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Background: The pathologic processes of aortic regurgitation (AR) and aortic stenosis (AS) can affect the rate of progression to symptoms differently, and insight into the management of mixed aorti...

Background: The purpose of this study was to perform a systematic review and pooled analysis to evaluate 30-day and 1-year outcomes of transcatheter mitral valve-in-valve (VIV) and valve-in-ring (VIR) procedures. Data from the Valve-in-Valve Data Registry revealed that there were several safety and efficacy concerns, although procedural success was achieved in most cases. Methods: Studies reporting data on either mitral VIV and/or VIR with at least five patients were pooled using weighted proportional analysis. Results: The 30-day pooled estimate of all-cause mortality in the mitral VIV group was 7%, valve embolization, 5%, stroke, 3%, and major bleeding, 9%. At 1 year the all-cause mortality was 11%, valve thrombosis, 10%, stroke, 6%, and major bleeding, 16%. In the mitral VIR group, the 30-day pooled estimate for all-cause mortality was 8%, renal failure, 11%, valve embolization, 3%, and left ventricular outflow tract obstruction, 10% and at 1 year the all-cause mortality was about 22%. Conclusions: Mitral VIV and VIR procedures are safe and feasible in high risk surgical candidates. The long-term safety and efficacy data beyond 1 year for both mitral VIV and VIR need to be established.

Background: The transapical (TA) route for mitral valve-in-valve (MVIV) and mitral valve-in-ring (MVIR) techniques has been predominantly used. Currently, there is an increasing trend towards the transseptal (TS) route. The purpose of the study was to assess the outcomes of TA and TS access for percutaneous MVIV and MVIR techniques in terms of procedural success, 30-day mortality, major bleeding events and valve embolization.Methods: A comprehensive literature search of EMBASE, PubMed, and the Cochrane CENTRAL was completed. We identified and pooled all studies reporting either the TS or TA approach for MVIV or MVIR with at least five patients using weighted proportional analysis. For analysis we used studies reporting the outcomes of percutaneous MVIV or MVIR based on the TS/TA approach.Results: From the initial 1,993 abstracts, 15 studies reporting on 236 patients were analyzed to find the pooled estimate of the endpoints. In the TA arm, 11 studies were included, and in the TS arm, 8 studies wer...

Mitral valve regurgitation poses a significant public health burden, with more than 3 million people in the US alone suffering from moderate or severe mitral valve regurgitation. Surgical correction with mitral valve repair or replacement is the mainstay of therapy. However, a significant proportion of elderly patients are not eligible for mitral valve repair or replacement due to prohibitive surgical risk from increased age, poor ventricular function, or associated comorbidities. Percutaneous mitral valve repair/replacement techniques have been developed to fill this void. The most advanced percutaneous technique with the highest safety and efficacy to date is the edge-to-edge MitraClip repair system. The majority of other catheter-based mitral valve repair/replacement devices are at early developmental stages, but have shown encouraging initial results in feasibility trials. Transcatheter mitral valve replacement holds promise to emerge as the leading transcatheter treatment of choice in the fu...

Pericardial diseases can be classified broadly as 3 entities: acute pericarditis, cardiac tamponade, and constrictive pericarditis. These disorders can be diagnosed and managed with noninvasive studies following a comprehensive history and physical examination, without the need for cardiac catheterization in most patients. Despite the advances in noninvasive cardiac imaging, there are limitations to their diagnostic accuracy. The invasive hemodynamic study offers the advantage of simultaneous, direct pressure measurement across multiple chambers, with direct examination of blood flow. Herein, the authors review the techniques for obtaining and interpreting invasive hemodynamic data in patients with suspected pericardial disease.

Background The optimal management for coronary drug eluting stent in-stent restenosis (DES ISR) is unclear. We performed a meta-analysis of observational and randomized studies to compare the outcomes of management of DES ISR using DES, drug eluting balloon (DEB), or balloon angioplasty (BA). Methods Eligible studies (25 single arm and 13 comparative, including 4 randomized studies with a total of 7,474 patients with DES ISR) were identified using MEDLINE search and proceedings of international meetings. Outcomes studied include major adverse cardiac events (MACE), target lesion revascularization (TLR), target vessel revascularization (TVR), myocardial infarction (MI), stent thrombosis (ST), and mortality. Follow-up ranged from 0.5 to 3.5 years (mean 1.4 years). Results The rate of TLR was significantly lower in the DES (odds ratio [OR] 0.50, 95% confidence interval [CI] 0.36–0.69) and DEB (OR 0.31, 95% CI 0.18–0.55) groups compared to BA. Similarly, TVR rate was significantly lower in the DES (OR 0.55, 95% CI 0.39–0.77) and DEB (OR 0.32, 95% CI 0.18–0.58) groups compared to BA. All other outcomes were similar between the DES/BA and DEB/BA comparisons. TLR was significantly lower in the DES group compared to BA for vessels 2.75 mm. Conclusion Treatment of coronary DES ISR with DES or DEB is associated with a reduction in the risk of TLR and TVR compared to BA alone. The relative risk reduction for TLR with DES is similar to DEB. DEBs have a potential role in the treatment of DES ISR by avoiding placement of another layer of stent. © 2015 Wiley Periodicals, Inc.

