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OBJECTIVESRepair outcomes of tricuspid regurgitation (TR) associated with ischaemic mitral regurgitation (IMR) are inferior to functional TR in terms of TR recurrence and right ventricular (RV) reverse remodelling. Our objective is to analyse right versus left heart reverse remodelling after surgery for IMR-associated TR.METHODSFrom 2001 to 2011, 568 patients with severe IMR underwent mitral valve surgery (repair 87%, replacement 13%), and 131 had concomitant tricuspid valve repair. Median follow-up was 3.0 years; 25% of living patients were followed up for 6.3 years. Longitudinal analysis of 1527 follow-up echocardiograms was performed to assess ventricular reverse remodelling and function.RESULTSUnlike the left heart, the right heart failed to reverse remodel (failed to recover ventricular function or halt dilatation). During follow-up after surgery, the right ventricle continued to dilate while the left ventricle regressed in size. RV ejection fraction decreased (46% at 1 month and 44% at 5 years), while left ventricular ejection fraction increased (33% and 37%, respectively). RV strain showed early (−11% at 1 month) and late (−12% at 5 years) dysfunction. Patients who underwent tricuspid valve repair had worse RV function. Mitral regurgitation remained stable after surgical intervention, and TR gradually recurred (37% moderate, 20% severe at 7 years).CONCLUSIONSSurgical treatment of IMR and TR along with revascularization failed to induce reverse remodelling of the right heart. These findings warrant further investigations to identify optimal timing and approach of intervention for IMR-associated TR with respect to RV remodelling.

Functional tricuspid regurgitation (TR) develops secondary to annular dilation and leaflet tethering as a result of right ventricular remodeling. Invasive surgery for isolated TR is rarely performed due to high inpatient mortality. Transcatheter tricuspid valve intervention is an appealing solution but is challenging as crucial structures are closely related to the tricuspid valve, and intracardiac devices pose further challenges to device delivery and implantation.

Background Transcatheter aortic valve implantation operators have adapted to a less invasive technique by foregoing the use of general anaesthesia and transoesophageal echocardiography. This is known as a ‘minimalist approach’. This approach has yet to be explored in transcatheter mitral valve replacement (TMVR). Two patients with high perioperative risk underwent TMVR using only monitored conscious sedation (CS) and intracardiac echocardiography (ICE). Case summary The patients were symptomatic and required treatment of severe mitral regurgitation and severe mitral stenosis in a mitral valve ring and prosthetic mitral valve, respectively. With the use of an antegrade transseptal approach, the procedure was conducted under CS using ICE only. After placement of the prosthetic mitral valve, the valve was assessed by advancing the ICE catheter through the interatrial septal defect and no significant paravalvular leak occurred. In one case, ad hoc treatment of right to left shunting was successfully pursued. Valve function was excellent immediately and at 24 h after implantation and resulted in significant haemodynamic improvement. Conclusion With more TMVR cases being conducted, the ‘minimalist approach’ with CS and ICE may be considered in selected cases.

The importance of a coronary artery, based on the myocardial mass it perfuses, is well documented, but little is known about the importance of a vessel that has been bypassed and its effect on survival in the context of bilateral internal thoracic artery (BITA) grafting.This study determined the effect of a dominant left anterior descending (LAD) artery and important non-LAD targets on outcomes after BITA grafting.From January 1972 to January 2011, of 6,127 patients who underwent BITA grafting, 2,551 received 1 ITA grafted to the LAD and had an evaluable coronary angiogram. A dominant LAD was defined as one that was wrapped around the left ventricular apex. Non-LAD targets were graded based on their terminal reach toward the apex: important:75% (n = 1,698); and less important: ≤75% (n = 853). Mean follow-up was 14 ± 8.7 years. Multivariable analysis was performed to identify risk factors for time-related mortality.A dominant LAD was present more frequently in patients with less important additional targets (51% vs. 35%; p 0.0001). A total of 179 patients (7.0%) received a second ITA to multiple targets, 77 (43%) of which were to multiple important target vessels. Unadjusted late survival was similar regardless of degree of importance of the second ITA target-77% at 15 years (p = 0.70) for the important and less important targets, respectively. In the multivariable model, grafting the second ITA to multiple important targets was associated with better long-term survival (p = 0.005). In patients with a nondominant LAD, a second ITA grafted to a less important artery was associated with higher risk of operative mortality (2.4% vs. 0.51%; p = 0.007). A saphenous vein graft to an important or less important target did not influence long-term survival.In BITA grafting, bypassing multiple important targets to maximize myocardium supplied by ITAs improved long-term survival. In patients with a nondominant LAD, selecting an important target for the second ITA lowered operative mortality.

Tricuspid regurgitation is a common finding in patients with left-sided valvular or myocardial disease, often being a marker for late-stage chronic heart failure with a grim prognosis. Howe...

Tricuspid regurgitation (TR) is a common entity, most commonly functional in nature due to right-sided dysfunction in the setting of concomitant cardiac disease or pulmonary hypertension. Patients living with TR often experience numerous limitations as a result of right-sided heart failure symptoms, including functional decline, frequent hospitalizations, liver failure, and kidney failure. Furthermore, patients with significant TR demonstrate worse survival, although a cause-and-effect relationship has not been proven. For patients with a degenerated surgical bioprosthesis or valve ring, placement of a transcatheter aortic valve prosthesis in a valve-in-valve or valve-in-ring fashion may provide symptomatic benefit. For patients with native valve regurgitation, novel devices for treatment are currently under development.

Patients with isolated functional or recurrent tricuspid regurgitation are often considered high risk and denied surgery. There has been growing experience for transcatheter tricuspid valve implantation through valve-in-valve or valve-in-ring, and recently, but to a lesser extent, in native annulus. The NaviGate is a novel self-expanding valved-stent designed with unique features to treat tricuspid regurgitation, particularly, in the settings of severely dilated tricuspid annulus. Herein, we present the innovation facets and clinical application of the NaviGate system.

IMPORTANCE: Infective endocarditis is a life-threating condition with annual mortality of as much as 40% and is associated with embolic events in as many as 80% of cases. These embolic events have notable prognostic implications and have been linked to increased length of stay in intensive care units and mortality. A vegetation size greater than 10 mm has often been suggested as an optimal cutoff to estimate the risk of embolism, but the evidence is based largely on small observational studies. OBJECTIVE: To study the association of vegetation size greater than 10 mm with embolic events using meta-analytic techniques. DATA SOURCES: A computerized literature search of all publications in the PubMed and EMBASE databases from inception to May 1, 2017, was performed with search terms including varying combinations of infective endocarditis, emboli, vegetation size, pulmonary infarct, stroke, splenic emboli, renal emboli, retinal emboli, and mesenteric emboli. This search was last assessed as being up to date on May 1, 2017. STUDY SELECTION: Observational studies or randomized clinical trials that evaluated the association of vegetation size greater than 10 mm with embolic events in adult patients with infective endocarditis were included. Conference abstracts and non–English language literature were excluded. The search was conducted by 2 independent reviewers blinded to the other’s work. DATA EXTRACTION AND SYNTHESIS: Following PRISMA guidelines, the 2 reviewers independently extracted data; disputes were resolved with consensus or by a third investigator. Categorical dichotomous data were summarized across treatment arms using Mantel-Haenszel odds ratios (ORs) with 95% CIs. Heterogeneity of effects was evaluated using the Higgins I(2) statistic. RESULTS: The search yielded 21 unique studies published from 1983 to 2016 with a total of 6646 unique patients with infective endocarditis and 5116 vegetations with available dimensions. Patients with a vegetation size greater than 10 mm had increased odds of embolic events (OR, 2.28; 95% CI, 1.71-3.05; P

