Mark A. Robbins

Racial differences in the prevalence of severe aortic stenosis.

Background In an era of expanded treatment options for severe aortic stenosis, it is important to understand risk factors for the condition. It has been suggested that severe aortic stenosis is less common in African Americans, but there are limited data from large studies. Methods and Results The Synthetic Derivative at Vanderbilt University Medical Center, a database of over 2.1 million de‐identified patient records, was used to identify individuals who had undergone echocardiography. The association of race with severe aortic stenosis was examined using multivariable logistic regression analyses adjusting for conventional risk factors. Of the 272 429 eligible patients (mean age 45 years, 44% male) with echocardiography, 14% were African American and 82% were Caucasian. Severe aortic stenosis was identified in 106 (0.29%) African‐American patients and 2030 (0.91%) Caucasian patients (crude OR 0.32, 95% CI [0.26, 0.38]). This difference persisted in multivariable‐adjusted analyses (OR 0.41 [0.33, 0.50], P<0.0001). African‐American individuals were also less likely to have severe aortic stenosis due to degenerative calcific disease (adjusted OR 0.47 [0.36, 0.61]) or congenitally bicuspid valve (crude OR 0.13 [0.02, 0.80], adjusted OR dependent on age). Referral bias against those with severe valvular disease was assessed by comparing the prevalence of severe mitral regurgitation in Caucasians and African Americans and no difference was found. Conclusions These findings suggest that African Americans are at significantly lower risk of developing severe aortic stenosis than Caucasians.

Percutaneous Management of RetroFlex 3 Balloon Rupture and Separation of the Edwards Sapien Delivery System

We report the case of an 85-year-old woman with severe aortic stenosis who underwent transcatheter aortic valve replacement with use of the Edwards Sapien(®) valve system. The procedure was complicated by rupture of the valve-deployment balloon, with separation and retention of the nose cone of the RetroFlex 3(®) delivery system in the iliac artery. Our endovascular retrieval of the equipment was successful, and we achieved access-site hemostasis by deploying a covered stent. To our knowledge, this is the first report of the endovascular retrieval of a malfunctioning delivery system during transcatheter aortic valve replacement.

Peripheral Vascular Complications During Transcatheter Aortic Valve Replacement

PURPOSE To report a case of a major vascular complication during transcatheter aortic valve replacement (TAVR) and the endovascular management thereof. Additionally, we discuss a possible correlation with long-term steroid use. CASE REPORT A 79-year-old woman with a history of critical aortic stenosis underwent elective TAVR. Her procedure was complicated by rupture of her right iliac artery, life-threatening retroperitoneal hemorrhage, and thrombus extending into the distal right lower extremity. This case was emergently managed by stent placement, thrombectomy, and tissue plasminogen activator via a percutaneous approach. CONCLUSIONS Peripheral vascular complications are common during percutaneous TAVR, and chronic steroid use may predispose patients. Endovascular management is often possible and may potentially save valuable time in emergent situations.

Peripheral vascular complications during transcatheter aortic valve replacement: management and potential role of chronic steroid use.

PURPOSE To report a case of a major vascular complication during transcatheter aortic valve replacement (TAVR) and the endovascular management thereof. Additionally, we discuss a possible correlation with long-term steroid use. CASE REPORT A 79-year-old woman with a history of critical aortic stenosis underwent elective TAVR. Her procedure was complicated by rupture of her right iliac artery, life-threatening retroperitoneal hemorrhage, and thrombus extending into the distal right lower extremity. This case was emergently managed by stent placement, thrombectomy, and tissue plasminogen activator via a percutaneous approach. CONCLUSIONS Peripheral vascular complications are common during percutaneous TAVR, and chronic steroid use may predispose patients. Endovascular management is often possible and may potentially save valuable time in emergent situations.

Aortic insufficiency following transcatheter aortic valve replacement is underestimated by echocardiography compared with cardiac MRI

Background The degree of aortic insufficiency (AI) after transcatheter aortic valve replacement (TAVR) has been identified as a predictor of increased mortality. Since even mild AI is associated with increased mortality in some studies, accurate quantification of post-TAVR AI is critical. Assessment of AI by echocardiography is typically performed by visual inspection and semi-quantitative methods. Most post-TAVR AI is paravalvular, however echocardiography has limited ability to quantify multiple eccentric paravalvular jets. Using flow quantification methods, cardiac MRI (CMR) may more accurately quantify AI severity post-TAVR and therefore more accurately assess risk in this population. Methods Twenty-three patients who underwent TAVR with a SAPIEN prosthesis were studied. All patients underwent an intraoperative transesophageal echocardiogram (TEE), as well as a post-procedure transthoracic echocardiogram (TTE) and CMR. Paravalvular AI by TTE and TEE was graded using color Doppler by quantifying the circumferential extent of AI as a percentage of the aortic annulus (none 30%) following recommendations from the Valve Academic Research Consortium. AI severity by CMR was quantified as the regurgitant fraction of forward aortic flow based on previously published recommendations (none 48%). Results The mean age was 79 +/- 10 years; 52% were men. TTE and CMR were performed at 1 [1-1] and 4 [1-4] days postTAVR respectively (median [IQR]). The left ventricular ejection fraction (LVEF) by CMR was 65 +/- 10%. AI severity by TTE was none in 9 (39.1%), trace in 11 (47.8%), and mild in 3 (13%) patients. TEE identified trace central AI in 6 patients (26%). Paravalvular AI by TEE was none in 4 (17.4%), trace in 14 (60.9%), and mild in 5 (21.7%) patients. AI by CMR was none in 2 (8.7%), trace in 5 (21.7%), mild in 13 (56.5%), and moderate in 3 (13%) patients; (Figure 1). A higher proportion of patients with mild or greater AI was identified by CMR (16/23, 70%) compared to TTE (3/23, 13%) and TEE (5/23, 22%); (Figure 2). Conclusions

The Link Between Inflammation and Thrombosis

Atherosclerosis is an inflammatory disease. This fact is now strongly supported by clinical, basic, and pathological research which has caused an evolution in thought concerning the evaluation and treatment of acute coronary syndromes (ACS). The initial insult is endothelial injury and subsequent dysfunction via the deleterious effects of the known cardiac risk factors such as oxidized LDL, hyperglycemia, hypertension, hyperhomocystinemia, and smoking. Irrespective of the cause of endothelial damage, the resultant activation and proliferation of inflammatory cells, smooth muscle cells, and generation of cytokines and growth factors lead to the progression of atherosclerosis. The presence and extent of inflammation, procoagulant state and composition of the atherosclerotic plaque have been strongly associated with an increased risk of future cardiac events. Thus, the perpetuation of the inflammatory response likely plays a pivotal roIe in the pathobiology and vulnerability of the atherosclerotic plaque. Inflammatory markers once thought to be passive observers are now being investigated as active participants in the progression of atherosclerosis and therefore targets for future pharmacologic intervention.