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Transcatheter aortic valve replacement is established as the standard treatment for severe aortic stenosis. Many approaches have been described, including the suprasternal technique, an alternative for patients with unsuitable femoral arteries. We now describe a trocar-free technique for the Suprasternal approach.Under endotracheal anesthesia, an incision is made above the manubrium and dissection is carried down to the innominate artery with adequate exposure for cannulation. Access site is closed with purse-string suture. The Suprasternal approach has relatively few contraindications.Our trocar-free technique is a safe and easily reproducible technique for TAVRs in patients with poor femoral access.

Transcatheter aortic valve replacement (TAVR) is now an established treatment option for patients with severe aortic stenosis. The most utilized approach remains transfemoral. In patients with difficult femoral access a variety of alternate approaches have been used. Recently, suprasternal access has emerged as a viable alternate approach in patients with very complex vascular access. We describe our 30-day outcomes of patients who underwent suprasternal transcatheter aortic valve replacement (suprasternal [SS]-TAVR), which constitutes the largest single-center cohort to date.From May 2016 to September 2021, 658 patients underwent TAVR at our institution. Of which 29 underwent SS-TAVR. We performed a retrospective analysis to evaluate early (30 days) outcomes of this procedure. Main outcomes evaluated included 30-day mortality, stroke and pacemaker rates, length of stay, readmission, and valvular function.All patients were alive 30 days after the procedure. The median hospital length-of-stay was 2 days. Two patients (6.9%) had a stroke on the contra-lateral side of access. Two patients (6.90%) had significant cardiac arrhythmias requiring pacemaker placement. In 30 days, one patient was readmitted (3.45%).Our data confirm the SS-TAVR as a feasible and safe alternative with comparable results to established approaches in patients who are unsuitable for femoral artery access and offers clinicians another access site in patients with very complex anatomy.

BackgroundThere are limited commercial valve sizes available for transcatheter aortic valve implantation (TAVI). This makes it challenging or even prohibitive to perform TAVI on large aortic annuli.Case summaryA 78-year-old male with known low-flow, low-gradient severe aortic stenosis presented with progressive dyspnoea, chest pressure, and decompensated heart failure. Successful off-label TAVI was performed for tricuspid aortic valve stenosis with an aortic annulus of >900 mm2. An Edwards S3 29 mm valve was overexpanded with an extra 7 mL of volume at valve deployment. No complications occurred, and only trivial paravalvular leak was seen following implantation. The patient died from a non-cardiovascular cause 8 months following the procedure.DiscussionPatients that require aortic valve replacement with prohibitive surgical risk and have very large aortic valve annuli pose significant technical challenges. This case shows the feasibility of TAVI by overexpanding an Edwards S3 valve.

BACKGROUND: Few studies characterize the epidemiology and outcomes of aortic stenosis (AS) in acute decompensated heart failure (ADHF). This study investigates the significance of AS in contemporary patients who have experienced an ADHF hospitalization. METHODS: The ARIC study (Atherosclerosis Risk in Communities) surveilled ADHF hospitalizations for residents ≥55 years of age in 4 US communities. ADHF cases were stratified by left ventricular ejection fraction (LVEF). Demographic differences in AS burden and the association of varying AS severities with mortality were estimated using multivariable logistic regression. RESULTS: From 2005 through 2014, there were 3597 (weighted n=16 692) ADHF hospitalizations of which 48.6% had an LVEF CONCLUSIONS: Among patients who have experienced an ADHF hospitalization, AS is prevalent and portends poor mortality outcomes. Notably, mild/moderate AS is independently associated with 1-year mortality in this high-risk population.

