Michael Barkagan

Mortality prediction following transcatheter aortic valve replacement: A quantitative comparison of risk scores derived from populations treated with either surgical or percutaneous aortic valve replacement. The Israeli TAVR Registry Risk Model Accuracy Assessment (IRRMA) study

BACKGROUND Accurate risk stratification is pivotal for appropriate selection of patients with severe symptomatic aortic stenosis for either surgical or transcatheter aortic valve replacement (TAVR). We sought to determine whether recent risk prediction models developed specifically in TAVR patients enhance prognostication in comparison with previous surgical scores used in clinical practice (EuroScore I, EuroScore II, STS). METHODS The Israeli TAVR Registry Risk Model Accuracy Assessment (IRRMA) study utilized a multicenter prospective TAVR database (n=1327) to perform a quantitative comparison between previous risk scores developed in either surgical or TAVR populations, with the present registry serving as an independent external validation set. RESULTS In the IRRMA population, 4 variables (NYHA functional class IV, chronic obstructive pulmonary disease, systolic pulmonary artery pressure ≥60mmHg, vascular access other than by the femoral route) identified by cross-validation and leave-one-out analyses provided the most discriminative model (C-statistic=0.63) for predicting 30-day mortality. Previous scores developed in surgical (EuroScores I and II, STS), TAVR (FRANCE-2, OBSERVANT), or mixed (German AV score) populations were applied to the IRRMA cohort. Resultant C-statistics ranged between 0.52-0.71 (for the German AV and FRANCE-2 scores, respectively) and did not differ significantly (p=0.07 for the comparison between the lowest and highest C-statistics). The observed C-statistic for 5 of these 6 scores was lower than originally reported when applied to the IRRMA population. CONCLUSION Available TAVR risk scores showed limited accuracy when applied to an independent validation set and did not enhance prognostication in comparison to previous surgical scores.

Impact of routine manual aspiration thrombectomy on outcomes of patients undergoing primary percutaneous coronary intervention for acute myocardial infarction: A meta-analysis

BACKGROUND The efficacy and safety of thrombectomy as an adjunct to primary percutaneous intervention (PCI) in the management of acute myocardial infarction (AMI) are debated. We performed a meta-analysis of randomized trials comparing primary PCI performed with versus without routine aspiration thrombectomy (AT). METHODS A meta-analysis of randomized AT trials reporting clinical outcomes was done in accordance with the PRISMA guidelines. Trials reporting only non-clinical endpoints and those of technologies other than manual devices were excluded. The primary endpoint of this meta-analysis was mortality (either all-cause or cardiovascular). Secondary endpoints were reinfarction, stent thrombosis, and stroke. RESULTS Seventeen randomized trials, involving 20,853 patients were included. Weighted mean follow-up was 9.3 ± 3.3 months. The rates of all-cause mortality (reported in 14 trials, n = 10,430) and cardiovascular mortality (reported in 6 trials, n = 11,810) did not differ significantly between patients treated with or without AT (4.6% vs. 5.3%, RR = 0.88 [95%CI = 0.75-1.04]; and, 3.0% vs. 3.7%, RR = 0.83 [95%CI = 0.68-1.01]; respectively). The rates of reinfarction and stent thrombosis were also similar in patients treated with versus those treated without AT (2.1% vs. 2.2%; RR = 0.96 [95%CI = 0.80-1.15]; and, 1.2% vs. 1.4%; RR = 0.84 [95%CI = 0.65-1.07], respectively). However, stroke rates were increased with AT (0.84% vs. 0.52%, RR = 1.56 [95%CI = 1.09-2.25]). CONCLUSIONS Routine AT as an adjunct to primary PCI does not reduce the rates of death, reinfarction, or stent thrombosis, but is associated with increased stroke risk.

Impact of Diabetes Mellitus and Hemoglobin A1C on Outcome After Transcatheter Aortic Valve Implantation.

