Search

Coronary artery fistulas (CAFs) are rare coronary anomalies that are usually diagnosed incidentally with cardiac imaging. Small CAFs are generally asymptomatic and can close over time, while some untreated medium or large CAFs can enlarge, leading to clinical sequelae such as cardiac chamber enlargement or myocardial ischemia. With the advancement of transcatheter equipment and techniques, CAFs have been increasingly closed using a percutaneous approach. However, the procedure is not free of limitations given the risk for myocardial infarction, device embolization, and fistula recanalization. In this review, the authors illustrate the contemporary procedural considerations, techniques, and outcomes of transcatheter CAF closure.

Cardiovascular disease (CVD) disproportionately affects older adults. It is expected that by 2030, one in five people in the United States will be older than 65 years. Individuals with CVD now live longer due, in part, to current prevention and treatment approaches. Addressing the needs of older individuals requires inclusion and assessment of frailty, multimorbidity, depression, quality of life, and cognition. Despite the conceptual relevance and prognostic importance of these factors, they are seldom formally evaluated in clinical practice. Further, although these constructs coexist with traditional cardiovascular risk factors, their exact prevalence and prognostic impact remain largely unknown. Development of the right decision tools, which include these variables, can facilitate patient-centered care for older adults. These gaps in knowledge hinder optimal care use and underscore the need to rigorously evaluate the optimal constructs for providing care to older adults. In this review, we describe available tools to examine the prognostic role of age-related factors in patients with CVD.

Cancer and cardiovascular diseases are the two leading causes of death in industrialized countries. Optimal management of life-threatening presentations of both of their diseases can pose significant challenges. The current study aimed to address the incidence, management, and outcome of acute coronary syndromes (ACS) in patients with active hematological malignancies.This retrospective registry-based cohort study included adults with active leukemia or lymphoma who were hospitalized at Mayo Clinic Rochester from 01/01/2004 to 12/31/2014. The diagnosis of ST-segment elevation MI (STEMI) or non-ST-segment elevation MI (NSTEMI) was made based on the 3rd Universal Definition for MI, or of unstable angina (UA) in the absence of cardiac troponin elevation. Main outcome measures included all-cause, cardiac, and non-cardiac death in-hospital and at one year.Of 5300 adult patients with active hematological malignancies, 73 (1.4%) were diagnosed with an ACS (78.1% NSTEMI and 13.7% STEMI). 17.5% and 40% of NSTEMI and STEMI patients underwent coronary angiography, with percutaneous coronary intervention in 5.3% and 30%, respectively. While80% of patients received β-blocker therapy, only half of all and50% of patients managed "medically" received antiplatelet, anticoagulant, and/or statin therapy. The in-hospital and 1-year mortality was 21.9% and 58.9%, respectively, of which 25% and 15% were cardiac in etiology. Aspirin, beta-blocker, statins, and angiotensin-converting enzyme inhibitor/angiotensin-II receptor blocker were associated with better mortality outcomes.In a large, contemporary study of adults with active hematologic malignancies, ACS was uncommon, but commonly managed not in keeping with societal guideline recommendations.

An 83-year-old man with a history of cerebral amyloid angiopathy and subarachnoid hemorrhage underwent uncomplicated left atrial appendage (LAA) occlusion using a 30-mm WATCHMAN device (Boston Scientific, Marlborough, Massachusetts). He was treated with aspirin and Eliquis (apixaban; Bristol-Myers

Cardiac masses can be caused by various etiologies [(1)][1]. Current practice relies on imaging to characterize masses without providing a definitive diagnosis, which is often made after surgical resection. In some cases, it would be prudent to have a definitive diagnosis before subjecting the

Transcatheter aortic valve replacement (TAVR) emerged as a promising alternative to surgical aortic valve replacement (SAVR) in extreme-aged patients with severe aortic stenosis (AS). Data on the outcomes of TAVR or SAVR in nonagenarians are limited. The Nationwide Inpatient Sample was used to identify patients aged 90 years or older who underwent TAVR or SAVR from 2004 to 2013. In-hospital morbidity and mortality were assessed. From 2004 to 2013, 9,066 (national estimate) nonagenarians underwent aortic valve replacement. After the introduction of TAVR, most nonagenarians were treated with TAVR (76%) compared with SAVR (24%). A total of 1,847 nonagenarians who underwent SAVR (n = 1,152) or TAVR (n = 695) were included in the analysis. In-hospital mortality was similar between patients who underwent SAVR (6.4%) compared with TAVR (6.5%; p = 0.29). Vascular complications were more common after TAVR (11.9% vs 6.3%, p 0.001), whereas blood transfusion (46.2% vs 33.7%, p0.001), and acute kidney injury (25.8% vs 20.4%, p = 0.009) were more common after SAVR. Pacemaker implantation and stroke rates were similar between the 2 groups. In a propensity-matched analysis of 630 patients who underwent isolated TAVR (n = 315) or SAVR (n = 315), in-hospital mortality was similar for (6.0% for SAVR vs 7.9% for TAVR, p = 0.35). SAVR was associated with higher rates of acute kidney injury (24.1% vs 16.8%, p = 0.02) and blood transfusion (46.0% vs 35.2%, p = 0.001), whereas TAVR was associated with increased rates of vascular complications (10.2% vs 6.0%, p = 0.07). Stroke (4.1% vs 4.1%, p = 0.99) and pacemaker implantation rates were also similar (13.0% vs 9.2%, p = 0.12) between the TAVR and SAVR groups, respectively. In conclusion, in nonagenarians, both SAVR and TAVR can be performed with acceptable in-hospital outcomes. Referral for aortic valve replacement in these patients should not be precluded based on age alone.

