Back to the basics: The need for an etiological classification of chronic heart failure

The left ventricular (LV) ejection fraction (LVEF), despite its severe limitations, has had an epicentral role in heart failure (HF) classification, management, and risk stratification for decades. The major argument favoring the LVEF based HF classification has been that it defines groups of patients in which treatment is effective. However, this reasoning has recently collapsed, since medical treatment with neurohormonal inhibitors, has proved beneficial in most HF patients regardless of the LVEF. In addition, there has been compelling evidence, that the LVEF provides poor guidance for device treatment of chronic HF (implantation of cardioverter defibrillator, cardiac resynchronization therapy) since sudden cardiac death may occur and cardiac dyssynchronization may be disastrous in all HF patients. The same holds true for LV assist device implantation, in which the LVEF has been used as a surrogate for LV size. In this review article we update the evidence questioning the use of LVEF-based HF classification and argue that guidance of chronic HF treatment should transition to more contemporary concepts. Specifically, we propose an etiologic chronic HF classification predominantly based on epidemiological data, which will be foundational for further higher resolution phenotyping in the emerging era of precision medicine.

A retrospective analysis of anticoagulant safety among heart transplant recipients undergoing endomyocardial biopsy

BACKGROUND

Transvenous endomyocardial biopsy is an invasive procedure which is used to diagnose rejection following an orthotopic heart transplant. Endomyocardial biopsy is widely regarded as low risk with all-cause complication rates below 5% in most safety studies. Following transplant, some patients require therapeutic anticoagulation. It is unknown whether anticoagulation increases endomyocardial biopsy bleeding risk.

METHODS

Records from 2061 endomyocardial biopsies performed for post-transplant rejection surveillance at our institution between November 2016 and August 2022 were reviewed. Bleeding complications were defined as vascular access-related hematoma or bleeding, procedure-related red blood cell transfusion, and new pericardial effusion. Relative risk and small sample-adjusted 95% confidence interval was calculated to investigate the association between bleeding complications and anticoagulation.

RESULTS AND CONCLUSIONS

The overall risk of bleeding was 1.2% (25/2061 cases). There was a statistically significant increase in bleeding among patients on intravenous (RR 4.46, CI 1.09-18.32) but not oral anticoagulants (RR .62, CI .15-2.63) compared to patients without anticoagulant exposure. There was a trend toward increased bleeding among patients taking warfarin with INR ≥ 1.8 (RR 3.74, CI .90-15.43). Importantly, no bleeding events occurred in patients taking direct oral anticoagulants such as apixaban. Based on these results, intravenous rather than oral anticoagulation was associated with a significantly higher risk of bleeding complications following endomyocardial biopsy.

Acute mitral regurgitation with and without acute heart failure

Acute severe mitral regurgitation (MR) is rare, but often leads to cardiogenic shock, pulmonary edema, or both. Most common causes of acute severe MR are chordae tendineae (CT) rupture, papillary muscle (PM) rupture, and infective endocarditis (IE). Mild to moderate MR is often seen in patients with acute myocardial infarction (AMI). CT rupture in patients with floppy mitral valve/mitral valve prolapse is the most common etiology of acute severe MR today. In IE, native or prosthetic valve damage can occur (leaflet perforation, ring detachment, other), as well as CT or PM rupture. Since the introduction of percutaneous revascularization in AMI, the incidence of PM rupture has substantially declined. In acute severe MR, the hemodynamic effects of the large regurgitant volume into the left atrium (LA) during left ventricular (LV) systole, and in turn back into the LV during diastole, are profound as the LV and LA have not had time to adapt to this additional volume. A rapid, but comprehensive evaluation of the patient with acute severe MR is essential in order to define the underline cause and apply appropriate management. Echocardiography with Doppler provides vital information related to the underlying pathology. Coronary arteriography should be performed in patients with an AMI to define coronary anatomy and need for revascularization. In acute severe MR, medical therapy should be used to stabilize the patient before intervention (surgery, transcatheter); mechanical support is often required. Diagnostic and therapeutic steps should be individualized, and a multi-disciplinary team approach should be utilized.

Percutaneous coronary intervention in patients with cancer using bare metal stents compared to drug-eluting stents

Background

Management of coronary artery disease (CAD) is unique and challenging in cancer patients. However, little is known about the outcomes of using BMS or DES in these patients. This study aimed to compare the outcomes of percutaneous coronary intervention (PCI) in cancer patients who were treated with bare metal stents (BMS) vs. drug-eluting stents (DES).

Methods

We identified cancer patients who underwent PCI using BMS or DES between 2013 and 2020. Outcomes of interest were overall survival (OS) and the number of revascularizations. The Kaplan–Meier method was used to estimate the survival probability. Multivariate Cox regression models were utilized to compare OS between BMS and DES.

