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De Gaspari M, Layman AJ, Pazdernik VK, Maalouf J, Padang R, Bois MC, Maleszewski JJ. The Morphologic Spectrum of the Tricuspid Valve: Anatomical Implications for Transcatheter Edge-to-Edge Repair. JACC Cardiovasc Interv 2024; 17:949-951. [PMID: 38599703 DOI: 10.1016/j.jcin.2024.01.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 01/17/2024] [Accepted: 01/30/2024] [Indexed: 04/12/2024]
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Herrmann HC, Mehran R, Blackman DJ, Bailey S, Möllmann H, Abdel-Wahab M, Ben Ali W, Mahoney PD, Ruge H, Wood DA, Bleiziffer S, Ramlawi B, Gada H, Petronio AS, Resor CD, Merhi W, Garcia Del Blanco B, Attizzani GF, Batchelor WB, Gillam LD, Guerrero M, Rogers T, Rovin JD, Szerlip M, Whisenant B, Deeb GM, Grubb KJ, Padang R, Fan MT, Althouse AD, Tchétché D. Self-Expanding or Balloon-Expandable TAVR in Patients with a Small Aortic Annulus. N Engl J Med 2024. [PMID: 38587261 DOI: 10.1056/nejmoa2312573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND Patients with severe aortic stenosis and a small aortic annulus are at risk for impaired valvular hemodynamic performance and associated adverse cardiovascular clinical outcomes after transcatheter aortic-valve replacement (TAVR). METHODS We randomly assigned patients with symptomatic severe aortic stenosis and an aortic-valve annulus area of 430 mm2 or less in a 1:1 ratio to undergo TAVR with either a self-expanding supraannular valve or a balloon-expandable valve. The coprimary end points, each assessed through 12 months, were a composite of death, disabling stroke, or rehospitalization for heart failure (tested for noninferiority) and a composite end point measuring bioprosthetic-valve dysfunction (tested for superiority). RESULTS A total of 716 patients were treated at 83 sites in 13 countries (mean age, 80 years; 87% women; mean Society of Thoracic Surgeons Predicted Risk of Mortality, 3.3%). The Kaplan-Meier estimate of the percentage of patients who died, had a disabling stroke, or were rehospitalized for heart failure through 12 months was 9.4% with the self-expanding valve and 10.6% with the balloon-expandable valve (difference, -1.2 percentage points; 90% confidence interval [CI], -4.9 to 2.5; P<0.001 for noninferiority). The Kaplan-Meier estimate of the percentage of patients with bioprosthetic-valve dysfunction through 12 months was 9.4% with the self-expanding valve and 41.6% with the balloon-expandable valve (difference, -32.2 percentage points; 95% CI, -38.7 to -25.6; P<0.001 for superiority). The aortic-valve mean gradient at 12 months was 7.7 mm Hg with the self-expanding valve and 15.7 mm Hg with the balloon-expandable valve, and the corresponding values for additional secondary end points through 12 months were as follows: mean effective orifice area, 1.99 cm2 and 1.50 cm2; percentage of patients with hemodynamic structural valve dysfunction, 3.5% and 32.8%; and percentage of women with bioprosthetic-valve dysfunction, 10.2% and 43.3% (all P<0.001). Moderate or severe prosthesis-patient mismatch at 30 days was found in 11.2% of the patients in the self-expanding valve group and 35.3% of those in the balloon-expandable valve group (P<0.001). Major safety end points appeared to be similar in the two groups. CONCLUSIONS Among patients with severe aortic stenosis and a small aortic annulus who underwent TAVR, a self-expanding supraannular valve was noninferior to a balloon-expandable valve with respect to clinical outcomes and was superior with respect to bioprosthetic-valve dysfunction through 12 months. (Funded by Medtronic; SMART ClinicalTrials.gov number, NCT04722250.).
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Affiliation(s)
- Howard C Herrmann
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Roxana Mehran
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Daniel J Blackman
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Stephen Bailey
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Helge Möllmann
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Mohamed Abdel-Wahab
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Walid Ben Ali
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Paul D Mahoney
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Hendrik Ruge
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - David A Wood
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Sabine Bleiziffer
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Basel Ramlawi
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Hemal Gada
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Anna Sonia Petronio
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Charles D Resor
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - William Merhi
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Bruno Garcia Del Blanco
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Guilherme F Attizzani
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Wayne B Batchelor
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Linda D Gillam
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Mayra Guerrero
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Toby Rogers
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Joshua D Rovin
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Molly Szerlip
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Brian Whisenant
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - G Michael Deeb
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Kendra J Grubb
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Ratnasari Padang
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Myra T Fan
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Andrew D Althouse
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
| | - Didier Tchétché
- From Perelman School of Medicine at the University of Pennsylvania (H.C.H.) and Lankenau Heart Institute (B.R.), Philadelphia, Allegheny General Hospital, Allegheny Health Network, Pittsburgh (S. Bailey), and the University of Pittsburgh Medical Center, Harrisburg (H.G.) - all in Pennsylvania; Icahn School of Medicine at Mount Sinai, New York (R.M.); Leeds Teaching Hospitals, Leeds, United Kingdom (D.J.B.); St. Johannes Hospital Dortmund, Dortmund (H.M.), Heart Center Leipzig at University of Leipzig, Leipzig (M.A.-W.), the Department of Cardiovascular Surgery, Institute Insure, German Heart Center Munich, School of Medicine and Health, Technical University of Munich, Munich (H.R.), and Herz- und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bochum (S. Bleiziffer) - all in Germany; Montreal Heart Institute, Montreal (W.B.A.), and the Centre for Cardiovascular Innovation, University of British Columbia, Vancouver (D.A.W.) - both in Canada; Sentara Heart Hospital, Norfolk (P.D.M.), and Inova Schar Heart and Vascular, Falls Church (W.B.B.) - both in Virginia; the University of Pisa, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy (A.S.P.); Tufts Medical Center, Boston (C.D.R.); Corewell Health, Grand Rapids (W.M.), and the University of Michigan Health Systems-University Hospital, Ann Arbor (G.M.D.) - both in Michigan; Hospital Vall D'Hebron, CIBER CV (Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares), Barcelona (B.G.B.); Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland (G.F.A.); Morristown Medical Center, Atlantic Health System, Morristown, NJ (L.D.G.); the Echocardiography Core Laboratory (R.P.), Mayo Clinic (M.G.), Rochester, and Medtronic, Minneapolis (M.T.F., A.D.A.) - both in Minnesota; MedStar Washington Hospital Center, Washington, DC (T.R.); Morton Plant Hospital, Clearwater, FL (J.D.R.); Baylor Scott and White Heart Hospital, Plano, TX (M.S.); Intermountain Medical Center, Murray, UT (B.W.); Emory University, Atlanta (K.J.G.); and Clinique Pasteur, Toulouse, France (D.T.)
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3
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Luong CL, Anand V, Padang R, Oh JK, Arruda-Olson AM, Bird JG, Pislaru C, Thaden JJ, Pislaru SV, Pellikka PA, McCully RB, Kane GC. Prognostic Significance of Elevated Left Ventricular Filling Pressures with Exercise: Insights from a Cohort of 14,338 Patients. J Am Soc Echocardiogr 2024; 37:382-393.e1. [PMID: 38000684 DOI: 10.1016/j.echo.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 10/22/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Exercise echocardiography can assess for cardiovascular causes of dyspnea other than coronary artery disease. However, the prevalence and prognostic significance of elevated left ventricular (LV) filling pressures with exercise is understudied. METHODS We evaluated 14,338 patients referred for maximal symptom-limited treadmill echocardiography. In addition to assessment of LV regional wall motion abnormalities (RWMAs), we measured patients' early diastolic mitral inflow (E), septal mitral annulus relaxation (e'), and peak tricuspid regurgitation velocity before and immediately after exercise. RESULTS Over a mean follow-up of 3.3 ± 3.4 years, patients with E/e' ≥15 with exercise (n = 1,323; 9.2%) had lower exercise capacity (7.3 ± 2.1 vs 9.1 ± 2.4 metabolic equivalents, P < .0001) and were more likely to have resting or inducible RWMAs (38% vs 18%, P < .0001). Approximately 6% (n = 837) had elevated LV filling pressures without RWMAs. Patients with a poststress E/e' ≥15 had a 2.71-fold increased mortality rate (2.28-3.21, P < .0001) compared with those with poststress E/e' ≤ 8. Those with an E/e' of 9 to 14, while at lower risk than the E/e' ≥15 cohort (hazard ratio [HR] = 0.58 [0.48-0.69]; P < .0001), had higher risk than if E/e' ≤8 (HR = 1.56 [1.37-1.78], P < .0001). On multivariable analysis, adjusting for age, sex, exercise capacity, LV ejection fraction, and presence of pulmonary hypertension with stress, patients with E/e' ≥15 had a 1.39-fold (95% CI, 1.18-1.65, P < .0001) increased risk of all-cause mortality compared with patients without elevated LV filling pressures. Compared with patients with E/e' ≤ 15 after exercise, patients with E/e' ≤15 at rest but elevated after exercise had a higher risk of cardiovascular death (HR = 8.99 [4.7-17.3], P < .0001). CONCLUSION Patients with elevated LV filling pressures are at increased risk of death, irrespective of myocardial ischemia or LV systolic dysfunction. These findings support the routine incorporation of LV filling pressure assessment, both before and immediately following stress, into the evaluation of patients referred for exercise echocardiography.
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Affiliation(s)
- Christina L Luong
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Jared G Bird
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Cristina Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Robert B McCully
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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4
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Danielson AP, Collins JD, Pislaru SV, Padang R, Kane GC, Foley TA, Williamson EE, Eleid MF, Thaden JJ. Comparison of Tricuspid Annular Dimension Measurements Using Automated Three-Dimensional Transthoracic Echocardiography and Computed Tomography in Patients Evaluated for Transcatheter Tricuspid Valve Intervention. J Am Soc Echocardiogr 2024:S0894-7317(24)00105-6. [PMID: 38452828 DOI: 10.1016/j.echo.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 02/20/2024] [Accepted: 02/25/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Alex P Danielson
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Thomas A Foley
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | | | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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5
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Ali MT, Johnson M, Irwin T, Henry S, Sugeng L, Kansal S, Allison TG, Bremer ML, Jones VR, Martineau MD, Wong C, Marecki G, Stebbins J, Michelena HI, McCully RB, Svatikova A, Padang R, Scott CG, Kanuga MJ, Arsanjani R, Pellikka PA, Kane GC, Thaden JJ. Incidence of Severe Adverse Drug Reactions to Ultrasound Enhancement Agents in a Contemporary Echocardiography Practice. J Am Soc Echocardiogr 2024; 37:276-284.e3. [PMID: 37879379 DOI: 10.1016/j.echo.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/02/2023] [Accepted: 10/12/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVES Prior data indicate a very rare risk of serious adverse drug reaction (ADR) to ultrasound enhancement agents (UEAs). We sought to evaluate the frequency of ADR to UEA administration in contemporary practice. METHODS We retrospectively reviewed 4 US health systems to characterize the frequency and severity of ADR to UEA. Adverse drug reactions were considered severe when cardiopulmonary involvement was present and critical when there was loss of consciousness, loss of pulse, or ST-segment elevation. Rates of isolated back pain and headache were derived from the Mayo Clinic Rochester stress echocardiography database where systematic prospective reporting of ADR was performed. RESULTS Among 26,539 Definity and 11,579 Lumason administrations in the Mayo Clinic Rochester stress echocardiography database, isolated back pain or headache was more frequent with Definity (0.49% vs 0.04%, P < .0001) but less common with Definity infusion versus bolus (0.08% vs 0.53%, P = .007). Among all sites there were 201,834 Definity and 84,943 Lumason administrations. Severe and critical ADR were more frequent with Lumason than with Definity (0.0848% vs 0.0114% and 0.0330% vs 0.0010%, respectively; P < .001 for each). Among the 3 health systems with >2,000 Lumason administrations, the frequency of severe ADR with Lumason ranged from 0.0755% to 0.1093% and the frequency of critical ADR ranged from 0.0293% to 0.0525%. Severe ADR rates with Definity were stable over time but increased in more recent years with Lumason (P = .02). Patients with an ADR to Lumason since the beginning of 2021 were more likely to have received a COVID-19 vaccination compared with matched controls (88% vs 75%; P = .05) and more likely to have received Moderna than Pfizer-Biotech (71% vs 26%, P < .001). CONCLUSION Severe and critical ADR, while rare, were more frequent with Lumason, and the frequency has increased in more recent years. Additional work is needed to better understand factors, including associations with recently developed mRNA vaccines, which may be contributing to the increased rates of ADR to UEA since 2021.