Aortic insufficiency (AI) is common after transcatheter aortic valve replacement (TAVR). It has been linked to mortality that has limited the expansion of this promising technique. Inappropriate valve sizing relative to the native annulus, calcification in the aortic annulus and imprecise implantation (too low relative to the annulus) are the most common causes for post-TAVR AI. A thorough understanding of these factors may therefore allow overcoming this complication. In this review, we describe the prediction and reduction of these factors to minimize post-TAVR AI.

Platelet adhesion and aggregation at the site of coronary stenting can have catastrophic clinical and economic consequences. Therefore, effective platelet inhibition is vital during and after percutaneous coronary intervention. Eptifibatide is an intravenous antiplatelet agent that blocks the final common pathway of platelet aggregation and thrombus formation by binding to glycoprotein IIb/IIIa receptors on the surface of platelets. In clinical studies, eptifibatide was associated with a significant reduction of mortality, myocardial infarction, or target vessel revascularization in patients with acute coronary syndrome undergoing percutaneous coronary intervention. However, recent trials conducted in the era of dual antiplatelet therapy and newer anticoagulants failed to demonstrate similar results. The previously seen favorable benefit of eptifibatide was mainly offset by the increased risk of bleeding. Current American College of Cardiology/American Heart Association guidelines recommend its use as an adjunct in high-risk patients who are undergoing percutaneous coronary intervention with traditional anticoagulants (heparin or enoxaparin), who are not otherwise at high risk of bleeding. In patients receiving bivalirudin (a newer safer anticoagulant), routine use of eptifibatide is discouraged except in select situations (eg, angiographic complications). Although older pharmacoeconomic studies favor eptifibatide, in the current era of P2Y12 inhibitors and newer safer anticoagulants, the increased costs associated with bleeding make the routine use of eptifibatide an economically nonviable option. The cost-effectiveness of eptifibatide with the use of strategies that decrease the bleeding risk (eg, transradial access) is unknown. This review provides an overview of key clinical and economic studies of eptifibatide well into the current era of potent antiplatelet agents, novel safer anticoagulants, and contemporary percutaneous coronary intervention., Video abstract

Objectives The study undertook a systematic review to establish and compare the risk of stroke between the 2 widely used approaches (transfemoral [TF] vs. transapical [TA]) and valve designs (CoreValve, Medtronic, Minneapolis, Minnesota vs. Edwards Valve, Edwards Lifesciences, Irvine, California) for transcatheter aortic valve replacement (TAVR). Background There has been a rapid adoption and expansion in the use of TAVR. The technique is however far from perfect and requires further refinement to alleviate safety concerns that include stroke. Methods All studies reporting on the risk of stroke after TAVR were identified using an electronic search and pooled using established meta-analytical guidelines. Results 25 multicenter registries and 33 single-center studies were included in the analysis. There was no difference in pooled 30-day stroke post-TAVR between the TF and TA approach in multicenter (2.8% [95% confidence interval (CI): 2.4 to 3.4] vs. 2.8% [95% CI: 2.0 to 3.9]) and single-center studies (3.8% [95% CI: 3.1 to 4.6] vs. 3.4% [95% CI: 2.5 to 4.5]). Similarly, there was no difference in pooled 30-day stroke post TAVR between the CoreValve and Edwards Valve in multicenter (2.4% [95% CI: 1.9 to 3.2] vs. 3.0% [95% CI: 2.4 to 3.7]) and single-center studies (3.8% [95% CI: 2.8 to 4.9] vs. 3.2% [95% CI: 2.4 to 4.3]). There was a decline in stroke risk with experience and technological advancement. There was no difference in the outcome of 30-day stroke between TAVR and surgical aortic valve replacement. Conclusions Our findings suggest that the risk of 30-day stroke after TAVR is similar between the approaches and valve types. There has been a decline in stroke risk after TAVR with improvements in valve technology, patient selection, and operator experience.

