Search

Objective: To test whether biological age calculated using deficits, functional impairments, or their combination will provide improved estimation of long-term mortality among older adults undergoing percutaneous coronary intervention., Patients and Methods: Cardiovascular deficits, noncardiovascular deficits, and functional impairments were prospectively studied in 535 patients aged 55 years or older from August 1, 2014, to March 31, 2018. Models for biological age included deficits (acquired, increase with age, associated with worse prognosis, did not saturate early), functional impairments (subjective-help with daily activities, difficulty with sensory input, continence, weight, balance, mobility; or objective-timed up and go, functional reach), or their combination., Results: The mean ± SD age of the study patients was 72.1±9.5 years. For every 5-year increase in chronological age, the mean number of cardiovascular deficits increased from 2.36 among patients younger than 70 years to 3.44 in nonagenarians. The mean number of functional impairments increased from 2.15 for those younger than 70 years to 6.74 for nonagenarians. During a median follow-up of 2.05 years, 99 patients died. Significant improvement in the Harrell concordance index (C index) for prediction of long-term all-cause mortality was noted with biological age calculated from deficits and impairments compared with chronological age (0.77 vs 0.65; P<.001) and when estimating biological age via functional impairments alone vs chronological age (0.75 vs 0.65; P<.001) but not via deficits alone (0.71 vs 0.65; P=.08). Biological age estimates from subjective functional impairments captured most of the prognostic information related to all-cause and noncardiac mortality, whereas deficit-based estimation favored cardiovascular mortality., Conclusion: The derivation of biological age from deficits and functional impairments provides a major improvement in the estimation of survival as estimated by chronological age., (Copyright © 2023. Published by Elsevier Inc.)

Objective: To study the incidence of complications when undergoing right heart catheterization (RHC) and right ventricular biopsy (RVB)., Methods: Complications following RHC and RVB are not well reported. We studied the incidence of death, myocardial infarction, stroke, unplanned bypass, pneumothorax, hemorrhage, hemoptysis, heart valve repair/replacement, pulmonary artery perforation, ventricular arrhythmias, pericardiocentesis, complete heart block, and deep vein thrombosis (primary endpoint) following these procedures. We also adjudicated the severity of tricuspid regurgitation and causes of in-hospital death following RHC. Diagnostic RHC procedures, RVB, multiple right heart procedures alone or combined with left heart catheterization, and complications from January 1, 2002, through December 31, 2013, were identified using the clinical scheduling system and electronic records at Mayo Clinic, Rochester, Minnesota. International Classification of Diseases, Ninth Revision billing codes were used. Registration was queried to identify all-cause mortality. All clinical events and echocardiograms for worsening tricuspid regurgitation were reviewed and adjudicated., Results: A total of 17,696 procedures were identified. Procedures were categorized into those undergoing RHC (n=5556), RVB (n=3846), multiple right heart catheterization (n=776), and combined right and left heart catheterization procedures (n=7518). Primary endpoint was seen in 21.6 and 20.8 of 10,000 procedures for RHC and RVB, respectively. There were 190 (1.1%) deaths during hospital admission and none was related to the procedure., Conclusion: Complications following diagnostic RHC and RVB are seen in 21.6 and 20.8 procedures, respectively, of 10,000 procedures and all deaths were secondary to acute illness., (Copyright © 2022 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: Aging is associated with progressive loss of muscle mass, as well as replacement of muscle with fat and fibrous tissue. We studied the contribution of muscle fat content, a surrogate marker of biological aging, to frailty and Length of Hospital Stay (LOS) following Transcatheter Aortic Valve Replacement (TAVR)., Methods: We evaluated 415 patients who underwent TAVR from February 2012 to December 2016 at Mayo Clinic, MN, USA. Densities between -190 to -30 Hounsfield Units within the abdominal muscle area were determined as muscle fat. Muscle Fat Index (MFI) was defined as muscle fat mass divided by height squared. LOS was considered as the primary outcome. Stepwise multivariable linear regression was used to identify the predictors of LOS., Results: Mean age ± SD of the study population was 81.2 ± 9.6 years and 58.07% were male. Seventy-two patients (17.35%) had frailty. Median (IQR) LOS was 4 (3-6) days. MFI was higher in patients with frailty (median (IQR); 18.1 [13.8-24.2] vs 14.4 [10.6-18.7], p < 0.001) and was positively correlated with LOS (r = 0.129, p = 0.009). In multivariable analysis of predictors of LOS, MFI (β = 0.06, p = 0.022), pre-TAVR atrial fibrillation/flutter (β = 0.5, p = 0.015), and post-TAVR complications (β = 0.91, p < 0.001) were directly, and femoral access route (β = -1.13, p < 0.001) and pre-TAVR hemoglobin (β = -0.35, p = 0.002) were inversely associated with LOS., Conclusions: MFI can be determined from pre-TAVR CT scans and is a novel predictor of LOS following TAVR. This objective indicator can potentially be used in a pre-TAVR clinic to plan for rehabilitation programs in selected patients., (Copyright © 2021. Published by Elsevier B.V.)

