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Heart failure (HF) most commonly occurs in patients who have had a myocardial infarction (MI), but factors other than MI size may be deterministic. Fibrosis of myocardium remote from the MI is associated with adverse remodeling. We aimed to 1) investigate the association between remote myocardial fibrosis, measured using cardiovascular magnetic resonance (CMR) extracellular volume fraction (ECV), and HF and death following MI, 2) identify predictors of remote myocardial fibrosis in patients with evidence of MI and determine the relationship with infarct size.

Bioprosthetic valve fracture (BVF) during valve-in-valve TAVR (transcatheter aortic valve replacement) is a procedural adjunct designed to optimize the expansion of the transcatheter heart valve and reduce patient-prosthesis mismatch by using a high-pressure balloon to intentionally fracture the surgical heart valve (SHV).

Objective Recent data have suggested that women have a survival benefit at 1-year follow-up. However, long-term gender-based TAVR outcomes are lacking.Methods All patients undergoing isolated TAVR from 2011 to 2017 were included. Patients were stratified by gender. The primary outcomes of the study were 3-year mortality and 3-year hospital readmissions. Multivariable logistic regression analysis was used to evaluate the risk-adjusted impact of gender on TAVR outcomes.Results A total of 1,036 patients were divided into male (n= 518) and female (n= 518) cohorts. Women had a borderline significantly increased STS PROM (8.3% ± 5 vs. 7.7% ± 4.4; P= 0.05). The majority of procedures were performed under conscious sedation (male: 89% vs. female: 88%; P= 0.62) and via transfemoral access (male: 81.8% vs. female: 81.4%; P= 0.46). There was no difference in operative (30-day) mortality (male: 15 [3.3%] vs. female: 17 [3.7%]; P= 0.77) or 30-day readmissions (male: 40 [10.8%] vs. female: 44 [12.2%]; P= 0.56). Perioperative blood product usage was higher for women (male: 8.1% vs. female: 14.1%; P= 0.002). There was no significant difference in major vascular complications (male: 0.4% vs. female: 1.0%; P= 0.26) or major bleeding (male: 0.2% vs. female: 0.4%; P= 0.56). Permanent pacemaker placement was higher for males (11.6% vs. 7.0%; P= 0.01). On risk-adjusted multivariable analysis, gender was not a factor associated with mortality (HR 0.99 [0.76 to 1.30]; P= 0.99) or readmission (HR 0.90 [0.72 to 1.14]; P =0.42) at 5 years.Conclusions There was no difference in survival or readmissions on multivariable analysis for women undergoing TAVR at 3 years. Longitudinal multi-institutional data will be important to validate these findings.

Introduction:The purpose of this study was to assess symptoms in patients undergoing class I/IIa ACC/AHA guideline directed lone mitral valve surgery.Hypothesis:Symptoms in patients undergoing guideline directed mitral valve surgery and are not associated with the severity of mitral regurgitation (MR).Methods:In this prospective multicenter study, 93 patients with a Class I/IIa indication for isolated mitral valve surgery were evaluated. Each patient had a cardiovascular magnetic resonance (CMR) exam prior to surgery and 3 to 5 months following surgery. The presence or absence of symptoms was determined by the treating physician. Symptoms were quantified using the Kansas City Cardiomyopathy Questionaire (KCCQ).Results:There were 55 (59%) patients who were symptomatic preoperatively. Based on CMR regurgitant volume, 30%, 39%, and 31% had mild, moderate, or severe MR, respectively. Among those with mild, moderate, and severe MR, the percentage of patients who were symptomatic at baseline did not differ significantly and the severity of symptoms as quantified by the KCCQ did not differ significantly (Figure1A). Post-surgical improvement in the percentage of patients with symptoms and the KCCQ score did not differ based on baseline MR severity (Figure1B). Patients who were symptomatic before surgery reported the greatest improvement in KCCQ symptom score following surgery compared to those who were asymptomatic at baseline (17 ± 25 vs. -0.4 ± 17, p<0.001).Conclusions:In a multi-center study of patients undergoing ACC/AHA class I/IIa indication for surgery for MR there was no of correlation between MR severity and symptoms. These findings question the assumptions that severity of MR is associated with worse symptoms prior to surgery and those with severe MR benefit the most from mitral valve surgery. The lack of correlation between MR severity, symptoms, and outcomes is concerning and it suggests symptoms may be often misattributed to MR.

Background:Primary systemic (AL) amyloidosis is a rare plasma cell disorder characterized by soft-tissue deposition of monoclonal light chain fragments. High-dose melphalan followed by autologous stem cell transplantation currently has become the treatment of choice. Favorable outcome is ensured with achievement of hematologic response, but little is known about organ response. This study was undertaken to determine the prognostic importance of renal response after high-dose melphalan and stem cell transplantation. Methods:All patients with AL amyloidosis who underwent autologous stem cell transplantation between 1996 and December 2002 were selected for study. Renal response is defined as a 50% or greater reduction in proteinuria with less than 25% decline in renal function. Exclusion criteria included pretransplantation dialysis therapy or dialysis dependence posttransplantation, treatment mortality, lack of proteinuria assessment posttransplantation, and baseline proteinuria with protein less than 1 g/d. Results:Of 105 patients, 47 were excluded for stated reasons. Renal response was achieved in 60.3% of evaluated patients. Proteinuria was reduced by greater than 90% in 37.9% and returned to normal in 15.5%. Median response time was 12 months. Renal response was associated with a greater increase in serum albumin level (P= 0.001), maintenance of renal function (P< 0.001), and better survival (P= 0.0003). Renal responders had better survival regardless of hematologic response (P= 0.01 to 0.05). Conclusion:Currently, high-dose melphalan followed by stem cell transplantation is the most effective treatment for AL amyloidosis for those who are eligible. Our data show that renal response after high-dose melphalan followed by stem cell transplantation is associated with improved survival. Renal response is an independent marker of treatment success and can be used in cases in which determination of hematologic response is difficult.

Background:Coronary Computed Tomography Angiography (CCTA) has been deemed appropriate to use in evaluating chest pain in the emergency department (ED). However, concerns remain regarding downstream resource utilization post CCTA. We performed a meta-analysis of existing studies to address whether there is an increase in downstream testing in patients undergoing CCTA vs. the standard of care.