Results

We included 346 cancer patients who underwent PCI with a median follow-up of 34.1 months (95% CI, 28.4–38.7). Among these, 42 patients were treated with BMS (12.1%) and 304 with DES (87.9%). Age and gender were similar between the BMS and DES groups (p = 0.09 and 0.93, respectively). DES use was more frequent in the white race, while black patients had more BMS (p = 0.03). The use of DES was more common in patients with NSTEMI (p = 0.03). The median survival was 46 months (95% CI, 34–66). There was no significant difference in the number of revascularizations between the BMS and DES groups (p = 0.43). There was no significant difference in OS between the BMS and DES groups in multivariate analysis (p = 0.26). In addition, independent predictors for worse survival included age > 65 years, BMI ≤ 25 g/m2, hemoglobin level ≤ 12 g/dL, and initial presentation with NSTEMI.

Conclusions

In our study, several revascularizations and survival were similar between cancer patients with CAD treated with BMS and DES. This finding suggests that DES use is not associated with an increased risk for stent thrombosis, and as cancer survival improves, there may be a more significant role for DES.

Effect of mitral valve transcatheter edge-to-edge repair on indices of left atrial performance in chronic mitral regurgitation

INTRODUCTION

Effect of transcatheter edge-to-edge repair (TEER) using MitraClip in patients with mitral regurgitation (MR) on left atrial (LA) kinetic energy (LAKE), an index of LA work, and LA strain, a measure of LA performance, have not been well defined.

METHODS

Patients with chronic primary or secondary 3+ or 4+ MR were analyzed pre- and post-TEER using MitraClip. LAKE was determined by echocardiography using LA stroke volume and A-wave velocity. Peak atrial longitudinal strain (PALS), peak atrial strain in early diastole, and peak atrial contraction strain (PACS) were obtained by speckle tracking echocardiography.

RESULTS

Thirty-nine patients undergoing TEER with MitraClip were screened, 12 met criteria for analysis (9 primary and 3 secondary MR). Compared to pre-TEER, there was a significant increase post-TEER in LAKE (71.0 ± 64.1 vs. 177.5 ± 167.9 dyne·cm·10³ , respectively; p = .008) and Doppler transmitral A-wave velocity (87.8 ± 41.4 vs. 138.5 ± 43.7 cm/s, respectively; p < .001); LA stroke volume did not change significantly. Mitral valve mean gradient significantly increased post-TEER compared to pre-TEER (5.7 ± 2.1 vs. 3.3 ± 2.1 mmHg, respectively; p = .01). There was a trend toward decrease in PALS post-TEER compared to pre-TEER (16.2 ± 4.8 vs. 20.7 ± 9.9%, respectively; p = .05). Peak atrial strain in early diastole significantly decreased post-TEER compared to pre-TEER (7.2 ± 3.0 vs. 14.1 ± 7.2%; respectively, p < .001), while PACS did not significantly change (9.1 ± 3.5 vs. 6.7 ± 5.2%, respectively; p = .07).

CONCLUSION

In patients with chronic MR, LAKE increases after TEER with MitraClip driven by an increase in LA emptying velocities. Changes were also seen in LA strain with MitraClip. These procedurally induced changes due to mild mitral stenosis may have clinical implications.

Comparison of Catheterization Versus Echocardiographic-Based Gradients in Balloon-Expandable Versus Self-Expanding Transcatheter Aortic Valve Implantation

OBJECTIVES

In patients with transcatheter aortic valve implantation (TAVI), accurate assessment of gradients is important to assess valve function and durability, which drives clinical decision-making. We sought to evaluate discrepancies in aortic valve mean gradients with balloon-expandable and self-expanding TAVI.

METHODS

We retrospectively reviewed 507 patients that underwent TAVI and compared mean gradients by catheterization to transthoracic Doppler echocardiography.

RESULTS

Mean gradients by Doppler in balloon-expandable (11.0 ± 5.8 mm Hg) and self-expanding devices (8.7 ± 4.5 mm Hg) were significantly higher than catheterization (3.2 ± 4.0 mm Hg vs 3.5 ± 4.1 mm Hg, respectively; P<.001). In a subgroup analysis of skirted valves, Doppler gradients in balloon-expandable (9.8 ± 4.4 mm Hg) and self-expanding devices (8.6 ± 5.1 mm Hg) were significantly higher than catheterization (3.5 ± 4.1 mm Hg vs 4.2 ± 4.8 mm Hg, respectively; P<.001). When the effect of valve size on gradients was analyzed, Doppler gradients were significantly higher than catheterization for all comparisons. When indexed for valve size, patients with large aortas who received a balloon-expandable TAVI had greater pressure differential than those who received a self-expanding TAVI (8.24 ± 0.46 mm Hg vs 5.16 ± 0.66 mm Hg; P<.001). This trend was not seen in patients with a small aorta-to-valve index.