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Affiliation(s)
- Mays T Ali
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark Johnson
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Timothy Irwin
- University of South Dakota, Yankton Medical Clinic, Yankton, South Dakota
| | - Sonia Henry
- Department of Cardiology, Northwell Health, Manhasset, New York
| | - Lissa Sugeng
- Department of Cardiology, Northwell Health, Manhasset, New York
| | - Sarita Kansal
- WellStar Center for Cardiovascular Medicine, WellStar Health System, Atlanta, Georgia
| | - Thomas G Allison
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Merri L Bremer
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Victoria R Jones
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael D Martineau
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Connie Wong
- Department of Cardiology, Northwell Health, Manhasset, New York
| | - Gregory Marecki
- Department of Cardiology, Northwell Health, Manhasset, New York
| | - Julie Stebbins
- WellStar Center for Cardiovascular Medicine, WellStar Health System, Atlanta, Georgia
| | - Hector I Michelena
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert B McCully
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anna Svatikova
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Mansi J Kanuga
- Division of Allergic Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Reza Arsanjani
- Division of Cardiac Imaging and Stress Testing, Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, Arizona
| | - Patricia A Pellikka
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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6
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El Shaer A, Chavez Ponce A, Ali M, Oguz D, Pislaru S, Vuyisile N, Padang R, Eleid M, Guerrero M, Reeder G, Rihal C, Alkhouli M, Thaden J. Pulmonary Vein Flow Morphology after Transcatheter Mitral Valve Edge-to-Edge Repair as Predictor of Survival. J Am Soc Echocardiogr 2024:S0894-7317(24)00057-9. [PMID: 38341053 DOI: 10.1016/j.echo.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/10/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Data on the prognostic factors after mitral valve transcatheter edge-to-edge repair (MV-TEER) are limited. Pulse-wave Doppler interrogation of pulmonary vein flow (PVF) is a convenient method to assess the hemodynamic burden of residual mitral regurgitation (MR), which could be of utility as a predictor of outcomes. METHODS Patients that underwent MV-TEER between May 2014 and December 2021 at our institution were evaluated. PVF patterns post-MV-TEER were reviewed on the procedural transesophageal echocardiogram and classified as normal (systolic dominant or codominant) or abnormal (systolic blunting or reversal). PVF pattern was correlated with all-cause mortality at follow up. RESULTS 265 patients had diagnostic PVF post-MV-TEER, with 73 (27.5%) categorized as normal and 192 (72.5%) categorized as abnormal. Patients with abnormal PVF morphology were more likely to have atrial fibrillation (70% vs 42%, p<0.001) and >moderate residual MR (16% vs 3%, p=0.01) and had higher mean left atrial pressure (18.1±5.0 vs 15.9±4.2 mmHg, p=0.002) and left atrial V-wave (26.6±8.5 vs 21.4±7.3 mmHg, p<0.001) post-procedure. In multivariable analysis, abnormal PVF morphology post MV-TEER was independently associated mortality at follow up (HR 1.70, 95% CI 1.06-2.74, p=0.03) after correction for end-stage renal disease, atrial fibrillation, and residual MR. Results were similar in subgroups of patients with moderate or less and those with mild or less residual MR. CONCLUSIONS PVF morphology is a simple and objective tool to assess MR severity immediately post MV-TEER and offers important prognostic information to optimize procedural results. Additional studies are needed to determine whether patients with abnormal PVF pattern post MV-TEER would benefit from more intensive goal-directed medical therapy post-procedure.
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Affiliation(s)
- Ahmed El Shaer
- Department of Internal Medicine, University of Wisconsin Hospital, Madison, Wisconsin, USA
| | | | - Mays Ali
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Didem Oguz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Sorin Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Nkomo Vuyisile
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Mackram Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Guy Reeder
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Charanjit Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Jeremy Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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7
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Alexandrino FB, Greason KL, Padang R. Intracardiac pseudophallus. Eur Heart J 2024; 45:73. [PMID: 37978870 DOI: 10.1093/eurheartj/ehad732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Affiliation(s)
- Francisco B Alexandrino
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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8
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Scalia IG, Farina JM, Padang R, Jokerst CE, Pereyra M, Mahmoud AK, Naqvi TZ, Chao CJ, Oh JK, Arsanjani R, Ayoub C. Aortic Valve Calcium Score by Computed Tomography as an Adjunct to Echocardiographic Assessment-A Review of Clinical Utility and Applications. J Imaging 2023; 9:250. [PMID: 37998097 PMCID: PMC10672559 DOI: 10.3390/jimaging9110250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023] Open
Abstract
Aortic valve stenosis (AS) is increasing in prevalence due to the aging population, and severe AS is associated with significant morbidity and mortality. Echocardiography remains the mainstay for the initial detection and diagnosis of AS, as well as for grading of severity. However, there are important subgroups of patients, for example, patients with low-flow low-gradient or paradoxical low-gradient AS, where quantification of severity of AS is challenging by echocardiography and underestimation of severity may delay appropriate management and impart a worse prognosis. Aortic valve calcium score by computed tomography has emerged as a useful clinical diagnostic test that is complimentary to echocardiography, particularly in cases where there may be conflicting data or clinical uncertainty about the degree of AS. In these situations, aortic valve calcium scoring may help re-stratify grading of severity and, therefore, further direct clinical management. This review presents the evolution of aortic valve calcium score by computed tomography, its diagnostic and prognostic value, as well as its utility in clinical care.
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Affiliation(s)
- Isabel G. Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Juan M. Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Ahmed K. Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Tasneem Z. Naqvi
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Chieh-Ju Chao
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Jae K. Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA; (I.G.S.)
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9
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Yang LT, Ye Z, Wajih Ullah M, Maleszewski JJ, Scott CG, Padang R, Pislaru SV, Nkomo VT, Mankad SV, Pellikka PA, Oh JK, Roger VL, Enriquez-Sarano M, Michelena HI. Bicuspid aortic valve: long-term morbidity and mortality. Eur Heart J 2023; 44:4549-4562. [PMID: 37611071 DOI: 10.1093/eurheartj/ehad477] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 06/26/2023] [Accepted: 07/14/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND AND AIMS Bicuspid aortic valve (BAV) is the most common congenital heart anomaly. Lifetime morbidity and whether long-term survival varies according to BAV patient-sub-groups are unknown. This study aimed to assess lifetime morbidity and long-term survival in BAV patients in the community. METHODS The authors retrospectively identified all Olmsted County (Minnesota) residents with an echocardiographic diagnosis of BAV from 1 January 1980 to 31 December 2009, including patients with typical valvulo-aortopathy (BAV without accelerated valvulo-aortopathy or associated disorders), and those with complex valvulo-aortopathy (BAV with accelerated valvulo-aortopathy or associated disorders). RESULTS 652 consecutive diagnosed BAV patients [median (IQR) age 37 (22-53) years; 525 (81%) adult and 127 (19%) paediatric] were followed for a median (IQR) of 19.1 (12.9-25.8) years. The total cumulative lifetime morbidity burden (from birth to age 90) was 86% (95% CI 82.5-89.7); cumulative lifetime progression to ≥ moderate aortic stenosis or regurgitation, aortic valve surgery, aortic aneurysm ≥45 mm or z-score ≥3, aorta surgery, infective endocarditis and aortic dissection was 80.3%, 68.5%, 75.4%, 27%, 6% and 1.6%, respectively. Survival of patients with typical valvulo-aortopathy [562 (86%), age 40 (28-55) years, 86% adults] was similar to age-sex-matched Minnesota population (P = .12). Conversely, survival of patients with complex valvulo-aortopathy [90 (14%), age 14 (3-26) years, 57% paediatric] was lower than expected, with a relative excess mortality risk of 2.25 (95% CI 1.21-4.19) (P = .01). CONCLUSION The BAV condition exhibits a high lifetime morbidity burden where valvulo-aortopathy is close to unavoidable by age 90. The lifetime incidence of infective endocarditis is higher than that of aortic dissection. The most common BAV clinical presentation is the typical valvulo-aortopathy with preserved expected long-term survival, while the complex valvulo-aortopathy presentation incurs higher mortality.
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Affiliation(s)
- Li-Tan Yang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
- Cardiology Division, National Taiwan University Hospital, Taipei, TW 100, Taiwan
| | - Zi Ye
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Muhammad Wajih Ullah
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | | | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN 55905, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Sunil V Mankad
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Veronique L Roger
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Maurice Enriquez-Sarano
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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10
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Tunthong R, Salama AA, Lane CM, Fine NM, Anand V, Padang R, Thaden JJ, Pislaru SV, Kane GC. Right ventricular systolic strain in patients with pulmonary hypertension: clinical feasibility, reproducibility, and correlation with ejection fraction. J Echocardiogr 2023; 21:105-112. [PMID: 36451073 DOI: 10.1007/s12574-022-00593-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/22/2022] [Accepted: 11/11/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Right ventricular (RV) systolic function is the major determinant of prognosis in patients with pulmonary hypertension (PH) with quantitative assessment by speckle-tracking strain echocardiography emerging as a viable candidate measure. METHOD We evaluated a prospective cohort of 231 patients with known or suspected PH referred for clinical echocardiography. All underwent measurement of RV free-wall systolic strain by sonographer staff. Digital images were recorded for blinded offline assessment by an expert echocardiographer. Reproducibility was assessed using the analysis methods of Bland-Altman and the Cohen's-Kappa coefficient. RESULTS RV strain was feasible in 213 (92%). The average RV systolic pressure was 59 ± 22 mmHg. RV systolic strain correlated with functional class, NT-proBNP, and the degree of RV enlargement. The average free-wall systolic strain was - 20 ± 7% (range - 2 to - 37%). The RV strain measures (clinical practice versus blinded expert) had an excellent correlation with a normal distribution (R2 0.87, p < 0.0001). By Bland-Altman analysis, the mean difference in measurement was - 1.7% (95% CI - 1.4 to - 2.1) with a correlation of 0.93, p value of < 0.0001. The reproducibility of RV strain for clinically relevant thresholds was also excellent (Kappa coefficients 0.68-0.83). There was no effect on the variability of strain measures across body mass, pulmonary pressures, or rhythm. RV strain correlated with RV diastolic volumes and ejection fraction with RV free wall strain being the best echo predictor for a reduction in ejection fraction. CONCLUSION Here RV systolic strain was found to be highly feasible and reproducible in clinical practice with excellent levels of agreement for clinically relevant thresholds.
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Affiliation(s)
- Ramaimon Tunthong
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
- Non-Invasive Cardiology Department, Bangkok Hospital Headquarters, BDMS, Bangkok, Thailand
| | - Abdalla A Salama
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | - Conor M Lane
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Nowell M Fine
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Vidhu Anand
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ratnasari Padang
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Jeremy J Thaden
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sorin V Pislaru
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA
| | - Garvan C Kane
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street SW, Rochester, MN, 55905, USA.