Background: Surgical intervention in patients with native mitral disease due to severe mitral annular calcification (MAC) carries significant risk. Transcatheter mitral valve replacement (TMVR) using balloon-expandable aortic transcatheter heart valve (THV) in MAC had emerged as alternative treatment., Objectives: We aim to study the temporal change in clinical outcomes of the procedure at a single center., Methods: We retrospectively studied 23 patients who underwent TMVR in MAC at Mayo Clinic from January, 14, 2014 to March, 15, 2019. Cases were divided into early (n = 11) and late (n = 12) experience. The primary end point was 30-day all-cause mortality. The secondary end points were immediate technical success, 30-day procedural success, and 1-year all-cause mortality., Results: Mean age of patients was 75.2 ± 8.9 years and 17 (74.0%) were female. Median STS score for 30-day mortality was 8 (Interquartile range 4.3-13.4) for the entire population. Immediate technical success was achieved in 21 out of 23 patients (two failures in the early experience were related to tamponade and procedural death). Thirty-day procedural success was higher in the late experience (10 out of 12 patients) compared to early experience (5 out of 11 patients, p = .06). Four deaths in the first 30-days were observed in the early experience while all patients survived to hospital discharge in the late experience (p = .01)., Conclusions: Procedural success and 30-day survival of transcatheter mitral valve replacement in severe mitral annular calcification procedure using balloon-expandable aortic prosthesis had improved over the years. This is likely attributed to significant advancement in procedural planning, valve design, and techniques., (© 2021 Wiley Periodicals LLC.)

Objectives: To evaluate the outcomes of transcatheter coronary artery fistula (CAF) closure and to identify anatomic/procedural factors that may impact outcomes., Background: Due to the rarity of CAF, reported experience with transcatheter closure remains limited and anatomic and procedural factors that may lead to unsuccessful closure, complications, or recanalization of CAF are unclear., Methods: All patients who underwent transcatheter CAF closure at Mayo Clinic from 1997 to 2018 were retrospectively reviewed. CAF anatomic characteristics, procedural techniques, and clinical/angiographic outcomes were assessed., Results: A total of 45 patients underwent transcatheter closure of 56 CAFs. The most commonly used devices were embolization coils in 40 (71.4%) CAFs, vascular occluders in 10 (17.8%), or covered stent in 2 (3.6%). Acute procedural success with no or trivial residual flow occurred in 50 (89.3%) CAFs. Residual flow was small in three (5.4%) and large in three (5.4%). Eight (17.8%) patients had complications, including device migration in three, intracranial hemorrhage from anticoagulation in one, and myocardial infarction (MI) in four. MI was a result of covered stent thrombosis or stagnation of flow after closure of large distal CAF. Twenty-two patients with 27 CAFs had follow-up angiography after successful index procedure at median time of 423 (IQ 97-1348) days. Of these, 23 (85.2%) had no/trace flow and 4 had large flow from recanalization., Conclusions: Transcatheter CAF closure is associated with a favorable acute procedural success and complication rate in selected patients. Procedural success and risk for complication are highly dependent on CAF anatomy and closure technique., (© 2020 Wiley Periodicals, Inc.)