CONCLUSION

Following TAVI, aortic valve mean gradients acquired by Doppler were higher than catheterization and the discrepancy was more pronounced in balloon-expandable than self-expanding prostheses. These differences persist in skirted valves and across valve sizes. These observations may reflect periprocedural hemodynamic changes, differences between prosthetic flow acceleration, and/or pressure recovery.

Genotype-Guided Use of P2Y12 Inhibitors: A Review of Current State of the Art

The pharmacodynamics of the purinergic receptor type Y, subtype 12 (P2Y12) inhibitors has evolved. Our understanding of the metabolism of P2Y12 inhibitors has revealed polymorphisms that impact drug metabolism and antiplatelet efficacy, leading to genetic testing guided therapy. In addition, assays of platelet function and biochemistry have provided insight into our understanding of the efficacy of "antiplatelet" therapy, identifying patients with high or low platelet reactivity on P2Y12 therapy. Despite the data, the implementation of these testing modalities has not gained mainstream adoption across hospital systems. Given differences in potency between the three clinically available P2Y12 inhibitors, the balance between thrombotic and bleeding complications must be carefully considered, especially for the large proportion of patients at higher risk for bleeding. Here we review the current data for genetic and functional testing, risk assessment strategies, and guidelines for P2Y12 inhibitors guided therapy.

Cardiovascular Disease, Cancer and Multimorbidity Interactions: Clinical Implications

BACKGROUND

With the aging population, the frequency of cardiovascular disease (CVD), cancer and other morbid conditions are increasing dramatically. In addition, one disease may affect the other leading to a vicious cycle.

SUMMARY

With aging, the function of organs and systems of the human body decline including the autoimmune system resulting in a diminished response to various pathogens and a chronic inflammatory process; these changes, in addition to other risk factors, contributes to the development of multiple morbid conditions including CVD and cancer. Multimorbidity in the elderly has become the rule rather than the exception today. Further, this association between CVD and cancer, at least partially, is explained by both diseases sharing common risk factors and from accelerated vascular aging due to cancer and its associated therapies. Multiple studies have shown that the incidence of cancer is much higher in patients with CVD compared to the general population. These associations among CVD, cancer and their connection to systems of the human body provide an opportunity for novel therapies. Development of new drugs should be addressed to focus on multiple systems and not just only to one disease. Further, collecting information from registries and processing large amounts of data using artificial intelligence may assist the clinician when treating an individual patient in the future. Key messages: As the aging population increases, CVD, cancer and multimorbidity will continue to constitute a major health problem in the years to come. The physician who is taking care of such a patient, in addition to knowledge, requires clinical wisdom, clinical experience and common sense in order to apply the continuous evolving knowledge to the individual patient.

Totally endoscopic aortic valve replacement with concomitant trans-aortic mitral valve repair for mitral regurgitation

Background

Minimally invasive aortic valve procedures through a hemi-sternotomy or a right anterior mini-thoracotomy have gained popularity over the last several years. Totally endoscopic aortic valve replacement (TEAVR) is an innovative and a less invasive (incision-wise) surgical aortic valve replacement technique. The operative steps of TEAVR have been reported previously from our group. Mitral regurgitation (MR) frequently accompanies aortic valve disease that at times may also require repair. Totally endoscopic surgery in such cases has not been tested.

Presentation of the technique

We present a surgical technique for a totally endoscopic approach to aortic valve replacement and concomitant mitral valve repair for primary and secondary MR. An aortotomy incision was used avoiding an atriotomy, which results in an increase in cross-clamp (XC) and cardiopulmonary bypass (CPB) times that could be associated with higher mortality and morbidity. Neochords (artificial chordae tendineae) were used for primary MR and an edge-to-edge approach for secondary MR.

Conclusion

TEAVR and concomitant mitral valve repair can be performed successfully with reasonable XC and CPB times with excellent short-term results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01694-6.

De novo Drug Delivery Modalities for Treating Damaged Hearts: Current Challenges and Emerging Solutions

Cardiovascular disease (CVD) is the leading cause of mortality, resulting in approximately one-third of deaths worldwide. Among CVD, acute myocardial infarctions (MI) is the leading cause of death. Current treatment modalities for treating CVD have improved over the years, but the demand for new and innovative therapies has been on the rise. The field of nanomedicine and nanotechnology has opened a new paradigm for treating damaged hearts by providing improved drug delivery methods, specifically targeting injured areas of the myocardium. With the advent of innovative biomaterials, newer therapeutics such as growth factors, stem cells, and exosomes have been successfully delivered to the injured myocardial tissue, promoting improvement in cardiac function. This review focuses on three major drug delivery modalities: nanoparticles, microspheres, and hydrogels, and their potential for treating damaged hearts following an MI.