Introduction Fluctuations in hormonal levels can alter cardiac myocytes at the cellular level, often resulting in deterioration of cardiac function. Endocrine cardiomyopathies have been described in the setting of hypo/hyperthyroidism, GH deficiency, acromegaly, and diabetes. However, it is rarely described in the setting of autoimmune polyglandular syndrome (APS). Case Report A 19 year-old male with a PMH of APS associated with hypothyroidism and adrenal insufficiency. He initially presented to an outside facility after a syncopal episode. Initial workup revealed a TSH of 70 and he was started on appropriate therapy. Soon after admission, he developed acute hypoxemic respiratory failure requiring urgent intubation. Due to severe pulmonary edema, an echo was obtained which revealed a severely decreased EF of 20%. An Impella CP® and Swan Ganz catheter were placed for management of cardiogenic shock. Due to persistent clinical deterioration with worsening renal and hepatic function, he underwent RPella® placement. Two days later he was transferred to our hospital for consideration of advanced Heart Failure therapies. Upon transfer, he was maintained on appropriate hormone therapies by endocrinology. An endomyocardial biopsy was unrevealing. We started low dose diuretics and noted marked improvement in right sided parameters with improving central venous pressures and resolving transaminitis. Repeat echo revealed normal right ventricular systolic function. The RPella® was then weaned off and electively removed. The Impella CP® device was weaned daily as per protocol. EF improved to 30% on repeat echo. Cardiac MRI was nonspecific. He was downgraded from ICU status after tolerance of comprehensive guideline based medical therapy. Summary Previously described is a 32 year old male with a history of APS who developed severe biventricular failure requiring inotropic support, counterpulsation, mechanical circulatory support (MCS), and ultimately cardiac transplantation. Though our patient presented to us in a highly compromised state, the use of MCS helped bridge the patient to a recovery in myocardial performance while undergoing hormonal replacement. To our knowledge, this is the first case of its nature and highlights the possibility of temporary MCS in APS-associated cardiomyopathy, and in turn, can be useful in other secondary cardiomyopathies.

As transcatheter aortic valve replacement (TAVR) has become routine, device manufacturers and investigational cardiologists have set their sights on the mitral valve. Although transcatheter mitral valve replacement (TMVR) poses several technical challenges, they appear to be surmountable, and work is proceeding. Here we review the various devices being developed and preliminary results of trials in humans.

A 75-year-old man presented with dyspnea requiring home oxygen, on a background of partial colectomy for colon cancer, chronic renal failure, and coronary artery bypass graft surgery in 1978 (left internal mammary artery to left anterior descending graft and saphenous vein grafts [SVG] to the right coronary artery [RCA] and left circumflex artery). Clinically, he had jugular venous distension and bibasal crepitations, without overt ascites or peripheral edema. Chest x-ray demonstrated remote postoperative changes, cardiomegaly, mild pericardial calcification, and other radiographic findings of congestive heart failure, without apparent mediastinal mass (Figure 1). However, echocardiography revealed a large (9.4×8.7 cm), apparently extracardiac, mass compressing the right ventricle with severe functional tricuspid stenosis (mean gradient, 10 mm Hg) and turbulence of forward transtricuspid flow on color Doppler imaging (Figures 2A, 2B, and 3; Movie IA and IB in the online-only Data Supplement). Noncontrast cardiac MRI revealed a large (10.9×7.4×6.5 cm), relatively homogenous structure adjacent to the atrioventricular groove anteriorly, which was compressing the right heart and obstructing the tricuspid valve. The mass was distinct from adipose tissue, well circumscribed by overlying pericardium, and had no invasive characteristics. Cine imaging demonstrated flow within the mass. The structure location and characteristics were consistent with a partially thrombosed SVG aneurysm (Figure 4; Movie II …

AIM Transcatheter mitral valve implantation (TMVI) is a novel technology for patients with severe mitral valve disease but at high surgical risk. Imaging guidance during the procedure is critical for successful device deployment. Identification of the mitral annular plane (MAP) with fluoroscopy during the procedure is limited by lack of clearly defined landmarks. We hypothesized that a plane defined by left circumflex-right coronary arteries (LCX-RCA) would have a consistent relationship to MAP. METHODS AND RESULTS We studied 25 patients with gated cardiac computed tomography. We identified the MAP and the LCX-RCA plane in mid systole and diastole. The distance between the two planes in prespecified four points (anterior, posterior, medial, and lateral) in the apical 2 and 3-chamber views. Alignment of the planes was described by cranial/caudal angulation for both planes in RAO 30° and LAO 90° (lateral) angulation. Mean age was 81 ± 9 years, 56% of patients had ≥2+ mitral regurgitation. In mid systole, the distances between the LCX-RCA plane and the MAP in the four points were

Introduction Cardiac allograft vasculopathy (CAV) is known as the primary cause of death in the first year after orthotopic heart transplant (OHT). Coronary artery spasm (CAS) in OHT is a rare and under-recognized phenomenon in patients undergoing surveillance. The mechanism of coronary vasospasm in OHT remain largely unknown. The presentation can vary from an incidental finding to severe episodes of symptomatic ventricular arrhythmias, high-degree atrioventricular block, syncope, cardiac arrest, or even myocardial infarction in cases of prolonged ischemia. Case Presentation 65 yo female with history of chronic kidney disease, diabetes mellitus type 2, hypertension, hyperlipidemia, and orthotopic heart transplantation with CMV mismatch in 2016 secondary to apical hypertrophic cardiomyopathy. Prior coronary angiography (CA) done at our institution had shown no evidence of vasculopathy. During one of her follow-up visits in the Clinic, she complained of increasing dyspnea on exertion, prompting urgent referral for CA, as per our surveillance protocols. Prior to the procedure, echocardiography was performed which revealed normal graft function and no valvular abnormalities. She underwent CA which showed a proximal significant diffuse luminal narrowing of the right coronary artery (RCA) (Image 1) and normal left coronary artery anatomy (Image 2). We proceed to repeat CA with intracoronary administration of nitroglycerin (ICN) and measurement of fractional flow reserve (FFR) of RCA (Image 3, 4). Angiography revealed near resolution of the RCA lesion, ultimately suggesting that transient vasospasm had been responsible for the previous angiographic appearance (Image 1). Summary CAS can present in patients with or without vasculopathy. It can produce luminal narrowing and can be difficult to distinguish angiographically from CAV. Misdiagnosis of this entity has led to the incorrect diagnosis of CAV and subsequent unnecessary stenting. ICN use can improve angiographic visualization, and prevent the adverse effects of coronary spasm. In conclusion, CAS is a rare and potential complication post OHT. It is a difficult entity to prognosticate due to scarcity of clinical evidence, as prevalence ranges from 4.9% to 12.1%. Some authors hypothesize that CAS in OHT carries a poor prognosis as it is often an early manifestation of CAV. However, this remains largely hypothetical and further studies are needed to better understand this disease.