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., (Copyright © 2019 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: MAVD, defined as severe aortic stenosis with moderate or severe aortic regurgitation, is frequently encountered in clinical practice. However, the data regarding TAVR outcomes in MAVD are sparse. We compared Transcatheter Aortic Valve Replacement (TAVR) outcomes between Mixed Aortic Valve Disease (MAVD) and Predominant Aortic Stenosis (PAS) patients., Methods: Patients who underwent TAVR at Mayo Clinic from February 7, 2012 to December 16, 2016 were enrolled. The primary end point was all-cause mortality. Secondary end points were central or paravalvular regurgitation, device success, and Valve Academic Research Consortium (VARC)-2 defined post TAVR complications (access site complications, bleedings, myocardial infarction, stroke, and cardiac arrest)., Results: A total of 622 patients were enrolled. Mean age was 81 ± 8.9 years, and 263 (42.3%) were female. Median follow-up duration was 1.5 years. One hundred and sixteen patients (18.6%) had MAVD. Central or paravalvular leak was higher in MAVD patients post-TAVR (15.5% vs 6.7%, P = 0.004). Device success and VARC-2 in-hospital complications were similar between the two groups. The cumulative probability of survival at 3 years was 71.3% in MAVD patients vs. 62.6% in PAS patients (Log-Rank P = 0.024). In a multi-variant logistic regression analysis, MAVD was an independent negative predictor of all-cause mortality (HR = 0.53, 95% CI 0.3-0.89, P = 0.015)., Conclusions: A significant number of patients referred for TAVR have MAVD disease. Despite higher rates of paravalvular regurgitation, all-cause mortality at mid-term was lower in patients with MAVD compared with those with PAS. Our results show the safety and efficacy of TAVR in MAVD patients., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: The clinical utility of routine electrocardiographic monitoring following percutaneous coronary interventions (PCI) is not well studied., Methods: We prospectively evaluated the incidence, cost, and the clinical implications of actionable arrhythmia alarms on telemetry monitoring following PCI. One thousand three hundred fifty-eight PCI procedures (989 [72.8%] for acute coronary syndrome and 369 [27.2%] for stable angina) on patients admitted to nonintensive care unit were identified and divided into 2 groups; group 1, patients with actionable alarms (AA) and group 2, patients with non-AA. AA included (1) ≥3 s electrical pause or asystole; (2) high-grade Mobitz type II atrioventricular block or complete heart block; (3) ventricular fibrillation; (4) ventricular tachycardia (>15 beats); (5) atrial fibrillation with rapid ventricular response; (6) supraventricular tachycardia (>15 beats). Primary outcomes were 30-day all-cause mortality. Cost-savings analysis was performed., Results: Incidence of AA was 2.2% (37/1672). Time from end of procedure to AA was 5.5 (0.5, 24.5) hours. Patients with AA were older, presented with acute congestive heart failure or non-ST-segment-elevation myocardial infarction, and had multivessel or left main disease. The 30-day all-cause mortality was significantly higher in patients with AA (6.5% versus 0.3% in non-AA [ P <0.001]). Applying the standardized costing approach and tailored monitoring per the American Heart Association guidelines lead to potential cost savings of $622 480.95 for the entire population., Conclusions: AA following PCI were infrequent but were associated with increase in 30-day mortality. Following American Heart Association guidelines for monitoring after PCI can lead to substantial cost saving.

Background: Treatment of hemodynamically significant mitral annular calcification (MAC) using transcatheter approaches is in the early learning phase. The occurrence of paravalvular leak (PVL) following transcatheter mitral valve in MAC is common., Aims: To report the initial experience and techniques of percutaneous PVL closure after transcatheter valve in MAC., Methods: This series includes five consecutive patients who underwent percutaneous PVL closure following transcatheter balloon expandable SAPIEN S3 valve in MAC., Results: Mean patient age was 73.6 ± 5.4 years (4 [80%] female), with average Society of Thoracic Surgeons score of 8.1 ± 2.8%. Three patients had a single PVL defect while two patients had two defects; all were located at the commissural sites. Closure was performed primarily for heart failure in four patients and hemolytic anemia in one patient. Transfemoral transseptal antegrade approach and Amplatz Vascular Plug (AVP)-II occluders were utilized in all patients. Procedure success was achieved in three patients. One patient developed significant occluder related leaflet impingement and subsequent severe prosthetic mitral regurgitation requiring a second transcatheter mitral valve in valve implantation. The procedure was aborted in one patient due to difficulty crossing PVL defect after balloon post-dilatation of SAPIEN prosthesis with 10 mL of additional volume. There was no in hospital or 30 day mortality or the need for emergent surgery., Conclusion: Early experience with percutaneous PVL closure of SAPIEN valve in MAC demonstrated feasibility of this approach. Careful procedure planning and monitoring for SAPIEN prosthesis leaflet impingement and frame instability is of utmost importance to increase the chances of procedural success., (© 2019 Wiley Periodicals, Inc.)

