Anavekar, Nandan S.

Introduction: The association of echocardiographic measurements and subsequent risk of left-sided native valve endocarditis (LS-NVE) is undefined. Aim: To determine if transthoracic echocardiographic (TTE) measurements are associated with the subsequent development of LS-NVE in patients without recognized cardiac predisposing conditions. Methods: Institutional databases were evaluated for adults diagnosed with LS-NVE from 2008 to 2020. Patients with prosthetic valves, cardiovascular implantable electronic devices, intracardiac devices, injection drug use, and recognized predisposing cardiac conditions were excluded. Patients with a TTE performed 6 months to 3 years before developing LS-NVE were included as cases. Controls were patients within the same Mayo Clinic location with a TTE report and were matched in a 1:3 ratio according to age, gender, Charlson Comorbidity Index (CCI), and echocardiography date. Multivariate logistic-regression analyses adjusting significant variables between cohort's were performed. A p-value <0.05 was considered significant. Results: There were 148 cases and 431 matched controls. The median age was 63.8 (IQR: 53.6 - 74.6) years, and 329 (56.8%) patients were males. LS-NVE cases had a higher prevalence of diabetes mellitus (46.6% vs. 30.4%) and chronic kidney disease (46.6% vs. 28.1%) when compared with controls (p<0.001 both). The median CCI score was 3 (IQR: 0-6) for cases and 2 (IQR: 0-6) for controls. After performing adjusted analyses, left ventricular outflow tract velocity (p=0.017), left ventricular ejection fraction (p=0.018), and E: e’ ratio (p=0.050) were associated with the development of LS-NVE ( Figure 1) . Conclusions: Echocardiographic measurements were associated with subsequent LS-NVE development in this preliminary investigation. A larger cohort of LS-NVE patients is needed to validate these findings.

Background Shock and preshock are defined on the basis of the presence of hypotension, hypoperfusion, or both. We sought to determine the hemodynamic underpinnings of shock and preshock noninvasively using transthoracic echocardiography (TTE). Methods and Results We included Mayo Clinic cardiac intensive care unit patients from 2007 to 2015 with TTE within 1 day of admission. Hypotension and hypoperfusion at the time of cardiac intensive care unit admission were used to define 4 groups. TTE findings were evaluated across these groups, and in‐hospital mortality was evaluated according to TTE findings in each group. We included 5375 patients with a median age of 69.2 years (36.8% women). The median left ventricular ejection fraction was 50%. Groups based on hypotension and hypoperfusion were assigned as follows: no hypotension or hypoperfusion, 59.7%; isolated hypotension, 15.3%; isolated hypoperfusion, 16.4%; and both hypotension and hypoperfusion, 8.7%. Most TTE variables of interest varied across these groups, with worse biventricular function, lower forward flow, and higher filling pressures as the degree of hemodynamic compromise increased. In‐hospital mortality occurred in 8.2%, and inpatient deaths had more TTE parameter abnormalities. In‐hospital mortality increased with the degree of hemodynamic compromise, and a marked gradient in in‐hospital mortality was observed when the clinical classification of shock and preshock was combined with TTE findings reflecting worse biventricular function, lower forward flow, or higher filling pressures. Conclusions Substantial differences in cardiac function are observed between cardiac intensive care unit patients with preshock and shock using TTE, and the combination of the clinical and TTE hemodynamic assessment provides robust mortality risk stratification.

Introduction: Valve-in-valve transcatheter mitral valve replacement (ViV-TMVR) and redo surgical mitral valve replacement (redo-SMVR) are two treatment strategies for patients with bioprosthetic mitral valve dysfunction. We conducted a systematic review and meta-analysis to compare the outcomes of ViV-TMVR versus redo-SMVR. Methods: We searched PubMed, EMBASE, Cochrane, and Google Scholar for studies comparing outcomes of ViV-TMVR versus redo-SMVR in degenerated bioprosthetic mitral valves. We used a random effects model to calculate risk ratios (RRs) with 95% confidence intervals (CIs). Outcomes included in-hospital, 30-day, 1-year, and 2-year mortality, stroke, bleeding and vascular complications, acute kidney injury (AKI), arrhythmias, and hospital length of stay (LOS). Results: Six observational studies with a total of 1,339 subjects were included. Median follow-up was 2 years. Compared to redo-SMVR, ViV-TMVR was associated with significantly lower in-hospital (RR 0.42; 95% CI 0.25-0.70; p=0.001) and 30-day mortality (RR 0.49; 95% CI 0.24-0.98; p=0.04) but similar 1-year (RR 0.97; 95% CI 0.64-1.47; p=0.89) and 2-year mortality (RR 1.14; 95% CI 0.71-1.81; p=0.59). Stroke, bleeding, AKI, and arrhythmias were less frequent and hospital LOS was shorter with ViV-TMVR, however vascular complications were similar between both strategies. Conclusion: In patients with degenerated bioprosthetic mitral valves, ViV-TMVR is associated with better outcomes compared to redo-SMVR including lower in-hospital and 30-day mortality, lower complication rates, and shorter hospital LOS. Given these findings and the ongoing advances in transcatheter therapeutics, ViV-TMVR may be preferred over redo-SMVR, particularly in individuals at intermediate-to-high surgical risk.

