Charl Khalil

Valvuloarterial Impedance Predicts Heart Failure Readmissions in Patients Undergoing Transcatheter Aortic Valve Replacement

ABSTRACT Background: Elevated valvuloarterial impedance (Zva) has been associated with mortality in severe aortic stenosis (AS) patients. However, its role in predicting heart failure (HF) readmissions after transcatheter aortic valve replacement (TAVR) remains unknown. Methods: We evaluated 198 consecutive patients who underwent TAVR at our institution from 2012 to 2016. Clinical, laboratory, procedural, echocardiographic (ECHO) data and HF readmissions at 1-year were collected. Zva was calculated from ECHO as (systolic blood pressure + transvalvular gradient)/stroke volume index. Results: The mean age of all patients was 82 ± 7 years, 51% were males and 95% were Caucasians. Median duration of follow-up was 9 (Interquartile range: 12) months. The majority of patients had hypertension (93%) and 24.7% had heart failure symptoms with reduced EF (<50%). Use of beta-blockers was 64%, diuretics was 64%, angiotensin converting enzyme inhibitors was 25%, aldosterone receptor blockers was 16%, and potassium-sparing diuretics was 8%. Patients with a high pre-TAVR Zva (≥6.3 mmHg.mL−1.m2) were more likely to present with HF readmissions at 1-year in both unadjusted (34.2% vs. 18.1%, p = 0.03) and adjusted analysis (Hazards Ratio [HR] = 2.08 [95%CI: 1.00–4.29], p = 0.04). Patients with a Zva that either remained unchanged or increased post-TAVR had significantly higher mortality at 1-year post-procedure in the unadjusted (18.2% vs. 6.3%, p = 0.02) and adjusted analysis (HR = 2.97 [95%CI: 1.07–8.25], p = 0.04). Conclusion: Zva is a novel prognostic marker for HF readmissions at 1-year post-TAVR and can be routinely measured on ECHO. Further prospective studies validating the utility of Zva for risk stratification are warranted.

Impact of Transcatheter Mitral Valve Repair on Left Ventricular Remodeling in Secondary Mitral Regurgitation: A Meta-Analysis

ABSTRACT Background: Secondary mitral regurgitation (MR) arises from left ventricular (LV) dilatation and remodeling, and commonly is treated with transcatheter mitral valve repair. We examined the impact of MitraClip on reverse cardiac remodeling in patients with severe, symptomatic secondary MR. Methods:: An electronic search was performed through January 2018 for studies that reported cardiac chamber dimensions prior to and after treatment with MitraClip in patients with secondary MR. The mean difference (MD) with 95% CI was calculated using fixed or random inverse variance models. Outcomes of interest were changes in LV end-systolic and end-diastolic volumes (LVESV, LVEDV) and dimensions (LVESD, LVEDD). Secondary outcomes included left atrial (LA) volume, systolic pulmonary artery pressure (sPAP) and LV ejection fraction (LVEF). Results: A total of 16 studies with 1,266 patients were included in the present analysis. The weighted mean follow-up period (±SD) was 11.5 ± 7.2 months. MitraClip was associated with significant reduction in LVEDV (−14.24 ml, 95% CI [−22.53, −5.94], p = 0.0008), LVESV (−7.67 ml, CI [−12.30, −3.03], p = 0.001), LVEDD (−2.92 mm [−3.65, −2.19 mm], p < 0.00001), and LVESD (−1.92 mm [−2.92, −0.92], p = 0.0002). MitraClip was also associated with reduction in LA volume (−16.36 ml [23.23, −9.49 ml], p < 0.00001) and sPAP (−6.93 mmHg [−8.76, −5.10], p < 0.00001), and a significant increase in LVEF (+ 2.78% [0.91, 4.66], p = 0.004). Conclusions: In patients with severe symptomatic secondary MR, MitraClip is associated with modest, but favorable LV and LA reverse remodeling. The impact of these changes on clinical outcomes deserves further study.

Impact of Atrial Fibrillation on the Outcomes after Mitraclip®: A Meta-Analysis

ABSTRACT Background: Atrial fibrillation (AF) has been associated with worse outcomes in patients undergoing mitral valve surgery for mitral regurgitation. The impact of preexisting AF on the outcomes after transcatheter mitral valve repair with MitraClip® (Abbott Vascular, Santa Clara, CA, USA) has not been well studied. Methods: An electronic search was performed until December 2017 for studies reporting outcomes after MitraClip® in patients with AF versus those with no AF. Outcomes of interest included all-cause mortality, stroke and major adverse cardiovascular events (MACE) defined as the composite outcome of death, stroke, and myocardial infarction at the longest follow-up reported. Results: A total of four studies including 1473 patients (AF n = 697; no AF n = 776) were included. There was no difference in procedural success or procedural time between patients with AF versus those without AF. AF was associated with increased mortality after MitraClip® compared with patients with no AF (OR 1.54, 95% CI (1.16, 2.04), p = 0.003, I 2 = 0%) over a mean follow-up period of 10.2 months. In a sensitivity analysis excluding early postoperative (30-day) outcomes, AF remained associated with higher mortality (OR 1.53, 95% CI (1.15, 2.03), p = 0.003, I 2 = 19%). AF was associated with a higher incidence of MACE after MitraClip® (OR 1.46, 95% CI (1.03, 2.07), p = 0.03, I 2 = 13%). No difference was observed in the risk of stroke between patients with versus without AF after MitraClip® (OR 1.13, 95%CI (0.36, 3.56), p = 0.84, I 2 = 37%). Conclusions: Compared with patients without AF, patients with preexisting AF are at higher risk of death and MACE after MitraClip®.