Background: The effect of utilizing transapical (TA) access for transcatheter aortic valve replacement (TAVR) on cardiac function has not been well studied., Aims: The aim of this retrospective study is to determine the direct effects of TA access for TAVR on myocardial function parameters and their correlation with 4-year survival., Methods: Three hundred and thirty propensity matched patients, who underwent TAVR using Sapien valve (Edwards Lifesciences Corp, Irvine, CA) between February 15, 2012 and June 17, 2016 (115 TA and 115 transfemoral [TF] routes) were studied. The pre- and 1 month post-TAVR echocardiographic features of both groups were compared. The 4-year survival in both groups was analyzed., Results: Baseline clinical characteristics, diastolic function parameters, left ventricular (LV) chamber size, and ejection fraction were similar between matched TA and TF groups. At 1 month following TAVR, there was a significant increase in stroke volume index (SVI) in both TA (mean increase 7 cm 3 /m 2 ; P = 0.03) and TF groups (mean increase 7 cm 3 /m 2 ; P < 0.001). Left ventricular ejection fraction (LVEF) significantly increased post TF TAVR (mean increase 2%; P = 0.008), but no significant increase was observed post TA TAVR (mean increase 1%; P = 0.27). Both groups had significant improvement in aortic valve (AV) hemodynamics post-TAVR (P < 0.001). Overall, there were no significant differences in the mean change of SVI, LVEF, or left ventricular end diastolic dimensions (LVEDDs) post TA versus TF TAVR. There was no significant difference in 4-year survival in the TF compared to TA group (49% vs 50%, P = 0.43)., Conclusion: Both TA and TF TAVR were equally associated with favorable changes in LV SVI and AV hemodynamics in 30 days. TA TAVR patients had similar 4 year survival to propensity matched TF TAVR; therefore, TA TAVR remains an acceptable alternative access route in patients not amenable to TF TAVR., (© 2019 Wiley Periodicals, Inc.)

Aims: Sarcopaenia is a prevalent disease of ageing, associated with adverse clinical outcomes. We aimed to compare in-hospital adverse outcomes and overall mortality in sarcopaenic and non-sarcopaenic patients undergoing transcatheter aortic valve replacement (TAVR)., Methods and Results: This was a retrospective cohort study including 602 patients who underwent TAVR. Sarcopaenia was defined as skeletal muscle mass index <55.4 cm2/m2 in males and <38.9 cm2/m2 in females obtained through pre-TAVR CT scan. Mortality, length of hospital stay, ICU admission, and Valve Academic Research Consortium (VARC)-2-defined post-TAVR complications were defined as outcomes. Study participants (mean age 80.9±8.9 years and 56.8% male) were followed for a median of 1.5 years. Two thirds of the TAVR population was sarcopaenic. In-hospital outcomes were similar in both groups; however, overall survival was worse in sarcopaenic patients (HR for mortality=1.46 [1.06-2.14], p=0.02). In a multivariable model, sarcopaenia, porcelain aorta, pre-TAVR atrial fibrillation/flutter, severe chronic kidney disease, chronic pulmonary disease, VARC-2 bleeding, acute renal failure following TAVR, and post-TAVR cardiac arrest were predictors of mortality., Conclusions: Sarcopaenic patients had similar in-hospital clinical outcomes to non-sarcopaenic patients following TAVR which reveals TAVR safety in sarcopaenic patients. However, sarcopaenia was an independent risk factor for midterm mortality indicating its potential value in systematic evaluation of this highly comorbid population in order to decide the best treatment approaches.

Background: We aim to study the incidence of major complications related to procedure defined as in-hospital death, myocardial infarction, stroke, pericardial effusion or tamponade, percutaneous coronary intervention due to iatrogenic coronary dissection, or unplanned bypass surgery within 72 hours after diagnostic left heart catheterization (LHC; primary end point). Furthermore, all causes of in-hospital death after LHC were adjudicated and reported (secondary end point)., Methods and Results: Diagnostic LHC procedures (aortic angiography; coronary, including graft, angiography; and left ventricular angiography) from January 1, 2002, through December 31, 2013, were identified using the clinical scheduling system at Mayo Clinic, Rochester, and complications were identified through electronic records. International Classification of Diseases, Ninth Revision billing codes were used. Registration was queried to identify all-cause mortality. All events were reviewed and adjudicated. There were 43 786 diagnostic LHC procedures; 97.3% were coronary angiograms. The mean age of patients was 64.5 years (13.6), and the majority were male (61.5%). Primary end point was seen in 36 (0.082%) procedures or 8.2 of 10 000 LHCs. Combined right sided procedures with LHC did not increase the risk of major complications. Cardiogenic and septic shock, cardiac arrhythmia, and postsurgical complication were the most common causes of in-hospital death after LHC., Conclusions: The overall rates of major complications related to diagnostic cardiac catheterization procedures are extremely rare. The majority of the deaths occurring post-diagnostic LHC procedures were secondary to acute illness rather than directly related to diagnostic procedure.