Objectives: The goal of this study was to provide a systematic review comparing the long-term outcomes of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus coronary art...

Background Evaluation of pain localized to the chest in the emergency room is, challenging, time-consuming, costly, and often inconclusive. Available research, though limited, suggests a role for MDCTA in the evaluation of patients with acute chest pain of low to intermediate risk, for identifying and excluding ACSs during the initial emergency department evaluation. Accordingly, our aim was to conduct a meta-analysis to assess the diagnostic accuracy of MDCTA in this setting. Methods We included all studies that compared MDCTA with either coronary angiography or standard of care for early and accurate triage of patients presenting with acute chest pain. Published studies were identified by searches of the Pubmed, Ovid and Google scholar databases as well as hand searches of selected references. Data were extracted independently by two reviewers. Included studies were evaluated for heterogeneity. Meta-analysis was performed at patient level using a random-effects model. Results 16 studies totaling 1119 patients were included in the current meta-analysis: one randomized trial, one retrospective analysis and fourteen prospective cohort studies. Pooled DOR was 190.80 (95%CI, 102.94–353.65). The pooled sensitivity and specificity were 0.96 (95%CI, 0.93–0.98) and 0.92(95%CI, 0.89–0.94) respectively. The pooled NLR and PLR were 0.09 (95%CI, 0.06–0.14) and 10.12 (95%CI, 6.73–15.22). Conclusion MDCTA has an excellent diagnostic accuracy in detection of significant coronary artery stenosis in patients with acute chest pain. This diagnostic accuracy of MDCTA has a potential for rapid triage of patients in the ED, with acute chest pain of low to intermediate risk of acute coronary syndrome, to rule out significant epicardial stenosis as the etiology of chest pain.

Despite its short length, the left main coronary artery remains one of the most challenging areas of disease in interventional cardiology today. This challenge draws from the need for an accurate diagnosis as well as a changing management strategy. Since the consequences are significant, the use of intravascular ultrasound or fractional flow reserve should be considered when making the diagnosis, especially in cases of intermediate disease. Noninvasive imaging modalities such as cardiac computed tomography have high sensitivity and specificity for the left main coronary artery and will likely have an increasing surveillance role in the future, especially in ruling out disease. Although coronary artery bypass grafting remains the standard of care for the revascularization of this area, advances in interventional cardiology have improved outcomes in selected patients so that they are now comparable to coronary artery bypass grafting at least up to medium-term follow-up. Going forward the preferred revascula...

AIMS To review the outcomes of studies and the safety of newer transcatheter aortic valves (THV). METHODS AND RESULTS All studies reporting on second-generation THV were identified and pooled using the systematic review guidelines. Twenty-four reports on 1,708 patients and eight THV were included in the analysis. The pooled 30-day event rate for mortality after transcatheter aortic valve implantation (TAVI) was 5.7% (95% CI: 4.0-7.8), myocardial infarction (MI) was 1.7% (95% CI: 1.1-2.6), stage 3 acute kidney injury (AKI) was 3.4% (95% CI: 2.0-5.6), life-threatening bleeding was 5.1% (95% CI: 3.3-7.8), major vascular complications was 4.9% (95% CI: 3.5-6.6%), major bleeding was 10.5% (95% CI: 5.1-20.4), major stroke was 2.4% (95% CI: 1.7-3.4), permanent pacemaker utilisation was 13.5% (95% CI: 10.8-16.9), and coronary obstruction was 1.2% (95% CI: 0.6%-2.4%). Moderate or severe aortic insufficiency (AI) after TAVI was 4.2% (95% CI: 2.0-8.5). The pooled 30-day mean gradient and effective orifice area (EOA) were 11.63 mmHg (95% CI: 10.19-13.07) and 1.60 cm2 (95% CI: 1.5-1.7), respectively. All estimates compare favourably to events reported for first-generation valves. CONCLUSIONS Our findings suggest that the new THV have a low risk of TAVI-related short-term complications.

