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Chronic kidney disease (CKD) is becoming increasingly common and is associated with development and rapid progression of aortic stenosis (AS). Patients with AS and CKD have higher mortality rates than those with AS of similar severity and normal kidney function. The diagnosis of severe AS in patients with CKD is often challenging due to alterations in haemodynamics and heart structure, and integration of data from multiple imaging modalities may be required. When indicated, the definitive treatment for severe AS is aortic valve replacement. Patients with CKD are candidates for bioprosthetic valve replacement (surgical or transcatheter aortic valve implantation) or mechanical valve replacement. However, for patients with CKD, lifetime management is complex, as patients with CKD have a higher competing risk of bioprosthetic structural valve deterioration, bleeding in the setting of systemic anticoagulation and mortality related to CKD itself. The involvement of a heart-kidney multidisciplinary team in the care of patients with CKD and severe AS is ideal to navigate the complexities of diagnosis and management decisions.

Introduction: The 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease recommends adults engage in ≥ 150 minutes of moderate or ≥75 minutes of vigorous intensity aerobic activity per week to reduce cardiovascular risk. Cardiologist adherence to these guidelines is unknown. Methods: Electronic surveys were sent to 437 ACC CardioSurve cardiologists, a representative sample of current ACC members. Demographic data was collected. Respondents were asked to quantify and rate intensity of exercise in an average week. Results: Between February and March 2020, a total of 189 panelists completed the survey for a response rate of 43%, of which 13% were women. There was even representation in number of years in practice: 33% early career, 27% mid-career, and 35% late career. Cardiologists across all career stages were evenly represented; 33% early career, 27% mid-career, and 35% late career. Overall only 56% of cardiologists met exercise guidelines (Figure). Less than half participated in vigorous activity (46%) with higher prevalence among mid versus early career (58% vs 38%, p=0.035). Interventional cardiologists were less likely to meet the standards for exercise intensity compared to general cardiology (44% vs. 59%, p=0.09). Early career respondents were less likely to adhere to activity recommendations (39% vs 59%, p=0.018). Those who reported vigorous activity were more likely to strength train at least twice per week (43% vs. 15%, p < 0.001). Conclusions: Nearly half of cardiologists are not adherent to the ACC recommended guidelines for aerobic activity. The impact on cardiologists’ health was not quantified, but this study suggests there is room for improvement in prevention behaviors. Since physicians are known to serve as role models for their patients, we hypothesize lack of adherence to activity guidelines may also negatively impact our patients.

Superior vena cava (SVC) syndrome results from the blockage of venous blood flow through the SVC, which is caused by either internal obstruction (eg, thrombus) or external compression (eg, thoracic malignancy and infection).1 While thrombus-related SVC syndrome is rising in prevalence, malignancy still accounts for the majority of cases.1 Regardless of cause, SVC syndrome is characterised by facial swelling and plethora, headache and dyspnoea.2 Although venous stenting has become standard of care for treatment of acute SVC syndrome, stent placement presents multiple risks including SVC rupture and cardiac tamponade. In these cases, a high index of suspicion and prompt action are required to avoid an often fatal outcome. Here, we present the case of a patient with cardiac tamponade and subsequent cardiac arrest after SVC stent placement.

Objectives The purpose of this study was to identify sex-specific outcomes of intermediate risk patients undergoing transcatheter aortic valve replacement with the SAPIEN 3 valve. Background A survival difference has been observed in women as compared with men in inoperable and high-risk patients receiving early-generation balloon-expandable valves for transcatheter aortic valve replacement (TAVR). Whether a sex-specific outcome difference persists with newer-generation valves and in lower-risk patients is unknown. Methods The PARTNER (Placement of Aortic Transcatheter Valves) II S3 trial included high-risk (HR) (Society of Thoracic Surgeons risk score >8% or heart team determination) and intermediate-risk (IR) (Society of Thoracic Surgeons risk score 4% to 8% or heart team determination) patients with severe symptomatic aortic stenosis who were treated with TAVR with the SAPIEN 3 valve. Patient characteristics and clinical outcomes at 30 days and 1 year were compared by sex. Results Between October 2013 and December 2014, 1,661 patients were enrolled: 583 were HR (338 men, 245 women) and 1,078 were IR (666 men, 412 women). In both cohorts, women were more likely than men to be frail (22% vs. 13%; p Conclusions The study found no apparent sex-specific differences in survival or stroke in this trial of TAVR. This may reflect the changing demographic of patients enrolled, use of newer-generation valves with more sizes available, and more accurate valve sizing techniques.