Paravalvular aortic regurgitation (AR) after transcatheter aortic valve replacement (TAVR) is a well-known complication. Post-TAVR AR is thought to be caused by incomplete apposition of the prosthesis, suboptimal expansion of the stent frame, misplacement of the prosthesis, or mismatch in the size

Previous studies have identified delayed heart block (DHB) as an important consideration of post-transcatheter aortic valve replacement (TAVR) patients, occurring at rates similar to heart block during the immediate hospitalization period. Patients post-TAVR therefore may need extended rhythm

Damage to the cardiac conduction system requiring permanent pacemaker implantation is a complication of aortic valve replacement (AVR) that may importantly affect quality of life. We investigated the prevalence of and preprocedure risk factors for new permanent pacemakers after surgical (SAVR) and transcatheter AVR (TAVR) at a single institution.Preoperative variables and baseline electrocardiograms were reviewed for 5807 patients undergoing elective SAVR, with or without coronary artery bypass grafting, and 1292 undergoing TAVR, with or without percutaneous coronary intervention, from 2006 to 2017 at Cleveland Clinic. Patients with previous permanent pacemakers were excluded. Risk factors for permanent pacemaker implantation were identified using multivariable logistic regression analysis.New permanent pacemakers were implanted in 151 (2.6%) after SAVR and in 125 (9.7%) after TAVR (whole group SAVR vs TAVR, P.0001). Risk factors for pacemaker implantation after TAVR included preoperative conduction disturbances and type of prosthesis (SAPIEN, 9.5%; SAPIEN XT, 4.8%; SAPIEN 3, 10% [Edwards Lifesciences, Irvine, CA]; CoreValve, 30% [Medtronic, Minneapolis, MN]; and other TAVR, 10%). There were no reliable risk factors for pacemaker implantation after SAVR. Bicuspid valves, mechanical vs bioprosthetic valves, higher Society of Thoracic Surgeons risk score, and concomitant coronary artery bypass grafting were not associated with elevated risk.At a high-volume institution in the current era, establishing a baseline for pacemaker implantation after AVR is necessary. Preoperative conduction disturbances and transcatheter valve type affect its prevalence. These data provide a benchmark that should be taken into account when considering TAVR in low-risk patients.

Infective endocarditis is a major cause of morbidity and mortality among individuals with opioid use disorder who use injection drugs. It is frequently associated with tricuspid valve endocarditis and Staphylococcus aureus bacteremia, with secondary pulmonary septic emboli. Herein, we report a unique case of pulmonary cavitation injury following pulmonary septic emboli in the setting of tricuspid valve endocarditis in an injection drug user with opioid use disorder. The pattern of cavitary lung injury mimics radiographically indistinguishable features from vanishing lung syndrome during the most advanced stage of her illness. .

Background Paravalvular leak (PVL) is often seen after aortic (AV) and mitral valve (MV) surgery, either due to infection or valve dehiscence. We sought to describe predictors of longer-term outcomes in patients who developed PVL after AV and MV surgery and were considered eligible for reoperative cardiac surgery (RCS). Methods We studied 495 such patients (65 ± 14 years, 65% men, 47% with MV PVL) who presented at our center between January 2003 and December 2011. Patients with severe mitral/aortic stenosis, patients with less than mild PVL, and those with prohibitive risk precluding RCS were excluded. Society of Thoracic Surgeons (STS) score was calculated. Primary endpoint was mortality. Results At baseline, mean STS score and left ventricular ejection fraction were 5.8 ± 4% and 52 ± 12%, respectively. In total, 105 (21%) had infective PVL and 72% had moderate or greater PVL. At a median of 8 days, 351 (71%) patients underwent RCS to repair PVL (3% in-hospital postoperative mortality), and at 6.6 ± 4 years, 230 (47%) patients died. On multivariable Cox survival analysis, greater STS score (hazard ratio or HR 1.35), mitral versus aortic PVL (HR 1.66), infectious etiology (HR 2.05), and greater right ventricular systolic pressure (HR 1.09) were associated with greater longer-term mortality, whereas surgery (HR 0.58) was associated with improved longer-term survival (all P Conclusions Patients who develop mild or greater PVL after AV/MV surgery have a high rate of longer-term mortality, despite excellent perioperative outcomes. Greater STS score, right ventricular systolic pressure, infectious etiology, and MV (vs AV) involvement were all independently associated with long-term mortality, whereas RCS for PVL closure was associated with improved longer-term survival.

We report a 62-year-old male who had severe aortic insufficiency after a homograft root replacement, requiring venoarterial extracorporeal membrane oxygenation prior to surgery due to profound cardiogenic shock. Severe aortic insufficiency is a contraindication for venoarterial extracorporeal membrane oxygenation, but we were able to stabilize the patient and successfully perform an urgent reoperative surgery.

Background Data regarding the risk of aortic dissection in patients with bicuspid aortic valve and large ascending aortic diameter are limited, and appropriate timing of prophylactic ascending aortic replacement lacks consensus. Thus our objectives were to determine the risk of aortic dissection based on initial cross-sectional imaging data and clinical variables and to isolate predictors of aortic intervention in those initially prescribed serial surveillance imaging. Methods From January 1995 to January 2014, 1,181 patients with bicuspid aortic valve underwent cross-sectional computed tomography (CT) or magnetic resonance imaging (MRI) to ascertain sinus or tubular ascending aortic diameter greater than or equal to 4.7 cm. Random Forest classification was used to identify risk factors for aortic dissection, and among patients undergoing surveillance, time-related analysis was used to identify risk factors for aortic intervention. Results Prevalence of type A dissection that was detected by imaging or was found at operation or on follow-up was 5.3% (n = 63). Probability of type A dissection increased gradually at a sinus diameter of 5.0 cm—from 4.1% to 13% at 7.2 cm—and then increased steeply at an ascending aortic diameter of 5.3 cm—from 3.8% to 35% at 8.4 cm—corresponding to a cross-sectional area to height ratio of 10 cm 2 /m for sinuses of Valsalva and 13 cm 2 /m for the tubular ascending aorta. Cross-sectional area to height ratio was the best predictor of type A dissection (area under the curve [AUC] = 0.73). Conclusions Early prophylactic ascending aortic replacement in patients with bicuspid aortic valve should be considered at high-volume aortic centers to reduce the high risk of preventable type A dissection in those with aortas larger than approximately 5.0 cm or with a cross-sectional area to height ratio greater than approximately 10 cm 2 /m.

