Al-Hijji, Mohammed A

AbstractBackgroundTreatment of hemodynamically significant mitral annular calcification (MAC) using transcatheter approaches is in the early learning phase. The occurrence of paravalvular leak (PVL) following transcatheter mitral valve in MAC is common.AimsTo report the initial experience and techniques of percutaneous PVL closure after transcatheter valve in MAC.MethodsThis series includes five consecutive patients who underwent percutaneous PVL closure following transcatheter balloon expandable SAPIEN S3 valve in MAC.ResultsMean patient age was 73.6 ± 5.4 years (4 [80%] female), with average Society of Thoracic Surgeons score of 8.1 ± 2.8%. Three patients had a single PVL defect while two patients had two defects; all were located at the commissural sites. Closure was performed primarily for heart failure in four patients and hemolytic anemia in one patient. Transfemoral transseptal antegrade approach and Amplatz Vascular Plug (AVP)‐II occluders were utilized in all patients. Procedure success was achieved in three patients. One patient developed significant occluder related leaflet impingement and subsequent severe prosthetic mitral regurgitation requiring a second transcatheter mitral valve in valve implantation. The procedure was aborted in one patient due to difficulty crossing PVL defect after balloon post‐dilatation of SAPIEN prosthesis with 10 mL of additional volume. There was no in hospital or 30 day mortality or the need for emergent surgery.ConclusionEarly experience with percutaneous PVL closure of SAPIEN valve in MAC demonstrated feasibility of this approach. Careful procedure planning and monitoring for SAPIEN prosthesis leaflet impingement and frame instability is of utmost importance to increase the chances of procedural success.

AbstractBackgroundThe effect of utilizing transapical (TA) access for transcatheter aortic valve replacement (TAVR) on cardiac function has not been well studied.AimsThe aim of this retrospective study is to determine the direct effects of TA access for TAVR on myocardial function parameters and their correlation with 4‐year survival.MethodsThree hundred and thirty propensity matched patients, who underwent TAVR using Sapien valve (Edwards Lifesciences Corp, Irvine, CA) between February 15, 2012 and June 17, 2016 (115 TA and 115 transfemoral [TF] routes) were studied. The pre‐ and 1 month post‐TAVR echocardiographic features of both groups were compared. The 4‐year survival in both groups was analyzed.ResultsBaseline clinical characteristics, diastolic function parameters, left ventricular (LV) chamber size, and ejection fraction were similar between matched TA and TF groups. At 1 month following TAVR, there was a significant increase in stroke volume index (SVI) in both TA (mean increase 7 cm3/m2; P = 0.03) and TF groups (mean increase 7 cm3/m2; P < 0.001). Left ventricular ejection fraction (LVEF) significantly increased post TF TAVR (mean increase 2%; P = 0.008), but no significant increase was observed post TA TAVR (mean increase 1%; P = 0.27). Both groups had significant improvement in aortic valve (AV) hemodynamics post‐TAVR (P < 0.001). Overall, there were no significant differences in the mean change of SVI, LVEF, or left ventricular end diastolic dimensions (LVEDDs) post TA versus TF TAVR. There was no significant difference in 4‐year survival in the TF compared to TA group (49% vs 50%, P = 0.43).ConclusionBoth TA and TF TAVR were equally associated with favorable changes in LV SVI and AV hemodynamics in 30 days. TA TAVR patients had similar 4 year survival to propensity matched TF TAVR; therefore, TA TAVR remains an acceptable alternative access route in patients not amenable to TF TAVR.