Background Patients with symptomatic severe aortic stenosis and a history of chest radiation therapy represent a complex and challenging cohort. It is unknown how transcatheter aortic valve replacement ( TAVR ) compares with surgical aortic valve replacement in this group of patients, which was the objective of this study. Methods and Results We retrospectively reviewed all patients with severe aortic stenosis who underwent either TAVR or surgical aortic valve replacement at our institution with a history of mediastinal radiation (n=55 per group). End points were echocardiographic and clinical outcomes in-hospital, at 30 days, and at 1 year. Inverse propensity weighting analysis was used to account for intergroup baseline differences. TAVR patients had a higher STS score than surgical aortic valve replacement patients (5.1% [3.2, 7.7] versus 1.6% [0.8, 2.6], P<0.001) and more often ( P<0.01 for all) a history of atrial fibrillation (45.5% versus 12.7%), chronic lung disease (47.3% versus 7.3%), peripheral arterial disease (38.2% versus 7.3%), heart failure (58.2% versus 18.2%), and pacemaker therapy (23.6% versus 1.8%). Postoperative atrial fibrillation was less frequent (1.8% versus 27.3%; P<0.001) and hospital stay was shorter in TAVR patients (4.0 [2.0, 5.0] versus 6.0 [5.0, 8.0] days; P<0.001). The ratio of observed-to-expected 30-day mortality was lower after TAVR as was 30-day mortality in inverse propensity weighting-adjusted Kaplan-Meier analyses. Conclusions In patients with severe aortic stenosis and a history of chest radiation therapy, TAVR performs better than predicted along with less adjusted 30-day all-cause mortality, postoperative atrial fibrillation, and shorter hospitalization compared with surgical aortic valve replacement. These data support further studies on the preferred role of TAVR in this unique patient population.

The purpose of this study was to test the hypothesis that an experimental high fat (HF) animal with metabolic syndrome results in structural degeneration of the aortic valve. Domestic pigs were divided (n = 12) and administered either a normal or HF diet. After 16-weeks, the HF diet group had increased weight (p ≤ 0.05), total cholesterol (p ≤ 0.05), and systolic and diastolic pressure (p ≤ 0.05). The aortic valve extracellular matrix showed loss of elastin fibers and increased collagen deposition in the HF diet group. Collagen was quantified with ELISA, which showed an increased concentration of collagen types 1 and 3 (p ≤ 0.05). In the HF diet group, the initial stages of microcalcification were observed. Uniaxial mechanical testing of aortic cusps revealed that the HF diet group expressed a decrease in ultimate tensile strength and elastic modulus compared to the control diet group (p ≤ 0.05). Western blot and immunohistochemistry indicated the presence of proteins: lipoprotein-associated phospholipase A2, osteopontin, and osteocalcin with an increased expression in the HF diet group. The current study demonstrates that experimental metabolic syndrome induced by a 16-week HF diet was associated with a statistically significant alteration to the physical architecture of the aortic valve.

Introduction: Three-dimensional (3D) prototyping is a novel technology which can be used to plan and guide complex procedures such as transcatheter mitral valve replacement (TMVR)., Methods: Eight patients with severe mitral annular calcification (MAC) underwent TMVR. 3D digital models with digital balloon expandable valves were created from pre-procedure CT scans using dedicated software. Five models were printed. These models were used to assess prosthesis sizing, anchoring, expansion, paravalvular gaps, left ventricular outflow tract (LVOT) obstruction, and other potential procedure pitfalls. Results of 3D prototyping were then compared to post procedural imaging to determine how closely the achieved procedural result mirrored the 3D modeled result., Results: 3D prototyping simulated LVOT obstruction in one patient who developed it and in another patient who underwent alcohol septal ablation prior to TMVR. Valve sizing correlated with actual placed valve size in six out of the eight patients and more than mild paravalvular leak (PVL) was simulated in two of the three patients who had it. Patients who had mismatch between their modeled valve size and post-procedural imaging were the ones that had anterior leaflet resection which could have altered valve sizing and PVL simulation. 3D printed model of one of the latter patients allowed modification of anterior leaflet to simulate surgical resection and was able to estimate the size and location of the PVL after inserting a valve stent into the physical model., Conclusion: 3D prototyping in TMVR for severe MAC is feasible for simulating valve sizing, apposition, expansion, PVL, and LVOT obstruction., (© 2018 Wiley Periodicals, Inc.)