Visual Abstract, Highlights • Surgery for isolated tricuspid regurgitation carries a high mortality risk, especially in the setting of right ventricular dysfunction and reoperation. • Transcatheter valve therapy is as promising alternative for treatment of isolated tricuspid valve disease associated with right heart failure. • The NaviGate bioprosthesis is a novel self-expanding valved stent designed to treat functional tricuspid regurgitation. • The preclinical evaluation shows that transcatheter tricuspid valve implantation using the NaviGate device is safe, is feasible through 2 different approaches, and results in a secure and stable engagement of the native annulus, with excellent hemodynamic and valve performance., Summary Patients with isolated functional or recurrent tricuspid regurgitation are often denied surgery because they are considered to be at high risk. Transcatheter valve therapy provides a less invasive alternative for tricuspid regurgitation associated with right heart failure. We have evaluated the feasibility of transcatheter tricuspid valve implantation of the NaviGate valved stent in a long-term swine model. The valved stent was successfully implanted through transjugular and transatrial approaches on the beating heart with excellent hemodynamic and valve performance. No conduction disturbance or coronary obstruction was observed. This technology could provide an alternative treatment for patients who are at high surgical risk with severe tricuspid regurgitation and compromised right ventricular function.

Based on an old misconception that the tricuspid valve is not important for cardiac performance, functional tricuspid regurgitation (TR) has been historically ignored. As a consequence, an increasing number of patients present in the current era with severe TR associated with right heart failure that is refractory to medical treatment. Traditional or redotricuspid valve surgery in that setting has been shown to have high mortality (up to 35% at 30 days).1–3 Thereby, transcatheter valve implantation technology seems as an attractive alternative. Herein, we report the first-in-human successful implantation of the NaviGate valved-stent (NaviGate Cardiac Structures, Inc, NCSI, Lake Forest, CA) in 2 patients with severe TR and prohibitive risk for conventional surgery, for which they received Food and Drug Administration and institutional review board approvals for compassionate use (Figure 1). Figure 1. The NaviGate valved-stent. A , Ventricular view. B , Lateral view. A 64-year-old woman presented after multiple admissions for refractory right heart failure with severe functional TR secondary to annular dilatation, severe right ventricular (RV) dysfunction, severe pulmonary hypertension (systolic pressure, 75 mm Hg), and moderate ischemic mitral regurgitation (Figure 2A). Other comorbidities included chronic kidney dysfunction, chest radiation for breast cancer, atrial fibrillation, obstructive lung disease, and coronary bypass surgery with patent grafts. The patient was deemed high risk for conventional open-heart surgery by the Multidisciplinary Heart Team and was found a candidate for compassionate use of a first-in-human NaviGate valved-stent implantation. Preoperative sizing included a focused 4-dimensional computed tomography that was used to develop a 3-dimensional printing model of the …

AIMS The aim of this study was to test the feasibility of transcatheter mitral valve implantation of the NaviGate device in acute and chronic preclinical models. METHODS AND RESULTS We evaluated NaviGate valved stent implantation in the mitral position in an acute swine model (n=24, ≤5 days) through three different approaches - transatrial, transapical, and transseptal - and in a chronic swine model (n=12, >10 days) through a transatrial approach. The NaviGate implantation procedures were successful in 83% of the acute model studies (n=20) and 83% of the chronic model studies (n=10). Echocardiographic assessment showed low gradient across the valved stent (mean gradient

Transition from compensated to decompensated left ventricular hypertrophy (LVH) is accompanied by functional and structural changes. Here, the aim was to evaluate dystrophin expression in murine models and human subjects with LVH by transverse aortic constriction (TAC) and aortic stenosis (AS), respectively. We determined whether doxycycline (Doxy) prevented dystrophin expression and myocardial stiffness in mice. Additionally, ventricular function recovery was evaluated in patients 1 year after surgery. Mice were subjected to TAC and monitored for 3 weeks. A second group received Doxy treatment after TAC. Patients with AS were stratified by normal left ventricular end-diastolic wall stress (LVEDWS) and high LVEDWS, and groups were compared. In mice, LVH decreased inotropism and increased myocardial stiffness associated with a dystrophin breakdown and a decreased mitochondrial O2 uptake (MitoMVO2). These alterations were attenuated by Doxy. Patients with high LVEDWS showed similar results to those observed in mice. A correlation between dystrophin and myocardial stiffness was observed in both mice and humans. Systolic function at 1 year post-surgery was only recovered in the normal-LVEDWS group. In summary, mice and humans present diastolic dysfunction associated with dystrophin degradation. The recovery of ventricular function was observed only in patients with normal LVEDWS and without dystrophin degradation. In mice, Doxy improved MitoMVO2. Based on our results it is concluded that the LVH with high LVEDWS is associated to a degradation of dystrophin and increase of myocardial stiffness. At least in a murine model these alterations were attenuated after the administration of a matrix metalloprotease inhibitor. Fil: Donato, Pablo Martín. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Fisiopatología Cardiovascular; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Buchholz, Bruno. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Fisiopatología Cardiovascular; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Morales, Celina. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Fisiopatología Cardiovascular; Argentina Fil: Valdez, Laura Batriz. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Bioquímica y Medicina Molecular. Universidad de Buenos Aires. Facultad Medicina. Instituto de Bioquímica y Medicina Molecular; Argentina Fil: Zaobornyj, Tamara. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Bioquímica y Medicina Molecular. Universidad de Buenos Aires. Facultad Medicina. Instituto de Bioquímica y Medicina Molecular; Argentina Fil: Baratta, Sergio. Hospital Austral; Argentina Fil: Paez, Diamela T.. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Fisiopatología Cardiovascular; Argentina Fil: Matoso, Mirian. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Fisiopatología Cardiovascular; Argentina Fil: Vaccarino, Guillermo. Hospital Austral; Argentina Fil: Chejtman, Demian. Hospital Austral; Argentina Fil: Agüero, Oscar. Hospital Austral; Argentina Fil: Telayna, Juan. Hospital Austral; Argentina Fil: Navia, José. Hospital Austral; Argentina Fil: Hita, Alejandro. Hospital Austral; Argentina Fil: Boveris, Alberto Antonio. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Bioquímica y Medicina Molecular. Universidad de Buenos Aires. Facultad Medicina. Instituto de Bioquímica y Medicina Molecular; Argentina Fil: Gelpi, Ricardo Jorge. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Fisiopatología Cardiovascular; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina

Hypoattenuating leaflet thickening/thrombosis (HALT) is a known complication post transcatheter aortic valve replacement (TAVR). No pathophysiologic mechanism has been identified to date. We aimed to evaluate the association between stasis within the non-coronary aortic sinus (NCC) and HALT. We

Atrioventricular conduction disturbances are common after Transcatheter Aortic Valve Replacement (TAVR) and many patients require a permanent pacemaker (PPM). Little is known about conduction abnormalities that exist before TAVR. We aimed to assess the prevalence and significance of brady

To provide proof of concept for a diagnostic method to assess diffuse coronary artery disease (CAD) on the basis of coronary computed tomography (CT) angiography.The study was approved by the Cleveland Clinic Institutional Review Board, and all subjects gave informed consent. Morphometric data from the epicardial coronary artery tree, determined with CT angiography in 120 subjects (89 patients with metabolic syndrome and 31 age- and sex-matched control subjects) were analyzed on the basis of the scaling power law. Results obtained in patients with metabolic syndrome and control subjects were compared statistically.The mean lumen cross-sectional area (ie, lumen cross-sectional area averaged over each vessel of an epicardial coronary artery tree) and sum of intravascular volume in patients with metabolic syndrome (0.039 cm(2) ± 0.015 [standard deviation] and 2.71 cm(3) ± 1.75, respectively) were significantly less than those in control subjects (0.054 cm(2)± 0.015 and 3.29 cm(3)± 1.77, respectively; P.05). The length-volume power law showed coefficients of 27.0 cm(-4/3) ± 9.0 (R(2) = 0.91 ± 0.08) for patients with metabolic syndrome and 19.9 cm(-4/3) ± 4.3 (R(2) = 0.92 ± 0.07) for control subjects (P.05). The probability frequency shows that more than 65% of patients with metabolic syndrome had a coefficient of 23 or more for the length-volume scaling power law, whereas approximately 90% of the control subjects had a coefficient of less than 23.The retrospective scaling analysis provides a quantitative rationale for diagnosis of diffuse CAD.