Background Racial and ethnic disparities in outcomes exist following many cardiac procedures. Transcatheter mitral valve replacement (TMVR) has grown as an alternative to mitral valve surgery for patients at high surgical risk. The outcomes of TMVR by race and ethnicity are unknown. We aimed to evaluate racial and ethnic disparities in the outcomes of TMVR. Methods and Results We analyzed the National Inpatient Sample database from 2016 to 2020 to identify hospitalizations for TMVR. Racial and ethnic disparities in TMVR outcomes were determined using logistic regression models. Between 2016 and 2020, 5005 hospitalizations for TMVR were identified, composed of 3840 (76.7%) White race, 505 (10.1%) Black race, 315 (6.3%) Hispanic ethnicity, and 345 (6.9%) from other races (Asian, Pacific Islander, American Indian or Alaska Native, Other). Compared with other racial and ethnic groups, Black patients were significantly younger and more likely to be women (both P <0.01). There were no significant differences between White, Black, and Hispanic patients in in‐hospital mortality (5.2% versus 5.0% versus <3.5%; P =0.89) and procedural complications, including heart block ( P =0.91), permanent pacemaker ( P =0.49), prosthetic valve dysfunction ( P =0.45), stroke ( P =0.37), acute kidney injury ( P =0.32), major bleeding ( P =0.23), and blood transfusion ( P =0.92), even after adjustment for baseline characteristics. Adjusted vascular complications were higher in Black compared with White patients ( P =0.03). Trend analysis revealed a significant increase in TMVR in all racial and ethnic groups from 2016 to 2020 ( P trend <0.05). Conclusions Between 2016 and 2020, Black and Hispanic patients undergoing TMVR had similar in‐hospital outcomes compared with White patients, except for higher vascular complications in Black patients. Further comparative studies of TMVR in clinically similar White patients and other racial and ethnic groups are warranted to confirm our findings.

The field of malignant hematology is transforming with novel immunotherapeutic approaches. Unfortunately, quality of life, treatment efficacy, and life expectancy are negatively affected by cardiotoxic side effects of treatment. To date, the exact mechanism and incidence of cardiotoxicity associated with these therapies is unclear. These events are believed to be triggered or occur concurrently with cytokine release syndrome. Furthermore, there are no formal guidelines to provide evaluation, treatment, and surveillance. We aim to synthesize available literature with updates on the cardiotoxic effects of novel therapies used in malignant hematologic disorders, with a focus on chimeric antigen receptor T-cell therapy and bispecific T-cell engager therapy, along with a proposed algorithm that may guide pretreatment evaluation, monitoring during treatment, and post-treatment surveillance.

Abstract Aims Cardiac point-of-care ultrasound (CV-POCUS) has become a fundamental part for the assessment of patients admitted to cardiac intensive care units (CICU). We sought to refine the practice of CV-POCUS by identifying 2D and Doppler-derived measurements from bedside transthoracic echocardiograms (TTEs) performed in the CICU that are associated with mortality. Methods and results We retrospectively included Mayo Clinic CICU patients admitted from 2007 to 2018 and assessed the TTEs performed within 1 day of CICU admission, including Doppler and 2D measurements of left and right ventricular function. Logistic regression and classification and regression tree (CART) analysis were used to determine the association between TTE variables with in-hospital mortality. A total of 6957 patients were included with a mean age of 68.0 ± 14.9 years (37.0% females). A total of 609 (8.8%) patients died in the hospital. Inpatient deaths group had worse biventricular systolic function [left ventricular ejection fraction (LVEF) 48.2 ± 16.0% vs. 38.7 ± 18.2%, P &lt; 0.0001], higher filling pressures, and lower forward flow. The strongest TTE predictors of hospital mortality were left ventricular outflow tract velocity–time integral [LVOT VTI, adjusted OR 0.912 per 1 cm higher, 95% confidence interval (CI) 0.883–0.942, P &lt; 0.0001] followed by medial mitral E/e′ ratio (adjusted OR 1.024 per 1 unit higher, 95% CI 1.010–1.039, P = 0.0011). Classification and regression tree analysis identified LVOT VTI &lt;16 cm as the most important TTE predictor of mortality. Conclusions Doppler-derived haemodynamic TTE parameters have a strong association with mortality in the CICU, particularly LVOT VTI &lt;16 cm or mitral E/e′ ratio &gt;15. The incorporation of these simplified Doppler-derived haemodynamics into admission CV-POCUS facilitates early risk stratification and strengthens the clinical yield of the ultrasound exam.

Background Cardiac arrest (CA) is associated with worse outcomes in patients with cardiogenic shock (CS). To better understand the contribution of CA on CS, we evaluated transthoracic echocardiography (TTE) parameters in CS patients with and without CA. Methods We retrospectively identified CS patients with a TTE performed near cardiac intensive care unit admission between 2007 to 2018. We compared TTE measurements of left ventricular (LV) and right ventricular (RV) function in patients with and without CA. The primary outcome was all-cause in-hospital mortality, as determined using multivariable logistic regression. Results We included 1085 patients, 35% of whom had CA. Median age was 70 years and 37% were females. CA patients had higher severity of illness, more invasive mechanical ventilation and greater vasopressor/inotrope use. In-hospital mortality was 31% and was higher in CA patients (45% vs. 23%, p <0.001). Although LV ejection fraction (LVEF) was similar (35% vs. 37%, p = 0.05), CA patients had lower cardiac index, mitral valve E wave peak velocity, E/A ratio and E/e' ratio. TTE variables that were associated with hospital mortality varied, among patients with CA, these included measures of RV pressure and function and among patients without CA, these included parameters reflecting LV systolic function. Conclusions Doppler assessments of RV systolic dysfunction were the strongest TTE predictors of hospital mortality in CS patients with CA, unlike CS patients without CA in whom LV systolic function was more important. This emphasizes the importance of RV assessment for mortality risk stratification after CA.