Black lives matter … in the cath lab, too! A proposal for the interventional cardiology community to counteract bias and racism

Structural racism in the United States underlies racial disparities in the criminal justice system, in the healthcare system generally, and with regards to the COVID-19 pandemic. In the year 2020, these inequities combined and magnified to such a degree that it left Black Americans and physicians caring for them questioning how much Black lives matter. Academic medical centers and the major cardiology organizations responded to a global call to end racism with bold statements and initiatives. Interventional cardiologists utilize advanced equipment to mechanically treat a wide spectrum of heart problems, yet this technology has not been applied in an equitable manner. Interventional therapies are often underutilized in Blacks, exacerbating healthcare disparities and contributing to the excess cardiovascular morbidity and mortality in these communities. Racial bias, whether intentional, unconscious, systemic, or at the individual level, plays a role in these disparities. Many in the interventional cardiology community aspire to take intentional steps to reduce the impact of bias and racism in our specialty. We discuss several proposals here and provide a "report card" for interventional programs to perform a self-assessment.

Proposal for Updated Nomenclature and Classification of Potential Causative Mechanism in Patent Foramen Ovale-Associated Stroke

Importance

Recent epidemiologic and therapeutic advances have transformed understanding of the role of and therapeutic approach to patent foramen ovale (PFO) in ischemic stroke. Patent foramen ovale is likely responsible for approximately 5% of all ischemic strokes and 10% of those occurring in young and middle-aged adults.

Observations

Randomized clinical trials have demonstrated that, to prevent recurrent ischemic stroke in patients with PFO and an otherwise-cryptogenic index ischemic stroke, PFO closure is superior to antiplatelet medical therapy alone; these trials have provided some evidence that, among medical therapy options, anticoagulants may be more effective than antiplatelet agents.

Conclusions and Relevance

These new data indicate a need to update classification schemes of causative mechanisms in stroke, developed in an era in which an association between PFO and stroke was viewed as uncertain. We propose a revised general nomenclature and classification framework for PFO-associated stroke and detailed revisions for the 3 major stroke subtyping algorithms in wide use.

Preoperative determination of artificial chordae tendineae length by transoesophageal echocardiography in totally endoscopic mitral valve repair

OBJECTIVES

Artificial chordae tendineae are widely used for surgical repair in patients with mitral regurgitation due to floppy mitral valve/mitral valve prolapse. Expanded polytetrafluoroethylene has been used to construct these artificial chordae; however, the determination of the optimal length of the chordae prior to surgery has been an issue. For this reason, such a method was developed and the results of its use are presented.

METHODS

Forty-seven consecutive patients with significant mitral regurgitation due to floppy mitral valve/mitral valve prolapse who underwent totally endoscopic mitral valve surgery were studied. The chordae length was predetermined using transoesophageal echocardiography. The length between the top of the fibrous body of the papillary muscle and the coaptation line of the 2 leaflets of the mitral valve was measured and used to define the length of the chordae to be used for repair. Then under stereoscopic vision, a total endoscopic mitral valve repair was performed.

RESULTS

The predicted mean length of chordal loops was 19.76 ± 0.71 mm (median 20, range 16-28) and the actual mean length of chordal loops used was 19.68 ± 0.74 mm (median 20, range 16-26) demonstrating an excellent correlation between the two (r = 0.959). The mean number of chordae loops used per patient was 5.12 ± 0.62 (median 4, range 2-12). All patients at the time of discharge had no or trivial mitral regurgitation on transoesophageal echocardiography.

CONCLUSIONS

The chordae length used for mitral valve repair can be determined prior to surgery using transoesophageal echocardiography with a high degree of accuracy. Further, total endoscopic repair in this group of patients provides excellent results. For these reasons, it is expected that this method will replace most traditional approaches to cardiac surgeries in the years to come.

Transcatheter Mitral Valve Repair in Patients with Heart Failure: A Meta-Analysis

BACKGROUND

Severe secondary mitral regurgitation (MR) is associated with poor prognosis in heart failure patients with left ventricular systolic dysfunction. Few observational and randomized controlled studies demonstrated the efficacy of transcatheter mitral valve repair in heart failure patients with significant MR. A meta-analysis of published studies was performed to evaluate the role of transcatheter mitral valve repair using the MitraClip device in heart failure patients with significant secondary MR.

METHODS

A literature search was performed using PubMed, Cochran CENTRAL, and Embase databases using the search terms "percutaneous mitral valve repair" or "transcatheter mitral valve repair" and "heart failure." Studies that compared medical therapy plus transcatheter mitral valve repair using MitraClip to medical therapy alone in heart failure patients with significant secondary MR were included for pooled analysis. A random-effects model with the Mantel-Haenszel method was used to analyze the data.