Objective The rarity of invasiveness of right-sided infective endocarditis (IE) compared with left-sided has not been well recognized and evaluated. Thus, we compared invasiveness of right- versus left-sided IE in surgically treated patients. Patients and Methods From January 2002 to January 2015, 1292 patients underwent surgery for active IE, 138 right-sided and 1224 left-sided. Among patients with right-sided IE, 131 had tricuspid and 7 pulmonary valve IE; 12% had prosthetic valve endocarditis. Endocarditis-related invasiveness was based on echocardiographic and operative findings. Results Invasive disease was rare on the right side, occurring in 1 patient (0.72%; 95% confidence interval 0.02%-4.0%); rather, it was limited to valve cusps/leaflets or was superficial. In contrast, IE was invasive in 408 of 633 patients with aortic valve (AV) IE (65%), 113 of 369 with mitral valve (MV) IE (31%), and 148 of 222 with AV and MV IE (67%). Staphylococcus aureus was a more predominant organism in right-sided than left-sided IE (right 40%, AV 19%, MV 29%), yet invasion was observed almost exclusively on the left side of the heart, which was more common and more severe with AV than MV IE and more common with prosthetic valve endocarditis than native valve IE. Conclusions Rarity of right-sided invasion even when caused by S aureus suggests that invasion and development of cavities/"abscesses" in patients with IE may be driven more by chamber pressure than organism, along with other reported host–microbial interactions. The lesser invasiveness of MV compared with AV IE suggests a similar mechanism: decompression of MV annulus invasion site(s) toward the left atrium.

Transcatheter aortic valve replacement (TAVR) is a viable option for patients with severe chronic obstructive pulmonary disease (COPD) who are deemed inoperable or high risk for surgery. We sought to determine outcomes of patients with severe aortic stenosis (AS) and severe COPD referred for aortic valve replacement (AVR). One hundred thirty-one patients with severe AS and severe COPD (GOLD criteria) were evaluated at our center between 2008 and 2013 and were divided retrospectively into 4 groups: 1-medical management, 2-balloon aortic valvuloplasty, 3-surgical aortic valve replacement (SAVR), and 4-TAVR. Baseline, clinical, and echo data were recorded. Primary outcome was cardiovascular death. From the study cohort, 54 (41.2%), 29 (22.1%), 21 (16.0%), and 27 (20.6%) were included in groups 1-4, respectively; the age was 74.9 ± 8.8, 76.2 ± 8.8, 78.8 ± 7.4, and 82.8 ± 6.8 years, respectively (P0.01). There was no significant difference between the groups for hypertension, diabetes, aortic valve area or gradients, forced expiratory volume in first second, right ventricular systolic pressure, ejection fraction, and Society of Thoracic Surgeons predicted risk of mortality score. At 3 ± 1.5 years, death occurred in 87%, 97%, 47.7%, and 51.8% of patients in groups 1-4, respectively. Heart failure readmissions occurred in 43%, 42%, 9.6%, and 14.8% of patients in groups 1-4, respectively. When SAVR and TAVR groups were compared, there was no significant difference in survival (P = 0.719) or heart failure readmissions (P = 0.19). In patients with severe or very severe COPD and severe AS, replacing the severely stenotic aortic valve by either SAVR or TAVR improves survival and reduces rehospitalization compared with medical therapy or balloon aortic valvuloplasty.

Background Data regarding long-term outcomes in cardiovascular pseudoaneurysms are sparse. In patients with prior cardiovascular surgery, we sought to assess characteristics and outcomes in patients with cardiovascular pseudoaneurysms (excluding ischemic left ventricular pseudoaneurysms). Methods We included 114 patients (mean age, 57 ± 16 years; 70% were men) with prior cardiovascular surgery who presented with paravalvular (n = 71, 59 aortic and 12 mitral valve) and ascending aortic (n = 43) pseudoaneurysms (27% with systemic infection). Baseline, surgical, and follow-up data were recorded. A composite end point of stroke or death during follow-up was recorded. Results Additive European System for Cardiac Operative Risk Evaluation was high (10%), and 81% of patients underwent another redo cardiovascular surgery. Over a mean follow-up period of 5.2 ± 4 years, there were 37 (32%) composite events (32 deaths and 5 strokes). Within the surgical subgroup, there were 10 (11%) composite events during the in-hospital stay. The 1-, 2-, 5-, and 10-year freedom from composite events were 86%, 82%, 74%, and 55%, respectively. Additive European System for Cardiac Operative Risk Evaluation (hazard ratio, 1.14) and presence of a documented systemic infection (hazard ratio, 3.90) were associated with a higher rate of composite events, whereas subsequent cardiovascular surgery as a time-dependent covariate hazard ratio (hazard ratio, 0.30) was associated with improved freedom from composite events (all P Conclusions Patients with a history of cardiovascular surgery in whom cardiovascular pseudoaneurysms subsequently develop have a high rate of short- and long-term adverse events. A higher additive European System for Cardiac Operative Risk Evaluation and documented systemic infection were associated with a higher rate of composite events, whereas cardiovascular surgery (to correct cardiovascular pseudoaneurysms) during follow-up was associated with improved freedom from adverse events.

Uncertainty about long-term effects of surgically unaddressed moderate (2+) secondary tricuspid valve (TV) regurgitation (TR) accompanying left-sided degenerative heart valve disease led us to identify reasons for and factors associated with TV repair, compare safety and clinical effectiveness of relieving TR, and identify factors associated with severe (3/4+) postoperative TR.From 1997 to 2008, 1,724 patients with 2+ TR underwent 830 mitral, 703 aortic, and 191 double-valve procedures; 91 (5%) had concomitant TV repair. Logistic regression analysis was used to identify factors associated with TV repair and for propensity-matched comparison of safety (in-hospital morbidity, mortality) and effectiveness of TV repair (longitudinal echocardiographic assessment of postoperative TR and New York Heart Association class, TV intervention, survival).Factors associated with TV repair of 2+ TR included larger right ventricles and left ventricles (p0.001), greater TV tethering height (p=0.0002), and prior concurrent mitral valve procedures (p≤0.004). In-hospital complications, subsequent TV interventions, and intermediate-term survival were similar for matched patients. The TV repair patients had less 3/4+ TR at discharge (7% versus 15%), sustained out to 3 years. No TV repair (p=0.05), female sex (p0.0001), and mitral valve replacement (p=0.008) were associated with 3/4+ TR.A TV repair for moderate TR concomitant with surgery for degenerative left-sided heart valve disease is reasonable to provide an opportunity to prevent its progression and development of right ventricle dysfunction, particularly for patients with important right ventricle remodeling and evidence of right ventricular failure, and for patients with advanced left-sided disease requiring mitral valve replacement.