Cardiac myxoma is the most common primary cardiac neoplasm in adults. They most commonly arise within the left atrium, but may arise from other cardiac chambers, rarely from the valves. Histologically, cardiac myxomas consist of lepidic (“myxoma”) cells within a myxoid stroma. They can be of

Percutaneous epicardial access (EpiAcc) is used in an attempt to improve outcomes of ablation. We aim to report our experience in EpiAcc for management of symptomatic ventricular premature complexes (VPC) and ventricular tachycardia (VT). All patients from January 2004 to July 2014 who underwent EpiAcc as part of a VPC or VT ablation procedure were included. Outcomes between those with endocardial-only (Gp1) and endocardial/epicardial (Gp2) ablation and those for VPC and VT ablation were compared. EpiAcc for VPC or VT ablation was attempted in 173 patients; 10 patients were excluded because of failure of access (n = 7) or no ablation performed (n = 3). Of the remaining 163, 131 patients (80.4%) had undergone previous endocardial ablation. Mean age was 53.7 ± 15.7 years; 115 (71%) were men. VT ablation was the indication in 105 patients (64%). The underlying substrate was predominately nonischemic cardiomyopathy (49.1%). Epicardial ablation was performed in 115 (70.6%). Procedural and clinical success was obtained in 92.0% and 69.9% of patients, respectively, with no difference between Gp1 and Gp2. Those who underwent VPC ablation had superior clinical outcomes at 1-year follow-up. EpiAcc is feasible in almost all patients with no previous cardiac surgery and permits acute procedural success in >90% of patients, most of whom had failed previous ablation. However, epicardial ablation was not delivered in 1/3 of patients. Epicardial mapping may be helpful as in the absence of an appropriate epicardial site for ablation, and focus can be shifted to more detailed endocardial mapping and ablation.

The association between the acute change in mean direct left atrial (LA) pressure and symptom improvement post MitraClip has been shown. Mean transmitral diastolic Doppler pressure gradient is routinely measured before and after MitraClip deployment and is used in assessing procedural success.

Low-flow, low-gradient (LFLG) severe aortic stenosis (AS) with preserved ejection fraction (EF) comprises 10% to 20% of patients with severe AS and is associated with poor prognosis [(1,2)][1]. The optimal treatment for patients with this syndrome is debated, and some have suggested that patients

We illustrate the novel approach of right iliac vein stenting for the delivery of a MitraClip steerable sheath system (Abbott Vascular, Santa Clara, California) in a patient with a unique case of venous obstruction. An 85-year-old man with decompensated heart failure due to severe mitral

A 70-year old man with end-stage ischemic cardiomyopathy status post HeartMate II (Thoratec, Pleasanton, California) left ventricular assist device (LVAD) implantation as destination therapy presented with recurrent gastrointestinal bleeding. He was seen by gastroenterology and had a work-up that

Cognitive dysfunction and memory loss are common features of Alzheimer9s disease (AD). Abnormalities in the expression profile of immediate early genes that play a critical role in memory formation, such as the cAMP-response element binding protein (CREB), have been reported in the brains of AD patients. Here we show that amyloid-β (Aβ) accumulation, which plays a primary role in the cognitive deficits of AD, interferes with CREB activity. We further show that restoring CREB function via brain viral delivery of the CREB-binding protein (CBP) improves learning and memory deficits in an animal model of AD. Notably, such improvements occur without changes in Aβ and tau pathology, and instead are linked to an increased level of brain-derived neurotrophic factor. The resulting data suggest that Aβ-induced learning and memory deficits are mediated by alterations in CREB function, based on the finding that restoring CREB activity by directly modulating CBP levels in the brains of adult mice is sufficient to ameliorate learning and memory. Therefore, increasing CBP expression in adult brains may be a valid therapeutic approach not only for AD, but also for various brain disorders characterized by alterations in immediate early genes, further supporting the concept that viral vector delivery may be a viable therapeutic approach in neurodegenerative diseases.

