Alkhouli, Mohamad

Background— Percutaneous closure of prosthetic mitral valve paravalvular leak (PVL) has emerged as an alternative to surgical treatment in high-risk patients. Limited data exist on the impact of successful percutaneous PVL closure on midterm outcomes. Methods and Results— We examined consecutive patients who underwent percutaneous mitral PVL closure at Mayo Clinic, Rochester, MN, between January 2006 and January 2017. Procedural success, in-hospital outcomes, and midterm mortality were assessed. A total of 231 patients underwent percutaneous mitral PVL repair at a mean age of 67±12 years. Mean time from mitral valve replacement to percutaneous PVL repair was 1.25 (0.31–7.25) years. One hundred sixty-two patients (70%) had ≤mild PVL after the procedure. Compared with those who had >mild residual PVL, patients with ≤mild residual PVL had lower rates of repeat surgical interventions (6% versus 17%; P =0.004) and lower all-cause mortality at 30 days (1% versus 14%; P <0.001) and 1 year (15% versus 39%; P <0.001). Survival at 3 years was 61% in patients who had ≤mild residual leak and 47% in patients with higher grade of residual PVL ( P =0.002). Conclusions— In a large consecutive cohort of patients undergoing percutaneous mitral PVL closure, successful percutaneous reduction of the PVL to mild or less was associated with significant midterm survival benefit.

Structural heart disease is a rapidly evolving field, and approaches to procedural training are not standardized. We describe a novel modular approach to procedural training that considers each procedure as a series of building blocks that may be taught and assessed separately. Ten key structural heart disease building blocks can be identified, which, when combined with the cognitive skills of structural intervention and device-specific training, allow appropriate planning and implementation of structural procedures. Structural procedures require careful navigation of the aorta, left atrium, and right heart, including detailed understanding of relational anatomy. Component blocks include large bore vascular access, navigation within the left atrium, occlusion, snaring, and 3-dimensional relational anatomy. These building blocks also provide the foundation for new procedures through innovative use of the skill sets and devices to approach new clinical problems. The addition of device-specific training may be provided via proctoring and industry support. Using this approach, competency in less common procedures may be achieved and maintained. We discuss each building block in detail, approaches specific to the structural heart disease patient, the need for cross-discipline training, and empirical recommendations for training using this approach. We postulate that this new paradigm may be the preferred approach for training and assessment of structural heart disease interventional skills.

AbstractBackgroundRacial disparities in cardiovascular care have been extensively investigated. The introduction of transcatheter aortic valve replacement (TAVR) revolutionized the treatment of aortic stenosis (AS) in the last decade. Whether a racial disparity in the utilization and outcome of TAVR exists is unknown.MethodsWe utilized the nationwide inpatient sample (NIS) to compare utilization rates, and in‐hospital outcomes of Caucasians and African American (AA) patients who underwent TAVR between August 2011 and December 2014.ResultsA total of 7,176 patients (6870 Caucasians, 95.7%) and (306 AAs, 4.3%) were included in this analysis. Among patients who underwent aortic valve replacement between 2011 and 2014, the rates of TAVR utilization increased from 0.32% to 7.6% in AAs and from 0.4% to 8.8% in Caucasians. In propensity‐matched cohorts of patients (n = 300 Caucasians and n = 300 AAs), in‐hospital mortality was similar (3.7% and 3.3%, respectively, P = 0.99). Also, rates of key complications including stroke, permanent pacemaker implantation (PPMI), vascular complications, acute kidney injury, new dialysis, blood transfusion, and tamponade were similar in both races. There was also no significant difference between Caucasians and AAs with regards to length of stay, cost of hospitalization, and intermediate care facility utilization.ConclusionsThere was no significant difference in the utilization rates, in‐hospital outcomes, and cost of TAVR between Caucasians and AA patients in contemporary US practice. Further comparative studies of surgical and TAVR in AAs and other racial minorities are warranted.

Background Studies assessing the differential impact of sex on outcomes of aortic valve replacement ( AVR ) yielded conflicting results. We sought to investigate sex‐related differences in AVR utilization, patient risk profile, and in‐hospital outcomes using the Nationwide Inpatient Sample. Methods and Results In total, 166 809 patients (63% male and 37% female) who underwent AVR between 2003 and 2014 were identified, and 48.5% had a concomitant cardiac surgery procedure. Compared with men, women were older and had more nonatherosclerotic comorbid conditions including hypertension, diabetes mellitus, obstructive pulmonary disease, atrial fibrillation/flutter, and anemia but fewer incidences of coronary and peripheral arterial disease and prior sternotomies. In‐hospital mortality was significantly higher in women (5.6% versus 4%, P <0.001). Propensity matching was performed to assess the impact of sex on the outcomes of isolated AVR and yielded 28 237 matched pairs of male and female participants. In the propensity‐matched groups, in‐hospital mortality was higher in women (3.3% versus 2.9%, P <0.001). Along with vascular complications and blood transfusion (6% versus 5.6%, P =0.027 and 40.4% versus 33.9%, P <0.001, respectively). Rates of stroke, permanent pacemaker implantation, and acute kidney injury requiring dialysis were similar (2.4% versus 2.4%, P =0.99; 6% versus 6.3%, P =0.15; and 1.4% versus 1.3%, P =0.14, respectively). Length of stay median and interquartile range were both similar between groups (7±6 days). Rates of nonhome discharge were higher among women (27.9% versus 19.6%, P <0.001). Conclusions Women have worse in‐hospital mortality following AVR compared with men. Coupled with the accumulating evidence suggesting higher magnitude of benefit of transcatheter AVR over AVR in women, women should perhaps be offered transcatheter AVR over AVR at a lower threshold than men.

