of these patients and for timely therapeutic strategies to best manage these coexisting conditions.

Background: Post-transcatheter aortic valve replacement (TAVR) patient outcome is an important research topic. To accurately assess post-TAVR mortality, we examined a family of new echo parameters (augmented systolic blood pressure (AugSBP) and arterial mean pressure (AugMAP)) derived from blood pressure and aortic valve gradients. Methods: Patients in the Mayo Clinic National Cardiovascular Diseases Registry-TAVR database who underwent TAVR between 1 January 2012 and 30 June 2017 were identified to retrieve baseline clinical, echocardiographic and mortality data. AugSBP, AugMAP and valvulo-arterial impedance (Zva) (Zva) were evaluated using Cox regression. Receiver operating characteristic curve analysis and the c-index were used to assess the model performance against the Society of Thoracic Surgeons (STS) risk score. Results: The final cohort contained 974 patients with a mean age of 81.4 ± 8.3 years old, and 56.6% were male. The mean STS risk score was 8.2 ± 5.2. The median follow-up duration was 354 days, and the one-year all-cause mortality rate was 14.2%. Both univariate and multivariate Cox regression showed that AugSBP and AugMAP parameters were independent predictors for intermediate-term post-TAVR mortality (all p < 0.0001). AugMAP1 < 102.5 mmHg was associated with a 3-fold-increased risk of all-cause mortality 1-year post-TAVR (hazard ratio 3.0, 95%confidence interval 2.0–4.5, p < 0.0001). A univariate model of AugMAP1 surpassed the STS score model in predicting intermediate-term post-TAVR mortality (area under the curve: 0.700 vs. 0.587, p = 0.005; c-index: 0.681 vs. 0.585, p = 0.001). Conclusions: Augmented mean arterial pressure provides clinicians with a simple but effective approach to quickly identify patients at risk and potentially improve post-TAVR prognosis.

Background: Prior studies have reported conflicting results of persistent iatrogenic atrial septal defect (iASD) and its impact following a transcatheter edge-to-edge repair (TEER) procedure. This study aims to evaluate the incidence of iASD and its clinical and hemodynamic impact after a TEER. Methods: Consecutive patients who underwent a TEER procedure from June 2014 to September 2020 at the Mayo Clinic were identified. The presence of iASD was retrospectively identified on post-procedure transthoracic echocardiography (TTE) to group patients into an iASD+ group and an iASD− group for comparison of prognosis and cardiac function. Results: A total of 316 patients were included; the mean age was 79.1 ± 9.1 years, and 67.7% were male. Persistent iASD was diagnosed in 108 (34.2%) patients. There was no difference concerning all-cause mortality, heart failure hospitalization, and stroke/TIA between groups at follow-up (median follow-up of 9 months). Post-procedure TTE demonstrated no differences regarding right ventricle (RV) and left ventricle (LV) dimensions and function, including TAPSE (15.2 ± 4.6 vs. 15.4 ± 5.5 mm, p = 0.875), and LV ejection fraction (51.1 ± 14.0% vs. 51.3 ± 13.9%, p = 0.933). However, patients with iASD had higher RV systolic pressure (48.7 ± 14.4 vs. 45.5 ± 14.5 mmHg, p = 0.042) compared with patients without iASD. Conclusion: Notwithstanding higher RV pressures, patients with persistent iASD had no hemodynamic compromise and an equal prognosis compared with those without a residual atrial defect after a TEER procedure. These findings support the mid-term safety of procedures in which an interatrial defect needs to be created and would argue against the need for interventional closure.

Background/Introduction: More than moderate tricuspid regurgitation (TR) at baseline is associated with worse outcome in MitraClip patients. The presence of iatrogenic ASD (iASD) may cause right-sided volume overload and lead to adverse events. However, the real effects of iASD are not well-investigated in these patients who are vulnerable to right-sided volume overload. Methods: Patients with more than moderate TR who underwent a successful MitraClip procedure in the period from June 2014 to September 2020 were identified from the Mayo institutional NCDR database. Follow-up transthoracic echocardiography (TTE) at about 1 year after the procedure was used to determine the presence of iASD, and speckle-tracking strain analysis was done. Patients were grouped according to the presence of iASD (iASD+ group vs. iASD- group) for statistical analysis. Results: A total of 141 consecutive patients were included for the final analysis (iASD+ group n=44 and iASD- group n=97). The mean age was 79.3 ± 8.8 years, and 72.3% were male. Follow-up echocardiography and speckle-tracking strain data did not show a significant difference in either left or right ventricular function in conventional echocardiographic parameters and strain. LA reservoir strain (13.7 ± 6.9 vs 11.5±7.5, P=0.0418) was the only parameter with significant difference among the two groups. Details are summarized in Table 1 . Conclusion: The presence of iASD can decompress the left atrium, but does not affect left or right ventricular strain function in MitraClip patients with more than moderate baseline TR.

External iliac vein stenosis related to cycling has rarely been reported as a cause of deep vein thrombosis. Ischemic stroke occurring in this condition due to paradoxical embolism across a preexisting patent foramen ovale (PFO) has yet to be reported. Here we report a case of embolic ischemic strokes in a young, avid cyclist with no prior known vascular risk factors. A thorough cerebrovascular workup revealed a right-to-left shunt on transesophageal echocardiogram that prompted venous thrombosis evaluation. Pelvic MR venogram demonstrated a 3.5 cm high-grade stenosis of the right external iliac vein, concerning for possible prior thrombotic disease. His strokes were deemed most likely a result of paradoxical emboli originating in the pelvis at the site of right external iliac vein stenosis. The patient ultimately opted for PFO closure for secondary stroke prevention, as he wished to continue daily cycling. This case highlights the importance of neurohospitalists considering iliac vein stenosis as a potential cause of embolic stroke of undetermined source, especially in young patients who are avid cyclists, as part of a thorough vascular workup.