Intensity modulated radiotherapy (IMRT) is the standard of care for oropharyngeal cancer management. IMRT can be applied using either the sequential boost or simultaneous integrated boost (SIB-IMRT) techniques. The purpose of the study was to assess the efficacy of sequential boost technique or SIB-IMRT) in locally advanced p16-negative oropharyngeal squamous cell carcinoma.Baseline characteristics and treatment outcomes were compared between patients with locally advanced p16-negative oropharyngeal squamous cell carcinoma, who received sequential RT (n=40) and those who received SIB-IMRT (n=38).In total, 78 patients with locally advanced p16-negative oropharyngeal cancer were identified. Mean age was 63 years. Patients treated with SIB-IMRT had better 5-year overall survival (OS; 78.7% vs. 52.5%, p=0.023) and 5-year disease-free survival (DFS; 87.4% versus 63.5%, p=0.046) compared to sequential group. There was no difference of total severe acute and late toxicity (grade ≥3) incidences. Patients treated with SIB technique had higher rates of mild to moderate late xerostomia (73.7% vs. 52.5%), dysgeusia (63.2% vs. 20%), and dysphagia (44.7% vs. 17.5%).Compared to sequential technique, SIB-IMRT improved both OS and DFS, but higher mild to moderate late toxicity was observed. As long as RT dose constraints to surrounding normal organs can be maintained, SIB technique should be the technique of choice for locally advanced p16-negative oropharyngeal squamous cell carcinoma treatment.

Objectives This study investigates the prevalence and prognostic significance of mitral regurgitation (MR) in acute decompensated heart failure (ADHF) patients. Background Few studies characterize the burden of MR in heart failure. Methods The ARIC (Atherosclerosis Risk In Communities) study surveilled ADHF hospitalizations for residents ≥55 years of age in 4 U.S. communities. ADHF cases were stratified by left ventricular ejection fraction (LVEF): Results From 2005 to 2014, there were 17,931 weighted ADHF hospitalizations of which 49.2% had an LVEF Conclusions Patients with ADHF have a significant MR burden that varies with sex and race. In ADHF patients with an LVEF

Background The burden of amyloidosis among hospitalized patients is increasing over time. However, amyloidosis remains an underdiagnosed cause of heart failure (HF) hospitalization among older adults. Objectives We investigated the prevalence and prognostic implications of amyloidosis among patients hospitalized with HF. Methods All hospitalizations for primary diagnosis of HF between January 1, 2010, and August 31, 2015, identified in the Nationwide Readmissions Database were categorized into those with and without a secondary diagnosis of amyloidosis. HF hospitalizations with amyloidosis were then matched in a 3:1 fashion to HF hospitalizations without amyloidosis using the year of admission, discharge quarter, age, sex, and Charlson comorbidity index. Primary outcomes were inpatient mortality and 30-day readmission. Multivariable logistic regression was used to estimate the association between HF with amyloidosis and clinical outcomes. Results Of 1,593,360 HF hospitalizations that met inclusion criteria, 2,846 (0.18%) had HF with a secondary diagnosis of amyloidosis and were matched to 8,515 hospitalizations for HF without amyloidosis. Hospitalizations for HF with amyloidosis were associated with higher prevalence of kidney disease (56% vs. 45%), malignancy (20% vs. 4%), and higher inpatient mortality (6% vs. 3%) as compared with HF without amyloidosis. In adjusted analyses, HF with amyloidosis was associated with higher odds of in-hospital mortality (odds ratio: 1.46; 95% confidence interval [CI]: 1.17 to 1.82), 30-day readmission (odds ratio: 1.17; 95% CI: 1.05 to 1.31), and longer mean length of stay (least-squares mean difference: 1.46; 95% CI: 1.12 to 1.80). Conclusions In patients hospitalized with decompensated HF, presence of amyloidosis was associated with higher risk of inpatient mortality and 30-day readmission., Central Illustration