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11
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Kane CJ, Lara-Breitinger KM, Alabdaljabar MS, Nkomo VT, Padang R, Pislaru C, Kane GC, Scott C, Pislaru SV, Lin G. Pulmonary artery pulsatility index in patients with tricuspid valve regurgitation: a simple non-invasive tool for risk stratification. Eur Heart J Cardiovasc Imaging 2023; 24:1210-1221. [PMID: 37097062 DOI: 10.1093/ehjci/jead070] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 04/26/2023] Open
Abstract
AIMS Tricuspid valve regurgitation (TR) is a common valvular disease associated with increased mortality. There is a need for tools to assess the interaction between the pulmonary artery (PA) circulation and the right ventricle in patients with TR and to investigate their association with outcomes. The pulmonary artery pulsatility index (PAPi) has emerged as a haemodynamic risk predictor in left heart disease and pulmonary hypertension (PH). Whether PAPi discriminates risk in unselected patients with greater than or equal to moderate TR is unknown. METHODS AND RESULTS In 5079 patients with greater than or equal to moderate TR (regardless of aetiology) and PA systolic and diastolic pressures measured on their first echocardiogram, we compared all-cause mortality at 5 years based on the presence or absence of PH and PAPi levels. A total of 2741 (54%) patients had PH. The median PAPi was 3.0 (IQR 1.9, 4.4). Both the presence of PH and decreasing levels of PAPi were associated with larger right ventricles, worse right ventricular systolic function, higher NT-pro BNP levels, greater degrees of right heart failure, and worse survival. In a subset of patients who had an echo and right heart catheterization within 24 h, the correlation of non-invasive to invasive PA pressures and PAPi levels was very good (r = 0.76). CONCLUSION In patients with greater than or equal to moderate TR with and without PH, lower PAPi is associated with right ventricular dysfunction, right heart failure, and worse survival. Incorporating PA pressure and PAPi may help stratify disease severity in patients with greater than or equal to moderate TR regardless of aetiology.
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Affiliation(s)
- Conor J Kane
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Kyla M Lara-Breitinger
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | | | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Cristina Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Christopher Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
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12
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Rezkalla J, Reddy Y, Nishimura RA, Padang R, Pislaru SV, Rihal CS, Eleid MF. Right heart catheterization predictors of symptomatic improvement in patients undergoing transcatheter tricuspid valve edge-to-edge repair. Catheter Cardiovasc Interv 2023. [PMID: 37350295 DOI: 10.1002/ccd.30754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/11/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Transcatheter tricuspid valve edge-to-edge repair (TTEER) is associated with improvement in outcomes for symptomatic patients with severe tricuspid regurgitation (TR). However, reliable predictors for clinical success are not yet fully defined. This study aims to describe right heart catheterization (RHC) findings in patients referred for TTEER and identify hemodynamic characteristics of patients who experience immediate symptomatic improvement following successful TR intervention. METHODS Patients who underwent TTEER and had a separate RHC within the preceding 6 months were included. Hemodynamic tracings from the RHC and TTEER procedures were reviewed and recorded. Clinical success was defined as a successful device implant with at least 1-grade of TR reduction and improvement in NYHA class by 1 or more grades on 30-day echocardiogram and clinical follow-up. RESULTS Thirteen patients underwent an RHC within 6 months of TTEER procedure (median age 76 years [IQR: 73-80]). All patients were on a stable dose of loop diuretics. Baseline right atrial pressure was severely elevated (mean 19 mmHg [IQR: 9-24 mmHg]) with prominent CV waves. Median pulmonary capillary wedge pressure (PCWP) was 20 mmHg (IQR: 14-22) and 70% of patients had a mean PCWP > 15 mmHg at rest. Median PCWP CV-wave was 34 mmHg (IQR: 23-42). Higher PCWP CV-wave height (40 mmHg [IQR 33-43] versus 18 mmHg [IQR 17-31]) was associated with lower likelihood of clinical success (OR 0.83, 95% CI: 0.35-0.97, p = 0.04). CONCLUSIONS Inclusion of invasive hemodynamics as part of pre-TTEER evaluation may allow for improved TR phenotyping and patient selection. Patients with a large left atrial CV wave on resting RHC were less likely to experience immediate symptomatic improvement despite procedural success with TTEER.
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Affiliation(s)
- Joshua Rezkalla
- Department of Cardiovascular Diseases, Mayo College of Medicine, Rochester, Minnesota, USA
| | - Yogesh Reddy
- Department of Cardiovascular Diseases, Mayo College of Medicine, Rochester, Minnesota, USA
| | - Rick A Nishimura
- Department of Cardiovascular Diseases, Mayo College of Medicine, Rochester, Minnesota, USA
| | - Ratnasari Padang
- Department of Cardiovascular Diseases, Mayo College of Medicine, Rochester, Minnesota, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Diseases, Mayo College of Medicine, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Diseases, Mayo College of Medicine, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Diseases, Mayo College of Medicine, Rochester, Minnesota, USA
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13
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Sanz JGR, Luis SA, Alkhouli MA, Padang R. Up, up and away! Atrial septal pouch thrombus: an unexpected encounter during transeptal puncture. J Echocardiogr 2023:10.1007/s12574-023-00608-w. [PMID: 37310611 DOI: 10.1007/s12574-023-00608-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/18/2022] [Accepted: 06/01/2023] [Indexed: 06/14/2023]
Affiliation(s)
| | - Sushil A Luis
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mohamad A Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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14
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Yang LT, Ullah MW, Ye Z, Maleszewski JJ, Scott C, Padang R, Pislaru S, Nkomo VT, Mankad SV, Pellikka PA, Oh JK, Roger VL, Enriquez-Sarano M, Michelena HI. LIFETIME OUTCOMES OF PATIENTS WITH BICUSPID AORTIC VALVES IN THE COMMUNITY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02372-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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15
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Salama AA, Padang R, Thaden JJ, Kane CJ, Elwazir MY, Anand V, McCully RB, Pislaru C, Pislaru SV, Kane GC. Value of a Right Ventricular-Specific Longitudinal Systolic Strain Software Package in Risk Prediction in Patients With Known or Suspected Pulmonary Hypertension. J Am Soc Echocardiogr 2023:S0894-7317(23)00018-4. [PMID: 36669594 DOI: 10.1016/j.echo.2022.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/26/2022] [Accepted: 12/31/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Abdalla A Salama
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Conor J Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; School of Medicine, University College Dublin, Dublin, Ireland
| | - Mohamed Y Elwazir
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Diseases, Suez Canal University, Ismailia, Egypt
| | - Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert B McCully
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Cristina Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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16
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Kronzer EK, Eleid MF, Alkhouli MA, Thaden JJ, Padang R, Nkomo VT, Rihal CS, Pislaru SV, Kane GC. Rates of Oropharyngeal and Esophageal Complications During Structural Heart Disease Procedures Under Transesophageal Echocardiography Guidance. J Am Soc Echocardiogr 2022; 36:431-433. [PMID: 36368437 DOI: 10.1016/j.echo.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Ellen K Kronzer
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohamad A Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Kronzer E, Pislaru S, Padang R, Oguz D, Nkomo V, Oh J, Alkhouli M, Guerrero M, Reeder G, Eleid M, Rihal C, Thaden J. Impact of proportionate versus disproportionate mitral regurgitation on acute procedural changes and clinical outcomes following transcatheter mitral valve repair. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Transcatheter mitral edge-to-edge repair (TEER) with MitraClip offers a less invasive alternative for patients with severe, symptomatic mitral regurgitation (MR) who are considered high risk for surgery. However, patient selection for TEER remains challenging given the variability in underlying MR pathology and current discordance among studies regarding predictors of procedural efficacy and clinical outcomes.
Purpose
This study aimed to assess acute procedural changes and long-term outcomes in patients who underwent TEER according to the proportionality of MR, defined as the ratio of the effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV).
Methods
We analyzed patients who underwent TEER at our institution between 2014 and 2020 with available biplane left ventricular volume measurement. Relevant clinical comorbidities, demographics, and anthropometrics, along with pertinent pre- and post-procedural echocardiogram measurements, were obtained by review of the electronic medical record. The EROA to LVEDV index was calculated for all patients who were then stratified by quartiles. Patients with an EROA/LVEDV index in the lowest quartile were defined as having the most proportionate MR and those with an index in the highest quartile were defined as the most disproportionate MR. Baseline and post-TEER parameters were used to assess acute procedural and longitudinal outcomes.
Results
Baseline clinical and echocardiographic parameters of the 230 subjects according to quartile are shown in the table. Following TEER, there was a larger reduction in the left ventricular end-diastolic diameter and increased MR reduction with increasingly disproportionate MR (p=0.03 and p=0.05, respectively). The change in ejection fraction pre- versus post-TEER did not significantly differ across groups (p=0.64). Median follow up time was 1.7 (0.7–3.5) years; mortality occurred in 77 patients (33.5%) and heart failure hospitalizations occurred in 20 patients (8.7%) during follow up. No significant difference in all-cause mortality or post-procedural heart failure hospitalizations was identified across groups.
Conclusions
In our series, patients with proportionate MR were similarly symptomatic to those with disproportionate MR but had less severe MR with increased comorbidities. Post-TEER MR grade was similar between groups. Longer-term follow up in larger groups of patients is needed to determine the clinical implications.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- E Kronzer
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - S Pislaru
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - R Padang
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - D Oguz
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - V Nkomo
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - J Oh
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - M Alkhouli
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - M Guerrero
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - G Reeder
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - M Eleid
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - C Rihal
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
| | - J Thaden
- Mayo Clinic Hospital-Rochester , Rochester , United States of America
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Luis SA, Ayoub C, Padang R. Paroxysmal sinus deceleration: an under-recognized show stopper. Eur Heart J Case Rep 2022; 6:ytac389. [PMID: 36420418 PMCID: PMC9593067 DOI: 10.1093/ehjcr/ytac389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
| | - Chadi Ayoub
- Division of Cardiac Imaging and Stress Testing, Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ, USA
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Abstract
Background Many patients with symptomatic severe aortic stenosis do not undergo aortic valve replacement (AVR) despite clinical guidelines. This study analyzed the association of managing provider type with cardiac specialist follow-up, AVR, and mortality for patients with newly diagnosed severe aortic stenosis (sAS). Methods and Results We identified adults with newly diagnosed sAS per echocardiography performed between January 2017 and March 2019 using Optum electronic health record data. We then selected from those meeting all eligibility criteria patients managed by a primary care provider (n=1707 [25%]) or cardiac specialist (n=5039 [75%]). We evaluated the association of managing provider type with cardiac specialist follow-up, AVR, and mortality, as well as the independent association of cardiac specialist follow-up and AVR with mortality, within 1 year of echocardiography detecting sAS. A subgroup analysis was limited to patients with symptomatic sAS. Patient characteristics and comorbidities at baseline were used for covariate-adjusted cause-specific and multivariable Cox proportional hazard models assessing group differences in outcomes by managing provider type. An adjusted Cox proportional hazard model with additional time-dependent covariates for follow-up and AVR was used to assess these practices' association with mortality. Within 1 year of echocardiography detecting sAS, data revealed that primary care provider management was associated with lower rates of cardiac specialist follow-up (hazard ratio [HR], 0.47 [95% CI, 0.43-0.50], P<0.0001) and AVR (HR, 0.58 [95% CI, 0.53-0.64], P<0.0001) and with higher 1-year mortality (HR, 1.45 [95% CI, 1.26-1.66], P<0.0001). Cardiac specialist follow-up and AVR were independently associated with lower mortality (follow-up: HR, 0.55 [95% CI, 0.48-0.63], P<0.0001; AVR: HR, 0.70 [95% CI, 0.60-0.83], P<0.0001). Results were similar for patients with symptomatic sAS. All analyses were adjusted for baseline patient characteristics and comorbidities. Conclusions For patients newly diagnosed with sAS, we observed differences in rates of cardiac specialist follow-up and AVR and risk of mortality between primary care provider- versus cardiologist-managed patients with sAS. In addition, a lower likelihood of receiving follow-up and AVR was independently associated with higher mortality.