RESULTS

Four studies, 2 randomized controlled and 2 nonrandomized studies met the criteria for analysis. Pooled analysis included a total of 1,421 patients, of which 746 patients underwent transcatheter mitral valve repair and 675 patients received medical therapy alone. When compared to medical therapy, transcatheter mitral valve repair significantly decreased all-cause mortality (OR 0.58, 95% CI 0.37-0.91; p = 0.02). A trend toward significant reduction in rehospitalizations (OR 0.35, 95% CI 0.12-1.00; p = 0.05) was also observed. Periprocedural complications ranged from 7.5 to 12.6%.

CONCLUSION

Evidence from pooled analysis suggests that transcatheter mitral valve repair using MitraClip on top of medical therapy, in appropriately selected symptomatic heart failure patients with significant secondary MR, provides survival benefit and may decrease hospitalizations when compared with guideline-directed medical therapy alone.

Multiple MitraClips: The balancing act between pressure gradient and regurgitation

OBJECTIVE

Transcatheter mitral valve repair with the MitraClip is used for the symptomatic management of mitral regurgitation (MR). The challenge is reducing MR while avoiding an elevated mitral valve gradient (MVG). This study assesses how multiple MitraClips used to treat MR can affect valve performance.

METHODS

Six porcine mitral valves were assessed using an in vitro left heart simulator in the native, moderate-to-severe MR, and severe MR cases. MR cases were tested in the no-MitraClip, 1-MitraClip, and 2-MitraClip configurations. Mitral regurgitant fraction (MRF), MVG, and effective orifice area (EOA) were quantified.

RESULTS

Native MRF, MVG, and EOA were 14.22%, 2.59 mm Hg, and 1.64 cm², respectively. For moderate-to-severe MR, MRF, MVG, and EOA were 34.07%, 3.31 mm Hg, and 2.22 cm², respectively. Compared with the no-MitraClip case, 1 MitraClip decreased MRF to 18.57% (P < .0001) and EOA to 1.50 cm² (P = .0002). MVG remained statistically unchanged (3.44 mm Hg). Two MitraClips decreased MRF to 14.26% (P < .0001) and EOA to 1.36 cm² (P = .0001). MVG remained unchanged (3.29 mm Hg). For severe MR, MRF, MVG, and EOA were 59.79%, 4.98 mm Hg, and 2.73 cm², respectively. Compared with the no-MitraClip case, 1 MitraClip decreased MRF to 30.72% (P < .0001) and EOA to 1.82 cm² (P < .0001); MVG remained unchanged (4.03 mm Hg). MVG remained statistically unchanged. Two MitraClips decreased MRF to 23.10% (P < .0001) and EOA to 1.58 cm² (P < .0001); MVG remained statistically unchanged (3.82 mm Hg). Both MR models yielded no statistical difference between 1 and 2 MitraClips.

CONCLUSIONS

There is limited concern regarding elevation of MVG when reducing MR using 1 or 2 MitraClips, although 2 MitraClips did not significantly continue to reduce MRF.

The Use of MitraClip in Secondary Mitral Regurgitation and Heart Failure

Secondary (also known as functional) mitral regurgitation (MR) has increased substantially over the last several decades due to an increase in the prevalence of dilated cardiomyopathy (ischemic and non-ischemic). Mortality and morbidity in patients with dilated cardiomyopathy is much greater when associated with MR as compared to without MR. MR will result in further left ventricular (LV) volume overload, LV dilation, and pupillary muscle displacement resulting in deterioration of the severity of MR leading to a vicious cycle. Optimization of heart failure medical therapy, and cardiac resynchronization therapy for those that qualify, can improve severity of MR; however, significant MR will persist in certain patients. Transcatheter mitral valve repair to treat significant MR using the MitraClip (Abbott, Menlo Park, California), which grasps and coapts the posterior and anterior mitral valve leaflets, in appropriately selected patients with dilated cardiomyopathy and secondary MR has been shown to improve quality of life and prolong survival.

Primary Patency With Stenting Versus Balloon Angioplasty for Arteriovenous Graft Failure: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the efficacy of advanced stent technology in the management of failing arteriovenous grafts (AVGs).

BACKGROUND

End-stage renal disease rates and the need for hemodialysis are increasing worldwide. AVG remains a common dialysis access site. Several techniques have been previously suggested to restore and preserve AVG patency. A quantitative evaluation and synthesis of this information are essential in elucidating the role of newer stent platforms for the management of failing AVG.

METHODS

We performed a literature search using PubMed, Web of Science, and Embase from January 2006 to December 2017. Studies comparing the primary patency rates with stent placement vs balloon angioplasty alone in patients with failed AVGs were included.

