The landmark clinical trials on the utility of transcatheter aortic valve implantation (TAVI) excluded patients with hypertrophic cardiomyopathy (HCM) and concomitant severe aortic stenosis.1 TAVI in ...HCM presents unique technical or physiologic challenges called “suicide left ventricle,” that is, sudden reduction in afterload after TAVI exacerbates subvalvular obstruction, which leads to hemodynamic collapse.2 Despite this, TAVI has increasingly been used in patients with HCM with no large-scale data on its safety. There was no significant difference in the proportion of co-morbidities such as heart failure (75.4% vs 78.7%), hypertension (91.0% vs 90.6%), chronic obstructive pulmonary disorder (30.5% vs 29.5%), pulmonary circulatory disorder (25.8% vs 25.4%), obesity (21.6% vs 20.8%), and diabetes mellitus (12.1% vs 11.5%) in the HCM-TAVI and non–HCM-TAVI group, respectively (Figure 1). During the index hospitalization, TAVI in HCM experienced significantly higher adjusted odds of net adverse cardiovascular events (NACE) (7.2% vs 4.4%, aOR 1.70, 95% CI 1.14 to 2.51, p = 0.01), in-hospital mortality (5.1% vs 0.6%, aOR 8.62, 95% CI 3.7 to 20.2, p <0.001), and cardiogenic shock (1.3% vs 0.2%, aOR 5.99, 95% CI 1.4 to 26.8, p = 0.02).
Solid organ transplant candidates encountered increased wait times and mortality rates during the coronavirus 2019 (COVID‐19) pandemic. Despite improvement in medical management and vaccination ...efficacy, this patient population remains at increased risk for complications post COVID‐19 including organ rejection. We describe the development of antibody mediated rejection with or without cellular rejection in heart transplant (HT) recipients and previous COVID‐19 infection or vaccination. Although centers have changed their management of outpatient follow‐up for orthotopic heart transplant patients, little is known on surveillance of rejection and management of HT recipients after COVID‐19 infection. We recommend frequent surveillance for rejection or allograft dysfunction after COVID‐19 infection. We have adopted a transplant surveillance protocol for HT recipients with COVID‐19 infection, given our recent experience with transplanted patients affected of COVID‐19.
Transcatheter aortic valve replacement (TAVR) has become the standard of care for the treatment of all patients with calcific aortic stenosis. Patients with end-stage renal disease (ESRD) on ...hemodialysis were excluded from participation in many of the seminal trials proving the safety and efficacy of TAVR. The outcomes of TAVR in the ESRD population from a national registry showed significantly higher in-hospital and 1-year mortality compared with patients not on hemodialysis. Comparisons of outcomes for surgical versus transcatheter interventions in patients with ESRD and heart failure with reduced ejection fraction (HFrEF) are limited. Using the United States Renal Data System, we identified all ESRD patients with aortic stenosis and HFrEF who underwent TAVR, surgical aortic valve replacement (SAVR), or those with HFrEF and aortic stenosis initiated on dialysis after the year 2012 to compare survival. Propensity score matching was performed, and groups were compared using Kaplan-Meier curves. The study population consisted of 7,660 patients, of which 5,064 (66.1%) were male. The median age at initiation of dialysis was 73 years (interquartile range: 65 to 80). There were 1,108 (14.5%) who underwent TAVR and 695 (9.1%) who underwent SAVR. After matching, patients who underwent TAVR had increased survival relative to those who were medically managed. In-hospital outcomes favored TAVR with less mortality and fewer complications when compared with SAVR. TAVR had improved mortality relative to SAVR in the early period, but survival curves crossed at approximately 9 months and SAVR had better mortality in the long-term. TAVR is a safe and effective procedure and is associated with improved mortality when compared with medical management. In conclusion, TAVR and SAVR are both viable options for patients with ESRD and HF with TAVR having better short-term outcomes and SAVR better long-term outcomes.
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Veno-arterial-venous extracorporeal membrane oxygenation (V-AV ECMO) is a less commonly used configuration of ECMO. We sought to understand the indications, utilization patterns, and outcomes of V-AV ...ECMO by quantitatively pooling the existing evidence from the literature.
