John Lisko

Association Between Transcatheter Aortic Valve Replacement and Subsequent Infective Endocarditis and In-Hospital Death

IMPORTANCEnLimited data exist on clinical characteristics and outcomes of patients who had infective endocarditis after undergoing transcatheter aortic valve replacement (TAVR).nnnOBJECTIVEnTo determine the associated factors, clinical characteristics, and outcomes of patients who had infective endocarditis after TAVR.nnnDESIGN, SETTING, AND PARTICIPANTSnThe Infectious Endocarditis after TAVR International Registry included patients with definite infective endocarditis after TAVR from 47 centers from Europe, North America, and South America between June 2005 and October 2015.nnnEXPOSUREnTranscatheter aortic valve replacement for incidence of infective endocarditis and infective endocarditis for in-hospital mortality.nnnMAIN OUTCOMES AND MEASURESnInfective endocarditis and in-hospital mortality after infective endocarditis.nnnRESULTSnA total of 250 cases of infective endocarditis occurred in 20u202f006 patients after TAVR (incidence, 1.1% per person-year; 95% CI, 1.1%-1.4%; median age, 80 years; 64% men). Median time from TAVR to infective endocarditis was 5.3 months (interquartile range [IQR], 1.5-13.4 months). The characteristics associated with higher risk of progressing to infective endocarditis after TAVR was younger age (78.9 years vs 81.8 years; hazard ratio [HR], 0.97 per year; 95% CI, 0.94-0.99), male sex (62.0% vs 49.7%; HR, 1.69; 95% CI, 1.13-2.52), diabetes mellitus (41.7% vs 30.0%; HR, 1.52; 95% CI, 1.02-2.29), and moderate to severe aortic regurgitation (22.4% vs 14.7%; HR, 2.05; 95% CI, 1.28-3.28). Health care-associated infective endocarditis was present in 52.8% (95% CI, 46.6%-59.0%) of patients. Enterococci species and Staphylococcus aureus were the most frequently isolated microorganisms (24.6%; 95% CI, 19.1%-30.1% and 23.3%; 95% CI, 17.9%-28.7%, respectively). The in-hospital mortality rate was 36% (95% CI, 30.0%-41.9%; 90 deaths; 160 survivors), and surgery was performed in 14.8% (95% CI, 10.4%-19.2%) of patients during the infective endocarditis episode. In-hospital mortality was associated with a higher logistic EuroSCORE (23.1% vs 18.6%; odds ratio [OR], 1.03 per 1% increase; 95% CI, 1.00-1.05), heart failure (59.3% vs 23.7%; OR, 3.36; 95% CI, 1.74-6.45), and acute kidney injury (67.4% vs 31.6%; OR, 2.70; 95% CI, 1.42-5.11). The 2-year mortality rate was 66.7% (95% CI, 59.0%-74.2%; 132 deaths; 115 survivors).nnnCONCLUSIONS AND RELEVANCEnAmong patients undergoing TAVR, younger age, male sex, history of diabetes mellitus, and moderate to severe residual aortic regurgitation were significantly associated with an increased risk of infective endocarditis. Patients who developed endocarditis had high rates of in-hospital mortality and 2-year mortality.

Socioeconomic Status and Cardiovascular Outcomes: Challenges and Interventions

Socioeconomic status (SES) has a measurable and significant effect on cardiovascular health. Biological, behavioral, and psychosocial risk factors prevalent in disadvantaged individuals accentuate the link between SES and cardiovascular disease (CVD). Four measures have been consistently associated with CVD in high-income countries: income level, educational attainment, employment status, and neighborhood socioeconomic factors. In addition, disparities based on sex have been shown in several studies. Interventions targeting patients with low SES have predominantly focused on modification of traditional CVD risk factors. Promising approaches are emerging that can be implemented on an individual, community, or population basis to reduce disparities in outcomes. Structured physical activity has demonstrated effectiveness in low-SES populations, and geomapping may be used to identify targets for large-scale programs. Task shifting, the redistribution of healthcare management from physician to nonphysician providers in an effort to improve access to health care, may have a role in select areas. Integration of SES into the traditional CVD risk prediction models may allow improved management of individuals with high risk, but cultural and regional differences in SES make generalized implementation challenging. Future research is required to better understand the underlying mechanisms of CVD risk that affect individuals of low SES and to determine effective interventions for patients with high risk. We review the current state of knowledge on the impact of SES on the incidence, treatment, and outcomes of CVD in high-income societies and suggest future research directions aimed at the elimination of these adverse factors, and the integration of measures of SES into the customization of cardiovascular treatment.