RESULTS

Seven studies with a total of 1109 patients met the inclusion criteria. The mean graft age was 2.89 years in the stent group and 3.29 years in the balloon angioplasty group. Stent placement was associated with improved primary patency rates compared with balloon angioplasty alone at short-term (3-month) follow-up (73.2% vs 42.6%, respectively; risk ratio [RR], 0.55; 95% confidence interval [CI], 0.35-0.88; P=.01) and mid-term (6-month) follow-up (50.8% vs 18.4%, respectively; RR, 0.65; 95% CI, 0.51-0.82; P<.001). The primary patency rates remained favorable with stent placement at 12-month (40.3% vs 13.0%, respectively; RR, 0.69; 95% CI, 0.63-0.77; P<.001) and 24-month follow-up (20.5% vs 6.8%; RR, 0.86; 95% CI, 0.80-0.92; P<.001) compared with balloon angioplasty alone.

CONCLUSIONS

Stent placement is associated with improved patency rates compared with balloon angioplasty alone.

Management of Antithrombotic Therapy in Patients with Coronary Artery Disease or Atrial Fibrillation who Underwent Abdominal Surgical Operations

BACKGROUND

Patients treated with antithrombotic therapy that require abdominal surgical procedures have progressively increased over time. The management of antithrombotics during both the peri- and postoperative period is of crucial importance.

METHODS

The goal of this review is to present current data concerning the management of antiplatelets in patients with coronary artery disease and of anticoagulants in patients with atrial fibrillation who had to undergo abdominal surgical operations. For this purpose, the incidence of major adverse cardiovascular events (MACE) and risk of antithrombotic use during surgical procedures, as well as the recommendations based on recent guidelines were reported. A thorough search of PubMed, Scopus and the Cochrane Databases was conducted to identify randomized controlled trials, observational studies, novel current reviews, as well as ESC and ACC/AHA guidelines on the subject.

RESULTS

Antithrombotic use in daily clinical practice leads to two different pathways: reduction of thromboembolic risk, but a simultaneous increase of bleeding risk. This may cause a therapeutic dilemma during the perioperative period. Nevertheless, careless cessation of antithrombotics can increase MACE and thromboembolic events. However, maintenance of antithrombotic therapy may increase bleeding complications. Studies and current guidelines can help clinicians in making decisions for the treatment of patients that undergo abdominal surgical operations while on antithrombotic therapy. Aspirin should not be stopped perioperatively in the majority of surgical operations. Determining whether to discontinue the use of anticoagulants before surgery depends on the surgical procedure. In surgical operations with a low risk for bleeding, oral anticoagulants should not be discontinued. Bridging therapy should only be considered in patients with a high risk of thromboembolism. Finally, in patients with an intermediate risk for thromboembolism, management should be individualized according to patient's thrombotic and bleeding risk.

CONCLUSION

Management of antithrombotics therapy during the perioperative period in patients undergoing abdominal surgery should follow a patient-centered approach according to a patient's medical history and thrombotic risk weighted for bleeding risk.

Mitral valve repair: moving towards a personalized ring

Background

Mitral valve repair with the use of an annuloplasty ring is the procedure of choice in patients with significant mitral regurgitation (MR) due to floppy mitral valve (FMV)/mitral valve prolapse (MVP). The mitral annular size, shape and motion may vary substantially among patients and thus, commercially available rings may not be suitable for each individual patient.

Methods

A “personalized ring” (PR) was easily constructed in the operating room using a Dacron sheet and titanium ligating clips to custom fit to each individual mitral annulus shape and size. There were 127 patients with severe MR due to FMV/MVP that underwent mitral valve repair surgery; 58 patients received a PR and 69 patients received a commercial Carpentier-Edwards Physio II ring. The patient records were retrospectively analysed.

Results

There were no surgical deaths. In-hospital length-of-stay and blood transfusions were not statistically different between the two groups. Mitral valve area was greater (p < 0.05) in the PR group (3.78 ± 0.22) compared to the Physio II ring group (3.13 ± 0.21). Mitral annular area changed from systole to diastole by 14.35% ± 3.28% in the PR group and did not change in the Physio II ring group (p < 0.05). Systolic anterior motion (SAM) of the mitral valve occurred in 2 patients with the Physio II ring and no patients with the PR. Up to 8 years follow-up, all patients in both groups were alive with NYHA functional class I-II symptoms and mild or less MR.

Conclusions

The PR is suitable for all patients with significant MR due to FMV/MVP who require MV repair. The precise fit of the PR to the mitral annulus better preserves valve area and sphincter function of the mitral annulus, prevents SAM and provides excellent short and long-term results.

Aortic Dysfunction in Mitral Regurgitation Due to Floppy Mitral Valve/Mitral Valve Prolapse

BACKGROUND

 Floppy mitral valve/mitral valve prolapse (FMV/MVP), a heritable disorder of connective tissue, often leads to mitral regurgitation (MR) and is the most common cause for mitral valve surgery in developed countries. Connective tissue disorders may affect aortic function, and a stiff aorta may increase the severity of MR. Aortic function, however, has not been studied in FMV/MVP with MR.