Background Insufficient data exist on the clinical course of hepatitis C virus (HCV) infection in heart transplant (HT) recipients. Our study reports the outcomes of heart transplantation in pretransplantation HCV-positive (HCV+) recipients. Methods A retrospective analysis of the heart transplantation database at our institution was performed to identify HT recipients who were HCV+ prior to transplantation. Chart reviews yielded demographic features, liver function tests, graft function, incidence of posttransplantation acute hepatitis and transplant coronary artery disease, and patient survival data. Results Between 1995 and 2006, 10 HCV+ patients underwent cardiac transplantation. The recipient mean age was 47 years (range, 23–69). Seven recipients were males and 3 were females. At listing 9 patients had no cirrhosis. One patient with Child-B cirrhosis was listed for combined heart-liver transplantation. Two of 10 donors were known to be HCV carriers. Posttransplantation in-hospital survival rate was 100%. At a mean follow-up of 58 months (range, 1.6–145), 3 deaths occurred, yielding an overall survival rate of 70%. Only 1 death (10%) was linked to accelerated acute hepatitis. Transplant coronary artery disease was detected in 2 patients (20%). Echocardiograms of survivors at last follow-up revealed normal ejection fractions. In addition, there were no cases of hepatocellular carcinoma; all survivors were without evidence of hepatic dysfunction. Conclusions Transplanting recipients known to have HCV did not seem to affect overall posttransplantation survival or to increase the risk of liver dysfunction or graft-related complications.

The DexAide right ventricular assist device (RVAD) has been developed as an implantable RVAD. The purpose of this study was to determine the final design and optimal anatomical placement of the DexAide RVAD when implanted simultaneously with either of two commercially available left ventricular assist devices (LVADs) in patients. A mock-up DexAide RVAD was used to assess configuration with each of two types of commercially available LVADs at the time of LVAD implantation in three human clinical cases. The pump body of the DexAide RVAD was placed either in the preperitoneal space or in the right thoracic cavity. The DexAide RVAD placed into the right thoracic cavity is suitable for use with the Novacor or HeartMate II LVADs. The results of this study will guide the finalization of the inflow cannula and optimal placement of the DexAide RVAD for human clinical trials.

A pressure-normalized left ventricular (LV) wall stress (dsigma*/dt(max)) was recently reported as a load-independent index of LV contractility. We hypothesized that this novel contractility index might demonstrate improvement in LV contractile function after surgical ventricular restoration (SVR) using magnetic resonance imaging. A retrospective analysis of magnetic resonance imaging data of 40 patients with ischemic cardiomyopathy who had undergone coronary artery bypass grafting with SVR was performed. LV volumes, ejection fraction, global systolic and diastolic sphericity, and dsigma*/dt(max) were calculated. After SVR, a decrease was found in end-diastolic and end-systolic volume indexes, whereas LV ejection fraction increased from 26% +/- 7% to 31% +/- 10% (p0.001). LV mass index and peak normalized wall stress were decreased, whereas the sphericity index (SI) at end-diastole increased, indicating that the left ventricle became more spherical after SVR. LV contractility index dsigma*/dt(max) improvement (from 2.69 +/- 0.74 to 3.23 +/- 0.73 s(-1), p0.001) was associated with shape change as evaluated by the difference in SI between diastole and systole (r = 0.32, p0.001, preoperative; r = 0.23, p0.001, postoperative), but not with baseline LV SI. In conclusion, SVR excludes akinetic LV segments and decreases LV wall stress. Despite an increase in sphericity, LV contractility, as determined by dsigma*/dt(max), actually improves. A complex interaction of LV maximal flow rate and LV mass may explain the improvement in LV contractility after SVR. Because dsigma*/dt(max) can be estimated from simple noninvasive measurements, this underscores its clinical utility for assessment of contractile function with therapeutic intervention.

Background Tricuspid regurgitation (TR) often accompanies ischemic mitral regurgitation and is generally assumed to be a secondary consequence of altered hemodynamics of the left-sided regurgitation. We hypothesized that it may also be a direct consequence of right-sided ischemic disease. Therefore, our objectives were to (1) characterize the nature of this TR and (2) describe its time course after mitral valve surgery for ischemic mitral regurgitation, with or without concomitant tricuspid valve repair. Methods From 2001 to 2011, 568 patients with ischemic mitral regurgitation underwent mitral valve surgery. They had varying degrees of TR and altered right-side heart morphology and function; 131 had concomitant tricuspid valve repair. Postoperatively, 1,395 echocardiograms were available to assess residual and recurrent TR. Results Greater severity of preoperative TR was accompanied by larger tricuspid valve diameter, greater leaflet tethering, worse right ventricular function, and higher right ventricular pressure (all p [trend] ≤ 0.002). Without tricuspid valve repair, 31% of patients with no preoperative TR had moderate or greater TR by 5 years, as did 62% with moderate TR. With tricuspid valve repair, 25% with moderate preoperative TR remained in that grade at 5 years, but 11% had severe TR. Conclusions Tricuspid regurgitation accompanying ischemic mitral regurgitation is associated with right-side heart remodeling and dysfunction often mirroring that occurring in the left side of the heart—ischemic TR. Tricuspid valve repair is effective initially, but as with mitral valve repair, TR progressively returns. Therefore, when the severity of TR and right-sided remodeling reaches the point of irreversibility, it may be an indication to eliminate the TR by replacing the tricuspid valve.

For mitral regurgitation (MR) from degenerative mitral disease in patients with coexisting coronary artery disease, the appropriate surgical strategy remains controversial.From 1985 to 2011, 1,071 adults (age 70 ± 9.3 years, 77% men) underwent combined coronary artery bypass grafting and either mitral valve repair (n = 872, 81%) or replacement (n=199, 19%) for degenerative MR. Propensity matching (177 patient pairs, 89% of possible matches) was used to compare early outcomes and time-related recurrence of MR after mitral valve repair, mitral valve reoperation, and mortality. Risk factors for death were identified with multivariable, multiphase hazard-function analysis.Patients undergoing valve replacement were older, with more valve calcification and a higher prevalence of preoperative atrial fibrillation and heart failure (all p.0001). Among matched pairs, mitral replacement versus repair was associated with higher hospital mortality (5.0% vs 1.0%, p = .0001) and more postoperative renal failure (7.0% vs 3.2%, p = .01), reexplorations for bleeding (6.0% vs 3.1%, p = .05), and respiratory failure (14% vs 4.7%, p.0001). Of matched patients undergoing repair, 18% had MR above 3+ by 5 years. Mitral valve durability was similar between matched groups, but survival at 15 years was 18% after replacement versus 52% after repair. Nomograms from the multivariable equation revealed that in 94% of cases, 10-year survival was calculated to be higher after repair than after replacement.In patients with coexisting degenerative mitral valve and coronary artery diseases, mitral valve repair is expected to confer a long-term survival advantage over replacement despite some recurrence of MR. When feasible, it is the procedure of choice for these patients.