The prognostic influence of individual components included in geriatric syndromes is known, however, co-prevalence and the influence on prognosis is unknown. We prospectively studied prevalence and prognostic influence of frailty (Rockwood criteria), functional reach, timed up-and-go, quality of

In patients with combined findings of calcific aortic stenosis (AS) and hypertrophic obstructive cardiomyopathy (HOCM), determining the major contributor to symptoms and the transaortic gradient can be a challenge 70 year old woman presents for evaluation of severe dyspnea on exertion. Coronary

Routine electrocardiographic monitoring is commonly utilized following percutaneous coronary interventions (PCI), but its clinical and prognostic implication has not been well studied. We aimed to prospectively evaluate the incidence of actionable alarms on telemetry monitoring and their clinical

Aging is associated with gradual replacement of muscle with fat and fibrous tissue as well as increased total body fat content. We assessed whether muscle fat index, visceral fat index, and total body fat index can predict frailty and Length of hospital Stay (LOS) following Transcatheter Aortic

Older adults have high prevalence of depression and cardiovascular disease (CVD). The precise association of depressive symptoms in CVD patients, especially as it relates to their long-term survival is not well reported from contemporary cohort. We, herein, report 1-year mortality among patients

Objectives This study sought to examine patient-level discordance between population percentiles of non–high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C). Background Non–HDL-C is an alternative to LDL-C for risk stratification and lipid-lowering therapy. The justification for the present guideline-based non–HDL-C cutpoints of 30 mg/dl higher than the LDL-C cutpoints remains largely untested. Methods We assigned population percentiles to non–HDL-C and Friedewald-estimated LDL-C values of 1,310,440 U.S. adults with triglyceride levels Results LDL-C cutpoints of 70, 100, 130, 160, and 190 mg/dl were in the same population percentiles as non–HDL-C values of 93, 125, 157, 190, and 223 mg/dl, respectively. Non–HDL-C values reclassified a significant proportion of patients within or to a higher treatment category compared with Friedewald LDL-C values, especially at LDL-C levels in the treatment range of high-risk patients and at triglyceride levels ≥150 mg/dl. Of patients with LDL-C levels Conclusions There is significant patient-level discordance between non–HDL-C and LDL-C percentiles at lower LDL-C and higher triglyceride levels, which has implications for the treatment of high-risk patients. Current non–HDL-C cutpoints for high-risk patients may need to be lowered to match percentiles of LDL-C cutpoints. Relatively small absolute reductions in non–HDL-C cutpoints result in substantial reclassification of patients to higher treatment categories with potential implications for risk assessment and treatment. (The Very Large Database of Lipids [VLDL-2]; NCT01698489 )

Electrocardiographic (ECG) strain pattern has been linked to myocardial fibrosis, and cardiovascular morbidity and mortality in patients with hypertension. We aim to determine the differential impact of strain on baseline ECG on long-term mortality after transcatheter aortic valve replacement (TAVR

Background: Despite guideline recommendations, surgery for isolated tricuspid valve (TV) disease is rarely performed. Existing series report wide variation in operative mortality, between 2-24%. Safety concerns have created a population with an unmet clinical need. Percutaneous repair could provide

Background Low serum levels of high-density lipoprotein cholesterol (HDL-C) are an important risk factor for atherosclerotic disease. To date, therapeutically raising HDL-C has not been shown to impact risk for cardiovascular events. Objective We aim to characterize lipid parameters at the extremes of HDL-C. Methods We examined cholesterol profiles from 1,350,908 US adults and children from the Very Large Database of Lipids who were clinically referred for advanced lipoprotein testing from 2009 to 2011. We categorized patients into HDL-C percentile categories ( 99th–99.9th, and >99.9th). Within these groups, we examined HDL-C subclasses, low-density lipoprotein cholesterol (LDL-C), LDL and very–low density lipoprotein densities, non–HDL-C, triglycerides (TG), very–low density lipoprotein cholesterol, and remnant lipoprotein cholesterol (RLP-C), as well as prevalence of Fredrickson–Levy dyslipidemias. Results Extremely low HDL-C percentiles were associated with increased LDL density, TG, and especially RLP-C. Very high HDL-C levels (≥92 mg/dL) showed increasing HDL 2 -C/HDL 3 -C ratio and very low levels of RLP-C and triglyceride-rich lipoproteins. Type IV dyslipidemia had the highest prevalence among classical dyslipidemia and was the most frequent at extremely low HDL-C percentiles. Conclusions These findings demonstrate a high prevalence of elevated triglyceride-rich lipoprotein levels and increased LDL density in patients with extremely low HDL-C levels. The relative contributions of these various changes in lipid profiles of patients with low HDL-C to cardiovascular risk need to be further scrutinized to more fully establish if low HDL-C is truly an independent risk factor for coronary heart disease or simply reflects detrimental shifts in the levels of atherogenic lipoproteins.

Constrictive pericarditis is a curable cause of chronic heart failure. The diagnosis of constrictive pericarditis can be missed due to misleading gastrointestinal manifestations. Surgical pericardectomy remains the primary therapy for constrictive pericarditis. A 41-year-old man presented for