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Affiliation(s)
| | | | | | | | | | - Jeremy J Thaden
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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20
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Kato N, Guerrero M, Padang R, Amadio JM, Eleid MF, Scott CG, Lee AT, Pislaru SV, Nkomo VT, Pellikka PA. Prevalence and Natural History of Mitral Annulus Calcification and Related Valve Dysfunction. Mayo Clin Proc 2022; 97:1094-1107. [PMID: 35662425 DOI: 10.1016/j.mayocp.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/10/2021] [Accepted: 12/15/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the prevalence and natural history of mitral annulus calcification (MAC) and associated mitral valve dysfunction (MVD) in patients undergoing clinically indicated echocardiography. METHODS A retrospective review was conducted of all adults who underwent echocardiography in 2015. Mitral valve dysfunction was defined as mitral regurgitation or mitral stenosis (MS) of moderate or greater severity. All-cause mortality during 3.0 (0.4 to 4.2) years of follow-up was compared between groups stratified according to the presence of MAC or MVD. RESULTS Of 24,414 evaluated patients, 5502 (23%) had MAC. Patients with MAC were older (75±10 years vs 60±16 years; P<.001) and more frequently had MVD (MS: 6.6% vs 0.5% [P<.001]; mitral regurgitation without MS: 9.5% vs 6.1% [P<.001]). Associated with MS in patients with MAC were aortic valve dysfunction, female sex, chest irradiation, renal dysfunction, and coronary artery disease. Kaplan-Meier 1-year survival was 76% in MAC+/MVD+, 87% in MAC+/MVD-, 86% in MAC-/MVD+, and 92% in MAC-/MVD-. Adjusted for age, diabetes, renal dysfunction, cancer, chest irradiation, ejection fraction below 50%, aortic stenosis, tricuspid regurgitation, and pulmonary hypertension, MAC was associated with higher mortality during follow-up (adjusted hazard ratio, 1.40; 95% CI, 1.31 to 1.49; P<.001); MVD was associated with even higher mortality in patients with MAC (adjusted hazard ratio, 1.79; 95% CI, 1.58 to 2.01; P<.001). There was no significant interaction between MAC and MVD for mortality (P=.10). CONCLUSION In a large cohort of adults undergoing echocardiography, the prevalence of MAC was 23%. Mitral valve dysfunction was more than twice as prevalent in patients with MAC. Adjusted mortality was increased in patients with MAC and worse with both MAC and MVD.
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Affiliation(s)
- Nahoko Kato
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Alexander T Lee
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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21
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Lim MS, Portelli SS, Padang R, Bannon PG, Hambly BD, Jeremy RW, Celermajer DS, Robertson EN. Novel insights into bicuspid aortic valve (BAV) aortopathy: Long non-coding RNAs TUG1 and MIAT are differentially expressed in BAV ascending aortas. Cardiovasc Pathol 2022; 60:107433. [PMID: 35588998 DOI: 10.1016/j.carpath.2022.107433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 05/10/2022] [Accepted: 05/10/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Whilst a combination of genetically mediated vulnerability and haemodynamic insult is suspected to contribute to bicuspid aortic valve (BAV) aortopathy, the underlying pathophysiological mechanisms are poorly understood. METHODS Utilising RT-qPCR, we compared the expression of 28 potentially relevant long non-coding RNA (lncRNA) in aortic tissue from BAV patients undergoing aortic surgery for aortopathy, to healthy controls. Relative lncRNA expression was measured using ΔΔCT, with fold-change calculated as RQ=2-ΔΔCT. RESULTS When comparing samples from BAV patients (n=29, males n=25; median age 58 years, Q1-Q3 51-65, maximum aortic dimension 50±5mm) with healthy controls (n=7; males n=4, p=0.12; median age 39 years, Q1-Q3 18-47, p=0.001), there were two differentially expressed lncRNA: TUG1 expression was significantly lower in BAV aortic tissue (RQ 0.59, 95% CI 0.50-0.69, p=0.02), whilst MIAT expression was significantly higher (RQ 2.87, 95% CI 1.96-4.20, p=0.01). Sensitivity analysis including only patients with normal BAV function showed similar trends of differential expression of TUG1 (RQ 0.69, 95% CI 0.50-0.90, p=0.29) and MIAT (RQ 2.55, 95% CI 1.21-5.36, p=0.29) compared to controls. CONCLUSIONS LncRNA TUG1 and MIAT are differentially expressed in BAV aortopathy compared to healthy controls, independent of BAV haemodynamics. Aberrant lncRNA expression may be involved in the pathogenesis of BAV aortopathy.
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Affiliation(s)
- M S Lim
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Camperdown, New South Wales, Australia.
| | - S S Portelli
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia
| | - R Padang
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Camperdown, New South Wales, Australia
| | - P G Bannon
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Department of Cardiothoracic Surgery, Camperdown, New South Wales, Australia
| | - B D Hambly
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia
| | - R W Jeremy
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Camperdown, New South Wales, Australia
| | - D S Celermajer
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Camperdown, New South Wales, Australia; Heart Research Institute, Sydney, Australia
| | - E N Robertson
- The University of Sydney, Sydney Medical School, Faculty of Medicine and Health, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Camperdown, New South Wales, Australia
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22
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Simard T, Reddy YNV, Thaden JJ, Padang R, Michelena HI, Nkomo VT, Lloyd JW, El Sabbagh A, Nishimura RA, Reeder GS, Guerrero M, Alkhouli M, Rihal CS, Eleid MF. Atrial mitral regurgitation: Characteristics and outcomes of transcatheter mitral valve edge-to-edge repair. Catheter Cardiovasc Interv 2022; 100:133-142. [PMID: 35535629 DOI: 10.1002/ccd.30224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/28/2022] [Accepted: 04/25/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Mitral transcatheter edge-to-edge repair (MTEER) is an established therapeutic approach for mitral regurgitation (MR). Functional mitral regurgitation originating from atrial myopathy (A-FMR) has been described. OBJECTIVES We sought to assess the clinical, echocardiographic and hemodynamic considerations in A-FMR patients undergoing MTEER. METHODS From 2014 to 2020, patients undergoing MTEER for degenerative MR (DMR), functional MR (FMR), and mixed MR were assessed. A-FMR was defined by the presence of MR > moderate in severity; left ventricular (LV) ejection fraction (LVEF) ≥ 50%; and severe left atrial (LA) enlargement in the absence of LV dysfunction, leaflet pathology, or LV tethering. The diagnosis of A-FMR (vs. ventricular-FMR [V-FMR]) was confirmed by three independent echocardiographers. Baseline characteristics, procedural outcomes as well as clinical and echocardiographic follow-up are reported. Device success was defined as final MR grade ≤ moderate; MR reduction ≥1 grade; and final transmitral gradient <5 mmHg. RESULTS 306 patients underwent MTEER, including DMR (62%), FMR (19%), and mixed MR (19%). FMR cases included 37 (63.8%) V-FMR and 21 (36.2%) A-FMR. Tricuspid regurgitation (≥ moderate) was higher in A-FMR (80.1%) compared to V-FMR (54%) and DMR (42%). Device success did not significantly differ between A-FMR and V-FMR (57% vs. 73%, p = 0.34) or DMR (57% vs. 64%, p = 1.0). The A-FMR cohort was less likely to achieve ≥3 grades of MR reduction compared to V-FMR (19% vs. 54%, p = 0.01) and DMR (19% vs. 49.7%, p = 0.01). Patients with V-FMR and DMR demonstrated significant reductions in mean left atrial pressure (LAP) and peak LA V-wave, though A-FMR did not (LAP -0.24 ± 4.9, p = 0.83; peak V-wave -1.76 ± 9.1, p = 0.39). In follow-up, echocardiographic and clinical outcomes were similar. CONCLUSIONS In patients undergoing MTEER, A-FMR represents one-third of FMR cases. A-FMR demonstrates similar procedural success but blunted acute hemodynamic responses compared with DMR and V-FMR following MTEER. Dedicated studies specifically considering A-FMR are needed to discern the optimal therapeutic approaches.
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Affiliation(s)
- Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - James W Lloyd
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Abdallah El Sabbagh
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Jacksonville, Florida, USA
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
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23
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Ye Z, Yang LT, Medina-Inojosa JR, Scott CG, Padang R, Luis SA, Nkomo VT, Enriquez-Sarano M, Michelena HI. Multi-chamber Strain Characterization is a Robust Prognosticator for both Bicuspid and Tricuspid Aortic Stenosis. J Am Soc Echocardiogr 2022; 35:956-965. [DOI: 10.1016/j.echo.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 11/25/2022]
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Yang LT, Takeuchi M, Scott CG, Thapa P, Wang TD, Villarraga HR, Padang R, Enriquez-Sarano M, Michelena HI. Automated Global Longitudinal Strain Exhibits a Robust Association with Death in Asymptomatic Chronic Aortic Regurgitation. J Am Soc Echocardiogr 2022; 35:692-702.e8. [PMID: 35341954 DOI: 10.1016/j.echo.2021.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/13/2021] [Accepted: 10/31/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether automated left ventricular global longitudinal strain (LVGLS) is associated with outcomes in asymptomatic aortic regurgitation (AR) is unknown. OBJECTIVE To explore the impact of automated LVGLS on survival and compare it with conventional LV parameters in chronic asymptomatic AR. METHODS LVGLS (presented as absolute value) was measured using fully-automated two-dimensional strain software in consecutive patients with isolated chronic ≥moderate-severe AR between 2004 and 2020; incremental value of LVGLS was assessed. Limited correction of endocardial border tracking was performed if needed. RESULTS Of 550 asymptomatic patients (age 60±17 years; 86% men), average LVGLS was 17±3% (1st and 2nd tertile, 15.8% and 18.5%). In 16% cases, tracking border was partially corrected; average time for analysis was 25±5 seconds. At a median (interquartile range) of 4.8(1.5-9.9) years, 87 patients had died (19 died after aortic-valve surgery [AVS]). Separate multivariable models adjusted for age, sex, Charlson index, AR severity and time-dependent AVS demonstrated that LVEF(hazard ratio[HR] per 10%: 0.9), LV end-systolic volume index(LVESVi; HR per 5ml/m2: 1.08) and LVGLS(HR per unit: 0.87) were independently associated with death(all p≤0.018); however, LVGLS remained statistically significant (HR: 0.86-0.9; P≤0.007) as compared head-to-head to LVEF, LVESVi and LV end-systolic dimension index(LVESDi). The association of LVGLS and mortality was consistent across all subgroups (P for interaction all≥0.08). Spline curves showed that continuous risk of death rose at LVGLS <15%. Those with LVGLS <15% had 2.6-fold risk of death [95% CI 1.54-4.23] while those with LVGLS <15% plus LVESVi≥45ml/m2 had 3.96-fold risk[95% CI 1.94-8.03]. CONCLUSION In this large cohort of asymptomatic patients with ≥moderate-severe AR, automated LVGLS was feasible, efficient, and independently associated with death on head-to-head comparison with conventional LVEF, LVESDi, and LVESVi. The automated-LVGLS threshold of <15% alone or combined with LVESVi≥45ml/m2, was significantly associated with increased mortality risk and may be considered in early surgery decision-making.
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Affiliation(s)
- Li-Tan Yang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota; Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester Minnesota
| | - Prabin Thapa
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester Minnesota
| | - Tzung-Dau Wang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | | | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | | | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota.
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25
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Naser JA, Crestanello JA, Nkomo VT, Luis SA, Thaden JJ, Geske JB, Anderson JH, Sinak LJ, Michelena HI, Pislaru SV, Padang R. Immobile Leaflets at Time of Bioprosthetic Valve Implantation: A Novel Risk Factor for Early Bioprosthetic Failure: A Novel Risk Factor for Early Bioprosthetic Failure. Heart Lung Circ 2022; 31:1166-1175. [PMID: 35339372 DOI: 10.1016/j.hlc.2022.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/18/2022] [Accepted: 02/16/2022] [Indexed: 12/22/2022]
Abstract
OBJECTIVES The clinical implications of finding immobile leaflet(s) at the time of bioprosthetic valve implantation but with acceptable prosthetic haemodynamics are uncertain. We sought to determine the characteristics of such patients and their impact on outcome. METHODS Patients with immobile leaflet at the time of surgical bioprosthetic valve implantation were identified retrospectively by a systematic search of an institutional echocardiography database (2010-2020). Intraoperative echocardiograms were reviewed de-novo to confirm immobile leaflet(s) at the time of implantation. Cases were matched 1:2 to controls with normal bioprosthetic leaflets motion for age, sex, prosthesis position, prosthesis model, size, year of implantation, and pre-implantation left ventricular ejection fraction. Proportional hazards method was used to analyse the composite endpoint of stroke, valve thrombosis or re-intervention. RESULTS Immobile leaflet at the time of bioprosthetic valve implantation were found in 26 patients (median age 71 ys 39% males) following tricuspid (n=13), mitral (n=11) and aortic (n=2) valve replacements; 96% received porcine prostheses; prosthesis size was 27 mm or larger in 92%. Immobile leaflet were recorded on intraoperative reports in 16 (62%) cases. It resulted in elevated gradient or mild-moderate prosthetic regurgitation in three (12%), but none led to immediate corrective action intraoperatively. At median follow-up of 21 (4-50) months, presence of immobile leaflet was associated with composite clinical endpoint of stroke, valve thrombosis or re-intervention (hazard ratio 6.8 95% CI 1.8-25.2 p<0.01) compared to controls. CONCLUSION Immobile leaflet immediately post-bioprosthetic valve implantation is frequently under-recognised intraoperatively and appears to be associated with early bioprosthetic dysfunction and worse clinical outcome.