Surgical aortic valve replacement (SAVR) is associated with an increased mortality risk in elderly or high-risk patients. Transcatheter aortic valve implantation (TAVI) is an alternative to surgery in patients with symptomatic severe aortic stenosis who are inoperable or at high operative risk. The impact of diabetes mellitus (DM) on patients referred to TAVI merits further investigation. The aim of our study was to evaluate the clinical characteristics and the impact of DM status on the updated Valve Academic Research Consortium 2-defined outcomes of TAVI and to stratify patient outcomes according to their initial glycated hemoglobin (HbA1c) levels. We enrolled and stratified patients who underwent TAVI at our institution according to DM status. A total of 586 patients were enrolled: 348 (59%) without DM and 238 (41%) with DM. There were no significant differences in 30-day mortality patients with diabetes compared to patients without diabetes (3.3% vs 2.9%, p = 0.974). Insulin-treated DM was not associated with adverse outcome in comparison to orally treated DM. To delineate the prognostic power of HbA1C in these patients, the cohort was divided into 3 groups according to HbA1C levels (<5.7%, 5.7% to 6.49%, and ≥6.5%). Patients with HbA1C ≥6.5% were at increased risk for mortality during follow-up (hazard ratio 2.571, 95% confidence interval 1.077 to 6.136, p = 0.033) compared to patients with HbA1C <5.7%. In conclusion, unlike SAVR, DM is not associated with an increased mortality risk after TAVI, nor is it associated with increased complications rates. A more poorly controlled disease, as manifested by elevated HbA1c levels, may be associated with increased mortality during long-term follow-up.

Atrial Tachycardia Originating in the Vicinity of the Noncoronary Sinus of Valsalva: Report of a Series Including the First Case of Ablation‐Related Complete Atrioventricular Block

A few series of focal atrial tachycardia (AT) originating from the noncoronary sinus of Valsalva (NCSV) have been reported in the literature during the last decade.

Atrial Tachycardia Originating in the Vicinity of the Non‐Coronary Sinus of Valsalva

A few series of focal atrial tachycardia (AT) originating from the noncoronary sinus of Valsalva (NCSV) have been reported in the literature during the last decade.

High-power and short-duration ablation for pulmonary vein isolation: Safety, efficacy, and long-term durability

PV reconnection is often the result of catheter instability and tissue edema. High‐power short‐duration (HP‐SD) ablation strategies have been shown to improve atrial linear continuity in acute pre‐clinical models. This study compares the safety, efficacy, and long‐term durability of HP‐SD ablation with conventional ablation.

Prognostic Implications of Chronic Kidney Disease on Patients Presenting with ST-Segment Elevation Myocardial Infarction with versus without Stent Thrombosis

Background: Limited data is present regarding long-term outcomes in chronic kidney disease (CKD) patients presenting with stent thrombosis (ST). We evaluated the possible implications of CKD on long-term mortality in patients presenting with ST-segment elevation myocardial infarction (STEMI) and treated with primary percutaneous coronary intervention (PCI), and its interaction with the presence of ST. Methods: We retrospectively studied 1,722 STEMI patients treated with primary PCI. Baseline CKD was categorized as an estimated glomerular filtration rate <60 mL/min/1.73 m2 at presentation. The presence of ST was determined using the Academic Research Consortium definitions. Patients were evaluated for the presence of CKD and ST, as well as for long-term mortality. Results: A total of 448/1,722 (26%) patients had baseline CKD. Patients with CKD were older and had more comorbidities and a higher rate of ST (4 vs. 7%, respectively, p < 0.001). In a univariate analysis, long-term mortality was significantly higher among those with CKD compared to those without CKD (17.6 vs. 2.7%, p < 0.001). The presence of ST did not alter long-term mortality in both CKD and no-CKD patients. In a Cox regression model, CKD was an independent predictor of long-term mortality (hazard ratio 2.04, 95% confidence interval 1.17-3.56, p = 0.01), while ST as a covariate was not significantly associated with long-term mortality. Conclusion: Among STEMI patients, CKD, but not ST, is a predictor of long-term mortality.

