Brandon M. Jones

Ventricular septal rupture complicating acute myocardial infarction: a contemporary review.

Ventricular septal rupture (VSR) after acute myocardial infarction is increasingly rare in the percutaneous coronary intervention era but mortality remains high. Prompt diagnosis is key and definitive surgery, though challenging and associated with high mortality, remains the treatment of choice. Alternatively, delaying surgery in stable patients may provide better results. Prolonged medical management is usually futile, but includes afterload reduction and intra-aortic balloon pump placement. Using full mechanical support to delay surgery is an attractive option, but data on success is limited to case reports. Finally, percutaneous VSR closure may be used as a temporizing measure to reduce shunt, or for patients in the sub-acute to chronic period whose comorbidities preclude surgical repair.

Reversibility of cardiac function predicts outcome after transcatheter aortic valve replacement in patients with severe aortic stenosis

Background Reversibility of left ventricular (LV) dysfunction in high‐risk aortic stenosis patient and its impact on survival after transcatheter aortic valve replacement (TAVR) are unclear. We aimed to evaluate longitudinal changes of LV structure and function after TAVR and their impact on survival. Methods and Results We studied 209 patients with aortic stenosis who underwent TAVR from May 2006 to December 2012. Echocardiograms were used to calculate LV end‐diastolic volume index (LVEDVi), LV ejection fraction, LV mass index (LVMi), and global longitudinal strain before, immediately (<10 days), late (1–3 months), and yearly after TAVR. During a median follow‐up of 1345 days, 118 patients died, with 26 dying within 1 year. Global longitudinal strain, LVEDVi, LV ejection fraction, and LVMi improved during follow‐up. In patients who died during the first year, death was preceded by LVEDVi and LVMi increase. Multivariable longitudinal data analysis showed that aortic regurgitation at baseline, aortic regurgitation at 30 days, and initial LVEDVi were independent predictors of subsequent LVEDVi. In a joint analysis of longitudinal and survival data, baseline Society of Thoracic Surgeons score was predictive of survival, with no additive effect of longitudinal changes in LVEDVi, LVMi, global longitudinal strain, or LV ejection fraction. Presence of aortic regurgitation at 1 month after TAVR was the only predictor of 1‐year survival. Conclusions LV reverse remodeling was observed after TAVR, whereas lack of LVEDVi and LVMi improvement was observed in patients who died during the first year after TAVR. Post‐TAVR, aortic regurgitation blocks reverse remodeling and is associated with poor 1‐year survival after TAVR.

Recognizing Transthyretin Cardiac Amyloidosis in Patients With Aortic Stenosis: Impact on Prognosis

Cardiac amyloidosis is an under recognized and underdiagnosed heart failure etiology characterized by protein misfolding, myocardial deposition, and restrictive cardiomyopathy. Cardiac involvement in elderly patients most commonly results from the transthyretin protein (ATTR) and carries a poor

Matching patients with the ever-expanding range of TAVI devices

Transcatheter aortic valve implantation (TAVI) has become a widely accepted strategy for the treatment of aortic stenosis in patients at intermediate, high, or prohibitive surgical risk. After >1 decade of innovation and clinical trial experience, the available technology for TAVI has grown enormously, and now includes a myriad of vascular access approaches and innovative valve designs. As a result, the range of patients who can benefit from these advances continues to grow rapidly. Furthermore, given the improved safety profile and clinical success of current-generation devices in randomized trials, the use of TAVI among even low-risk populations is justified in current trials. With the rapid dissemination and expansion of this technology, operators need to have a comprehensive understanding of how to select the appropriate procedural approach for each individual patient. In this Review, we detail the current evidence for TAVI among different patient populations, discuss the different vascular access approaches currently in use, and explore differences in design features among currently available and investigational valve systems. Furthermore, we provide an overview of important considerations for special patient populations, such as those with existing mitral prostheses, bicuspid aortic stenosis, isolated aortic regurgitation, or severe left ventricular outflow tract calcification.

Cerebral protection devices for transcatheter aortic valve replacement

ABSTRACT Introduction: Stroke is a devastating, potential complication of any cardiovascular procedure including transcatheter aortic valve implantation (TAVI). Even clinically silent lesions as detected by magnetic resonance imaging have been associated with poor long-term cognitive outcomes. As a result, extensive efforts have been focused on developing stroke preventative strategies including the development of novel embolic protection devices. These devices aim to reduce this risk by capturing or deflecting emboli away from the cerebral circulation. Areas covered: This review provides an insight into the incidence and mechanisms of neurologic events during TAVI, explores the design features and initial human experience of each of the cerebral embolic protection devices that have been used during TAVI, and carefully explains the major clinical trials of each of these devices with a focus on safety, efficacy and other reported outcomes. Expert commentary: The potential benefit of neuroprotection cannot be ignored as TAVI widens its scope to include younger and lower-risk patients wherein preventing a procedure related cerebral injury would potentially prevent long-term morbidity and mortality.