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Affiliation(s)
- Jwan A Naser
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sushil A Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey B Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lawrence J Sinak
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
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Roslan AB, Naser JA, Nkomo VT, Padang R, Lin G, Pislaru C, Greason KL, Pellikka PA, Eleid MF, Thaden JJ, Miller FA, Pislaru SV. Performance of Echocardiographic Algorithms for Assessment of High Aortic Bioprosthetic Valve Gradients. J Am Soc Echocardiogr 2022; 35:682-691.e2. [DOI: 10.1016/j.echo.2022.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 01/28/2022] [Accepted: 01/30/2022] [Indexed: 11/26/2022]
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27
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Portelli S, Padang R, Hambly B, Jeremy R, Robertson E. miR-151-3p and miR-214 Expression Associate With Clinical Phenotypes in BAV Aortopathy. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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28
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Mahowald MK, Nishimura RA, Pislaru SV, Mankad SV, Nkomo VT, Padang R, Thaden JJ, Alkhouli M, Guerrero M, Rihal CS, Eleid MF. Reduction in Right Atrial Pressures Is Associated With Hemodynamic Improvements After Transcatheter Edge-to-Edge Repair of the Tricuspid Valve. Circ Cardiovasc Interv 2021; 14:e010557. [PMID: 34814697 DOI: 10.1161/circinterventions.121.010557] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Investigational transcatheter edge-to-edge repair (TEER) for severe tricuspid regurgitation (TR) has shown promise as an alternative to surgery, but factors influencing outcomes, optimal patient selection, and procedural timing remain incompletely defined. Given the limitations of determining TR severity by conventional echocardiography, our objectives were to determine whether invasive right atrial (RA) pressures performed during the procedure are related to patient outcomes. METHODS This study was a retrospective review of patients who underwent off-label tricuspid TEER using MitraClip (Abbott Vascular, Menlo Park, CA) for significant TR at a single institution. Intraprocedural mean RA pressure, RA peak V-wave, RA pressure nadir, and systolic increase in RA pressure (XV height) were recorded. RESULTS Thirty-eight patients underwent tricuspid TEER; 33 underwent concomitant mitral TEER for mitral regurgitation. The study cohort was 39% female with a mean age of 78.6±14.3 years. Median follow-up was 339 days (interquartile range, 100-601). Any reduction in mean RA pressure, RA peak V-wave, RA nadir, and XV height occurred in 74%, 82%, 45%, and 87% of patients, respectively. At 1 year, event-free survival was 47%. Postprocedure XV height correlated with TR severity as determined by echocardiography (P<0.0001). The highest quartile of postprocedure XV height (>8 mm Hg) had worse event-free survival compared with those who had concluding XV height ≤8 mm Hg (P=0.02). Attainment of a concluding XV height less than or equal to median value was associated with a lower creatinine the next day (1.27±0.47 versus 1.64±0.47 mg/dL, P=0.04). CONCLUSIONS Intraprocedural XV height correlates with TR severity after tricuspid TEER, and lower concluding pressures are associated with improved outcomes. Analysis of RA pressures may serve as a complementary tool for the evaluation of disease severity and procedural guidance.
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Affiliation(s)
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Sunil V Mankad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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Alkhouli M, Simard T, Killu AM, Friedman PA, Padang R. First-in-Human Use of a Novel Live 3D Intracardiac Echo Probe to Guide Left Atrial Appendage Closure. JACC Cardiovasc Interv 2021; 14:2407-2409. [PMID: 34454857 DOI: 10.1016/j.jcin.2021.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Alkhouli M, Simard T, El Shaer A, Bird J, Nkomo VT, Freidman PA, Thaden J, Padang R. First Experience With a Novel Live 3D ICE Catheter to Guide Transcatheter Structural Heart Interventions. JACC Cardiovasc Imaging 2021; 15:1502-1509. [PMID: 34801455 DOI: 10.1016/j.jcmg.2021.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/03/2021] [Accepted: 09/09/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmed El Shaer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jared Bird
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul A Freidman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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De Jesus T, Alashry MM, Padang R, Pislaru SV, Nkomo VT, Pellikka PA, Pislaru C. Intrinsic cardiac elastography in patients with primary mitral regurgitation: predictive role after mitral valve repair. Eur Heart J Cardiovasc Imaging 2021; 22:912-921. [PMID: 32533173 DOI: 10.1093/ehjci/jeaa117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/17/2020] [Accepted: 04/27/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS Chronic volume-overload can impair systolic and diastolic myocardial properties. We tested the hypothesis that Intrinsic Cardiac Elastography may detect alterations in passive myocardial elasticity in patients with chronic severe mitral regurgitation (MR) and predict worsening left ventricular (LV) function after mitral valve repair (MVr). METHODS AND RESULTS Comprehensive transthoracic echocardiography and cardiac elastography were performed in 80 patients with primary MR (prolapse and/or flail leaflets) of varying severity and compared with 40 normal subjects. In patients who underwent MVr (n = 51), elastography measurements were related to changes in left ventricular ejection fraction (LVEF) at short-term (3-4 days post-op) and mid-term (1 year) follow-up. Most patients were asymptomatic or mildly symptomatic and had preserved LVEF (>60%). Intrinsic velocity propagation (iVP) of myocardial stretch, a direct measure of myocardial stiffness, was higher in patients with severe MR {median 2.0 [interquartile range (IQR) 1.5-2.2] m/s, range 1.1-3.4 m/s; n = 56} compared to normal subjects [median 1.7 (IQR 1.5-1.8) m/s; n = 40; P = 0.0005], but not in those with mild or moderate MR [median 1.7 (IQR 1.4-1.9) m/s; n = 24]. A higher iVP was associated with more severe LV volume-overload and LV and left atrial enlargement (P < 0.05 for all). In patients undergoing MVr, a higher iVP independently predicted a larger drop in LVEF post-intervention (short-term, P = 0.001; 1 year, P = 0.007), incrementally to pre-operative LVEF (P < 0.05). CONCLUSION Non-invasive measurements of myocardial stiffness were able to predict functional deterioration after MVr for chronic primary MR. Further studies should investigate the mechanisms and practical utility of this novel measurement.
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Affiliation(s)
- Tais De Jesus
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Mahmoud M Alashry
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Cristina Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Alsidawi S, Khan S, Pislaru SV, Thaden JJ, El-Am EA, Scott CG, Morant K, Oguz D, Luis SA, Padang R, Lane CE, McCully RB, Pellikka PA, Oh JK, Nkomo VT. High Prevalence of Severe Aortic Stenosis in Low-Flow State Associated With Atrial Fibrillation. Circ Cardiovasc Imaging 2021; 14:e012453. [PMID: 34250815 DOI: 10.1161/circimaging.120.012453] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a low-flow state and may underestimate aortic stenosis (AS) severity. Single-high Doppler signals (HS) consistent with severe AS (peak velocity ≥4 m/s or mean gradient ≥40 mm Hg) are averaged down in current practice. The objective for the study was to determine the significance of HS in AF low-gradient AS (LGAS). METHODS One thousand five hundred forty-one patients with aortic valve area ≤1 cm2 and left ventricular ejection fraction ≥50% were identified and classified as high-gradient AS (HGAS) (≥40 mm Hg) and LGAS (<40 mm Hg), and AF versus sinus rhythm (SR). Available computed tomography aortic valve calcium scores (AVCS) were retrieved from the medical record. Outcomes were assessed. RESULTS Mean age was 76±11 years, female 47%. Mean gradient was 51±12 in SR-HGAS, 48±10 in AF-HGAS, 31±5 in SR-LGAS, and 29±7 mm Hg in AF-LGAS, all P≤0.001 versus SR-HGAS; HS were present in 33% of AF-LGAS. AVCS were available in 34%. Compared with SR-HGAS (2409 arbitrary units; interquartile range, 1581-3462) AVCS were higher in AF-HGAS (2991 arbitrary units; IQR1978-4229, P=0.001), not different in AF-LGAS (2399 arbitrary units; IQR1817-2810, P=0.47), and lower in SR-LGAS (1593 arbitrary units; IQR945-1832, P<0.001); AVCS in AF-LGAS were higher when HS were present (P=0.048). Compared with SR-HGAS, the age-, sex-, comorbidity index-, and time-dependent aortic valve replacement-adjusted mortality risk was higher in AF-HGAS (hazard ratio=1.82 [1.40-2.36], P<0.001) and AF-LGAS with HS (hazard ratio=1.54 [1.04-2.26], P=0.03) but not different in AF-LGAS without HS or SR-LGAS (both P=not significant). CONCLUSIONS Severe AS was common in AF-LGAS. AVCS in AF-LGAS were not different from SR-HGAS. AVCS were higher and mortality worse in AF-LGAS when HS were present.
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Affiliation(s)
- Said Alsidawi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,Minneapolis Heart Institute, Minneapolis, MN (S.A.)
| | - Sana Khan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,University of Minnesota, Minneapolis, MN (S.K.)
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Edward A El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,Department of Medicine, Indiana University School of Medicine, Indianapolis (E.A.E.-A.)
| | | | - Kareem Morant
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.).,North York General Hospital, Toronto, ON, Canada (K.M.)
| | - Didem Oguz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Sushil A Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Colleen E Lane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Robert B McCully
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (S.A., S.K., S.V.P., J.J.T., E.A.E.-A., K.M., D.O., S.A.L., R.P., C.E.L., R.B.M., P.A.P., J.K.O., V.T.N.)
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Oguz D, Padang R, Pislaru SV, Nkomo VT, Mankad SV, Alkhouli M, Guerrero M, Reeder GS, Eleid MF, Rihal CS, Thaden JJ. Clinical predictors and impact of postoperative mean gradient on outcome after transcatheter edge-to-edge mitral valve repair. Catheter Cardiovasc Interv 2021; 98:E932-E937. [PMID: 34245208 DOI: 10.1002/ccd.29867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/31/2021] [Accepted: 07/01/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND The predictors and clinical significance of increased Doppler-derived mean diastolic gradient (MG) following transcatheter edge-to-edge mitral valve repair (MVTEER) remain controversial. OBJECTIVE We sought to examine baseline correlates of Doppler-derived increased MG post-MVTEER and its impact on intermediate-term outcomes. METHODS Patients undergoing MVTEER were analyzed retrospectively. Post-MVTEER increased MG was defined as >5 mmHg or aborted clip implantation due to increased MG intraprocedurally. Baseline MG and 3D-guided mitral valve area (MVA) by planimetry were retrospectively available in 233 and 109 patients. RESULTS 243 patients were included; 62 (26%) had MG > 5 mmHg post-MVTEER or aborted clip insertion, including 7 (11%) that had aborted clip implantation. Mortality occurred in 63 (26%) during a median follow up of 516 days (IQR 211, 1021). Increased post-MVTEER MG occurred more frequently in females (44% vs. 16%, p < 0.001), those with baseline MVA <4.0 cm2 (71% vs. 16%), baseline MG ≥4 mmHg (61% vs. 20%), or multiple clips implanted (33% vs. 21%, p = 0.04). Increased post-MVTEER MG was associated with increased subsequent mortality compared to those with normal gradient (HR 1.91 95% CI 1.15-3.18 p = 0.016) as was aborted clip insertion compared to all others (HR 5.23 95% CI 2.06-13.28 p < 0.001). CONCLUSIONS Smaller baseline MVA and increased baseline MG are associated with increased MG post-MVTEER and patients with a Doppler-derived post-MVTEER MG >5 mmHg suffered excess subsequent mortality. In high risk patients considered for MVTEER, identification of those at risk of iatrogenic mitral stenosis with MVTEER is important as they may be optimally treated with alternate surgical or transcatheter therapies.