Background Chronic kidney disease ( CKD ) remains an independent predictor of cardiovascular morbidity and mortality. CKD complicates referral for percutaneous coronary intervention ( PCI ) in non–ST‐segment–elevation myocardial infarction ( NSTEMI ) patients because of the risk for acute kidney injury and the need for dialysis, with American College of Cardiology/American Heart Association guidelines underscoring the limited data on these patients. Methods and Results Using the National Inpatient Sample to analyze hospitalizations in the United States from 2004 to 2014, we sought to assess PCI utilization and in‐hospital outcomes in NSTEMI admissions with CKD . NSTEMI admissions were identified by International Classification of Diseases, Ninth Edition, Clinical Modification (ICD‐9‐CM) code 410.7. CKD admissions were identified by ICD‐9‐CM code 585. Propensity score–matched cohorts of patients with NSTEMI were matched for age, sex, comorbidities, race, median household income, primary payer status, and hospital characteristics. Of 4 488 795 hospitalizations for NSTEMI , 31% underwent PCI . Overall, 89% of admissions had no CKD . In addition, 32% of NSTEMI admissions with no CKD and 23%, 14%, and 22% with CKD stages 3, 4, and 5 underwent PCI , respectively. Hospitalized NSTEMI patients with CKD stages 4 and 5 had 41% and 20% less likelihood, respectively, of undergoing PCI compared with those with no CKD . Among hospitalized NSTEMI patients with no CKD or CKD stage 3, 4, or 5, PCI ‐treated groups had 63%, 57%, 39%, and 59% lower likelihood, respectively, of all‐cause, in‐hospital mortality compared with propensity score–matched medically managed groups. Conclusions PCI use decreased among hospitalized NSTEMI patients as CKD severity increased, and all‐cause, in‐hospital mortality was greater for NSTEMI patients admitted with more severe CKD regardless of treatment strategy.

AbstractIntroductionThree‐dimensional (3D) prototyping is a novel technology which can be used to plan and guide complex procedures such as transcatheter mitral valve replacement (TMVR).MethodsEight patients with severe mitral annular calcification (MAC) underwent TMVR. 3D digital models with digital balloon expandable valves were created from pre‐procedure CT scans using dedicated software. Five models were printed. These models were used to assess prosthesis sizing, anchoring, expansion, paravalvular gaps, left ventricular outflow tract (LVOT) obstruction, and other potential procedure pitfalls. Results of 3D prototyping were then compared to post procedural imaging to determine how closely the achieved procedural result mirrored the 3D modeled result.Results3D prototyping simulated LVOT obstruction in one patient who developed it and in another patient who underwent alcohol septal ablation prior to TMVR. Valve sizing correlated with actual placed valve size in six out of the eight patients and more than mild paravalvular leak (PVL) was simulated in two of the three patients who had it. Patients who had mismatch between their modeled valve size and post‐procedural imaging were the ones that had anterior leaflet resection which could have altered valve sizing and PVL simulation. 3D printed model of one of the latter patients allowed modification of anterior leaflet to simulate surgical resection and was able to estimate the size and location of the PVL after inserting a valve stent into the physical model.Conclusion3D prototyping in TMVR for severe MAC is feasible for simulating valve sizing, apposition, expansion, PVL, and LVOT obstruction.

Objective Female sex is a known risk factor for cardiac surgery, and tricuspid valve (TV) disease is more common in women. There are few data on sex-stratified surgical outcomes for isolated TV surgery. An administrative database was used to compare acute in-hospital outcomes between men and women undergoing isolated TV surgery. Methods Patients aged >18 who underwent TV repair or replacement from 2004 to 2013 were identified using the National Inpatient Sample. Patients were excluded if they had congenital heart disease, endocarditis, or were undergoing concomitant cardiac surgeries except coronary bypass. Results were weighted to represent national averages. Sex-stratified analysis was performed using propensity score matching to compare in-hospital mortality, postoperative complications and hospital costs. Results Over 10 years, women represented 58% of the 5005 TV surgeries performed. With propensity matching, hospital mortality (7.9% vs 7.7%; P=0.99) and median length of stay (11 vs 11 days; P=0.99) were similar between men and women. However, median hospital charges were higher for men ($166 000 vs $155 000; P=0.04). Conclusion Isolated TV surgery is rare, but women more commonly undergo the procedure. In-hospital mortality was similar between men and women after propensity matching, but remains markedly high for both men and women in comparison to that reported for left-sided isolated valve surgery.

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.

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.