Impact of Coronary Artery Disease on 30‐Day and 1‐Year Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement: A Meta‐Analysis

Background The impact of coronary artery disease (CAD) on outcomes after transcatheter aortic valve replacement (TAVR) is understudied. Literature on the prognostic role of CAD in the survival of patients undergoing TAVR shows conflicting results. This meta‐analysis aims to investigate how CAD impacts patient survival following TAVR. Methods and Results We completed a comprehensive literature search of Embase, MEDLINE, and the Cochrane Library, and included studies reporting outcome of TAVR based on CAD status of patients for the analysis. From the initial 1631 citations, 15 studies reporting on 8013 patients were analyzed using a random‐effects model. Of the 8013 patients undergoing TAVR, with a median age of 81.3 years (79–85.1 years), 46.6% (40–55.7) were men and 3899 (48.7%) had CAD (ranging from 30.8% to 78.2% in various studies). Overall, 3121 SAPIEN/SAPIEN XT/SAPIEN 3 (39.6%) and 4763 CoreValve (60.4%) prostheses were implanted, with transfemoral access being the most frequently used approach for the implantation (76.1%). Our analysis showed no significant difference between patients with and without CAD for all‐cause mortality at 30 days post TAVR, with a cumulative odds ratio of 1.07 (95% confidence interval, 0.82–1.40; P=0.62). However, there was a significant increase in all‐cause mortality at 1 year in the CAD group compared with patients without CAD, with a cumulative odds ratio of 1.21 (95% confidence interval, 1.07–1.36; P=0.002). Conclusions Even though coexisting CAD does not impact 30‐day mortality, it does have an impact on 1‐year mortality in patients undergoing TAVR. Our results highlight a need to revisit the revascularization strategies for concomitant CAD in patients with TAVR.

Neurologic Events After Transcatheter Aortic Valve Replacement

Early trials involving transcatheter aortic valve replacement raised concerns for an elevated risk of neurologic events compared to surgical AVR. Contemporary studies suggest declining rates with better patient selection, improved operator experience, and newer generation devices. Events are usually embolic in nature, occur in the periprocedural period, and can lead to increased morbidity and mortality. Current investigations are focused on developing embolic protection devices for intraprocedural use and optimizing antiplatelet and anticoagulant regimens. These efforts aim to further reduce the incidence of stroke, which is particularly important as the technology expands to include intermediate and possibly low surgical risk populations.

Pushing with the pigtail: a novel approach to placing the MitraClip in a patient with a severely restricted posterior mitral leaflet.

The MitraClip is an US Food and Drug Administration‐approved device for inoperable patients with severe degenerative mitral regurgitation (MR) and is under investigation for use in patients with severe functional MR. Simultaneously grasping both leaflets of the mitral valve can be technically challenging, however, in patients with a restricted posterior leaflet. We present one such case in which a pigtail catheter, placed retrograde into the left ventricle, was able to push the ventricular surface of the posterior leaflet into closer approximation with the anterior leaflet, and facilitate successful clip placement. We provide this report in hopes that it will provide a useful strategy for interventionalists faced with this challenging situation.

How Symptomatic Should a Hypertrophic Obstructive Cardiomyopathy Patient Be to Consider Alcohol Septal Ablation

Hypertrophic cardiomyopathy (HCM) is a complex and heterogeneous disease with different anatomical variants, physiologic manifestations, and genetic underpinnings. Even asymptomatic patients with HCM are at potential risk for sudden cardiac death and require risk stratification and consideration of

Cerebrovascular Events After Cardiovascular Procedures: Risk Factors, Recognition, and Prevention Strategies

Stroke has long been a devastating complication of any cardiovascular procedure that unfavorably affects survival and quality of life. Over time, strategies have been developed to substantially reduce the incidence of stroke after traditional cardiovascular procedures such as coronary artery bypass grafting, isolated valve surgery, and carotid endarterectomy. Subsequently, with the advent of minimally invasive technologies including percutaneous coronary intervention, carotid artery stenting, and transcatheter valve therapies, operators were faced with a new host of procedural risk factors, and efforts again turned toward identifying novel ways to reduce the risk of stroke. Fortunately, by understanding the procedural factors unique to these new techniques and applying many of the lessons learned from prior experiences, we are seeing significant improvements in the safety of these new technologies. In this review, the authors: 1) carefully analyze data from different cardiac procedural experiences ranging from traditional open heart surgery to percutaneous coronary intervention and transcatheter valve therapies; 2) explore the unique risk factors for stroke in each of these areas; and 3) describe how these risks can be mitigated with improved patient selection, adjuvant pharmacotherapy, procedural improvements, and novel technological advancements.