Electronic search was performed to identify all relevant studies reporting V-AV ECMO usage. Five studies comprising 77 patients were selected and cohort-level data were extracted for further analysis.
Mean patient age was 61 (95% CI: 55.2, 66.5) years and 30% (23/77) were female. The majority of cases 91% (70/77) were transitioned to V-AV ECMO from another pre-existing ECMO configuration: V-A ECMO in 55% (42/77) vs. V-V ECMO in 36% (28/77), p = 0.04. Only 9% (7/77) of cases were directly placed on V-AV ECMO. The mean duration of hospital stay was 42.3 (95% CI: 10.5, 74.2) days, while ICU mortality was 46% (29, 64). Transition to durable left ventricular assist device was performed in 3% (2/64) of patients, while 3% (2/64) underwent heart transplantation. V-AV ECMO was successfully weaned to explantation in 33% (21/64) of patients.
V-AV ECMO is a viable option for optimizing cardiopulmonary support in selected patients. Survival to weaning or bridging therapy appears comparable to more common ECMO configurations.
Purpose of Review
Cardiac Allograft vasculopathy (CAV) is a major barrier to improving outcomes after heart transplantation. Coronary angiography has very low sensitivity to detect early CAV and ...intravascular ultrasound (IVUS) only improves it to some extent. In this article, we detail the current evidence surrounding use of Optical Coherence tomography (OCT) in patients with CAV.
Recent Findings
OCT has the ability to recognize CAV at earlier stages with intimal thickness < 150 μm, can characterize CAV in almost pathologic / microscopic detail – plaque characteristics are better visualized and novel early features such as layered fibrotic plaques and microchannels have been identified. Progression of CAV can be monitored also, with promise shown in automated serial measurements also.
Summary
OCT has significantly advanced our understanding of the pathophysiology—as well as permits precise monitoring and surveillance of the disease. Potential treatment options could also be evaluated using OCT.
Background
Microaxial circulatory support devices have been used to support patients treated with percutaneous coronary intervention (PCI) for acute myocardial infarction complicated by cardiogenic ...shock (AMICS). The purpose of this systematic review and meta‐analysis was to pool and analyze the existing evidence on the baseline characteristics, periprocedural data, and outcomes of microaxial support before and after PCI in AMICS.
Methods
An electronic database search was performed to identify all cohort studies on Impella and PCI for cardiogenic shock in the English language. A total of five articles comprising 543 patients were included. These patients received microaxial support either before (pre‐PCI) or after (post‐PCI) undergoing PCI. Comparative analyses were done between both groups.
Results
The mean patient age was 66 years 95% Confidence Interval (58–74), and 22% (89/396) of patients were female. ST‐elevation myocardial infarctions (MI) comprised 64% (44–80) of MIs and 50% (44–56) of MIs involved the left anterior descending artery. The mean number of diseased vessels was 2.21 (1.62–2.80). The mean left ventricular ejection fraction was 31% (23.4–38.6). The mean arterial pressure was 66.3 mm Hg (54.1–78.5). Mean serum lactate 6.1 mmol/L (3.3–8.9) and serum creatinine 1.4 mg/dl (1.0–1.7) were similar between groups. 30‐day mortality was lower in the pre‐PCI group 41% (34%–49%) compared to the post‐PCI group 61% (42%–77%), p < 0.01. Pooled Kaplan–Meier analysis showed better early survival in the pre‐PCI group (p < 0.001).
Conclusion
Patients presenting with AMICS were similar at baseline in both pre‐PCI and post‐PCI groups. Nevertheless, pre‐PCI group showed better early survival compared to post‐PCI group.
Pooling existing evidence on timing of Impella placement relative to percutaneous coronary intervention (PCI) for acute myocardial infarction complicated by cardiogenic shock (AMICS) showed similar baseline characteristics in patients supported by Impella before and after PCI. Notably, pooled Kaplan–Meier analysis showed better early survival in patients with AMICS who were supported with Impella before PCI. These findings highlight the importance of initiating Impella before PCI for AMICS despite perceived elevated risk in this patient population.
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