Pulmonary Venous Waveforms Predict Rehospitalization and Mortality After Percutaneous Mitral Valve Repair

OBJECTIVESnIn this study, the authors hypothesized that intraprocedural improvement of pulmonary venous (PV) waveforms are predictive of improved outcomes. In this report, they analyzed intraprocedural invasive and echocardiographic changes with respect to rehospitalization and mortality.nnnBACKGROUNDnThe effects of hemodynamic changes during percutaneous mitral valve repair (PMVR) with MitraClip (Abbott Vascular, Santa Clara, California) are incompletely characterized.nnnMETHODSnThe authors retrospectively reviewed records and intraprocedural transesophageal echocardiograms of 115 consecutive patients (age 76 ± 12 years) who underwent PMVR for mitral regurgitation (MR) from May 2013 to January 2017 at Emory University Hospital. They assessed intraprocedural PV waveforms for improvement in morphology, measured change in MR grade by semiquantitative methods, evaluated invasive changes in left atrial pressure (LAP) and V-wave, and compared with 30-day and 1-year rehospitalization and all-cause mortality.nnnRESULTSnNinety-three cases (80%) had PV waveforms before and after clip placement sufficient for analysis, of which 67 (73%) demonstrated intraprocedural improvement in PV morphology and 25 (27%) did not. At 24 months, 57 (85%) of those with PV improvement were living, compared with only 10 (40%) of those without improvement. Proportional hazards models demonstrated a significant survival advantage in those with PV improvement (hazard ratio [HR]xa0= 0.28, 95% confidence interval [CI] 0.08 to 0.93, pxa0= 0.038). By multivariable analysis, PV improvement predicted reduced 1-year cardiac rehospitalization (odds ratio [OR]xa0= 0.18, pxa0= 0.044). Intraprocedural assessment of MR grade and invasive hemodynamics did not consistently predict mortality and rehospitalization.nnnCONCLUSIONSnPV waveforms are important markers of procedural success after PMVR. Our data show intraproceduralxa0PV waveforms may predict rehospitalization and mortality after PMVR. A larger, multicenter cohort will be important to clarify this relationship.

EFFECT OF THIRD PARTY PAYOR PRE-AUTHORIZATION POLICY ON CONCORDANCE OF NUCLEAR STRESS PERFUSION IMAGING AND CORONARY ARTERIOGRAPHY

Non-invasive testing, primarily nuclear multiplanar perfusion imaging (MPI), predicts abnormal findings on coronary angiography(CATH) in 41% of patients(Patel et al NEJM 362:886-95). Due to radiation doses associated with MPI studies, concern has risen about over-utilization. In September 2010 the

The Role of Echocardiography in the Detection of Chemotherapy-Induced Cardiotoxicities

Advances in chemotherapy and radiation treatment have drastically improved mortality associated with numerous malignancies. This is counterbalanced by the short- and long-term cardiotoxic effects of cancer therapy. Given the significant morbidity and mortality associated with cardiovascular complications of cancer therapy, strategies for early detection, and prevention of cardiotoxicity are needed. While the exact timing and method of screening for cardiotoxicity remains uncertain, an ideal screening test would be widely available, radiation free, and relatively inexpensive. Echocardiography (echo) is the most widely used, noninvasive, radiation-free test of cardiac morphology and function. Advances in echocardiographic techniques, such as 3D echocardiography and speckle tracking and strain imaging, may allow for the successful detection and treatment of subclinical cardiac dysfunction prior to overt cardiomyopathy and heart failure.

The Long-Term Prognostic Value of Negative Contrast Stress Echocardiography

Chronic total occlusion (CTO) is probably caused by thrombus and lipid-rich cholesterol esters that are replaced over time by collagen and calcium deposition. Experimental models showed endothelial cell necrosis in response to vessel ligation, whereas more recent models suggest that the endothelium might retain viability guiding the subsequent development of CTO, including CTO neo-revascularization, which occurs within the lumen and in various layers of the vessel wall, by the release of paracrine substances. It is uncertain whether after CTO recanalization the recovery of anterograde reverses endothelial dysfunction, thus promoting vasodilation and positive remodeling.

TRANSIENT ISCHEMIC DILATION: A NEW PERSPECTIVE UTILIZING CARDIAC MRI

Stress-induced global LV myocardial ischemia is difficult to detect by nuclear myocardial perfusion imaging (MPI). Digital LV volume software is used to assess changes in overall scintigraphic LV volume after stress, and is termed transient ischemic dilation(TID). The mechanism of TID is thought to