METHODS

 A total of 17 patients (11 men, 6 women) with FMV/MVP and significant MR were compared with 20 controls matched for age and gender. Aortic diameters (AoD) were measured from left ventriculograms at 2 and 4 cm above the aortic valve. Aortic pressures were measured directly using fluid-filled catheters. Aortic distensibility was calculated using the formula: 2(systolic AoD-diastolic AoD)/(diastolic AoD x pulse pressure).

RESULTS

 Aortic distensibility was significantly lower in FMV/MVP compared with control at 2 cm above the aortic valve (1.00 ± 0.19 versus 3.78 ± 1.10 10^-3 mm Hg^-1, respectively; p = 0.027) and 4 cm above the aortic valve (0.89 ± 0.16 versus 3.22 ± 0.19 10^-3 mm Hg^-1, respectively; p = 0.007). FMV/MVP patients had greater left ventricular (LV) end-systolic (88 ± 72 mL versus 35 ± 15 mL, p = 0.002) and end-diastolic (165 ± 89 mL versus 100 ± 41 mL, p = 0.005) volumes, and lower LV ejection fraction, compared with control (50 ± 12% versus 57 ± 6%, p = 0.034).

CONCLUSION

 Aortic distensibility is decreased (consistent with a stiff aorta) in patients with FMV/MVP and MR. A stiff aorta may increase the severity of MR. Thus, abnormal aortic function, which also deteriorates with age, may play an important role in the natural history of MR due to FMV/MVP.

Bleeding Complications Related to Right Heart Catheterization in the Setting of Elevated INR

OBJECTIVES

Right heart catheterization (RHC) provides cardiovascular hemodynamic information in a variety of clinical settings. RHC performed in the setting of coagulopathy may have the potential to increase bleeding complications; however, data currently are limited. This study was undertaken to determine bleeding complications during RHC with an elevated international normalized ratio (INR) value.

METHODS

A total of 312 patients who underwent RHC were retrospectively studied. Patients were divided into two groups: INR <1.8 (257 patients; median INR, 1.2; range, 0.8-1.7) and INR ≥1.8 (55 patients; median INR, 2.1; range, 1.8-4.0). There were 80 patients (31.1%) and 46 patients (83.6%) taking oral vitamin K antagonist (warfarin) in the INR <1.8 and ≥1.8 groups, respectively.

RESULTS

Overall bleeding complications related to the procedure were extremely low, occurring in 2 patients (0.6%). All bleeding complications occurred in the INR <1.8 group, and both patients developed a small-sized hematoma requiring prolonged manual pressure without further intervention (0.8% vs 0.0% in the INR <1.8 vs INR ≥1.8 groups, respectively; P>.99).

CONCLUSION

Bleeding complications associated with RHC were extremely low when performed by experienced operators in the cardiac catheterization laboratory. Furthermore, these complications were not related to an elevated INR, as bleeding occurred in patients with INR <1.8. Performing RHC in patients with an elevated INR in the therapeutic range did not increase bleeding compared to lower INR values.

Complete Versus Incomplete Angiography Prior to Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction

OBJECTIVES

Shorter reperfusion times in ST-elevation myocardial infarction (STEMI) are associated with improved survival. Prehospital strategies have been developed to minimize door-to-balloon (DTB) time, but few strategies within the catheterization laboratory itself have been evaluated. Incomplete angiography (IA) prior to percutaneous coronary intervention (PCI) is undertaken in clinical practice as a means to further reduce DTB time. We sought to determine whether or not those with STEMI who underwent IA prior to PCI had different preprocedural characteristics or post-PCI outcomes.

METHODS

We retrospectively reviewed patients presenting to our institution between March 2013 and December 2015. Clinical, demographic, and angiographic data were reviewed. The frequency, predictors, and outcomes among those who received IA vs complete angiography (CA) prior to PCI were compared with analysis of variance.

RESULTS

Two hundred fifty-six patients were identified; 68 patients (26.6%) underwent IA and 188 patients (73.4%) had CA prior to PCI. Patients who received IA were younger, but no other preprocedural factors were predictive of IA. The practice of IA did vary by operator (range, 0%-47%; P<.01). DTB times were shorter in the IA group (28.1 min vs 37.3 min; P<.01). Overall outcomes, including peak troponin values, length of stay, in-hospital mortality, and discharge ejection fraction did not differ between the groups.

CONCLUSION

IA is associated with shorter DTB times, although in this population was not associated with improvements in short-term outcomes.

Matrix Metalloproteinase Polymorphisms in Patients with Floppy Mitral Valve/Mitral Valve Prolapse (FMV/MVP) and FMV/MVP Syndrome

BACKGROUND

It has been suggested that collagen abnormalities of the mitral valve are present in patients with floppy mitral valve (FMV)/mitral valve prolapse (MVP). Genetic factors determining collagen synthesis and degradation have not been well defined in these patients. This study was undertaken to determine whether selective polymorphisms of matrix metalloproteinase-2 (MMP2) or transforming growth factor-β (TGFβ), with known or putative effects on collagen turnover, are more frequent in FMV/MVP.