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Affiliation(s)
- Didem Oguz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sunil V Mankad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Wen S, Indrabhinduwat M, Brady PA, Pislaru C, Miller FA, Ammash NM, Nkomo VT, Padang R, Pislaru SV, Lin G. Post Procedural Peak Left Atrial Contraction Strain Predicts Recurrence of Arrhythmia after Catheter Ablation of Atrial Fibrillation. Cardiovasc Ultrasound 2021; 19:22. [PMID: 34116696 PMCID: PMC8194218 DOI: 10.1186/s12947-021-00250-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/04/2021] [Indexed: 12/12/2022] Open
Abstract
Background Left atrial (LA) function can be impaired by the atrial fibrillation (AF) ablation and might be associated with the risk of recurrence. We sought to determine whether the post-procedural changes in LA function impact the risk of recurrence following AF ablation. Methods We retrospectively reviewed patients who underwent AF ablation between 2009 and 2011 and underwent transthoracic echocardiography before ablation, 1-day and 3-month after ablation. Peak left atrial contraction strain (PACS) and left atrial emptying fraction (LAEF) were evaluated during sinus rhythm and compared across the three time points. The primary endpoint was atrial tachyarrhythmia recurrence after ablation. Results A total of 144 patients were enrolled (mean age 61 ± 11 years, 77% male, 46% persistent AF). PACS and LAEF initially decreased 1-day following ablation but partially recovered within 3 months in PAF patients, with a similar trend in the PerAF patients. After median 24 months follow-up, 68 (47%) patients had recurrence. Patients with recurrence had higher PACS1-day than that in non-recurrence subjects (-10.9 ± 5.0% vs. -13.4 ± 4.7%, p = 0.003). PACS1-day -12% distinguished recurrence cases with a sensitivity of 67.7% and specificity of 60.5%. The Kaplan–Meier curves showed significant difference in 5-year cumulative probability of recurrence between those with PACS ≥ -12% and PACS < -12% (log rank p < 0.0001). Multivariate regression showed that PACS1-day was an independent risk factor of arrhythmia recurrence. Conclusions Left atrial function deteriorates immediately following AF ablation and partially recovers in 3 months but remains abnormal in the majority of patients. PACS1-day post procedure predicts arrhythmia recurrence at long-term follow-up. Supplementary Information The online version contains supplementary material available at 10.1186/s12947-021-00250-5.
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Affiliation(s)
- Songnan Wen
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, MN, 55905, Rochester, USA
| | - Manasawee Indrabhinduwat
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, MN, 55905, Rochester, USA.,Department of Cardiology, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - Peter A Brady
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, MN, 55905, Rochester, USA
| | - Cristina Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, MN, 55905, Rochester, USA
| | - Fletcher A Miller
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, MN, 55905, Rochester, USA
| | - Naser M Ammash
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, MN, 55905, Rochester, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, MN, 55905, Rochester, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, MN, 55905, Rochester, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, MN, 55905, Rochester, USA
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, MN, 55905, Rochester, USA.
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Oguz D, Padang R, Rashedi N, Pislaru SV, Nkomo VT, Mankad SV, Malouf JF, Guerrero M, Reeder GS, Eleid MF, Rihal CS, Thaden JJ. Risk for Increased Mean Diastolic Gradient after Transcatheter Edge-to-Edge Mitral Valve Repair: A Quantitative Three-Dimensional Transesophageal Echocardiographic Analysis. J Am Soc Echocardiogr 2021; 34:595-603.e2. [DOI: 10.1016/j.echo.2021.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 01/22/2021] [Accepted: 01/22/2021] [Indexed: 02/08/2023]
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Naser J, Pislaru S, Nkomo V, Geske J, Thaden J, Luis S, Crestanello J, Anderson J, Michelena H, Padang R. IMMOBILE LEAFLETS AT THE TIME OF BIOPROSTHETIC VALVE IMPLANTATION: UNDER-RECOGNIZED BUT CLINICALLY IMPORTANT. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)03062-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Nordhues B, Arruda-Olson A, McCully R, Padang R, Pellikka P, Kane G. LONG-TERM PROGNOSTIC IMPLICATIONS OF AN ABNORMAL 12-LEAD ELECTROCARDIOGRAM DURING DOBUTAMINE STRESS ECHOCARDIOGRAM WITH NORMAL REST AND STRESS IMAGES. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01433-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Melduni R, Nkomo VT, Wysokinski W, Gersh BJ, Deshmukh A, Padang R, Greene EL, Oh JK, Lee HC. Risk of left atrial appendage thrombus and stroke in patients with atrial fibrillation and mitral regurgitation. Heart 2021; 108:29-36. [PMID: 33766985 DOI: 10.1136/heartjnl-2020-317659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 02/12/2021] [Accepted: 02/17/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the association of mitral regurgitation (MR) on thromboembolic risk of patients with non-valvular atrial fibrillation (NVAF) undergoing transoesophageal echocardiography (TEE)-guided cardioversion. METHODS Data for consecutive patients who underwent TEE-guided cardioversion for NVAF between 2000 and 2012 were analysed. MR severity was assessed by Doppler echocardiography and classified as ≤mild, moderate or severe. Left atrial appendage emptying velocities were averaged for five consecutive cycles. Multivariable regression models were used to identify independent predictors of left atrial appendage thrombus (LAAT) and stroke. RESULTS 2950 patients (age, 69.3±12.2 years, 67% men) were analysed. 2173 (73.7%) had ≤mild MR; 631 (21.4%), moderate MR; and 146 (4.9%), severe MR. Patients with moderate (age, 72.4±10.7 years) and severe (age, 72.8±12.1 years) MR were older than those with ≤mild MR (age, 68.2±12.5 years). The prevalence of LAAT was 1.5% (n=43). CHA2DS2-VASc scores (≤mild MR, 3.0±1.6; moderate MR, 3.5±1.5; severe MR, 3.9±1.5; p<0.001) and heart failure frequency (≤mild MR, 38.4%; moderate MR, 48.0%; severe MR, 69.2%; p<0.001) were increasingly higher with greater MR severity. Multivariable logistic regression analysis showed no association of moderate MR (OR 0.77, 95% CI 0.38 to 1.56) or severe MR (OR 0.55, 95% CI 0.21 to 1.49) with LAAT. During a mean follow-up of 7.3±5.1 years (median 7.5, IQR, 2.7-10.9), 216 patients had an ischaemic stroke. Adjusted Cox regression analysis showed no significant association of moderate MR (HR 1.22, 95% CI 0.88 to 1.68) or severe MR (HR 0.73, 95% CI 0.31 to 1.46) with stroke. CONCLUSIONS Among patients with NVAF, the presence or severity of MR was not associated with a decreased risk of LAAT or stroke.
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Affiliation(s)
- Rowlens Melduni
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Waldemar Wysokinski
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Eddie L Greene
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hon-Chi Lee
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Kato N, Pislaru SV, Padang R, Pislaru C, Scott CG, Nkomo VT, Pellikka PA. A Novel Assessment Using Projected Transmitral Gradient Improves Diagnostic Yield of Doppler Hemodynamics in Rheumatic and Calcific Mitral Stenosis. JACC Cardiovasc Imaging 2021; 14:559-570. [PMID: 33582068 DOI: 10.1016/j.jcmg.2020.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/24/2020] [Accepted: 12/04/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aims of this study were to: 1) develop a formula for projected transmitral gradient (TMG), expected gradient under normal heart rate (HR), and stroke volume (SV); and 2) assess the prognostic value of projected TMG. BACKGROUND In mitral stenosis (MS), TMG is highly dependent on hemodynamics, often leading to discordance between TMG and mitral valve area. METHODS All patients with suspected MS based on echocardiography from 2001 to 2017 were analyzed. Data were randomly split (2:1); projected TMG was modeled in the derivation cohort, then tested in the validation cohort. The composite endpoint was death or mitral valve intervention. RESULTS Of 4,973 patients with suspected MS, severe and moderate MS, defined as mitral valve area ≤1.5 and >1.5 to 2.0 cm2, were present in 437 (9%) and 936 (19%), respectively. In the derivation cohort (n = 3,315; age 73 ± 12 years; 34% male), corresponding gradients were TMG ≥6 and 4 to <6 mm Hg, respectively, under normal hemodynamics. Based on the impact of hemodynamics on TMG, the formula was projected TMG = TMG - 0.07 (HR - 70) - 0.03 (SV - 97) in men and projected TMG = TMG - 0.08 (HR - 72) - 0.04 (SV - 84) in women. In the validation cohort (n = 1,658), projected TMG had better agreement with MS severity than TMG (kappa 0.61 vs. 0.28). Among 281 patients with TMG ≥6 mm Hg, projected TMG ≥6 mm Hg, present in 171 patients (61%), was associated with higher probability of the endpoint versus projected TMG <6 mm Hg (adjusted hazard ratio: 1.8; 95% confidence interval: 1.2 to 2.6; p < 0.01). CONCLUSIONS The novel concept of projected TMG, constructed using the observed impact of HR and SV on TMG, significantly improved the concordance of gradient and valve area in MS and provided better risk stratification than TMG.
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Affiliation(s)
- Nahoko Kato
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Cristina Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher G Scott
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Naser J, Pislaru S, Nkomo V, Geske J, Thaden J, Luis A, Crestanello J, Anderson J, Michelena H, Padang R. Intraoperative finding of immobile leaflet(s) following freshly implanted bioprosthetic valves: clinical characteristics and impact on outcomes. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
BACKGROUND
Detection of immobile leaflets immediately following bioprosthetic valve implantation is a rare but important intraoperative finding. Restriction of leaflet movement can occur in the closed or open position, leading to abnormal prosthesis function. We sought to determine the clinical implications of immobile leaflets seen on intraoperative echocardiography.
METHODS
Patients with immobile leaflets identified on intra-operative/procedure echocardiography immediately post implantation between 2009-2020 were identified from an institutional database. All echocardiograms were reviewed de-novo to confirm immobile leaflets in the immediate post-implantation period. Identified cases were matched 1:2 to controls for age; sex; prosthesis position, model and size; and implantation approach (surgical vs. transcatheter). Nominal logistic regression and proportional hazards were used to analyze outcomes.
RESULTS
Thirty patients with immobile leaflets immediately post-bioprosthesis implantation were included. Clinical characteristics are summarized in the Table. Immobile leaflets were documented in procedural reports in only 18 (60%) patients. Moderate stenosis was present intraoperatively in 1 patient, none demonstrated ≥moderate regurgitation, and none resulted in immediate corrective action. In 3 (10%), valve re-intervention was required within 30 days due to symptomatic prosthesis dysfunction. Presence of restricted leaflet motion was associated with higher need for post-operative extracorporeal membrane oxygenation use (odds-ratio 7.3, p = 0.02) and composite end-point of death, valve re-replacement, prosthesis thrombosis, or cardiac hospitalizations (risk ratio 2.1, p = 0.03, Figure).
CONCLUSION
Immobile leaflet(s) immediately post-bioprosthetic valve implantation is an uncommon, under-reported, and under-treated phenomenon. Even in the absence of significant prosthetic valve dysfunction, it can be associated with worse post-operative course as well as worse outcomes.
