Abstract Calcific aortic valve stenosis is a common valve pathology that increases in prevalence with advancing age. Transcatheter aortic valve (TAV) replacement has now emerged as the preferred ...treatment for patients at high risk for surgery and for those who are inoperable. However, the use of this ground-breaking technology has inevitably been associated with a host of new problems. These new types of complications are frequently unrecognized or underestimated due to lack of familiarity with the normal and pathological appearance of TAV and often require redefining strategies for diagnosis and treatment. This review presents a systematic approach for follow-up assessment of TAV function, as well as pathology uniquely related to TAV. Because the worldwide transcatheter aortic valve replacement experience has been dominated by the Edwards Sapien (Irvine, California) and Medtronic CoreValve (Minneapolis, Minnesota) family of bioprosthetic aortic valves, we will focus our review on these valves, each with their unique set of advantages and technological challenges.
Abstract Background Cardiovascular disease among hemodialysis (HD) patients is linked to poor outcomes. The Acute Dialysis Quality Initiative Workgroup proposed echocardiographic (ECHO) criteria for ...structural heart disease (SHD) in dialysis patients. The association of SHD with important patient outcomes is not well defined. Objectives This study sought to determine prevalence of ECHO-determined SHD and its association with survival among incident HD patients. Methods We analyzed patients who began chronic HD from 2001 to 2013 who underwent ECHO ≤1 month prior to or ≤3 months following initiation of HD (n = 654). Results Mean patient age was 66 ± 16 years, and 60% of patients were male. ECHO findings that met 1 or more and ≥3 of the new criteria were discovered in 87% and 54% of patients, respectively. Over a median of 2.4 years, 415 patients died: 108 (26%) died within 6 months. Five-year mortality was 62%. Age- and sex-adjusted structural heart disease variables associated with death were left ventricular ejection fraction (LVEF) ≤45% (hazard ratio HR: 1.48; confidence interval CI: 1.20 to 1.83) and right ventricular (RV) systolic dysfunction (HR: 1.68; CI: 1.35 to 2.07). An additive of higher death risk included LVEF ≤45% and RV systolic dysfunction rather than neither (HR: 2.04; CI: 1.57 to 2.67; p = 0.53 for test for interaction). Following adjustment for age, sex, race, diabetic kidney disease, and dialysis access, RV dysfunction was independently associated with death (HR: 1.66; CI 1.34 to 2.06; p < 0.001). Conclusions SHD was common in our HD study population, and RV systolic dysfunction independently predicted mortality.
Aortic root enlargement has not been well studied as a modality to prevent patient prosthesis mismatch in octogenarian patients with a small aortic root.
We reviewed the records of 117 octogenarian ...patients who received surgical aortic valve replacement (AVR) between 1993 and 2010. From this group, 87 patients received a 19-mm AVR (small aortic valve, SAV group) and 30 received an aortic root enlargement and a 21-mm AVR (aortic root enlargement, ARE group).
The median age of the patients was 84 years (range, 80 to 93) and there were 111 women (95%). Aortic cross-clamp time was 50 minutes (26 to 116) in the SAV group and 67 (26 to 136) in the ARE group (p=0.02). There were no differences in the operative morbidity or morality rates between the groups. Postoperative aortic valve area index was 0.77 cm2/m2 (0.25 to 1.47) in the SAV group and 1.06 (0.51 to 1.94) in the ARE group (p<0.001). Severe patient prosthesis mismatch occurred in 23 patients (32%) in the SAV group in comparison with 3 (12%) in the ARE group (p=0.04). There were no differences in the mid-term outcomes of New York Heart Association functional class (p=0.230) or survival between patients with or without mismatch (p=0.84).
Aortic root enlargement in octogenarian patients allows for insertion of larger aortic valve prostheses without any apparent increase in operative morbidity or mortality. The larger prostheses demonstrate better hemodynamic performance and less patient prosthesis mismatch, but no apparent functional or survival advantage.
Abstract Background The occupational hazards of working in the interventional laboratory have been inadequately studied for physicians and remain unaddressed for nonphysician personnel. Objectives ...This study sought to determine whether the prevalence of work-related musculoskeletal pain, cancer, and other medical conditions is higher among physicians and allied staff who work in interventional laboratories compared with employees who do not. Methods Mayo Clinic employees who work in affiliated hospitals with interventional cardiology or interventional radiology laboratories took an electronic survey. Results were stratified on the basis of self-reported occupational exposure to procedures that involve radiation. Results There were 1,543 employees (mean age 43 ± 11.3 years, 33% male) who responded to the survey (response rate of 57%), and 1,042 (67.5%) reported being involved with procedures utilizing radiation. These employees reported experiencing work-related pain more often than the control group before (54.7% vs. 44.7%; p < 0.001) and after adjustment for age, sex, body mass index, pre-existing musculoskeletal conditions, years in profession, and job description (odds ratio: 1.67; 95% confidence interval: 1.32 to 2.11; p < 0.001). Musculoskeletal pain varied significantly by job description, with the highest incidence reported by technicians (62%) and nurses (60%) followed by attending physicians (44%) and trainees (19%; p < 0.001). There was no difference in cancer prevalence between groups (9% vs. 9%; p = 0.96). Conclusions Musculoskeletal pain is more common among healthcare workers who participate in interventional procedures and is highest in nonphysician employees. The diagnosis of cancer in employees who participate in procedures that utilize radiation was not elevated when compared to controls within the same departments, although any conclusion regarding causality is limited by the cross-sectional nature of the study, as well as the low overall prevalence of malignancy in our study group.