Background. Antibody mediated rejection (AMR) is an important cause of graft loss in the post heart transplant period. The following study was conducted to determine differences between survivors and nonsurvivors who developed post heart transplant AMR. Methods. We retrospectively reviewed the charts of patients who received a heart transplant between January 1993 and December 2002. Patients with biopsy proven AMR were identified. This group was divided into survivors and nonsurvivors. Groups were compared with regards to demographics, T-cell flow panel of reactive antibodies (PRA), flow cross-matches (anti-donor HLA Class I and II), and short- and long-term outcomes. Results of endomyocardial biopsies were collected to allow calculation of sensitivity, specificity, negative- and positive predictive values as well as accuracy of immunoglobulins and complement split products in association to death. Results. A total of 65 patients (8.9%) were diagnosed with AMR. Mean age was 48 y (range: 8-68 y) and 53.8% were males. Episodes of hemodynamic instability associated with AMR were observed in 37% of patients. Only two deaths were directly attributed to acute AMR. Nearly 20% of AMR patients developed transplant coronary artery disease. Univariate analysis identified T-PRA (P < 0.001), mean T-cell molecules of equivalent soluble fluorochrome (MESF) (P < 0.001) and mean B-cell MESF (P < 0.001) as possible factors associated with death. Neither demographics of complement split products were associated to late death. Conclusion. When studying patients with AMR, pre-transplant T-PRA, T-cell, and B-cell MESF may identify individuals at risk of late death.

To evaluate the effects of downsizing of the total artificial heart (TAH), we compared the anaerobic threshold (AT) values in calves with two different types of TAH (Cleveland Clinic–Nimbus TAH and the downsized MagScrew TAH). Exercise studies were performed using a treadmill in 12 calves. During the exercise, parameters to obtain the AT were measured. To evaluate the determinants of the AT, a linear regression analysis was performed between AT and potential variables. AT values from 29 studies revealed no significant differences between the two different TAHs, with no significant differences in hemodynamic or oxygen metabolic parameters. AT values correlated well with pump flow/body weight (Q) multiplied by the hemoglobin level, regardless of the TAH used. In conclusion, downsizing of the original TAH design did not reduce AT without any significant differences in hemodynamic or oxygen metabolic parameters during exercise in calves.

Ischemic mitral regurgitation is associated with substantial risk of death. We sought to: (1) detail significant recent improvements to the Dassault Systèmes human cardiac function simulator (HCFS); (2) use the HCFS to simulate normal cardiac function as well as pathologic function in the setting of posterior left ventricular (LV) papillary muscle infarction; and (3) debut our novel device for correction of ischemic mitral regurgitation. We synthesized two recent studies of human myocardial mechanics. The first study presented the robust and integrative finite element HCFS. Its primary limitation was its poor diastolic performance with an LV ejection fraction below 20% caused by overly stiff ex vivo porcine tissue parameters. The second study derived improved diastolic myocardial material parameters using in vivo MRI data from five normal human subjects. We combined these models to simulate ischemic mitral regurgitation by computationally infarcting an LV region including the posterior papillary muscle. Contact between our novel device and the mitral valve apparatus was simulated using Dassault Systèmes SIMULIA software. Incorporating improved cardiac geometry and diastolic myocardial material properties in the HCFS resulted in a realistic LV ejection fraction of 55%. Simulating infarction of posterior papillary muscle caused regurgitant mitral valve mechanics. Implementation of our novel device corrected valve dysfunction. Improvements in the current study to the HCFS permit increasingly accurate study of myocardial mechanics. The first application of this simulator to abnormal human cardiac function suggests that our novel annuloplasty ring with a sub-valvular element will correct ischemic mitral regurgitation., Cardiovascular Engineering and Technology, 6 (2), ISSN:1869-408X, ISSN:1869-4098

Background Stroke is a widely recognized complication after aortic valve replacement (AVR), especially among elderly patients. The literature contains substantial variability in reports of the actual incidence of stroke after AVR among high-risk patients. Our objective was to define risk of stroke in patients undergoing surgical AVR, using a large national database. Methods We used the 2002 to 2011 Nationwide Inpatient Sample database for this analysis. All patients undergoing isolated AVR, or AVR with coronary artery bypass grafting (AVR + CABG), were identified using standard International Classification of Diseases codes. In-hospital mortality and any adverse neurologic event were the primary outcomes of the study. Results The incidence of in-hospital mortality was 3.0% and 5.1%, respectively, among patients undergoing isolated AVR and AVR + CABG; it was significantly lower in high-volume centers. The incidence of any adverse neurologic event was 2.0% and 2.9%, respectively, among patients undergoing isolated AVR, and AVR + CABG. We demonstrated a progressive increase in the risk of in-hospital mortality and adverse neurologic events with increasing age. Neurologic events increased with age, from 1.3% for patients aged 85 years, for isolated AVR; and from 2.3% to 3.6% for AVR + CABG. The incidence of in-hospital mortality was as high as 5.7% and 7.4%, respectively, among patients aged >85 years undergoing isolated AVR, and AVR + CABG. Similarly, the incidence of any adverse neurologic event was 3.2% and 3.6%, respectively, among patients aged >85 years undergoing isolated AVR, and AVR + CABG. In addition, the risk of adverse neurologic events was significantly higher in the high-risk surgical cohort, compared with the low-risk surgical cohort (odds ratio [95% confidence interval]; isolated AVR: 2.38 [1.99-2.86]; AVR + CABG: 1.88 [1.57-2.24]). Conclusions The incidence of in-hospital mortality and adverse neurologic events was significantly higher among patients with advanced age and elevated surgical risk.

Objective: Left ventricular reconstruction (LVR) is performed to improve the morphologic structure and function of the heart in patients with heart failure. This procedure has been performed at the Cleveland Clinic Foundation since 1997. We assessed mortality, functional status, and predictors of outcome in these patients. Methods: Data were extracted from multiple prospectively acquired datasets on demographic, clinical, andoperativedetailsof220consecutivepatientswhounderwentLVRbetweenJuly1997andJuly2003,wheretheindicationforsurgerywasheart failure (of whom 66% had New York Heart Association (NYHA) functional class III or IV symptoms). Mortality, functional status, and postoperative complications were ascertained by reference to the clinical record, social security death index, and by phone contact. Mean preoperative left ventricular ejection fraction (LVEF) was 21.5 � 7.3% and mean left ventricular end-diastolic diameter was 6.4 � 1.0 cm. The mean age was 61.4 � 9.0 years and 80% were male. The majority (86%) of patients underwent concomitant coronary artery bypass grafting and 49% underwent mitralvalvesurgery.Results:Thirty-daymortalitywas1%andsurvivalat1,3,and5 yearswas92%,90%,and80%,respectively.Of thesurvivorsfor whom data on NYHA functional class were available, 85% were in NYHA functional class I or II. Mortality was predicted by reduced preoperative ejection fraction