Baseline characteristics Age 76 (67-84) Sex, male 10 (33%) Surgical approach 25 (83%) Aortic 5 (17%) Mitral 12 (40%) Tricuspid 12 (40%) Pulmonary 1 (3%) Re-intervention within 10 days 3 (10%) Numbers are presented as median (interquartile range) or number (percentage). Abstract Figure. Clinical outcome of stuck leaflets
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Affiliation(s)
- J Naser
- Mayo Clinic, Rochester, United States of America
| | - S Pislaru
- Mayo Clinic, Rochester, United States of America
| | - V Nkomo
- Mayo Clinic, Rochester, United States of America
| | - J Geske
- Mayo Clinic, Rochester, United States of America
| | - J Thaden
- Mayo Clinic, Rochester, United States of America
| | - A Luis
- Mayo Clinic, Rochester, United States of America
| | | | - J Anderson
- Mayo Clinic, Rochester, United States of America
| | - H Michelena
- Mayo Clinic, Rochester, United States of America
| | - R Padang
- Mayo Clinic, Rochester, United States of America
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Yang LT, Anand V, Zambito EI, Pellikka PA, Scott CG, Thapa P, Padang R, Takeuchi M, Nishimura RA, Enriquez-Sarano M, Michelena HI. Association of Echocardiographic Left Ventricular End-Systolic Volume and Volume-Derived Ejection Fraction With Outcome in Asymptomatic Chronic Aortic Regurgitation. JAMA Cardiol 2021; 6:189-198. [PMID: 33146680 DOI: 10.1001/jamacardio.2020.5268] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Volumetric measurements by transthoracic echocardiogram may better reflect left ventricular (LV) remodeling than conventional linear LV dimensions. However, the association of LV volumes with mortality in patients with chronic hemodynamically significant aortic regurgitation (AR) is unknown. Objective To assess whether LV volumes and volume-derived LV ejection fraction (Vol-LVEF) are determinants of mortality in AR. Design, Setting, and Participants This cohort study included consecutive asymptomatic patients with chronic moderately severe to severe AR from a tertiary referral center (January 2004 through April 2019). Exposures Clinical and echocardiographic data were analyzed retrospectively. Aortic regurgitation severity was graded by comprehensive integrated approach. De novo disk-summation method was used to derive LV volumes and Vol-LVEF. Main Outcome and Measures Associations between all-cause mortality under medical surveillance and the following LV indexes: linear LV end-systolic dimension index (LVESDi), linear LVEF, LV end-systolic volume index (LVESVi), and Vol-LVEF. Results Of 492 asymptomatic patients (mean [SD] age, 60 [17] years; 425 men [86%]), ischemic heart disease prevalence was low (41 [9%]), and 453 (92.1%) had preserved linear LVEF (≥50%) with mean (SD) LVESVi of 41 (15) mL/m2. At a median (interquartile range) of 5.4 (2.5-10.1) years, 66 patients (13.4%) died under medical surveillance; overall survival was not different than the age- and sex-matched general population (P = .55). Separate multivariate models, adjusted for age, sex, Charlson Comorbidity Index, and AR severity, demonstrated that in addition to linear LVEF and LVESDi, LVESVi and Vol-LVEF were independently associated with mortality under surveillance (all P < .046) with similar C statistics (range, 0.83-0.84). Spline curves showed that continuous risks of death started to rise for both linear LVEF and Vol-LVEF less than 60%, LVESVi more than 40 to 45 mL/m2, and LVESDi above 21 to 22 mm/m2. As dichotomized variables, patients with LVESVi more than 45 mL/m2 exhibited increased relative death risk (hazard ratio, 1.93; 95% CI, 1.10-3.38; P = .02) while LVESDi more than 20 mm/m2 did not (P = .32). LVESVi more than 45 mL/m2 showed a decreased survival trend compared with expected population survival. Conclusions and Relevance In this large asymptomatic cohort of patients with hemodynamically significant AR, LVESVi and Vol-LVEF worked equally as well as LVESDi and linear LVEF in risk discriminating patients with excess mortality. A LVESVi threshold of 45 mL/m2 or greater was significantly associated with an increased mortality risk.
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Affiliation(s)
- Li-Tan Yang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.,Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Elena I Zambito
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Prabin Thapa
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Anand V, Yang L, Luis SA, Padang R, Michelena HI, Tsay JL, Mehta RA, Scott CG, Pislaru SV, Nishimura RA, Pellikka PA. Association of Left Ventricular Volume in Predicting Clinical Outcomes in Patients with Aortic Regurgitation. J Am Soc Echocardiogr 2020; 34:352-359. [PMID: 33253815 DOI: 10.1016/j.echo.2020.11.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/16/2020] [Accepted: 11/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aortic regurgitation (AR) is a common valvular lesion associated with increased mortality once the left ventricle enlarges significantly or develops systolic dysfunction (ejection fraction < 50%). Valve guidelines recommend aortic valve repair or replacement (AVR) for left ventricular (LV) linear end-systolic dimension ≥ 50 mm or end-diastolic dimension ≥ 65 mm. However, chamber quantification guidelines recommend using LV volume for LV size determination because linear measurements may not accurately reflect LV remodeling. The aim of this study was to evaluate the correlation of LV volumes with linear dimensions, interobserver variability in the estimation of volumes, and the association of volumes with outcomes in patients with AR. METHODS A total of 1,100 consecutive patients with chronic moderate to severe and severe AR on echocardiography between 2004 and 2019 were retrospectively analyzed. The modified Simpson disk summation method was used for LV volume estimation. The primary outcome was all-cause mortality; the secondary outcome was mortality censored at AVR. RESULTS Patients' age was 60 ± 17 years, and 198 were women (18%). Volumes were measured using the biplane method in 939 patients (85%) and the monoplane method in 161 (15%); end-systolic volume was normal in 169 (11%). Correlations between volumes and linear dimensions were 0.5 for end-diastolic volume and 0.6 for end-systolic volume. At median follow-up of 5.4 years (interquartile range, 2.4-10.0 years), 216 patients had died and 539 had undergone AVR. Indexed LV end-systolic volume (iLVESV) and indexed left ventricular end-systolic dimension were both associated with mortality and symptoms, but the association of iLVESV was stronger. iLVESV, age, male gender, Charlson comorbidity index, New York Heart Association functional class III or IV, and time-dependent AVR were independently associated with all-cause mortality. Interobserver variability in the estimation of LV volumes in 200 patients included intraclass coefficients of 0.94 (95% CI, 0.92-0.95) for end-diastolic volume and 0.88 (95% CI, 0.78-0.93) for end-systolic volume. Patients with iLVESV ≥ 45 mL/m2 had lower survival and a higher prevalence of symptoms than those with volumes < 45 mL/m2. CONCLUSIONS Echocardiographic LV volume assessment had good reproducibility in patients with moderate to severe and severe AR. The correlation between linear dimensions and volumes was limited. Both iLVESV and indexed left ventricular end-systolic dimension were associated with worse outcomes, but the association of iLVESV was stronger. iLVESV ≥ 45 mL/m2 was associated with worse outcomes.
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Affiliation(s)
- Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Litan Yang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sushil Allen Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Julie L Tsay
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ramila A Mehta
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Christopher G Scott
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Padang R, Ali YZ, Mankad R, Bois MC, Maalouf JF, Sinak LJ, Pislaru SV, Nkomo VT, Michelena HI, Luis SA. Thromboembolic Complications of Annuloplasty Rings. JACC Cardiovasc Imaging 2020; 14:1659-1665. [PMID: 33221228 DOI: 10.1016/j.jcmg.2020.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/03/2020] [Accepted: 08/21/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Ratnasari Padang
- Division of Cardiac Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Yehia Z Ali
- Division of Cardiac Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rekha Mankad
- Division of Cardiac Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Melanie C Bois
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph F Maalouf
- Division of Cardiac Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lawrence J Sinak
- Division of Cardiac Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sorin V Pislaru
- Division of Cardiac Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Division of Cardiac Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hector I Michelena
- Division of Cardiac Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sushil A Luis
- Division of Cardiac Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Kato N, Padang R, Pislaru C, Scott C, Nkomo V, Pislaru S, Pellikka P. A novel mitral stenosis assessment using projected transmitral gradient improves the diagnostic and prognostic yields of doppler-based gradient. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Transmitral gradient (TMG) is highly dependent on hemodynamic state, leading to discordance between TMG and mitral valve area (MVA). The effect of heart rate (HR) and stroke volume (SV) on TMG among patients with mitral stenosis (MS) is poorly understood.
Purposes
We aimed to (1) develop a formula for projected TMG (proTMG) for assessment of MS severity under varying hemodynamics; (2) assess the prognostic value of proTMG in patients with MS.
Methods
All patients evaluated for suspected MS without ≥moderate other valve disorder at our tertiary center between 2001 and 2017 were analyzed. Projected TMG is the expected gradient under normal flow (SV 80–94 ml and HR 60–79 bpm), and was modeled based on the observed impact of HR and SV on TMG by multiple regression analysis. The data were randomly split (2:1) into training and testing sets. The improvement in agreement between MVA and proTMG was evaluated. Composite cardiac events including all-cause death and mitral valve interventions were compared according to TMG grade using TMG and proTMG. Severe and moderate MS were defined as MVA ≤1.5 cm2 and 1.5–2.0 cm2 respectively, by the continuity equation. MVA ≤1.0 cm2 was considered as very severe MS.
Results
Of 4973 patients with suspected MS (age 73±12 years, 33% male), severe MS was present in 437 (9%, including 98 with very severe MS) and moderate MS in 934 (19%). In 838 patients with normal HR and SV, very severe, severe and moderate MS corresponded to TMG ≥12 mmHg, ≥6 mmHg and 4–6 mmHg, respectively. In the training set (n=3315), the median [interquartile range] of HR and SV were 70 [61–80] bpm and 97 [83–113] mL in men (n=1120), and 72 [63–82] bpm and 84 [71–97] mL in women (n=2195), respectively. The impact of HR and SV on TMG for men and women were 0.07 and 0.08 mmHg per 1 bpm increase in HR (95% confidence interval [CI] 0.06–0.07 and 0.07–0.08), and 0.03 and 0.05 mmHg per 1 mL increase in SV (95% CI 0.03–0.03 and 0.04–0.05), respectively. Therefore, the final formula to calculate proTMG was: proTMG=TMG-0.07(HR-70)-0.03(SV-97) in men and proTMG=TMG-0.08(HR-72)-0.05(SV-84) in women. In the testing set (n=1658), the proTMG (kappa=0.63, 95% CI 0.60–0.66) had better agreement with MS severity by MVA than TMG (kappa=0.28, 95% CI 0.24–0.32). To explore the prevalence of patients reclassified using proTMG, in 98 with TMG ≥12 mmHg, proTMG remained ≥6 mmHg. Of 657 with TMG 6–12 mmHg, proTMG remained ≥6 mmHg in 356 (54%), and decreased to <6 mmHg in 301 (46%). In patients with TMG 6–12 mmHg, proTMG ≥6 mmHg was associated with higher probability of cardiac events compared with <6 mmHg during follow-up of 2.8±3.1 years (Figure).
Conclusion
We propose a novel concept of projected TMG defined as the expected transmitral gradient at normal HR and SV levels. This improved the diagnostic yield of Doppler TMG measurements for MS severity assessment and identified a low-risk subset of patients with elevated TMG due to high HR or SV.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- N Kato
- Mayo Clinic, Rochester, United States of America
| | - R Padang
- Mayo Clinic, Rochester, United States of America
| | - C Pislaru
- Mayo Clinic, Rochester, United States of America
| | - C.G Scott
- Mayo Clinic, Rochester, United States of America
| | - V.T Nkomo
- Mayo Clinic, Rochester, United States of America
| | - S.V Pislaru
- Mayo Clinic, Rochester, United States of America
| | - P.A Pellikka
- Mayo Clinic, Rochester, United States of America
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Kato N, Padang R, Scott C, Guerrero M, Pislaru S, Pellikka P. Symptoms and natural history in patients with isolated severe calcific mitral stenosis. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Prevalence of calcific mitral stenosis (MS) increases with age. Mitral valve interventions for calcific MS are often delayed until symptoms are severely limiting because the natural history of calcific MS and its relation to cardiac symptoms or comorbidities have not been well assessed.
Objectives
We assessed the prevalence of symptoms, comorbidities and determinants of all-cause mortality in patients with severe calcific MS.
Methods
We retrospectively investigated adults with echocardiographic isolated severe MS, defined as mitral valve area (MVA by the continuity equation) ≤1.5 cm2, from July 2003 to December 2017. Among them, calcific MS was identified as obstruction of left ventricular inflow due to degenerative calcification of the mitral annulus using echocardiography and, whenever available, operative findings including histopathological examination. Inactivity was defined as requirement for assistance with activities of daily living. Follow up was obtained by review of medical records.