METHODS

Single nucleotide polymorphisms (SNPs) in select genes related to collagen turnover, including MMP2 rs2285053, MMP2 rs243865, TGFβ1 rs1800469, and TGFβ2 rs900, were determined in 98 patients with FMV/MVP who had severe mitral regurgitation and compared to 99 controls.

RESULTS

MMP2 rs243865 was the only SNP significantly associated with FMV/MVP as compared to the control (odds ratio 2.07, 95% CI 1.23-3.50, p = 0.006). MMP2 rs228503 was the only SNP significantly associated with the FMV/MVP syndrome as compared to patients with FMV/MVP without the syndrome (odds ratio 2.41, 95% CI 1.08-5.40, p = 0.032).

CONCLUSION

The frequency of certain MMP2 polymorphisms is higher in patients with the FMV/MVP syndrome and patients with FMV/MVP without the syndrome. The data suggest that a genetic predisposition that alters collagen turnover may play a role in the pathogenesis and development of FMV/MVP.

Factors Determining Left Main Coronary Artery Luminal Area

BACKGROUND

A certain minimal luminal cross-sectional area has been traditionally used in clinical practice as a cut-off value to determine severity of left main coronary artery (LMCA) stenosis. The severity of stenosis, however, depends on the baseline luminal area (ie, area prior to stenosis), which may vary among individuals. The present study was undertaken to define normal LMCA luminal area using current technology in vivo.

METHODS

LMCA luminal area was determined using multislice computed tomography coronary angiography. Eighty-six subjects with normal coronary arteries and calcium score of zero were included in this study. Left ventricular (LV) mass and LV volumes (systolic, diastolic) were also measured.

RESULTS

A wide distribution was found in LMCA luminal area, with median value 17.3 mm² and range 8.1-33.9 mm². A relationship was found between log(LMCA luminal area) and log(LV mass) (r=.515; P<.001) and with body surface area (r=.273; P=.01). Significant relationships were also found between LMCA luminal area and LV volumes (systolic, diastolic). In multiple regression analysis, however, the LV mass was the only independent predictor of LMCA luminal area.

CONCLUSION

LMCA luminal area varies substantially among individuals with normal coronary arteries and is related to many other factors. The data suggest that the current practice of using a minimal luminal area cut-off when assessing LMCA stenosis may be misleading, and thus available information should be individualized.

Abstract 236: Coronary Artery Procedures in the Cardiac Catheterization Laboratory After Overnight Call: Are Patients at Higher Risk?

Background: Overnight call can lead to sleep deprivation and fatigue. It was hypothesized that complications will increase when coronary artery procedures are performed the day after overnight call (i.e. post-call). The present study was undertaken to test this hypothesis.

Methods: From June 2009 to May 2013, >20,000 patients underwent a cardiac procedure in a large referral catheterization laboratory of which 10,190 patients (12.7%, n=1,298 post-call) underwent only coronary arteriography with (37%) or without (83%) percutaneous coronary intervention (PCI) with no other cardiac procedure(s). Procedural complications related to post-call status were determined.

Results: Mean age was 61±12 years (male 65%). Overall complications were 2.6%: 1.0% bleeding, 1.0% myocardial infarction (MI), 0.3% new dialysis, 0.3% heart failure, 0.1% cardiogenic shock, 0.2% vascular, 0.1% stroke and 0.01% cardiac tamponade (certain patients had >1 complication). Overall there was statistically greater procedural complications when performed post-call (3.5%) compared to no post-call (2.5%; p=0.04); however, when adjusting for significant baseline variables, there was no difference seen between groups. From multivariate analysis of 23 factors, the following contributed independently to complications: ST-elevation MI (odds ratio 4.2, confidence interval [CI] 2.3-7.1), femoral vs. radial access (odds ratio 2.4, CI 1.7-3.3), non-ST-elevation MI (odds ratio 2.1, confidence interval [CI] 1.6-2.7), PCI (odds ratio 2.1, CI 1.6-2.7), history of heart failure (odds ratio 1.6, CI 1.2-2.1), female (odds ratio 1.4, CI 1.1-1.8), and age (odds ratio 1.2, CI 1.1-1.3 per 10 years). Glomerular filtration rate <60 ml/min was associated with more complications compared to >60 ml/min (p=0.007).

Conclusion: There were greater procedural complications when performed post-call compared to no post-call; however, when adjusting for significant baseline variables, there was no significant difference seen between groups. Taking into consideration factors that contributed to procedural complications most likely will improve patient outcomes.