Whether a complete Cox-maze procedure is needed to ablate permanent atrial fibrillation in patients undergoing concomitant cardiac surgery is unknown. Our objective was to assess the effectiveness of different lesion sets in such patients.From November 1991 to January 2004, 575 patients underwent surgical treatment of permanent atrial fibrillation (duration6 months); mitral valve disease was the primary indication for surgery in 74%. Procedures included pulmonary vein isolation alone (n = 68, 12%), pulmonary vein isolation with left atrial connecting lesions (n = 265, 46%), and Cox-maze (n = 242, 42%). Rhythm documented on 5,120 postoperative electrocardiograms was used to estimate time-related prevalence of, and risk factors for, atrial fibrillation.Prevalence of postoperative atrial fibrillation peaked at 46% two weeks after operation, declining to 24% at one year. Patient-related risk factors for increased prevalence included older age (p0.0001), larger left atrium (p0.0001), and longer duration of preoperative atrial fibrillation (p = 0.0008). The Cox-maze procedure and lesion sets resembling it created with alternative energy sources had a similarly low prevalence of late postoperative atrial fibrillation; in contrast, pulmonary vein isolation and lesion sets that did not include a lesion to the mitral anulus were less effective.This study suggests that in cardiac surgical patients with permanent atrial fibrillation the left atrial lesion set should include wide pulmonary vein isolation, at least one connection between right and left pulmonary veins, and a connection to the mitral anulus. Availability of alternative energy sources to create lesions sets has virtually eliminated the need for the cut-and-sew Cox-maze procedure.

ObjectivesBecause duration of inotropic support after left ventricular assist device implantation has been recognized as a surrogate for right ventricular dysfunction, we sought to (1) identify its preimplantation risk factors, particularly its association with preimplantation right ventricular dysfunction, and (2) assess its impact on clinical outcomes.MethodsBetween 1991 and 2002, left ventricular assist devices were implanted in 207 patients, exclusive of those receiving preoperative mechanical circulatory support, which precluded measuring right ventricular stroke work. Duration of inotropic support was analyzed as a continuous variable, truncated by death or transplantation, and in turn as a risk factor for these 2 events.ResultsInotropic support decreased from 100% on the day of implantation to 57%, 33%, and 22% by days 7, 14, and 21. Its duration was strongly associated with lower preimplantation right ventricular stroke work index, older age, and nonischemic cardiomyopathy and was associated (P < .04) with higher mortality before transplantation but not with transition to transplantation. We identified no preimplantation risk factors for right ventricular assist device use because of its relatively infrequent use in this population (18 patients, only 4 of whom survived to transplantation).ConclusionDuration of inotropic support after left ventricular assist device insertion is strongly correlated with low preimplantation right ventricular stroke work index. In turn, it was associated with reduced survival to transplantation. Thus, right ventricular stroke work measured before implantation might be useful in decision making for biventricular support, destination therapy, or total artificial heart.

OBJECTIVES The purpose of the present study is to report the five-year follow-up results of the ERACI II trial. BACKGROUND Immediate and one-year follow-up results of the ERACI II study showed a prognosis advantage of percutaneous coronary intervention (PCI) with stents over coronary artery bypass grafting (CABG). METHODS A total of 450 patients were randomly assigned to undergo either PCI (n = 225); or CABG (n = 225). Only patients with multi-vessel disease were enrolled. Clinical follow-up during five years was obtained in 92% of the total population after hospital discharge. The primary end point of the study was to compare freedom from major adverse cardiovascular events (MACE) at 30 days, 1 year, 3 years, and 5 years of follow-up. RESULTS At five years of follow-up, patients initially treated with PCI had similar survival and freedom from non-fatal acute myocardial infarction than those initially treated with CABG (92.8% vs. 88.4% and 97.3% vs. 94% respectively, p = 0.16). Freedom from repeat revascularization procedures (PCI/CABG) was significantly lower with PCI compared with CABG (71.5% vs. 92.4%, p = 0.0002). Freedom from MACE was also significantly lower with PCI compared with CABG (65.3% vs. 76.4%; p = 0.013). At five years similar numbers of patients randomized to each revascularization procedure were asymptomatic or with class I angina. CONCLUSIONS At five years of follow-up, in the ERACI II study, there were no survival benefits from any revascularization procedure; however patients initially treated with CABG had better freedom from repeat revascularization procedures and from MACE.

A 76-year-old male with ischemic cardiomyopathy presented with heart failure symptoms in the absence of angina. Several hospitalizations were required due to heart failure exacerbation and paroxysmal atrial fibrillation. Electrocardiography and tissue synchronization imaging confirmed ventricular dyssynchrony, requiring biventricular pacing. After a failed attempt of percutaneous placement of the left ventricular lead, a novel minimally invasive approach was indicated. It consisted of left ventricular epicardial lead placement, microwave pulmonary vein isolation, and left atrial appendage excision through bilateral minithoracotomies. The postoperative recovery was unremarkable, with reestablishment of the ventricular synchrony and regular rhythm.

We evaluated diastolic function in patients who underwent elective revascularization by standard on-pump coronary artery bypass graft (CABG) surgery versus off-pump CABG. Diastolic function improved in both groups, but indexes of early diastolic filling and myocardial relaxation improved more in patients who underwent on-pump than off-pump CABG.

Right ventricular (RV) maximal power (PWRmx) is dependent on preload. The objective of this study was to test our hypothesis that the PWRmx versus end-diastolic volume (EDV) relationship, analogous to the load-independent stroke work (SW) versus EDV relationship (preload-recruitable SW, PRSW), is linear, with the PWR x-axis intercept (V0PWR) corresponding to the PRSW intercept (V0SW). If our hypothesis is correct, the preload sensitivity of PWRmx could be eliminated by adjusting for EDV and V0PWR. Ten dogs were instrumented with a pulmonary flow probe, micromanometers, and RV conductance catheter. Data were obtained during bicaval occlusions under various conditions and fitted to PWRmx = a·(EDV − V0PWR)β, where a is the slope of the relationship. The PWRmx versus EDV relationship did not deviate from linearity (β = 1.09, P = not significant vs. 1), and V0PWR correlated with V0SW ( r = 0.93, P 0PRW was related to steady-state EDV and left ventricular end-diastolic pressure, allowing for estimation of V0PWR (V0Est) and single-beat PWRmx preload adjustment. Dividing PWRmx by the difference of EDV and V0PWR (PAMPV0PWR) eliminated preload dependency down to 50% of the baseline EDV. PWRmx adjustment using V0Est (PAMPV0Est) showed similar preload independency. Enhancing contractility increased PAMPV0PWR and PAMPV0Est from 176 ± 52 to 394 ± 205 W/ml × 104 and 145 ± 51 to 404 ± 261 W/ml × 104, respectively, accompanied by an increase of PRSW from 13.0 ± 4.5 to 29.7 ± 16.4 mmHg (all P V0PWR and PAMPV0Est correlated with PRSW ( r = 0.85; r = 0.77; both P mx should consider a linear PWRmx versus EDV relationship with distinct V0PWR. PAMPV0PWR is a preload-independent estimate of RV contractility that may eventually be determined noninvasively.