Objective: To study the influence of anemia on long-term outcomes of patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI)., Patients and Methods: The study included 5668 consecutive unique patients with acute coronary syndrome who underwent PCI at Mayo Clinic from January 1, 2004, through December 31, 2014. The patients were stratified on the basis of the presence (hemoglobin [Hgb] level, <13 g/dL in men and <12 g/dL in women) and severity (moderate to severe Hgb level, <11 g/dL in men and women) of pre-PCI anemia and compared with patients without anemia. The primary outcomes were in-hospital and long-term all-cause mortality after balancing baseline comorbidities using the inverse propensity weighting method., Results: Unadjusted all-cause in-hospital mortality (4.6% [84 of 1831] vs 2.0% [75 of 3837]) and 5-year follow-up mortality (44.4% [509] vs 15.4% [323]) were higher in patients with anemia than in those without anemia (P<.001 for both). After applying inverse propensity weighting analysis, the all-cause in-hospital mortality (2.0% [37] vs 2.0% [75]; P=.85) and 5-year mortality (17.8% [203] vs 15.4% [323]; P=.05) were not significantly different between patients with and without anemia; however, there were higher rates of all-cause 5-year mortality in patients with moderate to severe anemia (22.3% [113] vs 15.4% [323]; P<.001) compared with patients without anemia. The trend in 5-year mortality was driven by increased noncardiac mortality in patients with anemia (10.2% [91] vs 7.1% [148]; P=.04) and moderate to severe anemia (10.4% [52] vs 7.1% [148]; P=.006) when compared with nonanemic patients., Conclusion: After accounting for differences in risk profiles of anemic and nonanemic patients, anemia appeared to be an independent risk factor for increased long-term all-cause and noncardiac mortality., (Published by Elsevier Inc.)

Objective: Female sex is a known risk factor for cardiac surgery, and tricuspid valve (TV) disease is more common in women. There are few data on sex-stratified surgical outcomes for isolated TV surgery. An administrative database was used to compare acute in-hospital outcomes between men and women undergoing isolated TV surgery., Methods: Patients aged >18 who underwent TV repair or replacement from 2004 to 2013 were identified using the National Inpatient Sample. Patients were excluded if they had congenital heart disease, endocarditis, or were undergoing concomitant cardiac surgeries except coronary bypass. Results were weighted to represent national averages. Sex-stratified analysis was performed using propensity score matching to compare in-hospital mortality, postoperative complications and hospital costs., Results: Over 10 years, women represented 58% of the 5005 TV surgeries performed. With propensity matching, hospital mortality (7.9% vs 7.7%; P=0.99) and median length of stay (11 vs 11 days; P=0.99) were similar between men and women. However, median hospital charges were higher for men ($166 000 vs $155 000; P=0.04)., Conclusion: Isolated TV surgery is rare, but women more commonly undergo the procedure. In-hospital mortality was similar between men and women after propensity matching, but remains markedly high for both men and women in comparison to that reported for left-sided isolated valve surgery., Competing Interests: Competing interests: None declared.