Background Acute kidney injury after cardiac surgery significantly associates with morbidity and mortality. Despite not requiring cardiopulmonary bypass, transcatheter aortic valve replacement patients have an incidence of post-procedural acute kidney injury similar to patients who undergo open surgical aortic valve replacement. Packed red blood cell transfusion has been associated with morbidity and mortality after cardiac surgery. We hypothesized that packed red blood cell transfusion independently associates with acute kidney injury after transcatheter aortic valve replacement, after accounting for other risk factors. Methods This is a single-center retrospective cohort study of 116 patients undergoing transcatheter aortic valve replacement. Post-transcatheter aortic valve replacement acute kidney injury was defined by Kidney Disease: Improving Global Outcomes serum creatinine-based criteria. Univariate comparisons between patients with and without post-transcatheter aortic valve replacement acute kidney injury were made for clinical characteristics. Multivariable logistic regression was used to assess independent association of packed red blood cell transfusion with post-transcatheter aortic valve replacement acute kidney injury (adjusting for pre-procedural renal function and other important clinical parameters). Results Acute kidney injury occurred in 20 (17.2%) subjects. Total number of packed red blood cells transfused independently associated with post-procedure acute kidney injury (OR = 1.67 per unit, 95% CI 1.13–2.47, P = 0.01) after adjusting for pre-procedure estimated glomerular filtration rate (OR = 0.97 per ml/min/1.73m2, 95% CI 0.94–1.00, P = 0.05), nadir hemoglobin (OR = 0.88 per g/dL increase, CI 0.61–1.27, P = 0.50), and post-procedure maximum number of concurrent inotropes and vasopressors (OR = 2.09 per inotrope or vasopressor, 95% CI 1.19–3.67, P = 0.01). Conclusion Packed red blood cell transfusion, along with post-procedure use of inotropes and vasopressors, independently associate with acute kidney injury after transcatheter aortic valve replacement. Further studies are needed to elucidate the pathobiology underlying these associations.

Background— Women Methods and Results— Using the National Heart, Lung, and Blood Institute Dynamic Registry, we evaluated the association of sex and age on cardiovascular-related outcomes in10 963 patients (3797 women, 394 P =0.003), driven largely by higher rates of repeat revascularizations for target vessel or target lesion failure (coronary artery bypass graft surgery: 8.9% versus 3.9%, P P =0.005, adjusted hazard ratio 1.6, 95% confidence interval 1.2–2.2). At 5 years, young women remained at higher risk for repeat procedures (coronary artery bypass graft surgery: 10.7% versus 6.8%, P =0.04, adjusted hazard ratio 1.71, 95% confidence interval 1.01–2.88; repeat PCI [target vessel]: 19.7% versus 11.8%, P =0.002, adjusted hazard ratio 1.8, 95% confidence interval 1.24–2.82). Compared with older women, younger women remained at increased risk of major adverse cardiovascular events, whereas all outcome rates were similar in older women and men. Conclusions— Young women, despite having less severe angiographic coronary artery disease, have an increased risk of target vessel and target lesion failure. The causes of this difference deserve further investigation. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00005677.

Background— Some patients with severe symptomatic aortic stenosis (AS) do not undergo aortic valve replacement (AVR) despite demonstrated symptomatic and survival advantages and despite unequivocal guideline recommendations for surgical evaluation. Methods and Results— In 3 large tertiary care institutions (university, Veterans Affairs, and private practice) in Washtenaw County, Mich, patients were identified with unrefuted echocardiography/Doppler evidence of severe AS during calendar year 2005. Medical records were retrospectively reviewed for symptoms, referral for AVR, calculated operative risk for AVR, and rationale as to why patients did not undergo valve replacement. Of 369 patients with severe AS, 191 (52%) did not undergo AVR. Of these, 126 (66%, 34% of total) had symptoms consistent with AS. The most common reasons cited for absent intervention were comorbidities with high operative risk (61 patients [48%]), patent refusal (24 patients [19%]), and symptoms unrelated to AS (24 patients [19%]). Operated patients had a lower Society of Thoracic Surgery–calculated perioperative mortality risk than unoperated patients (1.8% [interquartile range, 1.0 to 3.0%] versus 2.7% [interquartile range, 1.6 to 5.5%], P Conclusions— One third of patients with severe AS are symptomatic but do not undergo AVR, with similar findings in multiple practice environments. For most unoperated patients, objectively calculated operative risks did not appear prohibitive. Despite this, a minority of unoperated patients were referred for surgical consultation. Some patients with severe symptomatic AS may be inappropriately denied access to potentially life-saving therapy.

A survival benefit following transcatheter aortic valve replacement (TAVR) was observed in females as compared to males in inoperable and high-risk patients receiving early generation balloon expandable valves. Whether sex specific outcomes benefit persists in lower risk patients treated with the