Results
Of 491 patients with isolated severe MS, calcific MS was present in 200 (41%; age 78±11 years, 18% men, 32% with atrial fibrillation). Charlson Comorbidity Index (CCI) was 5.1±1.7 and 14 (7%) were inactive. MVA and transmitral gradient (TMG) were 1.26±0.19 cm2 and 8.1±3.8 mmHg, respectively. Symptoms were present at baseline in 120 (60%) including dyspnea in 97, chest discomfort in 12, syncope in 3, lower extremity edema in 3, thrombosis in 3 and fatigue in 2. Of them, mitral valve interventions including surgical or transcatheter mitral valve replacement and mitral valve bypass were performed in 27 (23%): within 1 year after index TTE in 23 (19%) and at 2, 4, 5 and 6 years in 1 each. Of 80 patients without symptoms at index TTE, 20 (25%) developed symptoms at mean 2.9±3.2 years and interventions were performed in 5 (6%). Of 168 who did not receive interventions, 60 (36%) did not develop symptoms during follow up, 58 (35%) were considered to have moderate MS, 46 (27%) were not offered surgery because of high risk due to advanced age, multiple comorbidities or heavy calcification, and 2 (1%) declined interventions. During follow-up of 2.8±3.0 years, Kaplan-Meier survival at 1 and 3 years without intervention were 72% and 52%, respectively (Fig. A). Inactivity, CCI >5, left ventricular ejection fraction (LVEF) <50%, TMG ≥8 mmHg (the mean TMG) and right ventricular systolic pressure (RVSP) ≥50 mmHg were independently associated with mortality (Fig. B). Symptoms were associated with referral for interventions (OR 3.43, 95% CI 1.22–9.65; p=0.019), but not with mortality.
Conclusion
Patients with isolated severe calcific MS had a high burden of comorbidities and had high mortality without intervention. Symptoms were common (60%), but were not associated with mortality. TMG ≥8 mmHg, RVSP ≥50 mmHg, LVEF<50%, CCI >5 and inactivity were independently associated with mortality.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- N Kato
- Mayo Clinic, Rochester, United States of America
| | - R Padang
- Mayo Clinic, Rochester, United States of America
| | - C.G Scott
- Mayo Clinic, Rochester, United States of America
| | - M Guerrero
- Mayo Clinic, Rochester, United States of America
| | - S.V Pislaru
- Mayo Clinic, Rochester, United States of America
| | - P.A Pellikka
- Mayo Clinic, Rochester, United States of America
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Eleid MF, Padang R, Pislaru SV, Greason KL, Crestanello J, Nkomo VT, Pellikka PA, Jentzer JC, Gulati R, Sandhu GS, Holmes DR, Nishimura RA, Rihal CS, Borlaug BA. Effect of Transcatheter Aortic Valve Replacement on Right Ventricular-Pulmonary Artery Coupling. JACC Cardiovasc Interv 2020; 12:2145-2154. [PMID: 31699376 DOI: 10.1016/j.jcin.2019.07.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/03/2019] [Accepted: 07/16/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of this study was to test the hypothesis that the acute left ventricular (LV) unloading effect of transcatheter aortic valve replacement (TAVR) would improve right ventricular (RV) function and RV-pulmonary artery (PA) coupling in patients with severe aortic stenosis (AS). BACKGROUND RV dysfunction is an ominous prognostic marker in patients undergoing TAVR, suggesting that relief of obstruction might be less beneficial in this cohort. However, the left ventricle and right ventricle influence each other through ventricular interaction, which could lead to improved RV function through LV unloading. METHODS Prospective invasive hemodynamic measurements with simultaneous echocardiography were performed in symptomatic patients with severe AS before and immediately after TAVR. RESULTS Forty-four patients (mean age 81 ± 8 years, 27% women) with severe AS underwent TAVR. At baseline, right atrial, PA mean (27 ± 7 mm Hg), and pulmonary capillary wedge (16 ± 4 mm Hg) pressures were mildly elevated, with a low normal cardiac index (2.3 l/min/m2). Pulmonary vascular resistance was mildly elevated (222 ± 133 dynes · s/cm5) and PA compliance mildly reduced (3.4 ± 01.4 ml/mm Hg). Following TAVR, aortic valve area increased (from 0.8 ± 0.3 to 2.7 ± 1.1 cm2; p < 0.001) with a reduction in mean aortic gradient (from 37 ± 11 to 7 ± 4 mm Hg; p < 0.001) and an increase in cardiac index (from 2.3 ± 0.5 to 2.5 ± 0.6 l/min/m2; p = 0.03). LV stroke work, end-systolic wall stress, and systolic ejection period decreased by 23% to 27% (p < 0.001 for all), indicating substantial LV unloading. RV stroke work (from 16 ± 7 to 18 ± 7 mm Hg · ml; p = 0.04) and tricuspid annular systolic velocities (from 9.5 ± 2.0 to 10.4 ± 3.5 cm/s; p = 0.01) increased, along with a decrease in PVR (194 ± 113 dynes · s/cm5; p = 0.03), indicating improvement in RV-PA coupling. Increased RV stroke work following TAVR directly correlated with the magnitude of increase in aortic valve area (r = 0.58; p < 0.001). CONCLUSIONS Acute relief in obstruction to LV ejection with TAVR is associated with improvements in RV function and RV-PA coupling. These findings provide new insights into the potential benefits of LV unloading with TAVR on RV dysfunction in patients with severe AS.
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Affiliation(s)
- Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Juan Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gurpreet S Sandhu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Bird JG, Morant K, Al-Souri D, Scott CG, Padang R, McCully RB, Kane GC, Pellikka PA, Luis SA. Impact of Anemia on Exercise and Pharmacologic Stress Echocardiography. J Am Soc Echocardiogr 2020; 33:1067-1076. [PMID: 32709477 DOI: 10.1016/j.echo.2020.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND The safety and diagnostic accuracy of stress testing in anemic patients have not been well studied. Despite a lack of data, significant anemia may be considered a relative contraindication to stress testing because of safety concerns related to insufficient myocardial oxygen supply. METHODS The authors reviewed 28,829 consecutive patients with blood hemoglobin drawn within 48 hours of stress echocardiography (15,624 exercise and 13,205 dobutamine). The associations of blood hemoglobin concentration with arrhythmia and other stress echocardiographic findings were examined. Additionally, the effect of anemia on the positive predictive value of stress echocardiography for the detection of significant coronary artery stenosis (≥50%) was assessed in patients who subsequently underwent coronary angiography. RESULTS Anemia was present in 6,401 patients (22.2%) and was severe (hemoglobin < 8.0 g/dL) in 52. Stress testing with either exercise or dobutamine was safe, with no significant increase in serious arrhythmia events or need for hospitalization. In the exercise cohort, worsening anemia was associated with reduced treadmill exercise time, lower peak heart rate, peak rate-pressure product, and achieved workload. In the dobutamine stress cohort, worsening anemia was associated with higher resting heart rate, more use of atropine, and fewer patients attaining target heart rate. The positive predictive value of stress echocardiography was higher in patients with moderate anemia compared with those without anemia (71.8% vs 60.2%, P = .01). CONCLUSIONS This study demonstrates that stress testing is safe in patients with mild and moderately anemia, albeit with a small increase in mild supraventricular arrhythmias with exercise. However, worsening anemia was associated with a significant reduction in exercise capacity. Additionally, worsening anemia was associated with an improvement in the positive predictive value of stress echocardiography. Extrapolation of these data to patients with severe anemia should be performed with caution given the limited number of patients with severe anemia in this study.
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Affiliation(s)
- Jared G Bird
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kareem Morant
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Deema Al-Souri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert B McCully
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Sushil Allen Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Luis SA, Dohaei A, Chandrashekar P, Scott CG, Padang R, Lokineni S, Kane GC, Crestanello JA, Abel MD, Nkomo VT, Pislaru SV, Pellikka PA. Impact of Aortic Valve Replacement for Severe Aortic Stenosis on Perioperative Outcomes Following Major Noncardiac Surgery. Mayo Clin Proc 2020; 95:727-737. [PMID: 32247346 DOI: 10.1016/j.mayocp.2019.10.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 10/10/2019] [Accepted: 10/21/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the incidence of major adverse cardiac events and death among severe aortic stenosis patients with and without aortic valve replacement (AVR) before noncardiac surgery. PATIENTS AND METHODS We retrospectively evaluated 491 severe aortic stenosis patients undergoing non-emergency/non-urgent elevated-risk noncardiac surgery between January 1, 2000, and December 31, 2013, including 203 patients (mean age, 74±10 years, 63.5% men) with previous AVR and 288 patients (mean age, 77±12 years, 55.6% men) without prior AVR. RESULTS The incidence of major adverse cardiac events was significantly lower in the AVR group (5.4% vs 20.5%; P<.001), primarily because of the lower incidence of new or worsening heart failure (2.5% vs 17.7%; P<.001), compared with the non-AVR group. No significant differences were observed between the groups with and without AVR in the incidence of death (2.5% vs 3.5%; P=.56), myocardial infarction (0.5% vs 1.4%; P=.48), ventricular arrhythmia (0.0% vs 0.7%; P=.51), or stroke (0.0% vs 0.7%; P=.51) at 30-days. At a median follow-up of 4.2 (interquartile range,1.3-7.5) years, overall mortality was significantly worse in patients without versus with AVR (5-year rate: 57.0% vs 32.7%; P<.001). Symptomatic patients without AVR (n=35) had the worst outcomes overall, including increased 30-day and overall mortality rates, compared with the AVR-group and asymptomatic non-AVR patients. CONCLUSION In patients with severe aortic stenosis, AVR before noncardiac surgery was associated with decreased incidence of heart failure after noncardiac surgery and improved overall survival without differences in 30-day survival, myocardial infarction, ventricular arrhythmia, or stroke. Preoperative AVR should be considered in symptomatic patients for whom the benefit of AVR is greatest.
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Affiliation(s)
| | - Abolfazl Dohaei
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Sravani Lokineni
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Martin D Abel
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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49
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Mahowald MK, Pislaru SV, Reeder GS, Padang R, Michelena HI, Mankad SV, Maalouf JF, Guerrero M, Alkhouli M, Rihal CS, Eleid MF. Institutional learning experience for combined edge-to-edge tricuspid and mitral valve repair. Catheter Cardiovasc Interv 2020; 96:1323-1330. [PMID: 32180349 DOI: 10.1002/ccd.28856] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/03/2020] [Accepted: 03/07/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Transcatheter edge-to-edge repair with MitraClip is only approved for treatment of mitral regurgitation but is increasingly used to treat concomitant tricuspid regurgitation (TR) due to its common coexistence and association with poor outcomes. This study aimed to describe the learning curve associated with the challenge of off-label treatment of concomitant TR. METHODS This is a retrospective review of initial and consecutive patients who underwent combined edge-to-edge repair of mitral and tricuspid valves (TVs) at our institution from August 2017 to October 2019. RESULTS Repair of both valves with MitraClip was performed in 22 patients (median age 81.5 years, 32% female). Mean procedure time was 176 ± 47 min; mean fluoroscopy time was 65 ± 24 min. Procedure duration in the first tertile was significantly longer (223 ± 13 min) than in the third tertile (143 ± 23 min, p = .0003). Median number of total clips placed per case was 3; in 15 patients (68%), the anterior and septal leaflets of the TV were clipped. The average changes in mean right atrial (RA) and left atrial (LA) pressures were -1.7 ± 2.5 mmHg (p = .0080) and -3.2 ± 4.6 mmHg (p = .0045), respectively. The average changes in RA and LA V-wave heights were -3.3 ± 4.0 mmHg (p = .0009) and -8.1 ± 9.9 mmHg (p = .038), respectively. There was a significant trend toward decreasing residual TR over the course of the series (p = .046). At 30 days, survival was 100% and mean NYHA class decreased from 2.8 to 1.8 (p < .0001). CONCLUSIONS Combined edge-to-edge tricuspid and mitral valve repair is safe and feasible. With experience, procedure duration and residual TR decreased.
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Affiliation(s)
- Madeline K Mahowald
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sunil V Mankad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph F Maalouf
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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50
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Oguz D, Padang R, Pislaru S, Nkomo VT, Mankad SV, Maalouf Y, Guerrero M, Reeder G, Eleid M, Rihal CS, Thaden J. PRE- VS POST-PROCEDURE MITRAL VALVE AREA AND MEAN DIASTOLIC GRADIENT IN PATIENTS WITH SECONDARY MITRAL REGURGITATION UNDERGOING EDGE-TO-EDGE MITRAL VALVE REPAIR. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32764-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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