AbstractBackgroundData on the clinical utility of left atrial (LA) hemodynamic monitoring during percutaneous mitral interventions are limited.ObjectivesTo evaluate the association between intraprocedural LA pressures during percutaneous mitral paravalvular leak (PVL) closure and long term survival.MethodsPatients who underwent mitral PVL repair with invasive LA pressure monitoring were divided at baseline to three tertiles based on their mean final LA pressure (<25%; 25‐30%; >30% of mean systolic blood pressure). Primary outcome was all‐cause mortality.Results134 patients (mean age 68 ± 12 years) were studied. Over 3 year mean follow‐up, 81 (38%) patients died. The cumulative probability of death at 3 years was significantly higher among patients in the highest LA pressure tertile (56 ± 8% vs. 28 ± 5%, log rank P < 0.001). More than mild residual mitral regurgitation (MR) by transesophageal echocardiography (TEE) was associated with a 2.5‐fold increased risk of death and patients in the highest LA pressure tertile had 2.2‐fold higher mortality (P < 0.001 and = 0.003 respectively). After adjustment for residual MR by TEE, each 10% acute procedural reduction in LA pressures was associated with a significant 9% reduced risk of death (P = 0.023). Multivariate Cox regression with adjustment for multiple predictors of death showed that patients in lower LA pressure tertiles had 59% lower mortality (P = 0.003).ConclusionLower LA pressure following mitral PVL closure is an independent predictor of improved survival, even after adjustment for residual MR. LA pressure monitoring may be a useful tool for procedural guidance during mitral PVL closure.

Background— The introduction of transcatheter aortic valve replacement (TAVR) led to renewed interest in balloon aortic valvuloplasty (BAV). We sought to assess contemporary trends in BAV utilization and their outcomes. Methods and Results— The Nationwide Inpatient Sample was used to identify patients who underwent BAV between 2004 and 2013. In-hospital morbidity and mortality, and predictors of death after BAV were assessed. Outcomes of propensity-matched groups of patients undergoing elective BAV or TAVR were evaluated. BAV utilization increased from 707 cases in 2004 to 3715 cases in 2013 (national estimates). Procedural and in-hospital mortality were 1.4% and 8.5%, respectively. Vascular complications occurred in 7.0% of cases, blood transfusion in 17.5%, clinical stroke in 1.8%, and pacemaker implantation in 3.0%. The strongest predictors of in-hospital death were cardiogenic shock (odds ratio, 6.01; 95% confidence interval, 4.19–8.61; P <0.001), need for left ventricular assist device (odds ratio, 3.48; 95% confidence interval, 2.25–5.36; P <0.001), coagulopathy (odds ratio, 2.19; 95% confidence interval, 1.51–3.18; P <0.001), and low institutional volume of BAV (odds ratio, 1.58; 95% confidence interval, 1.06–2.37; P =0.03). In propensity-matched patients undergoing elective BAV or TAVR, rates of in-hospital mortality (2.9% versus 3.5%; P =0.60), clinical stroke (1.6% versus 3.1%; P =0.10), and vascular complications (8.2% versus 10.9%; P =0.14) were similar. However, BAV was associated with lower rates of pacemaker implantation (2.9% versus 8.0%; P <0.001) and blood transfusion (12.8% versus 22.9%; P <0.001). Conclusions— In a contemporary national registry, BAV is associated with significant morbidity and mortality that are similar to TAVR. With the substantial increase in BAV utilization and the continuous improvement in TAVR outcomes, these data have important implications to aid clinicians in the selection of appropriate BAV candidates.

BackgroundPercutaneous paravalvular leak (PVL) closure is an alternative treatment option for severely symptomatic, high‐surgical risk patients with PVL. Some patients require multiple percutaneous PVL closure procedures. However, the procedural characteristics and success rate of re‐do PVL closure have not been well studied.AimsThe aim of this study is to investigate the indications, procedural characteristics, technical success rate, and 30‐day major adverse cardiovascular events (MACE) in patients who underwent re‐do PVL closure.MethodsConsecutive patients who underwent percutaneous paramitral or paraaortic leak closure at Mayo Clinic, Rochester, Minnesota from 2004 through 2015 were studied. Clinical and procedural characteristics of patients who underwent re‐do PVL closure were compared to age‐ and sex‐matched patients who underwent their first percutaneous PVL closure. Procedure success and 30‐day MACE were compared in both the groups.ResultsAmong 223 identified percutaneous PVL closures, 16 (7%) were re‐do procedures. Patients who underwent re‐do PVL closure were predominantly men (87.5%) with a mean age of 68 ± 15 years and an estimated mean Society of Thoracic Surgery (STS) 30‐day mortality of 4.6 ± 2.8. Half of the re‐do PVL closures were performed on mechanical valves and 62.5% were performed on paramitral defects. Indications for re‐do PVL closure were: (1) emergence of new significant paravalvular defects in 50%, (2) incomplete index defect closure in 43.75%, and (3) index procedural complication in 6.25% of the cases. Procedural success was 75% in re‐do procedures vs. 85.4% in age‐ and sex‐matched control group (P = 0.45). Thirty‐day MACE was 12.5% in the re‐do group compared to 4.2% in the age‐ and‐sex matched patients who underwent PVL closure for the first time (P = 0.35).ConclusionRe‐do percutaneous PVL closure is feasible with favorable procedural success rate and low 30‐day MACE. Development of new paravalvular defects is the most common indication for re‐do PVL closure, highlighting the importance of careful longitudinal monitoring and follow‐up. © 2017 Wiley Periodicals, Inc.