Patient selection for transcatheter edge-to-edge mitral valve repair (TMVR) remains challenging because of heterogenous mitral valve pathology and highly variable anatomy. The aim of this study was ...to investigate whether quantitative three-dimensional (3D) transesophageal echocardiographic modeling parameters are associated with optimal mitral regurgitation (MR) reduction in patients undergoing TMVR.
Fifty-nine patients underwent 3D transesophageal echocardiography during TMVR. Volumetric data sets were retrospectively analyzed using mitral valve quantitative 3D modeling software (Mitral Valve Navigator). Optimal MR reduction was defined as less than moderate residual MR. Logistic regression was used to correlate 3D transesophageal echocardiographic quantitative data to procedural success.
Thirty-five patients had primary MR, 24 had mixed or secondary MR, and all patients had grade ≥ 3/4 MR before the procedure. Optimal MR reduction was achieved in 40 of 59 patients (68%). Univariate correlates of optimal MR reduction in patients with primary MR were lower mitral leaflet tenting volume (P = .049) and lower tenting height (P = .025); tenting height < 3 mm and tenting volume < 0.7 mL were associated with increased likelihood of optimal MR reduction (92% vs 48% P = .01 and 81% vs 47% P = .03, respectively). In mixed or secondary MR, annular height ≥ 5.5 mm was associated with increased likelihood of optimal MR reduction (94% vs 38%; P = .03). During follow-up, redo TMVR or surgical mitral valve replacement occurred exclusively in patients with suboptimal anatomy defined by 3D transesophageal echocardiography (10% vs 0%, P = .045).
Quantitative 3D echocardiographic data are associated with favorable response to TMVR and could help optimize patient selection.
Objectives The aim of the study is to clarify the clinical role of Doppler-echocardiographic parameters of left ventricular diastolic dysfunction (LVDD) as determinants of pulmonary hypertension in ...patients experiencing left ventricular systolic dysfunction (LVSD) with and without the presence of functional mitral valve regurgitation (FMR). Background Pulmonary hypertension (pulmonary venous or mixed pulmonary venous-arterial hypertension) complicating LVSD is associated with poor outcomes beyond that of LVSD alone. The view of the contribution of LVDD as a determinant of pulmonary hypertension is controversial and not well defined as a tool in clinical practice. Methods Data from patients with LVEF ≤40% undergoing Doppler-echocardiography evaluations during the period from August 2001 to December 2004 were analyzed. Pulmonary systolic pressure (PSP), parameters of diastolic function (mitral valve MV transmitral flow velocity E/mitral annular diastolic velocity e′ ratio, MV deceleration time DT), quantitated effective regurgitant orifice area (EROA) of FMR, and clinical characteristics were evaluated. Pulmonary hypertension was defined as an estimated PSP ≥45 mm Hg. Results Criteria were met in 1,541 patients; one-third (n = 533) demonstrating PSP ≥45 mm Hg (58 ± 10 mm Hg, range 45 to 102 mm Hg). Patients with pulmonary hypertension were older with higher E/e′ ratio, EROA, and lower DT and LVEF. In multivariate analysis, pulmonary hypertension was independently predicted not only by severity of FMR (EROA ≥20 mm2 , odds ratio: 3.8, p < 0.001) but also by parameters of LVDD (E/e′ ratio ≥15, odds ratio: 3.31, p < 0.001; DT ≤150 ms, odds ratio: 3.8, p < 0.001). Receiver-operating characteristics curve analysis showed that EROA, E/e′ ratio, and DT provided significant incremental value in predicting pulmonary hypertension (c-statistic 0.830, p < 0.001). Conclusions Patients with LVSD commonly have secondary pulmonary hypertension, which is largely determined by the severity of LVDD even with adjustment for FMR and low LVEF. Thus, measures of LVDD in routine clinical practice where PSP may not be estimated are important physiologic descriptors of hemodynamic status and are cumulatively linked in the prediction of pulmonary hypertension.