Quality of life outcomes in transcatheter aortic valve replacement patients requiring pacemaker implantation

Permanent pacemaker implantation is the most common complication after Transcatheter aortic valve replacement (TAVR) and is associated with worse outcomes and mortality. However, its impact on quality‐of‐life (QoL) outcomes remains unknown.

Neutrophil to Lymphocyte Ratio Predicts Heart Failure Readmissions and Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement

Objective Neutrophil-to-lymphocyte ratio (NLR) has prognostic value in acute coronary syndromes. We investigated its utility for predicting heart failure (HF) admissions and major adverse cardiac outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). Methods Data on clinical, laboratory, procedural, HF admissions, and major adverse cardiac events (MACEs) (all-cause mortality, recurrence of myocardial infarction requiring intervention, stroke) for 298 consecutive patients who underwent TAVR between 2012 and 2016 in our tertiary center were collected. Results Analysis included 298 patients. The mean age was 83 ± 8 years, 51% were males, and 95% were Caucasians. The median Society of Thoracic Surgeons risk score was 9 (interquartile range: 6.3–11.8). Receiver-operating curve analysis identified a cutoff value of NLR of 4.0 for MACE after TAVR and sensitivity of 68% and specificity of 68% {area under the curve [AUC] = 0.65 [95% confidence interval (CI): 0.51–0.79], p = 0.03}. An NLR of 4.0 for HF hospitalizations after TAVR and sensitivity of 60% and specificity of 57% [AUC = 0.61 (95% CI: 0.53–0.69), p = 0.01]. NLR ≥4.0 before TAVR significantly predicted MACE after TAVR (68.4% vs. 31.6%, p = 0.02) and HF hospitalizations (58.3% vs. 41.7%, p = 0.03). NLR with TAVR risk score increased the predictive value for MACE after TAVR from AUC = 0.61 (95% CI: 0.50–0.72, p = 0.06) to AUC = 0.69 (95% CI: 0.57–0.80, p = 0.007). Conclusion NLR predicts all-cause mortality, MACE, and HF hospitalization 1 year after TAVR. NLR with TAVR risk score improved predictability for MACE. Further studies for prognostication using NLR are warranted.

Elevated end-diastolic wall stress after acute myocardial infarction predicts adverse cardiovascular outcomes and longer hospital length of stay

Acute myocardial infarction (MI) leads to ventricular remodeling in response to oxygen demand. Such changes include left ventricular (LV) dilatation and increased myocardial wall stress. Prior studies showed that wall stress is a vital parameter of cardiac remodeling. However, outcome data are lacking. We aim to investigate wall stress post‐MI in relation to biomarkers of cardiac remodeling and cardiovascular outcomes.

A Partial Anomalous Pulmonary Venous Connection in a Severely Symptomatic Patient, Is Surgery Always Recommended?

Partial anomalous pulmonary venous connection (PAPVC) is a rare cardiac anomaly occurring when a pulmonary vein drains into the right atrium, coronary sinus or a systemic vein creating a left-to-right shunt. Symptoms develop from right-sided fluid overload and pulmonary vascular disease. We report a rare case of a severely symptomatic patient with an incidentally discovered PAPVC in the setting of underlying severe pulmonary hypertension from multifactorial severe restrictive lung disease. Despite his worsening symptoms, a multi-disciplinary meeting decided against surgical intervention. Nine months after the decision was made, the patient showed no signs or symptoms of clinical deterioration. Prior studies recommend surgery for PAPVCs with evidence of right ventricular dilation, mild-to-moderate tricuspid regurgitation, or early stages of pulmonary vascular disease. However, our case demonstrates how decision making should consider the shunt’s contribution to the overall clinical picture and underlying comorbidities. If a decision is made to defer surgical intervention, strict follow up and repeat re-evaluations for possible risk re-stratification and surgery reconsideration are warranted.

The Therapeutic Potential of Blocking Galectin-3 Expression in Acute Myocardial Infarction and Mitigating Inflammation of Infarct Region: A Clinical Outcome-Based Translational Study

Introduction: Increased galectin-3 is associated with ischemic cardiomyopathy, although its role in early remodeling post-myocardial infarction (MI) has not been fully elucidated. There are no data demonstrating that blocking galectin-3 expression would have an impact on the heart and that its relationship to remodeling is not simply an epiphenomenon. The direct association between galectin-3 and myocardial inflammation, dysfunction, and adverse cardiovascular outcomes post-MI was examined using clinical and translational studies. Methods: We performed expression analysis of 9753 genes in murine model of acute MI. For galectin-3 loss of function studies, homozygous galectin-3 knock-out (KO) mice were subjected to coronary artery ligation procedure to induce acute MI (MI, Nu2009=u20096; Sham, Nu2009=u20096). For clinical validation, serum galectin-3 levels were measured in 96 patients with ST-elevation MI. Echocardiographic and angiographic parameters of myocardial dysfunction and 3-month composite outcome including mortality, recurrent MI, stroke, and heart failure hospitalization were measured. Results: In the infarct regions of murine models, galectin-3 was a robustly expressed gene. Elevated galectin-3 expression strongly correlated with macrophage-mediated genes. Galectin-3 KO mice showed reduced myocardial macrophage infiltration after acute MI. Galectin-3 levels were higher in patients with early systolic dysfunction, and predicted 3-month major adverse cardiovascular events (area under the curve [AUC]: 0.917u2009±u20090.063; Pu2009=u2009.001). Conclusions: Galectin-3 is directly associated with early myocardial inflammation post-MI and may represent a potential target for therapeutic inhibition.