Dyslipidemia and the contributions of oxidized low-density lipoproteins (ox-LDL) are independent cardiovascular risk factors. There is growing evidence that dyslipidemia contributes not only to cardiovascular disease but also to the progressive decline of renal function in diabetic and non-diabetic kidney disease. Ox-LDL, by generating inflammation and oxidative stress, contributes to a pro-atherogenic mileu and leads to endothelial dysfunction, subsequent glomerular filtration barrier damage, and progressive renal injury. Chronic kidney disease (CKD), in turn, induces deleterious effects on lipid metabolism. Therefore, by inhibiting cholesterol synthesis and reducing ox-LDL, HMG CoA reductase inhibitors (statins) are attractive therapeutic options to preserve renal function. Current evidence demonstrates a reduction in cardiovascular risk and improved renal outcomes especially in patients with mild to moderate impairment of renal function. Evidence supports a beneficial role of statins thought to extend beyond their lipid-lowering effect, referred to as pleiotropic actions. These actions include modulatory effects on inflammation, oxidative stress and thrombosis, derived from their ability to prevent the formation of isoprenoid intermediates involved in cellular signaling, posttranslational modification of proteins and cellular function. This translates to potential reductions in the rate of decline in GFR in CKD and adverse effects of type 2 diabetes mellitus in the kidney. This review examines the role of statins for reno-protection as well as cardiovascular benefit in patients with CKD.

1 Background The optimal treatment of patients with severe mitral regurgitation (MR) at high surgical risk (HSR) is unknown. Recently, the EVEREST II (Endovascular Valve Edge-to-Edge Repair) High Risk Study suggested MitraClip (MC) was a safe and effective treatment option. 2 Methods We performed a search strategy for MC or mitral valve surgery (MVS) in patients at HSR for surgical mortality (logistic EuroSCORE >18 or STS score > 10) using Medline databases, proceedings of international meetings, and the STS database. We identified 21 studies utilizing MC (n = 3,198) and MVS (n = 3,265, >90% from the STS database) from 2003 to 2013. Information about patient characteristics, surgical risk, and 30-day and 1-year outcomes were extracted. 3 Results Patients who underwent MC or MVS had a mean age of 74 ± 10 years with no differences in surgical risk, NYHA class, or MR grade (P = 0.46). Technical success was achieved in 96% of patients undergoing MC versus 98% in the MVS group (P = 0.45). Patients undergoing MC were treated with one or two MC in 90% (n = 2,878) with only a few requiring repeat MC (0.4%, n = 13) or mitral surgery (0.3%, n = 52) at 30 days. The pooled event rates for mortality was 3.2% (95% CI [2.5–4.2]), stroke was 1.1% (95% CI [0.7–0.2]) at 30 days. At 31 days to 1 year, the pooled event rate for mortality was 13.0% [95% CI (9–18.3)], stroke was 1.6% [95% CI (0.8–3.2)], and repeat MVS was 1.3% [95% CI (0.7–2.6)] with the majority of patients in the mild/moderate MR grade and NYHA class after MC. The 30-day event rates for mortality and stroke were 16.8% (95% CI [14–19]) and 4.5% (95% CI [3.9–5.3]) after MVS, respectively. 4 Conclusion Based on high risk MC studies and high risk MVS data predominantly from STS database, patients with severe MR who are at HSR can be effectively treated with MC or MVS. MC can be safely implanted in high risk patients with relatively low mortality and stroke risk. © 2014 Wiley Periodicals, Inc.

Touraine Solente Gole syndrome, a relatively rare inherited disorder is epitomized by finger clubbing, skeletal changes and pachyderma. We report a typical case of complete pachydermoperiostosis in addition to a thick fissured tongue, a yet unrecognized association and discuss the social cum clinical relevance of identifying this relatively uncommon disorder.

Objectives This study was designed to establish the incidence, impact, and predictors of post-transcatheter aortic valve replacement (TAVR) aortic regurgitation (AR). Background AR is an important limitation of TAVR with ill-defined predictors and unclear long-term impact on outcomes. Methods Studies published between 2002 and 2012 with regard to TAVR were identified using an electronic search and reviewed using the random-effects model of DerSimonian and Laird. From 3,871 initial citations, 45 studies reporting on 12,926 patients (CoreValve [Medtronic CV Luxembourg S.a.r.l., Tolochenaz, Switzerland] n = 5,261 and Edwards valve [Edwards Lifesciences, Santa Ana, California] n = 7,279) were included in the analysis of incidence and outcomes of post-TAVR AR. Results The pooled estimate for moderate or severe AR post-TAVR was 11.7% (95% confidence interval [CI]: 9.6 to 14.1). Moderate or severe AR was more common with use of the CoreValve (16.0% vs. 9.1%, p = 0.005). The presence of moderate or severe AR post-TAVR increased mortality at 30 days (odds ratio: 2.95; 95% CI: 1.73 to 5.02) and 1 year (hazard ratio: 2.27; 95% CI: -1.84 to 2.81). Mild AR was also associated with an increased hazard ratio for mortality, 1.829 (95% CI: 1.005 to 3.329) that was overturned by sensitivity analysis. Twenty-five studies reported on predictors of post-TAVR AR. Implantation depth, valve undersizing, and Agatston calcium score (r = 0.47, p = 0.001) were identified as important predictors. Conclusions Moderate or severe aortic regurgitation is common after TAVR and an adverse prognostic indicator of short- and long-term survival. Incidence of moderate or severe AR is higher with use of the CoreValve. Mild AR may be associated with increased long-term mortality. Therefore, every effort should be made to minimize AR by a comprehensive pre-procedural planning and meticulous procedural execution.