Three-dimensional holographic visualization of high-resolution myocardial scar on HoloLens

Visualization of the complex 3D architecture of myocardial scar could improve guidance of radio-frequency ablation in the treatment of ventricular tachycardia (VT). In this study, we sought to develop a framework for 3D holographic visualization of myocardial scar, imaged using late gadolinium enhancement (LGE), on the augmented reality HoloLens. 3D holographic LGE model was built using the high-resolution 3D LGE image. Smooth endo/epicardial surface meshes were generated using Poisson surface reconstruction. For voxel-wise 3D scar model, every scarred voxel was rendered into a cube which carries the actual resolution of the LGE sequence. For surface scar model, scar information was projected on the endocardial surface mesh. Rendered layers were blended with different transparency and color, and visualized on HoloLens. A pilot animal study was performed where 3D holographic visualization of the scar was performed in 5 swines who underwent controlled infarction and electroanatomic mapping to identify VT substrate. 3D holographic visualization enabled assessment of the complex 3D scar architecture with touchless interaction in a sterile environment. Endoscopic view allowed visualization of scar from the ventricular chambers. Upon completion of the animal study, operator and mapping specialist independently completed the perceived usefulness questionnaire in the six-item usefulness scale. Operator and mapping specialist found it useful (usefulness rating: operator, 5.8; mapping specialist, 5.5; 1–7 scale) to have scar information during the intervention. HoloLens 3D LGE provides a true 3D perception of the complex scar architecture with immersive experience to visualize scar in an interactive and interpretable 3D approach, which may facilitate MR-guided VT ablation.

Aortoventricular annulus shape as a predictor of pacemaker implantation following transcatheter aortic valve replacement

Aims Conduction abnormalities following transcatheter aortic valve replacement (TAVR) are caused by damage of the aortoventricular conduction tissue during positioning of the valve. Therefore, our aim was to assess whether a higher difference between the long and short diameters of the elliptic aortoventricular annulus will possess higher forces on the annulus, and thus will be a predictor of pacemaker need following TAVR. Methods We retrospectively analyzed 123 patients who had the aortoventricular annulus measured by computed tomography angiography. The difference between maximal (Dmax) and minimal (Dmin) diameters of the annulus was considered the elliptic factor (ELFA), which was analyzed using t test to evaluate whether it differs between the group who received a pacemaker and the group without the need for a pacemaker. Then, using univariate and multivariate models adjusted for other confounders predicting the need for a pacemaker, we sought to evaluate whether a higher ELFA is a predictor of pacemaker implantation. Results Mean age was 82.2 ± 6.4 years, and 62.6% were women. Average Dmax, Dmin and ELFA were 25.8, 20.8 and 5 mm, respectively. Fourteen patients (11.4%) underwent pacemaker implantation. Those patients had an ELFA of 5.9 mm compared with 4.9 mm in those who did not receive a pacemaker (P < 0.01). In multivariate analysis, a higher ELFA remained a statistically significant and independent predictor for the need of a pacemaker (P = 0.046). Conclusion A high ELFA is an independent and significant predictor of the need for pacemaker implantation after TAVR and suggests further investigation whether it should be considered as a factor in managing TAVR patients.

The awareness to metabolic syndrome among hospital health providers

BACKGROUND Metabolic syndrome (MetS) was shown to be related to a variety of diseases. High level of vigilance for the diagnosis of MetS is expected among health providers. We evaluated the level of awareness to MetS among physician and nurses working in a central hospital. METHODS AND RESULTS A specially designed anonymous questionnaire was used, including both open and multiple choice questions set to evaluate the participants awareness to MetS. The study included 126 participants, 71% physicians and 29% nurses. Mean age was 36.2±3.8 years. Among physicians, 68.5% were residents and 45.5% were internists. 98% of the participants stated that they were familiar with the term MetS and that they treat MetS patients regularly. Most participants knew the correct number of criteria included in MetS definition and the number of criteria needed for MetS diagnosis (84% and 90%, respectively). However, only 12% were able to discriminate correctly all MetS cases from non-MetS ones. Physicians performed better than nurses (15.6% and 3.1%, respectively, P=0.003). Neither, field of practice nor seniority was found to have a significant influence on the results. The frequency of recommendation for MetS risk factor modulation in the discharge files was also analyzed. Such recommendations were scarcely given, with cardiology department being the exception (80% of discharge files from cardiology department compared with less than 20% in other departments). CONCLUSION Though hospital workers showed high level of awareness to the existence of MetS, they failed to differentiate correctly MetS cases from non-MetS ones.