Abstract IntroductionSimulation technology has an established role in teaching technical skills to cardiology fellows, but their impact on teaching trainees to interpret coronary angiographic (CA) images has not been systematically studied. The aim of this randomized controlled study was to test whether structured simulation training in addition to traditional methods would improve CA image interpretation skills in a group of novices to advanced medical trainees.MethodsWe prospectively randomized 105 subjects comprising of medical students (N=20), residents (N=68) and fellows (N=17) from the University of Arizona. Subjects were randomized into a simulation training group which received simulation training in addition to didactic teaching (n=53) and a control training group which received didactic teaching alone (n=52). The change in pre and post-test score (delta score) was analyzed by a two-way ANOVA for education status and training arm.ResultsSubjects improved in their post-test scores with a mean change of 4.6 ± 4.0 points. Subjects in the simulation training arm had a higher delta score compared to control (5.4 ± 4.2 versus 3.8 ± 3.7, p=0.04), with greatest impact for residents (6.6 ± 4.0 versus 3.5 ± 3.4) with a p=0.02 for interaction of training arm and education status.ConclusionsSimulation training complements traditional methods to improve CA interpretation skill, with greatest impact on novice trainees. This highlights the importance of incorporating high-fidelity simulation training early in cardiovascular fellowship curricula.

Introduction: Baseline thrombocytopenia (TP) is a common condition in patients with acute coronary syndrome (ACS) and acute ischemic stroke and has been shown to increase mortality. The effect of baseline TP on cerebrovascular events following initial ACS event is not well studied. Methods: We retrospectively reviewed all patients identified from the institutional NCDR Chest Pain registry database at Mayo Clinic Arizona from Oct 2015 to Sep 2018. Patients were classified into TP (platelet <150) and control (platelet > 150) groups for clinical outcome (stroke/TIA and bleeding events) analysis. P-value < 0.05 is considered significant. Results: Five hundred and thirty-six patients were included for final analysis. Patient demographics and clinical outcomes are shown in Table 1. The rates of dual antiplatelet therapy (DAPT) prescription at discharge (TP vs. control: 68.1% and 75.4%, P=0.197), stroke/TIA (1.3% vs. 2.4%, P=1.000) and recurrent myocardial infarction (11.1% vs. 11.2%, P=1.000) were similar between the two groups. The TP group has more bleeding events compared to control (Figure 1). Conclusions: In patients with ACS, baseline TP does not affect stroke/TIA events but is associated with higher bleeding rate. The results could not be explained by the DAPT or anticoagulation use alone. Further studies are needed to investigate the pathophysiologic correlation of thrombocytopenia, DAPT, and stroke in ACS patients.

Abstract Background Peripheral arterial disease is a marker of aggressive atherosclerosis. The ankle brachial index (ABI) is a simple and non-invasive tool to diagnose peripheral arterial disease (PAD). Patients with PAD are at increased risk for ischemic strokes and other cardiovascular diseases. Purpose To evaluate the association of abnormal ABI and poorly compressible vessels with ischemic stroke in a large patient cohort. Methods We analyzed lower extremity vascular studies of all patients with ABI measurements at a tertiary care hospital between January 1996 and August 2018. PAD is defined as ABI<1.0, and poorly or non-compressible (PC/NC) arteries as ABI>1.4 while ABI between 1.0–1.4 is normal. Association of these ABIs with new ischemic stroke events post ABI measurement were analyzed after adjusting for high risk confounders such as atrial fibrillation. Hazard ratios (HR) were calculated using multivariable Cox proportional regression with 95% confidence intervals. Results In total, 38,016 unique patients (mean age 66.1±14.8 years, female 42.3%) were included. Abnormal ABI was found to be more prevalent among elderly male patients compared to patients with normal ABI. In contrast to non-PAD patients, both PAD and PC/NC patients as defined by ABI had a statistically significant risk of ischemic stroke, with PAD conferring the greatest risk compared to PC/NC vessels. The data is summarized in Table 1. Table 1 Unadjusted HR p-value Adjusted HR p-value PAD vs. No PAD 2.77 (2.62, 2.92) <0.001 2.10 (1.98, 2.22) <0.001 PC/NC vs. No PAD 2.11 (1.95, 2.28) <0.001 1.38 (1.26, 1.51) <0.001 PAD vs. PC/NC 1.37 (1.28, 1.46) <0.001 1.37 (1.28, 1.48) <0.001 Adjusted and unadjusted hazard ratios with p-values. HR adjusted for age, sex, atrial fibrillation, ischemic stroke, transient ischemic attack, chronic heart failure, diabetes mellitus, hyperlipidemia, hypertension, and coronary artery disease. PAD = Peripheral artery disease and PC/NC = poorly compressible/non-compressible. Conclusion This study adds to the growing body of evidence that PAD and poorly-compressible vessels are independently associated with an increased risk of ischemic stroke. Given the associated risk of cerebrovascular disease, clinicians should aggressively treat to minimize risk factors in those with abnormal ABIs.