Objectives: Patients with symptomatic severe mitral annular calcification present a therapeutic challenge. Direct transatrial implantation of SAPIEN valve has emerged as an alternative to surgical mitral valve (MV) replacement for high-risk surgical candidates., Methods: This series includes 6 consecutive patients with symptomatic severe mitral annular calcification deemed to be at high risk for standard surgery. All patients underwent direct transatrial implantation of balloon-expandable SAPIEN valve in the mitral position., Results: Mean age was 81 years [3 (50%) female], with an average Society of Thoracic Surgeons score of 10.3%. All patients had at least New York Heart Association Class III symptoms. Procedure was performed using normothermic cardiopulmonary bypass. The MV was approached through a standard left atriotomy in 4 patients and via a vertical trans-septal approach in the remaining 2 patients. Resection of the anterior leaflet of the MV was performed in 4 patients. The valve was successfully deployed in all patients. The diastolic mean gradient across the MV decreased from an average of 14 ± 3 to 5 ± 1 mmHg post deployment. There was no left ventricular outflow tract obstruction. MV periprosthetic regurgitation was severe in 3 patients and moderate to severe in 1 patient. In-hospital mortality occurred in 3 (50%) patients due to a non-cardiac cause in 1 patient and cardiogenic shock in the other 2 patients., Conclusions: Early experience with direct transatrial balloon-expandable implantation for severe mitral annular calcification revealed feasibility of this approach but significant morbidity and mortality primarily related to periprosthetic regurgitation that requires further refinement of the technique., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Percutaneous paravalvular leak (PVL) closure is an alternative treatment option for severely symptomatic, high-surgical risk patients with PVL. Some patients require multiple percutaneous PVL closure procedures. However, the procedural characteristics and success rate of re-do PVL closure have not been well studied., Aims: The aim of this study is to investigate the indications, procedural characteristics, technical success rate, and 30-day major adverse cardiovascular events (MACE) in patients who underwent re-do PVL closure., Methods: Consecutive patients who underwent percutaneous paramitral or paraaortic leak closure at Mayo Clinic, Rochester, Minnesota from 2004 through 2015 were studied. Clinical and procedural characteristics of patients who underwent re-do PVL closure were compared to age- and sex-matched patients who underwent their first percutaneous PVL closure. Procedure success and 30-day MACE were compared in both the groups., Results: Among 223 identified percutaneous PVL closures, 16 (7%) were re-do procedures. Patients who underwent re-do PVL closure were predominantly men (87.5%) with a mean age of 68 ± 15 years and an estimated mean Society of Thoracic Surgery (STS) 30-day mortality of 4.6 ± 2.8. Half of the re-do PVL closures were performed on mechanical valves and 62.5% were performed on paramitral defects. Indications for re-do PVL closure were: (1) emergence of new significant paravalvular defects in 50%, (2) incomplete index defect closure in 43.75%, and (3) index procedural complication in 6.25% of the cases. Procedural success was 75% in re-do procedures vs. 85.4% in age- and sex-matched control group (P = 0.45). Thirty-day MACE was 12.5% in the re-do group compared to 4.2% in the age- and-sex matched patients who underwent PVL closure for the first time (P = 0.35)., Conclusion: Re-do percutaneous PVL closure is feasible with favorable procedural success rate and low 30-day MACE. Development of new paravalvular defects is the most common indication for re-do PVL closure, highlighting the importance of careful longitudinal monitoring and follow-up. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Aims: Outcomes among patients who do not receive device reimplantation after cardiovascular implantable electronic device (CIED) extraction have not been well studied. The present study aims to investigate the outcomes of patients without device reimplantation after lead extraction and device removal., Methods and Results: We retrospectively searched for consecutive patients who underwent CIED extraction at Mayo Clinic, Rochester, MN and University of California San Diego Medical Center from 2001 through 2012. Among the patients identified, we compared characteristics of those who did and did not have device reimplantation. The Kaplan-Meier survival was analysed. Among 678 patients, 97 patients had their device extracted without reimplantation during 1-year follow-up ('no-reimplant group'). Median age was younger in the no-reimplant group (60.7 vs. 70.6 years; P < 0.001). The reasons for no reimplantation were as follows: no longer meeting criteria for CIED (48%), inappropriate device indication at initial implantation (23%), patient preference (17%), and unresolved device complications (12%). Three major arrhythmias were reported in the no-reimplant group. Overall survival in the no-reimplant group was significantly lower than in the reimplant group (60 vs. 93%; P < 0.001). Ongoing device-related complications [hazard ratio (HR), 3.91; 95% CI, 1.74-8.81; P = 0.001], infection (HR, 3.06; 95% CI, 1.24-7.52; P = 0.02), and concurrent dialysis (HR, 2.74; 95% CI, 1.12-6.71; P = 0.03) were associated with increased mortality. Of 31 deaths in the no-reimplant group, 1 was secondary to cardiac arrhythmia., Conclusion: Fourteen per cent of patients who had device extraction did not undergo reimplantation mainly because they no longer met CIED indications. The high mortality in these patients is related to device complications and comorbid conditions, whereas mortality associated with arrhythmia is rare., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Current research on valvular heart repair has focused on tissue-engineered heart valves (TEHV) because of its potential to grow similarly to native heart valves. Decellularized xenografts are a promising solution; however, host recellularization remains challenging. In this study, decellularized porcine aortic valves were implanted into the right ventricular outflow tract (RVOT) of sheep to investigate recellularization potential. Porcine aortic valves, decellularized with sodium dodecyl sulfate (SDS), were sterilized by supercritical carbon dioxide (scCO2) and implanted into the RVOT of five juvenile polypay sheep for 5 months (n = 5). During implantation, functionality of the valves was assessed by serial echocardiography, blood tests, and right heart pulmonary artery catheterization measurements. The explanted valves were characterized through gross examination, mechanical characterization, and immunohistochemical analysis including cell viability, phenotype, proliferation, and extracellular matrix generation. Gross examination of the valve cusps demonstrated the absence of thrombosis. Bacterial and fungal stains were negative for pathogenic microbes. Immunohistochemical analysis showed the presence of myofibroblast-like cell infiltration with formation of new collagen fibrils and the existence of an endothelial layer at the surface of the explant. Analysis of cell phenotype and morphology showed no lymphoplasmacytic infiltration. Tensile mechanical testing of valve cusps revealed an increase in stiffness while strength was maintained during implantation. The increased tensile stiffness confirms the recellularization of the cusps by collagen synthesizing cells. The current study demonstrated the feasibility of the trans-species implantation of a non-fixed decellularized porcine aortic valve into the RVOT of sheep. The implantation resulted in recellularization of the valve with sufficient hemodynamic function for the 5-month study. Thus, the study supports a potential role for use of a TEHV for the treatment of valve disease in humans.