Transcatheter aortic valve replacement (TAVR) first received FDA approval for high-risk surgical patients in 2011 and has been approved for low-risk surgical patients since 2019. It is now the most common type of aortic valve replacement, and its use continues to accelerate. Computer modeling and simulation (CM&S) is a tool to aid in TAVR device design, regulatory approval, and indication in patient-specific care. This study introduces a computational fluid-structure interaction (FSI) model of TAVR with Medtronic’s CoreValve Evolut R device using the immersed finite element-difference (IFED) method. We perform dynamic simulations of crimping and deployment of the Evolut R, as well as device behavior across the cardiac cycle in a patient-specific aortic root anatomy reconstructed from computed tomography (CT) image data. These IFED simulations, which incorporate biomechanics models fit to experimental tensile test data, automatically capture the contact within the device and between the self-expanding stent and native anatomy. Further, we apply realistic driving and loading conditions based on clinical measurements of human ventricular and aortic pressures and flow rates to demonstrate that our Evolut R model supports a physiological diastolic pressure load and provides informative clinical performance predictions.

Graphical abstract, Highlights • Barlow's disease is a degenerative mitral valvulopathy with highly complex anatomy. • Barlow's disease is classically unfavorable for TMVr using MitraClip. • Patients with Barlow's disease, SAM, and high surgical risk may be candidates for TMVr.

Background: Atrial fibrillation (AF) is common in patients undergoing transcatheter aortic valve replacement (TAVR) but there is conflicting evidence on whether AF impacts outcomes after TAVR. Methods: Hospitalizations of adults ≥50 years old who had undergone elective TAVR from 2012 to 2015 were included. Poisson regression was used to assess changes in in-hospital complications, average length of stay (LOS) after TAVR, and discharge disposition over time. Multivariable logistic, linear, and generalized logistic regression models, adjusting for patient and hospital characteristics, were used to estimate the effect of AF on inpatient outcomes. Results: A total of 7,266 TAVR hospitalizations were included; AF was present in 44% of patients. Between 2012 and 2015, there was a significant decrease in the incidence of acute kidney injury, blood transfusion, average LOS, and inpatient mortality both for AF and non-AF patients. However, the incidences of vascular complications and major bleeding decreased only among non-AF patients. After adjustment, AF was associated with increased incidences of TIA/stroke (OR 1.36, 95% CI: 1.01, 1.85), acute kidney injury (OR 1.54, 95% CI: 1.33, 1.78), blood transfusion (OR 1.14, 95% CI: 1.00, 1.30), transfer to a skilled nursing facility (OR 1.38, 95% CI: 1.23, 1.55), and longer average LOS (CIE 1.30, 95% CI: 1.06, 1.54). AF was not associated with inpatient mortality (OR 1.09, 95% CI: 0.81, 1.48). Conclusions: AF is prevalent among patients undergoing TAVR, and is associated with higher incidences of inpatient complications, discharge to a skilled nursing facility, and longer average LOS. While the incidence of many complications has declined in the past few years, continued efforts to further reduce complications in patients with AF is urgently required for expansion of TAVR to broader populations.

The study aimed to evaluate cost trends associated with mitral valve transcatheter edge-to-edge repair (TEER).TEER is a treatment option for patients at prohibitive surgical risk with moderate to severe mitral valve regurgitation and NYHA class III or IV symptoms. The 30-day costs and causes of readmission following TEER have not been well studied.Patients undergoing mitral TEER in the United States from 2014 to 2018 were identified in the Nationwide Readmission Database. Patient characteristics, cause-specific readmission, and costs of the index hospitalization and readmissions were analyzed. Costs were trended over years using general linear regression.A total of 10,196 patients underwent mitral TEER during the study period. Thirty-day readmissions were stable over time at around 16%. The mean length of stay following TEER decreased from 7 days in 2014 to 5 days in 2018. There was a significant decline in the cost of the index hospitalization of $1311 per year, and a significant decline in the total 30-day cost of $1588 per year (p 0.001). This was strictly due to a reduction in the cost of the index hospitalization without a change in readmission costs over time (p = 0.23). Infectious causes of readmissions significantly decreased while total cardiovascular readmissions, including heart failure, remained constant.The decreasing 30-day cost burden of TEER is primarily driven by the shorter index length of stay, as experience in TEER has grown and, length of stay has declined. However, cardiovascular readmissions, and consequently readmission costs, have remained steady.