The management of cardiovascular disease has seen revolutionary changes within the past decade. The treatment of valvular heart disease, and more specifically symptomatic aortic stenosis, has been at the epicenter of these changes. Transcatheter aortic valve replacement (TAVR) has filled the gap in the treatment of patients who were previously deemed inoperable; a number that could be as high as 40% of all patients with aortic stenosis [1]. Since the first TAVR on April 16, 2002, transcatheter valve technology has been improved, and evaluation and selection of patients for this therapy refined, with rapid expansion. In this issue of Trends in Cardiovascular Medicine, Abdel-Wahab et al. [2] provide an in-depth narrative review of the clinical evidence base for transcatheter aortic valve replacement and offer a glimpse into the future of this field. They also discuss important complications and downsides of this new technology. PARTNER A and B (with the balloon-expandable Edwards Sapien valve) and the Extreme and High-Risk trials (with the self-expanding Medtronic CoreValve) are landmark clinical trials in this field and resulted in regulatory approvals for commercial implantation of both valves [3–6]. More recently, the CHOICE trial directly compared the Edwards SAPIEN XT to the Medtronic CoreValve in 241 patients undergoing TAVR. The primary end point was device success, with a higher rate of success seen in patients treated with the SAPIEN XT (95%) versus CoreValve (77.5%) (p o 0.001) [7]. Other similar trials

Although aortic stenosis (AS) is common, little data exist about the rate of aortic valve replacement (AVR) in patients with severe symptomatic AS. Many patients with severe symptomatic AS do not undergo AVR. Echocardiography databases for 3 large tertiary centers were searched for patients in 2005 with severe AS (mean gradient ≥ 40 mmHg, valve area of < 1.0 cm 2 , or overall clinical assessment of severe AS). Records were reviewed for symptoms, referral, surgical AVR, and outcome. Operative risk was calculated using the logistic EuroSCORE. Four hundred thirteen patients had an echocardiogram with severe AS; 44 were excluded based on additional testing or inadequate medical records. Of the remaining 368 patients, 188 (51%) underwent AVR, and 191 (49%) and were un-operated. Of 191 un-operated patients, 126 (66%, 34% of total) had symptoms consistent with AS, 182 (95%) were referred to cardiology, but 75 of 126 (60%) un-operated symptomatic patients were not referred for surgical assessment. Among un-operated symptomatic patients, operative risk was < 5% in 31 (25%) and < 10% in 59 (47%). The prevalence of un-operated patients was similar between institutions. Decisions not to operate most commonly were based on co-morbidities, patient preference, symptoms due to other conditions, and unrecognized AS. With an average follow-up of 13.9 ± 9.8 months, 52 of 191 (27%) un-operated patients died. Half of patients with severe symptomatic AS do not undergo AVR, with similar findings in multiple tertiary care environments. Some patients with severe symptomatic AS may be inappropriately denied access to potentially life-saving therapy.

Background: Left ventricular (LV) false chordae tendinae (false chords) have been implicated as a source of idiopathic left (IL) ventricular tachycardia (VT). However, it is unknown whether pretest bias contributes to an apparent association with disease. The purpose of this study was to determine the prevalence of false chords on direct inspection of the LV endocardium. Methods: In a prospective series, 75 hearts were examined to identify and characterize false chords, including 20 specimens examined at autopsy and 55 consecutive patients undergoing mitral valve surgery. Medical records were reviewed for history of VT, including ILVT. Results: Of 75 patients whose hearts were studied, none had a history of ILVT and only 5 had a history of any VT. False chords were present in 34 of 75 (45%) hearts, including 13 of 20 (65%) at postmortem and 21 of 55 (38%) examined at surgery (P = 0.07). The prevalence of false chords was not different among patients with (3 of 5 [60%]) versus those without (31 of 70 [44% p = 0.65]) a history of VT (P = 0.65). Conclusions: In this prospective anatomic series, the prevalence of LV false chords on autopsy and surgical inspection was approximately 45% among patients without ILVT. Previously reported associations of false chords with ILVT likely underestimated the prevalence of false chords in a normal population. (PACE 2007; 30:S156‐S159)

Paradoxical embolism resulting in cryptogenic stroke has received much attention recently, with the primary focus on patent foramen ovale (PFO). However, it is essential to be vigilant in the search for other causes of paradoxical embolic events, such as pulmonary arteriovenous malformations (PAVM). We describe successful closure of pulmonary AVM with a St Jude Medical (Plymouth, MN) Amplatzer TM vascular plug IV. The newer AVP-IV devices can be used for successful embolization of tortuous pulmonary AVM in remote locations where use of other traditional devices may be technically challenging.

Introduction: The annual US cost for CD patients is estimated at $1.4-1.7 billion; 81% is for surgery and hospitalization. We used a comprehensive, all-payor database of in-hospital discharge abstracts to identify factors predicting costly hospitalization in CD. Aims: Determine if inpatient utilization of healthcare services and complication rates vary by payor class or other patient characteristics. Methods: The UB-92 discharge abstracts of patients hospitalized with a principal diagnosis of CD(lCD-9:555.0-555.9) from 1996-1998 at 44 academic medical centers were analyzed. Results: There were 5237 admissions(40% male, 76% white, 84% age 18-64). The cost, length of stay (LOS) and resource utilization of the six largest payor classes are shown in the table. Self-pay had the lowest cost and length of stay. Medicare and Medicaid had the highest cost, length of stay, comorbidity and endoscopy rates but the lowest surgery rate. Managed care had the highest surgery rate but the lowest endoscopy rate. Patients transferred from an acute hospital (5% of total) had significantly higher costs($16676 vs. 7924, p