AIM: Percutaneous intervention of true coronary bifurcation lesions is challenging. Based on the results of randomized trials and registry data, the approach of stenting of main vessel only with balloon dilatation of the side branch has become the default approach for false bifurcation lesions except when a complication occurs or in cases of suboptimal result. However, the optimal stenting strategy for true coronary bifurcation lesions - to stent or not to stent the side branch - is still a matter of debate. The purpose of this study was, therefore, to compare the clinical and angiographic outcomes of the double stent technique (stenting of the main branch and side branch) over the single stent technique (stenting of main vessel only with balloon dilatation of the side branch) for treatment of true coronary bifurcation lesions, with drug-eluting stents (DES). METHODS: Comparative studies published between January 2000 and February 2009 of the double stent technique vs. single stent technique with DES for true coronary bifurcations were identified using an electronic search and reviewed using a random effects model. The primary endpoints of our study were side-branch and main-branch restenoses, all-cause mortality, myocardial infarction (MI) and target lesion revascularization (TLR) at longest available follow-up. The secondary endpoints of our analysis were postprocedural minimal luminal diameter (MLD) of the side branch and main branch, follow-up MLD of side branch and main branch and stent thrombosis. Heterogeneity was assessed and sensitivity analysis was performed to test the robustness of the overall summary odds ratios (ORs). RESULTS: Five studies comprising 1145 patients (616 single stent and 529 double stent) were included in the analysis. Three studies were randomized comparisons between the two techniques for true coronary bifurcation lesions. Incomplete reporting of data in the primary studies was common. The lengths of clinical and angiographic follow-up ranged between 6 and 12 months and 6 and 7 months, respectively. Postprocedural MLD of the side branch was significantly smaller in the single stent group [standardized mean difference (SMD) -0.71, 95% CI -0.88 to -0.54, P < 0.000, I2 = 0%]. The odds of side-branch restenosis (OR 1.11, 95% CI 0.47-2.67, P = 0.81, I2 = 76%), main-branch restenois (OR 0.88, 95% CI 0.56-1.39, P = 0.58, I = 0%), all-cause mortality (OR 0.52, 95% CI 0.11-2.45, P = 0.41, I2 = 0%), MI (OR 0.92, 95% CI 0.34-2.54, P = 0.87, I = 49%) and TLR (OR 0.87, 95% CI 0.46-1.65, P = 0.68, I2 = 0%) were similar between the two groups. Postprocedural MLD of the main branch [standardized mean difference (SMD) -0.08, 95% CI -0.42 to -0.26, P < 0.65, I2 = 67%], follow-up MLD of side branch (SMD -0.19, 95% CI -0.40 to 0.01, P < 0.31, I2 = 15%) and main branch MLD (SMD 0.17, 95% CI -0.18 to 0.542, P < 0.35, I2 = 65%) were also similar between the two groups. CONCLUSION: In patients undergoing percutaneous coronary intervention (PCI) for true coronary bifurcations, there is no added advantage of stenting both branches as compared with a conventional one-stent strategy. The results, however, need to be interpreted considering the poor study methods and/or poor quality of reporting in publications. We propose to move forward and consider the conduct of more systematic, well-designed and scientific trials to investigate the treatment of true coronary bifurcation lesions.

[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 46-year-old asymptomatic woman underwent a positron emission tomography scan as part of an evaluation for a stage 1B cervical cancer, which revealed a hypermetabolic area in the right atrium (RA) (A, asterisk) . A

The optimal treatment of drug eluting stent in-stent restenosis (DES ISR) is unclear. We performed a meta-analysis of published studies to compare the outcomes of treatment of DES ISR using DES, drug eluting balloon (DEB) or balloon angioplasty (BA). Eligible studies were identified using MEDLINE