The recent report that appropriately performed echocardiographic examinations result in active changes in management in only one third of patients has challenged the validity of current appropriate ...use criteria. Limited information exists about the clinical importance of transthoracic echocardiography (TTE) to guide management and rule out important alternative pathology.
The clinical impact of inpatient TTE performed at the Mayo Clinic over a 20-week period between October 14, 2013, and March 3, 2014, was investigated. Studies were included if they were ordered within 72 hours of admission, and treating physicians participated in a real-time survey regarding the clinical importance of TTE. Appropriate use was determined by two independent investigators, with differences adjudicated by a third investigator. Clinical impact was derived from physicians' survey responses and independently confirmed by chart review.
Of the 539 transthoracic echocardiographic examinations included in this study, 512 (95%) were appropriate, 16 (3%) may be appropriate and 11 (2%) rarely appropriate. Although only 48% of participating physicians actively changed management on the basis of findings on TTE, 97% responded that TTE answered their clinical questions, and 95% would still order TTE in similar clinical contexts.
Most early inpatient transthoracic echocardiographic studies at our institution were appropriate and answered specific clinical questions important for management decisions in the opinion of the treating physician. Confirming a plan of care already in place and ruling out alternative pathology may be as important clinically as uncovering new findings or changing management.
Decellularized heart valves are emerging as a potential alternative to current bioprostheses for valve replacement. Whereas techniques of decellularization have been thoroughly examined, terminal ...sterilization techniques have not received the same scrutiny.
This study evaluated low-dose gamma irradiation as a sterilization method for decellularized heart valves. Incubation of valves and transmission electron microscopy evaluation after different doses of gamma irradiation were used to determine the optimal dose of gamma irradiation. Quantitative evaluation of mechanical properties was done by tensile mechanical testing of isolated cusps. Sterilized decellularized heart valves were tested in a sheep model (n = 3 1 at 1,500 Gy and 2 at 3,000 Gy) of pulmonary valve replacement.
Valves sterilized with gamma radiation between 1,000 Gy and 3,000 Gy were found to be optimal with in vitro testing. However, in vivo testing showed deteriorating valve function within 2 months. On explant, the valve with 1,500 Gy gamma irradiation showed signs of endocarditis with neutrophils on hematoxylin and eosin staining, and positive gram stain resembling streptococcus infection. The 3,000 Gy valves had no evidence of infection, but the hematoxylin and eosin staining showed evidence of wound remodeling with macrophages and fibroblasts. Tensile strength testing showed decreased strength (0 Gy: 2.53 ± 0.98 MPa, 1,500 Gy: 2.03 ± 1.23 MPa, and 3,000 Gy: 1.26 ± 0.90 MPa) with increasing levels of irradiation.
Low-dose gamma irradiation does not maintain the mechanical integrity of valves, and the balance between sterilization and damage may not be able to be achieved with gamma irradiation. Other methods of terminal sterilization must be pursued and evaluated.
Coronary artery imaging is required for most adult patients undergoing aortic valve replacement (AVR).
Between January 1, 2000, and December 31, 2007, 1413 patients underwent elective AVR at Mayo ...Clinic. Two propensity-matched groups at low risk for acute kidney injury were created: 321 patients with coronary angiography on the same day as AVR (same day) and 321 patients with coronary angiography more than 1 day before AVR (non-same day). We defined acute postoperative kidney injury with Acute Kidney Injury Network criteria (≥0.3 mg/dL or a 50% increase in serum creatinine from baseline).
The same-day vs non-same-day groups were comparable in age (mean SD years: 70.6 11.0 vs 70.8 11.5), sex (111 women 34.6% vs 114 women 35.5%), preoperative serum creatinine (1.14 0.22 vs 1.15 0.23 mg/dL), and ejection fraction (0.62 0.12 vs 0.61 0.12). Coronary artery revascularization was performed in 118 patients (36.8%) in the same-day group and in 123 (38.3%) in the non-same-day group (p=0.68). Maximum (30-day) postoperative serum creatinine levels were not significantly different between the same-day and non-same day groups (1.30 0.43 mg/dL vs 1.29 0.42 mg/dL; p=0.87). Perioperative (30-day) acute kidney injury occurred in 75 patients (23.4%) in the same-day group and in 71 (22.3%) in the non-same-day group (p=0.99). Perioperative (30-day) death occurred in 5 patients (1.6%) in the same-day group and in 7 (2.2%) in the non-same-day group (p=0.56). Other nonfatal complications rates were comparable between groups.
In properly selected patients, coronary angiography can be performed the same day as elective AVR with no increase in perioperative morbidity or death.
Transcatheter aortic valves may develop structural valve deterioration. With that development the issue arises of repeated transcatheter aortic valve insertion. There are, unfortunately, limited data ...about repeated transapical valve insertion, with only a single case report in the literature. We report an additional successful case.
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