A 75-year-old man presented with infective endocarditis. Transesophageal echocardiogram (TEE) revealed mild-moderate mitral regurgitation (MR). After 4 weeks of antibiotics, he presented with New York Heart Association class III dyspnea. Repeat TEE demonstrated severe MR. After consultation with Infectious Diseases, it was determined the infection risk was low and transcatheter mitral valve repair (TMVR) was offered. Deployment of two MitraClip devices (Abbott Vascular) resulted in symptom relief. This case demonstrates a potential role of TMVR in treating acute severe MR due to endocarditis.

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., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Atrial fibrillation (AF) ablation is superior to pharmacologic therapy in achieving maintenance of normal sinus rhythm in selected patient populations. However, the procedure is resource intensive, and repeat ablations are sometimes required. We examined the predictors and trends of repeat ablation using a large national administrative claims database., Methods: Privately insured and Medicare Advantage patients who underwent catheter ablation for AF between January 1, 2004, and September 30, 2014, were included in the study. The primary outcome was repeat AF ablation during enrollment. We examined the associations between repeat ablation and patient demographics (age, gender, socioeconomic demographics), comorbid conditions (CHA2DS2-Vasc score and Charlson index), and year of the index ablation. Cox proportional hazard models were used to identify predictors of repeat ablation., Results: We included 8,648 adult patients in the analysis. Median age was 61.0 (interquartile range [IQR] 54-68) years, and 70.9% were men. Median follow-up was 1.1 (IQR 0.5-2.3) years. A total of 1,263 patients underwent repeat ablation (14.6%) over a total of 14,280 person-years (12.1% at 1 year). The hazard ratio (HR) for repeat ablation was higher in younger patients (HR 0.75 [0.61-0.91; P < .01] for age 65-75 and 0.55 [0.4-0.75; P < .001] for age ≥ 75 compared with age 18-54), those with higher household income (HR 1.24 [1-1.54; P < .05] for household income ≥ $100,000 compared with household income < $40,000), patients treated in the south (HR 1.15 [1-1.31]; P < .05), and those on antiarrhythmic medications (HR 1.15 [1.01-1.31]; P < .05). In particular, younger patients (ages 18-54 years) continued to undergo repeat ablations over the entire follow-up period, and the cumulative rate was approximately 40% among those followed for 5 years. Clinical characteristics including those included in the CHA2DS2-Vasc score and Charlson index did not predict likelihood of repeat ablation. The rate of repeat ablation remained constant over the available follow-up., Conclusion: Approximately 1 in 8 patients treated with catheter ablation for AF will undergo a second procedure within 1 year, although the rate is as high as 40% in young patients at 5 years. The rate of repeat ablation appears to be associated with demographic characteristics (younger age and higher household income) rather than medical comorbidities., (Copyright © 2015 Elsevier Inc. All rights reserved.)

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 <400 mg/dl who underwent lipid testing by vertical spin density gradient ultracentrifugation (Atherotech, Birmingham, Alabama) from 2009 to 2011., 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 <70 mg/dl, 15% had a non-HDL-C level ≥ 100 mg/dl (guideline-based cutpoint) and 25% had a non-HDL-C level ≥ 93 mg/dl (percentile-based cutpoint); if triglyceride levels were 150 to 199 mg/dl concurrently, these values were 22% and 50%, respectively., 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., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)